Laparoscopic Distal Pancreatectomy in Children: Four Cases and Review of the Literature

Laparoscopic Management of Blunt Pancreatic Trauma in Adults and Pediatric Patients: A Systematic Review

Background

Pancreatic trauma is an uncommon injury that occurs usually in a young population and is frequently overlooked and not readily appreciated on initial examination. Nowadays, the diagnosis and management of pancreatic trauma are still controversial, and there is no gold standard for the treatment. The aim of this study is to describe our experience in the management of blunt pancreatic trauma with a laparoscopic approach and review the literature on laparoscopic management of pancreatic trauma.

Methods

A systematic literature review was performed, and 40 cases were reported and analysed; 10 cases were excluded because the complete data were not retrievable. We also reported our experience with the case of an 18-year-old male diagnosed with a deep laceration of the pancreas between body and tail, involving the main pancreatic duct, and with a concomitant hematoma. The patient underwent exploratory laparoscopy with abdominal toilet, necrosectomy, and suture of main pancreatic duct; the total blood loss was less than 200 ml, and the total operative time was 180 minutes. The patient recovered uneventfully and was discharged on the 6th postoperative day.

Results

30 patients with pancreatic trauma, 10 adults and 20 pediatrics (mean age 28.2 years and 10.5 years), underwent a total laparoscopic approach: 2 distal pancreatic-splenectomy, 22 spleen-preserving distal pancreatectomy, and 6 laparoscopic drainage. The mean operative time for the adult and pediatric populations was 160.6 and 214.5 minutes, the mean estimated blood loss was 400 ml and 75 ml, and the mean hospital stay was 14.9 and 9 days, respectively.

Conclusion

Laparoscopic management for pancreatic trauma can be considered feasible and safe when performed by an experienced laparoscopic pancreatic team, and in such a setting, it can be considered a viable alternative to open surgery, offering the well-known benefits of minimally invasive surgery.

Precision anatomy for minimally invasive spleen-preserving distal pancreatectomy in children: A case report of solid-pseudopapillary neoplasm in a 12-year-old girl

INTRODUCTION

Solid pseudopapillary neoplasm (SPN) is a rare and low malignant tumor found mainly in young females. There is no standardized procedure for SPN of the pancreatic body and tail in children. In adults, an international consensus on precision anatomy for minimally invasive distal pancreatectomy (MIDP) was established recently (PAM-HBP Surgery Project). The aim of this study is to demonstrate that precision anatomy can also be safely and effectively implemented in the pediatric population.

PRESENTATION OF CASE

A 12-year-old girl with an incidentally found SPN located in the pancreatic tail was referred to our hospital. She successfully underwent an R0 resection by laparoscopic spleen-preserving distal pancreatectomy (LSPDP) under the concept of precision anatomy. The patient recovered uneventfully and was discharged on day 7.

DISCUSSION

This is the first successful report of LSPDP under the concept of precision anatomy in children. In accordance with the recommendations from the international consensus, the "anterior approach" was selected to dissect and encircle the splenic artery based on the vascular anatomy identified by preoperative imaging. The dorsal dissection border of the pancreas along the anterior layer above the Gerota's fascia was carefully maintained and the splenic vessels were preserved taking into consideration the low malignant potential of SPN and to decrease the risk of complications associated with splenectomy, which were also the essential issues of the consensus.

CONCLUSION

The implementation of precision anatomy for pediatric pancreas surgery should facilitate the safe diffusion of MIDP for SPN and other benign or low-malignant tumors in children.

Solid Pseudopapillary Epithelial Neoplasm of the Pancreas in the Paediatric Population: A Report of Two Cases

A rare pathology, the solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas accounts for approximately 1% of pancreatic neoplasms. Initially called ‘Frantz’s tumour’, it has now been renamed to SPEN by the World Health Organization (WHO). This tumour has a predilection for females and a good prognosis with surgical excision being the treatment of choice.

Palpable abdominal masses in children are of significant clinical importance. Identifying cystic lesions in the pancreas from CT or MRI scans always warrant further investigations. Primary pancreatic neoplasms account for 0.1% of pancreatic tumours in the paediatric population; an extremely rare circumstance constituting a diagnostic and therapeutic challenge to surgeons. This article comprises two paediatric cases of SPEN in 14- and 11-year-old females, respectively, and a literature review on current management.

Minimally invasive hepatopancreatic and biliary surgery in children: a large centre experience and review of the literature

BACKGROUND

Minimally invasive surgery (MIS) for hepatopancreatic and biliary (HPB) diseases has been widely used in adults, while in children, its application is limited due to its complexity. Herein, we report the experience of MIS for paediatric HPB diseases and literature review.

METHODS

All children (≤18 years-old) undergoing major HPB operations by MIS during January 2017-June 2020 in our institution were prospectively enrolled.

RESULTS

Out of 139 children operated on for HPB diseases with MIS, 26 (18.7%) patients (age: 11 (1-17) years-old; weight: 41.9 (10.7-75.5) kg) underwent major HPB surgery, including 11 pancreatic resections and 15 liver resections, all performed by a full-laparoscopic-technique. Four (15.3%) surgeries were electively converted to an open-technique for safer operative management. None required a blood transfusion. The median hospital admission was 6 days. Post-operatively, all patients had early mobilization and good recovery. Two (7.7%) patients experienced post-operative complications requiring radiological intervention. Oncological radical resection (R0) was achieved in all tumours, and after 2 years, all children were free of tumour recurrence.

CONCLUSION

MIS for HPB surgery is safe and feasible in children, with less surgical trauma, short hospital-stay and better aesthetic results. An adequate learning curve in specialized centres is essential for good 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 Approaches to Pediatric Solid Tumors

Over the last decade, driven in part by the favorable adult experience and a crescendoing number of case series and retrospective reports in the pediatric surgical literature, minimally invasive surgical (MIS) approaches are increasingly used as adjunctive or definitive surgical treatments for an ever-expanding list of pediatric tumors. Although most current treatment protocols lack surgical guidelines regarding the use of MIS, this growing body of MIS literature provides a framework for the development of multicenter trial groups, prospective registries, and further centralization of subspecialist services. This article highlights the current available data on MIS approaches to a variety of pediatric malignancies.

Advances in minimally invasive surgery in pediatric patients

Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.

Laparoscopic distal pancreatectomy to treat solid pseudopapillary tumors in children: transition from open to laparoscopic approaches in suitable cases

PURPOSE

The aim of this study was to evaluate the outcomes of open and laparoscopic distal pancreatectomy (LDP) in the treatment of solid pseudopapillary tumors (SPT) in children.

METHODS

This was a retrospective study of 22 patients under 18 years of age who underwent a distal pancreatectomy for SPT between January 1995 and December 2012.

RESULTS

Fourteen patients and eight patients underwent LDP and open distal pancreatectomy (ODP), respectively, and 71.4 % of the LDP and 25.0 % of the ODP procedures were spleen-sparing operations. The median duration of surgery in the LDP group was shorter than that in the ODP group [175 (range 120-540) vs. 257 (range 200-305) min, p = 0.024]. There were no differences in postoperative complications. The LDP patients commenced oral intake earlier than the ODP patients [2.0 (range 1.0-7.0) vs. 4.0 (range 3.0-12.0) days, p = 0.010], and had an earlier discharge from hospital [7.0 (range 5.0-20.0) vs. 13.0 (range 7.0-22.0) days, p = 0.009].

CONCLUSION

LDP treatment for SPT in children is associated with a shorter hospitalization and a shorter time to oral intake compared to ODP. LDP is a safe and feasible option for SPT in select pediatric patients.

Minimally invasive surgery for pediatric tumors - current state of the art

During recent years, minimally invasive surgery (MIS) has become the standard approach for various operations in infants and children. This also holds true for surgery in children with solid tumors. Meanwhile, more and more oncological biopsies and resections are being performed laparoscopically or thoracoscopically. Despite its increasing role in pediatric tumor surgery, the different national and international multicenter trial groups have not yet implemented MIS within guidelines and recommendations in most of the current treatment protocols. An increasing number of reports describe a potential role of MIS in the different entities of pediatric surgical oncology. Over the time, there has been a diverse development of this approach with regard to the different neoplasms. The aim of this article is to give an overview and to describe the current state of the art of MIS in pediatric solid tumors.

[Videosurgery in infancy and childhood: state of the art. Experience with 1408 procedures in the Instituto da Criança "Pedro de Alcântara"]

The videosurgery in Pediatric Surgery has a large field of applications unfortunately still underexplored. There are few services that routinely use this techinic , and Brazilian articles published are scarce. The Institute of Children's Hospital of the Faculty of Medicine, University of São Paulo, has been using for fifteen years the videosurgery which is now the first choice of treatment, among other diseases as gastroesophageal reflux, the cholecystolithiasis, the nonpalpable undescended testicles and megaesophagus. In this article we report our experience in laparoscopic pediatric surgery, acquired with 1408 surgical procedures, to present this useful method, and beneficial to a large number of situations and still underused in Pediatric Surgery.

The role of laparoscopy in pediatric trauma

Minimally invasive techniques have now become standard for the treatment of many surgical conditions in children. During the past decade, there has been increasing interest in the use of this technology for the management of injured children. Laparoscopy has become an important adjunct in the evaluation of both blunt and penetrating intra-abdominal trauma and frequently is both diagnostic and therapeutic. Laparoscopic techniques have been used to repair injuries involving the gastrointestinal tract, solid organs, and the diaphragm. These procedures have been performed successfully, and avoid the complications associated with formal laparotomy.