Central pancreatectomy with pancreaticogastrostomy in children

Preservation of Pancreatic Function Should Not Be Disregarded When Performing Pancreatectomies for Pancreatoblastoma in Children

Complete surgical resection in the context of a multimodal approach has been associated with excellent long-term survival in children diagnosed with pancreatoblastoma (PB). Traditionally, curative intent surgery for PB implies standard pancreatic resections such as pancreaticoduodenectomies and distal pancreatectomies with splenectomies, surgical procedures that may lead to significant long-term pancreatic functional deficiencies. Postoperative pancreatic functional deficiencies are particularly interesting to children because they may interfere with their development, considering their long life expectancy and the significant role of pancreatic functions in their nutritional status and growth. Thus, organ-sparing pancreatectomies, such as spleen-preserving distal pancreatectomies and central pancreatectomies, are emerging in specific tumoral pathologies in children. However, data about organ-sparing pancreatectomies' potential role in curative-intent PB surgery in children are scarce. Based on the literature data, the current review aims to present the early and late outcomes of pancreatectomies in children (including long-term deficiencies and their potential impact on the development and quality of life), particularly for PB, and further explore the potential role of organ-sparing pancreatectomies for PB. Organ-sparing pancreatectomies are associated with better long-term pancreatic functional outcomes, particularly central pancreatectomies, and have a reduced impact on children's development and quality of life without jeopardizing their oncological safety. The long-term preservation of pancreatic functions should not be disregarded when performing pancreatectomies for PB in children. A subset of patients with PB might benefit from organ-sparing pancreatectomies, particularly from central pancreatectomies, with the same oncological results as standard pancreatectomies but with significantly less impact on long-term functional outcomes.

Solid pancreatic masses in children: A review of current evidence and clinical challenges

Pancreatic tumors in children are infrequently encountered in clinical practice. Their non-specific clinical presentation and overlapping imaging characteristics often make an accurate preoperative diagnosis difficult. Tumors are categorized as epithelial or non-epithelial, with epithelial tumors further classified as tumors of the exocrine or endocrine pancreas. Although both are tumors of the exocrine pancreas, solid pseudopapillary neoplasm is the most prevalent solid pancreatic tumor in children, while pancreatoblastoma is the most common malignant tumor. Insulinoma is the most common pediatric pancreatic tumor of the endocrine pancreas. Malignant tumors require a complete, often radical, surgical resection. However, pancreatic parenchyma-sparing surgical procedures are utilized for benign tumors and low-grade malignancy to preserve gland function. This review will discuss the epidemiology, pathophysiology, clinical and diagnostic characteristics, and management options associated with both common and rare solid pancreatic masses in children. We will also discuss current challenges encountered in their evaluation and treatment.

Minimally invasive surgery of the pancreas: a narrative review of current practice

Minimally invasive surgery has moved from the fringe of pediatric surgery to the mainstream to address a variety of problems. Pancreatic pathology, though uncommon and complex, is frequently amenable to laparoscopic intervention. Indications for pediatric pancreatic operative intervention includes trauma, congenital hyperinsulinemia and neoplasm. Children may require distal pancreatectomy, subtotal pancreatectomy, enucleation, lateral pancreaticojejunostomy and pancreaticoduodenectomy. Of these operations, all but pancreaticoduodenectomy have been successfully described in children using a minimally invasive approach. Traumatic transection of the main pancreatic duct may require operative intervention if endoscopic techniques are unsuccessful. Distal pancreatectomy has been successfully utilized in this circumstance. Additionally, near total pancreatectomy may also be performed laparoscopically although successful reports are limited. Enucleation, especially with the use of intraoperative ultrasound may avoid a large laparotomy for isolated benign masses. Finally, chronic pancreatitis resulting in a dilated main pancreatic duct may benefit from a lateral pancreaticojejunostomy. This operation has also successfully been performed in children. Included is a review of pediatric pancreatic minimally invasive operations paired with corresponding pathology.

Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma

INTRODUCTION

Pancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures.

PATIENTS AND METHODS

We retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003-2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification.

RESULTS

The median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety.

CONCLUSIONS

Often extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.

Early Results of an Innovative Modified Central Pancreatectomy Technique Without Gastroenteric Drainage: Achieving Normal Pancreatic Function

PURPOSE

Central pancreatectomy (CP) has been used sparingly because the spectrum of indications is quite narrow. The author has modified the procedure of CP in such a way to avoid distal pancreatic segment drainage, in addition to reserving the patient euo-insulinemic.

MATERIALS AND METHODS

Between March 2010 and January 2015, 41 cases have been recruited. Cases presented with blunt abdominal trauma showing central pancreatic transection with or without duodenal transection have been recruited. Technique of CP has been modified to enable sparing distal pancreatic drainage procedure. The study describes a case series where the modified technique in the field of pancreatic surgery is applied on trauma patients through both laparoscopic and open approaches according to patients' hemodynamic stability.

RESULTS

There was no pancreatic fistula, deficiency nor any of the major complications related to the traditional CP technique.

CONCLUSIONS

None of the cases developed pancreatic necrosis or fistula, steatorrhea or showed picture of diabetes mellitus. The new technique has used the available anatomic and functional pancreatic facts to revolute sparing the distal pancreatic drainage procedure.

Management of pancreatic trauma: A pancreatic surgeon's point of view

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.

Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy

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.

Central pancreatectomy for pancreatoblastoma in a 16-year-old girl

Long-term functional results after standard pancreatic resections are a major concern, especially in children. An alternative pancreas-sparing procedure (such as central pancreatectomy) should be taken into consideration whenever it is feasible, and a prolonged survival is expected. Pancreatoblastoma is an unusual malignant tumor in childhood. However, in initially resectable tumors, the 15-year survival is more than 80%. Thus, there is a potential role of a conservative pancreatic resection in successful treatment of pancreatoblastoma. The management in a case of a 16-year-old girl with a pancreatoblastoma in the body of pancreas is presented. Complete surgical resection by central pancreatectomy followed by chemotherapy led to a prolonged disease-free survival, with good functional results. Central pancreatectomy could be an alternative surgical technique in some selected cases of pancreatoblastoma, having the lowest incidence of postoperative exocrine and endocrine insufficiency rate and offering the best nutritional status.

Pancreaticojejunostomy in proximal pancreatic transection: A viable option

Complete pancreatic transection following blunt abdominal trauma is not a common injury. Distal pancreatectomy with or without splenectomy is routinely performed if the transection is to the left of the superior mesenteric vessels. We performed pancreaticojejunostomy on a six-year-old female patient who presented with complete transection at the pancreatic neck following blunt abdominal trauma. The aim was to preserve the pancreatic parenchyma and the spleen and assess the feasibility of the procedure. The patient has been followed for more than one year and is doing well. We conclude that the procedure should be considered in proximal pancreatic transection, particularly in the pediatric age group.

Traumatic Transection of Pancreas at the Neck: Feasibility of Parenchymal Preserving Strategy

BACKGROUND

To assess the feasibility and safety of a pancreas preserving operative technique in the management of isolated complete pancreatic neck transection following blunt abdominal trauma.

METHODS

Two patients with isolated blunt fracture of the pancreatic neck underwent pancreas preserving procedure comprising of oversewing of the proximal pancreas and Roux-en-Y pancreatico jejunostomy to the distal remnant. A feeding jejunostomy tube was placed for postoperative nutritional support in these patients. Both patients received subcutaneous octreotide 300 µg/day.

RESULTS

Their ages ranged from 15 years to 20 years, mode of injury was bicycle handle-bar injury (n = 2). Both had pancreatic transection at neck in the line of superior mesenteric vessels. One had ascites. These patients had pancreas parenchyma preserving surgery - internal drainage of the left remnant in a Roux-en-Y jejunal loop. The postoperative course was uneventful in these and both are well on follow-up.

CONCLUSIONS

Pancreas preserving strategy - suture of head side of pancreas and an internal drainage of left remnant with a Roux-en-Y jejunal loop is feasible and safe and should be considered in selected cases. Substantial amount of normal pancreatic parenchyma is preserved.