International Journal of Surgery xxx (2015) 1e4
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Laparoscopic perspectives for distal biliary obstruction Stefano Berti a, Alessia Ferrarese b, *, Cosimo Feleppa a, Elisa Francone a, Valter Martino b, Claudio Bianchi a, Emilio Falco a a
Department of Surgery, POLL-ASL 5, La Spezia, Italy University of Turin, Department of Oncology, School of Medicine, “San Luigi Gonzaga” Teaching Hospital, Section of General Surgery, Orbassano, Turin, Italy
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 March 2015 Received in revised form 24 March 2015 Accepted 10 April 2015 Available online xxx
Background: In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. Methods: We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. Results: In the sixyears period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. Conclusions: Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Keywords: Laparoscopy Distal biliary obstruction Pancreas Pancreas cancer
1. Background In patients affected by distal biliary obstruction not suitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain [1]. Biliary decompression can be obtained either by conservative procedures (endoscopic stenting
* Corresponding author. Regione Gonzole n 10, 10040, Orbassano, Torino, Italy. E-mail address: [email protected] (A. Ferrarese).
and percutaneous treatment) or by surgery, respectively associated with reduced earlier and later complications [1]. Moreover pancreatic surgery for cancer is demanding and requires experience and skills [2e11]. Because of the weakening of conventional open surgical approach, for a long time this option has been reserved only to low surgical risk patients with longer survival perspectives and given the recent introduction of long term patency stents, conservative procedures have been advocated as the best choice in chasing decompressive purposes [12,13]. As innovations in stents materials and applications are evolving, at the same time skills and expertise in mini-invasive surgery are in progressive expansion.
http://dx.doi.org/10.1016/j.ijsu.2015.04.092 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Berti, et al., Laparoscopic perspectives for distal biliary obstruction, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.04.092
2
S. Berti et al. / International Journal of Surgery xxx (2015) 1e4
Data on laparoscopic approach in biliary diversion are lacking but nowadays it is possible to propose the same long-term benefit achievable with open surgery, adding all the advantages arising from a mini-invasive approach, with less impact on morbidity and improved quality of life. The aim of this paper is to present our six-years preliminary experience and results in approaching palliative biliary diversions by laparoscopy. 2. Methods We analyzed data regarding patients affected by distal biliary neoplastic obstruction admitted to our Unit between December 2008 and November 2014. The main reason for Emergency Unit Department referral was jaundice. Other symptoms reported were lack of appetite and weight loss. Disease assessment was obtained by submitting every patient to full-blood tests, including tumor markers, abdomen ultrasound evaluation followed by abdominal computed tomography scan and endoscopic ultrasound evaluation if needed. In planning a tailored approach case by case, once assessed each patient was discussed at a multidisciplinar team meeting constituted by surgeons, radiologists, gastroenterologists, oncologists and pathologists. Variables considered were demographics, anesthesiological risk assessment (according to the American Society of Anesthesiologist) and the chance to achieve an R0 resection at surgery. Considering these parameters, patients evaluated unsuitable for pancreatoduodenectomy but with acceptable performance status were scheduled to receive laparoscopic palliation. Depending on disease location, epatico-jejunal bypass or choledochoduodenostomy have been proposed. Hepaticojejunostomies have been realized between common bile duct, at least 1 cm from its bifurcation, and the first jejunal loop, at about 30 cm from Treitz ligament. In choledochoduodenostomies biliary tract has been anastomosed with third duodenal portion. For both procedures, the posterior row of the anastomoses has been constructed with an absorbable 3-0 running suture, while the anterior row with 5e7 interrupted 3-0 absorbable stitches. Intraoperative and post-operative 30-days results have been prospectively collected. We also analyzed outcomes on survival and quality of life. 3. Results From December 2008 to November 2014, 12 patients (8 female, 4 male), mean age 77 years old (range 69e86 years), affected by distal biliary neoplastic obstruction were evaluated unsuitable for pancreatoduodenectomy and therefore submitted to laparoscopic palliative bypass (Table 1). Underlying disease was distal choledochal carcinoma in four cases, advanced periampullary carcinoma in one case and pancreatic head cancer in seven cases. In total we performed 10 hepatico-jejunal bypasses and 2 choledochoduodenostomy. All the procedures were completely accomplished by laparoscopy and no conversion to open surgery was encountered in this series. Globally, mean operative time was 85 min (range 60e110 min), mean blood loss was 75 ml (range Table 1 Perioperative variables. n Vascular invasion Peritoneal localization Comorbidity Mean age Metastatic disease
5 2 11 77 years 4
30e115 ml). Mean hospitalization was 4.5 days (range 3e7 days). According to Clavien Dindo Classification one class II and one class IIIb complications occurred. Median survival has been 9.2 months (range 4e17 months) (Table 2). 4. Discussion Nowadays mini-invasive surgery has gained more and more popularity being an accepted surgical approach for several abdominal procedures. In respect of pancreatic diseases, laparoscopic surgery, is widely accepted and performed for pancreatic tail neoplasms but its application in pancreatic head resections still remains a matter of debate [1]. Several factors are responsible for such deference: first of all the connections of pancreatic head to several important anatomical structures, further on recognized complexity of surgical procedures in this field, technically demanding also for highly skilled laparoscopic surgeons. Since the first technical description of laparoscopic pancreaticoduodenectomy performed by Gagner and Pomp in 1994 [1], only few cases and case series have been published, and firm data on safety, feasibility and advantages of mini-invasive approach compared with conventional open procedures couldn't confirm it is worthwhile [2,3]. Moreover literature lacks of short and long term data. Especially if combined with intraoperative ultrasound, laparoscopy revealed instead high capability in improving diagnostic work-up of pancreatic head cancer [13,14], being efficient in detecting peritoneal or liver metastases disregarded at computed tomography scan [6,15]. Another matter of debate is the rule of mini-invasive surgery as palliative proposal to treat bile and digestive obstruction in inoperable pancreatic cancer or advanced choledochal disease. Up to 15e20% of patients with local advanced tumours present with digestive obstruction and for years standard surgical treatment has been an open gastrojejunal anastomosis [16]. Several reports on laparoscopic palliation have been recently described, but only few of these compared open to laparoscopic gastrojejunal anastomosis [17,18]. In a retrospective cohort evaluation Guzman reported notable differences in terms of hospital stay between conventional and laparoscopic approaches, even if, given the small amount of patient in this series, any statistical evidence has been recorded [19,20]. In a randomized trial, Navarra reported improved outcomes in terms of postoperative ileus and complications for the laparoscopic group, but again the small number of patients enrolled doesn't allow to draw firm conclusions [19]. Regarding laparoscopic biliodigestive derivations, one of the most representative case series has been conducted on 26 patients affected by either malignant and benign biliary obstruction. Mean hospital stay reported was 12.6 days (±11.5), post operative complication rate was up to 23% [20]. With a mean hospital stay of 4.5 days and a postoperative complication rate around 16.6%, our experience is in contrast with these data. Considering poor early postoperative outcomes, surgical bypasses are actually recommended for patients with longer life expectancy, proposing instead endoscopic or percutaneous stenting
Table 2 Operative variables. Mean operative time Blood loss Mean hospital stay Complication Median survival
85 min 75 ml 4,5 days 2 9,2 months
Please cite this article in press as: S. Berti, et al., Laparoscopic perspectives for distal biliary obstruction, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.04.092
S. Berti et al. / International Journal of Surgery xxx (2015) 1e4
to those with shorter survival perspectives [21,22]. Several types of stents are available [23,24]. Lasting up to six months, metal stents are characterized by longer term patency if compared with plastic stents, but in patients with longer life expectancy tumour overgrowth within mesh interstices can produce a new biliary obstruction. To solve this inconvenience, covered metal stents have been developed but again these new stents are not free from possible complications, including cholecystitis and migration [24]. As a consequence surgical biliary bypass must be considered for those patients who are likely to survive more than 6 months [25]. Moreover laparoscopic approach can be safely used to relieve from chronic neoplastic pain, by injecting a 20 ml 50% ethanol solution in the celiac plexus under direct vision obtaining neurolytic celiac plexus block [26,27].
5. Conclusions Although the number of cases included in this series is restricted, our experience suggests that in selected patients laparoscopic biliary bypass could be a valid option in treating distal biliary obstruction. Combining long-term lasting outcomes reachable in open surgery with improved short-term outcomes granted by conservative procedures, laparoscopic approach could result in low perioperative morbidity, effective long-lasting palliation of symptoms and improved quality of life.
Ethical approval This is a retrospective study based only on the analyses of recorded data and then no Ethical Approval was necessary.
Sources of funding All Authors have no source of funding.
Author contribution Stefano Berti: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Alessia Ferrarese Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Cosimo Feleppa: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Elisa Francone: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Valter Martino: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Claudio Bianchi: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Emilio Falco: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data.
3
Conflicts of interest The Authors have no conflict of interest or any financial support. References [1] M. Gagner, A. Pomp, Laparoscopic pylorus-preserving pancreaticoduodenectomy, Surg. Endosc. 8 (5) (1994) 408e410. [2] M. Gagner, A. Pomp, Laparoscopic pancreatic resection: is it worthwhile? J. Gastrointest. Surg. 1 (1) (1997) 20e26. [3] S.A. Cuschieri, J.J. Jakimowicz, Laparoscopic pancreatic resections, Semin. Laparosc. Surg. 5 (3) (1998) 168e179. [4] D.A. Kooby, T. Gillespie, D. Bentrem, et al., Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches, Ann. Surg. 248 (3) (2008) 438e446. [5] D.A. Kooby, W.G. Hawkins, C.M. Schmidt, et al., A multicenter analysis of distal pancreatectomy for adenocarcinoma: is laparoscopic resection appropriate? J. Am. Coll. Surg. 210 (5) (2010 May) 779e785. [6] A.L. Warshaw, Laparoscopy in the staging and planning of therapy for pancreatic cancer, Am. J. Surg. 151 (1) (1986) 76e80. [7] K.C. Conlon, E. Dougherty, D.S. Klimstra, D.G. Coit, A.D. Turnbull, M.F. Brennan, The value of minimal access surgery in the staging of patients with potentially resectable peripancreatic malignancy, Ann. Surg. 223 (2) (1996 Feb) 134e140. [8] Lu DS, S. Vedantham, R.M. Krasny, B. Kadell, W.L. Berger, H.A. Reber, Twophase helical CT for pancreatic tumors: pancreatic versus hepatic phase enhancement of tumor, pancreas, and vascular structures, Radiology 199 (3) (1996 Jun) 697e701. [9] A. Surace, A. Ferrarese, R. Benvenga, S. Marola, J. Cumbo, M. Rivelli, V. Martino, M. Solej, M. Nano, ACTH-secreting neuroendocrine pancreatic tumor: a case report, Int. J. Surg. 12 (Suppl. 1) (2014) S222eS224. [10] A. Ferrarese, A. Borello, V. Gentile, M. Bindi, Y. Ferrara, M. Solej, V. Martino, M. Nano, Meso-pancreatectomy for pancreatic neuroendocrine tumor, Int. J. Surg. 12 (1) (2014) S123eS125. [11] Pisters PW, J.E. Lee, J.N. Vauthey, C. Charnsangavej, D.B. Evans, Laparoscopy in the staging of pancreatic cancer, Br. J. Surg. 88 (3) (2001 Mar) 325e337. [12] R.C. Liu, L.W. Traverso, Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography, Surg. Endosc. 19 (5) (2005 May) 638e642. [13] L.E. Hann, K.C. Conlon, E.C. Dougherty, S. Hilton, A.M. Bach, M.F. Brennan, Laparoscopic sonography of peripancreatic tumors: preliminary experience, Am. J. Roentgenol. 169 (5) (1997 Nov) 1257e1262. [14] A. Pietrabissa, D. Caramella, G. Di Candio, A. Carobbi, U. Boggi, G. Rossi, F. Mosca, Laparoscopy and laparoscopic ultrasonography for staging pancreatic cancer: critical appraisal, World J. Surg. 23 (10) (1999 Oct) 998e1002. [15] D. Hariharan, V.A. Constantinides, F.E. Froeling, et al., The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of pancreaticobiliary cancerseA meta-analysis, Eur. J. Surg. Oncol. 36 (10) (2010 Oct) 941e948. [16] T. Kuroki, Y. Tajima, A. Kitasato, T. Adachi, T. Kanematsu, Pancreas-hanging maneuver in laparoscopic pancreaticoduodenectomy: a new technique for the safe resection of the pancreas head, Surg. Endosc. 24 (7) (2010 Jul) 1781e1783. [17] E.A. Guzman, A. Dagis, L. Bening, et al., Laparoscopic gastrojejunostomy in patients with obstruction of the gastric outlet secondary to advanced malignancies, Am. Surg. 75 (2) (2009) 129e132. [18] R. Bergamaschi, R. Marvik, J.E. Thoresen, et al., Open versus laparoscopic gastrojejunostomy for palliation in advanced pancreatic cancer, Surg. Laparosc. Endosc. 8 (2) (1998) 92e96. [19] G. Navarra, C. Musolino, A. Venneri, M.L. De Marco, M.P. Bartolotta, Alliative antecolic isoperistaltic gastrojejunostomy: a randomized controlled trial comparing open and laparoscopic approaches, Surg. Endosc. 20 (12) (2006 Dec) 1831e1834. [20] Tang CN, W.T. Siu, J.P. Ha, et al., Laparoscopic biliary bypassea single centre experience, Hepatogastroenterology 54 (74) (2007 Mar) 503e507. [21] R.S. Date, A.K. Siriwardena, Current status of laparoscopic biliary bypass in the management of non-resectable peri-ampullary cancer, Pancreatology 5 (4e5) (2005) 325e329. [22] J. Ly, G. O'Grady, A. Mittal, L. Plank, J.A. Windsor, A systematic review of methods to palliate malignant gastric outlet obstruction, Surg. Endosc. 24 (2) (2010 Feb) 290e297. [23] S.M. Jeurnink, C.H. van Eijck, E.W. Steyerberg, E.J. Kuipers, P.D. Siersema, Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review, BMC Gastroenterol. 7 (2007 Jun 8) 18. [24] T. Tsuyuguchi, T. Takada, M. Miyazaki, et al., Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinomas. Japanese association of biliary surgery; Japanese society of hepato-biliary-pancreatic surgery; Japan society of clinical oncology, J. Hepatobiliary Pancreat. Surg. 15 (1) (2008) 69e73. [25] R.P. van den Bosch, G.P. van der Schelling, J.H. Klinkenbijl, et al., Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas, Ann. Surg. 219 (1) (1994 Jan)
Please cite this article in press as: S. Berti, et al., Laparoscopic perspectives for distal biliary obstruction, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.04.092
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18e24. [26] A. Dicitore, M. Caraglia, G. Gaudenzi, C. Arra, G. Vitale, Type I interferonmediated pathway interacts with peroxisome proliferator activated receptor-g (PPAR-g): at the cross-road of pancreatic cancer cell proliferation, Biochim. Biophy. Acta e Rev. Cancer 1845 (1) (2014) 42e52, http://dx.doi.org/10.1016/
j.bbcan.2013.11.003. [27] V.E. Strong, K.M. Dalal, V.T. Malhotra, et al., Initial report of laparoscopic celiac plexus block for pain relief in patients with unresectable pancreatic cancer, J. Am. Coll. Surg. 203 (1) (2006) 129e131.
Please cite this article in press as: S. Berti, et al., Laparoscopic perspectives for distal biliary obstruction, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.04.092
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Laparoscopic perspectives for distal biliary obstruction Stefano Berti a, Alessia Ferrarese b, *, Cosimo Feleppa a, Elisa Francone a, Valter Martino b, Claudio Bianchi a, Emilio Falco a a
Department of Surgery, POLL-ASL 5, La Spezia, Italy University of Turin, Department of Oncology, School of Medicine, “San Luigi Gonzaga” Teaching Hospital, Section of General Surgery, Orbassano, Turin, Italy
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 March 2015 Received in revised form 24 March 2015 Accepted 10 April 2015 Available online xxx
Background: In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. Methods: We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. Results: In the sixyears period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. Conclusions: Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Keywords: Laparoscopy Distal biliary obstruction Pancreas Pancreas cancer
1. Background In patients affected by distal biliary obstruction not suitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain [1]. Biliary decompression can be obtained either by conservative procedures (endoscopic stenting
* Corresponding author. Regione Gonzole n 10, 10040, Orbassano, Torino, Italy. E-mail address: [email protected] (A. Ferrarese).
and percutaneous treatment) or by surgery, respectively associated with reduced earlier and later complications [1]. Moreover pancreatic surgery for cancer is demanding and requires experience and skills [2e11]. Because of the weakening of conventional open surgical approach, for a long time this option has been reserved only to low surgical risk patients with longer survival perspectives and given the recent introduction of long term patency stents, conservative procedures have been advocated as the best choice in chasing decompressive purposes [12,13]. As innovations in stents materials and applications are evolving, at the same time skills and expertise in mini-invasive surgery are in progressive expansion.
http://dx.doi.org/10.1016/j.ijsu.2015.04.092 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Berti, et al., Laparoscopic perspectives for distal biliary obstruction, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.04.092
2
S. Berti et al. / International Journal of Surgery xxx (2015) 1e4
Data on laparoscopic approach in biliary diversion are lacking but nowadays it is possible to propose the same long-term benefit achievable with open surgery, adding all the advantages arising from a mini-invasive approach, with less impact on morbidity and improved quality of life. The aim of this paper is to present our six-years preliminary experience and results in approaching palliative biliary diversions by laparoscopy. 2. Methods We analyzed data regarding patients affected by distal biliary neoplastic obstruction admitted to our Unit between December 2008 and November 2014. The main reason for Emergency Unit Department referral was jaundice. Other symptoms reported were lack of appetite and weight loss. Disease assessment was obtained by submitting every patient to full-blood tests, including tumor markers, abdomen ultrasound evaluation followed by abdominal computed tomography scan and endoscopic ultrasound evaluation if needed. In planning a tailored approach case by case, once assessed each patient was discussed at a multidisciplinar team meeting constituted by surgeons, radiologists, gastroenterologists, oncologists and pathologists. Variables considered were demographics, anesthesiological risk assessment (according to the American Society of Anesthesiologist) and the chance to achieve an R0 resection at surgery. Considering these parameters, patients evaluated unsuitable for pancreatoduodenectomy but with acceptable performance status were scheduled to receive laparoscopic palliation. Depending on disease location, epatico-jejunal bypass or choledochoduodenostomy have been proposed. Hepaticojejunostomies have been realized between common bile duct, at least 1 cm from its bifurcation, and the first jejunal loop, at about 30 cm from Treitz ligament. In choledochoduodenostomies biliary tract has been anastomosed with third duodenal portion. For both procedures, the posterior row of the anastomoses has been constructed with an absorbable 3-0 running suture, while the anterior row with 5e7 interrupted 3-0 absorbable stitches. Intraoperative and post-operative 30-days results have been prospectively collected. We also analyzed outcomes on survival and quality of life. 3. Results From December 2008 to November 2014, 12 patients (8 female, 4 male), mean age 77 years old (range 69e86 years), affected by distal biliary neoplastic obstruction were evaluated unsuitable for pancreatoduodenectomy and therefore submitted to laparoscopic palliative bypass (Table 1). Underlying disease was distal choledochal carcinoma in four cases, advanced periampullary carcinoma in one case and pancreatic head cancer in seven cases. In total we performed 10 hepatico-jejunal bypasses and 2 choledochoduodenostomy. All the procedures were completely accomplished by laparoscopy and no conversion to open surgery was encountered in this series. Globally, mean operative time was 85 min (range 60e110 min), mean blood loss was 75 ml (range Table 1 Perioperative variables. n Vascular invasion Peritoneal localization Comorbidity Mean age Metastatic disease
5 2 11 77 years 4
30e115 ml). Mean hospitalization was 4.5 days (range 3e7 days). According to Clavien Dindo Classification one class II and one class IIIb complications occurred. Median survival has been 9.2 months (range 4e17 months) (Table 2). 4. Discussion Nowadays mini-invasive surgery has gained more and more popularity being an accepted surgical approach for several abdominal procedures. In respect of pancreatic diseases, laparoscopic surgery, is widely accepted and performed for pancreatic tail neoplasms but its application in pancreatic head resections still remains a matter of debate [1]. Several factors are responsible for such deference: first of all the connections of pancreatic head to several important anatomical structures, further on recognized complexity of surgical procedures in this field, technically demanding also for highly skilled laparoscopic surgeons. Since the first technical description of laparoscopic pancreaticoduodenectomy performed by Gagner and Pomp in 1994 [1], only few cases and case series have been published, and firm data on safety, feasibility and advantages of mini-invasive approach compared with conventional open procedures couldn't confirm it is worthwhile [2,3]. Moreover literature lacks of short and long term data. Especially if combined with intraoperative ultrasound, laparoscopy revealed instead high capability in improving diagnostic work-up of pancreatic head cancer [13,14], being efficient in detecting peritoneal or liver metastases disregarded at computed tomography scan [6,15]. Another matter of debate is the rule of mini-invasive surgery as palliative proposal to treat bile and digestive obstruction in inoperable pancreatic cancer or advanced choledochal disease. Up to 15e20% of patients with local advanced tumours present with digestive obstruction and for years standard surgical treatment has been an open gastrojejunal anastomosis [16]. Several reports on laparoscopic palliation have been recently described, but only few of these compared open to laparoscopic gastrojejunal anastomosis [17,18]. In a retrospective cohort evaluation Guzman reported notable differences in terms of hospital stay between conventional and laparoscopic approaches, even if, given the small amount of patient in this series, any statistical evidence has been recorded [19,20]. In a randomized trial, Navarra reported improved outcomes in terms of postoperative ileus and complications for the laparoscopic group, but again the small number of patients enrolled doesn't allow to draw firm conclusions [19]. Regarding laparoscopic biliodigestive derivations, one of the most representative case series has been conducted on 26 patients affected by either malignant and benign biliary obstruction. Mean hospital stay reported was 12.6 days (±11.5), post operative complication rate was up to 23% [20]. With a mean hospital stay of 4.5 days and a postoperative complication rate around 16.6%, our experience is in contrast with these data. Considering poor early postoperative outcomes, surgical bypasses are actually recommended for patients with longer life expectancy, proposing instead endoscopic or percutaneous stenting
Table 2 Operative variables. Mean operative time Blood loss Mean hospital stay Complication Median survival
85 min 75 ml 4,5 days 2 9,2 months
Please cite this article in press as: S. Berti, et al., Laparoscopic perspectives for distal biliary obstruction, International Journal of Surgery (2015), http://dx.doi.org/10.1016/j.ijsu.2015.04.092
S. Berti et al. / International Journal of Surgery xxx (2015) 1e4
to those with shorter survival perspectives [21,22]. Several types of stents are available [23,24]. Lasting up to six months, metal stents are characterized by longer term patency if compared with plastic stents, but in patients with longer life expectancy tumour overgrowth within mesh interstices can produce a new biliary obstruction. To solve this inconvenience, covered metal stents have been developed but again these new stents are not free from possible complications, including cholecystitis and migration [24]. As a consequence surgical biliary bypass must be considered for those patients who are likely to survive more than 6 months [25]. Moreover laparoscopic approach can be safely used to relieve from chronic neoplastic pain, by injecting a 20 ml 50% ethanol solution in the celiac plexus under direct vision obtaining neurolytic celiac plexus block [26,27].
5. Conclusions Although the number of cases included in this series is restricted, our experience suggests that in selected patients laparoscopic biliary bypass could be a valid option in treating distal biliary obstruction. Combining long-term lasting outcomes reachable in open surgery with improved short-term outcomes granted by conservative procedures, laparoscopic approach could result in low perioperative morbidity, effective long-lasting palliation of symptoms and improved quality of life.
Ethical approval This is a retrospective study based only on the analyses of recorded data and then no Ethical Approval was necessary.
Sources of funding All Authors have no source of funding.
Author contribution Stefano Berti: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Alessia Ferrarese Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Cosimo Feleppa: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Elisa Francone: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Valter Martino: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Claudio Bianchi: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Emilio Falco: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data.
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Conflicts of interest The Authors have no conflict of interest or any financial support. References [1] M. Gagner, A. Pomp, Laparoscopic pylorus-preserving pancreaticoduodenectomy, Surg. Endosc. 8 (5) (1994) 408e410. [2] M. Gagner, A. Pomp, Laparoscopic pancreatic resection: is it worthwhile? J. Gastrointest. Surg. 1 (1) (1997) 20e26. [3] S.A. Cuschieri, J.J. Jakimowicz, Laparoscopic pancreatic resections, Semin. Laparosc. Surg. 5 (3) (1998) 168e179. [4] D.A. Kooby, T. Gillespie, D. Bentrem, et al., Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches, Ann. Surg. 248 (3) (2008) 438e446. [5] D.A. Kooby, W.G. Hawkins, C.M. Schmidt, et al., A multicenter analysis of distal pancreatectomy for adenocarcinoma: is laparoscopic resection appropriate? J. Am. Coll. Surg. 210 (5) (2010 May) 779e785. [6] A.L. Warshaw, Laparoscopy in the staging and planning of therapy for pancreatic cancer, Am. J. Surg. 151 (1) (1986) 76e80. [7] K.C. Conlon, E. Dougherty, D.S. 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