Cystadenomas of the pancreas: is enucleation an adequate operation?

Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis

BACKGROUND

Pancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications.

MATERIALS AND METHODS

Pubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD.

RESULTS

Concordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15-1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28-0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178-5.34); p = 0.96].

CONCLUSIONS

DPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms.

Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity

BACKGROUND

Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity.

METHODS

PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval.

RESULTS

Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients.

CONCLUSION

DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.

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

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.

Comparison of Outcomes of Enucleation vs. Standard Surgical Resection for Pancreatic Neoplasms: A Systematic Review and Meta-Analysis

Background

With advancement in health technology, the detection rate of pancreatic neoplasms is increasing. Tissue sparing surgery (enucleation) as well as standard surgical resection are two commonly used modalities of management. There are studies comparing clinical outcomes between these two modalities; however, there is lack of studies that systematically pool the available findings to present conclusive and reliable evidence.

Methods

A systematic search was conducted using the PubMed, Scopus, and Google Scholar databases. Studies that were randomised controlled trials or cohort based or analysed retrospective data were considered for inclusion. Studies should have been done in adult patients with pancreatic neoplasms and should have examined the outcomes of interest by the two management modalities i.e., enucleation and standard surgical resection. Statistical analysis was performed using STATA software.

Results

A total of 20 studies were included in the meta-analysis. The operation time (in minutes) (WMD −78.20; 95% CI: −89.47, −66.93) and blood loss (in ml) (WMD −204.30; 95% CI: −281.70, −126.90) for enucleation was significantly lesser than standard surgical resection. The risk of endocrine (RR 0.32; 95% CI: 0.18, 0.56) and exocrine insufficiency (RR 0.16; 95% CI: 0.07, 0.34) was lower whereas the risk of post-operative pancreatic fistula (RR 1.46; 95% CI: 1.22, 1.75) was higher in enucleation, compared to standard surgical resection group. There were no differences in the risk of reoperation, readmission, recurrence, mortality within 90 days and 5-years overall mortality between the two groups.

Conclusions

Enucleation, compared to standard surgical resection, was associated with better clinical outcomes and therefore, might be considered for selected pancreatic neoplasms. There is a need for randomised controlled trials to document the efficacy of these two management techniques.

Solid pseudopapillary neoplasm-diagnostic approach and post-surgical follow up: Three case reports and review of literature

BACKGROUND

Solid pseudopapillary neoplasm (SPN) is a rare tumor that was first described by Frantz in 1959. Although this tumor is benign, some may have malignant potential that can be predicted based on demographics, imaging characteristics, and pathologic evaluation. This case series presents 3 SPN cases with discussion on gender differences, preoperative predictors of malignancy, and a suggested algorithm for diagnostic approach as well as post-surgical follow up.

CASE SUMMARY

Three adult patients in a tertiary hospital found to have SPN, one elderly male and two young females. Each of the cases presented with abdominal pain and were discovered incidentally. Two cases underwent endoscopic ultrasound with fine needle aspiration and biopsy to assess tumor markers and immuno-histochemical staining (which were consistent with SPN before undergoing surgery), and one case underwent surgery directly after imaging. The average tumor size was 5 cm. Diagnosis was confirmed by histology. Two patients had post-surgical complications requiring intervention.

CONCLUSION

Demographic and imaging characteristics can be sufficient to establish diagnosis for SPN, while malignant cases require pre-operative evaluation with endoscopic ultrasound fine needle aspiration/fine needle biopsy.

Endoscopic placement of pancreatic stent for "Deep" pancreatic enucleations operative technique and preliminary experience at two high-volume centers

BACKGROUND

Pancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of "deep" PE preceded by endoscopic stenting of the MPD.

METHODS

From January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3 weeks before surgery, depending on the participating institute.

RESULTS

Ten patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases.

CONCLUSION

In the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.

Open and minimally invasive pancreatic neoplasms enucleation: a systematic review

BACKGROUND

Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting. Nowadays, pEN is frequently carried out through a minimally invasive approach either laparoscopic or robotic. Its impact on overall perioperative complications and pancreatic fistula (POPF) is still under evaluation. The scope of our systematic review is to assess pEN's perioperative outcomes and to evaluate the effect of the minimally invasive techniques over POPF and other surgical complications.

METHODS

We performed a systematic literature search (time-frame January 1999-September 2018), considering exclusively those studies which included at least 5 cases of either open or minimally invasive pEN. Data regarding postoperative outcome and POPF were extracted and analyzed. We defined postoperative morbidities by the Clavien-Dindo classification while POPF according to the International Study Group of Pancreatic Fistula (ISGPF) definition.

RESULTS

Sixty-three studies met the criteria selected, accounting for a study population of 2485 patients. 27.7% had a minimally invasive pEN. The overall postoperative morbidity rate was 46.1% with 11.9% rated as severe (Clavien-Dindo ≥ 3). Mortality rate was 0.69%. The minimally invasive approach to pEN led to a statistically significant reduction of both the overall POPF rate (28.7% vs. 45.9%, p < 0.001), and clinically significant B-C POPF (p < 0.027). The postoperative overall morbidity rate was clearly in favor of the minimally invasive approach (27.6% vs. 55.2%, p < 0.001).

CONCLUSIONS

Our review confirms that pEN is a safe and feasible technique for the treatment of small benign or low-grade pancreatic neoplasms and it can be implemented with an acceptable morbidity rate along with low mortality. The minimally invasive approach is gaining widespread acceptance due to its supposed non-inferiority compared with the traditional open approach. In our review, it showed to be even better in terms of POPF incidence rate and short-term postoperative outcome. Still, such data need to be corroborated by randomized clinical trials.

Endoscopic versus percutaneous drainage of post-operative peripancreatic fluid collections following pancreatic resection

BACKGROUND

Post-operative peripancreatic fluid collection (PFC) is a common complication following pancreatic resection which can be managed with endoscopic or percutaneous drainage.

METHODS

Patients who underwent either endoscopic or percutaneous drainage of post-operative PFC were extracted from a prospectively-maintained database. The two groups were matched for surgery type, presence of a surgical drain and timing of drainage.

RESULTS

Thirty-nine matched patients were identified in each group with a median age of 62 years. For primary drainage, technical success was achieved in almost all patients in both endoscopic and percutaneous groups (100% and 97%, p = NS); clinical success was achieved in 67% and 59%, respectively (p = 0.63). At least one "salvage" drainage procedure was required in 13 endoscopic patients versus 16 in the percutaneous group. Clinical success was achieved following the first salvage. Procedure in 85% of the endoscopic patients and 88% of the percutaneous patients (p = 0.62). Stent/drain duration (59 vs 33 days, p < 0.001) and number of post-procedural CT studies (2 vs 1, p = 0.02) were significantly higher in the endoscopic group. There was no difference in length of stay, complication, or recurrence between the two groups.

CONCLUSION

Endoscopic drainage of post-operative PFC appears to be safe and effective with comparable success rates and outcomes to percutaneous drainage.

Mucinous cystadenoma of the pancreas associated with pregnancy. Case report and review of the literature

Objective. We present a rare pathology with uncommon onset. Background. Mucinous cystic pancreatic neoplasms (MCNs) are rare tumors, which generally occur in the fifth and sixth decades of women. Although some tumours are frankly malignant, all are in fact considered to be potentially malignant. Case report. We present the case of a 30-year-old patient, with a 16/11 cm tumor located in the pancreas body, which was diagnosed 8 months after birth. The preoperative assessment of the pancreatic lesion suggested the diagnosis of mucosal cyst neoplasm, without being able to determine its benign or malignant nature. Central pancreatectomy was performed with a good postoperative evolution. Histopathologic result was represented by mucinous pancreatic chistadenoma. Two years after surgical intervention, the patient presented no signs of recurrence or pancreatic (exocrine or endocrine) secretion deficiency. Conclusions. Preoperative imaging evaluation could be suggestive for mucinous cystic tumour, but this cannot specify however the nature of the tumor. The postpartum occurrence could establish a possible relationship between hormonal levels encountered during pregnancy and the development of this tumor, taking into considerations the ovarian-type stroma and the presence of hormone (estrogen and progesterone) receptors in this neoplasm. Central pancreatectomy without anastomosis preserves the functions of pancreas, and also decreases morbidity.

Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections

OBJECTIVE

The aim of this study was to evaluate the safety and efficiency of enucleation (EU) for proximal pancreatic non-invasive neoplasms.

METHODS

Patients with solitary non-invasive neoplasms in the proximal pancreas from January 1998 to April 2014 at the Second Affiliated Hospital of Zhejiang University, Hangzhou, China were included. Different operations and outcomes were analyzed.

RESULTS

A total of 123 patients were enrolled. Forty patients (32.5%) underwent EU including 18 patients who had tumors close to the main pancreatic duct (MPD). Sixty-one patients (49.6%) had pancreaticoduodenectomy (PD) performed and 22 (17.9%) underwent central pancreatectomy (CP). Pathological outcomes included neuroendocrine tumors, cystic lesions, and solid pseudopapillary tumors. Operation time, intra-operative blood loss, and duration of hospital stay were significantly reduced in the EU group. PD was associated with the greatest complication rate (55.7%), followed by EU (50%) and CP (40.9%), though the pancreatic fistula rate after EU was the highest (50%), especially in patients with tumors larger than 3 cm and tumors close to the MPD. EU had advantages in the preservation of pancreatic parenchyma and endocrine and exocrine function.

CONCLUSIONS

EU can be carried out safely and effectively for tumors in the proximal pancreas with improved outcomes compared with standard resections, even if the tumor is larger than 3 cm and close to the MPD.

Predictive factors of endocrine and exocrine insufficiency after resection of a benign tumour of the pancreas

BACKGROUND

The aim of the present study is to evaluate the risk factors of endocrine and exocrine insufficiency occurring few years after pancreatic resections in a consecutive series of patients who underwent pancreatoduodenectomy (PD), left pancreatectomy (LP) or enucleation for benign neoplasms at a referral centre.

METHODS

Pancreatic exocrine insufficiency (PEI) was defined by the onset of steatorrhea associated with weight loss, and endocrine insufficiency was determinate by fasting plasma glucose. Association between pancreatic insufficiency and clinical, pathological, and perioperative features was studied using univariate and multivariate Cox regression analysis.

RESULTS

A prospective cohort of 92 patients underwent PD (48%), LP (44%) or enucleation (8%) for benign tumours, from 2005 to 2016 in the University Hospital in Poitiers (France). The median follow-up was 68.6±42.4months. During the following, 54 patients developed exocrine insufficiency whereas 32 patients presented endocrine insufficiency. In the Cox model, a BMI>28kg/m², being a man and presenting a metabolic syndrome were significantly associated with a higher risk to develop postoperative diabetes. The risks factors for the occurrence of PEI were preoperative chronic pancreatitis, a BMI<18.5kg/m², tumours located in the pancreatic head, biological markers of chronic obstruction and fibrotic pancreas. Undergoing LP or enucleation were protective factors of PEI. Histological categories such as neuroendocrine tumours and cystadenomas were also associated with a decreased incidence of PEI.

CONCLUSION

Men with metabolic syndrome and obesity should be closely followed-up for diabetes, and patients with obstructive tumours, pancreatic fibrosis or chronic pancreatitis require a vigilant follow up on their pancreatic exocrine function.

Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: A single-center experience of 142 patients

BACKGROUND

Enucleation is increasingly used for benign or low-grade pancreatic neoplasms. Enucleation preserves the pancreatic parenchyma as well as decreases the risk of long-term endocrine and exocrine dysfunction, but may be associated with a higher rate of postoperative pancreatic fistula (POPF). The aim of this study was to assess short-term outcomes, in particular, POPF.

METHODS

Data were collected retrospectively from all 142 patients who underwent pancreatic enucleation between 2009 and 2014 in our institution were analyzed.

RESULTS

Lesions were most frequently located in the head and uncinate process of the pancreas (60.6%), and the most common types were neuroendocrine neoplasms (52.1%). Overall morbidity was 66%, mainly due to POPF (53.5%), and severe morbidity was only 8.4%, including one death (0.7%). Clinical POPF (Grade B or C) occurred in 22 patients (15.5%). Independent risk factors for clinical POPF were age ≥60 years, an episode of acute pancreatitis, and cystic morphology. Tumor size, coverage, histological differentiation, and prolonged operative time were not associated with the risk of POPF.

CONCLUSIONS

Enucleation is a safe and feasible procedure for benign or low-grade pancreatic neoplasms. The rate of clinical POPF is acceptable, and clinical POPF occurs more frequently in elderly patients (≥60 years of age), patients with cystic neoplasms, or patients with an episode of acute pancreatitis.

Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas

The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.

Surgical Management of Pancreatic Cysts: A Shifting Paradigm Toward Selective Resection

Due to the widespread use of high-quality cross-sectional imaging, pancreatic cystic neoplasms are being diagnosed with increasing frequency. Clinicians are therefore asked to counsel a growing number of patients with pancreatic cysts diagnosed incidentally at an early, asymptomatic stage. Over the last two decades, accumulating knowledge on the biologic behavior of these neoplasms along with improved diagnostics through imaging and endoscopic cyst fluid analysis have allowed for a selective therapeutic approach toward these neoplasms. On one end of the management spectrum, observation is recommended for typically benign lesions (serous cystadenoma), and on the other end, upfront resection is recommended for likely malignant lesions (main duct IPMN, mucinous cystadenoma, solid pseudopapillary tumor, and cystic pancreatic neuroendocrine tumors). In between, management of premalignant lesions (branch duct IPMN) is dictated by the presence of high-risk features. In general, resection should be considered whenever the risk of malignancy is higher than the risk of the operation. This review aims to describe the evolution and current status of evidence guiding the selection of patients with pancreatic cystic neoplasms for surgical resection, along with a specific discussion on the type of resection required and expected outcomes.

Surgical treatment of pancreatic cystic tumors

The aim of this study was to assess short-term outcomes of surgical treatment of pancreatic cystic tumors (PCTs).

MATERIAL AND METHODS

We retrospectively reviewed medical records of 46 patients (31 women and 15 men) who had undergone surgery for pancreatic cystic tumors in our department.

RESULTS

Pancreatic cystic tumors were located within the pancreatic head (21), body (11), tail (13), and whole pancreas (1). The following surgical procedures were performed: pancreatoduodenectomy (20), central pancreatectomy (9), distal pancreatectomy (3), distal pancreatectomy with splenectomy (3), distal extended pancreatectomy with splenectomy (2), total pancreatectomy (1), duodenum preserving pancreatic head resection (1), local tumor resection (4), and other procedures (2). Histopathological tumor types were as follows: serous cystadenoma (14), intraductal papillary mucinous adenoma (5), intraductal papillary mucinous carcinoma (5), solid pseudopapillary tumor (5), mucinous cystadenoma (5), mucinous cystadenoma with border malignancy (1), mucinous cystadenocarcinoma (2), adenocarcinoma (4), and other tumors (5). Early postoperative complications were observed in 14 (30.43%) patients. Reoperations were performed in 9 (19.56%) patients. The perioperative mortality rate was 6.52%.

CONCLUSIONS

Serous cystadenoma was the most common pancreatic cystic tumor in the analyzed group. PCTs were most frequently located within the pancreatic head. Pancreatic resection was possible in most patients, and pancreatoduodenectomy was the most common pancreatic resection type.

Perioperative application of somatostatin analogs for pancreatic surgery-current status in Germany

BACKGROUND

The most common major complication after pancreatic resection is the postoperative pancreatic fistula (POPF). Somatostatin analogs can reduce POPF, but the use of somatostatin analogs is still controversial. The aim of this study was to assess treatment algorithms for pancreatic surgery in Germany with a special focus on the application of somatostatin analogs.

METHODS

A questionnaire evaluating the perioperative management-especially the use of somatostatin analogs-and postoperative complications after pancreatic surgery was developed and sent to 209 German hospitals performing >12 pancreatoduodenectomies per year (the requirement for certification as a pancreas center). Statistical analysis was carried out using SPSS 21.

RESULTS

The final response rate was 77 % (160/209), 14.5 % of hospitals never, 37 % always, and 45 % occasionally apply somatostatin analogs after pancreatic surgery. A (standard) drug of choice was defined in 64 % of hospitals. When standard and occasional usage was analyzed, it appeared that hospitals favored somatostatin (69 %) > sandostatin (50 %) > pasireotide (5 %). A relation between the usage of the different somatostatin analogs and morbidity (POPF) or mortality (84 and 16 % of hospitals reported <5 and 5-10 %, respectively) was not seen. Eighty-seven percent of hospitals were interested in participating in future studies analyzing somatostatin use.

CONCLUSION

This is the first national survey in Germany evaluating the perioperative application of somatostatin analogs for pancreatic surgery. Despite controversial results in the literature, the majority of German pancreas surgeons apply somatostatin analogs perioperatively. The ideal drug to reduce POPF is still unclear. This uncertainty has aroused significant interest and prompted surgeons to participate in future studies in order to elucidate this issue.

Short- and long-term outcomes after enucleation of pancreatic tumors: An evidence-based assessment

BACKGROUND AND OBJECTIVE

Enucleation of pancreatic tumors is rarely performed. The aim of this study was to evaluate the published evidence for its short- and long-term outcomes.

METHODS

PubMed (MEDLINE) and EMBASE databases were searched from 1990 to March 2016. Studies including at least ten patients who underwent enucleation of pancreatic lesions were included. Data on the outcomes were synthesized and meta-analyzed where appropriate.

RESULTS

Twenty-seven studies involving 1316 patients were included in the systematic review. The postoperative mortality was 0.3%, and the postoperative morbidity was 50.3%, mainly represented by pancreatic fistula (38.1%). Endocrine insufficiency, exocrine insufficiency and tumor recurrence was observed in 2.4%, 1.1% and 2.3% of the patients respectively. Compared with typical resection, the operation time, blood loss, length of hospital stay, and the incidence of endocrine and exocrine insufficiency were all significantly reduced after enucleation. The occurrence of pancreatic fistula was significantly higher in enucleation group, but overall morbidity, the reoperation rate and mortality were comparable between the two groups. There was no significant difference in disease recurrence between the two groups. Compared with central pancreatectomy, enucleation had a shorter operation time, lower blood loss, less morbidity, and better pancreatic function. Compared with open enucleation, minimally invasive enucleation had a shorter operation time and a shorter length of hospital stay.

CONCLUSIONS

Enucleation is an appropriate surgical procedure in selected patients with benign or low-malignant lesions of the pancreas. The benefits of minimally invasive approach need to be validated in further investigations with larger groups of patients.

Roux-en-Y pancreaticojejunostomy reconstruction after deep enucleation of benign or borderline pancreatic lesions: a single-institution experience

BACKGROUND

Standard pancreatectomy for benign and borderline pancreatic lesions involves resecting a substantial amount of normal pancreatic parenchyma and leads to a subsequent impairment of both exocrine and endocrine pancreatic functions. A limited resection such as enucleation is the preferred option for such neoplasms. However, enucleation is associated with a high risk of postoperative complications in some cases. This study evaluated the feasibility and outcomes of performing deep enucleation with Roux-en-Y pancreaticojejunostomy reconstruction.

METHODS

This study included patients who underwent pancreatic lesion enucleation from February 2010 to April 2014 in our hospital. The clinical data were collected and retrospectively analyzed.

RESULTS

This study examined 53 patients who underwent enucleation, 33 of the procedures included deep enucleation with Roux-en-Y pancreaticojejunostomy reconstruction. There was no mortality, and the morbidity rate was 66.7% in this group. No patients developed grade C pancreatic fistulas in both group. None of the patients developed tumor recurrence or exocrine or endocrine insufficiency at a median follow-up of 25 months.

DISCUSSION

Enucleation with Roux-en-Y pancreaticojejunostomy reconstruction is a safe and feasible procedure for the treatment of benign and borderline pancreatic neoplasms adjacent to the common pancreatic duct. This procedure can effectively mitigate the limitations of simple enucleation.

Limited surgery for benign tumours of the pancreas: a systematic review

BACKGROUND

Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections.

METHODS

Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively.

RESULTS

The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2%, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5% of patients; pancreatic fistula in 36.7, 35.2 and 20.1%; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72%; and after DPPHRt/p 0.49%. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001).

CONCLUSION

EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.

Pancreatic mucinous cystoadenomas and cystoadenocarcinomas: differential diagnosis by means of MRI

OBJECTIVE

To determine the accuracy of MRI in differentiating mucinous cystoadenomas (MCAs) from mucinous cystoadenocarcinomas (MCACs) of the pancreas, with histopathological analysis as the reference standard, for better surgical planning.

METHODS

A total of 65 patients with histopathologically proven mucinous cystic neoplasms (MCNs) underwent MRI and surgery. Quantitative image analysis included size, septa and wall thickness and number of loculations. Qualitative image analysis included nodules; hyperintensity of the cystic content on T1 weighted images; compression and/or infiltration of adjacent vessels or organs; and metastases. A comparison between MCAs and MCACs was performed with Student's t-test for quantitative variables and with Fisher test for qualitative variables. Receiver operating characteristic analysis was performed to determine the accuracy in the differential diagnosis between MCAs and MCACs on the basis of a score system obtained by giving 1 point for each quantitative and qualitative variable observed in each patient.

RESULTS

At histopathology, 43 lesions were MCAs and 22 lesions were MCACs. A statistically significant difference was observed for size >7cm (<0.001), septa and wall thickness >3 mm (<0.0001), number of loculations >4 (<0.0001), nodules (<0.0001), hyperintensity of the cystic content on T1 weighted images (<0.0001), compression (<0.01) and/or infiltration (<0.01) of adjacent vessels or organs and metastases (<0.05). The best cut-off value to discriminate MCAs from MCACs was the presence of three features (p < 0.001), with an accuracy of 91%.

CONCLUSION

MRI has an accuracy of 91% in the differential diagnosis between MCA and MCAC, helping in identifying forms that could undergo parenchyma-sparing surgery (MCAs), reducing post-surgical morbidity and mortality.

ADVANCES IN KNOWLEDGE

In this study, the differentiation between MCAs and MCACs of the pancreas by means of MRI is addressed. The differential diagnosis allows selecting benign forms, susceptible of parenchyma-sparing surgery, with the advantage of reducing post-surgical morbidity and stratifying prognosis of MCNs.

Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients

INTRODUCTION

Conventional pancreatic resections may be unnecessary for benign tumours or for tumours of low malignant potential located in the neck and body of pancreas. Such extensive resections can place the patient at increased risk of developing postoperative exocrine and endocrine insufficiency. Central pancreatectomy is a plausible surgical option for the management of tumours located in these locations. Laparoscopic approach seems appropriate for such small tumours situated deep in the retroperitoneum.

AIMS

To assess the technical feasibility, safety and long-term results of laparoscopic central pancreatectomy in patients with benign and low malignant potential tumours involving the neck and body of pancreas.

SETTINGS AND DESIGN

This study was an observational study which reports a single-centre experience with laparoscopic central pancreatectomy over a 9-year period.

MATERIALS AND METHODS

14 patients underwent laparoscopic central pancreatectomy from October 2004 to September 2013. These included patients with tumours located in the neck and body of pancreas that were radiologically benign-looking tumours of less than 3 cm in size.

STATISTICAL ANALYSIS USED

The statistical analysis was done using GraphPad Prism software.

RESULTS

The mean age of patients was 48.93 years. The mean operative time was 239.7 min. Mean blood loss was 153.2 ml. Mean postoperative ICU stay was 1.2 days and overall mean hospital stay was 8.07 days. There were no mortalities and no major postoperative complications. Margins were negative in all cases and with a median follow-up of 44 months, there was no recurrence.

CONCLUSIONS

Laparoscopic central pancreatectomy is a feasible procedure with acceptable morbidity. In the long term, there were no recurrences and pancreatic function was well preserved.

Meta-analysis of surgical outcome after enucleation versus standard resection for pancreatic neoplasms

BACKGROUND

Pancreatic enucleation is a tissue-sparing approach to pancreatic neoplasms and may result in better postoperative pancreatic function than standard pancreatic resection. The objective of this review was to compare the postoperative outcome after pancreatic enucleation versus standard resection.

METHODS

MEDLINE, Embase and the Cochrane Library were searched systematically until February 2015 to identify studies comparing the outcome of enucleation versus standard resection for pancreatic neoplasms. After critical appraisal, meta-analysis was performed and the findings were presented as odds ratios or weighted mean differences with corresponding 95 per cent c.i.

RESULTS

Twenty-two observational studies (1148 patients) were included. Duration of surgery (P < 0.001), blood loss (P < 0.001), length of hospital stay (P = 0.04), and postoperative endocrine (P < 0.001) and exocrine (P = 0.01) insufficiency were lower after enucleation than after standard resection. Mortality (P = 0.44), overall complications (P = 0.74), reoperation rate (P = 0.93) and delayed gastric emptying (P = 0.15) were not significantly different between the two approaches. The overall rate of postoperative pancreatic fistula (POPF) was higher after enucleation than after standard resection (P < 0.001). However, the raised POPF rate did not result in higher mortality or overall morbidity. Sensitivity analysis of high-volume studies (total of more than 20 enucleations and more than 4 per year) showed that, in specialized centres, enucleation can be performed with no increased risk of POPF (P = 0.12).

CONCLUSION

Compared with standard resection, pancreatic enucleation can be performed effectively and with comparable safety in high-volume institutions. Enucleation should be considered instead of standard resection for selected pancreatic neoplasms.

Feasibility and outcomes of laparoscopic enucleation for pancreatic neoplasms

Purpose

With the advancement of laparoscopic techniques and instruments, laparoscopic approach for pancreatic lesions has become an increasingly used procedure. But, there are few and limited studies about laparoscopic enuleation (LE) for pancreatic lesions. Therefore, the purpose of this study was to present our experience and to evaluate the clinical outcome of LE for pancreatic benign or borderline malignant tumors.

Methods

Between May 2005 and December 2011, 11 patients who underwent LE were analyzed. Candidates for LE met the following criteria: benign or borderline malignant pancreatic tumor, no involvement of main pancreatic duct, and outwardly growing tumor with small tumor bed.

Results

All 11 patients (10 women and 1 man with a mean age of 43.1 ± 11.9 years) who underwent LE were completed laparoscopically without conversion. The mean diameter of tumor was 4.0 ± 3.3 cm and all cases had benign tumors at the final pathologic diagnosis. One patient (9%) developed pancreatic fistula and mean postoperative hospital stay was 5.5 ± 1.7 days. During follow-up period (mean, 44.3 ± 23.9 months), all patients were alive with no recurrence or new onset of diabetes.

Conclusion

LE is a safe and effective procedure, and should be considered as a treatment option for pancreatic lesions that do not involve the main pancratic duct and have an outgrowing aspect with small tumor bed.

Giant mucinous cystadenoma: case report with review of literature

Cystic tumors of the pancreas are rare and can be confused with hydatid cyst especially in endemic areas like ours. We present a 30-year-old woman with a huge mucinous cystadenoma of the pancreas initially diagnosed and prepared on table as hydatid cyst. After incising the cyst the diagnosis of cystic tumor was considered and underwent total excision with spleen and healthy pancreatic margin. Histologically and biochemistry of fluid confirmed potentially benign mucinous cystic tumor of pancreas tumor excision after histological diagnosis. Sensitivity of radiological imaging values in differentiating between cystic pancreatic tumors and other limited. Cyst wall histology is diagnostic and biopsy of cyst wall should be done in cases with inconclusive preoperative diagnosis or questionable operative findings.

Ethanol lavage of 14 mucinous cysts of the pancreas: A retrospective study in two tertiary centers

Background:

Mucinous cysts are lesions with malignant potential. Their management is stil difficult. Ethanol lavage under EUS can be used and could be a good alternative treatment. We report a bi-center experience of ethanol lavage in mucinous cysts of the pancreas.

Patients and methods:

A total of 13 patients in 2 tertiary centers (7 men, 6 women, mean age=68.5 years) underwent ethanol lavage for mucinous cysts under endoscopic ultrasound (EUS) from 2001 to 2010. One of the patients had 2 cysts treated during the same procedure. One patient underwent a second procedure of ethanol lavage. Mucinous cyst diagnosis required: (1) EUS showing cystic lesion without nodule and without communication with pancreatic branch duct. Six cysts were located in the isthmus of the pancreas, 3 in the head, 3 in the body, and 2 in the tail. The mean size was 24 mm (11-50); and (2) Intra-cystic ACE level >400 UI/l and/or histologic proof. Diagnosis of mucinous cyst was obtained using ACE levels in 5 cases, histology in 8 cases, and both in 1 case.

Results:

No complication was reported. Complete responses were observed in 11 cases (85%), with no responses in 2 cases (15%). Mean follow-up was 26 months (4-118 months). Contact was lost with 1 patient. No recurrence was noticed in patients with complete responses.

Conclusion:

This study confirms the feasibility and effectiveness of a loco-regional treatment under EUS for pancreatic cysts. The good ratio of response is probably explained by the lack of septa and the small size of the cysts. The follow-up is still short and needs to be increased. Nethertheless loco-regional treatment of pancreatic cysts lesions under EUS should form a part of the management of pancreatic lesions.

Benign cystic neoplasm and endocrine tumours of the pancreas--when and how to operate--an overview

BACKGROUND

The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard.

OBJECTIVES

To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate.

RESULTS

Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2-3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20% of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11%, pancreatic fistula in 33%. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33% pancreatic fistula and severe post-operative complications of 18% is related to management of proximal pancreatic stump. DPPHRt/s is used in 70% for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10% for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy.

CONCLUSION

The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.

Pancreatic cysts: etiology, diagnosis and management

Pancreatic cysts involve a wide spectrum of pathologies from post-inflammatory cysts to malignant neoplasms. Pancreatic pseudocysts, serous cystadenomas, mucinous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary tumors occur most frequently. Differential diagnosis involves the following imaging investigations: transabdominal ultrasonography (TUS), contrast enhanced ultrasonography (CEUS) and endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance (MR) and magnetic resonance cholangiopancretography (MRCP), endoscopic retrograde cholangiopancretography (ERCP). The cyst fluid cytology is performed in difficult differential diagnosis between pseudocysts and benign and potentially malignant or malignant tumors. Most frequently, viscosity, amylase, CEA and CA 19-9 levels are determined. Imaging findings should be correlated with cytology. The management depends on the cyst type and size. Small asymptomatic pseudocysts, serous cystadenomas and branchduct IPMNs should be carefully observed, whereas symptomatic large or uncertain serous cystadenomas and cystadenocarcinomas, mucinous cystadenomas and cystadenocarcinomas, main-duct IPMNs and large branch-duct IPMNs with malignant features, serous and mucinous cystadenocarcinomas, and solid pseudopapillary tumors require surgery. Pseudocysts are usually drained. Percutaneous / EUS-guided or surgical cyst drainage can be performed. Complicated and uncertain pseudocysts and cystic tumors need surgical resection. The type of surgery depends on cyst location and size and includes proximal, central, distal, total pancreatectomies and enucleation.

Enucleation of pancreatic lesions: indications, outcomes, and risk factors for clinical pancreatic fistula

BACKGROUND

There are few large samples and single-center series that focus on the outcomes of pancreatic enucleation and risk factors for clinical pancreatic fistula (PF). This study aimed to evaluate the indications, short- and long-term results, and risk factors for clinical PF after pancreatic enucleation.

METHODS

Patients who underwent pancreatic enucleation from January 2005 to April 2011 at the Peking Union Medical College Hospital in China were included. Clinical data were collected and analyzed.

RESULTS

A total of 119 patients underwent enucleation. PF was the most common complication; the incidence of clinical PF (grades B and C) was 27.7 %. The most common indications were endocrine neoplasms (76.5 %). During a median follow-up of 41 months, no patient developed exocrine insufficiency. Three elderly patients developed non-insulin-dependent diabetes mellitus. One patient with VIPoma developed recurrence and liver metastasis. New York Heart Association (NYHA) class II or III (P = 0.009; hazard ratio (HR) 3.191; 95 % confidence interval (CI) 1.334-7.632), operative time ≥180 min (P = 0.025; HR 2.664; 95 % CI 1.112-6.386) were the independent risk factors for clinical PF.

CONCLUSION

Enucleation is a safe and effective treatment for benign and low malignant lesions of the pancreas. NYHA class II or III and operation time of ≥180 min are independent risk factors for clinical PF.

Long-term outcome of laparoscopic surgery for pancreatic neuroendocrine tumors

BACKGROUND

As most pancreatic neuroendocrine tumors (PNET) are relatively small and solitary, they may be considered well suited for removal by a minimally invasive approach. There are few large series that describe laparoscopic surgery for PNET. The primary aim of this study was to describe the feasibility, outcome, and histopathology associated with laparoscopic pancreatic surgery (LS) of PNET in a large series.

METHODS

All patients with PNET who underwent LS at a single hospital from March 1997 to April 2011 were included retrospectively in the study.

RESULTS

A total of 72 patients with PNET underwent 75 laparoscopic procedures, out of which 65 were laparoscopic resections or enucleations. The median operative time of all patients who underwent resections or enucleations was 175 (60-520) min, the median blood loss was 300 (5-2700) ml, and the median length of hospital stay was 7 (2-27) days. The overall morbidity rate was 42%, with a surgical morbidity rate of 21% and postoperative pancreatic fistula (POPF) formation in 21%. Laparoscopic enucleations were associated with a higher rate of POPF than were laparoscopic resections. Five-year disease-specific survival rate was 90%. The T stage, R stage, and a Ki-67 cutoff value of 5% significantly predicted 5-year survival.

CONCLUSION

LS of PNET is feasible with acceptable morbidity and a good overall disease-specific long-term prognosis.

Efficacy of nasopancreatic stenting prior to laparoscopic enucleation of pancreatic neuroendocrine tumor

We report a patient who underwent laparoscopic enucleation for a nonfunctioning pancreatic neuroendocrine tumor. The patient was a 55-year-old man who had a 12- × 11-mm tumor close to the main pancreatic duct (MPD) in the pancreatic body. To avoid and detect injury to the main pancreatic duct during operation, a nasopancreatic drainage stent (NPDS) was endoscopically placed prior to the operation. According to the NPDS, the relation between the tumor and MPD was easily identified by laparoscopic ultrasonography during enucleation, thus enabling the resecting line to be determined. Moreover, after enucleation, pancreatography through the NPDS was able to clarify the absence of injury to the MPD. The NPDS was removed postoperatively, and the patient was discharged uneventfully on postoperative day 8. Preoperative placement of the NPDS seems to be a useful option for performing safe laparoscopic enucleation of pancreatic neuroendocrine tumor, especially when the lesion is located close to the MPD.

Pancreatic surgery: beyond the traditional limits

Pancreatic cancer is one of the five leading causes of cancer death for both males and females in the western world. More than 85 % pancreatic tumors are of ductal origin but the incidence of cystic tumors such as intrapapillary mucinous tumors (IPMN) or mucinous cystic tumors (MCN) and other rare tumors is rising. Complete surgical resection of the tumor is the mainstay of any curative therapeutic approach, however, up to 40 % of patients with potentially resectable pancreatic cancer are not offered surgery. This is despite 5-year survival rates of up to 40 % or even higher in selected patients depending on tumor stage and histology. Standard procedures for pancreatic tumors include the Kausch-Whipple- or pylorus-preserving Whipple procedure, and the left lateral pancreatic resection (often with splenectomy), and usually include regional lymphadenectomy. More radical or extended pancreatic operations are becoming increasingly utilised however and we examine the data available for their role. These operations include major venous and arterial resection, multivisceral resections and surgery for metastatic disease, or palliative pancreatic resection. Portal vein resection for local infiltration with or without replacement graft is now well established and does not deleteriously affect perioperative morbidity or mortality. Arterial resection, however, though often technically feasible, has questionable oncologic impact, is not without risk and is usually reserved for isolated cases. The value of extended lymphadenectomy is frequently debated; the recent level I evidence demonstrates no advantage. Multivisceral resections, i.e. tumors, often in the tail of the pancreas, with invasion of the colon or stomach or other surrounding tissues, while associated with an increased morbidity and a longer hospital stay, do however show comparable mortality-and survival rates to those without such infiltration and therefore should be performed if technically feasible. Routine resection for metastatic disease however does not seem to show any advantage over palliative treatment but may be an option in selected patients with easily removable metastases. In conclusion pancreatic surgery beyond the traditional limits is established in tumors infiltration the venous system and may be a considered approach in selected patients with locally infiltrating pancreatic cancer or metastasis.

Pancreatic cystic neoplasms: predictors of malignant behavior and management

BACKGROUND/AIM

Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts.

PATIENTS AND METHODS

Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed.

RESULTS

Eighty-one patients had true pancreatic cyst. The mean age was 47 ± 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men (P = 0.04), older age (0.0001), cysts larger than 3 cm in diameter (P = 0.001), presence of solid component (P = 0.0001), and cyst wall thickening (P = 0.0001). The majority of patients with malignancy were symptomatic (26/28, 92.9%). The symptoms that correlated with malignancy included abdominal pain (P = 0.04) and weight loss (P = 0.0001). Surgical procedures were based on the location and extension of the lesion.

CONCLUSION

The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst.

Laparoscopic pancreatectomy for malignancy

Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.

Pancreatic enucleation: improved outcomes compared to resection

INTRODUCTION

Pancreatic enucleation is associated with a low operative mortality and preserved pancreatic parenchyma. However, enucleation is an uncommon operation, and good comparative data with resection are lacking. Therefore, the aim of this analysis was to compare the outcomes of pancreatic enucleation and resection.

MATERIAL AND METHODS

From 1998 through 2010, 45 consecutive patients with small (mean, 2.3 cm) pancreatic lesions underwent enucleation. These patients were matched with 90 patients undergoing pancreatoduodenectomy (n = 38) or distal pancreatectomy (n = 52). Serious morbidity was defined in accordance with the American College of Surgeons-National Surgical Quality Improvement Program. Outcomes were compared with standard statistical analyses.

RESULTS

Operative time was shorter (183 vs. 271 min, p < 0.01), and operative blood loss was significantly lower (160 vs. 691 ml, p < 0.01) with enucleation. Fewer patients undergoing enucleation required monitoring in an intensive care unit (20% vs. 41%, p < 0.02). Serious morbidity was less common among patients who underwent enucleation compared to those who had a resection (13% vs. 29%, p = 0.05). Pancreatic endocrine (4% vs. 17%, p = 0.05) and exocrine (2% vs. 17%, p < 0.05) insufficiency were less common with enucleation. Ten-year survival was no different between enucleation and resection.

CONCLUSION

Compared to resection, pancreatic enucleation is associated with improved operative as well as short- and long-term postoperative outcomes. For small benign and premalignant pancreatic lesions, enucleation should be considered the procedure of choice when technically appropriate.

Giant pancreatic incidentaloma: Report of a case and literature review

INTRODUCTION

Asymptomatic lesions of the pancreas, referred to as 'incidentalomas', have appeared with increased frequency in recent years. Giant incidentalomas have rarely been reported in the literature.

PRESENTATION OF CASE

We report herein a rare case of a giant cystic pancreatic incidentaloma measuring 12.7cm×8cm, which was found in an otherwise healthy male patient during a routine genitourinary imaging work-up. The patient underwent a distal pancreatectomy and splenectomy; the pathology report demonstrated a giant serous cystadenoma of the body and tail of the pancreas.

DISCUSSION

The management of pancreatic incidentalomas is challenging. While solid lesions almost always warrant surgery, there is ongoing debate concerning the management of cystic lesions that are found incidentally in the pancreas and have no clinical manifestations.

CONCLUSION

We report herein an interesting case of a voluminous incidental cystic pancreatic lesion. The appropriate approach and the decision whether to operate or not in such cases can be puzzling to the physician.

International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas

The international consensus guidelines for management of intraductal papillary mucinous neoplasm and mucinous cystic neoplasm of the pancreas established in 2006 have increased awareness and improved the management of these entities. During the subsequent 5 years, a considerable amount of information has been added to the literature. Based on a consensus symposium held during the 14th meeting of the International Association of Pancreatology in Fukuoka, Japan, in 2010, the working group has generated new guidelines. Since the levels of evidence for all items addressed in these guidelines are low, being 4 or 5, we still have to designate them "consensus", rather than "evidence-based", guidelines. To simplify the entire guidelines, we have adopted a statement format that differs from the 2006 guidelines, although the headings are similar to the previous guidelines, i.e., classification, investigation, indications for and methods of resection and other treatments, histological aspects, and methods of follow-up. The present guidelines include recent information and recommendations based on our current understanding, and highlight issues that remain controversial and areas where further research is required.

Comparison of efficacy of enucleation and pancreaticoduodenectomy for small (<3 cm) branch duct type intraductal papillary mucinous neoplasm located at the head of pancreas and the uncinate process

PURPOSE

Accurate indications and the extent of surgery for branch duct intraductal papillary mucinous neoplasm (IPMN) of the pancreas are still debatable. In particular, small tumor is located at the head portion of pancreas presents a dilemma. The purpose of this study is to compare the efficacy of enucleation (EN) with that of pancreaticoduodenectomy (PD) in patients with small (2 cm<size<3 cm) branch duct IPMN located at the head of pancreas or uncinate process.

MATERIALS AND METHODS

Among 155 patients who underwent pancreatic surgery due to pancreatic cystic tumors between January 2000 and December 2007 at Yonsei University Health System in Seoul, Korea, 14 patients with small (2 cm<size<3 cm) branch duct IPMN located at the head of pancreas or uncinate process were included in this study. Ten patients underwent PD, and four patients underwent EN. We compared short term surgical outcomes between the two groups. Correlation of the variables was analyzed using Mann-Whitney test and Fisher's exact test (SPSS Window 12.0). p-values less than 0.05 were considered significant.

RESULTS

The average age was 62.21 years (±6.71 years) and consisted of 8 men and 6 women. The mean operation time and blood loss were significantly lower in EN group. There were no significant differences in other surgical morbidities.

CONCLUSION

The result suggests that enucleation for small branch duct IPMN located at the head of pancreas or uncinate process is feasible and as safe as PD, despite a high rate of minor complications.

Mucinous cystic neoplasms of the pancreas: definition of preoperative imaging criteria for high-risk lesions

BACKGROUND/AIM

Pancreatic mucinous cystic neoplasms (MCN) are premalignant lesions whose natural history is poorly known. Whether the dysplasia grade might be determined with precision by preoperative clinical and imaging criteria is not known. We aimed to determine if CT scan data might be useful to predict the grade of dysplasia in a series of 60 histologically proven MCN.

METHODS

All consecutive patients who were operated on with pathological confirmation of MCN were included. Careful CT scan evaluation was reviewed without knowledge of pathological results. Imaging and pathological results were correlated.

RESULTS

Sixty patients (59 females) were included. Low- and intermediate-grade dysplasias were identified in 47 and 3 patients (benign MCN), respectively, and high-grade dysplasia and invasive carcinoma in 7 and 3 patients (malignant MCN), respectively. Patients with benign lesions were significantly younger. None of the studied clinical data were statistically different to distinguish benign and malignant MCN, except age (42 vs. 48 years, p < 0.05). Only maximal diameter and mural nodules on CT scan were significantly more frequent in the malignant group. No malignant MCN had a maximal diameter <40 mm. At a 40-mm threshold, the sensitivity and specificity of the maximal diameter to diagnose malignant MCN were 100 and 54%, respectively. Mural nodules seen on CT scan were confirmed in all cases but one upon pathological examination of the surgical specimen. The sensitivity and specificity of the presence of a mural nodule seen on CT scan for the diagnosis of a malignant lesion were 100 and 98%, respectively.

CONCLUSION

Preoperative CT scan detection of a mural nodule within a cystic pancreatic neoplasm suggestive of MCN strongly suggests malignancy. A diameter <40 mm is associated with no risk of malignancy.

New trends in diffusion-weighted magnetic resonance imaging as a tool in differentiation of serous cystadenoma and mucinous cystic tumor: a prospective study

BACKGROUND/AIMS

Pancreatic cystic lesions are increasingly being recognized. Magnetic resonance imaging (MRI) is the method that brings the greatest amount of information about the morphologic features of pancreatic cystic lesions. To establish if diffusion-weighted MRI (DW-MRI) can be used as a tool to differentiate mucinous from nonmucinous lesions.

METHODS

Fifty-six patients with pancreatic cystic lesions (benign, n = 46; malignant, n = 10) were prospectively evaluated with DW-MRI in order to differentiate mucinous from nonmucinous lesions. Final diagnosis was obtained by follow-up (n = 31), surgery (n = 16) or endoscopic ultrasound-guided fine needle aspiration (n = 9). Serous cystadenoma was identified in 32 (57%) patients.

RESULTS

The threshold value established for the differentiation of mucinous from nonmucinous lesions was 2,230.06 s/mm(2) for ADC of 700. DWI-MRI behavior between mucinous and nonmucinous groups revealed sensitivity, specificity, positive predictive value, negative predictive value and accuracy to be 80, 98, 92, 93 and 93%, respectively (p < 0.01, power of sample = 1.0). In the comparison of the diffusion behavior between mucinous (n = 13) and serous (n = 32) lesions, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100, 97, 92, 100 and 98%, respectively (p < 0.01, power of sample = 1.0). The results of endoscopic ultrasound-guided fine needle aspiration were similar to those of DW-MRI.

CONCLUSIONS

DW-MRI can be included as part of the array of tools to differentiate mucinous from nonmucinous lesions and can help in the management of pancreatic cystic lesions. and IAP.

Side-branch intraductal papillary mucinous neoplasms of the pancreatic head/uncinate: resection or enucleation?

INTRODUCTION

Side-branch intraductal papillary mucinous neoplasms (IPMN) of the pancreatic head/uncinate are an increasingly common indication for pancreaticoduodenectomy (PD). However, enucleation (EN) may be an alternative to PD in selected patients to improve outcomes and preserve pancreatic parenchyma.

AIM

To determine peri-operative outcomes in patients with side-branch IPMN of the pancreatic head/uncinate undergoing EN or PD compared with a cohort of patients with pancreatic adenocarcinoma (PA) undergoing PD.

METHODS

Retrospective review of a prospectively collected, combined, academic institutional series from 2005 to 2008. Of 107 pancreatic head/uncinate IPMN, enucleation was performed in 7 (IPMN EN) and PD was performed in 100 (IPMN PD) with 17 of these radiographically amenable to EN (IPMN PD(en) ). During the same time period, 281 patients underwent PD for PA (Control PD).

RESULTS

Operative time was shorter (p<0.05) and blood loss (p<0.05) was less in the IPMN EN group compared with all other groups. Peri-operative mortality and morbidity of all IPMN groups (IPMN EN, IPMN PD(en) ) were similar to the Control PD group. Overall pancreatic fistulae rate in the IPMN EN group was higher than in the IPMN PD(en) and Control PD groups; however, the rate of grade C pancreatic fistulae was the same in all groups.

CONCLUSIONS

Pancreaticoduodenectomy for side-branch IPMNs can be performed safely. Compared with PD, enucleation for IPMN has less blood loss, shorter operative time and similar morbidity, mortality, hospital length of stay (LOS) and readmission rate. Enucleation should be considered more frequently as an option for patients with unifocal side-branch IPMN.