The objective of LCP is to preserve more normal pancreatic parenchyma as much as possible to avoid an endocrine dysfunction. However, studies about LCP reported in the literature were mostly few-case reports or small series, which the largest series were 26 cases [1, 7, 14]. Can the patients really benefit from LCP? In fact, LCP brought huge risks to the patients. The study by Lv et al. [15] showed that LCP had a higher complication rate compared with LDP. Even in the hands of the most experienced pancreatic surgeons in the world at that time, the incidence of postoperative-related clinical pancreatic fistula (CR-POPF) after LCP was as high as 60% [16]. LCP operation changed the normal physiological structure, which added more operation and cost. In our opinion, the ideal surgery should be simple, readily available, reliable, and minimally invasive for the patients [17]. Hence, this case-control study was performed to analyze the postoperative outcomes to compare the real effect, safety, and feasibility of LDP and LCP and to provide a high-confidence evidence.
The baseline features (gender, age, main diameter, and Child-Pugh score) of both the LCP and LDP groups had no significant difference. Our surgical outcomes showed that the LDP group had many advantages such as its operation time, time to oral intake, and hospital stay were significantly shorter and the hospital expenses were lower than LCP. Our results were consistent with the previous studies [7, 9, 18, 19]. There is a reconstruction phase for the LCP group, such as pancreaticojejunostomy and bowel anastomosis, which increased the operation time. In addition, pancreaticojejunostomy and bowel anastomosis were performed, which changed the physiological structures. It disrupted the normal gastrointestinal function, increased the gastroparesis risk, and prolonged the fasting time. Coupled with the increase in complications such as the pancreatic leakage, it is not surprising that our results showed that the patient’s hospital stay was longer. As for the higher hospital expenses, it was understandable. There were three reasons that might be responsible for the result as follows: 1. because the LCP operation time and hospital stay were longer, this means that longer anesthesia time and more medications were needed; 2. prolonged fasting led to increase nutritional support, which increased the hospitalization costs; and 3. the most important is that LCP needed more surgical supplies, such as at least two Endo-GIA, more surgical sutures, etc. The difference [3, 19, 20] was that blood loss for both the LCP and LDP groups had no significant difference. Moreover, there were no significant differences for the conversion rate, first random blood glucose after the operation, and ascites amylase on the third day after the surgery for the two groups.
For the complications, these problems of LCP have not been significantly improved in the recent years. Consistently with the previous research results, the pancreatic fistula and postoperative hemorrhage of LCP were higher than LDP. A recent meta-analysis still pointed out that the LCP group had a higher incidence of CR-POPF compared with the LDP group [(62.1–63.0% vs. 26.7–44.0%)] and more high incidence of postoperative bleeding (6.9% vs. 4.5%) [18, 20]. Safi Dokmak et al. [14] reported the largest number of cases of LCP, and the results showed that the postoperative complication rate was 74% and the CR-POPF rate was 22%. This is partly due to the fact that LCP implied the presence of the two pancreatic stumps and at least one pancreatico-digestive anastomosis. Compared with LDP, in addition to the same leak that was from the proximal stump, there is another pancreatic segment from the pancreaticojejunostomy. In theory, the risk of pancreatic leakage and bleeding is doubled.
To the best of our knowledge, the main benefit of LCP is the preservation of endocrine and exocrine functions because it spares more pancreatic parenchyma than LDP. In theory, LCP retains more pancreas, and the probability of diabetes should be lower than LDP. However, to our surprise, which was different from the previous studies [3, 9, 18, 19], our results were not as stated in that. There were also no significant differences for the postoperative new-onset diabetes after LDP or LCP. In addition, there was no increase in the postoperative diabetes incidence. We observed that the endocrine or exocrine insufficiency after LDP was similar to that after LCP. Consistent with our results, the study by Lv et al. [15] showed that, in the long-term follow-up, only two patients in the LDP group and none in the LCP group developed diabetes.We believe that LCP retains the pancreatic head and pancreatic uncinate process, which occupy most of the pancreatic tissue, and these will have enough volume to retain pancreatic function. The tail of pancreas is only a small part of the tissue.