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Taweerutchana V, Choksakunwong S, Lerwattrakarn A, Chalermwai WV, Intralawan T, Lertwattanarak R. Pioneering robotic-assisted surgery for insulinoma during pregnancy: The first case report and literature review. Heliyon 2024; 10:e34239. [PMID: 39100462 PMCID: PMC11296031 DOI: 10.1016/j.heliyon.2024.e34239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Insulinoma during pregnancy is a rare condition with vague clinical symptoms, making diagnosis challenging. The standard treatment for insulinoma is surgical tumor removal, preferably using a minimally invasive method. However, there have been no recorded examples of employing a robotic platform in pregnant women with insulinoma. In this report, we present the first successful case of robotic enucleation for insulinoma during pregnancy. Case presentation A 30-year-old pregnant woman presented with recurrent hypoglycemic symptoms throughout her first trimester that were relieved by food intake. After confirming endogenous hyperinsulinemia, an abdominal magnetic resonance imaging scan was performed to locate the tumor. A well-defined 2-cm mass was found in the pancreatic body. Robotic enucleation was performed at week 18 of gestation, and the patient experienced relief from hypoglycemic episodes postoperatively. Her blood glucose levels returned to normal, and she had an uneventful pregnancy. The patient eventually delivered a healthy baby via cesarean section without any complications. Conclusions For a subset of pregnant individuals with insulinoma, a minimally invasive approach as robotic-assisted surgery is safe and feasible. This innovative technique has the potential to both mothers and fetuses.
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Affiliation(s)
- Voraboot Taweerutchana
- Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sawaraj Choksakunwong
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Diabetes, Thyroid, and Endocrine Clinic, Siriraj Piyamaharajkarun Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Amornrat Lerwattrakarn
- Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wipapat Vicki Chalermwai
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thita Intralawan
- Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Raweewan Lertwattanarak
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Lim TW, Tan HL, Tan EK, Cheow PC, Goh BKP. Short-term outcomes of laparoscopic and robotic limited resections of pancreatic neuroendocrine tumours of the uncinate process: Report of six cases and review of the literature. J Minim Access Surg 2024; 20:288-293. [PMID: 38726970 DOI: 10.4103/jmas.jmas_335_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/26/2024] [Indexed: 07/26/2024] Open
Abstract
INTRODUCTION Minimally invasive surgery (MIS) for limited resections for pancreatic uncinate lesions is not widely performed but can adequately treat benign or low-grade malignant lesions. The aim of this study was to evaluate the short-term outcomes of MIS-limited pancreatic resections for patients with suspected pancreatic neuroendocrine tumours (PNETs). PATIENTS AND METHODS This was a retrospective study of six consecutive patients who underwent MIS for PNET within a single institution between 2017 and 2022. RESULTS Six patients underwent limited pancreas-preserving MIS of the uncinate process (uncinectomy or enucleation), of which two were performed through the robotic approach and four through laparoscopic approach. The median operation time was 212.5 (175-338.75) min, and the median blood loss was 50 (50-112.5) ml. The median post-operative hospital length of stay was 5.5 (3.75-11.5) days. Two patients (33.3%) had major post-operative morbidities (Clavien-Dindo ≥Grade 3). There were no open conversions or post-operative mortalities. Five patients had histologically proven Grade 1 neuroendocrine tumours. One was T2 and four were T1. CONCLUSIONS This study suggests that limited MIS resections of pancreatic uncinate PNETs are a feasible procedure with good patient outcomes. It offers a safe alternative to radical surgical resections like pancreatoduodenectomies in selected patients with low-grade malignant or benign tumours.
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Affiliation(s)
- Teik-Wen Lim
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre, Singapore
| | - Hwee-Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre, Singapore
- Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Ek-Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre, Singapore
- Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre, Singapore
- Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre, Singapore
- Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
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Patrone R, Mongardini FM, Conzo A, Cacciatore C, Cozzolino G, Catauro A, Lanza E, Izzo F, Belli A, Palaia R, Flagiello L, De Vita F, Docimo L, Conzo G. Pancreatic Neuroendocrine Tumors: What Is the Best Surgical Option? J Clin Med 2024; 13:3015. [PMID: 38792555 PMCID: PMC11121769 DOI: 10.3390/jcm13103015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used ("NET", "pancreatic", "surgery", "laparoscopic", "minimally invasive", "robotic", "enucleation", "parenchyma sparing") and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body-tail, while laparoscopic enucleation is better for head pNETs.
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Affiliation(s)
- Renato Patrone
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Alessandra Conzo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Chiara Cacciatore
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Giovanni Cozzolino
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Antonio Catauro
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Eduardo Lanza
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Francesco Izzo
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Andrea Belli
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Raffaele Palaia
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Luigi Flagiello
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Ferdinando De Vita
- Division of Medical Oncology, Department of Internal and Experimental Medicine ‘F. Magrassi’, Università della Campania ‘Luigi Vanvitelli’, 80138 Naples, Italy;
| | - Ludovico Docimo
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Giovanni Conzo
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
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Xiao D, Zhu L, Xiong S, Yan X, Jiang Q, Wang A, Jia Y. Outcomes of endoscopic ultrasound-guided ablation and minimally invasive surgery in the treatment of pancreatic insulinoma: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1367068. [PMID: 38645424 PMCID: PMC11026617 DOI: 10.3389/fendo.2024.1367068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Background and aims Most pancreatic insulinomas can be treated by minimally invasive modalities. The aim of this meta-analysis was to assess the clinical outcomes of endoscopic ultrasound (EUS)-guided ablation and minimally invasive surgery (MIS) in the treatment of pancreatic insulinoma. Materials and methods Online databases were searched for relevant studies. The primary aim was to compare the rates of adverse events (AEs) and the secondary aims were to compare the clinical and technical success rates, length of hospital stays, and symptom recurrence rates between EUS and MIS approaches. Results Eight studies with 150 patients were identified that reported EUS-guided ablation outcomes, forming the EUS group, and 9 studies with 236 patients reported MIS outcomes, forming the MIS group. The pooled median age of the included patients in the EUS group was greater than that of the MIS group (64.06 vs. 44.98 years old, p < 0.001). Also, the technical success rate was significantly higher in the EUS group (100% vs. 96.6%, p = 0.025), while the clinical success was significantly higher (6%) in the MIS group (94% vs. 98.7%, p = 0.021). The AE rates (18.7% vs. 31.1%, p = 0.012) and severe AE rates (1.3% vs. 7.9%, p = 0.011) were significantly lower in the EUS group. The median length of hospital stay in the EUS group (2.68 days, 95% CI: 1.88-3.48, I2 = 60.3%) was significantly shorter than in the MIS group (7.40 days, 95% CI: 6.22-8.58, I2 = 42.2%, p < 0.001). The recurrence rate was significantly higher in the EUS group (15.3% vs. 1.3%, p < 0.001). Conclusions EUS-guided ablation is associated with a lower AE rate and a shorter length of hospital stay, but a higher recurrence rate for the treatment of insulinoma compared with MIS. The EUS approach may be an alternative, even first-line, treatment for poor surgery candidates.
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Affiliation(s)
- Dan Xiao
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Li Zhu
- Gastrointestinal Surgery, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Si Xiong
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei, China
| | - Xu Yan
- Internal Medicine Department, University Hospital, Wuhan Institute of Technology, Wuhan, Hubei, China
| | - Qin Jiang
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Ao Wang
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Yegui Jia
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
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Debraine Z, Borbath I, Deprez P, Bosly F, Maiter D, Furnica RM. Long-term clinical and radiological outcomes of endoscopic ultrasound-guided radiofrequency ablation of benign insulinomas. Clin Endocrinol (Oxf) 2023. [PMID: 37859570 DOI: 10.1111/cen.14981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/26/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE In recent years, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as an alternative nonsurgical treatment for pancreatic neuroendocrine tumours. The aim of our study was to assess the long-term follow-up of patients treated with EUS-RFA for a sporadic insulinoma in our centre in terms of efficacy, safety and risk of recurrence. DESIGN, PATIENTS AND MEASUREMENTS We retrospectively analysed the data of 11 patients with an insulinoma treated by EUS-RFA in our tertiary centre between June 2018 and April 2022. Clinical and biological, as well as imaging, follow-up was planned at 3, 6, 12 months and then annually. RESULTS In our series, there were nine women and two men with a median age of 65 years. All tumours were sporadic, with a mean size of 11 mm. The procedure allowed an immediate and complete symptomatic and biological remission in all patients without notable complications. Complete radiological resolution of the tumour after ablation was observed in seven patients, and persistence of an asymptomatic tumour residue was observed in four patients. During the mean follow-up period of 26 months, two patients presented a significant but asymptomatic increase of the tumour residue; a second EUS-RFA session was performed in one patient and the other patient is being closely monitored. CONCLUSIONS EUS-RFA treatment of benign insulinomas provides a long-term complete clinical resolution of hypoglycaemia. A long-term follow-up is essential if residual tumour persists after initial EUS-RFA treatment.
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Affiliation(s)
- Zoé Debraine
- Division of Endocrinology and Nutrition, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ivan Borbath
- Division of Hepatogastroenterology, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre Deprez
- Division of Hepatogastroenterology, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Florence Bosly
- Division of Endocrinology, Clinique Vivalia, Arlon Hospital, Arlon, Belgium
| | - Dominique Maiter
- Division of Endocrinology and Nutrition, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Raluca M Furnica
- Division of Endocrinology and Nutrition, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
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Endoscopic ultrasound-guided radiofrequency ablation: An effective and safe alternative for the treatment of benign insulinoma. ANNALES D'ENDOCRINOLOGIE 2020; 81:567-571. [PMID: 33285105 DOI: 10.1016/j.ando.2020.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Insulinomas are usually benign, small-sized, well-encapsulated and often solitary pancreatic tumors. Currently, enucleation is the treatment of choice for sporadic solitary insulinoma if diameter is less than 2cm and the structural integrity of the pancreatic duct can be maintained. However, the procedure has a risk of postoperative complications, and especially of pancreatic fistula. There is growing interest in endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) as an effective and less invasive alternative treatment for benign sporadic insulinoma. METHOD We retrospectively analyzed the efficacy and safety of EUS-RFA in four patients with benign localized insulinoma treated in our tertiary care center between June 2018 and November 2019. EUS-RFA was performed with a EUS-guided RFA 19-gauge needle electrode (Starmed; Taewoong Medical, Seoul, South Korea) that released energy at 50W up to 100 Ohms impedance. RESULTS The series comprised three women and one man, with a median age of 58 years (range 52-82 years). Mean tumor size was 12mm. Although three of the four patients would have been eligible for surgery, EUS-RFA was proposed to them. Symptomatic and biological improvement occurred immediately, generally straight after the procedure, in all patients, and no serious complications were observed. During the mean follow-up period of 22 months, no symptom recurrence was observed. CONCLUSIONS This preliminary report in 4 patients showed that EUS-RFA was an effective and relatively safe alternative treatment, devoid of major complications, for benign sporadic insulinoma. Larger-scale prospective multicenter studies are, however, needed to confirm the long-term effectiveness and safety of this novel technique.
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Open and minimally invasive pancreatic neoplasms enucleation: a systematic review. Surg Endosc 2019; 33:3192-3199. [PMID: 31363894 DOI: 10.1007/s00464-019-06967-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting. Nowadays, pEN is frequently carried out through a minimally invasive approach either laparoscopic or robotic. Its impact on overall perioperative complications and pancreatic fistula (POPF) is still under evaluation. The scope of our systematic review is to assess pEN's perioperative outcomes and to evaluate the effect of the minimally invasive techniques over POPF and other surgical complications. METHODS We performed a systematic literature search (time-frame January 1999-September 2018), considering exclusively those studies which included at least 5 cases of either open or minimally invasive pEN. Data regarding postoperative outcome and POPF were extracted and analyzed. We defined postoperative morbidities by the Clavien-Dindo classification while POPF according to the International Study Group of Pancreatic Fistula (ISGPF) definition. RESULTS Sixty-three studies met the criteria selected, accounting for a study population of 2485 patients. 27.7% had a minimally invasive pEN. The overall postoperative morbidity rate was 46.1% with 11.9% rated as severe (Clavien-Dindo ≥ 3). Mortality rate was 0.69%. The minimally invasive approach to pEN led to a statistically significant reduction of both the overall POPF rate (28.7% vs. 45.9%, p < 0.001), and clinically significant B-C POPF (p < 0.027). The postoperative overall morbidity rate was clearly in favor of the minimally invasive approach (27.6% vs. 55.2%, p < 0.001). CONCLUSIONS Our review confirms that pEN is a safe and feasible technique for the treatment of small benign or low-grade pancreatic neoplasms and it can be implemented with an acceptable morbidity rate along with low mortality. The minimally invasive approach is gaining widespread acceptance due to its supposed non-inferiority compared with the traditional open approach. In our review, it showed to be even better in terms of POPF incidence rate and short-term postoperative outcome. Still, such data need to be corroborated by randomized clinical trials.
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Hopper AD, Jalal M, Munir A. Recent advances in the diagnosis and management of pancreatic neuroendocrine tumours. Frontline Gastroenterol 2019; 10:269-274. [PMID: 31290854 PMCID: PMC6583562 DOI: 10.1136/flgastro-2018-101006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 02/06/2023] Open
Abstract
The incidence of pancreatic neuroendocrine tumours (PNET) is rising mainly due to the increased use of cross-sectional imaging. Although many PNETs are asymptomatic and non-functioning, the overall 5-year survival is still less than 50%. In this article, we review the advances in diagnosis, classification and staging of PNET that have evolved with the development of new cross-sectional imaging methods and biopsy techniques. With accurate classification, evidence-based, individualised prognostic outcomes and treatments are able to be given which are also discussed.
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Affiliation(s)
- Andrew D Hopper
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mustafa Jalal
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Alia Munir
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield, UK
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Minimally Invasive Versus Open Treatment for Benign Sporadic Insulinoma Comparison of Short-Term and Long-Term Outcomes. World J Surg 2018; 42:3223-3230. [DOI: 10.1007/s00268-018-4628-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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10
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Guerra F, Giuliani G, Bencini L, Bianchi PP, Coratti A. Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes. J Surg Oncol 2018; 117:1509-1516. [PMID: 29574729 DOI: 10.1002/jso.25026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/23/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Francesco Guerra
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery; Misericordia Hospital; Grosseto Italy
| | - Lapo Bencini
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Paolo P. Bianchi
- Division of General and Minimally Invasive Surgery; Misericordia Hospital; Grosseto Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
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Shirota T, Nagakawa Y, Sahara Y, Takishita C, Hijikata Y, Hosokawa Y, Nakajima T, Osakabe H, Katsumata K, Tsuchida A. Surgical resection of neuroendocrine tumors of the pancreas (pNETs) by minimally invasive surgery: the laparoscopic approach. Gland Surg 2018; 7:12-19. [PMID: 29629315 DOI: 10.21037/gs.2017.11.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Neuroendocrine tumors of the pancreas (pNETs) are a rare group of neoplasms that originate from the endocrine portion of the pancreas. Tumors that either secrete or do not secrete compounds, resulting in symptoms, can be classified as functioning and non-functioning pNETs, respectively. The prevalence of such tumors has recently increased due to the use of more sensitive imaging techniques, such as multidetector computed tomography, magnetic resonance imaging and endoscopic ultrasound. The biological behavior of pNETs varies widely from indolent, well-differentiated tumors to those that are far more aggressive. The most effective and radical treatment for pNETs is surgical resection. Over the last decade, minimally invasive surgery has been increasingly used in pancreatectomy, with laparoscopic pancreatic surgery (LPS) emerging as an alternative to open pancreatic surgery (OPS) in patients with pNETs. Non-comparative studies have shown that LPS is safe and effective. In well-selected groups of patients with pancreatic lesions, LPS was found to results in good perioperative outcomes, including reduced intraoperative blood loss, postoperative pain, time to recovery, and length of hospital stay. Despite the encouraging results of studies from highly specialized centers with extensive experience, no randomized trials to date have conclusively validated these findings. Indications for minimally invasive LPS for patients with pNETs remain unclear. This review presents the current state of LPS for pNETs.
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Affiliation(s)
- Tomoki Shirota
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yatsuka Sahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yosuke Hijikata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Hosokawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsushi Nakajima
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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Hu MG, Xiao YH, Song DD, Zhao GD, Liu YZ, Wang Z, Li HY, Liu R. First experience of robotic spleen-preserving distal pancreatectomy in a child with insulinoma. World J Surg Oncol 2017; 15:199. [PMID: 29121944 PMCID: PMC5680789 DOI: 10.1186/s12957-017-1265-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023] Open
Abstract
Background An insulinoma is a functional neuroendocrine pancreatic tumor, and surgical resection is indicated. Robot-assisted laparoscopic surgeries have been shown to be generally safe and feasible for treatment of pediatric cases of urologic and digestive disease. Case presentation In July 2016, a 9-year-old girl (24 kg, 120 cm) was admitted with a pancreatic tail insulinoma and underwent robot-assisted spleen-preserving laparoscopic distal pancreatectomy. The total procedure time was 155 min, and the blood loss was about 10 ml. The patient recovered without complications. Conclusions This case supports that robot-assisted spleen-preserving laparoscopic distal pancreatectomy may be safe and feasible in pediatric insulinoma patients.
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Affiliation(s)
- Ming-Gen Hu
- Department of Surgical Oncology (HBP), Chinese PLA General Hospital, Beijing, 100853, China
| | - Yuan-Hong Xiao
- Department of Pediatric Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Dong-Da Song
- Department of Surgical Oncology (HBP), Chinese PLA General Hospital, Beijing, 100853, China
| | - Guo-Dong Zhao
- Department of Surgical Oncology (HBP), Chinese PLA General Hospital, Beijing, 100853, China
| | - Yan-Zhe Liu
- Department of Surgical Oncology (HBP), Chinese PLA General Hospital, Beijing, 100853, China
| | - Zheng Wang
- Department of Pediatric Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Hao-Yu Li
- Department of Pediatric Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Rong Liu
- Department of Surgical Oncology (HBP), Chinese PLA General Hospital, Beijing, 100853, China.
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13
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Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference. Surg Endosc 2017; 31:2023-2041. [PMID: 28205034 DOI: 10.1007/s00464-017-5414-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/07/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients. METHODS An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey. RESULTS LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe. CONCLUSIONS LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.
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Wu M, Wang H, Zhang X, Gao F, Liu P, Yu B, Qiu H, Huang G, Tan X. Efficacy of laparoscopic ultrasonography in laparoscopic resection of insulinoma. Endosc Ultrasound 2017. [PMID: 28621290 PMCID: PMC5488516 DOI: 10.4103/2303-9027.194703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Insulinoma is the most common functioning islet cell tumor of the pancreas, with an annual incidence of 4 cases/1 million individuals. It is treated by surgical methods. Open surgery was once considered the standard approach for the treatment of insulinoma. However, the procedure is traumatic and requires a large incision, which does not satisfy the growing expectations of minimally invasive management of small-sized tumors. Insulinomas are usually benign solitary tumors and mostly occur sporadically, which makes them suitable candidates for laparoscopic management. The potential advantages of laparoscopic management of insulinoma over open surgery include shorter duration of hospitalization, quicker recovery, and better cosmetic effect. However, because of the small tumor size as well as the depth and uncertainty of the location of the tumor, laparoscopic localization of the lesion without tactile sensation is difficult. Laparoscopic ultrasonography can detect about 90% of insulinomas, and its sensitivity is comparable to that of manual palpation along with intraoperative ultrasonography during open surgery; thus, it ensures the feasibility of laparoscopic management of insulinoma and reinforces its advantage as a minimally invasive procedure. Laparoscopic ultrasonography is vital for the localization of insulinomas and characterization of the surrounding pancreatic structure and should, therefore, be considered an integral part of the laparoscopic management of insulinoma.
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Affiliation(s)
- Mengwei Wu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Huaitao Wang
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiaobo Zhang
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Feng Gao
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Peng Liu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Boqiang Yu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Huanbing Qiu
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Guanlong Huang
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiaodong Tan
- Department of Pancreatic and Thyroidal Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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15
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Insulinoma Detection With MDCT: Is There a Role for Whole-Pancreas Perfusion? AJR Am J Roentgenol 2016; 208:306-314. [PMID: 27929662 DOI: 10.2214/ajr.16.16351] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the role of whole-pancreas perfusion in detecting insulinomas with the use of MDCT. MATERIALS AND METHODS From January 2011 to December 2011, a total of 70 consecutive patients (33 men and 37 women; mean age, 46 years; range, 17-73 years) who underwent biphasic contrast-enhanced CT and whole-pancreas CT perfusion for suspected insulinomas were identified retrospectively. Patients were monitored for at least 3 years. Two radiologists who were blinded to the clinical and surgical data independently evaluated the images, first assessing only the biphasic contrast-enhanced CT images to detect tumor and assess diagnostic confidence on a 5-point scale. Next, perfusion parametric maps were evaluated and pancreatic perfusion parameters measured, and the presence of tumor was reidentified using a combination of the biphasic CT and perfusion image sets. A ROC curve was generated to compare the diagnostic accuracy of the two image sets. RESULTS The mean blood flow (BF) values of both the insulinomas and the insulinoma-harboring regions were statistically significantly higher (p < 0.01, for both) than the BF value of tumor-free pancreatic parenchyma. For the detection of insulinoma, biphasic CT had a sensitivity of 88.1%, a specificity of 85.7%, a positive predictive value of 91.1%, and a negative predictive value of 81.4%, whereas combined biphasic CT and perfusion had a sensitivity of 94.6%, a specificity of 94.7%, a positive predictive value of 96.7%, and a negative predictive value of 91.5%. The mean area under the ROC curve increased from 0.939 with biphasic CT to 0.999 with the addition of perfusion. Nine of 46 tumors (19.6%) for which findings were negative (n = 2) or indeterminate (n = 7) on biphasic CT were correctly diagnosed with the addition of perfusion. CONCLUSION The addition of pancreatic perfusion to biphasic contrast-enhanced CT may improve the detection of insulinomas.
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16
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Umemura A, Nitta H, Takahara T, Hasegawa Y, Sasaki A. Current status of laparoscopic pancreaticoduodenectomy and pancreatectomy. Asian J Surg 2016; 41:106-114. [PMID: 27688035 DOI: 10.1016/j.asjsur.2016.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/05/2016] [Accepted: 09/05/2016] [Indexed: 12/22/2022] Open
Abstract
This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic pancreaticoduodenectomy (LPD), laparoscopic distal pancreatectomy (LDP), laparoscopic central pancreatectomy (LCP), and laparoscopic total pancreatectomy (LTP). Some retrospective studies comparing LPD or LDP and open procedures have demonstrated the safety and feasibility as well as the intraoperative outcomes and postoperative recovery of these procedures. In contrast, LCP and LTP have not been widely accepted as common laparoscopic procedures owing to their complicated reconstruction and limited indications. Nevertheless, our concise review reveals that LCP and LTP performed by expert laparoscopic surgeons can result in good short-term and long-term outcomes. Moreover, as surgeons' experience with laparoscopic techniques continues to grow around the world, new innovations and breakthroughs in MIPS will evolve. Well-designed and suitably powered randomized controlled trials of LPD, LDP, LCP, and LTP are now warranted to demonstrate the superiority of these procedures.
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Affiliation(s)
- Akira Umemura
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan.
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
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17
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Sahakyan MA, Røsok BI, Kazaryan AM, Barkhatov L, Haugvik SP, Fretland ÅA, Ignjatovic D, Labori KJ, Edwin B. Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis. Surg Endosc 2016; 31:2310-2316. [PMID: 27620912 DOI: 10.1007/s00464-016-5233-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/30/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution. METHODS Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital-Rikshospitalet. Twenty-four (53.3 %) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7 %) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP). RESULTS Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53-320) vs 102 (50-373) min, P = 0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3 %; P = 0.19 and 20.8 vs 33.3 %, P = 0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2-80) vs 7 (2-52), P = 0.49]. A case-matched analysis demonstrated shorter operating time [145 (90-350) vs 103 (50-233) min, P = 0.02], but higher readmission rate following LLPE (25 vs 3.1 %, P = 0.037). CONCLUSION LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway.
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
- Department of Surgery No 1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Bård Ingvald Røsok
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Leonid Barkhatov
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Sven-Petter Haugvik
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Knut Jørgen Labori
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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Isoattenuating insulinomas at biphasic contrast-enhanced CT: frequency, clinicopathologic features and perfusion characteristics. Eur Radiol 2016; 26:3697-705. [PMID: 26815370 DOI: 10.1007/s00330-016-4216-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 12/30/2015] [Accepted: 01/13/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to determine the frequency of isoattenuating insulinomas, to investigate their clinicopathological features and to assess their regional pancreatic perfusion characteristics. METHODS Institutional review board approval was obtained, and patient informed consent was waived. From July 2010 to June 2014, 170 patients (66 male, 104 female) with endogenous hyperinsulinemic hypoglycemia underwent biphasic contrast-enhanced CT before surgery, and 129 of those patients also received preoperative whole-pancreas CT perfusion. A total of 181 tumours were proved histopathologically after surgery. Enhancement pattern and regional pancreatic perfusion characteristics were analyzed. Clinical features, tumour size and pathological grading were investigated. RESULTS The frequency of isoattenuating tumours was 24.9 %. Tumour size and WHO grading was not significantly different between isoattenuating and hyperattenuating tumours. Tumour-free regions had identical blood flow (BF) regardless of their location (p = 0.35). Isoattenuating tumour-harbouring regions had lower BF compared with hyperattenuating tumour-harbouring regions; both showed higher BF compared with tumour-free neighbourhood regions (all p < 0.01). For patients with isoattenuating tumours, the overall hospital stay was longer (p < 0.01). CONCLUSIONS A substantial subset of insulinomas were isoattenuating on biphasic CT. CT perfusion showed higher BF in tumour-harbouring regions compared to tumour-free regions, providing a clue for tumour regionalization. KEY POINTS • About a quarter of all insulinomas were isoattenuating on biphasic contrast-enhanced CT. • CT perfusion finds tumour-harbouring regions have higher blood-flow compared to tumour-free regions. • CT perfusion provides important information for tumour regionalization, for isoattenuating tumours.
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A novel technique of needle-guided laparoscopic enucleation of insulinomas. Surg Laparosc Endosc Percutan Tech 2015; 25:e24-e26. [PMID: 24743673 DOI: 10.1097/sle.0000000000000010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Insulinomas are rare, usually benign and solitary neuroendocrine tumors that cause oversecretion of insulin. Surgical excision remains the only treatment modality with the potential for cure. Compared to open extensive pancreatic resections, laparoscopic enucleation of these tumors offers effective treatment, and significantly reduced risks of complications. However, accurate tumor localization is extremely important, especially in cases of lesions deep seated into the head of the pancreas. We present here a novel technique of intraoperative localization of lesions that are not visible on the surface of pancreas. Using laparoscopic intraoperative ultrasound, tumors were located in the parenchyma of the pancreatic head and then an 18-G needle was inserted into the pancreatic lesion intraoperatively under laparoscopic sonographic guidance. The pancreatic parenchyma was then divided until the dome of tumor was visible, minimizing tissue trauma, and enucleation was performed. This technique is a useful tool that substantially improves the chances of successful laparoscopic enucleation of deep-seated small pancreatic insulinomas.
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20
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Antonakis PT, Ashrafian H, Martinez-Isla A. Pancreatic insulinomas: Laparoscopic management. World J Gastrointest Endosc 2015; 7:1197-1207. [PMID: 26566426 PMCID: PMC4639741 DOI: 10.4253/wjge.v7.i16.1197] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/22/2015] [Accepted: 09/07/2015] [Indexed: 02/05/2023] Open
Abstract
Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign, solitary, and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple’s triad, along with corroborating measurements of blood glucose, insulin, proinsulin, C-peptide, β-hydroxybutyrate, and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this, careful preoperative planning is required, with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound, which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings, but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit, laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore, this approach confers equivalent safety and efficacy rates to open resection, while improving cosmesis and reducing hospital stay. As such, laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.
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21
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Tarchouli M, Ali AA, Ratbi MB, Belhamidi MS, Essarghini M, Aboulfeth EM, Bouzroud M, Sbitti Y, Oukabli M, Elfahssi M, Sair K. Long-standing insulinoma: two case reports and review of the literature. BMC Res Notes 2015; 8:444. [PMID: 26374700 PMCID: PMC4572617 DOI: 10.1186/s13104-015-1424-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 09/07/2015] [Indexed: 02/07/2023] Open
Abstract
Background Insulinomas are rare pancreatic endocrine tumors. Most are benign and solitary. However, the nonspecific symptoms and small size of these tumors led to difficulties of diagnosis and localization. Case presentation We present two Arab patients with pancreatic long-standing insulinoma. Both patients presented episodic hypoglycemic symptoms respectively during 10 and 2 years. Biochemical and morphological workup detected localized pancreatic insulinoma. Open procedure surgery was done for the two patients and insulinomas were successfully removed by enucleation. Conclusion Insulinoma remains a diagnostic challenge to practitioners. Diagnosis of suspected cases is easily confirmed by standard endocrine tests, especially the supervised fasting test. Accurate preoperative localization is essential for more effective and safest surgery.
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Affiliation(s)
- Mohamed Tarchouli
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Abdelmounaim Ait Ali
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Moulay Brahim Ratbi
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Mohamed said Belhamidi
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Mohamed Essarghini
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - El Mehdi Aboulfeth
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Mohamed Bouzroud
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Yassir Sbitti
- Department of Oncology, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Mohamed Oukabli
- Department of Pathology, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Mohammed Elfahssi
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
| | - Khalid Sair
- Department of Digestive Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Hospital, Mohammed V University, Rabat, Morocco.
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Soheilipour F, Jesmi F, Ahmadi M, Pazouki A, Alibeigi P, Abdolhosseini M. Minimally invasive surgical interventions in the treatment of primary persistent hyperinsulinemic hypoglycemia of infancy. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015; 59:466-9. [PMID: 26331229 DOI: 10.1590/2359-3997000000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 04/20/2015] [Indexed: 11/22/2022]
Abstract
Hyperinsulinemia, diagnosed by laboratory tests, should be diagnosed and treated as soon as possible to prevent fatal complications such as neurological damage. Patients who are resistant to medical therapy should be treated surgically. Minimally invasive surgery, a newly developed approach, is a good choice among surgical procedures to avoid unnecessary extensive pancreatectomy. Here, a 12-year-old boy is presented with diagnosis of hyperinsulinemic hypoglycemia who had recurrent attacks of hypoglycemia and seizures from infancy. Because of his unresponsiveness to medical therapy and his family's preference, he underwent laparoscopic pancreatectomy to reduce morbidity and hospital stay. Two years postsurgical follow-up revealed a normo-glycemic state.
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Affiliation(s)
- Fahimeh Soheilipour
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Jesmi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ahmadi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolreza Pazouki
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Peyman Alibeigi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
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Nakamura Y, Matsushita A, Katsuno A, Yamahatsu K, Sumiyoshi H, Mizuguchi Y, Uchida E. Clinical outcomes of 15 consecutive patients who underwent laparoscopic insulinoma resection: The usefulness of monitoring intraoperative blood insulin during laparoscopic pancreatectomy. Asian J Endosc Surg 2015; 8:303-9. [PMID: 25869736 DOI: 10.1111/ases.12187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/16/2015] [Accepted: 02/25/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Insulinoma is a very serious functional tumor. Surgeons should confirm complete resection of insulinomas before completing the operation, even in laparoscopic surgery. METHODS Between August 2007 and September 2014, 15 consecutive patients with biochemical evidence of an insulinoma underwent laparoscopic pancreatectomy. Intraoperatively, a peripheral arterial blood sample was taken, and insulin was measured by quick insulin assay. Insulin levels were determined before anesthesia induction, every 30 min thereafter, and every 30 min for at least 1 h after tumor resection to confirm insulin levels did not increase before surgery was completed. RESULTS All 15 patients (3 men and 12 women, average age 57.2 years) successfully underwent laparoscopic resection. One patient had two tumors, and the remaining 14 patients had one tumor each (three in the head, five in the body, and eight in the tail of the pancreas). Preoperative localization and regionalization studies identified the tumor correctly through CT (12/15 [80.0%]), MRI (9/12 [75.0%]), angiography (11/13 [84.6%]), endoscopic ultrasonography (7/10 [70.0%]), and selective arterial calcium injection (14/14 [100%]). Intraoperative ultrasonography detected 13 of 15 tumors (86.7%), and intraoperative blood insulin monitoring confirmed the complete resection of 16 of 16 tumors (100%). All patients were discharged with normal insulin levels and have been followed up for 3-88 months. There has been no recurrence of symptoms in any patients and none has died. CONCLUSION Complete removal of an insulinoma can be reliably predicted by intraoperative blood insulin monitoring even in laparoscopic pancreatectomies.
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Affiliation(s)
- Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Akira Matsushita
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Akira Katsuno
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kazuya Yamahatsu
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroki Sumiyoshi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Yoshiaki Mizuguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Eiji Uchida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Mohkam K, Farges O, Pruvot FR, Muscari F, Régimbeau JM, Regenet N, Sa Cunha A, Dokmak S, Mabrut JY. Toward a standard technique for laparoscopic distal pancreatectomy? Synthesis of the 2013 ACHBT Spring workshop. J Visc Surg 2015; 152:167-78. [DOI: 10.1016/j.jviscsurg.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Doi R. Determinants of surgical resection for pancreatic neuroendocrine tumors. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:610-7. [PMID: 25773163 DOI: 10.1002/jhbp.224] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/14/2015] [Indexed: 12/14/2022]
Abstract
Pancreatic neuroendocrine tumors (pNETs) include functioning and non-functional tumors. Functioning tumors consist of tumors that produce a variety of hormones and their clinical effects. Therefore, determinants of resection of pNETs should be discussed for each group of tumors. Less than 10% of insulinomas are malignant, therefore more than 90% of the cases can be cured by surgical resection. Lymphadenectomy is generally not necessary in insulinoma operation. If preoperative localization of the insulinoma is completed, enucleation from the pancreatic body or tail, and distal pancreatectomy can be performed safely by laparoscopy. When preoperative localization of a sporadic insulinoma is not confirmed, surgical exploration is needed. Intraoperative localization of a tumor, intraoperative insulin sampling and frozen section are required. The crucial purpose of surgical resection is to control inappropriate insulin secretion by removing all insulinomas. Gastrinomas are usually located in the duodenum or pancreas, which secrete gastrin and cause Zollinger-Ellison syndrome (ZES). Duodenal gastrinomas are usually small, therefore they are not seen on preoperative imaging studies or endoscopic ultrasound, and can be found only at surgery if a duodenotomy is performed. In addition, lymph node metastasis is found in 40-60% of cases. Therefore, the experienced surgeons should direct operation for gastrinomas. Surgical exploration with duodenotomy should be performed at a laparotomy. Other functioning pNETs can occur in the pancreas or in other locations. Curative resection is always recommended whenever possible after optimal symptomatic control of the clinical syndrome by medical treatment. Indications for surgery depend on clinical symptom control, tumor size, location, extent, malignancy and presence of metastasis. A lot of non-functioning pNETs are found incidentally according to the quality improvement of imaging techniques. Localized, small, malignant non-functioning pNETs should be operated on aggressively, while in possibly benign tumors smaller than 2 cm the surgical risk-benefit ratio should be carefully weighted. Surgical liver resection is generally proposed in curative intent to all patients with operable metastases from G1 or G2 pNET. The benefits of surgical resection of liver metastases have been demonstrated in terms of overall survival and quality of life. Complete resection is associated with better long-term survival.
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Affiliation(s)
- Ryuichiro Doi
- Department of Surgery, Otsu Red Cross Hospital, 1-1-35 Nagara, Otsu, Shiga, 520-8511, Japan
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D’Haese JG, Tosolini C, Ceyhan GO, Kong B, Esposito I, Michalski CW, Kleeff J. Update on surgical treatment of pancreatic neuroendocrine neoplasms. World J Gastroenterol 2014; 20:13893-13898. [PMID: 25320524 PMCID: PMC4194570 DOI: 10.3748/wjg.v20.i38.13893] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/07/2014] [Accepted: 06/23/2014] [Indexed: 02/07/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (PNENs) are rare and account for only 2%-4% of all pancreatic neoplasms. All PNENs are potential (neurendocrine tumors PNETs) or overt (neuroendocrine carcinomas PNECs) malignant, but a subset of PNETs is low-risk. Even in case of low-risk PNETs surgical resection is frequently required to treat hormone-related symptoms and to obtain an appropriate pathological diagnosis. Low-risk PNETs in the body and the tail are ideal for minimally-invasive approaches which should be tailored to the individual patient. Generally, surgeons must aim for parenchyma sparing in these cases. In high-risk and malignant PNENs, indications for tumor resection are much wider than for pancreatic adenocarcinoma, in many cases due to the relatively benign tumor biology. Thus, patients with locally advanced and metastatic PNETs may benefit from extensive resection. In experienced hands, even multi-organ resections are accomplished with acceptable perioperative morbidity and mortality rates and are associated with excellent long term survival. However, poorly differentiated neoplasms with high proliferation rates are associated with a dismal prognosis and may frequently only be treated with chemotherapy. The evidence on surgical treatment of PNENs stems from reviews of mostly single-center series and some analyses of nation-wide tumor registries. No randomized trial has been performed to compare surgical and non-surgical therapies in potentially resectable PNEN. Though such a trial would principally be desirable, ethical considerations and the heterogeneity of PNENs preclude realization of such a study. In the current review, we summarize recent advances in the surgical treatment of PNENs.
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Abstract
Surgical resection is a standard treatment for insulinomas; however, it is associated with a high risk of complications and limited to specific suitable candidates. In recent years, endoscopic ultrasound (EUS)-guided ethanol ablation of insulinomas has emerged as a new therapeutic option, especially for elderly patients and candidates unfit for surgery. We aimed to evaluate the feasibility and safety of this technique for insulinomas. Four patients diagnosed with insulinomas based on EUS-fine-needle aspiration and immunohistochemistry results underwent EUS-guided 95% ethanol ablation. A comprehensive literature review was performed to understand the current status of the feasibility, safety, and effects of EUS-guided ethanol ablation of insulinomas. EUS-guided ethanol ablation of insulinomas was successfully completed in all the 4 patients. There were no perioperative or postoperative complications. The patients were discharged at 3 days after the procedure. No recurrence of hypoglycemia or tumors was noted during follow-up (range, 3-6 months). Literature review showed 8 patients with insulinomas who underwent EUS-guided ethanol ablation. All the procedures were successful, with no need for further surgical treatment. Among these reviewed cases, 6 patients had no post-procedural complications, while other 2 patients showed a mild increase in the serum levels of lipase and/or pancreatic enzymes within 48 h post-procedure; furthermore, 1 of these 2 patients presented at a later date with medically controllable hematoma and ulceration. During follow-up, 6 patients remained asymptomatic and normoglycemic, while the 2 patients who presented post-procedural complications developed occasional mild confusion. EUS-guided ethanol ablation of insulinomas is an effective and safe modality, with an acceptable level of post-procedural complications. However, the long-term effects of this new therapeutic option need to be validated in a large randomized controlled trial with longer follow-up.
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Affiliation(s)
- Shan-Yu Qin
- Department of Gastroenterology (SQ, XL, HJ), First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Laparoscopic spleen-preserving distal pancreatectomy for insulinoma: experience of a single center. Int J Surg 2014; 12 Suppl 1:S152-5. [PMID: 24862672 DOI: 10.1016/j.ijsu.2014.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Laparoscopic spleen-preserving distal pancreatectomy is gaining acceptance for the treatment of insulinomas of the pancreatic body and tail. The aim of this report is to evaluate the feasibility, safety and outcomes of this procedure in a retrospective series. METHODS From May 2004 to November 2013, 9 patients underwent laparoscopic spleen-preserving distal pancreatectomy for benign insulinomas in our department. Tumors were single and sporadic in eight patients, while the remaining patient had insulinomas in the setting of multiple endocrine neoplasia type 1. Tumors were located by preoperative imaging in all cases. Laparoscopic ultrasound was always performed to guide the surgical procedure. RESULTS All the operations were carried out laparoscopically with a mean operative time of 110 min (range 90-210 min) and a mean blood loss of 50 ml (range 30-120 ml). One patient (11.1%) died on the 22nd post-operative day for massive intra-abdominal bleeding associated with pancreatitis of the stump. Two patients (22.2%) developed pancreatic fistula that healed conservatively. Mean postoperative hospital stay was 7.1 days (range 5-18 days). All alive patients were free from recurrence after a mean follow-up of 45 months (range 11-72 months). CONCLUSION Laparoscopic spleen-preserving distal pancreatectomy is safe and feasible for the management of benign insulinomas. Definition of the tumor with preoperative imaging and laparoscopic ultrasound is essential to achieve high cure rate with minimal conversion.
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Joseph AJ, Kapoor N, Simon EG, Chacko A, Thomas EM, Eapen A, Abraham DT, Jacob PM, Paul T, Rajaratnam S, Thomas N. Endoscopic ultrasonography--a sensitive tool in the preoperative localization of insulinoma. Endocr Pract 2014; 19:602-8. [PMID: 23425640 DOI: 10.4158/ep12122.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A number of imaging modalities have been used in the preoperative localization of insulinomas. Computed tomography (CT) is the most commonly employed modality. Endoscopic ultrasound (EUS) allows the transducer to be placed in close proximity to the pancreas, thereby yielding higher quality images, which facilitates accurate localization, minimally invasive surgery, and a lower occurrence of residual tumors, all of which contribute to a better clinical outcome. METHODS We analyzed the hospital records of all adult patients (age >18 years) diagnosed with insulinoma between October 2004 and September 2010. The diagnosis was based on the clinical practice guidelines of the American Endocrine Society. We compared the sensitivities of EUS and multidetector computed tomography (MDCT) in lesion. RESULTS Eighteen patients were seen over a period of 6 years, and all underwent EUS. MDCT scans were carried out in 17 patients. EUS had greater sensitivity (89%) in localizing insulinomas compared to CT (69%). In this series, the lesions that were missed on CT but picked up on EUS were smaller (<12 mm, P<.001). Lesions that were near mesenteric vessels and those located in the head of the pancreas were more likely to be missed on CT. CONCLUSIONS EUS has a greater sensitivity in identifying and localizing insulinomas. As availability increases, EUS should be part of a preoperative insulinoma workup.
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Affiliation(s)
- A J Joseph
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Al-Saigh TH. Insulinoma: rare yet important. BMJ Case Rep 2014; 2014:bcr-2013-202395. [PMID: 24577177 DOI: 10.1136/bcr-2013-202395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report our experience with six cases of insulinoma that were managed at our hospital between 2009 and 2013. Four patients were women and two men, with mean age of 43 years and mean duration of symptoms before diagnosis of 5.7 years. Biochemical confirmation was made in all cases and preoperative localisation was successful in two cases only. In the other four, intraoperative localisation was made. Enucleation was performed in four patients and distal pancreatectomy in the other two. The tumour was proved benign in all patients by histopathology. Postoperatively, all patients were asymptomatic during a follow-up period ranging from 9 months to 4 years and both serum glucose and insulin were normal during that period. We think that careful preoperative workup and skilful surgical techniques can end the prolonged suffering of patients with insulinomas with excellent results.
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Subar D, Gobardhan PD, Gayet B. Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center. Best Pract Res Clin Gastroenterol 2014; 28:123-32. [PMID: 24485260 DOI: 10.1016/j.bpg.2013.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/10/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.
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Affiliation(s)
- D Subar
- Department of General and HPB Surgery, Royal Blackburn Hospital, Lancashire, UK.
| | - P D Gobardhan
- Department of Surgery, Amphia Hospital, Breda, The Netherlands.
| | - B Gayet
- Department of Digestive Diseases, Institut Mutualiste Montsouris, Paris, France.
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Kuroki T, Eguchi S. Laparoscopic parenchyma-sparing pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:323-7. [PMID: 24027045 DOI: 10.1002/jhbp.29] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In recent years laparoscopic pancreatic procedures have developed rapidly, and reports of laparoscopic resection including laparoscopic distal pancreatectomy and laparoscopic pancreaticoduodenectomy have increased in number. On the other hand, many benign and low-grade malignant pancreatic lesions have recently been detected by the improved diagnostic modalities. Parenchyma-sparing pancreatectomy is a preferred surgical procedure for such benign and low-malignancy pancreatic lesions, because parenchyma-sparing pancreatectomy can avoid the unnecessary resection of the normal pancreatic parenchyma, thereby preserving the endocrine and exocrine functions of the pancreas. Simultaneously, laparoscopic surgery has contributed to minimally invasive approaches for various pancreatic surgical procedures. The combination of laparoscopic surgery and parenchyma-sparing pancreatectomy is an ideal surgical procedure for benign and low-grade malignant pancreatic lesions. For laparoscopic parenchyma-sparing pancreatectomy to become more widely known and its indications clarified, it is necessary to demonstrate the clinical benefits, technical feasibility, and safety of this complex and difficult surgical procedure.
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Affiliation(s)
- Tamotsu Kuroki
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
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Su AP, Ke NW, Zhang Y, Liu XB, Hu WM, Tian BL, Zhang ZD. Is laparoscopic approach for pancreatic insulinomas safe? Results of a systematic review and meta-analysis. J Surg Res 2013; 186:126-34. [PMID: 23992857 DOI: 10.1016/j.jss.2013.07.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/14/2013] [Accepted: 07/26/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND No consensus exists as to whether laparoscopic treatment for pancreatic insulinomas (PIs) is safe and feasible. The aim of this meta-analysis was to assess the feasibility, safety, and potential benefits of laparoscopic approach (LA) for PIs. The abovementioned approach is also compared with open surgery. METHODS A systematic literature search (MEDLINE, EMBASE, Cochrane Library, Science Citation Index, and Ovid journals) was performed to identify relevant articles. Articles that compare the use of LA and open approach to treat PI published on or before April 30, 2013, were included in the meta-analysis. The evaluated end points were operative outcomes, postoperative recovery, and postoperative complications. RESULTS Seven observational clinical studies that recruited a total of 452 patients were included. The rates of conversion from LA to open surgery ranged from 0%-41.3%. The meta-analysis revealed that LA for PIs is associated with reduced length of hospital stay (weighted mean difference, -5.64; 95% confidence interval [CI], -7.11 to -4.16; P < 0.00001). No significant difference was observed between LA and open surgery in terms of operation time (weighted mean difference, 2.57; 95% CI, -10.91 to 16.05; P = 0.71), postoperative mortality, overall morbidity (odds ratio [OR], 0.64; 95% CI, 0.35-1.17; P = 0.14], incidence of pancreatic fistula (OR, 0.86; 95% CI, 0.51-1.44; P = 0.56), and recurrence of hyperglycemia (OR, 1.81; 95% CI, 0.41-7.95; P = 0.43). CONCLUSIONS Laparoscopic treatment for PIs is a safe and feasible approach associated with reduction in length of hospital stay and comparable rates of postoperative complications in relation with open surgery.
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Affiliation(s)
- An-Ping Su
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Ćwik G. Standards of the Polish Ultrasound Society - update. Pancreas examination. J Ultrason 2013; 13:167-77. [PMID: 26676070 PMCID: PMC4613590 DOI: 10.15557/jou.2013.0017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 01/25/2013] [Accepted: 02/03/2013] [Indexed: 01/18/2023] Open
Abstract
Ultrasound examination of the pancreas constitutes an integral part of the abdominal ultrasound. It is mostly indicated to diagnose pain in the epigastrium, discomfort and jaundice as well as to monitor the patients with acute pancreatitis. The assessment of this organ in an ultrasound examination may be problematic due to its anatomical location and the fact that it might be covered by gastric and duodenal contents as well as due to a number of possible pathological changes, including inflammation and benign or malignant neoplasms, which require differentiation. The basis for establishing a correct diagnosis is the knowledge of the examination technique, correct pancreas structure and images of individual pathologies. This paper presents the standards of ultrasound examination published in 2011 and updated with the current knowledge. The following are discussed: preparation of the patient for the examination, abnormal lesions in the pancreas, acute pancreatitis, chronic pancreatitis, cystic lesions (benign and malignant cysts) and solid focal lesions. Ultrasound is also used to guide the drainage of fluid cisterns, abscesses and cysts. The prime role in the diagnosis and treatment of selected diseases of the upper gastrointestinal tract and parenchymal organs of the abdomen belongs to endosonography of the upper gastrointestinal tract, with the possibility to conduct a fine needle aspiration biopsy, and intraoperative or laparoscopic ultrasound.
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Affiliation(s)
- Grzegorz Ćwik
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie, Lublin, Polska
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Carrère N, Mathonnet M, Mirallié É, Pattou F, Sa-Cunha A. Surgical treatment. ANNALES D'ENDOCRINOLOGIE 2013; 74:191-5. [PMID: 23806168 DOI: 10.1016/j.ando.2013.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Nicolas Carrère
- Service de chirurgie générale et digestive, pôle digestif, hôpital Purpan, CHU de Toulouse, 31059 Toulouse cedex 9, France
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Knigge U, Hansen CP. Surgery for GEP-NETs. Best Pract Res Clin Gastroenterol 2012; 26:819-31. [PMID: 23582921 DOI: 10.1016/j.bpg.2012.12.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/27/2012] [Indexed: 01/31/2023]
Abstract
Surgery is the only treatment that may cure the patient with gastroentero-pancreatic (GEP) neuroendocrine tumours (NET) and neuroendocrine carcinomas (NEC) and should always be considered as first line treatment if R0/R1 resection can be achieved. The surgical and interventional procedures for GEP-NET are accordingly described below. Life-long follow-up should be performed in almost all patients at a specialized NET center.
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Affiliation(s)
- Ulrich Knigge
- Department of Gastrointestinal Surgery C, Neuroendocrine Tumor Centre of Excellence, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Risk factors for postoperative pancreatic fistulization subsequent to enucleation. J Gastrointest Surg 2012; 16:1883-7. [PMID: 22872510 DOI: 10.1007/s11605-012-1971-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 07/15/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Pancreatectomies increase the risk of postoperative pancreatic fistula (POPF) and pancreatic insufficiency. Pancreatic enucleation preserves pancreatic parenchyma, lowers the risk of pancreatic insufficiency, but may induce specific complications (tumor recurrence or pancreatic fistulization). The aim of this study was to determine the risk factors for POPF following a pancreatic enucleation. METHODS A retrospective analysis was designed based on data from patients who underwent pancreatic enucleation in five university hospitals (1998-2008). The presence of a pancreatic fistula was determined according to the criteria of the International Study Group of Pancreatic Fistula (Bassi et al. Surgery 138:8-13, 2005). RESULTS Fifty-two patients (mean age 52 years) were included. Histological analysis revealed 35 endocrine tumors (68.6 %), 6 mucinous and 2 serous cyst adenomas, 2 metastases of renal cancer, and 8 benign tumors. Nineteen patients (36.5%) suffered postoperative complications including 14 POPF (27 %). Median postoperative hospital stay was 12.9 days; 9.1 days without POPF versus 29 days with POPF (p < 0.05). Size of the tumor, its location, histological differentiation, and use of somatostatin analogs were not predictors for POPF. We defined the cutoff for POPF at a distance of 2 mm from the main pancreatic duct based on 60% risk (≤2 mm) versus 19 % (>2 mm) of POPF (p < 0.01). With a mean follow-up of 30.8 months, one patient experienced recurrence of the tumor. No patients exhibited a new onset of diabetes or pancreatic insufficiency. CONCLUSION Enucleation for resection of pancreatic tumors located at less than or equal to two 2 mm from the main pancreatic duct is a risk factor for POPF. Enucleation is a safe and effective treatment for benign or borderline pancreatic tumors.
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Fisher SB, Kooby DA. Laparoscopic pancreatectomy for malignancy. J Surg Oncol 2012; 107:39-50. [PMID: 22991263 DOI: 10.1002/jso.23253] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/09/2012] [Indexed: 12/15/2022]
Abstract
Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.
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Affiliation(s)
- Sarah B Fisher
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Advanced staging laparoscopy using single-incision approach for unresectable pancreatic cancer. Surg Laparosc Endosc Percutan Tech 2012; 21:e301-5. [PMID: 22146176 DOI: 10.1097/sle.0b013e31823bae57] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE As laparoscopy can detect imaging-occult metastatic lesions, it has been validated as a means of improving the assessment of tumor staging. Although controversy exists as to whether the procedure should be used routinely or selectively in pancreatic cancer patients, patients considered for treatment protocols for locally unresectable pancreatic cancer should be staged laparoscopically before initiation of therapy. We evaluate the feasibility and safety of advanced staging laparoscopy including peritoneal lavage cytology, laparoscopic ultrasound sonography (LUS), and LUS-guided biopsy through a single incision for locally advanced pancreatic cancer. METHODS Staging laparoscopy was performed in 44 patients with pancreatic cancer for deciding on treatment strategy. Our procedures included extensive peritoneal lavage of abdominal cavity for cytology, LUS for small metastasis detection, and tissue sample excision including LUS-guided biopsy. Eleven consecutive patients were treated with a single-incision staging laparoscopy approach (SI-SL group). The clinical parameters were compared between the SI-SL group and the multi-incision staging laparoscopy group (multi-incision group). RESULTS The mean operating time was longer and bleeding volume was less in the SI-SL group, although the differences were without statistical significance. The conversion rates to laparotomy were 9% in the SI-SL group and 30% in the multi-incision group. There were no severe postoperative complications. LUS-guided biopsy revealed malignancy for 3 patients in the SI-SL group. CONCLUSIONS Advanced SI-SL is a feasible and safe alternative to the multi-incision approach for pancreatic cancer.
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Jensen RT, Cadiot G, Brandi ML, de Herder WW, Kaltsas G, Komminoth P, Scoazec JY, Salazar R, Sauvanet A, Kianmanesh R. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: functional pancreatic endocrine tumor syndromes. Neuroendocrinology 2012; 95:98-119. [PMID: 22261919 PMCID: PMC3701449 DOI: 10.1159/000335591] [Citation(s) in RCA: 337] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Richards ML, Thompson GB, Farley DR, Kendrick ML, Service JF, Vella A, Grant CS. Setting the bar for laparoscopic resection of sporadic insulinoma. World J Surg 2011; 35:785-9. [PMID: 21293961 DOI: 10.1007/s00268-011-0970-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Laparoscopic insulinoma resection (LIR) for sporadic disease is increasingly supported as a feasible and safe operation in small series of patients. To determine whether LIR is an acceptable alternative to the open operation, it is necessary to compare LIR to historical controls. The purpose of this study was to identify the skills and technology needed for LIR and establish outcome standards. METHODS A database of patients with benign sporadic insulinoma who underwent an open procedure at the Mayo Clinic was reviewed for demographics, imaging, operative/pathology reports, and outcomes. Outcomes were compared to a world-wide meta-analysis of patients who had undergone LIR reported in the English literature between 1996 and 2009. RESULTS Two hundred fifteen patients underwent a primary open operation for benign sporadic insulinoma. Solitary tumors were found in 97%. Meta-analysis identified 232 patients who underwent LIR. The open and LIR groups underwent comparable operations that included enucleations (64 vs. 68%) and distal pancreatectomies (28 vs. 35%) (p = 0.06). The mean estimated blood loss, operating time, and length of stay were comparable between the open and LIR groups (p = NS). Pancreatic fistula occurred more often in the LIR group (24 vs. 11%, p < 0.05). A curative operation was performed in 98% of control patients and in 99% of the LIR group (p = NS). CONCLUSIONS Multiple insulinomas are rare and a focused resection guided by imaging may be performed. LIR is associated with an increased incidence of pancreatic fistula. Success of LIR will depend on accurate multimodality preoperative imaging, skilled use of lap-US to replace palpation for localization, and safe methods to dissect the tumor adjacent to the pancreatic duct.
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Affiliation(s)
- Melanie L Richards
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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Li W, An L, Liu R, Yao K, Hu M, Zhao G, Tang J, Lv F. Laparoscopic ultrasound enhances diagnosis and localization of insulinoma in pancreatic head and neck for laparoscopic surgery with satisfactory postsurgical outcomes. ULTRASOUND IN MEDICINE & BIOLOGY 2011; 37:1017-1023. [PMID: 21640474 DOI: 10.1016/j.ultrasmedbio.2011.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 04/04/2011] [Accepted: 04/08/2011] [Indexed: 05/30/2023]
Abstract
This study explored the value of laparoscopic ultrasonography (LUS) for tumor localization in laparoscopic pancreatic surgery of insulinomas, especially for tumors located at anatomically unfavorable positions. Twenty-eight patients with insulinomas were enrolled in this study between July 2007 and March 2009. Various image examinations were performed preoperatively. An iU22 ultrasound system equipped with a 5.0-9.0 MHz transducer was used for LUS. The tumor localization and postsurgical outcomes were evaluated. Intraoperative LUS precisely localized 33 insulinomas in 26 of 28 patients, whereas the preoperative imaging studies detected 27 of 33 (82%) tumors. No definite tumor in the pancreas and extra-pancreatic organs was identified in two patients by both preoperative and intraoperative imaging examinations. Of 33 tumors, 32 (97%) were localized in the pancreas (14 in the head and neck, 18 in the body and tail), whereas one (3%) was found in the duodenal ligament. Successful laparoscopic resection of insulinoma was performed in 21 of 26 patients, including resection of 11 tumors located in the head and neck of the pancreas. Five patients required conversion to open surgery. All insulinomas were benign with a mean size 13.8 mm. Four patients had pancreatic-related complications that spontaneously healed within 3 weeks after surgery. The median hospital stay was 8.5 days. Our study demonstrates that laparoscopic pancreatic resection under the guidance of advanced LUS is not only feasible and safe for tumors located at the body and tail but also for tumors located at the head and neck of the pancreas.
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Affiliation(s)
- Wenxiu Li
- Department of Ultrasound, Chinese People's Liberation Army General Hospital of Airforce, Beijing, P.R. China.
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Sun MRM, Brennan DD, Kruskal JB, Kane RA. Intraoperative ultrasonography of the pancreas. Radiographics 2011; 30:1935-53. [PMID: 21057128 DOI: 10.1148/rg.307105051] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Intraoperative ultrasonography (US) of the pancreas is a versatile technique that provides excellent spatial and contrast resolution and real-time imaging capabilities, making it useful for diagnostic imaging as well as for guidance of laparoscopic and open operative procedures. Intraoperative US may be used for applications such as staging and localizing tumors; performing regional metastatic surveys; documenting arterial and venous patency; identifying endocrine tumors; distinguishing pancreatitis from a neoplasm; and guiding biopsy, duct cannulation, and drainage of abscesses or cysts. The scanning approach and technique vary according to the application, with many different equipment and transducer options and sterilization methods available. With increasing clinical demands for intraoperative US, it is essential that radiologists be familiar with its uses and technique. In addition, to properly perform intraoperative US and accurately interpret the images, knowledge of normal and variant pancreatic and vascular anatomy and relevant landmarks is needed. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.307105051/-/DC1.
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Affiliation(s)
- Maryellen R M Sun
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, CCW, Boston, MA 02215, USA.
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Butturini G, Partelli S, Crippa S, Malleo G, Rossini R, Casetti L, Melotti GL, Piccoli M, Pederzoli P, Bassi C. Perioperative and long-term results after left pancreatectomy: a single-institution, non-randomized, comparative study between open and laparoscopic approach. Surg Endosc 2011; 25:2871-8. [PMID: 21424200 DOI: 10.1007/s00464-011-1634-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 01/28/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic left pancreatic resections are being increasingly performed. In this study, we provide a nonrandomized comparison between laparoscopic and open left pancreatectomy (OLP) for benign and borderline tumors, focusing on both perioperative and long-term results. METHODS Demographic, pathologic, and perioperative details from patients who underwent laparoscopic and OLP between 1999 and 2006 were retrieved from our database and analyzed. Long-term results, including resume to full-time work, occurrence of incisional hernias, and incidence of exocrine and endocrine insufficiency also were evaluated. RESULTS A total of 116 patients were included in the analysis; 43 (37.1%) were managed laparoscopically and 73 (62.9%) underwent the open procedure. There were no significant differences regarding clinical and pathological data. All of the resections attempted laparoscopically were completed. The rate of splenic preservation was significantly higher in the laparoscopic group (P = 0.0001). Postoperative outcomes were similar between the two groups. Longitudinal comparison between two time periods (1999-June 2004 vs. July 2004-2006) showed that pancreatic fistula and hospital stay significantly diminished over time in the laparoscopic group (P = 0.04 and P = 0.004, respectively). Median follow-up was 53 months. The incidence of exocrine insufficiency and incisional hernias was significantly higher after open resections (both P = 0.05). After hospital discharge, median time to resume full-time work was 6 weeks in the open group and 3 weeks after laparoscopic resections (P < 0.0001). Laparoscopy also resulted as an independent factor for an early resume to full-time activities in the multivariate analysis (P < 0.0001). CONCLUSIONS Laparoscopic left pancreatectomy is a safe procedure for benign and borderline tumors, with similar perioperative outcomes compared with the open procedure. In the long term, the laparoscopic approach is likely to be superior thanks to a more rapid resume of full-time activities and to the lower incidence of incisional hernias and exocrine insufficiency. Clearly, these results have yet to be confirmed in large, randomized trials.
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Affiliation(s)
- Giovanni Butturini
- Department of Surgery, G.B. Rossi Hospital, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy.
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Zhao YP, Zhan HX, Zhang TP, Cong L, Dai MH, Liao Q, Cai LX. Surgical management of patients with insulinomas: Result of 292 cases in a single institution. J Surg Oncol 2010; 103:169-74. [PMID: 21259252 DOI: 10.1002/jso.21773] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 09/14/2010] [Indexed: 01/18/2023]
Abstract
BACKGROUND Insulinoma is rare tumor with an incidence of approximately four cases per million per year. There are few large sample, single-center series that focus on the surgical management strategy of insulinomas. PATIENTS AND METHODS Medical records of patients diagnosed as insulinoma from 1990 to 2010 in Peking Union Medical College Hospital were reviewed retrospectively. Clinical data were collected and statistically analyzed. RESULTS A total of 328 patients were diagnosed with insulinomas; 292 of them underwent 320 operations, which included 46 laparoscopic surgeries. Tumor enucleation was the most common operative procedure. Multiple tumors were found in 30 cases; 17 cases were multiple endocrine neoplasia-1 syndrome. Thirteen patients with malignant insulinomas underwent tumor resection. Pancreatic fistula (PF) was the most frequent complication, and the incidence of clinical PFs (Grades B and C) was 14.4%. There was no significant statistical difference between open and laparoscopic surgery in blood loss, operative time, and complications. Metachronous tumors were noted in 11 patients. CONCLUSION Surgery is the best treatment of choice for insulinoma patients. Surgical approach depends on tumor size, location, and its pathological characters. Laparoscopic management of insulinomas is feasible and safe for tumors located in the body or tail of the pancreas. Open surgery combined with intraoperative ultrasonography is recommended to avoid omission of lesions in patients with multiple insulinomas. An aggressive surgical approach is indicated for malignant insulinoma patients.
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Affiliation(s)
- Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, PR China.
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Kulke MH, Anthony LB, Bushnell DL, de Herder WW, Goldsmith SJ, Klimstra DS, Marx SJ, Pasieka JL, Pommier RF, Yao JC, Jensen RT. NANETS treatment guidelines: well-differentiated neuroendocrine tumors of the stomach and pancreas. Pancreas 2010; 39:735-52. [PMID: 20664472 PMCID: PMC3100728 DOI: 10.1097/mpa.0b013e3181ebb168] [Citation(s) in RCA: 370] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Well-differentiated neuroendocrine tumors (NETs) of the stomach and pancreas represent 2 major subtypes of gastrointestinal NETs. Historically, there has been little consensus on the classification and management of patients with these tumor subtypes. We provide an overview of well-differentiated NETs of the stomach and pancreas and describe consensus guidelines for the treatment of patients with these malignancies.
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Affiliation(s)
- Matthew H Kulke
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston MA 02115, USA.
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Abstract
The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.
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Affiliation(s)
- Carrie K Chu
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road, NE, H120, Atlanta, GA 30322, USA
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Abstract
Insulinoma is a rare neuroendocrine tumor that causes oversecretion of insulin and, as a result, patients present with symptoms of hypoglycemia. Fortunately, insulinomas are usually benign and solitary, and surgical cure rates are highly favorable. Most of these tumors occur sporadically, but they can also be associated with multiple endocrine neoplasia type-1 syndrome. The diagnosis is confirmed by a supervised fast, and early detection is important. Several preoperative and intraoperative techniques with various success rates have been employed in order to localize the lesion. When technically feasible, tumor enucleation is the procedure of choice; however, a more formal resection may be necessary for certain tumors. In the age of laparoscopy, the role of laparoscopic surgery in the management of insulinomas is continuing to attract attention. This review will discuss the historical background, pathogenesis, diagnosis, localization and management of insulinomas.
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Affiliation(s)
- Joyce J Shin
- Montefiore Medical Center/Albert Einstein, College of Medicine, Greene Medical Arts, Pavilion 4th Floor, 3400 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Phillip Gorden
- NIDDK, National Institutes of Health, Building 10-CRC, Room 6-5952, 10 Center Dr., Bethesda, MD, USA, Tel.: +1 301 402 7340, Fax: +1 301 435 5873
| | - Steven K Libutti
- Montefiore-Einstein Center for Cancer Care, NY, USA and Department of Surgery, Montefiore, Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 4th Floor, 3400 Bainbridge Avenue, Bronx, NY 10467, USA, Tel.: +1 718 920 4231, Fax: +1 718 798 0309
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Ueda J, Nakamura Y, Aimoto T, Hiroi M, Cho K, Yamahatsu K, Kawamoto M, Uchida E. Laparoscopic Distal Pancreatectomy Preserving Spleen and Splenic Vessels for Pancreatic Insulinoma. J NIPPON MED SCH 2010; 77:175-80. [DOI: 10.1272/jnms.77.175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Junji Ueda
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Yoshiharu Nakamura
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Takayuki Aimoto
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Makoto Hiroi
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Kazumitsu Cho
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Kazuya Yamahatsu
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Masao Kawamoto
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Eiji Uchida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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