Middle segment pancreatectomy: a useful tool in the management of pancreatic neoplasms

State-of-the-art surgical treatment of IPMNs

Background

A “pandemic” of incidentally discovered pancreatic cyst neoplasms (PCNs) is ongoing. Among PCNs, intraductal papillary mucinous cystic neoplasms (IPMNs) are the most common and with their complex biology could represent a precursor lesion of pancreatic cancer. Although multiple guidelines exist to guide their treatment, there are still many “gray areas” on indications for surgery for IPMNs.

Methods

The current indications for surgery of IPMNs were reappraised, considering potential discrepancies between available evidence and guidelines policies. The practice at a high-volume center for the diagnosis and treatment of PCN was presented and discussed.

Results

Most IPMNs do not and will never require surgery, as they won’t progress to malignancy. The current literature is solid in identifying high-grade dysplasia (HGD) as the right and timely target for IPMN resection, but how to precisely assess its presence remains controversial and guidelines lack of accuracy in this regard. Multiple tumorigenic pathways of progression of IPMNs exist, and their knowledge will likely lead to more accurate tests for malignancy prediction in the future.

Conclusions

The surgical management of IPMNs still is a matter of debate. Indication for resection should be considered only in highly selected cases with the ideal target of HGD. Clinicians should critically interpret the guidelines’ indications, refer to a multidisciplinary team discussion, and always consider the outcome of an adequate counselling with the patient.

Minimally invasive (laparoscopic and robot-assisted) versus open approach for central pancreatectomies: a single-center experience

BACKGROUND

There continues to be an interest in minimally invasive approaches to pancreatic surgery. At our institution, there has been a progressive change from an open to minimally invasive surgery (MIS) (laparoscopic, robotic, or laparoscopic-robotic) approach for central pancreatectomies (CP). The aim of this study was to evaluate surgical outcomes with open CP (O-CP) versus minimally invasive CP (MI-CP).

METHODS

A retrospective medical review of patients who underwent CP between 1993 and 2018 at Yonsei University Health System, Seoul, Korea was performed. Short-term perioperative outcomes were compared between O-CP and MI-CP.

RESULTS

Thirty-one CPs (11 open, 20 MIS) were identified during the study period. No difference was observed in admission days between O-CP and MI-CP (21.2 vs. 16.7 days, p = 0.340), although operating time was significantly increased in the MI-CP group (296.8 vs. 374.8 min, p = 0.036). Blood loss was significantly less in MI-CP vs. O-CP (807.1 vs. 214.0 mls, p = 0.001), with no difference in post-operative new-onset diabetes (9% vs. 5%). The overall post-operative pancreatic fistula rate was 25.8%, and no significant difference between O-CP and MI-CP or complication rates (45% vs. 40%) was observed.

CONCLUSION

Despite increased operative time, MI-CP is feasible and comparable to conventional O-CP with regard to surgical outcomes in well-selected patients.

Is Central Pancreatectomy Truly Recommendable? A 9-Year Single-Center Experience

AIMS

To compare the short- and long-term outcomes in patients with pancreatic benign or borderline neoplasm who underwent central pancreatectomy (CP) and distal pancreatectomy (DP).

METHODS

The inclusion criteria were as follows: (1) single benign or low-grade malignant tumor; (2) tumor confined to the pancreatic neck or proximal body; and (3) tumor amenable to either CP or DP. Short and long-term outcomes, including complications, pancreatic exocrine and endocrine function, and quality of life (QoL) were analyzed retrospectively.

RESULTS

Sixteen patients who underwent CP and 26 patients who underwent DP were included. The median follow-up period was 53 months (range 21-117 months). Patients undergoing CP were significantly more likely to experience complications (68.7 vs. 23%, p = 0.003) especially grade B/C postoperative pancreatic fistula (62.5 vs. 23%, p = 0.011) than those undergoing DP. During the long-term follow-up, 2 patients in the DP group developed new-onset diabetes mellitus, but no patient in CP group developed this condition (8 vs. 0%, p = 0.382). Evidence of exocrine insufficiency, including severe diarrhea or steatorrhea, was not observed in either group. Both groups were equally satisfied with the overall health status and overall QoL.

CONCLUSION

CP is associated with excellent pancreatic function but a significantly increased postoperative morbidity and risk compared to DP. Therefore, the indication of CP should be chosen strictly.

Robotic central pancreatectomy

Central pancreatectomy (CP) is a parenchyma-sparing procedure that can be utilized in the resection of tumors of the neck or the proximal body of the pancreas. Among 872 open CP reported since 1993, the mean rate of morbidity was 43.2% and mean rate of mortality was 0.24%. The mean pancreatic fistula rate was 28%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 19%. The rate of development of post-operative diabetes mellitus was at 2% and the average incidence of exocrine insufficiency experienced by patients undergoing open CP was 4.4%. Also, the mean length of hospital stay was around 15 days. In comparison, a total of 100 patients underwent either laparoscopic or robotic CP with a mean rate of morbidity of 37.3% and mean rate of mortality of 0%. Also, the mean rate of development of pancreatic fistula was 36.6%. The rate of clinically significant pancreatic fistulas with ISGPF Grades B and C was 17%. The rate of development of post-operative diabetes mellitus was at 1.5%. None of the patients included in these series developed any postoperative exocrine insufficiency. The mean length of hospital stay was around 13 days. Standard procedures such as DP and PD are associated with lower rates of short-term morbidity such as pancreatic fistula development but are also accompanied with a higher rate of long-term endocrine and exocrine insufficiency due to the significant loss of normal pancreatic parenchyma when compared to CP. It can be inferred, albeit from limited and small retrospective studies and case reports, that conventional and robotic-assisted laparoscopic approaches to CP are safe and feasible in highly specialized centers.

The Pancreas: Causes for Malabsorption

Background

The pancreas has a central function in digestion and glucose homeostasis. With regard to the exocrine function, which is responsible for the digestion and absorption of nutrients and vitamins, the most important disturbances of these physiological processes are based on deficiencies in enzyme production and secretion, either due to impaired excretion caused by obstruction of the pancreatic duct or due to loss of pancreatic tissue. Both conditions result in maldigestion, malabsorption, and malnutrition.

Methods

Systematic literature review.

Results

Symptoms associated with pancreatic exocrine failure are gastrointestinal discomfort, steatorrhea, and weight loss. Pancreatic exocrine insufficiency caused by ductal obstruction occurs in chronic pancreatitis or with neoplasia of the pancreatic head. Loss of functional parenchyma can be caused either by chronic pancreatitis resulting in fibrotic replacement of the destroyed parenchyma or by a postoperative state of pancreatic resection.

Conclusion

In patients with chronic pancreatitis, a stage-adapted and timely therapy including conservative as well as surgical measures is essential to prevent functional deterioration and to preserve residual function. In the case of pancreatic resection for chronic pancreatitis, this can be achieved with modern organ-sparing surgery such as the duodenum-preserving pancreatic head resection. In patients requiring more extended pancreatic resections and even total duodenopancreatectomy, regardless of the underlying indication, adequate enzyme replacement and monitoring of the nutritional status is critical to prevent impairment of quality of life as well as detrimental malnutrition in the long term.

Central pancreatectomy versus spleen-preserving distal pancreatectomy: a comparative analysis of early and late postoperative outcomes

BACKGROUND/AIM

The aim of the present study is to compare the postoperative and long-term outcomes of central pancreatectomy (CP) and spleen-preserving distal pancreatectomy (SPDP).

METHODS

Clinical, pathological and long-term data were compared between 22 patients who underwent CP and 25 patients who underwent SPDP (2002-2012).

RESULTS

The median length of resected pancreas was 8.5 cm in the SPDP group and 5 cm in the CP group (p < 0.001). The median estimated blood loss was significantly lower in the CP group (p = 0.019). Morbidity was 50% for CPs and 40% for SPDPs (p = 0.564). The rate of pancreatic fistulae was 36% for CPs and 40% for SPDPs (p = 0.530). The rate of new-onset diabetes was nil in the successful CP group and 16% in the SPDP group (p = 0.111).

CONCLUSION

Morbidity and pancreatic fistula rates are not higher after CP when compared to SPDP. The loss of normal pancreatic tissue is significantly lower for CP, and thus there is potentially better preservation of the pancreatic endocrine functions. CP should be considered only in selected cases when preservation of the pancreas is of utmost importance, especially for lesions situated at the level of the pancreatic neck.

Risk factors for postoperative pancreatic fistulization subsequent to enucleation

INTRODUCTION

Pancreatectomies increase the risk of postoperative pancreatic fistula (POPF) and pancreatic insufficiency. Pancreatic enucleation preserves pancreatic parenchyma, lowers the risk of pancreatic insufficiency, but may induce specific complications (tumor recurrence or pancreatic fistulization). The aim of this study was to determine the risk factors for POPF following a pancreatic enucleation.

METHODS

A retrospective analysis was designed based on data from patients who underwent pancreatic enucleation in five university hospitals (1998-2008). The presence of a pancreatic fistula was determined according to the criteria of the International Study Group of Pancreatic Fistula (Bassi et al. Surgery 138:8-13, 2005).

RESULTS

Fifty-two patients (mean age 52 years) were included. Histological analysis revealed 35 endocrine tumors (68.6 %), 6 mucinous and 2 serous cyst adenomas, 2 metastases of renal cancer, and 8 benign tumors. Nineteen patients (36.5%) suffered postoperative complications including 14 POPF (27 %). Median postoperative hospital stay was 12.9 days; 9.1 days without POPF versus 29 days with POPF (p < 0.05). Size of the tumor, its location, histological differentiation, and use of somatostatin analogs were not predictors for POPF. We defined the cutoff for POPF at a distance of 2 mm from the main pancreatic duct based on 60% risk (≤2 mm) versus 19 % (>2 mm) of POPF (p < 0.01). With a mean follow-up of 30.8 months, one patient experienced recurrence of the tumor. No patients exhibited a new onset of diabetes or pancreatic insufficiency.

CONCLUSION

Enucleation for resection of pancreatic tumors located at less than or equal to two 2 mm from the main pancreatic duct is a risk factor for POPF. Enucleation is a safe and effective treatment for benign or borderline pancreatic tumors.

Postoperative pancreatic fistula

Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically. The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.

Do transanastomotic pancreatic ductal stents after pancreatic resections improve outcomes?

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.

Tumors of the Pancreatic Body and Tail

Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.

Enucleation of pancreatic cystadenomas

BACKGROUND

Optimal surgical treatment of pancreatic cystadenomas is controversial due to the rarity of the tumors and paucity of studies regarding long-term outcomes. This is especially true for large pancreatic cystadenomas. The objective of this study was to determine the safety and effectiveness of treating pancreatic cystadenomas by enucleation.

METHODS

Eleven cases of pancreatic mucinous or serous cystadenomas were selected for enucleation according to the following criteria: (1) the benign nature of the tumors was ascertained preoperatively and intraoperatively, (2) small tumors or larger tumors no more than 6 cm in diameter growing outwardly with small tumor beds, and (3) the main pancreatic duct was not in jeopardy of damage by enucleation. The patients' demographics, tumor features, morbidity, and follow-up results were retrospectively reviewed and analyzed.

RESULTS

Among 11 cases, three were serous cystadenomas and eight were mucinous cystadenomas; the average size of the neoplasms was 4.8 cm (ranging from 3 to 6 cm). Two cases were complicated by the development of fistulas postoperatively and one had an incision infection. All cases were followed up from 23 to 67 months, which revealed no neoplasm recurrence or new onset of diabetes mellitus; one patient developed a pseudocyst in the body 30 months after enucleation.

CONCLUSIONS

It is safe and effective to perform enucleation for well-selected benign pancreatic cystadenomas even if the tumor size is as large as 6 cm, and the endocrine or exocrine function of the pancreas is maintained as much as possible.

Prevention and management of pancreatic fistula

Despite significant improvements in the safety and efficacy of pancreatic surgery, post-operative pancreatic fistulae remain an unsolved dilemma. These occur when the transected pancreatic gland, pancreatic-enteric anastomosis, or both, leak rendering the patient at significant risk. They are especially important today since indications for resection (IPMN, carcinoma) continue to increase. This review considers definitions and classifications of pancreatic fistulae, risk factors, preventative approaches and offers management strategies for when they do occur. Key citations from the past seventeen years have been scrutinized, and together with personal experience, provide the basis for this review.

Middle segment pancreatectomy can be safely incorporated into a pancreatic surgeon's clinical practice

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.

Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery?

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.