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Trone K, Pommier R. Surgical treatment of neuroendocrine tumors. Curr Probl Cancer 2024; 52:101132. [PMID: 39181041 DOI: 10.1016/j.currproblcancer.2024.101132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/22/2024] [Indexed: 08/27/2024]
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Karam E, Nassar A, Elkurdi S, Péré G, Freville T, Wasielewski E, Palen A, Périnel J, Lifante JC, Lermite E, Marchese U, Adham M, Turrini O, Sulpice L, Régenet N, Carrère N, Gaujoux S, Pattou F, Sauvanet A. Enucleation for Sporadic Nonfunctioning Pancreatic Neuroendocrine Tumors Larger than 2 Centimeters Is Associated with Equivalent Morbidity and Survival Compared to Smaller Tumors: A Multi-Institutional Study. Neuroendocrinology 2024:1-11. [PMID: 39182485 DOI: 10.1159/000541078] [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: 02/21/2024] [Accepted: 07/09/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Nonfunctioning pancreatic neuroendocrine tumor (NF-PanNET) ≤2 cm can be observed or resected. Surgery remains recommended for NF-PanNET >2 cm but its extent, enucleation (EN) versus formal resection, remains controversial. METHODS Multicentric retrospective cohort of sporadic NF-PanNET patients treated with EN. Short- and long-term outcomes were compared according to tumor size on imaging ≤2 cm versus >2 cm. RESULTS 131 patients underwent EN for NF-PanNET, including 103 (79.0%) ≤2 cm and 28 (21.0%) >2 cm (extremes, 4-55 mm). Patients' characteristics were comparable, and tumor characteristics only differed in their diameter. Clavien III-IV complications were similar (18.4% vs. 17.9%, p = 1.00) with one death in NF-PanNET ≤2 cm. Grade B/C pancreatic fistula were comparable (16.5% vs. 10.7%, p = 0.850). In NF-PanNET >2 cm there were more pT2/3 stage tumors (85.7% vs. 21.4%, p < 0.001), similar rates of grade G2/3 tumors (25% vs. 16.5%, p = 0.408) with a median Ki67 of 2 (interquartile range: 1-3), and of lymphovascular and perineural invasions. Lymph node picking was done in 46 (35.1%) patients, with a higher median number of harvested lymph nodes in NF-PanNET >2 cm (4 vs. 3, p = 0.01). All were pN0. R0 resection rate (78.6% vs. 82.5%, respectively; p = 0.670) was equivalent. Five-year overall (100% vs. 99%, p = 0.602) and 10-year disease-free (96% vs. 92%, respectively; p = 0.532) survivals were comparable. CONCLUSIONS EN for selected NF-PanNET >2 cm carries equivalent morbidity, overall and disease-free survivals compared to those observed with NF-PanNET ≤2 cm.
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Affiliation(s)
- Elias Karam
- Department of Digestive Surgery and Liver Transplant, Tours University Hospital, Tours, France,
| | - Alexandra Nassar
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris University, Paris, France
| | - Sara Elkurdi
- Department of General and Endocrine Surgery, Lille University Hospital, Lille, France
| | - Guillaume Péré
- Digestive Surgery Department, Toulouse University Hospital, Toulouse, France
| | - Thomas Freville
- Digestive and Endocrine Surgery Unit, Nantes University Hospital, Nantes, France
| | - Edouard Wasielewski
- Department of Hepatobiliary and Digestive Surgery and Clinical Investigation Center, Rennes University Hospital, Rennes, France
| | - Anaïs Palen
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Julie Périnel
- Department of Surgery, Edouard Herriot Hospital, Lyon, France
| | - Jean-Christophe Lifante
- Department of Endocrine Surgery, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Emilie Lermite
- Digestive Surgery Department, Angers University Hospital and Angers University, Angers, France
| | - Ugo Marchese
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris University, Paris, France
| | - Mustapha Adham
- Department of Surgery, Edouard Herriot Hospital, Lyon, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive Surgery and Clinical Investigation Center, Rennes University Hospital, Rennes, France
| | - Nicolas Régenet
- Digestive and Endocrine Surgery Unit, Nantes University Hospital, Nantes, France
| | - Nicolas Carrère
- Digestive Surgery Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - François Pattou
- Department of General and Endocrine Surgery, Lille University Hospital, Lille, France
| | - Alain Sauvanet
- Hepato-Biliary and Pancreatic Surgery Department, Beaujon Hospital, AP-HP and Paris University, Paris, France
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Li Z, Zhuo Q, Shi Y, Chen H, Liu M, Liu W, Xu W, Chen C, Ji S, Yu X, Xu X. Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area. Heliyon 2023; 9:e21917. [PMID: 38027678 PMCID: PMC10658339 DOI: 10.1016/j.heliyon.2023.e21917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation. Methods Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed. Results Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up. Conclusions The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.
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Affiliation(s)
- Zheng Li
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Qifeng Zhuo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Yihua Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Haidi Chen
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Mengqi Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Wensheng Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Wenyan Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Chen Chen
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Shunrong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Xiaowu Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
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Minimally Invasive vs Open Pancreatectomy for Pancreatic Neuroendocrine Tumors: Multi-Institutional 10-Year Experience of 1,023 Patients. J Am Coll Surg 2022; 235:315-330. [PMID: 35839409 DOI: 10.1097/xcs.0000000000000257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Resection of pancreatic neuroendocrine tumors (PNETs) may be associated with adverse perioperative outcomes compared with pancreatic adenocarcinoma given the high-risk nature of soft glands with small pancreatic ducts. The effect of minimally invasive surgery (MIS) pancreatectomy on outcomes of PNETs remains to be examined, which is the aim of this study. STUDY DESIGN Between 2009 and 2019, 1,023 patients underwent pancreatectomy for PNETs at 4 institutions. Clinicopathologic data and perioperative outcomes of patients who underwent MIS (n = 447) and open resections (n = 576) were compared. RESULTS Of the 1,023 patients, 51% were male, the mean age was 58, the median tumor size was 2.1 cm, and 73% were grade 1 PNETs. There were 318 (31%) pancreatoduodenectomies (PDs), 541 (53%) distal pancreatectomies (DPs), 80 (7.8%) enucleation (ENs), 72 (7%) central pancreatectomies (CPs), and 12 (1.2%) total pancreatectomies. Almost half of the patients (N = 447, 44%) had MIS operations, of which 230 (51%) were robotic and 217 (49%) were laparoscopic. Compared with open operations, MIS PDs had significantly lower operative blood loss (150 vs 400 mL, p < 0.001) and rate of clinically relevant postoperative pancreatic fistulas (CR-POPFs; 13% vs 27%, p = 0.030), and MIS DPs had a shorter length of stay (5 vs 6 days, p < 0.001). Although MIS DPs and ENs had CR-POPFs comparable with open operations, MIS CPs had a higher CR-POPF rate (45% vs 15%, p = 0.013). After adjusting for pathological differences, MIS pancreatectomy was associated with recurrence-free survival and overall survival comparable with open pancreatectomy. CONCLUSIONS MIS pancreatectomy for PNETs is associated with improved outcomes or outcomes comparable with open resection.
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van Beek DJ, Takkenkamp TJ, Wong-Lun-Hing EM, de Kleine RHJ, Walenkamp AME, Klaase JM, Nijkamp MW, Valk GD, Molenaar IQ, Hagendoorn J, van Santvoort HC, Borel Rinkes IHM, Hoogwater FJH, Vriens MR. Risk factors for complications after surgery for pancreatic neuroendocrine tumors. Surgery 2022; 172:127-136. [PMID: 35341591 DOI: 10.1016/j.surg.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/03/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical resection is the only potentially curative treatment for pancreatic neuroendocrine tumors. The choice for the type of procedure is influenced by the expected oncological benefit and the anticipated risk of procedure-specific complications. Few studies have focused on complications in these patients. This cohort study aimed to assess complications and risk factors after resections of pancreatic neuroendocrine tumors. METHODS Patients undergoing resection of a pancreatic neuroendocrine tumor were identified within 2 centers of excellence. Complications were assessed according to the Clavien-Dindo classification and the comprehensive complication index. Logistic regression was performed to compare surgical procedures with adjustment for potential confounders (Clavien-Dindo ≥3). RESULTS The cohort comprised 123 patients, including 12 enucleations, 50 distal pancreatectomies, 51 pancreatoduodenectomies, and 10 total/combined pancreatectomies. Mortality was 0.8%, a severe complication occurred in 41.5%, and the failure-to-rescue rate was 2.0%. The median comprehensive complication index was 22.6 (0-100); the comprehensive complication index increased after more extensive resections. After adjustment, a pancreatoduodenectomy, as compared to a distal pancreatectomy, increased the risk for a severe complication (odds ratio 3.13 [95% confidence interval 1.32-7.41]). Of the patients with multiple endocrine neoplasia type 1 or von Hippel-Lindau, 51.9% developed a severe complication vs 38.5% with sporadic disease. After major resections, morbidity was significantly higher in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau (comprehensive complication index 45.1 vs 28.9, P = .029). CONCLUSION Surgery for pancreatic neuroendocrine tumors is associated with a high rate of complications but low failure-to-rescue in centers of excellence. Complications are procedure-specific. Major resections in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau appear to increase the risk of complications.
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Affiliation(s)
- Dirk-Jan van Beek
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim J Takkenkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Edgar M Wong-Lun-Hing
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruben H J de Kleine
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annemiek M E Walenkamp
- Department of Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Frederik J H Hoogwater
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Menno R Vriens
- Department of Endocrine Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
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Beane JD, Borrebach JD, Billderback A, Onuma AE, Adam MA, Zureikat AH, Pitt HA. Small pancreatic neuroendocrine tumors: Resect or enucleate? Am J Surg 2021; 222:29-34. [DOI: 10.1016/j.amjsurg.2020.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 12/18/2022]
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van Dongen JC, Smits FJ, van Santvoort HC, Molenaar IQ, Busch OR, Besselink MG, Aziz MH, Groot Koerkamp B, van Eijck CHJ. C-reactive protein is superior to white blood cell count for early detection of complications after pancreatoduodenectomy: a retrospective multicenter cohort study. HPB (Oxford) 2020; 22:1504-1512. [PMID: 32171648 DOI: 10.1016/j.hpb.2020.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/17/2019] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early detection of major complications after pancreatoduodenectomy could improve patient management and decrease the "failure-to-rescue" rate. In this retrospective cohort study, we aimed to compare the value of C-reactive protein (CRP) and white blood cell count (WBC) in the early detection of complications after pancreatoduodenectomy. METHODS We assessed pancreatoduodenectomies between January 2012 and December 2017. Major complications were defined as grade III or higher according to the Clavien-Dindo classification. Postoperative pancreatic fistula (POPF) was a secondary endpoint. ROC-curve and logistic regression analysis were performed for CRP and WBC. Results were validated in an external cohort. RESULTS In the development cohort (n = 285), 103 (36.1%) patients experienced a major complication. CRP was superior to WBC in detecting major complications on postoperative day (POD) 3 (AUC:0.74 vs. 0.54, P < 0.001) and POD 5 (AUC:0.77 vs. 0.68, P = 0.031), however not on POD 7 (AUC:0.77 vs. 0.76, P = 0.773). These results were confirmed in multivariable analysis and in the validation cohort (n = 202). CRP was also superior to WBC in detecting POPF on POD 3 (AUC: 0.78 vs. 0.54, P < 0.001) and POD 5 (AUC: 0.83 vs. 0.71, P < 0.001). CONCLUSION CRP appears to be superior to WBC in the early detection of major complications and POPF after pancreatoduodenectomy.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands.
| | - F Jasmijn Smits
- Department of Surgery, Utrecht MC, University Medical Centre, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Utrecht MC, University Medical Centre, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Utrecht MC, University Medical Centre, Utrecht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Hossein Aziz
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
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Complications of surgery for gastro-entero-pancreatic neuroendocrine neoplasias. Langenbecks Arch Surg 2020; 405:137-143. [PMID: 32291468 PMCID: PMC7239819 DOI: 10.1007/s00423-020-01869-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/22/2020] [Indexed: 12/14/2022]
Abstract
Purpose Surgery is recommended for most patients with gastro-entero-pancreatic neuroendocrine neoplasias (GEP-NENs). Rates of complications and perioperative mortality have been reported in few mostly retrospective single-center series, but there has been no detailed analysis on risk factors for perioperative complications and mortality to date. Methods Data of patients with GEP-NENs operated between January 2015 and September 2018 were retrieved from EUROCRINE©, a European online endocrine surgical quality registry, and analyzed regarding rate and risk factors of surgical complications. Risk factors were assessed by logistic regression. Results Some 376 patients (211 female, 167 male; age median 63, range 15–89 years) were included. Most NENs were located in the small intestine (SI) (n = 132) or pancreas (n = 111), the rest in the stomach (n = 34), duodenum (n = 30), appendix (n = 30), colon, and rectum (n = 22), or with unknown primary (n = 15). Of the tumors, 320 (85.1%) were well or moderately differentiated, and 147 (39.1%) of the patients had distant metastases at the time of operation. Severe complications (Dindo-Clavien ≥ 3) occurred in 56 (14.9%) patients, and 4 (1.1%) patients died perioperatively. Severe complications were more frequent in surgery for duodenopancreatic NENs (n = 31; 22.0%) compared with SI-NENs (n = 15; 11.4%) (p = 0.014), in patients with lymph node metastases operated with curative aim of surgery (n = 24; 21.4%) versus non-metastasized tumors or palliative surgery (n = 32; 12.1%) (p = 0.020), and in functioning tumors (n = 20; 23.0%) versus non-functioning tumors (n = 30; 13.5%) (p = 0.042). Complication rates were not significantly associated with tumor stage or grade. Conclusions Severe complications are frequent in GEP-NEN surgery. Besides duodenopancreatic tumor location, curative resection of nodal metastases and functioning tumors are risk factors for complications.
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Howe JR, Merchant NB, Conrad C, Keutgen XM, Hallet J, Drebin JA, Minter RM, Lairmore TC, Tseng JF, Zeh HJ, Libutti SK, Singh G, Lee JE, Hope TA, Kim MK, Menda Y, Halfdanarson TR, Chan JA, Pommier RF. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:1-33. [PMID: 31856076 PMCID: PMC7029300 DOI: 10.1097/mpa.0000000000001454] [Citation(s) in RCA: 220] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
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Affiliation(s)
- James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Claudius Conrad
- Department of Surgery, St. Elizabeth Medical Center, Tufts University School of Medicine, Boston, MA
| | | | - Julie Hallet
- Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven K. Libutti
- §§ Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gagandeep Singh
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Michelle K. Kim
- Department of Medicine, Mt. Sinai Medical Center, New York, NY
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rodney F. Pommier
- Department of Surgery, Oregon Health & Sciences University, Portland, OR
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10
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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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Early and Late Complications After Surgery for MEN1-related Nonfunctioning Pancreatic Neuroendocrine Tumors. Ann Surg 2019; 267:352-356. [PMID: 27811505 DOI: 10.1097/sla.0000000000002050] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate short and long-term morbidity after pancreatic surgery for multiple endocrine neoplasia type 1 (MEN1)-related nonfunctioning pancreatic neuroendocrine tumors (NF-pNETs). BACKGROUND Fifty percent of the MEN1 patients harbor multiple NF-pNETs. The decision to proceed to NF-pNET surgery is a balance between the risk of disease progression versus the risk of surgery-related morbidity. Currently, there are insufficient data on the surgical complications after MEN1 NF-pNET surgery. METHODS MEN1 patients diagnosed with a NF-pNET who underwent surgery were selected from the DutchMEN1 study group database, including >90% of the Dutch MEN1 population. Early postoperative complications, new-onset diabetes mellitus, and exocrine pancreatic insufficiency were captured. RESULTS Sixty-one patients underwent NF-pNET surgery at 1 of the 8 Dutch academic centers. Patients were young (median age 41 years) with low American Society of Anesthesiologists scores. Median NF-pNET size on imaging was 22 mm (3-157). Thirty-three percent (19/58) of the patients developed major early-Clavien-Dindo grade III to IV-complications mainly consisting International Study Group of Pancreatic Surgery grade B/C pancreatic fistulas. Twenty-three percent of the patients (14/61) developed endocrine or exocrine pancreas insufficiency. The development of major early postoperative complications was independent of the NF-pNET tumor size. Twenty-one percent of the patients (12/58) developed multiple major early complications. CONCLUSIONS MEN1 NF-pNET surgery is associated with high rates of major short and long-term complications. Current findings should be taken into account in the shared decision-making process when MEN1 NF-pNET surgery is considered.
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Lu WJ, Cai HL, Ye MD, Wu YL, Xu B. Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections. J Zhejiang Univ Sci B 2018; 18:906-916. [PMID: 28990381 DOI: 10.1631/jzus.b1600597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficiency of enucleation (EU) for proximal pancreatic non-invasive neoplasms. METHODS Patients with solitary non-invasive neoplasms in the proximal pancreas from January 1998 to April 2014 at the Second Affiliated Hospital of Zhejiang University, Hangzhou, China were included. Different operations and outcomes were analyzed. RESULTS A total of 123 patients were enrolled. Forty patients (32.5%) underwent EU including 18 patients who had tumors close to the main pancreatic duct (MPD). Sixty-one patients (49.6%) had pancreaticoduodenectomy (PD) performed and 22 (17.9%) underwent central pancreatectomy (CP). Pathological outcomes included neuroendocrine tumors, cystic lesions, and solid pseudopapillary tumors. Operation time, intra-operative blood loss, and duration of hospital stay were significantly reduced in the EU group. PD was associated with the greatest complication rate (55.7%), followed by EU (50%) and CP (40.9%), though the pancreatic fistula rate after EU was the highest (50%), especially in patients with tumors larger than 3 cm and tumors close to the MPD. EU had advantages in the preservation of pancreatic parenchyma and endocrine and exocrine function. CONCLUSIONS EU can be carried out safely and effectively for tumors in the proximal pancreas with improved outcomes compared with standard resections, even if the tumor is larger than 3 cm and close to the MPD.
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Affiliation(s)
- Wen-Jie Lu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Hao-Lei Cai
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Ma-Dong Ye
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Yu-Lian Wu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Bin Xu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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Tseng WW, Tsao-Wei DD, Callegaro D, Grignani G, D'Ambrosio L, Bonvalot S, Ethun CG, Cardona K, Mullen JT, Canter RJ, Mullinax JE, Gonzalez RJ, van Coevorden F, Albertsmeier M, Dhanireddy KK, Renne SL, Gronchi A. Pancreaticoduodenectomy in the surgical management of primary retroperitoneal sarcoma. Eur J Surg Oncol 2018; 44:810-815. [PMID: 29452860 DOI: 10.1016/j.ejso.2018.01.086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/03/2018] [Accepted: 01/15/2018] [Indexed: 01/08/2023] Open
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14
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Teo RYA, Goh BKP. Surgical resection of pancreatic neuroendocrine neoplasm by minimally invasive surgery-the robotic approach? Gland Surg 2018; 7:1-11. [PMID: 29629314 DOI: 10.21037/gs.2017.10.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Over the past decade, there has been increasing adoption of minimally invasive pancreatic surgery world-wide and this has naturally expanded to the management of pancreatic neuroendocrine neoplasms (PNENs). More recently, robotic pancreatic surgery (RPS) was introduced to overcome the limitations during laparoscopic pancreatic surgery (LPS). Due to the relative rarity of PNEN and the novelty of minimally invasive pancreatic surgery in particular RPS today, the evidence for robotic surgery in PNENs remains extremely limited. Presently, the available evidence is limited to a few low level retrospective case-control studies. These studies suggest that RPS may be associated with a higher splenic preservation rates and lower open conversion rates compared to conventional laparoscopic surgery. Ideally a prospective randomized trial should be performed but this would be extremely challenging due to the rarity of PNEN, making it almost impossible to conduct a sufficiently powered trial.
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Affiliation(s)
- Roxanne Y A Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-National University of Singapore Medical School, Singapore
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15
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Renard Y, de Mestier L, Perez M, Avisse C, Lévy P, Kianmanesh R. Unraveling Pancreatic Segmentation. World J Surg 2017; 42:1147-1153. [DOI: 10.1007/s00268-017-4263-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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16
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Finkelstein P, Sharma R, Picado O, Gadde R, Stuart H, Ripat C, Livingstone AS, Sleeman D, Merchant N, Yakoub D. Pancreatic Neuroendocrine Tumors (panNETs): Analysis of Overall Survival of Nonsurgical Management Versus Surgical Resection. J Gastrointest Surg 2017; 21:855-866. [PMID: 28255853 DOI: 10.1007/s11605-017-3365-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 01/05/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes of patients with pancreatic neuroendocrine tumors (panNETs) undergoing surgical or nonsurgical management and outcomes of enucleation versus standard resection were compared. METHODS MEDLINE, EMBASE, PubMed, Scopus, and Cochrane were queried (2000 to present). All studies comparing patients undergoing surgical versus nonsurgical treatments, or enucleation versus standard resection, were included. Pooled risk ratios and 95% CI for survival were calculated. RESULTS Eleven studies met criteria with 1491 resected and 1607 nonsurgically managed patients. Meta-analysis showed improved overall survival with resection at 1 year (risk ratio (RR) = 1.281, CI 1.064-1.542, p = 0.009), 3 years (RR = 1.837, CI 1.594-2.117, p < 0.001), and 5 years (RR = 2.103, CI 1.50-2.945, p < 0.001). OS of patients with resected nonfunctioning panNETs was improved at 3 years (RR = 1.847, CI 1.477-2.309, p < 0.001) and 5 years (RR = 1.767, CI 1.068-2.924, p = 0.027). OS was improved when panNETs ≤2 cm were resected at 3 years (RR = 1.695, CI 1.269-2.264, p < 0.001) and 5 years (RR = 2.210, CI 1.749-2.791, p < 0.001). Fifteen articles met criteria for enucleation versus standard resection (n = 1035; 620 were nonfunctioning). Enucleation had shorter operative time (weighted mean difference (WMD) = -95.6 min, 95% CI -131.4 to -59.8, p < 0.01), less operative blood loss (WMD = -172.6 ml, 95% CI -340 to -5.1, p = 0.04), but increased postoperative pancreatic fistula (POPF) (RR = 2.08, 95% CI 1.39-3.12, p < 0.01). CONCLUSION Surgical resection of panNETs, including small and nonfunctioning, appears to be associated with improved OS. Enucleation is associated with shorter operative time, less blood loss, but greater incidence of POPF. Prospective, randomized clinical trials are needed to confirm these results.
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Affiliation(s)
- Paige Finkelstein
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Rishika Sharma
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Omar Picado
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Rahul Gadde
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Heather Stuart
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Caroline Ripat
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Alan S Livingstone
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Danny Sleeman
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Nipun Merchant
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA
| | - Danny Yakoub
- Division of Surgical Oncology, Jackson Memorial Hospital/Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, FL, 33136, USA.
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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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Ge W, Zhou D, Xu S, Wang W, Zheng S. Surveillance and comparison of surgical prognosis for asymptomatic and symptomatic non-functioning pancreatic neuroendocrine tumors. Int J Surg 2017; 39:127-134. [PMID: 28137555 DOI: 10.1016/j.ijsu.2017.01.088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/21/2017] [Accepted: 01/23/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND The treatment of non-functioning pancreatic neuroendocrine tumors (NF-PNETs) still remains controversial. It is uncertain whether asymptomatic patients have better prognosis than symptomatic patients and whether surgery is necessary for asymptomatic patients. METHODS Patients with NF-PNETs who were managed surgically or by surveillance between June 2007 and December 2013 were retrospectively studied. The choice of surgery or surveillance was based entirely on the patient's desire. Survival prognosis was compared between asymptomatic and symptomatic patients, and evaluated among patients who were under surveillance. RESULTS Of the 53 patients with NF-PNETs, 48 (90%) were treated surgically. 25 patients (47%) were symptomatic patients, 23 (43%) asymptomatic, and five (10%) detected by surveillance. Among the latter group, one patient suffered from tumor progression and four had stable disease. When compared with symptomatic NF-PNETs, asymptomatic NF-PNETs showed lower pathology grades (P = 0.006), better 3-year cumulative progression-free survival and overall survival after surgical treatment. Parenchyma-preserving resection was associated with a higher risk of pancreatic fistula (71 vs. 17%, P = 0.007). A positive lymph node status (P = 0.003) and perineural or vascular invasion (P = 0.01) were significant predictors of tumor recurrence or metastasis. Patients with grade G3 disease (P = 0.005) or a tumor size >4 cm (P = 0.019) had poor prognosis. CONCLUSIONS Compared with symptomatic NF-PNETs, asymptomatic NF-PNETs had a lower degree of malignancy and better prognosis. Surveillance for small asymptomatic NF-PNETs needs to be further studied.
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Affiliation(s)
- Wenhao Ge
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Dongkai Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Shaoyan Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China; Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, 79 Qingchun Road, Hangzhou, 310003, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, 79 Qingchun Road, Hangzhou, 310003, China.
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China; Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, 79 Qingchun Road, Hangzhou, 310003, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, 79 Qingchun Road, Hangzhou, 310003, China.
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Tonelli F, Giudici F, Nesi G, Batignani G, Brandi ML. Operation for insulinomas in multiple endocrine neoplasia type 1: When pancreatoduodenectomy is appropriate. Surgery 2016; 161:727-734. [PMID: 27863775 DOI: 10.1016/j.surg.2016.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Distal pancreatectomy is the most frequent operation for insulinomas complicating multiple endocrine neoplasia type 1 insulinoma, although there are conditions for which a different operative approach might be preferable. In this article, we report the operative experience of a referral center for multiple endocrine neoplasia type 1 insulinoma. METHODS Twelve patients underwent operations between 1992 and 2015: 8 underwent a distal pancreatic resection, and 4 underwent a pancreatoduodenectomy. Enucleation of other macroadenomas present in the remnant pancreas was performed in 9 out of these 12 patients. RESULTS Operative complications (2 pancreatic fistulas and 2 cases of pancreatitis) occurred in 4 of the 8 distal pancreatic resections. In 1 patient, reoperation was required to resolve the complications of the first operation. At pathologic analysis, multiple insulinomas were found in 5 patients, lymph-nodal metastasis positive for insulin in 2 patients, multiple nonfunctioning pancreatic tumors in all patients, glucagonoma in 4 patients, and gastrinoma in the duodenum or lymph nodes in 4 patients. All the patients were treated successfully for the hypoglycemic/hyperinsulinemic syndrome with no clinical recurrence at a mean follow-up of 85 months (range 4-242 months). Recurrent nonfunctioning pancreatic tumor macroadenomas in the remnant pancreas occurred in only 1 of the 12 patients, and no progression of the gastrinomas was observed. None of the patients developed diabetes mellitus. CONCLUSION Resection of the most severely affected part of the pancreas, whether left or right, associated with enucleation of concomitant macroadenomas in the preserved pancreas is recommended for the treatment of hypoglycemic/hyperinsulinemic syndrome and to prevent malignant progression of nonfunctioning pancreatic tumors in patients with multiple endocrine neoplasia type 1. If the head of the pancreas is the most affected site and the Zollinger-Ellison syndrome is concomitant, then pancreatoduodenectomy should be preferred over distal pancreatectomy.
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Affiliation(s)
- Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy.
| | - Francesco Giudici
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Gabriella Nesi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Giacomo Batignani
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor. World J Surg 2016; 40:715-28. [PMID: 26608956 PMCID: PMC4746212 DOI: 10.1007/s00268-015-3341-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Either enucleation or more extended resection is performed to treat patients with pancreatic neuroendocrine tumor (pNET). Aim was to analyze the postoperative complications for each operation separately. Furthermore, independent risk factors for complications and incidence of pancreatic insufficiency were analyzed. Methods Retrospective all resected patients from two academic hospitals in The Netherlands between 1992 and 2013 were included. Postoperative complications were scored by both ISGPS and Clavien–Dindo criteria. Based on tumor location, operations were compared. Independent risk factors for overall complications were identified. During long-term follow-up, pancreatic insufficiency and recurrent disease were analyzed. Results Tumor enucleation was performed in 60/205 patients (29 %), pancreatoduodenectomy in 65/205 (31 %), distal pancreatectomy in 72/205 (35 %) and central pancreatectomy in 8/205 (4 %) patients. Overall complications after tumor enucleation of the pancreatic head and pancreatoduodenectomy were comparable, 24/35 (69 %) versus 52/65 (80 %). The same was found after tumor enucleation and resection of the pancreatic tail (36 vs.58 %). Number of re-interventions and readmissions were comparable between all operations. After pancreatoduodenectomy, 33/65 patients had lymph node metastasis and in patients with tumor size ≤2 cm, 55 % had lymph node metastasis. Tumor in the head and BMI ≥25 kg/m2 were independent risk factors for complications after enucleation. During follow-up, incidence of exocrine and endocrine insufficiency was significant higher after pancreatoduodenectomy (resp. 55 and 19 %) compared to the tumor enucleation and distal pancreatectomy(resp. 5 and 7 % vs.8 and 13 %). After tumor enucleation 19 % developed recurrent disease. Conclusion Since the complication rate, need for re-interventions and readmissions were comparable for all resections, tumor enucleation may be regarded as high risk. Appropriate operation should be based on tumor size, location, and functional status of the pNET.
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Tian F, Hong XF, Wu WM, Han XL, Wang MY, Cong L, Dai MH, Liao Q, Zhang TP, Zhao YP. Propensity score-matched analysis of robotic versus open surgical enucleation for small pancreatic neuroendocrine tumours. Br J Surg 2016; 103:1358-64. [PMID: 27480993 DOI: 10.1002/bjs.10220] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/16/2016] [Accepted: 04/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enucleation of pancreatic neuroendocrine tumours (pNETs) via robotic surgery has rarely been described. This study sought to assess the safety and efficiency of robotic surgery for the enucleation of small pNETs. METHODS A comparison was conducted of enucleation of pNETs smaller than 2 cm by robotic or open surgery between January 2000 and May 2015. Propensity score matching was used to balance sex, age, BMI, tumour location and tumour diameter. Pathological results, safety-related outcomes (postoperative pancreatic fistula (POPF) rate, estimated blood loss, and short-term mortality and morbidity) and efficiency-related outcomes (duration of surgery and postoperative length of hospital stay) were compared between the groups. RESULTS A cohort of 120 patients with pNET were enrolled in the study (1 : 1 matched for open or robotic surgery, 60 per group). Ninety-three patients (77·5 per cent) had a grade 1 tumour and 114 (95·0 per cent) had an insulinoma. Robotic surgery had a conversion rate of 5 per cent (3 of 60), and was not associated with an increased POPF rate (10 per cent versus 17 per cent after open surgery; P = 0·283) or grade III-V surgical complications according to the Dindo-Clavien classification (3 versus 10 per cent respectively; P = 0·272). Estimated blood loss was reduced with the robotic approach (32·5 versus 80·0 ml in the open group; P = 0·008), as was duration of surgery (117 versus 150 min; P < 0·001). Length of hospital stay after surgery was similar in the two groups (12·0 versus 13·5 days respectively; P = 0·071). CONCLUSION Robotic surgery for enucleation of pNETs smaller than 2 cm did not increase POPF or major complication rates, and reduced the duration of surgery and estimated blood loss, compared with open surgery. REGISTRATION NUMBER NCT02125929 ( https://www.clinicaltrials.gov/).
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Affiliation(s)
- F Tian
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - X-F Hong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - W-M Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - X-L Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - M-Y Wang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - L Cong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - M-H Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - Q Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - T-P Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
| | - Y-P Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Wangfujing Avenue, Dongcheng District, Beijing, 100730, China
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The Effect of Body Mass Index on Surgical Outcomes in Patients Undergoing Pancreatic Resection: A Systematic Review and Meta-Analysis. Pancreas 2016; 45:796-805. [PMID: 27295531 DOI: 10.1097/mpa.0000000000000525] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Previous studies that investigated the association between body mass index (BMI) and pancreatectomy outcomes have produced conflicting conclusions. We conducted this meta-analysis to assess the association between them. METHODS We searched PubMed, EMBASE, and Cochrane Library databases up to December 28, 2014. Patients were divided into high-BMI group (BMI ≥ 25 kg/m) and normal-BMI group (BMI < 25 kg/m). Postoperative and intraoperative outcomes were evaluated. Meta-regression and subgroup analysis were performed to evaluate any factors accountable for the heterogeneity. Meta-analysis was performed using a random-effect model. RESULTS We included 22 studies involving 8994 patients. Patients in the high-BMI group had significantly increased postoperative pancreatic fistula rate (odds ratio [OR],1.96; 95% confidence interval [CI], 1.43-2.67), delayed gastric emptying rate (OR, 1.62; 95% CI, 1.15-2.29), wound infection rate (OR, 1.43; 95% CI, 1.07-1.93), operation time (mean difference [MD],15; 95% CI, 13.40-16.60), blood loss (MD, 270.71; 95% CI, 248.93-292.49), and length of hospital stay (MD, 2.87; 95% CI, 1.51-4.24). For modest heterogeneity in postoperative pancreatic fistula, regional distribution tended to be the contributor. CONCLUSIONS High BMI not only increased the surgical difficulty but also decreased the surgical safety for pancreatectomy.
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Nell S, Brunaud L, Ayav A, Bonsing BA, Groot Koerkamp B, Nieveen van Dijkum EJ, Kazemier G, de Kleine RH, Hagendoorn J, Molenaar IQ, Valk GD, Borel Rinkes IH, Vriens MR. Robot-assisted spleen preserving pancreatic surgery in MEN1 patients. J Surg Oncol 2016; 114:456-61. [DOI: 10.1002/jso.24315] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 05/21/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Sjoerd Nell
- Department of Endocrine Surgical Oncology and Endocrine Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Laurent Brunaud
- Department of Digestive, Hepatobiliary and Endocrine Surgery; Université de Lorraine, Hôpital Brabois Adultes, CHU Nancy; Nancy France
| | - Ahmet Ayav
- Department of Digestive, Hepatobiliary and Endocrine Surgery; Université de Lorraine, Hôpital Brabois Adultes, CHU Nancy; Nancy France
| | - Bert A. Bonsing
- Department of Surgery; Leiden University Medical Center; Leiden The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery; Erasmus Medical Center; Rotterdam The Netherlands
| | | | - Geert Kazemier
- Department of Surgery; VU University Medical Center; Amsterdam The Netherlands
| | - Ruben H.J. de Kleine
- Department of Hepatobiliary Surgery and Liver Transplantation; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgical Oncology and Hepato-Pancreato-Biliary Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - I. Quintus Molenaar
- Department of Surgical Oncology and Hepato-Pancreato-Biliary Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Gerlof D. Valk
- Department of Endocrine Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Inne H.M. Borel Rinkes
- Department of Surgical Oncology and Endocrine Surgical Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Menno R. Vriens
- Department of Endocrine Surgical Oncology; University Medical Center Utrecht; Utrecht The Netherlands
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24
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Evaluation and management of pancreatic lesions in patients with von Hippel–Lindau disease. Nat Rev Clin Oncol 2016; 13:537-49. [DOI: 10.1038/nrclinonc.2016.37] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Minimally Invasive Versus Open Pancreatic Surgery in Patients with Multiple Endocrine Neoplasia Type 1. World J Surg 2016; 40:1729-36. [DOI: 10.1007/s00268-016-3456-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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26
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Jilesen APJ, van Eijck CHJ, in't Hof KH, van Dieren S, Gouma DJ, van Dijkum EJMN. Postoperative Complications, In-Hospital Mortality and 5-Year Survival After Surgical Resection for Patients with a Pancreatic Neuroendocrine Tumor: A Systematic Review. World J Surg 2016; 40:729-48. [PMID: 26661846 PMCID: PMC4746219 DOI: 10.1007/s00268-015-3328-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Studies on postoperative complications and survival in patients with pancreatic neuroendocrine tumors (pNET) are sparse and randomized controlled trials are not available. We reviewed all studies on postoperative complications and survival after resection of pNET. A systematic search was performed in the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE from 2000-2013. Inclusion criteria were studies of resected pNET, which described postoperative complications separately for each surgical procedure and/or 5-year survival after resection. Prospective and retrospective studies were pooled separately and overall pooled if heterogeneity was below 75%. The random-effect model was used. Overall, 2643 studies were identified and after full-text analysis 62 studies were included. Pancreatic fistula (PF) rate of the prospective studies after tumor enucleation was 45%; PF-rates after distal pancreatectomy, pancreatoduodenectomy, or central pancreatectomy were, respectively, 14-14-58%. Delayed gastric emptying rates were, respectively, 5-5-18-16%. Postoperative hemorrhage rates were, respectively, 6-1-7-4%. In-hospital mortality rates were, respectively, 3-4-6-4%. The 5-year overall survival (OS) and disease-specific survival (DSS) of resected pNET without synchronous resected liver metastases were, respectively, 85-93%. Heterogeneity between included studies on 5-year OS in patients with synchronous resected liver metastases was too high to pool all studies. The 5-year DSS in patients with liver metastases was 80%. Morbidity after pancreatic resection for pNET was mainly caused by PF. Liver resection in patients with liver metastases seems to have a positive effect on DSS. To reduce heterogeneity, ISGPS criteria and uniform patient groups should be used in the analysis of postoperative outcome and survival.
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Affiliation(s)
- Anneke P J Jilesen
- Department of Surgery, Academic Medical Center, Meibergdreef 9, P. O. Box 22660, 1105 AZ, Amsterdam, The Netherlands.
| | | | - K H in't Hof
- Department of Surgery, Academic Medical Center, Meibergdreef 9, P. O. Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - S van Dieren
- Department of Methodology and Statistics Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Meibergdreef 9, P. O. Box 22660, 1105 AZ, Amsterdam, The Netherlands
| | - Els J M Nieveen van Dijkum
- Department of Surgery, Academic Medical Center, Meibergdreef 9, P. O. Box 22660, 1105 AZ, Amsterdam, The Netherlands
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Assadipour Y, Azoury SC, Schaub NN, Hong Y, Eil R, Inchauste SM, Steinberg SM, Venkatesan AM, Libutti SK, Hughes MS. Significance of preoperative radiographic pancreatic density in predicting pancreatic fistula after surgery for pancreatic neuroendocrine tumors. Am J Surg 2015; 212:40-6. [PMID: 26782807 DOI: 10.1016/j.amjsurg.2015.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/30/2015] [Accepted: 07/17/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula remains the most severe and worrisome complication after surgery. Predictive preoperative assessment remains challenging. The authors examine the role of pancreatic computed tomography density in predicting postoperative pancreatic fistula after surgery for pancreatic neuroendocrine tumors. METHODS A single institutional retrospective review of pancreatic surgery for neuroendocrine tumors between 1998 and 2010 was conducted. Preoperative contrast-enhanced computed tomography scans were reviewed, with mean region of interest measurements of pancreatic parenchymal density obtained from 10-mm thick axial computed tomography images. RESULTS A total of 119 patients were identified: 59 with enucleations and 60 with resections. Decreased preoperative pancreatic density was significantly associated with an increased grade of postoperative pancreatic fistula (P < .01). Subgroup analyses revealed that decreased gland density was associated with increased grade of postoperative pancreatic fistula in the resection (P < .01) but not in the enucleation group (P = .34). CONCLUSIONS A significant association between postoperative pancreatic fistula grade and preoperative pancreatic computed tomography density is observed in patients undergoing resection for pancreatic neuroendocrine tumors.
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Affiliation(s)
- Yasmine Assadipour
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Saïd C Azoury
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Nicholas N Schaub
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Young Hong
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Robert Eil
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Suzanne M Inchauste
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Aradhana M Venkatesan
- Radiology and Imaging Sciences NIH Clinical Center, National Institutes of Health, Bethesda, MD
| | - Steven K Libutti
- Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Marybeth S Hughes
- Surgery Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD; Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD.
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Beger HG, Siech M, Poch B, Mayer B, Schoenberg MH. Limited surgery for benign tumours of the pancreas: a systematic review. World J Surg 2015; 39:1557-66. [PMID: 25691214 DOI: 10.1007/s00268-015-2976-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections. METHODS Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively. RESULTS The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2%, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5% of patients; pancreatic fistula in 36.7, 35.2 and 20.1%; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72%; and after DPPHRt/p 0.49%. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001). CONCLUSION EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.
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Affiliation(s)
- H G Beger
- Department of General-and Visceral Surgery, c/o University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany,
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Regenet N, Carrere N, Boulanger G, de Calan L, Humeau M, Arnault V, Kraimps JL, Mathonnet M, Pessaux P, Donatini G, Venara A, Christou N, Bachelier P, Hamy A, Mirallié E. Is the 2-cm size cutoff relevant for small nonfunctioning pancreatic neuroendocrine tumors: A French multicenter study. Surgery 2015; 159:901-7. [PMID: 26590096 DOI: 10.1016/j.surg.2015.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 09/22/2015] [Accepted: 10/01/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) are often discovered at a small size. No clear consensus exists on the management of NF-PNETs ≤ 2 cm. The aim of our study was to determine the prognostic value of indicators of malignancy in sporadic NF-PNETs ≤ 2 cm. METHODS Eighty patients were evaluated retrospectively in 7 French University Hospital Centers. Patients were managed by operative resection (operative group [OG]) or observational follow-up (non-OG [NOG]). Pathologic characteristics and outcomes were analyzed. RESULTS Sixty-six patients (58% women) were in the OG (mean age, 59 years; 95% CI, 56.0-62.3; mean tumor size, 1.6 cm; 95% CI, 1.5-1.7); 14 (72% women, n = 10) were in the NOG (mean age, 63 years; 95% CI, 56-70; mean tumor size, 1.4 cm; 95% CI, 1.0-1.7). All PNETs were ranked using the European Neuroendocrine Tumor Society grading system. Fifteen patients (19%) had malignant tumors defined by node or liver metastasis (synchronous or metachronous). The median disease-free survival was different between malignant and nonmalignant PNETs, respectively: 16 (range, 4-72) versus 30 months (range, 1-156; P = .03). On a receiver operating characteristic (ROC) curve, tumor size had a significant impact on malignancy (area under the curve [AUC], 0.75; P = .03), but not Ki-67 (AUC, 0.59; P = .31). A tumor size cutoff was found on the ROC curve at 1.7 cm (odd ratio, 10.8; 95% CI; 2.2-53.2; P = .003) with a sensitivity of 92% and a specificity of 75% to predict malignancy. CONCLUSION Based on our retrospective study, the cutoff of 2 cm of malignancy used for small NF-PNETs could be decreased to 1.7 cm to select patients more accurately.
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Affiliation(s)
- Nicolas Regenet
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (IMAD), Hôtel Dieu, CHU de Nantes, Nantes, France.
| | - Nicolas Carrere
- Service de Chirurgie Générale et Digestive, Hôpital Purpan, CHU de Toulouse, Toulouse, France
| | - Guillaume Boulanger
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (IMAD), Hôtel Dieu, CHU de Nantes, Nantes, France
| | - Loic de Calan
- Service de Chirurgie Digestive et Endocrine, Hôpital Trousseau, CHU de Tours, Tours, France
| | - Marine Humeau
- Service de Chirurgie Générale et Digestive, Hôpital Purpan, CHU de Toulouse, Toulouse, France
| | - Vincent Arnault
- Service de Chirurgie Digestive et Endocrine, Hôpital Trousseau, CHU de Tours, Tours, France
| | - Jean-Louis Kraimps
- Service de Chirurgie Viscérale et Endocrinienne Hôpital de la Miletrie, CHU de Poitiers, Poitiers, France
| | - Murielle Mathonnet
- Service de Chirurgie Digestive, Générale et Endocrinienne, Hôpital Dupuytren, CHU de Limoges, Limoges, France
| | - Patrick Pessaux
- Service de Chirurgie Digestive et Viscérale, Hôpital Hautepierre, CHU de Strasbourg, Strasbourg, France
| | - Gianluca Donatini
- Service de Chirurgie Viscérale et Endocrinienne Hôpital de la Miletrie, CHU de Poitiers, Poitiers, France
| | - Aurelien Venara
- Service de Chirurgie Digestive et Viscérale, Hôpital Hautepierre, CHU de Strasbourg, Strasbourg, France
| | - Niki Christou
- Service de Chirurgie Viscérale, Hôpital Larrey, CHU d'Angers, Angers, France
| | - Philippe Bachelier
- Service de Chirurgie Digestive et Viscérale, Hôpital Hautepierre, CHU de Strasbourg, Strasbourg, France
| | - Antoine Hamy
- Service de Chirurgie Viscérale, Hôpital Larrey, CHU d'Angers, Angers, France
| | - Eric Mirallié
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (IMAD), Hôtel Dieu, CHU de Nantes, Nantes, France
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Harper S, Harrison B. First surgery for pancreatic neuroendocrine tumours in a patient with MEN1: enucleation versus disease-modifying surgery. Clin Endocrinol (Oxf) 2015; 83:618-21. [PMID: 25807996 DOI: 10.1111/cen.12774] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/14/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022]
Abstract
Pancreatic neuroendocrine tumours (PNETs) are the second most common manifestation of MEN1, affecting up to 80% of patients. The secretion of peptide hormones by PNETs causes clinical syndromes requiring therapeutic intervention. Malignant progression of PNETs is a leading cause of mortality in patients with MEN1. The goal of surgery, when required, is to alleviate a biochemical syndrome or to treat established tumour(s) to reduce the risk of local progression or metastases against the background of preservation of pancreatic function. Determining the need and optimum timing for an operative intervention is complex and requires an approach individualized for each patient. When a clinically significant biochemical syndrome is confirmed, the time course to surgery is clear. In patients with a potentially malignant PNET, the decision as to when to intervene is more challenging. In all cases surgical treatment carries the potential for harm, of more than usual concern because many of the patients are young. In this study, we explain an approach to the surgical treatment of MEN1 patients with biochemical or radiological evidence of PNETs where other manifestations of the syndrome are either treated or controlled and the patient lacks comorbidity that would preclude pancreatic surgery. In each scenario we present, a normal serum gastrin will be assumed as the surgical approach to this usually duodenal manifestation of MEN1 is significantly different to the management of other PNETs.
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Affiliation(s)
- Simon Harper
- Department of Endocrine Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Barney Harrison
- Department of Endocrine Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
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Long-term Prognosis of Resected Pancreatic Neuroendocrine Tumors in von Hippel-Lindau Disease Is Favorable and Not Influenced by Small Tumors Left in Place. Ann Surg 2015; 262:384-8. [PMID: 25185468 DOI: 10.1097/sla.0000000000000856] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Management of pancreatic neuroendocrine tumors (PNETs) associated with von Hippel-Lindau disease (VHL) is challenging because of the malignant potential and difficulty in predicting prognosis. OBJECTIVE Compare the long-term outcome of resected VHL-PNET and sporadic PNET. METHODS Data of all patients with VHL (n = 23) operated on for nonmetastatic PNET were reviewed. Patient characteristics and recurrence-free survival rates were compared with those in patients operated on for sporadic PNET, matched for tumor size, stage, and Ki-67 index. RESULTS Patients in both groups had similar demographic characteristics, except that patients with VHL were younger (36 vs 56 years, P < 0.0001). Median tumor size was 30 mm. Median Ki-67 index was 3% and 4% in the VHL and sporadic groups (P = 0.95), respectively, and lymph node metastases were present in 43% and 30% of cases, respectively (P = 0.45). Sixteen (70%) patients with VHL had multiple PNET; lesions less than 15 mm were left in place in 11 patients. Median postoperative follow-up was 107 months (interquartile range, 57-124 months) and 71 months (interquartile range, 58-131 months) in the VHL and control groups, respectively. Median recurrence-free survival could not have been estimated in the VHL group due to the low number of events (hazard ratio, 5.6; 95% confidence interval, 1.4-22.6; P = 0.013). Five patients with VHL died (3 from VHL-related tumors including 1 from PNET), whereas only one control patient died due to unrelated causes. CONCLUSIONS The long-term outcome of resected VHL-PNET is better than that of sporadic PNET. PNET less than 15 mm left in place did not progress. A parenchyma-sparing surgical strategy seems appropriate in patients with VHL-PNET, who may develop more life-threatening tumors of other organs.
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Jilesen APJ, Tol JAMG, Busch ORC, van Delden OM, van Gulik TM, Nieveen van Dijkum EJM, Gouma DJ. Emergency management in patients with late hemorrhage after pancreatoduodenectomy for a periampullary tumor. World J Surg 2015; 38:2438-47. [PMID: 24791669 DOI: 10.1007/s00268-014-2593-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported. METHODS From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients. RESULTS Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention. CONCLUSION The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.
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Affiliation(s)
- Anneke P J Jilesen
- Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
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Cirocchi R, Graziosi L, Sanguinetti A, Boselli C, Polistena A, Renzi C, Desiderio J, Noya G, Parisi A, Hirota M, Donini A, Avenia N. Can the measurement of amylase in drain after distal pancreatectomy predict post-operative pancreatic fistula? Int J Surg 2015; 21 Suppl 1:S30-3. [PMID: 26117433 DOI: 10.1016/j.ijsu.2015.06.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 03/19/2015] [Accepted: 04/10/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumors, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important. METHODS From a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease. RESULTS Postoperative pancreatic fistula occurred in four cases. One patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy. DISCUSSION Postoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day. CONCLUSION POPF is the most frequently complication after pancreatectomy. In our analysis DFA1>5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice.
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Affiliation(s)
- Roberto Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, Terni, Italy.
| | - Luigina Graziosi
- General and Emergency Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy.
| | - Alessandro Sanguinetti
- Department of General Surgery, Saint Mary Hospital, University of Perugia, Terni, Italy.
| | - Carlo Boselli
- Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy.
| | - Andrea Polistena
- Department of General Surgery, Saint Mary Hospital, University of Perugia, Terni, Italy.
| | - Claudio Renzi
- Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy.
| | - Jacopo Desiderio
- Department of General and Oncologic Surgery, University of Perugia, Terni, Italy.
| | - Giuseppe Noya
- Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy.
| | - Amilcare Parisi
- Department of Digestive Surgery, St. Maria Hospital, Terni, Italy.
| | | | - Annibale Donini
- General and Emergency Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy.
| | - Nicola Avenia
- Department of General Surgery, Saint Mary Hospital, University of Perugia, Terni, Italy.
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Meng HB, Zhou B, Wu F, Xu J, Song ZS, Gong J, Khondaker M, Xu B. Continuous suture of the pancreatic stump and Braun enteroenterostomy in pancreaticoduodenectomy. World J Gastroenterol 2015; 21:2731-2738. [PMID: 25759543 PMCID: PMC4351225 DOI: 10.3748/wjg.v21.i9.2731] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/19/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate a new modification of pancreaticoduodenectomy (PD)-a mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy.
METHODS: Two hundred and three patients underwent PD from 2009 to 2014 and were classified into two groups: Group A (98 patients), who received PD with a mesh-like running suturing for the pancreatic remnant, and Braun’s enteroenterostomy; and Group B (105 patients), who received standard PD. Demographic data, intraoperative findings, postoperative morbidity and perioperative mortality between the two groups were compared by univariate and multivariate analysis.
RESULTS: Demographic characteristics between Group A and Group B were comparable. There were no significant differences between the two groups concerning perioperative mortality, and operative blood loss, as well as the incidence of the postoperative morbidity, including reoperation, bile leakage, intra-abdominal fluid collection or infection, and postoperative bleeding. Clinically relevant postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) were identified more frequently in Group B than in Group A. Technique A (PD with a mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy) was independently associated with decreased clinically relevant POPF and DGE, with an odds ratio of 0.266 (95%CI: 0.109-0.654, P = 0.004) for clinically relevant POPF and 0.073 (95%CI: 0.010-0.578, P = 0.013) for clinically relevant DGE.
CONCLUSION: An additional mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy during PD decreases the incidence of postoperative complications and is beneficial for patients.
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Atema JJ, Jilesen APJ, Busch ORC, van Gulik TM, Gouma DJ, van Dijkum EJMN. Pancreatic fistulae after pancreatic resections for neuroendocrine tumours compared with resections for other lesions. HPB (Oxford) 2015; 17:38-45. [PMID: 25041879 PMCID: PMC4266439 DOI: 10.1111/hpb.12319] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/18/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection for pancreatic neuroendocrine tumours (PNET) is suggested to be associated with an increased risk of a post-operative pancreatic fistula (POPF). The aim of this study was to describe morbidity after resections for PNET, focusing on POPF. Outcomes were compared with resections for other lesions. METHODS Patients undergoing an elective pancreatic resection during a 12-year period were retrospectively analysed. Morbidity was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definitions. RESULTS Eighty-eight out of 832 patients (10.6%) underwent a resection for PNET. Atypical pancreatic resections (enucleation and central pancreatectomy) and distal pancreatectomies were more frequently performed for PNET. The POPF rate was 22.7% in patients operated for PNET compared with 17.2% in other patients (P = 0.200). In univariate analysis, body mass index (BMI), pancreatic duct diameter, somatostatin analogue administration, type of resection and type of pathology were associated with a POPF. In multivariate analysis, BMI, a pancreatic duct diameter <3 mm and central pancreatectomy remained independent risk factors [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.22-3.07 and OR 3.04, 95% CI 1.05-8.82, respectively]. CONCLUSIONS High rates of POPF were found in patients operated for PNET. However, this was mainly owing to the fact that atypical resections, known to be associated with a higher fistula rate, were performed more frequently in these patients.
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Affiliation(s)
| | | | | | | | | | - Els J M Nieveen van Dijkum
- Correspondence, Els J.M. Nieveen van Dijkum, Department of Surgery, Academic Medical Center, Meibergdreef 9; PO Box 22660, 1105 AZ Amsterdam, The Netherlands. Tel: +31 20 566 3067. Fax: +31 20 566 2659. E-mail:
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McKenna LR, Edil BH. Update on pancreatic neuroendocrine tumors. Gland Surg 2014; 3:258-75. [PMID: 25493258 DOI: 10.3978/j.issn.2227-684x.2014.06.03] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 05/27/2014] [Indexed: 12/12/2022]
Abstract
Pancreatic neuroendocrine tumors (pNETs) are relatively rare tumors comprising 1-2% of all pancreas neoplasms. In the last 10 years our understanding of this disease has increased dramatically allowing for advancements in the treatment of pNETs. Surgical excision remains the primary therapy for localized tumors and only potential for cure. New surgical techniques using laparoscopic approaches to complex pancreatic resections are a major advancement in surgical therapy and increasingly possible. With early detection being less common, most patients present with metastatic disease. Management of these patients requires multidisciplinary care combining the best of surgery, chemotherapy and other targeted therapies. In addition to surgical advances, recently, there have been significant advances in systemic therapy and targeted molecular therapy.
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Affiliation(s)
- Logan R McKenna
- Department of Surgery, University of Colorado, Academic Office One, Aurora, CO, USA
| | - Barish H Edil
- Department of Surgery, University of Colorado, Academic Office One, Aurora, CO, USA
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Tsang YP, Lang BHH, Shek TWH. Assessing the short- and long-term outcomes after resection of benign insulinoma. ANZ J Surg 2014; 86:706-10. [PMID: 25345822 DOI: 10.1111/ans.12891] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Insulinoma is a rare functional pancreatic neuroendocrine tumour (NET) believed to have an excellent long-term outcome, but few studies have solely focused on this issue after apparently curative resection. This study aimed to assess post-operative and long-term outcomes after resection of benign insulinomas. METHODS From 1998 to 2013, 36 consecutive patients with insulinomas underwent surgery. Three patients had multiple endocrine neoplasia type-1 (MEN-1). Demographics, operative findings, tumour grade (2010 World Health Organization (WHO) NET classification), post-operative pancreatic fistula (POPF) grade (International Study Group of Pancreatic Fistula (ISGPF)), complications and recurrence were analysed. RESULTS Eighteen (50%) had enucleation while the rest underwent pancreatic resection. The majority (86.1%) of insulinomas belonged to WHO NET grade G1. POPF occurred in 58.3% of patients while clinical fistula (ISGPF grades B and C) occurred in 19.4%. One (2.8%) patient required reoperation. The occurrence of POPF was not related to type of resection or surgical approach. There was no perioperative mortality. After a mean follow-up of 83.6 months, two patients (5.7%) developed disease recurrence at 34.4 and 131.9 months after initial surgery. No patients developed distant metastasis. The 10- and 15-year disease-free rates were 95.6 and 85.4%, respectively. CONCLUSION POPF occurred frequently and posed a significant morbidity after resection of insulinoma. However, it occurred independently of type of resection or surgical approach. Although the immediate cure rate after resection was high (100%), long-term disease recurrence in sporadic (non-MEN-1) cases was not insignificant. Regular long-term follow-up is recommended.
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Affiliation(s)
- Yi-Po Tsang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
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Beger HG, Poch B, Vasilescu C. Benign cystic neoplasm and endocrine tumours of the pancreas--when and how to operate--an overview. Int J Surg 2014; 12:606-14. [PMID: 24742543 DOI: 10.1016/j.ijsu.2014.03.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 03/31/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard. OBJECTIVES To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate. RESULTS Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2-3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20% of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11%, pancreatic fistula in 33%. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33% pancreatic fistula and severe post-operative complications of 18% is related to management of proximal pancreatic stump. DPPHRt/s is used in 70% for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10% for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy. CONCLUSION The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.
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Affiliation(s)
- H G Beger
- Department of General- and Visceral Surgery, c/o University of Ulm, Ulm, Germany.
| | - B Poch
- Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donouklinikum Neu-Ulm, Germany
| | - C Vasilescu
- Department of General Surgery and Liver Transplantation, Fundei Clinical Institute, Bucharest, Romania
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Peranteau WH, Palladino AA, Bhatti TR, Becker SA, States LJ, Stanley CA, Adzick NS. The surgical management of insulinomas in children. J Pediatr Surg 2013; 48:2517-24. [PMID: 24314196 PMCID: PMC4140562 DOI: 10.1016/j.jpedsurg.2013.04.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 04/29/2013] [Accepted: 04/29/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE Insulinomas are rare pediatric tumors for which optimal localization studies and management remain undetermined. We present our experience with surgical management of insulinomas during childhood. METHODS A retrospective review was performed of patients who underwent surgical management for an insulinoma from 1999 to 2012. RESULTS The study included eight patients. Preoperative localization was successful with abdominal ultrasound, abdominal CT, endoscopic ultrasound, or MRI in only 20%, 28.6%, 40%, and 50% of patients, respectively. Octreotide scan was non-diagnostic in 4 patients. For diagnostic failure, selective utilization of 18-Fluoro-DOPA PET/CT scanning, arterial stimulation/venous sampling, or transhepatic portal venous sampling were successful in insulinoma localization. Intraoperatively, all lesions were identified by palpation or with the assistance of intraoperative ultrasound. Surgical resection using pancreas sparing techniques (enucleation or distal pancreatectomy) resulted in a cure in all patients. Postoperative complications included a pancreatic fistula in two patients and an additional missed insulinoma in a patient with MEN-1 requiring successful reoperation. CONCLUSIONS Preoperative tumor localization may require many imaging modalities to avoid unsuccessful blind pancreatectomy. Intraoperative palpation with the assistance of ultrasound offers a reliable method to precisely locate the insulinoma. Complete surgical resection results in a cure. Recurrent symptoms warrant evaluation for additional lesions.
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Affiliation(s)
- William H. Peranteau
- The Congenital Hyperinsulinism Center and the Department of Surgery at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew A. Palladino
- The Congenital Hyperinsulinism Center and the Department of Pediatrics at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tricia R. Bhatti
- The Congenital Hyperinsulinism Center and the Department of Pathology at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan A. Becker
- The Congenital Hyperinsulinism Center and the Department of Pediatrics at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa J. States
- The Congenital Hyperinsulinism Center and the Department of Radiology at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Charles A. Stanley
- The Congenital Hyperinsulinism Center and the Department of Pediatrics at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - N. Scott Adzick
- The Congenital Hyperinsulinism Center and the Department of Surgery at the Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Corresponding author. Department of Surgery, The Children’s Hospital of Philadelphia, 5th Floor Wood Building, 34th Street and Civic Center Blvd., Philadelphia, PA 19105, USA. Tel.: +1 215 590 2727; fax: +1 215 590 4875. (N.S. Adzick)
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Abstract
BACKGROUND AND OBJECTIVES Computer-assisted robotic surgery allows complex resections and anastomotic reconstructions to be performed with nearly identical standards to open surgery. We applied this technology to a variety of pancreatic resections to assess the safety, feasibility, versatility, and reliability of this technology. METHODS A retrospective review of a prospective database of robotic pancreatic resections at a single institution between August 2008 and November 2012 was performed. Perioperative outcomes were analyzed. RESULTS A total of 250 consecutive robotic pancreatic resections were analyzed; pancreaticoduodenectomy (132), distal pancreatectomy (83), central pancreatectomy (13), pancreatic enucleation (10), total pancreatectomy (5), Appleby resection (4), and Frey procedure (3). Thirty-day and 90-day mortality was 0.8% and 2.0%. Rate of Clavien 3 and 4 complications was 14% and 6%. The International Study Group on Pancreatic Fistula grade C fistula rate was 4%. Mean operative time for the 2 most common procedures was 529 ± 103 minutes for pancreaticoduodenectomy and 257 ± 93 minutes for distal pancreatectomy. Continuous improvement in operative times was observed over the course of the experience. Conversion to open procedure was required in 16 patients (6%) (11 with pancreaticoduodenectomy, 2 with distal pancreatectomy, 2 with central pancreatectomy, 1 with total pancreatectomy) for failure to progress (14) and bleeding (2). CONCLUSIONS This represents to our knowledge the largest series of robotic pancreatic resections. Safety and feasibility metrics including the low incidence of conversion support the robustness of this platform and suggest no unanticipated risks inherent to this new technology. By defining these early outcome metrics, this report begins to establish a framework for comparative effectiveness studies of this platform.
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Abstract
Pancreatic neuroendocrine tumors (PanNETs) have increased in incidence in the USA over the last 20 years. Although PanNETs are often misconceived as being indolent tumors as they have a far more favorable prognosis over pancreatic adenocarcinoma, roughly 60-70% of patients have metastatic disease at the time of diagnosis due to presentation late in the disease process. While improvements in imaging modalities allow for early detection and better tumor localization, recent advancements in basic science, as well as surgical and medical management of PanNETs have further improved the prognosis. The mainstay of therapy for localized PanNETs is surgical intervention, which has become safer and is slowly shifting towards a more minimally invasive approach. However, the prognosis still remains relatively bleak for patients with unresectable disease. Fortunately, novel molecular targeted therapies, such as everolimus and sunitinib, have recently come into the limelight and have shown significant promise for the treatment of locally advanced and metastatic disease.
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Affiliation(s)
- Miral R Sadaria
- Department of Surgery, University of Colorado Anschutz Medical Campus, Division of GI, Tumor and Endocrine Surgery, Academic Office One, 12631 East 17th Avenue, C311, Aurora, CO 80045, USA
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Abstract
PURPOSE OF REVIEW Neuroendocrine tumors of the gastrointestinal tract are rare tumors, but as they have become recognized more often, and their care has been concentrated at some centers, standards of care have developed. With these standards, questions in the field have led to focused studies to inform practitioners. RECENT FINDINGS The efficacy and morbidity of care have been well delineated now for pancreatic neuroendocrine tumors, as well as the effect of stretching the bounds of resection to include vascular reconstruction. The management of the gallbladder in patients with mid-gut carcinoid tumors and palliative approaches to mesenteric vein compression have been reported. The operative management of liver metastases shows the benefit of this approach, even when incomplete, as well as the safety of performing complex procedures in appropriate situations. SUMMARY Some of the difficult or controversial decision areas in the surgical care of patients with neuroendocrine tumors are now more clear because of recently reported data.
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