The article type: Original Article
Does tumor size influence the outcome of laparoscopic distal pancreatectomy?
Airazat M. Kazaryan, MD, PhD1,2,3,4, Ingeborg Solberg5, Davit L. Aghayan, MD2,4,6, Mushegh A. Sahakyan, MD, PhD4,7, Ola Reiertsen, MD, PhD6, Vasiliy I. Semikov, MD, PhD3,
Alexander M. Shulutko, MD, PhD3, Bjørn Edwin, MD, PhD2,6,8
1 Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway
2 Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
3 Department of Faculty Surgery N2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
4 Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
5 Medical Faculty, the University of Oslo, Oslo, Norway
6 Institute of Clinical Medicine, University of Oslo, Oslo, Norway
7 Department of General and Laparoscopic Surgery, Central Clinical Military Hospital, Yerevan, Armenia
8 Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
Keywords: Laparoscopy, pancreatectomy, tumour size, outcomes
Corresponding author:
Department of Gastrointestinal Surgery Østfold Hospital Trust
Grålum, Norway
Email: [email protected]
Presented in part at the 27th International Congress of the European Association for Endoscopic Surgery, 12 - 15 June 2019 in Sevilla, Spain
Abstract
Background: Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned.
Methods: Patients who underwent LDP for pancreatic solitary tumors in 1997-2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5cm(group I);
from 3.5cm to 7.0cm (group II), and ≥7cm(group III). Perioperative data were compared.
Results: 218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5mm (p<0.001). Nine procedures (2.1 %) were converted including 1(0.5%), 5(3.4%) and 3(5.2 %) in the groups I, II and III (p=0.036). Median operative time was longer in the group III compared with the groups I and II – 195 vs 158 and 159 min(p=0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R=0.103; P=0.035) and no correlation between tumor size and blood loss(R=0.075; P=0.125). Hospital stay was 5 days, similar in all groups. Perioperative mortality was 0.2%. Postoperative morbidity was similar – 38.5, 32 and 34% in the group I, II and III.
Conclusion: LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.
Introduction
Laparoscopic distal pancreatectomy (LDP) was first described by Gagner in 1992 (1). Since then, laparoscopic techniques have been widely developed and are now a standard alternative to the open approach in the treatment of pancreatic neoplasms (2-9). LDP has also been proven to have advantages in terms of reduced blood loss and in shorter hospital stay reflecting a better postoperative recovery compared to open distal pancreatectomy (ODP). Moreover, LDP has shown a lower risk of overall postoperative complications and wound infection, without a substantial increase of operative time in earlier series and shortening of operative time in recent series (2, 3, 10-16).
However, there has been some skepticism regarding the use of LDP for large pancreatic lesions (›7 cm) as these patients were underrepresented in LDP cohort when compared with ODP (17). Furthermore, the recent worldwide survey among pancreatic surgeons demonstrated that almost one-third considered large tumor size a contraindication for minimally-invasive distal pancreatectomy (18).
The aim of this study was to evaluate and compare the results of LDP for tumors of different sizes and define whether tumor size has influence on its surgical outcomes.
Materials and methods Patients:
Four hundred ninety-four patients underwent LDP with a curative intent between April 1997 and February 2017 at the Oslo University Hospital, Rikshospitalet. This study represents retrospective analysis of a prospectively collected patient database, following the institutional review board approval.
In the same period very few cases were referred to open distal pancreatectomy due to a need for vascular reconstruction. There were also few cases with vascular resections done laparoscopically (only resection of the portal vein wall).
Seventy-two patients were excluded due to the following reasons: missing data on tumor size (n=45), several lesions in the pancreas (n=12) and surgery for non-tumorous pancreatic lesions (n=15).The patients were divided into three groups according to size of tumor: patients with tumors <3.5 cm (group I); with tumors from 3.5 cm to 7.0 cm (group II), and with tumors 7 cm (group III). The core perioperative parameters of the three groups were compared.
Somatostatin analogues were not used for prevention of pancreatic fistula (PF).
Procedural techniques
The patient was placed in a modified supine position with the left side raised, as previously described by Edwin et al (8). The procedures were planned ahead of surgery, but the surgeons based their approach on intraoperative laparoscopic and ultrasonographic findings. The first 12-mm trocar was inserted at the umbilicus followed by the placement of three 5-12-mm trocars; one in the midline between the xiphoid process and the umbilicus, one lateral to the left rectus muscle at the level of the umbilicus and one subcostally in the left medioclavicular line.
Distal pancreatectomy accompanied by splenectomy was a standard applied technique, although spleen- preserving procedures were performed in some cases. Spleen preservation was only considered in cases of non-malignant pancreatic lesions. It was because of our believe that splenic preservation might compromise oncologic outcomes in this group of patients. Tumor size itself was not a factor to influence on decision to attempt splenic preservation. In such cases we used Kamura vessel preserving technique, though Warshaw technique was applied in few cases too. Bipoar coagulator LigaSure® (Medtronic, Minneapolis, MN, USA) was the main dissection instrument. Intraoperative laparoscopic ultrasonography was applied in majority of the cases. The splenic vessels were transected separately using EndoGIA linear stapling device (Medtronic, Minneapolis, MN, USA). The pancreas was divided by an EndoGIA and resected specimens were placed in an EndoCatch (Medtronic, Minneapolis, MN, USA) and retrieved through an extension of umbilical trocar incision. At the end of the procedure, a drain was placed near the pancreatic stump which was covered by TachoSil® or Surgiflo®. The drains were routinely removed on 2nd to 5th postoperative days, unless there was significant drain fluid and / or increased amylase concentration. In those cases, the patients were discharged home with drain.
Outcome parameters and definitions
The following intraoperative factors were compared in the two groups: operative time, blood loss, need for blood transfusion, conversion and intraoperative unfavorable incidents. Postoperatively, the following were compared: postoperative hospital stay, postoperative complications, reoperations, readmissions and 30 days mortality. Histologic types of tumors were registered in all groups. Tumor size was defined as the largest diameter described in the pathology report. Microscopically positive resection margins (R1) were defined in accordance with the seventh edition of the American Joint Committee on Cancer Staging Manual (i.e., if tumor cells were detected at the surface of pancreatic
transection and/or tangential margins) (19). R0 status was compared in the subgroup of patients with pancreatic adenocarcinoma.
Intraoperative unfavorable incidents were assessed using the Oslo classification of intraoperative unfavorable incidents based on the Satava approach to grade surgical error, adapted for distal pancreatectomy (20, 21). The postoperative complications were rated according to the Accordion Classification (22, 23). We also compared a rate of severe complications between groups (Accordion grade 3-6). PF was defined and graded according to recommendations by the International Study Group on Pancreatic Fistula (24). PF grade B and C were considered as clinically relevant.
Statistics
For continuous variables the data are presented as mean ± standard deviation and median (range). For categorical variables data are presented as number (percentage). SPSS 25.0 was used for statistical calculations (IBM Corporation, Armonk, New York, USA). For comparison of frequencies, Chi square or Fisher’s exact test was performed where appropriate. For analysis of continuous variables, a One- Way ANOVA for normally distributed data and Kruskal-Wallis test for non-normal distributed data were applied. Pearson’s r was used to examine the association between tumor size and operative time and between tumor size and blood loss.
Results
Four hundred twenty-two patients eligible for analysis were identified. It included 218, 146 and 58 patients in the groups I, II and III respectively.
Baseline characteristics are presented in Table 1. One hundred seventy-three (40%) patients had previously undergone abdominal surgery, including 151 patients (35.5%) by means of open approach.
All patients had a lesion located in the distal or central part of the pancreas, and the size differed from 7 mm to 180 mm, whereas the median size for all three groups was 32 mm. The median tumor size in the groups I, II and III was 20, 47 and 81.5 mm, respectively. Except for tumor size, the variations between the groups with respect to baseline characteristics were small and not significant (Table 1).
Core perioperative outcomes are presented in Table 1. Spleen-preserving surgery was performed in 23.9%, 8.2% and 6.9% of the cases in the groups I, II and III, respectively (0.001). The median operative time was significantly higher in group III compared with the groups I and II - 195 vs 158 and 159 min (p=0.005), respectively. The regression analysis revealed significant but slight correlation
between tumor size and operative time (R=0.103; P=0.035). The median blood loss was 50, 100 and 150 ml, in the groups I, II and III respectively (P=0.152). The regression analysis did not reveal correlation between tumor size and intraoperative blood loss (R=0.075; P=0.125). There was significantly less requirement for erythrocyte mass transfusions in the group I compared with the groups II and III - 6 vs 13 and 13.8% (p=0.042), respectively.
The difference in the rate of intraoperative unfavorable incidents was statistically significant with 17 (7.7%), 19 (12.9%) and 11 (19%) cases in the groups I, II and III, respectively (p=0.038). This reflected higher rate of extensive intraoperative blood loss (Table 2). Rate of R0 resections (patients with adenocarcinoma only) were similar in the groups, 77.5%, 75.6% and 68.8% in the groups 1, 2, and 3 respectively.
Nine procedures (2.1%) were converted to open surgery and there was a statistically significant difference between the groups with 1 (0.5%), 5 (3.4%) and 3 (5.2%) cases in the groups I, II and III respectively (p=0.036). Reasons for conversion are listed in Table 3.
There was one case of perioperative mortality (0.2%). This patient aged 66 underwent LDP with splenectomy for mucinous cystadenoma (40 mm in size). The procedure was complicated by extensive blood loss - 1900 ml. The patient developed the left side hemiparesis (cerebral insult) right after surgery followed by pulmonary embolism on the second postoperative day. She died of cardiac arrest owing to pulmonary hypertension on the 12th postoperative day.
Histopathologic diversity of the pancreatic specimens are listed in Table 4. There was some heterogeneity in pathology representation in the groups which reflected typical sizes of different pancreas pathologies referred to surgery. When comparing the frequency of various histological types of lesions within the groups, neuroendocrine tumors prevailed in the group I, while adenocarcinoma was more common in the groups II and III. The differences between the groups consisted of a higher proportion of neuroendocrine tumors, adenocarcinomas and solid pseudo-papillary neoplasm in the groups I, II and III respectively.
The rates of postoperative complications were similar in all groups, 38.5%, 32.2% and 34.5%, including 22.5%, 19.2%, and 17.2% of severe complications (Accordion grade 3-6) in the groups I, II and III respectively. The same pattern was in regard to clinically relevant PF which were recorded in 18.3%, 15.7% and 17.2% in the groups I, II and III respectively (Table 1). The median postoperative hospital stay compiled 5 (0-81) days was similar in all groups. Readmissions and reoperations were registered in 34 (8.1%) and 29 (6.9%) cases, respectively with a similar rate in all groups. Conclusively, there were no any statistical difference in postoperative variables.
Details in regard to pancreatic fistula distribution in the groups and cases requiring reoperation are presented in Tables 5 and 6 respectively.
Discussion
This study includes a cohort of 422 LDPs throughout a 20-year period (1997-2017). To the best of our knowledge the present series represents a largest material analyzing tumor size impact internationally.
Besides our series represent a wide spectrum of different pancreatic pathologies referred to surgery. Our study analyzed a single institution experience, so indications for LDP and procedure itself were standardized.
This series has a wide spectrum of represented tumor sizes. Median size in the group I is 20 mm, in the group II − 48 mm and in group III − 81.5 mm. The range in size is from 7 to 180 mm, which is the wider than range of 55-130 mm presented in a study of similar design earlier published by Fernandez-Cruz et al (10). They considered tumors over 5 cm as large tumors. In the present study we used our perception from own procedural experience and data from the literature and defines tumors less than 3.5cm in diameter as small, from 3.5 to 7 cm as intermediate and larger than 7 cm as large tumors.
The overall rate of conversion to laparotomy was 2.1%, this is lower than reported by others (21-23).
The conversion rate seemed to increase with increasing tumor size (p=0.017), which contradicts the results of Goh et al and Lee et al, who found that tumor size was not a risk factor for open conversion after LDP (16, 25).
A slight but statistically significant correlation was found between tumor size and operative time in our series (R=0.103; P=0.035). However, the median operative time was 195 min in the group of large tumors versus 158 min in the group of small tumors, so such correlation had no clinical significance.
Furthermore, operative time in the group of large tumors favorably corresponded to data for LDP without selection by tumor size (26-28). Similar studies have found a correlation between tumor size and operative time (29). Nevertheless, LDP can be also quite time consuming in some cases of very small tumors due to challenges to verify tumor location. This emphasizes the importance of intraoperative ultrasonography during LDP both to locate the tumor and control its margin-free resection(30). In our experience intraoperative ultrasonography was initially applied routinely, however, we switch to selective use of intraoperative ultrasonography in our later cases. There is need in studies to detect whether routine or selective application of intraoperative ultrasonography is a sensible choice.
Detection of advisory criteria for application of intraoperative ultrasonography for DLP is wanted.
Earlier studies have shown that LDP is associated with less blood loss than ODP (2, 3, 9, 31). The regression analysis failed to reveal correlation between tumor size and blood loss in our series (R=0.075;
P=0.125). However, the blood loss has a trend to increase in the group of large tumors compares with the group of medium-sized and small tumors, 150, 100 and 50 ml of median blood loss respectively (P=0.062). Correlation was failed to be revealed by the regression analysis possibly due to a fact that the considerable blood loss was recorded in only small proportion of patients. Nevertheless, number of intraoperative unfavorable incidents and rate of blood transfusions were moderately but statistically significantly higher in the group of large tumors. This indicates significant tendency to higher blood loss in the group of large tumors.
The observed pattern in association of the tumor size and operative time from one side and the tumor size and blood loss from another side enables us to support the fact that LDP in the group of patients with large tumors is associated with fairly higher, but still acceptable intraoperative complexity related to slightly higher probability for prolonged operative time and increased blood loss.
Rate of R0 resections was 78% in total. There were not statistically significant differences between the group of small tumors compared with the groups of intermediate and large tumors. R0 resection rates in all groups corresponds to rates reported in the literature for LDP (17, 32).
However, in our series these intraoperative challenges did not transfer to a higher rate of postoperative complications (35%), neither total rate nor severe (21%) complications. Duration of postoperative hospital stay (5 days), readmissions (8%) or reoperation (7%) rates were not either influenced by tumor size. The pattern of postoperative complications was similar in all groups with intraoperative bleeding as most usual major postoperative complications that required reoperation.
Although LDP for large pancreatic tumors is more technically challenging for the surgeon than LDP for small tumors, we can argue that large tumor size itself does not increase postoperative morbidity.
Expectedly, the most common postoperative complication after LDP was PF, which occurred in 154 patients (36%). The total rate of clinically relevant PF was 17%, and did not differ significantly between the three groups. Souche et al found a total PF rate of 43% (33). Furthermore, similar results were found by other groups regarding PF grade B and C (33-35). In our series, there were three cases of grade C fistulas; 2 in the group I and 1 in the group III. According to our findings, there is no elevated risk of clinically relevant PF with increased tumor size. This corresponds to Wang et al who that tumor size, coverage, prolonged operative time and histological differentiation were not risk factors of PF.
The most common indication for reoperations was postoperative bleeding, this also corresponds to the outcomes reported by others (9). Surprisingly, all cases of reoperations due to wound dehiscence were recorded in the groups of small tumors, although one would expect some longer extension of trocar
incision namely in the group of large tumors (due to need to extract larger specimen), so theoretically higher probability of wound dehiscence. This was not statically significant, i.e. an accidental finding (P=0.151), nevertheless this show that LDP for large tumors are not inferiorly in regard to wound dehiscence than LDP more small pancreatic tumors.
A laparoscopic approach is known to produce less surgical trauma than the open counterpart (36, 37).
Several studies, including the European Association for Endoscopic Surgery’s clinical consensus conference, showed that when comparing LDP with ODP, the patients who underwent LDP had shorter hospital stays than the open group (2, 3, 31, 38). In our series, we found no significant difference in median postoperative hospital stay between the patients with large, intermediate and small tumors. This shows that application of LDP in patients with large tumors does not really compromise the known benefits of laparoscopic approach.
However, the latter may become less pronounced when dealing with a larger tumor, because a larger extension of trocar incision is needed to remove the surgical specimen. Our series has indirectly shown that a larger tumor does not mean less benefits in postoperative reconvalescence, because these patients did not require longer hospital stay. When it comes to cosmetics LDP is superior to OPD (10, 39), but the benefits when dealing with a large tumor are apparently less pronounced due to the larger incision.
There are several other factors that influence on expected technical challenges during execution of LDP.
Ohtsuka et al. attempted to score difficulty of laparoscopic distal pancreatectomy base on few lesion- and procedure-related factors (40). This scoring system was favorably validated by Goh et al (41).
Our study has its limitations. Firstly, the number of patients in the group III is low, so statistical type 2 error may be present, especially in regard where the applied statistics have observed some trends, but they were not reached statistical significance. Retrospective design is a drawback of this study. Further studies on this important topic are required. Besides surgical and immediate oncologic outcome recorded from our expert center in laparoscopic liver surgery are not necessarily reproducible in non-expert centers. This series could not lighten issues of long-term survival in relation to application of LDP in regard to patients with small, intermediate and large tumors. This was due to both relatively small cohort of patients and known poor survival of patients with pancreatic adenocarcinoma. Multicenter studies on this issue are wanted.
Conclusion
Our experience shows that although LDP for large pancreatic tumors up to 18 cm is associated with higher technical challenges for the surgeon, it can be safely performed, with outcomes similar to those for small pancreatic tumors.
Conflict of interest
A.M.Kazaryan, I.Solberg, D.L.Aghayan, M.A.Sahakyan, O.Reiertsen, V.I.Semikov, A.M.Shulutko and B.Edwin have no conflict of interest.
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Table 1.
Baseline characteristicsand core perioperative outcomes
Parameters Group I
N=218
Group II N=146
Group III N=58
P value Total N=422
Age, years 61.4±14.1
65 (14-87)
62.6±13.1 65 (17-85)
57.6 ±15.9 62 (21-83)
0.077 61.3±14 65 (14-87)
ASA score 2.2±0.6
2 (1-4)
2.3±0.6 2 (1-4)
2.2±0.6 2 (1-3)
0.288 2.2±0.6 2 (1-4)
BMI 25.8±4.7
25.4 (12-44)
25.1±4.7 24.8 (15-45)
26±4.5 25.8 (16-43)
0.359 25.6±4.7 25 (12-45)
Female / Male 121 /97 67 / 79 33 / 25 0.150 221 / 201
Previous abdominal surgery
• Laparoscopic /open
92 (42%) 14/78
58 (40%) 6/52
23 (40%) 2/21
0.871 173 (40%) 22/151
Tumor size, mm 21.5±7
20 (7-34)
48.2±9.3 47 (35-68)
89.9±22.3 81.5 (70-180)
<0.001 40±25.9 32 (7-180)
Spleen-preserving surgery 52 (23.9%) 12 (8.2%) 4 (6.9%) 0.001 68 (16%)
Conversions to laparotomy 1 (0.5%) 5 (3.4%) 3 (5.2%) 0.036 9 (2.1%)
Operative time, min 163±65
158 (29-520)
170±65 159 (56-428)
208±97 195 (61-560)
0.005 171.6±71.6 160 (29-560)
Blood loss, ml 215±398
50 (50-2700)
304±703 100 (50-6250)
376±595 150 (50-3000)
0.152 268±549 (50-6250)
Transfusion requirements 13 (6%) 19 (13%) 8 (13.8%) 0.042 40 (9.5%)
Intraoperative unfavorable Incidents
17 (7.7%) 19 (12.9%) 12 (20.7%) 0.017 48 (11.4%) Postoperative complications 84 (38.5%) 47 (32.2%) 20 (34.5%) 0.454 151 (35%) Severe postoperative complications
(Accordion grade 3-6)
49 (22.5%) 28 (19.2%) 10 (17.2%) 0.592 87 (20.6%) Clinically relevant
pancreatic fistula
40 (18.3%) 23 (15.7%) 10 (17.2%) 0.814 74 (17.3%) Postoperative stay,
days
4.7±2.1 6 (0-58)
4.6±2(4.3-5) 5 (0-81)
4.6±1.9(4-5) 5 (2-23)
0.564 4.65±2.1 5 (0-81)
Readmissions 20 (9.2%) 10 (6.8%) 4 (6.9%) 0.684 34 (8.1%)
Reoperation 18 (8.3%) 7 (4.8%) 4 (6.9%) 0.441 29 (6.9%)
The values are presented as
mean ± standard deviation andmedian (range), or n (%).
ASA indicates American Society of Anesthesiologists. BMI indicates body mass index.
Table 2. Intraoperative unfavorable incidents graded in accordance to
the Oslo classification of intraoperative unfavorable incidents, adapted for distal pancreatectomy (20).Intraoperative unfavorable incidents Group I N=218
Group II N=146
Group III N=58
Total N=422
Grade 1 10 (4.6%) 10 (6.8%) 5 (8.6%) 25 (5.9%)
• Blood loss 700 ml, ≤ 1500 ml 8 7 4 19
• Iatrogenic injury of adjacent organs and structures
- Diaphragm, sutured
- Ductus choledochus, sutured
- Transverse colon wall injury, sutured.
- Stomach wall injury, sutured.
2 1 1 0 0
3 0 0 2 1
1 0 0 0 1
6 1 1 2 2
Grade 2 7 (3.2%) 9 (6.2%) 7 (12.1%) 23 (5.5%)
• Blood loss 1500 ml 5 7 4 16
• Conversion 1 5 3 9
• Pneumothorax 1 0 0 1
Grade 3 0 0 0 0
Total 17 (7.7%) 19 (12.9%) 12 (20.7%) 48 (11.4%)
The values are presented as n (%).
Table 3. Reasons for conversion to laparotomy
Parameters Group I
N=218
Group II N=146
Group III N=58
Total N=422 Bleeding:
- Truncus coeliacus and aorta;
- Splenic vessels*;
- Splenic capsule*;
- Portal vein;
0 0 0 0 0
4 1 2 1 0
1 0 0 0 1
5 1 2 1 1 Portal vein reparation and atypical lever
resection, segment 7
0 0 1 1
Tumor infiltration:
- Arteria colica media;
- Portal vein.
1 0 1
1 1 0
1 0 1
3 1 2
Total 1 (0.5%) 5 (3.4%) 3 (5.2%) 9 (2.1%)
* Not spleen-preserving surgery
The values are presented as n (%).
Table 4. Histologic types of pancreatic lesions
Tumor type Group I
N=218
Group II N=146
Group III N=58
Total N=422 Neuroendocrine tumors 87
(39.9%)
32 (21.9%)
12 (20.7%)
131 (31%)
Adenocarcinoma 40
(18.3%)
62 (42.5%)
16 (27.6%)
118 (28%) Serous
cystic neoplasm
29(13.3%)
15 (10.3%)
6 (10.3%)
50 (11.8%) Intraductal papillary
mucinous neoplasm
15 (6.9%)
8 (5.5%)
6 (10.3%)
29 (6.9%) Mucinous
cystic neoplasm
12(5.5%)
11 (7.6%)
6 (10.3%)
29 (6.9%) Solid pseudo-papillary
neoplasm
5 (2.3%)
3 (2.1%)
5 (8.6%)
13 (3.1%) Benign cysts and
pseudocysts
17 (7.8%)
9 (6.2%)
7 (12.1%)
33 (7.8%) Metastasis:
• RCC
• Colon
• Malignant melanoma
• Esophagus
7 (3.2%)
3 2 2 0
4 (2.7%)
3 0 0 1
0 11
(2.6%) 6 2 2 1
Other lesions 6
(2.8%)
2 (1.4%)
0 8
(1.9%)
The values are presented as n (%).
Table 5. Pancreatic fistulas graded according to recommendations by the International Study Group on Pancreatic Fistula (24).
Group I N=218
Group II N=146
Group III N=58
Total N=422
Grade A 45 (20.6%) 23 (15.7%) 8 (14%) 80 (18.7%)
Grade B 38 (17.4%) 23 (15.7%) 9 (15.5%) 71 (16.6%)
Grade C 2 (0.9%) 0 1 (1.8%) 3 (0.7%)
Total 85 (39%) 46 (31.5%) 18 (31.6%) 154 (36%)
The values are presented as n (%).
Table 6: Cases requiring reoperations Group I
N=218
Group II N=146
Group III N=58 18 patients:
•Intraabdominal bleeding, relaparoscopy (5 cases);
•Intraabdominal bleeding, open reoperation (4 cases);
•Reoperation due wound dehiscence (4 cases);
•Open reoperation due to leakage in the transverse colon anastomosis (resected during primary operation); Pulmonary embolism;
•Relaparoscopy due to leakage in the stomach stapling line (limited gastric resection during primary operation);
•Intraabdominal bleeding, open reoperation, then development of pancreatic leakage, percutaneous drainage;
•Major pancreatic leakage, pleural effusion, wound dehiscence; Reoperation, with wound closure and drainage of pancreatic leakage, pleural drainage, gastroscopy with a nutrition probe placement, endoscopic retrograde cholangiopancreatography with placement of a stent in the pancreatic duct and papillotomy
•Open reoperation due the transvers colon necrosis and perforation, pancreatic leakage, wound infection;
Subtotal colectomy, ileostomy.
7 patients:
•Intraabdominal bleeding, relaparoscopy (4 cases);
•Intraabdominal bleeding, relaparoscopy twice; Pleural effusion, drainage; Subhepatic hematoma, drainage;
•Chylus; Open reoperation due to intestinal obstruction
•Embolism of the popliteal artery, embolectomy, fasciotomy on the leg
4 patients:
•Open reoperation due to a leakage from gastroraphy (The stomach was injured during primary operation and sutured);
•Pancreatic leakage, (percutaneous drainage), then open reoperation due to bleeding;
•Intraabdominal bleeding, relaparoscopy
•Reoperated twice, first - relaparotomy due to bleeding, then due to intraabdominal abscess.
This patient also developed lung embolism and multiorgan failure.