Minireview on laparoscopic hepatobiliary and pancreatic surgery文档格式.docx
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Minireview on laparoscopic hepatobiliary and pancreatic surgery文档格式.docx
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StephenWChung
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Abstract
Thefirstlaparoscopiccholecystectomywasperformedinthemid-1980s.Sincethen,laparoscopicsurgeryhascontinuedtogainprominenceinnumerousfields,andhas,insomefields,replacedopensurgeryasthepreferredoperativetechnique.Theroleoflaparoscopyinstagingcanceriscontroversial,withregardstogallbladdercarcinoma,pancreaticcarcinoma,hepatocellularcarcinomaandlivermetastasisfromcolorectalcarcinoma,laparoscopyinconjunctionwithintraoperativeultrasoundhaspreventednontherapeuticoperations,andfacilitatedtherapeuticoperations.Laparoscopiccholecystectomyisthepreferredoptioninthemanagementofgallbladderdisease.Meta-analysescomparinglaparoscopictoopendistalpancreatectomyshowthatlaparoscopicpancreatectomyissafeandefficaciousinthemanagementofbenignandmalignantdisease,andhavebetterpatientoutcomes.Apancreaticoduodenectomyisamorecomplexoperationandthelaparoscopictechniqueisnotfeasibleforthisoperationatthistime.Roboticassistedpancreaticoduodenectomyhasbeentriedwithlimitedsuccessatthistime,butwithcontinuingadvancementinthisfield,thisoperationwouldeventuallybefeasible.Liverresectionremainstobethebestmanagementforhepatocellularcarcinoma,cholangiocarcinomaandcolorectallivermetastases.Systematicreviewsandmeta-analyseshaveshownthatlaparoscopicliverresectionsresultinpatientswithequalorlessbloodlossandshorterhospitalstays,ascomparedtoopensurgery.Withimprovingequipmentandtechnique,andtheincorporationofroboticsurgery,minimallyinvasiveliverresectionoperativetimeswillimproveandbemoreefficacious.Withtheincorporationofroboticsurgeryintohepatobiliarysurgery,donorhepatectomieshavealsobeencompletedwithsuccess.Themanagementofbenignandmalignantdiseasewithminimallyinvasivehepatobiliaryandpancreaticsurgeryissafeandefficacious.
Keywords:
Laparoscopic,Liverresection,Pancreatectomy,Cholecystectomy,Pancreaticoduodenectomy,Cancer,Tumour
Coretip:
Thisminireviewpresentstheimportanceoflaparoscopyinfacilitatinglaparoscopichepatobiliaryandpancreaticsurgery,andtheefficacyandsafetyoflaparoscopichepatobiliaryandpancreaticsurgery.Laparoscopicsurgeryisthepreferredmanagementofbenignandmalignantdiseaseforselectedpatients.Theadvantagesincludeconfirmationofdiagnosis,preventionofnontherapeuticoperations,decreasedhospitalstayandbetterpost-operativefunctionandcosmeticoutcome.Meta-analysesdemonstratethatlaparoscopicliverresections,pancreatectomiesandcholecystectomiesareefficacious.Thereislessbloodloss;
thehospitalstaysareshorterwithlaparoscopicsurgeries.Thereisnocompromisetotheoncologicalresectionmarginswhencomparedtoopensurgery.Laparoscopicsurgeryissafeandefficaciousinthemanagementofbenignandmalignanthepatobiliaryandpancreaticdiseases.
LAPAROSCOPY
Pancreas
Pancreaticcancercarriesapoorprognosiswitha5-yearrelativesurvivalrateof5.8%(SEERStatFactSheets:
Pancreas).Atleast80%ofpatientswithpancreaticcancerpresentwitheitherlocallyadvancedormetastaticdiseaseandarenotresectableatthetimeofdiagnosis[1].Completesurgicalresectionistheonlycurativetreatmentwithpotentialforlong-termsurvival[2].Accuratestagingisessentialintreatmentplanningandindeterminingappropriatemanagementofpatientswithpancreaticcancerbyselectingpatientswhocanbenefitfromsurgeryandidentifyingpatientswithnon-resectablediseasetoavoidnon-therapeuticlaparotomies[3].
Uptoonethirdofpatientswithhigh-qualitypreoperativeimagingwillhaveradiographicallyoccultdistantmetastaticorlocallyunresectablediseaseatthetimeofstaginglaparoscopy[2].Inpancreaticadenocarcinoma,laparoscopicstagingallowsfortheidentificationofsub-radiographicmetastaticdiseasein10%-15%ofpatientswithradiographicallyresectablecancer,andinapproximately30%ofpatientswithlocallyadvanceddisease[2].Staginglaparoscopyisassociatedwithdecreasedlengthofstay,reducedpostoperativepain,andahigherlikelihoodofreceivingsystemictherapycomparedtolaparotomywithoutsignificantlyincreasingoperativetime[2,4,5].
However,advancesinimagingtechnologyhavedecreasedtheyieldofstaginglaparoscopyovertime.Multiphase,multidetectorthin-slidecomputedtomography(CT)scansproducehigh-resolutionimagesprovidingdetailsaboutlocalvascularinvolvementanddistantmetastaticdisease[6].Endoscopicultrasound(EUS)isalsobeingincreasinglyusedtoimagethetumoranditsrelationshiptoadjacentstructuresandtoobtainbiopsiesofpancreaticlesionsandregionallymphnodes[6].AstudybyWhiteetal[7]evaluated1045patientsfromaprospectivedatabasewhounderwentstaginglaparoscopyforradiographicallyresectablepancreaticandperipancreatictumorsovera10yearperiodfrom1995to2005toexaminetheyieldofstaginglaparoscopy.Thestudyreportsthattheyieldoflaparoscopyhasdiminishedoverthe10yearperiodandexceeds10%onlyforpatientswithpancreaticadenocarcinoma[7].
Theuseofstaginglaparoscopyinpancreaticcancerremainscontroversial.Whetherstaginglaparoscopyshouldbeusedroutinelyoronlyinselectedcasesisamatterofdebate.Studiessuggestthatstaginglaparoscopyshouldbereservedforselectedcaseswheretheyieldislikelytojustifytheadditionalproceduralriskandcost.Studiesrecommendthatpatientswithtumourslargerthanthreecentimeters,tumoursintheneck,bodyortail,orpatientswithequivocalCTscanfindingsformetastaticdisease,maybenefitfromlaparoscopy[8,9].
Gallbladder
Gallbladdercarcinomaisararemalignancyandtheincidenceofintraorpost-operativediagnosisisbetween0.2%to2.8%.Duetoanincreaseinlaparoscopiccholecystectomies,incidentalfindingofgallbladdercancerhasalsoincreased[10].Thebestmanagementforgallbladdercarcinomaissurgicalresection:
aresectionwithmalignancynegativemargins(R0resection).InaT3toT4gallbladdercarcinoma,anR0resectionwouldresultina26%5-yearsurvivalrate,ascomparedtoa9%survivalrateinalessthanR0resection[11].Ifgallbladdercarcinomaissuspectedonimaging,theroleoflaparoscopicstagingforgallbladdercarcinomahasbeenshowntobesensitiveindetectingunresectablediseaseanddiseasedlesions.Theevidencesupportsthatstaginglaparoscopydoesnotimpactonoverallsurvival,andpreventspatientswithunresectablediseasefromanontherapeuticlaparotomy[12].Theuseofalaparoscopicultrasoundasanadjuncttolaparoscopyfurtherincreasestheaccuracyandspecificityofdiagnosisandstaging[13].AretrospectivereviewcompletedbyFerrareseetal[10],furtherre-enforcestheroleofmeticulousperi-operativediagnosis,intraoperativestagingandcholecystectomyinpreventingunnecessarylaparotomies,andidentifythepatientswhowillbenefitfromaresection.
Liver
Thissectiondiscussestheimportanceoflaparoscopyandtheroleoflaparoscopicultrasoundinconfirmingthediagnosisandplanningtheliverresectionorablation.
Laparoscopyisparticularlyusefulincaseswhenresectabilityisuncertainpriortosurgery.Jarnaginetal[4]examinedthebenefitsofpreoperativelaparoscopyinpatientswithcolorectalmetastasis(CRM),andidentifiedfivefactorsthatmaypredictthepresenceofoccultintrahepaticorextrahepaticdiseasethatmaymakepatientsunresectable.Thesefactorsarethepresenceofmorethanonelivertumor,positivenodestatusofprimarytumor,disease-freeintervaloflessthan1year,presenceoflivertumorthatislargerthan5cmandcarcinoembryonicantigen(CEA)levelgreaterthan200ng/mL.Ifanypatienthasmorethan2ofthesefactors,42%ofthetimewouldhaveoccultdiseaserenderingthemunresectable.
Accuratestagingofintrahepaticcholangiocarcinoma(IHC)isjustasimportant,ascompleteresectionoffersthebestlong-termsurvival.Patientswithlargelesions,positivenodesormultifocalIHCdonotbenefitfromresection[14].Anadjuncttostaginglaparoscopyisthelaparoscopicultrasound.Thelaparoscopicultrasoundissensitiveindetectingparenchymalliverlesions[15].Becauseofthis,theroutineuseoflaparoscopywithconcomitantlaparoscopicultrasoundcansavepatientsfromunnecessarylaparotomy[4,14].
Ifapatientwithhepatocellularcarcinoma(HCC)isnoteligibleforliverresection,thereareothermultimodalapproachestomanageHCCprimarilyorinconjunctionwithliverresectionorabridgetotransplantation:
localablationwithalcoholorradiofrequency,chemoembolization,andradioembolization[16].Thelaparoscopicultrasoundisusefulinthesecasesasitallowspreciseexaminationoftheselesionsandthesurroundingvessels,andfacilitatesultrasound-guidedablationofHCC.
PANCREAS
Thissectionwillfocusontheroleoflaparoscopicdistalpancreatectomyandpancreaticoduodenectomy,andthealternativestomanagementofunresectablebiliaryandduodenalobstructivecancers.
Distalpancreatectomy
Reportofthefirstlaparoscopicdistalpancreatectomy(LDP)wasin1996[17,18].Subsequentstudieshavedemonstratedthatlaparoscopicdistalpancreatectomyisassafeasopendistalpancreatectomy[19].Itisnowincreasinglyperformedasthebetteralternateapproachfordistalpancreatectomyinselectedpatients.Twometa-analysesfurthersupportthatlaparoscopicdistalpancreatectomyisassociatedwithasignificantlylowerbloodlossandreducedle
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