ª 2013 by the American College of Surgeons

Published by Elsevier Inc.

LETTERS

LaparoscopicPancreaticoduodenectomies:A Word of Caution

Sebastian G de la Fuente, MD

Orlando, FL

Drs Asburn and Stauffer1 should be congratulated fortheir recent article comparing open with laparoscopicpancreaticoduodenectomies for cancer. This retrospectivestudy serves to emphasize the extraordinary complexity ofthe procedure despite the approach chosen. Most hepato-pancreatobiliary surgeons would agree that the concept ofminimally invasive is misleading in pancreatic surgerybecause there is little “minimally invasive” when oper-ating on the pancreas. Rather, the technique should beregarded as “minimal access surgery;” the findings ofsimilar morbidity and mortality between open and lapa-roscopic cases in this study confirm this.I fully agree with the authors with their statement, “a few

number of days that the minimally invasive approachreduces hospital stay might not be sufficient to justify itsuse.” Furthermore, having the patient in the operatingroom under general anesthetics for a mean of 9 hours(541 � 88 minutes) is difficult to justify in times of finan-cial difficulties. Are these operative times only associatedwith the steep learning curve of the procedure or are theyinheritable with resection of the head of the pancreas?Have the authors noticed any significant reductions inoperative time with experience? Were all laparoscopicprocedures performed by 2 attending surgeons? And ifso, how do we train the next generation of residents andfellows if their participation in these cases is limited?In regards to what the authors called “oncologic

outcomes,” a common variable reported in studies address-ing minimally invasive oncologic operations is the numberof lymph nodes harvested during surgery. It is clear thatpatients with lymph node metastases have a worse survivalthan do patients with node-negative disease;2 however, therole of extended lymphadenectomy in pancreatic canceris less understood. A recent multicenter randomizedcontrolled trial from Japan failed to show survival benefitsin patients undergoing extended lymphadenectomies forpancreatic cancer.3 Among all findings, however, themost intriguing one is the timing of initiation of adjuvantchemotherapy after resection. One would expect that fasterrecoveries and re-establishment of preoperative function-ality would have expedited initiation of adjuvant therapy.

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Last, who do the authors believe should be performingthese operations? Laparoscopic surgeons who are versed inminimally invasive techniques of the upper abdomen, orhepatopancreatobiliary surgeons and surgical oncologistswho are generally more familiar with the disease processand systemic therapies?

REFERENCES

1. Asbun HJ, Stauffer JA. Laparoscopic vs open pancreaticoduode-nectomy: overall outcomes and severity of complications usingthe accordion severity grading system. J Am Coll Surg 2012;215:810e819.

2. Pawlik TM, Gleisner AL, Cameron JL, et al. Prognostic rele-vance of lymph node ratio following pancreaticoduodenectomyfor pancreatic cancer. Surgery 2007;141:610e618.

3. Nimura Y, Nagino M, Takao S, et al. Standard versus extendedlymphadenectomy in radical pancreatoduodenectomy for ductaladenocarcinoma of the head of the pancreas: long-term resultsof a Japanese multicenter randomized controlled trial. J Hepato-biliary-pancreatic Sci 2012;19:230e241.

Disclosure Information: Nothing to disclose.

Reply

Horacio J Asbun, MD, FACS, John A Stauffer, MD

Jacksonville, FL

Wewould like to thankDrde laFuente for his interest in ourmanuscript and his desire to learn more details about ourseries of laparoscopic pancreaticoduodenectomies (LPD).We agree with the statement that “minimal access

surgery” is a better term when used referring to the lapa-roscopic approach to complex operations, as in pancreassurgery. Unfortunately, the “minimally invasive” term isthe one more commonly used for any laparoscopic proce-dure, even for other complex cases such as esophagec-tomy, bariatrics, etc.Regarding Dr de la Fuentes’ questions about operative

times, the operative times for the laparoscopic approachwere significantly longer than for the open approach.We believe that more than a traditional “learning curve,”they reflect an attempt to change the surgical steps ofa previously established technique in order to improvethe procedure. Dr Asbun, the senior author, has morethan 10 years experience in performing LPD and thetechnique used in the first years consisted mainly ofduplicating the steps of an open approach with minimalvariance. Once it was realized that the benefits ofdecreasing the hospital stay a couple of days or avoiding

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http://dx.doi.org/10.1016/j.jamcollsurg.2013.02.016