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Laparoscopic distal pancreatectomy employing radical en bloc procedure for adenocarcinoma: Technical details and outcomes Yoshikuni Kawaguchi, MD,a,b David Fuks, MD, PhD,a,c Takeo Nomi, MD, PhD,a Hughes Levard, MD,a and Brice Gayet, MD, PhD,a,c Paris, France, and Tokyo, Japan

Background. Although laparoscopic distal pancreatectomy (LDP) has increasingly gained popularity, there are only a few reports mentioning application and outcomes of LDP for adenocarcinoma of the body and tail of the pancreas. The aim of our study is to demonstrate technical details of LDP employing radical en bloc procedure (en bloc LDP) and to evaluate the short- and long-term outcomes of en bloc LDP applied for adenocarcinoma. Methods. We evaluated 23 consecutive patients who underwent LDP for adenocarcinoma in the body or tail of the pancreas. Our concepts of en bloc LDP for adenocarcinoma comprise 3 principles: en bloc removal of retroperitoneal structures, lymph node (LN) dissection, and preservation of the spleen. Results. En bloc LDP without splenectomy was performed in 17 patients (74%) and en bloc LDP with splenectomy was in 6 patients (26%). Mean ± standard deviation operation time was 203 ± 54 minutes, and mean estimated blood loss was 208 ± 264 mL. Conversion to open distal pancreatectomy was required in 1 patient (4%) owing to the severe adhesions around the pancreas. The overall morbidity rate following en bloc LDP was 47% (n = 11), and the rate of pancreatic fistula was 39% (n = 9). There were no 30-day or in-hospital mortalities. Mean tumor size was 32 ± 12 mm, and mean number of harvested LNs was 19.8 ± 9.3. No patient had positive margins on final histologic diagnosis. The 1-, 3-, and 5-year overall survival rates were 67%, 49%, and 33%, respectively. Conclusion. En bloc LDP can be applied safely by the surgeon with advanced experience in minimally invasive surgery with satisfactory short- and long-term outcomes, supporting further application of LDP for adenocarcinoma with advances in operative techniques and technological innovations. (Surgery 2015;j:j-j.) From the Department of Digestive Diseases,a Institut Mutualiste Montsouris, Universite Paris Descartes, Paris, France; the Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery,b Graduate School of Medicine, University of Tokyo, Tokyo, Japan; and the Institut des Syste mes Intelligents et Robotique (ISIR),c Universite Pierre et Marie Curie, Paris, France

IN THE LAST 2 DECADES, pancreatic laparoscopic surgery has been recognized and performed through the world, including diagnostic laparoscopy for cancer staging, enucleation, distal pancreatectomy, and pancreaticoduodenectomy.1-7 Among these procedures, laparoscopic distal pancreatectomy Funding/Support: None. Conflicts of interest: The authors have no conflicts of interest. Accepted for publication December 23, 2014. Reprint requests: Brice Gayet, MD, PhD, Department of Digestive Diseases, Institut Mutualiste Montsouris, Universite Paris Descartes, 42 boulevard Jourdan, 75014 Paris, France. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.12.015

(LDP) for the treatment of benign or lowmalignancy tumors is increasingly gaining popularity, presumably because of its comparative technical simplicity8 and improved perioperative outcomes compared with open distal pancreatectomy (ODP).9,10 However, application of LDP for adenocarcinoma may be a debatable issue. There are few existing reports mentioning long-term outcomes in patients undergoing LDP for adenocarcinoma of the body and tail of the pancreas11,12 and, to the best of our knowledge, no published report have shown long-term outcomes of LDP for adenocarcinoma based on surgical standardization in a single center. In the author’s institution, LDP for adenocarcinoma has been performed with the standardized procedure, comprising en bloc removal of SURGERY 1

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retroperitoneal structures, lymph node (LN) dissection, and preservation of the spleen (en bloc LDP). The aim of this study was to demonstrate technical details for en bloc LDP with a video and to evaluate its short- and long-term outcomes applied for adenocarcinoma of the body and tail of the pancreas by comparing the results in previous reports of ODP and LDP for adenocarcinoma. MATERIALS AND METHODS Patients. From 2002 to 2013, 130 consecutive patients underwent distal pancreatectomy, including 115 patients undergoing LDP and 15 patients undergoing ODP by a single surgeon (BG) at the Institut Mutualiste Montsouris, Universit e Paris Descartes. Of these, 23 patients underwent LDP for adenocarcinoma in the body or tail of the pancreas. Before 2002, indications for a laparoscopic approach were limited mainly to benign diseases. A laparoscopic approach has been selected routinely for both benign and malignant indications since 2002, except for limited cases, including large tumors adjacent to other organs or involving superior mesenteric vessels. The clinical records of these patients were retrospectively reviewed. All operations were performed after obtaining informed consent from each patient. Operative procedures. Our concepts of LDP employing radical en bloc procedure (en bloc LDP) for adenocarcinoma comprised 3 principles. First, the Gerota fascia is removed and, as a consequence, the left kidney, the left renal vein, and the left adrenal vessels/gland are exposed to ensure negative tangential margin,13,14 in other words, corresponding with the plane of the posterior radical antegrade modular pancreatosplenectomy14 without the excision of the left adrenal gland. Second, lymphadenectomy of the common hepatic artery and the celiac trunk are performed in addition to dissection of the left side of the neuroplexus of the superior mesenteric artery. Last, the spleen is preserved with ligation of the splenic vessels (the so-called Warshaw technique15) if the pancreatic adenocarcinoma is not directly invading the spleen nor the left gastroepiploic pedicle, based on the preoperative imaging studies or the intraoperative findings. Patients are placed in the low lithotomy position, with the legs spread apart and bent at the knees (French position). Four ports are usually placed. Two 10-mm ports are placed on the umbilicus and higher on the midclavicular line below the costal arch for the camera and the

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ultrasonography device. In addition, two 5-mm trocars are placed at the left upper quadrant. After the greater omentum is divided from left to right and the transverse mesocolon is separated from the Gerota fascia, the anterior branch of the splenic artery/vein at the pancreatic tail are ligated and divided, preserving the left gastroepiploic artery/vein. The inferior edge of the pancreas is identified and the dissection is started far from the pancreas by opening the Gerota fascia to ensure circumferential margins behind the pancreas. Mobilization of the body and tail of the pancreas en bloc with Gerota fascia is performed while exposing the surface of the left kidney. Subsequently, the plane of the dissection proceeds laterally to medially, following the left renal vein; the left adrenal gland and the inferior mesenteric vein are exposed. The pancreas is retracted superiorly and anteriorly, and the dissection behind the neck of the pancreas is continued from caudad to cephalad to expose the junction between the splenic vein and the superior mesenteric vein. Lymphadenectomy is performed, preserving the left gastric vein and skeletonizing the common hepatic artery and the celiac trunk. Pancreatic parenchymal transection is performed using ultrasonic laparoscopic coagulation shears, after which the splenic artery and vein are ligated and divided at their root or ending. The left side of the neuroplexus on the superior mesenteric artery is dissected and lymphadenectomy around the left adrenal gland is performed (the left adrenal gland is dissected and resected only in case of invasion by tumors). After these procedures, the common hepatic artery, the lower part of the left gastric pedicle, the celiac trunk, the left side of the superior mesenteric artery, the left adrenal gland and its vessels, the left renal vein, and the left kidney are all exposed. The dissection is continued close to the stomach, along the superior edge of the pancreas from medial to lateral, cutting the posterior gastric artery when it exists. As the distal pancreas is reached, the posterior branch of the splenic artery/vein are ligated and divided, preserving the left gastroepiploic pedicle. The en bloc LDP is finished by the section of the tissues between the pancreas and the splenic hilum. The last step is to oversew the stump of the main pancreatic duct and the stump of the pancreas with a nonabsorbable monofilament suture. The resected specimen is placed in a plastic bag and retrieved unfragmentedly through a supra pubic small incision or an enlarged umbilical port. In principle, a drain is placed in the operative bed (Supplementary Video 1).

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Outcome measures. Complications were graded using Clavian-Dindo classification.16 Pancreatic fistula were classified using the definition by the International Study Group of Pancreatic Fistula.17 Splenic infarction was defined as partial regions or the whole spleen with decreased or no enhancement, which were identified by CT with contrast material. Patients were discharged from the hospital when postoperative complications including pancreatic fistula were controlled, when there was no drainage tube and no further need for intravenous analgesics, and when they had recovered from impaired activities of daily living. As for follow-up evaluation, blood tumor marker measurements (carcinoembryonic antigen and carbohydrate antigen 19-9), contrast-enhanced CT, and/or MRI were performed every 3 months after discharge. Statistical analysis. Categorical variables are expressed in numerical figures (%), and were compared between groups using the Fisher exact test or the Chi-square test as appropriate. Continuous variables were expressed as mean values ± standard deviation, and were compared between groups using the Student t test. Survival was measured from the time of surgery, and overall and recurrence-free survival curves were constructed using the Kaplan–Meier method. When calculating recurrence-free survival, data on patients who died without recurrence were censored. Consequently, recurrence-free survival was equal to the time to recurrence in this study. Statistical analysis was conducted using JMP software (version 9.0.2; SAS Institute Inc., Cary, NC). RESULTS Patients. Among 23 patients, there were 12 males and 11 females; their mean age was 65 ± 11.4 years, mean body mass index was 25.9 ± 4.4 kg/m2, and median American Society of Anesthesiologists classification was 2 (range, 1– 3). Thirteen patients (57%) had comorbidity and 2 patients (8.5%) underwent preoperative neoadjuvant chemotherapy. Intraoperative outcomes. Intraoperative factors are summarized in Table I. En bloc LDP without splenectomy was performed in 17 patients (74%) and en bloc LDP with splenectomy in patients 6 (26%). Mean operation time was 203 ± 54 minutes (range, 90–280). Mean estimated blood loss (EBL) was 208 ± 264 mL (range, 10–1,100). Conversion to ODP was required in 1 patient (4%) in whom severe adhesions around the pancreas with the greater omentum, the transverse mesocolon, and the jejunum was observed. There

Table I. Intraoperative outcomes Variables

Value, n (%) or mean ± SD

Type of resection En bloc LDP 17 without splenectomy* En bloc LDP 6 with splenectomy Transection using 3 stapler Placement of drain 18 Operative time (min) 203 ± 54 EBL (mL) 208 ± 264 Transfusion Conversion to 1 laparotomy

(74%) (26%) (13%) (78%) (range, 90–280) (range, 10–1,100) 0 (4%)y

*With ligation of splenic the vessels.15 yOwing to the severe adhesions around the pancreas with the greater omentum, the transverse mesocolon, and the intestine. EBL, Estimated blood loss; LDP, laparoscopic distal pancreatectomy.

Table II. Postoperative outcomes Variables Morbidity Clavian-Dindo* Grade I or II Grade III or IVy Pancreatic fistulaz Overall Grade A Grade B Grade C Operative procedures En bloc LDP without splenectomy (n = 17) En bloc LDP with splenectomy (n = 6) Transection method Ultrasonic laparoscopic coagulation shears (n = 20) Stapler devices (n = 3) Splenic infarctionx Mortality Duration of postoperative stay (d)

Value, n (%) or mean ± SD 7 (30%) 4 (17%)y 9 5 3 1

(39%) (22%) (13%) (4%)

6 (35%) 3 (50%)

7 (35%)

1 (33%) 3 (18%)x 0 17 ± 8 (range, 7–34)

*Clavien PA, Barkun J, de Oliveira ML, et al. Ann Surg 2009; 250:187-96. yPercutaneous drainage for fluid collection (n = 2) and endoscopic retrograde cholangiopancreatography for pancreatic fistula (n = 2). zInternational Study Group of Pancreatic Fistula Classification. xApplied for en bloc LDP without splenectomy.

were no differences between patients undergoing en bloc LDP without splenectomy and those undergoing en bloc LDP with splenectomy in operative time (198 ± 59 vs 223 ± 29 minutes; P = .45) and EBL (184 ± 65 vs 275 ± 109 mL; P = .49).

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Postoperative and histologic outcomes. Postoperative factors are shown in Table II. The overall morbidity rate following en bloc LDP was 47% (n = 11), and the rate of pancreatic fistula was 39% (n = 9). There was no difference in overall morbidity between patients undergoing en bloc LDP without splenectomy and those undergoing en bloc LDP with splenectomy (48% [n = 8] vs 50% [n = 3]; P = .90). There were no 30-day or in-hospital mortalities. Postoperative complications categorized as grade IIIa (Clavien–Dindo classification16) developed in 4 patients (21%); percutaneous drainage for fluid collection (n = 2) and endoscopic retrograde cholangiopancreatography for pancreatic fistula (n = 2). Of the 17 patients who underwent en bloc LDP without splenectomy, 3 patients (18%) were diagnosed with partial splenic infarction and presented symptomatic fever, whereas 12 patients (71%) presented no splenic infarction and 2 patients (11%) did not undergo postoperative imaging studies owing to an uneventful postoperative course. Patients with splenic infarction were treated conservatively and did not require reoperation for splenectomy. Mean duration of hospital stay was 17 ± 8 days and was not different between patients undergoing en bloc LDP without splenectomy and those undergoing en bloc LDP with splenectomy (18 ± 8 vs 15 ± 7 days; P = .36). Mean tumor size was 32 ± 12 mm, and mean number of harvested LNs was 19.8 ± 9.3; 14 patients (61%) had $1 positive LN. Eighteen tumors were ductal adenocarcinoma, whereas 4 tumors were associated with intraductal papillary mucinous adenocarcinoma and 1 tumor was diagnosed as mucinous cystadenocarcinoma. No patient had positive margins on final histologic diagnosis. The Union for International Cancer classification included 2 stage IA (8.5%), 5 stage IB (22%), 2 stage IIA (8.5%), 13 stage IIB (57%), and 1 stage III (4%; Table III). Long-term outcome. Mean and median followup periods were 19 and 10 months (range, 8–61), respectively. The 1-, 3-, and 5-year overall survival rates were 67%, 49% and 33%, respectively (Figure). Among them, 2 patients have been confirmed to live >5 years. Eight patients were diagnosed with recurrence. The site of recurrence is known in 6 patients and unknown in 2. One patient had both local recurrence and liver metastases, 3 had liver metastases, and 2 had peritoneal recurrence. Mean and median time to recurrence was 14 and 6 months (range, 1–23), respectively. The 1-, 3-, and 5-year recurrence-free survival rates were 62%, 44% and 44%, respectively.

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Table III. Histologic outcomes Variables

Value, n (%) or mean ± SD

Histologic factors Tumor size (mm) 32 ± 12 Final histologic diagnosis Ductal adenocarcinoma 18 Adenocarcinoma 4 associated with IPMC Mucinous 1 cystadenocarcinoma Differentiation Well 11 Others 12 Harvested LNs 19.8 ± 9.3 Metastatic LNs 2.0 ± 4.1 Surgical margin positive Stage of tumor (UICC classification) pT1 3 pT2 8 pT3 11 pT4 1 pN0 9 pN1 14 p Stage IA 2 IB 5 IIA 2 IIB 13 III 1

(range, 10–60) (79%) (17%) (4%)

(48%) (52%) (range, 5–40) (range, 0–20) 0 (13%) (35%) (48%) (4%) (39%) (61%) (8.5%) (22%) (8.5%) (57%) (4%)

IPMC, Intraductal papillary mucinous carcinoma; LN, lymph node; UICC, Union for International Cancer Control classification, 7th edition.

Figure. Overall survival for patients who underwent en bloc laparoscopic distal pancreatectomy (LDP).

DISCUSSION In the present study, LDP for adenocarcinoma employing a radical en bloc procedure showed satisfactory surgical and long-term outcomes (5year survival, 33%), suggesting that this approach

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22 (26x) 16k NS 16 26 NS 13 NS NS 18 25 27 23 29 19 79 NS 50 45 55 NS 45 33 43 44 *Approximately 20% according to the overall survival curve. yIncluding robotic surgery. zIncluding 12 patients who underwent Appleby procedures. xExcluding 12 patients who underwent Appleby procedures. kSeventy patients matched for 23 patients who underwent LDP. LDP, Laparoscopic distal pancreatectomy; ODP, open distal pancreatectomy; OR, operating time; NS, not stated.

0 1 0 NS 0 NS NS 24 NS 83 NS 790 707 NS 744 NS 231 329 NS 244 66 66 68 66 65 2006 88z 2010 189 2010 73 2010 94 2012 47

72/28 42/58 60/40 46/54 43/57

NS NS* NS 33 14 16 13 28 15 14 8 20 23 26 0 0 38 NS 20 61 NS 35 24 32 NS 0 NS 0 NS NS NS 47 720 422 510 208 310 238 422 203 46/54 52/48 80/20 52/48 63 65 60 65 13 23 5y 23 2007 2010 2010 2014

LDP Fernandez-Cruz, et al11 Kooby, et al12 Kang, et al20 Current study ODP Shimada, et al Kooby et al12 Yamamoto, et al21 Redmond, et al22 Mitchem, et al14

No. of Mean Sex, male/ Mean OR Mean blood Morbidity Mortality Mean tumor N1 R1 Mean no. of Median 5-Year cases age (y) female (%) time (min)* loss (mL)* (%) (%) size (mm) (%) (%) harvested LN survival (mo) survival (%) Year Source

Table IV. Short- and long-term outcomes in literature of LDP and ODP for adenocarcinoma

is acceptable for treatment of selected patients with adenocarcinoma by advanced surgeons with experience in minimally invasive surgery. This is the largest experiences with LDP for adenocarcinoma that has been performed with the standardized procedure in a single center. En bloc LDP is based on the concepts to provide as much margin-negative R0 resection as possible and adequate lymphadenectomy, as pointed in the previous reports for achieving the improved oncological outcome.13,18,19 Our surgical outcomes are satisfactory compared with recent reports (Table IV); the R0 resection rate and the number of harvested LN in our series are comparable with previous experiences of LDP9,11,20 as well as those of ODP.9,13,14,21,22 A 0% R0 resection is one of the satisfying results in our series as the treatment for adenocarcinoma, presumably owing to en bloc removal of retroperitoneal structures, although a relatively small mean tumor size (32 ± 12 mm) should be noted in comparison with previous reports comprising patients who underwent open operations9,14,22 (Table IV). The decreased EBL in our study was led by the advantages in laparoscopic approach which comprise the potential benefit of the intra-abdominal pressure caused by the pneumoperitoneum23 and precision hemostasis through the magnified view.24,25 In fact, mean EBL found to be lower in our series than in the study by Strasberg et al,14 which proposed radical antegrade modular pancreatosplenectomy (208 ± 264 vs 744 ± 570 mL). The concepts of en bloc LDP were comparable to theirs, except that ours basically remove the Gerota fascia and preserve the spleen with ligation of the splenic vessels. Other short- and long-term outcomes were similar between the 2 series, although surgeon and historical bias need to be considered. Our techniques emphasize negative tangential margin by removing the Gerota fascia and splenic preservation with ligation of splenic vessels while sparing lymphadenectomy in the splenic hilum. By contrast, commonly performed distal pancreatectomy with splenectomy does not remove the Gerota fascia, but dissects LNs in the splenic hilum. Splenic preservation with the ligation of splenic vessels may be a debatable issue with respect to splenic hilar lymphadenectomy and the complications related to splenic ischemia or infarction ranging from 11 to 29%.26-28 However, there have been no data in the literature to support a routine splenectomy in adenocarcinoma of the pancreas. Kim et al29 proposed the reevaluation of the role of routine splenectomy for distal pancreatectomy based on a low incidence of splenic hilar LN metastasis.29,30

19 NS* 30 NS* 36

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Moreover, preservation of the spleen was reported to avoid the risk of postosplenectomy sepsis31,32 and improve the oncological outcomes for gastric, colorectal, and pancreatic cancers.33-35 These results, therefore, support our procedures in en bloc LDP. In fact, there has been neither death related to postoperative splenic hilar LN metastasis nor reoperation for splenectomy in our study. The long duration of hospital (17 ± 8 days) stay seems rather paradoxical in our study evaluating patients who received the potential advantage of the less invasiveness provided by laparoscopic approach as reported in laparoscopic hepatectomy.36,37 Mitchem et al14 reported that the mean duration of stay of the patients who underwent ODP with radical antegrade modular pancreatosplenectomy was 11 ± 7 days14 and Kooby et al12 reported that of patients who underwent LDP for ductal adenocarcinoma was 7 ± 3 days. However, difficulty in gathering meaningful information regarding duration of stay needs to be noted, because of various criteria in determining hospital discharge among different countries.38 Particularly, patients in France desire to stay in hospitals as long as possible because their admission charges are well supported by the national insurance system. The prolonged stay in our study was led by the factors such as the relatively high rate of postoperative morbidity (47%) and pancreatic fistula (39%), most likely owing to employing the radical procedure, as reported in the open approach.14 Optimal techniques to reduce incidences of pancreatic fistula during LDP need to be addressed, although those were similar, irrespective of preservation of spleen or transection method in small cohort of our study. Long-term outcomes of the patients who underwent en bloc LDP in our study (median survival, 28 months; 5-year survival, 33%) seem comparative to the previous reports, which have showed a median survival in the range of 13 and 26 months9,11,13,14,20-22 and a 5-year survival in the range of 19–36%.12-14,21 There is only 1 report with long term-outcomes of LDP for adenocarcinoma, which showed no difference in survival between LDP and ODP based on a multiinstitutional series.12 However, to the best of our knowledge, this is the first report showing the long-term outcomes of LDP that has been performed for adenocarcinoma with the surgical standardization. The main limitations of our study are its retrospective nature, the limited number of cases including 3 histologic subtypes, and short median follow-up time. A randomized, controlled trial with a sufficient number of cases and

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sufficient duration of follow-up is needed to overcome these drawbacks, although it may not be achieved because of limited cases with resectable adenocarcinoma of the body and tail of the pancreas, as noted in previous reports.12,14 In conclusion, en bloc LDP can be safely applied to patients with adenocarcinoma of the body and tail of the pancreas. The short- and longterm outcome of the patients who underwent en bloc LDP are satisfactory compared with previous reports, supporting further application of LDP for adenocarcinoma with advances in operative techniques and technological innovations. The authors thank Dr. Beatrice Ulloa-Severino helping with acquisition of data and providing useful insights. SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.surg.2014.12.015. REFERENCES 1. Gagner M, Pomp A. Laparoscopic pancreatic resection: is it worthwhile? J Gastrointest Surg 1997;1:20-5. 2. Underwood RA, Soper NJ. Current status of laparoscopic surgery of the pancreas. J Hepatobiliary Pancreat Surg 1999;6:154-64. 3. Ammori BJ. Pancreatic surgery in the laparoscopic era. JOP 2003;4:187-92. 4. Ammori BJ. Applications of minimally invasive surgery in the management of inflammatory and neoplastic diseases of the pancreas. J Hepatobiliary Pancreat Surg 2004;11: 107-11. 5. Gumbs AA, Gayet B. The laparoscopic duodenopancreatectomy: the posterior approach. Surg Endosc 2008;22: 539-40. 6. Karaliotas C, Sgourakis G. Laparoscopic versus open enucleation for solitary insulinoma in the body and tail of the pancreas. J Gastrointest Surg 2009;13:1869. 7. Kendrick ML, Sclabas GM. Major venous resection during total laparoscopic pancreaticoduodenectomy. HPB (Oxford) 2011;13:454-8. 8. Kneuertz PJ, Patel SH, Chu CK, Fisher SB, Maithel SK, Sarmiento JM, et al. Laparoscopic distal pancreatectomy: trends and lessons learned through an 11-year experience. J Am Coll Surg 2012;215:167-76. 9. Kooby DA, Gillespie T, Bentrem D, Nakeeb A, Schmidt MC, Merchant NB, et al. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008;248:438-46. 10. Vijan SS, Ahmed KA, Harmsen WS, Que FG, Reid-Lombardo KM, Nagorney DM, et al. Laparoscopic vs open distal pancreatectomy: a single-institution comparative study. Arch Surg 2010;145:616-21. 11. Fernandez-Cruz L, Cosa R, Blanco L, Levi S, Lopez-Boado MA, Navarro S. Curative laparoscopic resection for pancreatic neoplasms: a critical analysis from a single institution. J Gastrointest Surg 2007;11:1607-21. 12. Kooby DA, Hawkins WG, Schmidt CM, Weber SM, Bentrem DJ, Gillespie TW, et al. A multicenter analysis of distal

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Laparoscopic distal pancreatectomy employing radical en bloc procedure for adenocarcinoma: Technical details and outcomes.

Although laparoscopic distal pancreatectomy (LDP) has increasingly gained popularity, there are only a few reports mentioning application and outcomes...
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