Our contribution shows that the most difficult procedure of visceral surgery—pancreatic resection—has now arrived to the age of laparoscopy (1). In this registry, the indication for pancreatic left resection was made in 56% of all cases (that is, 359 times), followed by the indication for laparoscopic pancreatic head resection in 23%, and for laparoscopic enucleation in 9%, of the cases. The diagnosis-based indication for the laparoscopic procedure shifted from initially only benign neoplasia to currently very frequently malignant ones. In 2012, we published the indications for the extent of resection as well as for the laparoscopic procedure (2).
We fully agree with Dr. Lampl, that prospective randomized studies as the gold standard will not be replaced in the foreseeable future. As a rule, a new procedure is established after the following four phases have been completed:
1. Case descriptions;
2. Small-scale, followed by larger-scale, monocenter case series;
3. Multicenter registry;
4. Multicenter prospective randomized controlled trial.
With the currently largest data available in the literature, comprising 550 patients from 34 centers, we have now reached phase 3 of the procedure establishment and would like to fully support an upcoming multicenter randomized study.
The time needed for this will most likely be considerable, as it requires homogeneous groups of patients with tumors of the same type and approximately the same size, and who are in similar condition, if possible. Additionally, left-sided pancreatic tumors occur significantly less frequently than right-sided pancreatic tumors, are usually discovered later, and often cannot be resected unless using vascular resection. Recruitment is also hindered by the fact that patients who visit a specialized center for laparoscopy and pancreas diseases are reluctant to be randomly assigned to the open surgical procedure. Thus, we can expect that results will not be available for a few years.
On behalf of the authors
Prof. Dr. med. Marco Siech
Chirurgie I, Ostalb-Klinikum Aalen, Germany
Conflict of interest statement
The authors of both contributions declare that no conflict of interest exists.
|1.||Siech M, Strauß P, Huschitt S, et al.: The indications for laparoscopic pancreatectomy—results on 550 patients in the German Laparoscopic Pancreas Registry in comparison to other registries. Dtsch Arztebl Int 2017; 114: 263–8 VOLLTEXT|
|2.||Siech M, Bartsch D, Beger HG, et al.: Indications für laparoscopic pancreas operations: results of a consensus conference and the previous laparoscopic pancreas register. Chirurg 2012; 83: 247–53 CrossRef MEDLINE|