Laparoscopic versus open distal pancreatectomy: A meta-analysis

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JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 22, Number 6, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2012.0002

2012 IPEG Papers

Laparoscopic Versus Open Distal Pancreatectomy in the Management of Traumatic Pancreatic Disruption Corey W. Iqbal, MD,1 Shauna M. Levy, MD,2 Kuojen Tsao, MD,2 Mikael Petrosyan, MD,3 Timothy D. Kane, MD,3 Elizabeth M. Pontarelli, MD,4 Jeffrey S. Upperman, MD,4 Marcus Malek, MD,5 R. Cartland Burns, MD,5 Sarah Hill, MD,6 Mark L. Wulkan, MD,6 and Shawn D. St. Peter, MD1


Purpose: Traumatic pancreatic transection is uncommon. The role of laparoscopy in the setting of this injury has not been well described. Patients and Methods: Six large-volume pediatric trauma centers contributed patients < 18 years of age who underwent a distal pancreatectomy for traumatic pancreatic transection from 2000 to 2010. Results: Twenty-one patients without another indication for emergency laparotomy underwent a distal pancreatectomy for Grade III pancreatic injuries, of which 7 underwent laparoscopic distal pancreatectomy. Mean ( – SD) age was 8.6 – 4.7 years, and 67% were male. There was no difference in the presence of other injuries between the two groups (43% in each group). Computed tomography revealed a transected pancreas in 85% of the laparoscopic patients and 75% of the open group (P = 1.0). Mean operative time was 218 – 101 minutes with laparoscopy compared with 195 – 111 minutes with the open procedure (P = .7). Median duration of hospitalization was 6 days (range, 6–18 days) in the laparoscopic group compared with 11 days (range, 5–26 days) in the open group (P = 0.3). Postoperative morbidity was not different between the two groups (57% versus 21% for laparoscopic versus open, P = .2). Conclusions: Laparoscopy is equivalent to open distal pancreatectomy in children with select traumatic pancreatic injuries.


Patients and Methods


We conducted a multi-institutional retrospective review of patients < 18 years of age who underwent a distal pancreatic resection for a traumatic pancreatic injury from 2000 through 2010. Institutional Review Board approval was obtained at each participating institution. Six Level One pediatric trauma centers contributed data. Patients who underwent emergency laparotomy for other life-threatening traumatic injuries were excluded. Additionally, patients who had Grade IV or V pancreatic injuries were also excluded as we were looking specifically at distal pancreatectomy. Patients with Grade II injuries were not intentionally excluded; however, all patients with pancreatic transection who underwent a resection were found to have a transected pancreatic duct and were all classified as Grade III, and therefore we did not have any

raumatic injuries to the pancreas occur in 3%–12% of all pediatric blunt abdominal trauma.1–3 When they occur, 16%–60% have associated intra-abdominal injuries, many of which will not require surgical intervention.4,5 This creates a population of stable patients whose only possible indication for an operation is a pancreatic injury. When the pancreatic injury is Grade III or parenchymal transection with main pancreatic duct disruption, an operation is often performed.6 In this group of stable patients other approaches to the pancreas such as laparoscopy can be considered.7–10 However, the safety and efficacy of laparoscopic distal pancreatectomy compared with open resection in the setting of Grade III pancreatic injuries have not been reported.


The Children’s Mercy Hospital, Kansas City, Missouri. University of Texas Health Science Center at Houston and Children’s Memorial Hermann Hospital, Houston, Texas. 3 Children’s National Medical Center, Washington, D.C. 4 Children’s Hospital of Los Angeles, Los Angeles, California. 5 Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. 6 Children’s Healthcare of Atlanta at Egleston, Atlanta, Georgia. 2




Grade II injuries in this series. Pancreatic injury grade was classified according to the American Association for the Surgery of Trauma.6 Those patients who underwent laparoscopic distal pancreatic resection were compared with those who underwent an open procedure. All outcome variables were compared using two-tailed Student’s t test for continuous datasets and chi-squared test for nominal datasets with Yates’s correction where appropriate. All results are expressed as mean – SD values. A value of Pp.05 was considered significant. Results Twenty-one patients meeting inclusion criteria were identified. Of these, 7 underwent laparoscopic distal pancreatectomy, and 14 underwent open procedures. The overall mean age was 8.6 – 4.7 years, and 67% of patients were male. There was no difference in patient age, body mass index, or presence of associated injuries between the two groups (Table 1). All patients in the laparoscopic group had been diagnosed with a traumatic pancreatic injury during their initial trauma evaluation, whereas 3 of the patients in the open group had a delay of 1.5 – 0.7 days from injury to the diagnosis of a pancreatic injury. Two patients in the open group were intubated upon admission, whereas no patients in the laparoscopic group were intubated. Additionally, more patients in the open group had stays in the pediatric intensive care unit, but this was not statistically significant because of the small samples (50% versus 17%, P = .3) (Table 1). No laparoscopic cases were performed prior to 2006; however, open procedures were performed throughout the study period. All patients underwent imaging with computed tomography (CT). CT was diagnostic for a pancreatic injury in all patients, and pancreatic transection was identified in 79% in the entire population and 85% in the laparoscopic group compared with 75% in the open group. Only 1 patient with uncertainty about the status of the main pancreatic duct underwent additional imaging with a magnetic resonance cholangiopancreatogram, which was diagnostic for duct disruption. Those patients without clear main pancreatic duct injury on CT who did not have additional imaging studies underwent exploration because of a high index of suspicion.

Table 1. Preoperative Characteristics of Patients Comparing the Open and Laparoscopic Distal Pancreatectomy Groups Characteristic Age (years) Sex (male) Body mass index (kg/m2) Associated injuries Splenic injury Preoperative blood transfusion Time from injury to diagnosis (days) Intubated PICU stay

Laparoscopic Open group group (n = 7) (n = 14) P value 9.1 – 4.2 57% 16.2 – 2.0 43% 14% 17%

8.4 – 5.0 71% 18.5 – 3.9 43% 21% 8%

.7 .6 .1 1.0 1.0 1.0

0.4 – 0.5

1.1 – 1.4


0% 17%

14% 50%

.5 .3

PICU, pediatric intensive care unit.

Table 2. Intraoperative Characteristics of Patients Comparing the Open and Laparoscopic Distal Pancreatectomy Groups Laparoscopic Open group group (n = 7) (n = 14) P value

Characteristic Time to operation (days) Operative time (minutes) Stapled pancreatic stump Oversewn pancreatic stump Fibrin seal on the pancreatic stump Splenectomy Intraoperative transfusion Drain

1.1 – 1.2 218 – 101 57% 57% 43%

1.0 – 1.5 195 – 111 40% 70% 0%

.8 .7 .6 .6 .4

0% 17% 100%

21% 31% 100%

.5 1.0 1.0

All patients were found to have a transected main pancreatic duct at the time of operation and were classified as Grade III. There was no difference in the mean time from injury to pancreatic resection. Intraoperatively, there was no difference between operative time, need for transfusion, management of the pancreatic stump, or need for splenectomy (Table 2). Postoperative complications were also not different between the two groups with a 57% morbidity rate in the laparoscopic group and 21% morbidity in the open group (P = .2). All postoperative complications are listed in Table 3. Postoperative outcomes are listed in Table 4. Although return to full feeds was 2.5 days sooner on average in the laparoscopic group, this was not significant. Likewise, length of stay was 3 days shorter in the laparoscopic group. but the difference was not significant either. One patient in the laparoscopic group was readmitted compared with 2 in the open group. When total hospital days were compared including these readmissions there was no difference. Discussion Traumatic pancreatic injuries are uncommon, and the need for pancreatic resection due to a transected pancreas is even less common as represented by our series of 21 patients from six high-volume Level One pediatric trauma centers over a 10-year period. However, the pediatric surgeon will encounter these injuries, and establishing evidence-based treatment algorithms is paramount in optimizing patient care. Certainly, the trauma patient with hemodynamic compromise from uncontrolled intra-abdominal hemorrhage or a perforated hollow viscous yields few options for the surgeon. In the setting of an isolated pancreatic injury or for the patient with a

Table 3. Postoperative Complications of Patients Between the Open and Laparoscopic Distal Pancreatectomy Groups Complication Pancreatic leak Postoperative ileus Wound infection Pleural effusion Total

Laparoscopic group (n = 7)

Open group (n = 14)

2 1 1 0 4

0 1 1 1 3

LAPAROSCOPIC VERSUS OPEN DISTAL PANCREATECTOMY Table 4. Postoperative Characteristics of Patients Comparing the Open and Laparoscopic Distal Pancreatectomy Groups Characteristic

Laparoscopic group (n = 7)

Open group (n = 14) P value

Total parenteral 50% 29% nutrition Time to initial feeds 4.3 – 2.2 4.1 – 2.8 (days) Time to full feeds (days) 7.6 – 4.1 10.2 – 9.5 Duration of 9.6 – 5.0 12.4 – 6.4 hospitalization (days) Total days in hospital 12.6 – 8.0 12.9 – 7.0 Median (range) length 50 (10–140) 42 (13–2.154) of follow-up (days)

.6 .9 .4 .3 .9 .2


leaks could have been missed.21 Pancreatic surgeons often site the lack of adhesion formation as a reason for higher pancreatic leaks in laparoscopic pancreatic resections compared with open procedures; however, the published data do not support higher pancreatic leak rates with laparoscopy.22,23 Furthermore, those series involved patients undergoing resection for pancreatic neoplasms and not patients with traumatic transection where a localized inflammatory process has been initiated that would incite adhesion formation regardless of an open or laparoscopic approach. We believe that for the stable patient with pancreatic transection, laparoscopic distal pancreatectomy is a safe and feasible approach. Clearly, there is no disadvantage to offering laparoscopic pancreatic resection. How this impacts operative versus nonoperative management has yet to be determined. Disclosure Statement

pancreatic injury and other injuries that do not require celiotomy, more options are at the surgeon’s disposal. It is widely accepted that pancreatic resection should be advocated for Grade III pancreatic injuries.11–16 However, successful nonoperative management has been described for pancreatic transections that involve the main pancreatic duct, oftentimes trading pancreatic fistula associated with up to 21% of pancreatic resections with pseudocyst formation associated with 10%–73% in cases of nonoperative management.2,3,16–19 However, the largest pediatric series comparing nonoperative with operative management of Grade II and Grade III pancreatic injuries did not clearly distinguish between those patients who were operated on for an isolated pancreatic transection and those who underwent laparotomy for other indications.20 Certainly, less invasive approaches to the management of traumatic pancreatic injuries are favorable as long as they benefit patients by imparting lower complication rates and fewer and shorter hospitalizations. How the application of a minimally invasive approach to pancreatic resections fits into the treatment strategies of traumatic pancreatic injuries has not been described. We believe that in order to provide a more even comparison of nonoperative versus operative management, the role of laparoscopic pancreatic resections must be explored first. In the series presented here we did not appreciate any differences between laparoscopic distal pancreatectomy compared with open distal pancreatectomy for Grade III pancreatic injuries. Granted, the size of this series is modest, and we may not have had enough patients to demonstrate differences statistically. Nonetheless, it is apparent that laparoscopy does not carry any additional risk while posing potential advantages in recovery with more experience and greater numbers. Moreover, the operative time was not different between the groups nor the need to perform a splenectomy. In fact, no splenectomies were performed in the laparoscopic group. The Achilles heel for any type of partial pancreatic resection has always been pancreatic leak and/or fistula. We did observe that the pancreatic leak rate was higher in the laparoscopic group even though there was no difference in how the pancreatic stump was managed. There were no pancreatic leaks reported in the open group. However, we did not use a standardized definition of pancreatic leak because the retrospective nature of the study prohibited that, and so subclinical

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Address correspondence to: Shawn D. St. Peter, MD The Children’s Mercy Hospital 2401 Gillham Road Kansas City, MO 64108 E-mail: [email protected]

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