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

Laparoscopic pancreatic enucleation: how far should we go for parenchyma preservation? A study by the French National Association of Surgery

BACKGROUND

Pancreatic enucleation is indicated for selected patients and tumours with very low oncological risk to preserve a maximum of healthy pancreatic parenchyma. Minimally invasive pancreatic enucleation (MIPE) is increasingly performed. This study aims to assess the impact of tumor location and center experience on textbook outcomes (TBO) in patients undergoing MIPE.

METHODS

Retrospective nationwide multicentric cohort study including MIPE performed between 2010 and 2021. Tumor localization was classified as head/uncus, neck or body/tail (results are presented in this order). Centers were classified according to a mean volume of MI pancreatectomies performed per year: lower (< 5/year), intermediate (5 to 10/year) and higher volume (≥ 10/year). TBO was defined as meeting all 6 criteria: no postoperative pancreatic fistula (POPF), no post-pancreatectomy haemorrhage (PPH), no bile leak, no readmission, no mortality, and no severe morbidity.

RESULTS

27 participating centers performed 200 MIPE located in head/uncus (n = 65, 33%), neck (n = 26, 13%) and body/tail (n = 109, 55%), 8% of them performed by robotic approach. Mortality reached 1.5% (n = 3). Head/uncus lesions were larger (p = 0.03), frequently BD-IPMN (p = 0.04), with significant longer operative time (p = 0.002). TBO achievement was high across all tumor locations (52 vs. 73 vs. 67%, p = 0.09) with higher PPH (p = 0.03) or bile leaks (p = 0.03) for head/uncus lesions. In multivariate analysis, overweight (OR 0.49), preoperative biopsy (OR 0.41) and head/uncus lesion (OR 0.34) were independently associated with lower TBO. No independent risk factor was found for POPF or severe morbidity. While expertise level influenced indications, with more cystic lesions (p = 0.002), larger tumors (p = 0.003), 3D use (p = 0.001), and head/uncus lesions (p = 0.04) in high volume centers, TBO was not significantly different (p = 0.45).

CONCLUSIONS

MIPE is feasible with 1.5% mortality whatever its localization with higher morbidity for head/uncus lesions, justified by the will to avoid pancreaticoduodenectomy. High volume centers push the limits of MIPE without increasing morbidity.

Repeated Minimally Invasive Pancreatectomy for Intraductal Papillary Mucinous Neoplasm in the Remnant Pancreas: A Case Report

BACKGROUND Minimally invasive pancreatectomy has become the standard practice for the management of benign and malignant pancreatic tumors. Techniques such as robotic and laparoscopic approaches are known to reduce morbidity by offering benefits such as less blood loss, reduced pain, shorter hospital stays, and quicker recovery times. The indication for repeated minimally invasive pancreatectomy for recurrent or de novo pancreatic neoplasm after primary pancreatic surgery remains debated. CASE REPORT A 50-year-old woman was admitted to our hospital with a diagnosis of an intraductal papillary mucinous neoplasm in the pancreatic head. In 2010, she underwent laparoscopic single-branch resection for a branch-type tumor in the pancreatic uncinate process. During a 5-year follow-up, a de novo intraductal papillary mucinous neoplasm was detected, showing gradual growth and the presence of a mural nodule over the next 7 years. The patient's CEA level was elevated to 7.0 ng/mL. Considering the tumor's progression and the appearance of a mural nodule, we recommended a robot-assisted Whipple procedure. The operation began with laparoscopic adhesiolysis. After detachment of the adhesions and remobilization of the duodenum using the Kocher maneuver, the operation continued with the Da Vinci surgical system. The postoperative period was uneventful, and the patient was discharged on postoperative day 20. Pathological examination revealed intraductal papillary mucinous carcinoma in situ with negative resection margins. CONCLUSIONS This case verifies the safety and feasibility of performing a robotic Whipple procedure for a newly diagnosed pancreatic neoplasm in patients who have previously undergone minimally invasive pancreatic surgery.

Robotic enucleation & uncinectomy of complex lesions of the proximal pancreas

BACKGROUND

Malignant tumours within the proximal pancreas traditionally require pancreaticoduodenectomy (PD) for cure. For smaller lesions with borderline malignant potential the risk/benefit of PD becomes difficult to justify. Robotic approaches to these lesions allow for parenchymal preserving resection with reduced complication profile without oncological compromise.

METHODS

A review of a single surgeons prospectively collated database across two institutions of consecutive robotic enucleations or parenchyma preserving resections of the proximal pancreas was performed between July 2018 and October 2021. Standard demographic data, preoperative variables, intraoperative parameters, post-operative outcomes, morbidity and mortality were recorded.

RESULTS

Thirteen patients (8 female and 5 male) underwent robotic enucleation (EN) (8) and/or uncinectomy (UN) (5) in the proximal pancreas. Mean BMI was 32(kg/m2 ). Three patients (21%) underwent preoperative prophylactic pancreatic duct stenting. One patient required conversion to open. The median operative time in the EN group was 170 min (108-224 min) and the UN group was 160 min (110-204 min). The majority (8) of lesions were pNETs. Three lesions were IPMNs, with 1 solitary fibrous tumour and a serous cystic neoplasm (SCN) respectively. Median tumour size was 23 mm (11-58 mm) in the EN group, and 27 mm (17-38 mm) in the UN group. Ten of 13 patients had an R0 resection. There was no mortality in our series. Four (31%) patients across both groups developed clinically relevant POPF while none developed new endocrine or exocrine insufficiency. Average outpatient follow-up has been 6 months (1-18 months).

CONCLUSION

A robotic approach in proximal parenchymal preserving pancreatectomy is expanding, safe and feasible.

Do Patients Benefit from Micronutrient Supplementation following Pancreatico-Duodenectomy?

Pancreatico-duodenectomy (PD) includes resection of the duodenum and use of the proximal jejunum in a blind loop, thus reducing the absorptive capacity for vitamins and minerals. Several studies have analysed the frequency of micronutrient deficiencies, but there is a paucity of data on those taking routine supplements. A retrospective review of medical notes was undertaken on 548 patients under long-term follow-up following PD in a tertiary hepato-pancreatico-biliary centre. Data were available on 205 patients from 1-14 years following PD, and deficiencies were identified as follows: vitamin A (3%), vitamin D (46%), vitamin E (2%), iron (42%), iron-deficiency anaemia (21%), selenium (3%), magnesium (6%), copper (1%), and zinc (44%). Elevated parathyroid hormone was present in 11% of cases. There was no significant difference over time (p > 0.05). Routine supplementation with a vitamin and mineral supplement did appear to reduce the incidence of biochemical deficiency in vitamin A, vitamin E, and selenium compared to published data. However, iron, vitamin D, and zinc deficiencies were prevalent despite supplementation and require surveillance.

Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003-2021

Middle segment-preserving pancreatectomy (MPP) can treat multilocular diseases in the pancreatic head and tail while avoiding impairments caused by total pancreatectomy (TP). We conducted a systematic literature review of MPP cases and collected individual patient data (IPD). MPP patients (N = 29) were analyzed and compared to a group of TP patients (N = 14) in terms of clinical baseline characteristics, intraoperative course, and postoperative outcomes. We also conducted a limited survival analysis following MPP. Pancreatic functionality was better preserved following MPP than TP, as new-onset diabetes and exocrine insufficiency each occurred in 29% of MPP patients compared to near-ubiquitous prevalence among TP patients. Nevertheless, POPF Grade B occurred in 54% of MPP patients, a complication avoidable with TP. Longer pancreatic remnants were a prognostic indicator for shorter and less eventful hospital stays with fewer complications, whereas complications of endocrine functionality were associated with older patients. Long-term survival prospects after MPP appeared strong (median up to 110 months), but survival was lower in cases with recurring malignancies and metastases (median < 40 months). This study demonstrates MPP is a feasible treatment alternative to TP for selected cases because it can avoid pancreoprivic impairments, but at the risk of perioperative morbidity.

Enucleation for low-grade branch duct intraductal papillary mucinous neoplasms: Long-term follow-up

BACKGROUND

Pancreatic enucleation allows resection of branch-duct intraductal papillary mucinous neoplasms with full parenchyma preservation. The aim of this study was to assess intraductal papillary mucinous neoplasms recurrence and functional outcomes during long-term follow-up after enucleation.

METHODS

Patient characteristics, as well as radiologic and clinicopathologic follow-up data of patients who underwent enucleation for branch-duct intraductal papillary mucinous neoplasms between 2004 and 2014, were analyzed. Quality of life was assessed using the EORTC QLQ-C30 and QLQ-PAN26 questionnaires.

RESULTS

Seventy-four patients underwent enucleation for low-grade branch-duct intraductal papillary mucinous neoplasms in 71 and high-grade branch-duct intraductal papillary mucinous neoplasms in 3 patients. Long-term follow-up data were available for 66 patients (89%; median follow-up: 87 months). Radiologic imaging (n = 56) showed intraductal papillary mucinous neoplasm recurrence in 10 patients (18%) including local recurrence at the site of enucleation in 3 patients (5%) and new onset intraductal papillary mucinous neoplasms manifestation in 7 patients (13%) at a distant site in the pancreatic remnant. Four patients (6%) underwent reoperation. Two of these patients had intraductal papillary mucinous neoplasm-associated carcinoma, one of them at the enucleation site. During the follow-up period, no intraductal papillary mucinous neoplasm-related deaths occurred and no new onsets of insulin-dependent diabetes mellitus were observed. QLQ-C30 revealed a global health status of 66.0% and overall functioning and symptom scores of 81.0% and 22.8%, respectively. Additionally, QLQ-PAN26 showed an overall symptom score of 26.5%.

CONCLUSION

Enucleation is an organ-preserving surgical treatment option for low-grade branch-duct intraductal papillary mucinous neoplasms with low local recurrence risk and excellent functional long-term outcome. However, postoperative life-long follow-up must be performed as for any type of partial pancreatectomy for intraductal papillary mucinous neoplasms due to the risk of recurrence and potential malignancy.

Resektionsstrategien beim BD-IPMN - Enukleation oder onkologische Resektion?

Hintergrund Das maligne Potenzial und die chirurgische Behandlung intraduktaler papillärer muzinöser Neoplasien der Seitengänge der Bauchspeicheldrüse (BD-IPMNs) bleiben umstritten. Die Enukleation (EN) als parenchymsparende Resektion des Pankreas kann eine wertvolle Alternative zu Standardresektionen (SR), z. B. Whipple oder distale Pankreatektomie, für die Behandlung von BD-IPMNs darstellen, ihre Rolle ist jedoch noch unzureichend definiert. Ziel dieser Übersichtsarbeit ist es, Indikationen und postoperative Ergebnisse nach Pankreas-Enukleation im Vergleich zur Standardresektion (SR) zu vergleichen.

Methoden Es wurde eine selektive Literaturrecherche durchgeführt. Die postoperativen Kurz- und Langzeitergebnisse beider Operationsverfahren wurden ausgewertet.

Ergebnisse Die EN ist im Vergleich zur SR mit einer kürzeren Operationszeit und einem geringeren Blutverlust verbunden. Die chirurgische Gesamtmorbidität unterscheidet sich nicht zwischen den beiden Verfahren. Obwohl die EN weniger invasiv ist, stellt die Entwicklung einer Pankreasfistel die häufigste Komplikation nach EN dar, und in mehreren Studien wird über eine höhere Rate an Pankreasfisteln nach EN als nach SR berichtet. Die Unterschiede, bezogen auf die Pankreasfistel, werden zwischen den beiden Verfahren in High-Volume-Zentren abgemildert. Die EN ermöglicht im Vergleich zur SR öfter den Erhalt der exokrinen und endokrinen Funktion der Bauchspeicheldrüse, dies ist der wichtigste Vorteil dieses Verfahrens.

Schlussfolgerungen Die EN scheint eine sichere und wirksame Alternative in der Behandlung der Seitengang-IPMN mit geringem Risiko zu sein, die den Erhalt der endokrinen und exokrinen Funktion ermöglicht. Außerdem sind die postoperativen Komplikationen und Rezidivraten nach EN vergleichbar mit den wesentlich umfangreicheren chirurgischen Verfahren. Die EN der Bauchspeicheldrüse sollte jedoch von erfahrenen Chirurgen durchgeführt werden. Da es sich um ein nicht onkologisches Verfahren handelt, muss die Auswahl der Patienten sehr genau erfolgen, was die Bedeutung der Behandlung in Einrichtungen mit hohem Patientenaufkommen unterstreicht.

Surgical exploration without resection in pancreatic and periampullary tumors: Report from a national database

Background and objective:

Pancreatic and periampullary cancers are sometimes found to have a too advanced disease during surgery to allow resection. The aim was to describe characteristics, treatment, outcome, and time trends for patients that were planned for pancreatic surgery but found unresectable during surgery.

Methods:

Data from the Swedish National Pancreatic and Periampullary Cancer Registry were used. All patients registered between January 2010 and August 2018 were included. The patient cohort was divided in two halves based on year of diagnosis.

Results:

In total, 12,377 patients were included in the registry and finally 4568 patients were scheduled for surgery. During surgical exploration, 3879 (84.9%) patients underwent pancreatic resection, 658 (14.4%) patients were found unresectable, and 31 (0.7%) had no pancreatic resection due to other reasons (e.g. benign lesion, comorbidity). More patients underwent surgical exploration and resection during the second time period, but exploration without resection was unchanged (15.7% vs 13.7%; p = 0.062). Survival rates were lower among the unresectable patients with pancreatic and periampullary tumors compared to the resectable patients, including 30-day mortality (n = 17 (3.5%) vs n = 39 (1.6%), p = 0.004) and 90-day mortality (n = 72 (15.0%) vs n = 70 (2.8%), p < 0.001). Palliative surgery became less common during the second half of the time period (p < 0.001).

Conclusions:

Unresectability is associated with an unfavorable prognosis. The frequency did not decrease during the study period, but palliative surgical procedures became less common.

Enucleation for branch duct intraductal papillary mucinous neoplasms: a systematic review and meta-analysis

BACKGROUND

The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN and compare it with pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy and central pancreatectomy).

METHODS

A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases.

RESULTS

Sixteen studies were included in the final analysis comprising 991 patients with 293 EN patients and 698 resected patients. EN was most often performed for low grade (77%, 151/197) BD-IPMN's (99%, 251/253) of the pancreatic head (64%, 106/165), with a pooled mean diameter of 21 mm (SD 28 mm). EN was a shorter procedure (MD -115.8 min, CI -142.2 to -89.5 min, P=<0.001) with a lower rate of post-pancreatectomy haemorrhage (EN 1% 2/144, Resection 5% 10/186, RR 0.32, CI 0.11 to 0.94, P = 0.043) and postoperative exocrine and endocrine insufficiency (P = <0.001 and P = 0.003 respectively) than resection.

CONCLUSION

EN for BD-IPMN's appears to be a reasonable alternative to resection in low risk BD-IPMN's, allowing preservation of exocrine and endocrine function with comparable reoperation and recurrence rates to resection. However, surveillance was indicated in these low risk patients based on current published guidelines.

Does surgical approach affect outcomes of enucleation for benign and low-grade pancreatic tumors? An ACS-NSQIP evaluation

BACKGROUND

Enucleation of low-grade pancreatic tumors achieves oncological outcomes equivalent to resection but conserves parenchyma. Given strict selection criteria, we hypothesized that minimally-invasive (MI) enucleation is associated with decreased composite major morbidity (CMM) compared to open.

METHODS

Pancreas-targeted ACS NSQIP (2014 -2016) was queried for enucleation (CPT code: 48120) and analyzed by intended surgical approach regardless of conversion. The primary outcome was CMM, a validated 30-day composite metric of adverse events.

RESULTS

Enucleation was performed using an open (n = 71; 62.3%) or MI (n = 43; 37.7%) approach with 7 conversions (16.2%). Both cohorts had interchangeable baseline characteristics. No selection factors governing MI were identified. MI-enucleation reduced median length of stay (4 vs. 5 days; p = 0.003), whereas rates of CMM after open (24; 34%) and MIenucleation (12; 28%) were equivalent (p = 0.541). Multivariable analysis demonstrated an association between CMM and prolonged operative time (OR 2.7, 95% CI 1.14 -6.74), female sex (OR 0.38, 95% CI 0.16 -0.94), and ASA score <3 (OR 0.39, 95% CI 0.16 -0.96) but not surgical approach.

CONCLUSION

MI-enucleation was not associated with reduced 30-day CMM compared to open, whereas prolonged operating time and unmodifiable patient factors were correlated with adverse outcomes.

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.

First results from the Swedish National Pancreatic and Periampullary Cancer Registry

BACKGROUND

Despite improvements in therapy regimens over the past decades, overall survival rates for pancreatic and periampullary cancer are poor. Specific cancer registries are set up in various nations to regional differences and to enable larger prospective trials. The aim of this study was to describe the Swedish register, including possibilities to improve diagnostic work-ups, treatment, and follow-up by means of the register.

METHODS

Since 2010, all patients with pancreatic and periampullary cancer (including also patients who have undergone pancreatic surgery due to premalignant or benign lesions) have been registered in the Swedish National Periampullary and Pancreatic Cancer registry.

RESULTS

In total 9887 patients are listed in the registry; 8207 of those have malignant periampullary cancer. Approximately one-third (3282 patients) have had resections performed, including benign/premalignant resections. 30-day and 90-day mortality after pancreatoduodenectomy is 1.5% and 3.5%, respectively. The overall 3-year survival for resected pancreatic ductal adenocarcinoma is 35%. Regional variations decreased over the studied period, but still exist.

CONCLUSION

Results from the Swedish National Registry are satisfactory and comparable to international standards. Trends over time show increasing resection rates and some improved results. Better collaboration and openness within pancreatic surgeons is an important side effect.

Intraductal papillary mucinous neoplasms of the pancreas: a clinical challenge

The incidental detection rate of intraductal papillary mucinous neoplasms (IPMNs) has significantly increased. However, little is known about the natural history of these tumors. Their optimal management and appropriate follow-up are still unclear. We have, therefore, reviewed the available literature on IPMN focusing on their diagnosis, treatment according to the risk of malignant transformation, and follow-up. Areas covered: Bibliographical searches were performed in PubMed for the terms 'intraductal papillary mucinous neoplasm' and 'natural history' and 'diagnosis' and 'treatment' and 'surgery' and 'follow-up' and 'prognosis.' PubMed was used to search for all the relevant articles published over the last 10 years. A total of 7244 records were identified. After filtering for year range, English language, human studies, article types, and removing duplicates, 74 articles were left with the strongest level of evidence. Expert commentary: Available guidelines for IPMN management are mainly based on expert opinions and may lack strong evidence. Further studies are warranted to better predict the risk of recurrence/future malignancy and to establish standardized guidelines. IPMNs management should be based on multidisciplinary discussion and treatment should be tailored to an individual patient according to patient and tumor characteristics.

A pancreatic zone at higher risk of fistula after enucleation

Background

To determine predictive factors of postoperative pancreatic fistula (POPF) in patients undergoing enucleation (EN).

Methods

From 2005 to 2017, 47 patients underwent EN and had magnetic resonance imaging available for precise analysis of tumor location. Three pancreatic zones were delimited by the right side of the portal vein and the main pancreatic head duct (zone #3 comprising the lower head parenchyma and the uncinate process).

Results

The mortality and morbidity rates were 0% and 62%, respectively. POPF occurred in 23 patients (49%) and was graded as B or C (severe) in 15 patients (32%). Four patients (8.5%) developed a postoperative hemorrhage, and 5 patients (11%) needed a reintervention. In univariate and multivariate analyses, the pancreatic zone was the unique predictive factor of overall (P = .048) or severe POPF (P = .05). We did not observe any difference in postoperative courses when comparing the EN achieved in zones #1 and #2. We noted a longer operative duration (P = .016), higher overall (P = .017) and severe POPF (P = .01) rates, and longer hospital stays (P = .04) when comparing the EN achieved in zone #3 versus that in zones #1 and #2. Patients who underwent EN in zone #3 had a relative risk of developing a severe POPF of 3.22 compared with patients who underwent EN in the two other pancreatic zones.

Conclusion

Our study identifies the lower head parenchyma and the uncinate process as a high-risk zone of severe POPF after EN. Patients with planned EN in this zone could be selected and benefit from preoperative and/or intraoperative techniques to reduce the severe POPF rate.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1476-5) contains supplementary material, which is available to authorized users.

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.

Fukuoka-Negative Branch-Duct IPMNs: When to Worry? A Study from the French Surgical Association (AFC)

BACKGROUND

This study analyzed the pathologic findings for patients with Fukuoka-negative branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) who theoretically were eligible for surveillance care with follow-up assessment, but instead underwent resection.

METHODS

From January 2005 to December 2012, 820 patients underwent evaluation for IPMN. At initial staging, 319 patients had BD-IPMN, and 89 of these patients presented with Fukuoka-negative criteria. These 89 patients were included in this study.

RESULTS

Of the 89 patients, 55 (62%) underwent pancreatectomy. After pathologic examination, the ultimate diagnosis was MT-IPMN for 20 (36%) of these patients (the MT group) and BD-IPMN for 35 (64%) of these patients (the BD group). The remaining 34 patients (38%) underwent enucleation. The patients in the MT group were more likely to be male (P = 0.01) and to have a higher rate of recent (< 1 year) diabetes mellitus diagnosis (P = 0.007) than the patients in the BD group. In the multivariate analysis, diabetes mellitus was independently associated with involvement of the main pancreatic duct (P = 0.05). Malignancy was diagnosed for 14 (16%) of the 89 patients. The rate of invasive IPMN was higher in the MT group than in the BD group (20% vs. 0%, P = 0.02). The 5-year overall survival rate was 100% for the BD group and 84% for the MT group (P = 0.02). For the male patients with diabetes mellitus, the rate of malignancy rose to 67%.

CONCLUSIONS

For patients with a diagnosis of Fukuoka-negative BD-IPMN, resection should be considered primarily for male patients with a recent diabetes mellitus diagnosis.

[Laparoscopic pancreatic resection]

INTRODUCTION AND PURPOSE

Despite being technically challenging, laparoscopic surgical procedures are increasingly being used also in pancreatic surgery. This review attempts to evaluate these procedures based on the currently available literature against the background of the high mortality of pancreatic surgery observed nationwide and the as yet unclear oncological validation of these procedures.

MATERIAL AND METHODS

Recently published retrospective cohort and register trials have evaluated not only perioperative outcome but also long-term survival after laparoscopic pancreatic resection.

RESULTS AND CONCLUSION

Laparoscopic interventions are increasingly being used for treatment of malignant tumors of the pancreas. The advantages of laparoscopy, such as less intraoperative blood loss, reduced postoperative pain and a shorter duration of hospital stay, have all been demonstrated in retrospective trials. Equivalent long-term survival after oncological laparoscopic pancreatic surgery compared to open procedures was also observed in these trials; however, mortality even after laparoscopic pancreatic surgery was found to be significantly increased in low-volume centers. Prospective trials are still needed to prove adequate oncological treatment. Laparoskopische Verfahren haben sich in den letzten Jahren in fast allen Bereichen der Chirurgie quasi zum Standard entwickelt und werden von Patienten zunehmend nachgefragt. Die kosmetischen Ergebnisse sind deutlich besser als bei konventionellem Vorgehen und sie reduzieren unter anderem den postoperativen Schmerz, Schmerzmittelbedarf sowie den Krankenhausaufenthalt [29]. Daher ist es wenig überraschend, dass minimal-invasive Verfahren auch bei technisch hochkomplexen Eingriffen, wie z. B. am Pankreas, zunehmend eingesetzt werden. Allerdings wird ihr Einsatz hier noch immer kontrovers diskutiert.

Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms

BACKGROUND

Small, asymptomatic, branch-duct intraductal papillary mucinous neoplasms of the pancreas are often kept under surveillance despite their malignant potential. The management of branch-duct intraductal papillary mucinous neoplasm is controversial with regard to indications and extent of any operative intervention. The present study aimed to evaluate enucleation as an alternative operative approach for branch-duct intraductal papillary mucinous neoplasms to exclude and prevent malignancy.

METHODS

For branch-duct intraductal papillary mucinous neoplasms of <30 mm in diameter and an acceptable distance from the main pancreatic duct, enucleation was considered as the operative approach of choice. All patients scheduled for enucleation of branch-duct intraductal papillary mucinous neoplasm on the basis of these features between January 2004 and September 2014 were analyzed. Among these, patients with successful enucleation were compared with those who were scheduled for enucleation but converted intraoperatively to pancreatic resection (intention-to-treat analysis). End points were hospital morbidity and mortality as well as histopathology and functional outcome at a mean follow-up of 32 months.

RESULTS

In the study, 115 patients with presumed branch-duct intraductal papillary mucinous neoplasm and the intention to perform pancreatic enucleation were included; 87 enucleations were performed in 74 patients. In 41 patients, enucleation was converted to a pancreatic resection (procedure-specific success rate 64%); indications for conversion included location or size (46%), presence of multicystic lesions (39%), or involvement of the main pancreatic duct (15%). Of the 74 patients with enucleation, 64 branch-duct intraductal papillary mucinous neoplasms revealed low- (85%), 11% moderate dysplasia-, and 4% high-grade dysplasia on histology. Among converted resections, 6 intraductal papillary mucinous neoplasms revealed high-grade dysplasia or invasive carcinoma (15%). Intention-to-treat analysis with patients converted to pancreatic resection showed that enucleations resulted in less blood loss (100 vs 400 mL) and a shorter operation time (146 vs 255 minutes; P < .001 each). Postoperative morbidity including postoperative pancreatic fistula was similar in both groups. No mortality occurred after enucleation; after formal resection, 1 patient died due to multiorgan failure. Both hospital stay (10 vs 14 days) and rates of postoperative endocrine and exocrine dysfunction rates were less after enucleation (P < .02 each). Intraductal papillary mucinous neoplasm-specific recurrence rates (3% vs 6%) were similar in both groups.

CONCLUSION

Enucleation is a safe procedure that can be performed successfully in a high proportion of branch-duct intraductal papillary mucinous neoplasms and should be considered instead of standard resections as an important function-preserving alternative. Limitations may occur due to malignancy, size, localization, multilocularity, or main-duct involvement requiring conversion to a formal, anatomic resection. Beside the advantages in the short-term course, functional outcome seems to be superior after enucleation, and intraductal papillary mucinous neoplasm-specific recurrence rates are not increased compared with standard resections, at least at a mean follow-up of 32 months.

Treatment of branch-duct intraductal papillary mucinous neoplasms of the pancreas: state of the art

The diagnosis of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) has been dramatically increased. BD-IPMNs are frequently discovered as incidental findings in asymptomatic individuals, mainly in elderly patients. An accurate evaluation of BD-IPMNs with high-resolution imaging techniques and endoscopic ultrasound is necessary. Patients with high-risk stigmata (HRS, obstructive jaundice, enhanced solid component) should undergo resection. Patients with worrisome features (WF, cyst size ≥3 cm, thickened enhanced cyst walls, non-enhanced mural nodules, and clinical acute pancreatitis) may undergo either a strict surveillance based on patients' characteristics (age, comorbidities) or surgical resection. Non-operative management is indicated for BD-IPMNs without HRS and WF. Patients with BD-IPMN who do not undergo resection may develop malignant change over time as well as IPMN-distinct pancreatic cancer. However, non-operative management of BD-IPMNs lacking WF and HRS is safe and the risk of malignant degeneration seems relatively low. The optimal surveillance protocol is currently unclear.

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.

Postoperative sepsis in cancer patients undergoing major elective digestive surgery is associated with increased long-term mortality

BACKGROUND

Major postoperative events (acute respiratory failure, sepsis, and surgical complications) are frequent early after elective gastroesophageal and pancreatic surgery. It is unclear whether these complications impact equally on long-term outcome.

METHODS

Prospective observational study including the patients admitted to the surgical intensive care unit between January 2009 and October 2011 after elective gastroesophageal and pancreatic surgery. Risk factors for 30-day major postoperative events and long-term outcome were evaluated.

RESULTS

During the study period, 259 patients were consecutively included. Among them, 166 (64%), 54 (21%), and 39 (15%) patients underwent pancreatic surgery, gastric surgery, and esophageal surgery, respectively. Using the Clavien-Dindo classification, 117 patients (45%) developed at least 1 postoperative complication, including 60 (23%) patients with acute respiratory failure, 77 (30%) with sepsis, and 89 (34%) with surgical complications. The median follow-up from the time of intensive care unit admission was 34 months (95% confidence interval, 30-37 months). The 1-year survival was 95% (95% confidence interval, 92-98). Among the perioperative variables, postoperative sepsis and an American Society of Anesthesiologists score higher than 2 were independently associated with long-term mortality. In septic patients, death (n = 16) was significantly associated with cancer recurrence (n = 10; P < .0001). Independent factors associated with postoperative sepsis were a Sequential Organ Failure Assessment score on day 1, a systemic inflammatory response syndrome on day 3, positive intraoperative microbiological samples, Simplified Acute Physiology Score II and an American Society of Anesthesiologists score higher than 2 (P < .005).

CONCLUSIONS

Postoperative sepsis was the only major postoperative event associated with long-term mortality. Postoperative sepsis may reflect a deep impairment of immune response, which is potentially associated with cancer recurrence and mortality.

Main- and Branch-Duct Intraductal Papillary Mucinous Neoplasms: Extent of Surgical Resection

Background

Surgical treatment of intraductal papillary mucinous neoplasms (IPMN) requires a differentiated approach regarding indications and extent of resection.

Methods

The review summarizes the current literature on indication, timing, and surgical procedures in IPMN.

Results

The most important differentiation has to be made between main-duct and branch-duct IPMN as well as mixed-type lesions that biologically mimic main-duct types. In main-duct and mixed-type IPMN, the resection should be indicated by the time of the diagnosis – in accordance with the international consensus guidelines – and should follow oncological principles. Depending on IPMN localization, this implies partial pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy and includes the corresponding types of lymphadenectomy. Furthermore, branch-duct IPMN > 3 cm or bearing high-risk features (mural nodules in magnetic resonance imaging, computed tomography, or endoscopic ultrasound imaging; symptomatic lesions; elevated tumor markers) are similarly treated. As the risk for malignancy in smaller branch-duct IPMN is lower, the decision for surgical treatment is often individually made – despite the updated 2012 guidelines. In these lesions, limited surgical approaches, including enucleation and central pancreatectomy, are possible.

Conclusion

Timely and radical resection of IPMN offers the unique opportunity to prevent pancreatic cancer, and even in malignant IPMN surgery can offer a curative approach with excellent long-term outcome in early stages. A structured imaging follow-up should be considered to recognize IPMN recurrence and metachronous pancreatic cancer as well as gastrointestinal neoplasias by endoscopic surveillance.

Emergency management in patients with late hemorrhage after pancreatoduodenectomy for a periampullary tumor

BACKGROUND

The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported.

METHODS

From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients.

RESULTS

Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention.

CONCLUSION

The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.

Laparoscopic Hand-Assisted Parenchymal-Sparing Resections for Presumed Side-Branch Intraductal Papillary Mucinous Neoplasms

BACKGROUND

The diagnosis of side-branch intraductal papillary mucinous neoplasms (IMPNs) is increasingly more common, but their appropriate management is still evolving. We recently began performing laparoscopic hand-assisted enucleation or duodenal-sparing pancreatic head resection for these lesions with vigilant postoperative imaging.

MATERIALS AND METHODS

Seventeen patients with pancreatic cystic lesions were included in this single-center retrospective review from January 1, 2008 to March 30, 2013. Indication for surgical intervention was growth in size of the cyst, symptoms, cyst size >3 cm, and/or presence of a mural nodule. Twelve patients underwent laparoscopic hand-assisted enucleation, and 5 patients underwent laparoscopic hand-assisted pancreatic head resection.

RESULTS

The mean age of patients was 64 years old. The most common presenting symptom was abdominal pain. The indication for surgical intervention was growth in the cyst or symptoms in the majority of patients. Fourteen lesions were in the head/uncinate, two were in the pancreatic body, and one was in the tail. Final pathology was consistent with side-branch IPMN in 13 patients (1 with focal adenocarcinoma). Three patients had serous cysts, and 1 had a mucinous cyst. Three patients developed pancreatic leaks, which were controlled with intraoperative placed drains, whereas 1 patient required additional drain placement. Median time from surgery to latest follow-up imaging is over 2 years. No patients have developed recurrent cysts or adenocarcinoma.

CONCLUSIONS

Duodenal-sparing pancreatic head resection or pancreatic enucleation for patients with presumed side-branch IPMN is a safe and efficacious option, in terms of both operative outcomes and postoperative recurrence risk.

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.

'Peripheric' pancreatic cysts: performance of CT scan, MRI and endoscopy according to final pathological examination

OBJECTIVE

To assess the accuracy of pre-operative staging in patients with peripheral pancreatic cystic neoplasms (pPCNs).

METHODS

From 2005 to 2011, 148 patients underwent a pancreatectomy for pPCNs. The pre-operative examination methods of computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) were compared for their ability to predict the suggested diagnosis accurately, and the definitive diagnosis was affirmed by pathological examination.

RESULTS

A mural nodule was detected in 34 patients (23%): only 1 patient (3%) had an invasive pPCN at the final histological examination. A biopsy was performed in 79 patients (53%) during EUS: in 55 patients (70%), the biopsy could not conclude a diagnosis; the biopsy provided the correct and wrong diagnosis in 19 patients (24%) and 5 patients (6%), respectively. A correct diagnosis was affirmed by CT, EUS and pancreatic MRI in 60 (41%), 103 (74%) and 80 (86%) patients (when comparing EUS and MRI; P = 0.03), respectively. The positive predictive values (PPVs) of CT, EUS and MRI were 70%, 75% and 87%, respectively.

CONCLUSIONS

Pancreatic MRI appears to be the most appropriate examination to diagnose pPCNs accurately. EUS alone had a poor PPV. Mural nodules in a PCN should not be considered an indisputable sign of pPCN invasiveness.

The changing spectrum of surgically treated cystic neoplasms of the pancreas

Introduction. While the incidence of pancreatic cystic lesions has steadily increased, we sought to evaluate the changes in their surgical management. Methods. Patients with pancreatic cystic lesions who underwent surgical resection from 2003 to 2013 were identified. Clinicopathologic factors were analyzed and compared to a similar cohort from 1992 to 2002. Results. There were 134 patients with pancreatic cystic lesions who underwent surgical resection from 2003 to 2013, compared to 73 from 1992 to 2002. The most common preoperative imaging was a CT scan, although 66% underwent EUS and 63% underwent biopsy. Pathology included 18 serous, 47 mucinous, 11 pseudopapillary, and 58 intraductal papillary mucinous neoplasms (IPMN). In comparing cohorts, there were significantly fewer serous lesions and more IPMN. Postoperative complication rates were similar, and perioperative mortality rates were comparable. Conclusion. There has been a dramatic change in surgically treated pancreatic cystic tumors over the past two decades. Our data suggests that the incorporation of new imaging and diagnostic tests has led to greater detection of cystic tumors and a decreased rate of potentially unnecessary resections. Therefore, all patients with cystic pancreatic lesions should undergo a focused CT-pancreas, and an EUS biopsy should be considered, in order to best select those that would benefit from surgical resection.

Intraductal papillary mucinous neoplasm: clinical surveillance and management decisions

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively rare cystic neoplasm. Although most IPMNs appear to be benign and may be managed by surveillance, all IPMNs are considered premalignant lesions with malignant potential. As such, current efforts are focused on identifying those neoplasms that are at high risk for malignancy to optimize treatment strategy and outcome. IPMNs with invasive carcinoma have clinical outcomes that approach those of conventional pancreatic ductal adenocarcinoma. Management guidelines recommend surgical resection for IPMNs with high-risk imaging or cytologic features. The role of adjuvant therapy is unclear, and we review the evidence for chemoradiation here. Some studies suggest adjuvant chemoradiation may have the greatest impact in malignant IPMNs with adverse histologic features, that is, lymph node metastasis at the time of diagnosis or positive surgical margins. As more IPMNs are recognized and treated, more evidence will accumulate to guide clinicians regarding appropriate use of radiotherapy in the management of IPMN.

[Minimally invasive pancreatic tumor surgery : oncological safety and surgical feasibility]

INTRODUCTION AND PURPOSE

Despite being technically challenging, minimally-invasive pancreatic surgery is increasingly being used to treat pancreatic diseases. Therefore, the evaluation of its oncological safety and its advantages arebecoming increasingly more important. This review focuses on these questions based on the currently available literature.

MATERIAL AND METHODS

The technically less demanding laparoscopic distal pancreatectomy has been evaluated in numerous meta-analyses. Minimally invasive pancreaticoduodenectomy has only been reported from a few centers worldwide.

RESULTS AND CONCLUSION

Minimally invasive pancreatic surgery, in particular laparoscopic distal pancreatectomy, is increasingly being used to treat pancreatic tumors. The advantages of laparoscopy, such as less intraoperative blood loss, reduced postoperative pain and a shorter length of stay have all been demonstrated in large trials. However, a sufficient oncological treatment was only assessed via indirect surrogate parameters, such as the number of lymph nodes obtained and R0 resection rates; therefore, larger prospective trials are needed to prove adequate oncological treatment. To date, minimally invasive techniques should only be employed in trials on treatment of pancreatic malignancies.

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.

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.

Use and results of consensus definitions in pancreatic surgery: a systematic review

BACKGROUND

Because of the lack of standardized definitions of complications in gastrointestinal operations, consensus definitions have been developed in recent years. The aim of the current study was to systematically review the available consensus definitions and to report their use, acceptance, and results.

METHODS

A systematic search of the literature was conducted of the Medline, Cochrane, and ISI Web of Science databases. All articles published until August 2011 and that applied the identified consensus definitions were considered. Inclusion criteria for quantitative analysis were studies with correct usage of the definition and 100 or more patients who were treated after the year 2000.

RESULTS

Seven consensus definitions were identified: postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, posthepatectomy liver failure, bile leakage after hepatobiliary and pancreatic surgery, posthepatectomy hemorrhage, and anastomotic leakage after anterior resection of the rectum. Of 1,637 articles retrieved from the literature search, 59 articles that correctly applied the definitions met the inclusion criteria. Subanalyses were feasible for definitions after pancreatic surgery. According to the consensus definitions, the median complication rates of retrospective studies were 21.9% (postoperative pancreatic fistula, n = 11,244 patients), 5.9% (postpancreatectomy hemorrhage, n = 3,311 patients), and 22.8% (delayed gastric emptying, n = 4,553 patients) after pancreatic resections. The incidences were not substantially different in prospective trials. Validation was performed for all three definitions, demonstrating that the severity grades significantly correlated with the clinical course of the patients.

CONCLUSION

The available consensus definitions were increasingly cited and facilitate scientific comparability and transparency if appropriately applied. The present data update the incidences of major pancreatic complications.

Dysplasia at the surgical margin is associated with recurrence after resection of non-invasive intraductal papillary mucinous neoplasms

BACKGROUND

The significance of a positive margin in resected non-invasive pancreatic intraductal papillary mucinous neoplasms (IPMN) remains controversial. The aim of this study was to determine recurrence rates when dysplasia was present at the final surgical margin.

METHODS

A prospectively maintained database identified 192 patients undergoing resection of non-invasive IPMN. Pathological, peri-operative and recurrence data were analysed.

RESULTS

Ductal dysplasia was identified at the final surgical margin in 86 patients (45%) and defined as IPMN or Pancreatic Intraepithelial Neoplasia PanIN in 38 (20%) and 54 (28%) patients, respectively. At a median follow-up of 46 months, 40 (21%) patients recurred with 31 developing radiographical evidence of new cysts, 6 re-resected for IPMN and 3 diagnosed with pancreatic cancer within the remnant. Of those with margin dysplasia, 31% developed recurrent disease compared with 13% in those without dysplasia (P = 0.002). On multivariate analysis, margin dysplasia was associated with a three-fold increased risk of recurrence (P = 0.02). No relationship between dysplasia and development of pancreatic cancer was found.

DISCUSSION

In this study, dysplasia at the margin after a pancreatectomy for non-invasive IPMN was associated with recurrence in the remnant gland, but not at the resection margin. While this finding may warrant closer follow-up, it does not identify a gland at higher risk for the subsequent development of invasive disease.

Laparoscopic pancreatic resections

PURPOSE

Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade.

METHODS

In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide.

RESULTS AND CONCLUSIONS

Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.

Proposal for a morphological classification of intraductal papillary neoplasm of the bile duct (IPN-B)

PURPOSE

We propose a morphological classification of intraductal papillary neoplasm of the bile duct (IPN-B).

METHODS

A retrospective analysis of 16 patients with IPN-B who had undergone surgical resection was conducted. These 16 cases were classified into three types based on the primary lesion's anatomical location: branch duct type (6 cases), main duct type (5 cases) and mixed type (5 cases). In this paper we have analyzed the characteristics of IPN-B according to our new classification.

RESULTS

All branch duct type IPN-B was located in the left lobe and 5 of them were resected by left hepatectomy without extrahepatic bile duct resection (EBDR). On the other hand, all patients with main duct and mixed type IPN-B underwent EBDR in addition to hepatectomy or pancreatoduodenectomy. Microscopically, 2 of 6 patients with branch duct type IPN-B had no malignant component and, in the remaining 4 patients, cancer invasion was restricted to within the ductal wall. There were no cases of branch duct type IPN-B with lymph node metastasis and superficial intraductal tumor spread. In contrast, all patients with main duct and mixed duct type IPN-B had the malignant component. In all cases, lymph node metastasis was not observed, but superficial intraductal tumor spread was frequently found in extrahepatic bile duct lesions: 3 of main duct type and 3 of mixed type. Four patients with superficial intraductal spread had non-curative resection due to a cancer-positive ductal margin. Most patients with IPN-B obtained a good prognosis, but two patients with a cancer-positive ductal margin developed local recurrence.

CONCLUSIONS

Our classification vividly reflects clinical and pathological characteristics of IPN-B and is useful to determine appropriate surgical strategy.

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.