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Ribeiro T, Castanheira-Rodrigues S, Bastos P, Cristino H, Fernandes A, Rodrigues-Pinto E, Bispo M, Rio-Tinto R, Vilas-Boas F. Portuguese Pancreatic Club Perspectives on Endoscopic Ultrasound-Guided and Surgical Treatment of Pancreatic Neuroendocrine Tumors. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:225-235. [PMID: 39022303 PMCID: PMC11250664 DOI: 10.1159/000534032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/11/2023] [Indexed: 07/20/2024]
Abstract
Pancreatic neuroendocrine tumors (panNETs) are a group of neoplasms with heterogenous biological and clinical phenotypes. Although historically regarded as rare, the incidence of these tumors has been increasing, mostly owing to improvements in the detection of small, asymptomatic tumors with imaging. The heterogeneity of these lesions creates significant challenges regarding diagnosis, staging, and treatment. Endoscopic ultrasound (EUS) has improved the characterization of pancreatic lesions. Furthermore, EUS nowadays has evolved from a purely diagnostic modality to allow the performance of minimally invasive locoregional therapy for pancreatic focal lesions. The choice of treatment as well as the treatment goals depend on several factors, including tumor secretory status, grading, staging, and patient performance status. Surgery has been the mainstay for the management of these patients, particularly for localized, low-grade, large panNETs >2 cm. Over the last decade, a significant body of evidence has been accumulated evaluating the role of EUS for the ablative therapy of panNETs, namely by the use of chemoablative agents and radiofrequency. Although endoscopic techniques are not routinely recommended by international guidelines, they may be considered for the treatment of smaller lesions in patients who are unwilling or unfit for pancreatic surgery. In this review, we summarize the existing evidence on the interventional techniques for the treatment of patients with panNETs, focusing on the EUS-guided and surgical approaches.
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Affiliation(s)
- Tiago Ribeiro
- Department of Gastroenterology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | - Pedro Bastos
- Department of Gastroenterology, Instituto Português de Oncologia do Porto, Porto, Portugal
| | - Humberto Cristino
- Department of General Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Eduardo Rodrigues-Pinto
- Department of Gastroenterology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Miguel Bispo
- Digestive Oncology Unit, Gastroenterology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Rio-Tinto
- Digestive Oncology Unit, Gastroenterology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Filipe Vilas-Boas
- Department of Gastroenterology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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Dumitrascu T, Popescu I. Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy? J Pers Med 2023; 13:jpm13050858. [PMID: 37241028 DOI: 10.3390/jpm13050858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.
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Affiliation(s)
- Traian Dumitrascu
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania
| | - Irinel Popescu
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Titu Maiorescu University, 022328 Bucharest, Romania
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Gupta V, Bhandare MS, Chaudhari V, Parray A, Shrikhande SV. Organ preserving pancreatic resections offer better long-term conservation of pancreatic function at the expense of high perioperative major morbidity: a fair trade-off for benign or low malignant potential pancreatic neoplasms-a single-center experience. Langenbecks Arch Surg 2022; 407:1507-1515. [PMID: 35298681 DOI: 10.1007/s00423-022-02491-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 03/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard pancreatic resections (SPRs) might have long-term deleterious effects on pancreatic function, without added oncological advantage in low malignant potential (LMP) or benign neoplasms. This study aimed to evaluate outcomes following organ-preserving pancreatic resections (OPPARs) and SPRs. METHOD Post hoc analysis of patients undergoing OPPAR or SPR for benign or LMP pancreatic tumors from January 2011 to January 2020 at Tata Memorial Hospital, Mumbai. RESULTS Thirty-six and 114 patients were identified in OPPAR and SPR groups respectively. The overall morbidity (58.3% vs 43.9%, p-0.129) was comparable. Major morbidity (41.7% vs 21.9%, p-0.020), post-operative pancreatic fistula (POPF) (63.9% vs 35.1%, p-0.002), and clinically relevant POPF (41.7% vs 20.2%, p-0.010) were significantly higher with OPPAR. Post-operative endocrine insufficiency (14.9% vs 11.1%, p-0.567), exocrine insufficiency (19.3% vs 0%, p-0.004), and requirement of long-term pancreatic enzyme replacement (17.5% vs 0%, p-0.007) were higher in SPRs. Comparing left-sided and right-sided resections in the entire cohort, incidence of endocrine insufficiency was 17.1% vs 11.2% (p-0.299) and that of exocrine insufficiency was 8.6% vs 20% (p-0.048) respectively. CONCLUSION OPPAR is associated with high post-operative major morbidity and pancreatic fistula rate but offers long-term benefit due to better preservation of pancreatic function than SPR. The incidence of exocrine insufficiency is higher in right sided as compared to left-sided pancreatic resections.
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Affiliation(s)
- Vikas Gupta
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India.
| | - Vikram Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Amir Parray
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
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Cai H, Peng B. Letter to Editor: Central Pancreatectomy Versus Distal Pancreatectomy and Pancreaticoduodenectomy for Benign and Low-Grade Malignant Neoplasms: A Retrospective and Propensity Score-Matched Study with Long-Term Functional Outcomes and Pancreas Volumetry. Ann Surg Oncol 2020; 27:952-953. [PMID: 32388743 DOI: 10.1245/s10434-020-08557-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Indexed: 02/05/2023]
Affiliation(s)
- He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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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: 198] [Impact Index Per Article: 49.5] [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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Hain E, Sindayigaya R, Fawaz J, Gharios J, Bouteloup G, Soyer P, Bertherat J, Prat F, Terris B, Coriat R, Gaujoux S. Surgical management of pancreatic neuroendocrine tumors: an introduction. Expert Rev Anticancer Ther 2019; 19:1089-1100. [PMID: 31825691 DOI: 10.1080/14737140.2019.1703677] [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] [Indexed: 12/13/2022]
Abstract
Introduction: Neuroendocrine tumors of the pancreas (pNETs) represent only 1% to 2% of all pancreatic neoplasms. These tumors can be classified as functional or nonfunctional tumors; as sporadic or from a genetic origin; as neuroendocrine neoplasms or carcinoma. Over the last decade, diagnosis of pNETs has increased significantly mainly due to the widespread use of cross-sectional imaging. Those tumors are usually associated with a good prognosis. Surgery, the only curative option for those patients, should always be discussed, ideally in a multidisciplinary team setting.Areas covered: We discuss i), the preoperative management of pNETs and the importance of accurate diagnosis, localization, grading and staging with computed tomography, magnetic resonance imaging, endoscopic ultrasound, and nuclear medicine imaging; ii), surgical indications and iii), the surgical approach (standard pancreatectomy vs pancreatic-sparing surgery).Expert opinion: The treatment option of all patients presenting with pNETs should be discussed in a multidisciplinary team setting with surgeon's experienced in both pancreatic surgery and neuroendocrine tumor management. A complete preoperative imaging assessment - morphological and functional - must be performed. Surgery is usually recommended for functional pNETs, nonfunctional pNETs >2 cm (nf-pNETs) or for symptomatic nf-pNETs.
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Affiliation(s)
- Elisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.,Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Rémy Sindayigaya
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Jade Fawaz
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Joseph Gharios
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Gaspard Bouteloup
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Philippe Soyer
- Department of Radiology, Cochin Hospital, APHP, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology, Cochin Hospital, APHP, Paris, France
| | - Frédéric Prat
- Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Benoit Terris
- Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Pathology, Cochin Hospital, APHP, Paris, France
| | - Romain Coriat
- Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.,Facultéde Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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7
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Dragomir MP, Sabo AA, Petrescu GED, Li Y, Dumitrascu T. Central pancreatectomy: a comprehensive, up-to-date meta-analysis. Langenbecks Arch Surg 2019; 404:945-958. [PMID: 31641855 DOI: 10.1007/s00423-019-01829-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/23/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers. METHODS A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed. RESULTS Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p < 0.0001), overall and clinically relevant pancreatic fistula (p < 0.0001), postoperative hemorrhage (p = 0.02), but with significantly lower incidences of new-onset (p < 0.0001) and worsening diabetes mellitus (p = 0.004). Furthermore, significantly longer length of hospital stay (p < 0.0001) was observed for CP patients. CONCLUSIONS CP is superior to DP regarding the preservation of pancreatic functions, but at the expense of significantly higher complication rates and longer hospital stay. Proper selection of patients is of utmost importance to maximize the benefits and mitigate the risks of CP.
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Affiliation(s)
- Mihnea P Dragomir
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of General Surgery and Liver Transplantation, Division of Surgical Oncology, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Street, 022328, Bucharest, Romania.,Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexandru A Sabo
- Department of Pediatrics, "Marie S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania
| | | | - Yongfeng Li
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Traian Dumitrascu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. .,Department of General Surgery and Liver Transplantation, Division of Surgical Oncology, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 258 Fundeni Street, 022328, Bucharest, Romania.
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Serra F, Barbato G, Tazzioli G, Gelmini R. Pancreaticogastrostomy as reconstruction choice in pancreatic trauma surgery: Case report and review of the literature. Int J Surg Case Rep 2019; 65:102-106. [PMID: 31704658 PMCID: PMC6920313 DOI: 10.1016/j.ijscr.2019.10.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Due to its retroperitoneal location and its proximity to major vascular structures and other organs, isolated pancreatic injuries are rare. The optimal management for pancreatic injuries of grades III and IV, where a main ductal transection is present, remains controversial. Isolated complete traumatic transection of the pancreatic neck is uncommon, but this condition is associated with some peculiar technical aspects that allow more conservative treatments. PRESENTATION OF THE CASE A closed abdominal blunt trauma in a young patient underwent emergency surgery for suspect hemoperitoneum. Intraoperatively evidence of complete traumatic transection of the pancreatic neck treated with pancreas tissue debridement, suture of the cephalic stump and pancreaticogastrostomy reconstruction. DISCUSSION Preservation of pancreatic volume and avoidance of adjacent organ resection is associated with lesser mortality and morbidity rate. The advantages of conservative treatments are related to reductions in the postoperative exocrine and endocrine insufficiencies. CONCLUSION In selected cases of complete neck transection with preserved pancreatic parenchyma in a stable patient, parenchymal-sparing interventions should be considered. Pancreaticogastrostomy offers an easier to learn and faster technique also suited for less experienced surgeons.
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Affiliation(s)
- Francesco Serra
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
| | - Giuseppe Barbato
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
| | - Giovanni Tazzioli
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
| | - Roberta Gelmini
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
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Gharios J, Hain E, Dohan A, Prat F, Terris B, Bertherat J, Coriat R, Dousset B, Gaujoux S. Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas. Best Pract Res Clin Endocrinol Metab 2019; 33:101294. [PMID: 31351817 DOI: 10.1016/j.beem.2019.101294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic neuroendocrine tumours (PanNET) are rare tumours, accounting for 1%-2% of all pancreatic neoplasms. These tumors are classified as functioning neuroendocrine tumours (F-PanNETs) or non-functioning (NF-PanNETs) depends on whether the tumour is associated with clinical hormonal hypersecretion syndrome or not. In the last decades, diagnosis of PanNETs has increased significantly due to the widespread of cross-sectional imaging. Whenever possible, surgery is the cornerstone of PanNETs management and the only curative option for these patients. Indeed, after R0 resection, the 5-year overall survival rate is around 90-100% for low grade lesions but significantly drops after incomplete resections. Compared to standard resections, pancreatic sparing surgery, i.e. enucleation and central pancreatectomy, significantly decreased the risk of pancreatic insufficiency. It should be performed in patients with good general condition and normal pancreatic function to limit the operative risk and enhance the benefit of surgery. Nowadays, due to many known advantages of minimally invasive surgery, there is an ongoing trend towards laparoscopic and robotic pancreatic surgery. The aim of this study is to describe the pre- and intraoperative diagnostic requirements for the management of PanNETs and the benefits and risks of minimally invasive surgery including laparoscopic and robotic approach in view of the recent literature.
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Affiliation(s)
- Joseph Gharios
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Elisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Anthony Dohan
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Radiology, Cochin Hospital, APHP, Paris, France
| | - Fréderic Prat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Benoit Terris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Pathology, Cochin Hospital, APHP, Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Endocrinology, Cochin Hospital, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Romain Coriat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France.
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Yamaguchi H, Kimura Y, Nagayama M, Imamura M, Tanaka S, Yoshida M, Yoshida E, Fujino H, Machiki T, Miyanishi K, Mizuguchi T, Kato J, Takemasa I. Central pancreatectomy in portal annular pancreas for metastatic renal cell carcinoma: a case report. World J Surg Oncol 2019; 17:76. [PMID: 31039791 PMCID: PMC6492400 DOI: 10.1186/s12957-019-1622-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/23/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Portal annular pancreas (PAP) is a rare congenital anatomical abnormality of the pancreas in which the portal vein is encircled by aberrant parenchyma, and special attention is needed for pancreatic resections. This is the first report of central pancreatectomy (CP) in a PAP for metastatic renal cell carcinoma (RCC). CASE PRESENTATION A 76-year-old man who had a history of left nephrectomy for renal cancer not otherwise specified 36 years earlier and radical cystectomy for bladder cancer 4 years earlier was incidentally found to have a pancreatic tumor and a liver tumor. The pancreatic tumor was diagnosed as metastasis of clear cell RCC, and the liver tumor was diagnosed as moderately differentiated hepatocellular carcinoma (HCC) on preoperative histological evaluation. Preoperative computed tomography imaging showed a type 3A PAP, in which the main pancreatic duct (MPD) ran ventral to the portal vein (anteportal type), and the aberrant parenchyma was located cranial to the confluence of the portal vein and splenic vein (suprasplenic type). After adhesiotomy and partial liver resection, CP was performed. With intraoperative ultrasound guidance, the aberrant parenchyma of the PAP could be preserved, avoiding additional resection. Thus, two pancreatic transections were performed, creating a single-cut margin that contained the MPD in the distal pancreas. Oncologically safe margins were confirmed by intraoperative pathological diagnosis. The distal pancreas was reconstructed by pancreatojejunostomy in the routine procedures. The pathological diagnosis of the surgical specimens was identical to the preoperative diagnosis. A postoperative pancreatic fistula (POPF) developed from the proximal stump of the head of the pancreas, necessitating no specific treatment other than drainage. The patient showed no signs or symptoms of recurrent RCC or abnormal pancreatic function for 2 years after the operation, although a histologically proven new HCC lesion developed distant from the initial site 8 months after the operation. CONCLUSIONS Precise preoperative evaluation of the tumor features and PAP allowed adequate surgical strategies to be planned. Intraoperative ultrasound was useful to minimize parenchymal resections of the PAP. CP is still a challenging procedure in terms of the development of POPF.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan.
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
| | - Minoru Nagayama
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
| | - Masafumi Imamura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
| | - Shingo Tanaka
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Eiji Yoshida
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
| | - Hiroki Fujino
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
| | - Takashi Machiki
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
| | - Koji Miyanishi
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toru Mizuguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan.,Sapporo Medical University School of Health Science, Sapporo, Japan
| | - Junji Kato
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido, 060-8543, Japan
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Xiao W, Zhu J, Peng L, Hong L, Sun G, Li Y. The role of central pancreatectomy in pancreatic surgery: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:896-904. [PMID: 29886106 DOI: 10.1016/j.hpb.2018.05.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP) and pancreaticoduodenectomy (PD). METHODS A systematic literature research in PubMed/Medline, Embase and Cochrane Library was performed to identify articles reporting CP from January 1983 to November 2017. RESULTS Fifty studies with 1305 patients undergoing CP were identified. The overall morbidity, mortality, pancreatic fistula (PF) rate and reoperation rate was 51%, 0.5%, 35% and 4% respectively. Endocrine and exocrine insufficiency were occurred in 4% and 5% of patients after CP. Meta-analysis of CP versus DP favored CP with regard to less blood loss (WMD = -143.4, P = 0.001), lower rates of endocrine (OR = 0.13, P < 0.001) and exocrine insufficiency (OR = 0.38, P < 0.001). CP was associated with higher morbidity and PF rate. In comparison with PD, CP had a lower risk of endocrine (OR = 0.14, P < 0.001) and exocrine insufficiency (OR = 0.14, P < 0.001), but a higher PF rate (OR = 1.6, P = 0.015). CONCLUSIONS CP maintains pancreatic endocrine and exocrine function better than DP and PD, but is associated with a higher PF rate.
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Affiliation(s)
- Weidong Xiao
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Jisheng Zhu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Long Peng
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Le Hong
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Gen Sun
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yong Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Santangelo M, Esposito A, Tammaro V, Calogero A, Criscitiello C, Roberti G, Candida M, Rupealta N, Pisani A, Carlomagno N. What indication, morbidity and mortality for central pancreatectomy in oncological surgery? A systematic review. Int J Surg 2016; 28 Suppl 1:S172-6. [DOI: 10.1016/j.ijsu.2015.12.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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13
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Iacono C, Zicari M, Conci S, Valdegamberi A, De Angelis M, Pedrazzani C, Ruzzenente A, Guglielmi A. Management of pancreatic trauma: A pancreatic surgeon's point of view. Pancreatology 2015; 16:302-8. [PMID: 26764528 DOI: 10.1016/j.pan.2015.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/24/2015] [Accepted: 12/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic trauma occurs in 0.2% of patients with blunt trauma and 1-12% of patients with penetrating trauma. Traumatic pancreatic injuries are characterised by high morbidity and mortality, which further increase with delayed diagnoses. The diagnosis of pancreatic trauma is challenging. Signs and symptoms can be non-specific or even absent. METHODS A critical review of studies reporting the management and outcomes of pancreatic trauma was performed. RESULTS The management of pancreatic trauma depends on the haemodynamic stability of the patient, the degree and location of parenchymal injury, the integrity of the main pancreatic duct, and the associated injuries to other organs. Nevertheless, the involvement of the main pancreatic duct is the most important predictive factor of the outcome. The majority of pancreatic traumas are managed by medical treatment (parenteral nutrition, antibiotic therapy and somatostatin analogues), haemostasis, debridement of devitalised tissue and closed external drainage. If a proximal duct injury is diagnosed, endoscopic transpapillary stent insertion can be a viable option, while surgical resection by pancreaticoduodenectomy is restricted to an extremely small number of selected cases. Injuries of the distal parenchyma or distal duct may be managed with distal pancreatectomy with spleen preservation. At the pancreatic neck, when pancreatic transection occurs without damage to the parenchyma, a parenchyma-sparing procedure is feasible. CONCLUSION The management of pancreatic injuries is complex and often requires a multidisciplinary approach. Here, we propose a management algorithm that is based on parenchymal damage and the site of duct injury.
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Affiliation(s)
- Calogero Iacono
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy.
| | - Marianna Zicari
- Department of Radiology, University of Verona Medical School, Verona, Italy
| | - Simone Conci
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy
| | - Alessandro Valdegamberi
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy
| | - Michela De Angelis
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy
| | - Corrado Pedrazzani
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Division of General Surgery, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy
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Cherif R, Gaujoux S, Cros J, Ruszniewski P, Sauvanet A. Parenchyma-sparing pancreatectomies for pancreatic neuroendocrine tumors. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Parenchyma-sparing pancreatectomy, including enucleation and central pancreatectomy, has been investigated as an alternative to standard resection (pancreaticoduodenectomy or left/distal pancreatectomy) for pancreatic neuroendocrine tumor (PNET). In selected patients, with small (<2 cm) and low-grade tumors, PSP are associated with excellent both overall and disease-free survivals. These procedures are associated with an increased postoperative morbidity but an excellent long-term postoperative pancreatic function. Therefore, they should be considered as a valid therapeutic option in selected well-differentiated PNET.
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Affiliation(s)
- Rim Cherif
- Department of Hepatobiliary & Pancreatic Surgery – Hospital Beaujon, 100, Bd du Général Leclerc - 92110 Clichy, France
| | - Sébastien Gaujoux
- Department of Hepatobiliary & Pancreatic Surgery – Hospital Beaujon, 100, Bd du Général Leclerc - 92110 Clichy, France
- UNITY Hospitalo-Universitary Department, Université Paris Diderot, Paris, France
| | - Jérome Cros
- Department of Pathology, Hopital Beaujon, Clichy, 92110, France
| | - Philippe Ruszniewski
- UNITY Hospitalo-Universitary Department, Université Paris Diderot, Paris, France
- Department of Gastroenterology, Pôle des Maladies de l'Appareil Digestif (PMAD), Hopital Beaujon, Clichy, 92110, France
| | - Alain Sauvanet
- Department of Hepatobiliary & Pancreatic Surgery – Hospital Beaujon, 100, Bd du Général Leclerc - 92110 Clichy, France
- UNITY Hospitalo-Universitary Department, Université Paris Diderot, Paris, France
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Nachulewicz P, Rogowski B, Obel M, Woźniak J. Central Pancreatectomy as a Good Solution in Frantz Tumor Resection: A Case Report. Medicine (Baltimore) 2015; 94:e1165. [PMID: 26200617 PMCID: PMC4603021 DOI: 10.1097/md.0000000000001165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Solid pseudopapillary tumors of the pancreas located in the head or body are a challenging clinical problem because they usually demand extensive surgical procedures, and in most reported cases pancreaticoduodenectomy is the operation of choice in such a location. An alternative method of surgery in precisely selected patients is a procedure known as central pancreatectomy. The authors present the case of a 13-year-old girl with a 5 cm tumor located in the body of the pancreas. The favorable anatomical location of the tumor suggested central pancreatic resection. The tumor was excised with 1 cm oncologic margins from both sides, and the distal remnant of the pancreas was protected with a Roux-en-Y loop. In the postoperative period the patient required reoperation because of intensive bleeding in the resection site but the duodenal loop was saved and the patient protected from biliary tract reconstruction and exocrine and endocrine insufficiency. Progress in pancreatic surgery, especially in children, allows less radical options for the reason that preservation of endocrine and exocrine function is very important and protects them, especially from insulin-dependent diabetes in the future.
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Affiliation(s)
- Pawel Nachulewicz
- From the Clinic of Paediatric Surgery and Traumatology, Medical University of Lublin, Lublin, Poland
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16
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Kang CM, Lee JH, Lee WJ. Minimally invasive central pancreatectomy: current status and future directions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:831-840. [DOI: 10.1002/jhbp.143] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Chang Moo Kang
- Department of Surgery; Yonsei University College of Medicine; Pancreaticobiliary Cancer Clinic; Yonsei Cancer Center; Severance Hospital; 50 Yonsei-ro, Seodaemun-ku Seoul 120-752 Korea
| | - Jin Ho Lee
- Department of Surgery; Yonsei University College of Medicine; Pancreaticobiliary Cancer Clinic; Yonsei Cancer Center; Severance Hospital; 50 Yonsei-ro, Seodaemun-ku Seoul 120-752 Korea
| | - Woo Jung Lee
- Department of Surgery; Yonsei University College of Medicine; Pancreaticobiliary Cancer Clinic; Yonsei Cancer Center; Severance Hospital; 50 Yonsei-ro, Seodaemun-ku Seoul 120-752 Korea
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Iacono C, Ruzzenente A, Bortolasi L, Guglielmi A. Central pancreatectomy: The Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach. World J Gastroenterol 2014; 20:15674-15681. [PMID: 25400451 PMCID: PMC4229532 DOI: 10.3748/wjg.v20.i42.15674] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/19/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection (SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot (1957) and Letton and Wilson (1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came.
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18
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Iacono C, Ruzzenente A, Conci S, Xillo L, Guglielmi A. Head dorsal pancreatectomy: an alternative to the pancreaticoduodenectomy for not enucleable benign or low-grade malignant lesions. Pancreatology 2014; 14:419-24. [PMID: 25163807 DOI: 10.1016/j.pan.2014.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 07/16/2014] [Accepted: 07/18/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Head dorsal pancreatectomy (HDP) is a segmental pancreatic resection, conservative variant of total dorsal pancreatectomy, applied to preserve the functional pancreatic parenchyma as an alternative to pancreaticoduodenectomy in not enucleable benign or low-grade malignant lesions. The absences of biliary and gastrointestinal resection/reconstruction are the other advantages of the technique. METHODS We reported a case of HDP performed in a female 39-year-old patient for a neuroendocrine tumour of the dorsal portion of the pancreatic head. RESULTS The superior mesenteric vein was dissected from the pancreatic neck. The pancreas was transected at the left margin of the superior mesenteric vein. After identification and mobilisation of gastroduodenal artery and the anterior superior pancreatico-duodenal artery, the head dorsal segment was dissected stepwise from the duodenal wall toward the common bile duct plane; the dissection of the pancreatic parenchyma was completed along the anterior surface of the common bile duct. An end-to-side duct-to-mucosa pancreaticojejunostomy was performed. The main pancreatic duct in the ventral segment on the dissection parenchymal surface was ligated. With the inclusion of this case, there are a total of 3 cases involving resection of the dorsal portion of the pancreatic head reported in the literature. CONCLUSION HDP seems to be technically feasible and safe for not enucleable benign or low-grade malignant neoplasms involving the dorsal pancreatic head. However, due to the singularity of the indications and the few cases reported in the literature, further studies are needed to validate the technique.
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Affiliation(s)
- Calogero Iacono
- Department of Surgery, Division of General Surgery A, Unit of Hepato-Pancreatico-Biliary-Surgery, University of Verona Medical School, Verona, Italy.
| | - Andrea Ruzzenente
- Department of Surgery, Division of General Surgery A, Unit of Hepato-Pancreatico-Biliary-Surgery, University of Verona Medical School, Verona, Italy
| | - Simone Conci
- Department of Surgery, Division of General Surgery A, Unit of Hepato-Pancreatico-Biliary-Surgery, University of Verona Medical School, Verona, Italy
| | - Laura Xillo
- Department of Surgery, Division of General Surgery A, Unit of Hepato-Pancreatico-Biliary-Surgery, University of Verona Medical School, Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Division of General Surgery A, Unit of Hepato-Pancreatico-Biliary-Surgery, University of Verona Medical School, Verona, Italy
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19
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Iacono C, Verlato G, Ruzzenente A, Campagnaro T, Bacchelli C, Valdegamberi A, Bortolasi L, Guglielmi A. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg 2013; 100:873-85. [PMID: 23640664 DOI: 10.1002/bjs.9136] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP). METHODS Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate. RESULTS Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45·3 and 40·9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5·0 and 9·9 per cent of patients. The overall mortality rate was 0·8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0·22, 95 per cent confidence interval 0·14 to 0·35; P < 0·001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0·59, 0·32 to 1·07; P = 0·082). CONCLUSION CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.
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Affiliation(s)
- C Iacono
- Department of Surgery, Unit of Hepato-Biliary-Pancreatic Surgery, Verona, Italy.
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20
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Robotic-assisted minimally invasive central pancreatectomy: technique and outcomes. J Gastrointest Surg 2013; 17:1002-8. [PMID: 23325340 DOI: 10.1007/s11605-012-2137-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 12/19/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Central pancreatectomy is a definitive treatment for low-grade tumors of the pancreatic neck that preserves pancreatic and splenic function at the potential expense of postoperative pancreatic fistula. We analyzed outcomes after robot-assisted central pancreatectomy (RACP) to reexamine the risk-benefit profile in the era of minimally invasive surgery. METHODS Retrospective analysis of nine RACP performed between August 2009 through June 2010 at a single institution. RESULTS The average age of the cohort was 64 (range 18-75 years) with six women (67 %). Indications for surgery included: five benign cystic neoplasm and four pancreatic neuroendocrine tumor. Median operative time was 425 min (range 305-506 min) with 190 ml median blood loss (range 50-350 ml) and one conversion to open due to poor visualization. Median tumor size was 3.0 cm (range 1.9-6.0 cm); all patients achieved R0 status. Pancreaticogastrostomy was performed in seven cases and pancreaticojejunostomy in two. The median length of hospital stay was 10 days (range 7-19). Two clinically significant pancreatic fistulae occurred with one requiring percutaneous drainage. No patients exhibited worsening diabetes or exocrine insufficiency at the 30-day postoperative visit. CONCLUSIONS RACP can be performed with safety and oncologic outcomes equivalent to published open series. Although the rate of pancreatic fistula was high, only 22 % had clinically significant events, and none developed worsening pancreatic endocrine or exocrine dysfunction.
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Xu SB, Zhu YP, Zhou W, Xie K, Mou YP. Patients get more long-term benefit from central pancreatectomy than distal resection: a meta-analysis. Eur J Surg Oncol 2013; 39:567-74. [PMID: 23465182 DOI: 10.1016/j.ejso.2013.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 01/16/2013] [Accepted: 02/01/2013] [Indexed: 01/18/2023] Open
Abstract
AIMS Central pancreatectomy (CP) protects more normal pancreatic parenchyma than distal pancreatectomy (DP), but the safety, feasibility and long-term benefit of CP are inconclusive. This meta-analysis aims to ascertain the relative merits of CP. METHODS A systematic literature research was performed to identify comparative studies on CP and DP. Perioperative and long-term outcomes constituted the end points. Pooled risk ratios (RR) and weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either fixed effects or random effects model. RESULTS Nine studies with 735 patients were included in this meta-analysis. Although CP cost more operative time than DP, the two groups had no significant differences in the volume of intraoperative blood loss, rate of intraoperative blood transfusion and length of postoperative hospital stay. According to the postoperative outcomes, although the CP group had higher overall complication rate (Fixed effects model; RR: 1.30; 95% CI: 1.05-1.62; P < 0.05) as well as overall pancreatic fistula rate (Fixed effects model; RR: 1.58; 95% CI: 1.20-2.08; P < 0.05), the two groups did not differ significantly in the fateful surgical complications such as clinically significant pancreatic fistula (Grades B and C), postoperative bleeding, reoperation and intra-abdominal effusion/abscess. Furthermore, the perioperative mortality rate was comparable between the two groups. During the follow-up period, the patients after DP were more likely to suffer pancreatic exocrine insufficiency (Fixed effects model; RR: 0.53; 95% CI: 0.32-0.86; P < 0.05) and endocrine impairment (Fixed effects model; RR: 0.19; 95% CI: 0.11-0.33; P < 0.05). CONCLUSION CP was still an acceptable and feasible procedure, especially when considering the postoperative pancreatic function preservation ability by CP.
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Affiliation(s)
- S B Xu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang Province, China.
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Parenchyma-sparing resections for pancreatic neuroendocrine tumors. J Gastrointest Surg 2012; 16:2045-55. [PMID: 22911124 DOI: 10.1007/s11605-012-2002-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 08/08/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Parenchyma-sparing pancreatectomy (PSP), including enucleation and central pancreatectomy, has been investigated as an alternative to standard resection for pancreatic endocrine neoplasm, but the benefit/risk of these procedures remains little known. METHODS From 1998 to 2010, among 197 patients operated for well-differentiated pancreatic neuroendocrine tumors, 67 underwent PSP (45 enucleations and 22 central pancreatectomies) and 66 standard resections (35 pancreaticoduodenectomies and 31 distal pancreatectomies) for a tumor below 4 cm, without synchronous distant metastasis. Groups were compared regarding postoperative morbidity, mortality, long-term pancreatic function, and survival calculated using the Kaplan-Meier method. RESULTS Tumors operated by PSP had a median size of 15 mm, were mainly incidentally diagnosed (n = 46, 69 %), and nonfunctioning (n = 55, 82 %). Overall morbidity rate was higher after PSP than standard resection (SR) (76 vs 58 %, p = 0.0028), including more frequent pancreatic fistulas (69 vs 42 %, p = 0.003). Postoperative diabetes was less frequent following PSP than pancreaticoduodenectomy (5 vs 21 %; p = 0.022) but equivalent to the one observed after distal pancreatectomy (4 %, p = 1). Exocrine insufficiency was significantly less frequent after PSP than SR (3 vs 32 %; p < 0.0001). The overall and recurrence-free 5-year survival after PSP for nonfunctioning tumors was 96 and 98 %, respectively. CONCLUSION In selected patients, with small and low-grade tumors, PSP are associated with excellent overall and recurrence-free survivals. These procedures are associated with an increased postoperative morbidity but an excellent postoperative pancreatic function. Therefore, they should be considered as a valid therapeutic option in selected well-differentiated pancreatic neuroendocrine tumors.
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Di Benedetto F, D'Amico G, Ballarin R, Tarantino G, Cautero N, Pecchi A, Gerunda GE. Meso-pancreatectomy: new surgical technique for Wirsung reconstruction. J Am Coll Surg 2011; 214:e1-4. [PMID: 22192893 DOI: 10.1016/j.jamcollsurg.2011.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 10/31/2011] [Accepted: 10/31/2011] [Indexed: 11/30/2022]
Affiliation(s)
- Fabrizio Di Benedetto
- Department of General Surgery, Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, Italy.
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DiNorcia J, Ahmed L, Lee MK, Reavey PL, Yakaitis EA, Lee JA, Schrope BA, Chabot JA, Allendorf JD. Better preservation of endocrine function after central versus distal pancreatectomy for mid-gland lesions. Surgery 2011; 148:1247-54; discussion 1254-6. [PMID: 21134558 DOI: 10.1016/j.surg.2010.09.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 09/13/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Traditional resections for benign and low-grade malignant neoplasms of the mid pancreas result in loss of normal parenchyma that can cause pancreatic endocrine and exocrine insufficiency. Central pancreatectomy (CP) is a parenchyma-sparing option for such lesions. This study evaluates a single institution's experience with CP and compares outcomes with distal pancreatectomy (DP). METHODS We retrospectively collected data on CP patients from 1997 through 2009 and evaluated outcomes. In a subset of 50 patients, we performed a matched-pairs analysis to directly compare the short- and long-term outcomes of CP and DP. RESULTS Seventy-three patients underwent CP with a median operating room time of 254 minutes. Overall morbidity was 41.1% with pancreatic fistula in 20.5%. Mortality was 0%. There were no differences in fistula, morbidity, and mortality rates between the CP and DP groups. The CP group had resected for smaller lesions. CP patients had a lower rate of new-onset and worsening diabetes than DP patients (14% vs 46%; P = .003). Of new-onset and worsening diabetics, only 1 CP patient required insulin compared with 14 DP patients (P = .002). CONCLUSION CP is safe and effective for select neoplasms of the mid pancreas. Patients undergoing CP have markedly decreased insulin requirements compared with DP patients.
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Affiliation(s)
- Joseph DiNorcia
- Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
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Crippa S, Partelli S, Falconi M. Extent of surgical resections for intraductal papillary mucinous neoplasms. World J Gastrointest Surg 2010; 2:347-51. [PMID: 21160842 PMCID: PMC2999200 DOI: 10.4240/wjgs.v2.i10.347] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 09/10/2010] [Accepted: 09/17/2010] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) can involve the main pancreatic duct (MD-IPMNs) or its secondary branches (BD-IPMNs) in a segmental of multifocal/diffuse fashion. Growing evidence indicates that BD-IPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively. For surgery, clarification is required on: (1) when to resect an IPMN; (2) which type of resection should be performed; and (3) how much pancreas should be resected. In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations. However, oncological radicality is of paramount importance, and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs. In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed, evaluating perioperative and long-term outcomes. The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.
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Affiliation(s)
- Stefano Crippa
- Stefano Crippa, Stefano Partelli, Massimo Falconi, Department of Surgery - Chirurgia Generale B, Policlinico "GB Rossi" Hospital, University of Verona, 10 - 37134 Verona, Italy
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Abstract
OBJECTIVES Despite strategies aimed at reducing a postoperative pancreatic fistula (POPF) after pancreatectomies, the overall incidence remains unchanged. One such procedure, until now incompletely explored, is transanastomotic pancreatic (TAP) ductal stenting. METHODS We conducted a systematic search using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1983-2008 to determine if TAP ductal stents provide any benefit and, if so, in which clinical scenarios they can be recommended. RESULTS Stents can be internal or external, intraoperative only, or temporary (several days). One randomized trial on internal stents across pancreaticojejunostomy (PJ) suggested a higher POPF rate in the stented group. One nonrandomized study using an internal stent for pancreaticogastrostomy (PG) revealed a 0% POPF rate. Results from studies where external stents were used across PJ/PG reported a lower incidence of POPF. No statistically significant difference was reported in a POPF incidence when internal stents were compared with externalized stents. Available data suggest improved outcomes of pancreatoenteric anastomosis when TAP ductal stent is inserted in small ducts (< or =3 mm). CONCLUSIONS There is insufficient evidence to support or refute improved outcomes after TAP ductal stent insertion in patients with PJ/PG with small ducts (< or =3 mm) or soft pancreata. More evidence of benefit is needed before use of external stents can be recommended.
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Sperti C, Beltrame V, Milanetto AC, Moro M, Pedrazzoli S. Parenchyma-sparing pancreatectomies for benign or border-line tumors of the pancreas. World J Gastrointest Oncol 2010; 2:272-81. [PMID: 21160640 PMCID: PMC2999190 DOI: 10.4251/wjgo.v2.i6.272] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 01/25/2010] [Accepted: 02/01/2010] [Indexed: 02/05/2023] Open
Abstract
Standard pancreatic resections, such as pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy, result in an important loss of normal pancreatic parenchyma and may cause impairment of exocrine and endocrine function. Whilst these procedures are mandatory for malignant tumors, they seem to be too extensive for benign or border-line tumors, especially in patients with a long life expectancy. In recent years, there has been a growing interest in parenchyma-sparing pancreatic surgery with the aim of achieving better functional results without compromising oncological radicality in patients with benign, border-line or low-grade malignant tumors. Several limited resections have been introduced for isolated or multiple pancreatic lesions, depending on the location of the tumor: central pancreatectomy, duodenum-preserving pancreatic head resection with or without segmental duodenectomy, inferior head resection, dorsal pancreatectomy, excavation of the pancreatic head, middle-preserving pancreatectomy, and other multiple segmental resections. All these procedures are technically feasible in experienced hands, with very low mortality, although with high morbidity rate when compared to standard procedures. Pancreatic endocrine and exocrine function is better preserved with good quality of life in most of the patients, and tumor recurrence is uncommon. Careful patient selection and expertise in pancreatic surgery are crucial to achieve the best results.
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Affiliation(s)
- Cosimo Sperti
- Cosimo Sperti, Valentina Beltrame, Anna Caterina Milanetto, Margherita Moro, Sergio Pedrazzoli, Department of Medical and Surgical Sciences, IV Surgical Clinic, University of Padua, 35128 Padova, Italy
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Sudo T, Murakami Y, Uemura K, Hayashidani Y, Hashimoto Y, Ohge H, Sueda T. Middle pancreatectomy with pancreaticogastrostomy: a technique, operative outcomes, and long-term pancreatic function. J Surg Oncol 2010; 101:61-5. [PMID: 19894223 DOI: 10.1002/jso.21430] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Middle pancreatectomy is infrequently performed in selected patients. The rationale is to preserve pancreatic function. This study evaluates a technique, operative outcomes, and long-term exocrine and endocrine pancreatic function of the middle pancreatectomy procedure. METHODS Nineteen patients who underwent middle pancreatectomy between 1996 and 2008 were reviewed. Indications included eight intraductal papillary-mucinous neoplasms, five endocrine tumors, one serous and two mucinous cystadenomas, and three other benign lesions. Reconstruction of the distal pancreatic remnant was performed with pancreaticogastrostomy using the duct-to-mucosa method in 16 patients and with Roux-en-Y end-to-end pancreaticojejunostomy in 3 patients. RESULTS Median operative time was 215 min. Perioperative mortality was nil. Morbidity was 53%, including 9 (47%) pancreatic fistulas. One patient with hemorrhage, complicated by a pancreatic fistula was successfully treated by endovascular embolization. No patients required postsurgical reoperation. Only one patient had clinical exocrine insufficiency requiring pancreatic enzyme supplementation. None developed postresection new-onset insulin-dependent diabetes. CONCLUSIONS Middle pancreatectomy with pancreaticogastrostomy is feasible and reasonable technique. Although the incidence of pancreatic fistula formation may still be higher compared to conventional resection, long-term exocrine, and endocrine pancreatic function may be preserved. Thus, careful patient selection and experienced pancreatic surgeons in high-volume centers are of great importance.
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Affiliation(s)
- Takeshi Sudo
- Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
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Hirono S, Yamaue H. Middle pancreatectomy for pancreatic neoplasms. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:803-7. [PMID: 19907916 DOI: 10.1007/s00534-009-0222-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND A middle pancreatectomy (MP) is a parenchyma-preserving procedure for benign or low-malignant neoplasms in the neck or body of the pancreas that reduces long-term endocrine and exocrine insufficiency. MP requires the handling of 2 (distal and proximal) pancreatic remnants, and therefore, the higher rates of pancreatic fistula and morbidity may occur after MP rather than after standard pancreatectomies, such as for a pancreaticoduodenectomy and distal pancreatectomy. Though there have so far been few reports regarding a high number of series in MP as opposed to standard pancreatic resections, recently reports describing more than 50 case outcomes of MP were published. METHODS A literature search, which examined articles related to MP, was performed using the PubMed database. Data were compiled to generate conglomerate results of mortality and morbidity rates, and the long-term pancreatic functional insufficiency and recurrence after MP. RESULTS The mortality rates varied from 0 to 3%, and the morbidity from 13 to 62%. The rates of pancreatic fistula in more than 50 cases of MP varied from 8 to 30%. The rates of endocrine and exocrine insufficiency were very low (range, 0-9% and 0-8%, respectively). CONCLUSIONS MP is a safe procedure for the treatment of benign or low-grade malignant neoplasms in the pancreatic neck or body, and in this procedure, the postoperative endocrine and exocrine functions are well preserved.
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Affiliation(s)
- Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Crippa S, Boninsegna L, Partelli S, Falconi M. Parenchyma-sparing resections for pancreatic neoplasms. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:782-7. [PMID: 19865792 DOI: 10.1007/s00534-009-0224-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND/PURPOSE In recent years there has been an increase in the indications for pancreatic resection of benign or low-grade malignant lesions, especially in young patients with long life expectancy. In this setting, patients may benefit from parenchyma-sparing resections in order to decrease the risk of development of exocrine/endocrine insufficiency. METHODS A review of the literature and authors experience was undertaken. RESULTS Parenchyma-sparing resections of the pancreas including enucleation, middle pancreatectomy (MP) and middle-preserving pancreatectomy are described. Short and long-term outcomes after surgery are analyzed with special regard to postoperative morbidity/mortality, and oncological and functional long-term results. CONCLUSIONS Parenchyma-sparing resections are safe and effective procedures for treatment of benign and low-grade malignant neoplasms. Despite a significant postoperative morbidity they are associated with good long-term functional and oncological results. Enucleation should preferentially be performed laparoscopically whenever possible.
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Affiliation(s)
- Stefano Crippa
- Department of Surgery, Chirurgia Generale B, Policlinico GB Rossi, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
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A central pancreatectomy for benign or low-grade malignant neoplasms. J Gastrointest Surg 2009; 13:1659-65. [PMID: 19488821 DOI: 10.1007/s11605-009-0934-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 05/20/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION A central pancreatectomy is a parenchyma-sparing procedure that is performed to reduce long-term endocrine and exocrine insufficiency. METHOD In this study, we analyzed the perioperative course, the frequency of postoperative onset of diabetes mellitus, and long-term change of body weight in patients undergoing a central pancreatectomy, in comparison to the patients undergoing a distal pancreatectomy for low-grade neoplasms including cystic neoplasms and neuroendocrine tumors. RESULTS AND DISCUSSION The rate of postoperative complications including grade B/C pancreatic fistula was no different between both groups. Only one patient undergoing a central pancreatectomy (4.7%) developed new onset of mild diabetes, whereas 35% in the distal pancreatectomy group developed new onset or worsening diabetes (p = 0.0129). The body weight in the distal pancreatectomy group was significant lower than that in the central pancreatectomy group at 1 and 2 years after surgery (1 year; P < 0.0001, 2 years; P = 0.0055), and the body weight in the patients undergoing a central pancreatectomy improved to preoperative values within 2 years after surgery. CONCLUSION A central pancreatectomy is a safe procedure for the treatment of low-grade malignant neoplasms in the pancreatic body; the rate of onset of diabetes is minimal, and the body weight improves early in the postoperative course.
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Chirletti P, Peparini N, Caronna R, Fanello G, Delogu G, Meniconi RL. Roux-en-Y end-to-end and end-to-side double pancreaticojejunostomy: application of the reconstructive method of the Beger procedure to central pancreatectomy. Langenbecks Arch Surg 2009; 395:89-93. [PMID: 19707783 DOI: 10.1007/s00423-009-0550-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 08/05/2009] [Indexed: 01/18/2023]
Abstract
PURPOSES Central pancreatectomy is indicated for treatment of traumatic lesions and benign or low-grade tumors of the pancreatic neck and proximal body. After central pancreatectomy, the proximal pancreatic stump is usually closed, and pancreaticojejunostomy or pancreaticogastrostomy carried out with the distal pancreas. Adopting these reconstructive techniques in most series revealed a prevalence of postoperative fistula that was higher than after pancreaticoduodenectomy or left pancreatectomy. We present a case treated by novel application of the reconstructive method of the Beger procedure. METHODS Reconstruction by Roux-en-Y double pancreaticojejunostomy after central pancreatectomy was done in a 71-year-old female suffering from insulinoma of the proximal pancreatic body. RESULTS Postoperative complications were not observed. No alteration of pancreatic endocrine and exocrine function occurred at 22-month follow-up. CONCLUSIONS Double pancreaticojejunostomy is a promising method for treating the proximal pancreatic stump after central pancreatectomy.
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Affiliation(s)
- Piero Chirletti
- Department of General Surgery Francesco Durante, La Sapienza University, viale del Policlinico, 155, 00161, Rome, Italy.
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Middle pancreatectomy: safety and long-term results. Surgery 2009; 147:21-9. [PMID: 19682717 DOI: 10.1016/j.surg.2009.04.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 04/17/2009] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy and distal pancreatectomy for lesions of the neck or body of the pancreas sacrifice a large amount of normal pancreatic tissue. Middle pancreatectomy (MP) is a parenchyma sparing technique that reduces the risk of postoperative endocrine and exocrine insufficiency. This study aims to evaluate the perioperative and long-term results of MP and to clarify whether MP can be performed with outcomes comparable with traditional pancreatectomies. METHOD Twenty-six patients who underwent MP for benign or low-grade malignant tumor of the pancreas between 1991 and 2006 at the Department of Surgery II, Nagoya University Graduate School of Medicine, were identified. Their outcomes were compared with 2 separate control groups, 35 left-side pancreatectomies (LSP) and 60 right-side pancreatectomies (RSP). RESULTS The mean operating time of the MP group was 295 minutes, which was significantly shorter than that for RSP (P=.0001). The rate of pancreatic fistula formation was higher in the MP group than in the 2 control groups, although the differences did not reach statistical significance. After a mean follow-up of 71 months, postoperative endocrine function was equivalent to the pre-operative values in the MP group, and none of the patients developed diabetes mellitus postoperatively. Only 1 patient in the MP group required enzyme substitution postoperatively for exocrine insufficiency. The MP group was inclined to be superior to the other 2 control groups in terms of postoperative nutritional status. CONCLUSION Middle pancreatectomy is a reasonable technique that is indicated for selected patients with benign or low malignant tumors in the neck and body of the pancreas. Middle pancreatectomy seems to result in better preservation of exocrine and endocrine functions as well as in better nutritional status postoperatively.
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Lavu H, Knuth JL, Baker MS, Shen C, Zyromski NJ, Schmidt M, Nakeeb A, Howard TJ. Middle segment pancreatectomy can be safely incorporated into a pancreatic surgeon's clinical practice. HPB (Oxford) 2008; 10:491-7. [PMID: 19088938 PMCID: PMC2597310 DOI: 10.1080/13651820802356580] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Indexed: 12/12/2022]
Abstract
Middle segment pancreatectomy (MSP) is a new operation where the advantages of parenchymal preservation are counterbalanced by a high postoperative complication rate and unease among surgeons with adopting a new technique. This study reviews our experience incorporating MSP into our clinical practice focusing on the initial 34 consecutive patients operated on by one surgeon at a single institution between 1998 and 2007. Patients were divided into early (initial 17 operations) and late (subsequent 17 operations) groups for analysis. Thirty-one reconstructions were by Roux-en-y pancreaticojejunostomy and three were by pancreaticogastrostomy. Using multiple linear regression and logistic regression, we found no significant differences in performance outcomes (operative time, blood loss, tumor size, margin negative resection rate, pancreatic fistula rate, hospital length of stay, postoperative complications, and hospital readmission rate) between our early and late experience even after adjusting for potential confounding variables (patient demographics, co-morbidities, neoplasm, pancreatitis). The pancreatic fistula rate in this series was 29.4% (10/34) and they were all International Study Group on Pancreatic Fistula (ISGPF) Grade A (60%) or B (40%). In summary, MSP is an operation with a flat learning curve and acceptable morbidity rate that can be safely incorporated as a parenchymal preserving option by pancreatic surgeons in their clinical practice.
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Affiliation(s)
- Harish Lavu
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
| | - Jamie L. Knuth
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
| | - Marshall S. Baker
- Department of Surgery, School of Medicine, Northwestern UniversityChicago ILUSA
| | - Changyu Shen
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
| | - Nicholas J. Zyromski
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
| | - Max Schmidt
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
| | - Atilla Nakeeb
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
| | - Thomas J. Howard
- Department of Surgery, Division of Biostatistics, Indiana University School of MedicineIndianapolis INUSA
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Glanemann M, Shi B, Liang F, Sun XG, Bahra M, Jacob D, Neumann U, Neuhaus P. Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery? World J Surg Oncol 2008; 6:123. [PMID: 19014474 PMCID: PMC2596481 DOI: 10.1186/1477-7819-6-123] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 11/12/2008] [Indexed: 01/08/2023] Open
Abstract
Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the above mentioned topics.
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Affiliation(s)
- Matthias Glanemann
- Department of General, Visceral, and Transplantation Surgery, Charité, Campus Virchow Klinikum, Universitätsmedizin Berlin, Germany.
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