Surgical treatment of benign and borderline neoplasms of the pancreatic body

Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.

METHODS

The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.

RESULTS

A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.

CONCLUSIONS

Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.

Laparoscopic distal pancreatectomy versus laparoscopic central pancreatectomy for benign or low-grade malignant tumors in the pancreatic neck

AIMS

Laparoscopic distal pancreatectomy (LDP) and laparoscopic central pancreatectomy (LCP) are two surgical methods that can remove pancreatic neck lesions. However, their benefits remain controversial. We aimed to compare the benefits and limitations of LDP and LCP.

METHODS

In total, 50 patients who underwent LDP (n = 34) or LCP (n =16) between January 2014 and November 2019 were retrospectively reviewed using our database. We analyzed their preoperative characteristics, operative data, pathological features, and postoperative outcomes.

RESULTS

The baseline features of patients did not differ significantly between the two groups (P < 0.05). Compared with the LDP group, the LCP group showed significantly prolonged operation time (392 ± 144 vs. 269 ± 130 min, P = 0.007), time to oral intake (3.8 ± 1.3 vs. 2.8 ± 0.9 days, P = 0.017), and hospital stay (19.6 ± 5.1 vs. 15.4 ± 4.1 days, P = 0.008) as well as increased hospital expenses (10.1 ± 6.2 vs. 6.6 ± 1.5 WanRMB, P = 0.023). However, no significant differences were observed in conversion rate (0/16 vs. 0/34), blood loss (154 ± 93 vs. 211 ± 170 mL, P = 0.224), postoperative white blood cell count (10.3 ± 2.7 vs. 11.1 ± 3.1, P = 0.432), first random blood glucose level after operation (8.2 ± 2.1 vs. 8.6 ± 2.6 mmol/L, P = 0.696), and ascites amylase level on day 3 after operation (5212 [3110-14,176] vs. 3142 [604-13,761] U/L, P = 0.167) between the two groups. Moreover, no significant differences were noted in the incidence of postoperative diabetes (1/16 vs. 5/34) between the two groups. However, LCP was associated with significantly higher incidences of pancreatic fistula grades B and C (P = 0.005) and postoperative hemorrhage (P = 0.031).

CONCLUSION

Compared with the LCP, LDP is a useful and safer technique for benign or low-grade malignant tumors in the pancreatic neck.

Minimally invasive versus open central pancreatectomy: Systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to give an overview on the postoperative outcome after a minimally invasive (ie, laparoscopic and robot-assisted) central pancreatectomy and open central pancreatectomy with a specific emphasis on the postoperative pancreatic fistula. For benign and low-grade malignant lesions in the pancreatic neck and body, central pancreatectomy may be an alternative to distal pancreatectomy. Exocrine and endocrine insufficiency occur less often after central pancreatectomy, but the rate of postoperative pancreatic fistula is higher.

METHODS

An electronic search was performed for studies on elective minimally invasive central pancreatectomy and open central pancreatectomy, which reported on major morbidity and postoperative pancreatic fistula in PubMed, Cochrane Register, Embase, and Google Scholar until June 1, 2021. A review protocol was developed a priori and registered in PROSPERO as CRD42021259738. A meta-regression was performed by using a random effects model.

RESULTS

Overall, 41 studies were included involving 1,004 patients, consisting of 158 laparoscopic minimally invasive central pancreatectomies, 80 robot-assisted minimally invasive central pancreatectomies, and 766 open central pancreatectomies. The overall rate of postoperative pancreatic fistula was 14%, major morbidity 14%, and 30-day mortality 1%. The rates of postoperative pancreatic fistula (17% vs 24%, P = .194), major morbidity (17% vs 14%, P = .672), and new-onset diabetes (3% vs 6%, P = .353) did not differ significantly between minimally invasive central pancreatectomy and open central pancreatectomy, respectively. Minimally invasive central pancreatectomy was associated with significantly fewer blood transfusions, less exocrine pancreatic insufficiency, and fewer readmissions compared with open central pancreatectomy. A meta-regression was performed with a random effects model between minimally invasive central pancreatectomy and open central pancreatectomy and showed no significant difference for postoperative pancreatic fistula (random effects model 0.16 [0.10; 0.24] with P = .789), major morbidity (random effects model 0.20 [0.15; 0.25] with P = .410), and new-onset diabetes mellitus (random effects model 0.04 [0.02; 0.07] with P = .651).

CONCLUSION

In selected patients and in experienced hands, minimally invasive central pancreatectomy is a safe alternative to open central pancreatectomy for benign and low-grade malignant lesions of the neck and body. Ideally, further research should confirm this with the main focus on postoperative pancreatic fistula and endocrine and exocrine insufficiency.

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.

Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis

OBJECTIVE

To assess metabolic dysfunctions and steatohepatosis after standard and local pancreatic resections for benign and premalignant neoplasms.

SUMMARY OF BACKGROUND DATA

Duodenopancreatectomy, hemipancreatectomy, and parenchyma-sparing, limited pancreatic resections are currently in use for nonmalignant tumors.

METHODS

Medline, Embase, and Cochrane libraries were searched for studies reporting measured data of metabolic functions following PD, pancreatic left resection (PLR), duodenum-sparing pancreatic head resection (DPPHR), pancreatic middle segment resection (PMSR), and tumor enucleation (TEN). Forty cohort studies comprising data of 2729 patients were eligible.

RESULTS

PD for benign tumor was associated in 46 of 327 patients (14.1%) with postoperative new onset of diabetes mellitus (pNODM) and in 109 of 243 patients (44.9%) with postoperative new onset of pancreatic exocrine insufficiency measured after a mean follow-up of 32 months. The meta-analysis displayed pNODM following PD in 32 of 204 patients (15.7%) and in 10 of 200 patients (5%) after DPPHR [P < 0.01; OR: 0.33; (95%-CI: 0.15-0.22)]. PEI was found in 77 of 174 patients following PD (44.3%) and in 7 of 104 patients (6.7%) following DPPHR (P < 0.01;OR: 0.15; 95%-CI: 0.07-0.32). pNODM following PLR was reported in 107 of 459 patients (23.3%) and following PMSR 23 of 412 patients (5.6%) (P < 0.01; OR: 0.20; 95%-CI: 0.12-0.32). Postoperative new onset of pancreatic exocrine insufficiency was found in 17% following PLR and in 8% following PMSR (P < 0.01). pNODM following PPPD and tumor enucleation was observed in 19.7% and 5.7% (P < 0.03) of patients, respectively. Following PD/PPPD, 145 of 608 patients (23.8%) developed a nonalcoholic fatty liver disease after a mean follow-up of 30.4 months. Steatohepatosis following DPPHR developed in 2 of 66 (3%) significantly lower than following PPPD (P < 0.01).

CONCLUSION

Standard pancreatic resections for benign tumor carry a considerable high risk for a new onset of diabetes, pancreatic exocrine insufficiency and following PD for steatohepatosis. Parenchyma-sparing, local resections are associated with low grade metabolic dysfunctions.

Overall Postoperative Morbidity and Pancreatic Fistula Are Relatively Higher after Central Pancreatectomy than Distal Pancreatic Resection: A Systematic Review and Meta-Analysis

Objective

To compare the intraoperative and postoperative outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP).

Methods

A systematic literature search was performed on electronic databases from MEDLINE, Embase, and PubMed from 1998 to 2018. Statistical analysis and meta-analysis were performed using statistics/data analysis (Stata®) software, version 12.0 (StataCorp LP, College Station, Texas 77845, USA). Dichotomous variables were analyzed by estimation of relative risk (RR) with a 95 percent (%) confidence interval (CI) and continuous variables were analyzed by standardized mean differences (SMD) with 95% CI.

Results

Twenty-four studies with 593 CP and 1226 DP were included in the meta-analysis. CP had significantly longer operation time (SMD: 1.03; 95% CI 0.62 to 1.44; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.01). Estimated blood loss was significantly lower in CP (SMD: -0.34; 95% CI -0.58 to -0.09; P = 0.007). Overall postoperative morbidity (RR: 1.30; 95% CI: 1.13 to 1.50; P < 0.001), overall pancreatic fistula (RR: 1.41; 95% CI: 1.20 to 1.66; P < 0.001), clinically relevant fistula (RR: 1.64; 95% CI: 1.25 to 2.16; P < 0.001), and postoperative hemorrhage (RR: 1.90; 95% CI: 1.18 to 3.06; P < 0.05) were all significantly higher after CP. On long-term follow-up, DP patients were more likely to have postoperative exocrine (RR: 0.56; 95% CI: 0.37 to 0.84; P < 0.05) and endocrine (RR: 0.27; 95% CI: 0.18 to 0.40; P < 0.001) insufficiency. There was no statistically significant difference in transfusion requirement, postoperative mortality, reoperation, and tumor recurrence.

Conclusion

CP is associated with significantly higher morbidity and clinically relevant pancreatic fistula. CP should only be reserved for selected patients who require postoperative pancreatic function preservation.

Central versus Distal Pancreatectomy for Benign or Low-Grade Malignant Lesions in the Pancreatic Neck and Proximal Body

The purpose of this meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). PubMed, Web of Knowledge, and Ovid's database were searched for studies published in English language between January 1990 and December 2018. A meta-analysis was performed to compare the clinical outcomes of CP versus DP. Nineteen trials with 1440 patients were analyzed. Although there were no significant differences in the rate of intra-operative blood transfusion between two groups, CP costs more operative time as well as had more intraoperative blood loss than DP. Furthermore, the overall complication rate, pancreatic fistula rate, and the clinically significant pancreatic fistula rate were significantly higher in the CP group. On the other hand, CP had a lower risk of endocrine (odds ratio: 0.17; 95% confidence interval: 0.10, 0.29; P < 0.05) and exocrine insufficiency (odds ratio: 0.22; 95% confidence interval: 0.10, 0.48; P < 0.05). CP was associated with a higher pancreatic fistula rate, and it should be performed in selected patients who need preservation of the pancreas, which is of utmost importance.

Central pancreatectomy: a comprehensive, up-to-date meta-analysis

BACKGROUND

Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers.

METHODS

A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed.

RESULTS

Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p < 0.0001), overall and clinically relevant pancreatic fistula (p < 0.0001), postoperative hemorrhage (p = 0.02), but with significantly lower incidences of new-onset (p < 0.0001) and worsening diabetes mellitus (p = 0.004). Furthermore, significantly longer length of hospital stay (p < 0.0001) was observed for CP patients.

CONCLUSIONS

CP is superior to DP regarding the preservation of pancreatic functions, but at the expense of significantly higher complication rates and longer hospital stay. Proper selection of patients is of utmost importance to maximize the benefits and mitigate the risks of CP.

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.

The role of central pancreatectomy in pancreatic surgery: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP) and pancreaticoduodenectomy (PD).

METHODS

A systematic literature research in PubMed/Medline, Embase and Cochrane Library was performed to identify articles reporting CP from January 1983 to November 2017.

RESULTS

Fifty studies with 1305 patients undergoing CP were identified. The overall morbidity, mortality, pancreatic fistula (PF) rate and reoperation rate was 51%, 0.5%, 35% and 4% respectively. Endocrine and exocrine insufficiency were occurred in 4% and 5% of patients after CP. Meta-analysis of CP versus DP favored CP with regard to less blood loss (WMD = -143.4, P = 0.001), lower rates of endocrine (OR = 0.13, P < 0.001) and exocrine insufficiency (OR = 0.38, P < 0.001). CP was associated with higher morbidity and PF rate. In comparison with PD, CP had a lower risk of endocrine (OR = 0.14, P < 0.001) and exocrine insufficiency (OR = 0.14, P < 0.001), but a higher PF rate (OR = 1.6, P = 0.015).

CONCLUSIONS

CP maintains pancreatic endocrine and exocrine function better than DP and PD, but is associated with a higher PF rate.

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.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic central pancreatectomy

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

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

OBJECTIVE

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery.

BACKGROUND

EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients.

METHODS

Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement.

RESULTS

These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement.

CONCLUSIONS

EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

Minimally invasive central pancreatectomy and pancreatogastrostomy: current surgical technique and outcomes

Recent improvements in imaging techniques and more frequent use of cross-sectional imaging have led to an increase in the identification of benign and low-grade lesions of the pancreas. Patients with resectable cancers are commonly treated by either a Whipple procedure or distal pancreatectomy (DP) based on the location of the tumor. Central pancreatectomy (CP) is a less commonly performed operation that has recently been utilized for resection of these now more frequently diagnosed low-grade and benign lesions located in the mid pancreas. Lesions that may have a relatively more indolent nature include branch-type intraductal papillary mucinous neoplasm (IPMNs), mucinous cystic neoplasms, neuroendocrine tumors, and solid pseudopapillary tumors. The goal of a CP is complete extirpation of the lesion, while preserving pancreatic parenchyma to reduce the risks of developing diabetes and exocrine insufficiency (EI). Although open CP has been shown to be safe and efficacious, the outcomes of a minimally invasive approach are still relatively underreported and therefore unknown. In this paper, we describe our surgical approach to performing a CP with an accompanying video demonstration of the key portions of the operation.

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.

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.

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.

New-onset diabetes after distal pancreatectomy: a systematic review

OBJECTIVE

The true rate of new-onset diabetes (NODM) after distal pancreatectomy (DP) is not known. This systematic review was carried out to obtain exact percentages regarding the incidence of NODM after DP for different indications.

BACKGROUND

Distal pancreatectomy is the standard procedure for removal of benign or (potentially) malignant lesions from the pancreatic body or tail and increasingly used for removal of often benign lesions. It is associated with low mortality rates, though postoperative diabetes remains a serious problem.

METHODS

Embase, PubMed, Medline, Web of Science, the Cochrane Library, and Google Scholar were searched for articles reporting incidence of NODM after DP. Methodological quality of the included studies was assessed by means of the Newcastle-Ottawa scale for cohort studies and the Moga scale for case series. Mean weighted overall percentages of NODM after DP for different indications were calculated with 95% confidence intervals (CI) and corresponding P values.

RESULTS

Twenty-six studies were included, comprising 1.731 patients undergoing DP. The average cumulative incidence of NODM after DP performed for chronic pancreatitis was 39% and for benign or (potentially) malignant lesions it was 14%. Comparing the proportions of these 2 groups showed a significant difference (95% CI: 0.351-0.434 and 0.110-0.172, respectively, P < 0.000). The average percentage of insulin-dependent diabetes among patients with NODM after DP was 77%.

CONCLUSIONS

This review is the largest of its kind to assess the cumulative incidence of NODM after DP and shows that NODM is a frequently occurring complication, with incidence depending on the preexisting disease and follow-up time. Because NODM can affect quality of life, patients undergoing DP should be preoperatively provided with this information as specific as possible.

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.

Combined laparoscopic spleen-preserving distal pancreatectomy and islet autotransplantation for benign pancreatic neoplasm

AIM: To evaluate the safety and feasibility of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with autologous islet transplantation (AIT) for benign tumors of the pancreatic body-neck.

METHODS: Three non-diabetic, female patients (age 37, 44 and 35 years, respectively) were declared candidates for surgery, between May and September 2011, because of pancreatic body/neck cystic lesions. The planned operation was an LSPDP associated with AIT from the normal pancreas distal to the neoplasm. Islets isolation was performed on the residual pancreatic parenchyma after frozen section examination of the margin. Purified autologous islets were infused into the portal vein by a percutaneous transhepatic approach the day after surgery.

RESULTS: The procedure was performed successfully in all the three cases, and the spleen was preserved along with its vessels. Mean operation time was 283 ± 52 min and average blood loss was 133 ± 57 mL. Residual pancreas weights were 33, 22 and 30 g, and 105.200, 40.390 and 94.790 islet equivalents were isolated, respectively. Surgical complications occurred in one patient (grade A pancreatic fistula). Postoperative stays were 6, 6 and 7 d, respectively. Histopathological evaluation revealed mucinous cystic neoplasm in cases 1 and 3, and serous cystic neoplasm in patient 2. No postoperative insulin administration was required. One patient developed a transient partial portal thrombosis 2 mo after islet infusion. Patients are insulin independent at a mean follow up of 8 ± 2 mo.

CONCLUSION: Combination of LSPDP and AIT is feasible and could be effective to minimize the surgical impact for benign neoplasm of pancreatic body-neck.

Pancreatic fistula after central pancreatectomy: case series and review of the literature

BACKGROUND

Postoperative pancreatic fistula is one of the most common complications after pancreatectomy. This study aimed to assess the occurrence and severity of pancreatic fistula after central pancreatectomy.

METHODS

The medical records of 13 patients who had undergone central pancreatectomy were retrospectively studied, together with a literature review of studies including at least five cases of central pancreatectomy. Pancreatic fistula was defined and graded according to the recommendations of the International Study Group on Pancreatic Fistula (ISGPF).

RESULTS

No death was observed in the 13 patients. Pancreatic fistula developed in 7 patients and was successfully treated non-operatively. None of these patients required re-operation. A total of 40 studies involving 867 patients who underwent central pancreatectomy were reviewed. The overall pancreatic fistula rate of the patients was 33.4% (0-100%). Of 279 patients, 250 (89.6%) had grade A or B fistulae of ISGPF and were treated non-operatively, and the remaining 29 (10.4%) had grade C fistulae of ISGPF. In 194 patients, 15 (7.7%) were re-operated upon. Only one patient with grade C fistula of ISGPF died from multiple organ failure after re-operation.

CONCLUSION

Despite the relatively high occurrence, most pancreatic fistulae after central pancreatectomy are recognized a grade A or B fistula of ISGPF, which can be treated conservatively or by mini-invasive approaches.

Exocrine pancreatic insufficiency in adults: A shared position statement of the Italian association for the study of the pancreas

This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas (AISP). We covered the main diseases associated with exocrine pancreatic insufficiency (EPI) which are of common interest to internists/gastroenterologists, oncologists and surgeons, fully aware that EPI may also occur together with many other diseases, but less frequently. A preliminary manuscript based on an extended literature search (Medline/PubMed, Cochrane Library and Google Scholar) of published reports was prepared, and key recommendations were proposed. The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012. Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached. The final draft of the manuscript was then sent to the AISP Council for approval and/or modification. All concerned parties approved the final version of the manuscript in June 2013.

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

BACKGROUND

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP).

METHODS

Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate.

RESULTS

Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45·3 and 40·9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5·0 and 9·9 per cent of patients. The overall mortality rate was 0·8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0·22, 95 per cent confidence interval 0·14 to 0·35; P < 0·001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0·59, 0·32 to 1·07; P = 0·082).

CONCLUSION

CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.

Robotic-assisted minimally invasive central pancreatectomy: technique and outcomes

BACKGROUND

Central pancreatectomy is a definitive treatment for low-grade tumors of the pancreatic neck that preserves pancreatic and splenic function at the potential expense of postoperative pancreatic fistula. We analyzed outcomes after robot-assisted central pancreatectomy (RACP) to reexamine the risk-benefit profile in the era of minimally invasive surgery.

METHODS

Retrospective analysis of nine RACP performed between August 2009 through June 2010 at a single institution.

RESULTS

The average age of the cohort was 64 (range 18-75 years) with six women (67 %). Indications for surgery included: five benign cystic neoplasm and four pancreatic neuroendocrine tumor. Median operative time was 425 min (range 305-506 min) with 190 ml median blood loss (range 50-350 ml) and one conversion to open due to poor visualization. Median tumor size was 3.0 cm (range 1.9-6.0 cm); all patients achieved R0 status. Pancreaticogastrostomy was performed in seven cases and pancreaticojejunostomy in two. The median length of hospital stay was 10 days (range 7-19). Two clinically significant pancreatic fistulae occurred with one requiring percutaneous drainage. No patients exhibited worsening diabetes or exocrine insufficiency at the 30-day postoperative visit.

CONCLUSIONS

RACP can be performed with safety and oncologic outcomes equivalent to published open series. Although the rate of pancreatic fistula was high, only 22 % had clinically significant events, and none developed worsening pancreatic endocrine or exocrine dysfunction.

Middle segmental pancreatectomy: A safe and organ-preserving option for benign and low-grade malignant lesions

AIM: To study the feasibility and safety of middle segmental pancreatectomy (MSP) compared with pancreaticoduodenectomy (PD) and extended distal pancreatectomy (EDP).

METHODS: We studied retrospectively 36 cases that underwent MSP, 44 patients who underwent PD, and 26 who underwent EDP with benign or low-grade malignant lesions in the mid-portion of the pancreas, between April 2003 and December 2009 in Ruijin Hospital. The perioperative outcomes and long-term outcomes of MSP were compared with those of EDP and PD. Perioperative outcomes included operative time, intraoperative hemorrhage, transfusion, pancreatic fistula, intra-abdominal abscess/infection, postoperative bleeding, reoperation, mortality, and postoperative hospital time. Long-term outcomes, including tumor recurrence, new-onset diabetes mellitus (DM), and pancreatic exocrine insufficiency, were evaluated.

RESULTS: Intraoperative hemorrhage was 316.1 ± 309.6, 852.2 ± 877.8 and 526.9 ± 414.5 mL for the MSP, PD and EDP groups, respectively (P < 0.05). The mean postoperative daily fasting blood glucose level was significantly lower in the MSP group than in the EDP group (6.3 ± 1.5 mmol/L vs 7.3 ± 1.5 mmol/L, P < 0.05). The rate of pancreatic fistula was higher in the MSP group than in the PD group (42% vs 20.5%, P = 0.039), all of the fistulas after MSP corresponded to grade A (9/15) or B (6/15) and were sealed following conservative treatment. There was no significant difference in the mean postoperative hospital stay between the MSP group and the other two groups. After a mean follow-up of 44 mo, no tumor recurrences were found, only one patient (2.8%) in the MSP group vs five (21.7%) in the EDP group developed new-onset insulin-dependent DM postoperatively (P = 0.029). Moreover, significantly fewer patients in the MSP group than in the PD (0% vs 33.3%, P < 0.001) and EDP (0% vs 21.7%, P = 0.007) required enzyme substitution.

CONCLUSION: MSP is a safe and organ-preserving option for benign or low-grade malignant lesions in the neck and proximal body of the pancreas.

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

BACKGROUND/AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler

PURPOSE

No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler.

METHODS

A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses.

RESULTS

Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %.

CONCLUSION

Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.

Extent of surgical resections for intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) can involve the main pancreatic duct (MD-IPMNs) or its secondary branches (BD-IPMNs) in a segmental of multifocal/diffuse fashion. Growing evidence indicates that BD-IPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively. For surgery, clarification is required on: (1) when to resect an IPMN; (2) which type of resection should be performed; and (3) how much pancreas should be resected. In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations. However, oncological radicality is of paramount importance, and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs. In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed, evaluating perioperative and long-term outcomes. The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.

Surgical treatment of pancreatic endocrine tumours in Italy: results of a prospective multicentre study of 262 cases

BACKGROUND

Information on the treatment of pancreatic endocrine tumours (PETs) comes mostly from small, retrospective, uncontrolled studies.

METHODS

Newly diagnosed, histologically proven PETs, observed from June 2004 to March 2007 in 24 Italian centres, were included in a specific dataset.

RESULTS

Three-hundred and ten patients (mean age 57.6 years, females 46.6%) were analysed. At the time of recruitment, 262 (84.5%) underwent surgery. The percentage of operated patients was 91.9% and 62.0% in surgical and non-surgical centres, respectively. A curative resection was carried out in 83.6% (n = 219) of cases, a palliative resection (debulking) in 10.7% (n = 28), an exploratory laparotomy in 4.6% (n = 12), and a bypass procedure in 1.1% (n = 3). Laparoscopy was performed in 8.0% (n = 21) of cases. Resection consisted of a pancreatoduodenectomy in 46 cases (21.0%), a distal pancreatectomy in 95 (43.4%), an enucleation in 50 (22.8%), a middle pancreatectomy in 16 (7.3%) and a total pancreatectomy in 12 (5.5%). Liver resection was associated with pancreatic resection in 26 cases (9.9%). Post-operative mortality was 1.5% and morbidity 39.7%, respectively. A curative resection was performed more frequently in asymptomatic, small, non-metastatic, benign and at uncertain behaviour tumours, with low Ki67 values.

CONCLUSIONS

This study strongly indicates the fact that surgical resection represents the cornerstone treatment of PETs.

Parenchyma-sparing pancreatectomies for benign or border-line tumors of the pancreas

Standard pancreatic resections, such as pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy, result in an important loss of normal pancreatic parenchyma and may cause impairment of exocrine and endocrine function. Whilst these procedures are mandatory for malignant tumors, they seem to be too extensive for benign or border-line tumors, especially in patients with a long life expectancy. In recent years, there has been a growing interest in parenchyma-sparing pancreatic surgery with the aim of achieving better functional results without compromising oncological radicality in patients with benign, border-line or low-grade malignant tumors. Several limited resections have been introduced for isolated or multiple pancreatic lesions, depending on the location of the tumor: central pancreatectomy, duodenum-preserving pancreatic head resection with or without segmental duodenectomy, inferior head resection, dorsal pancreatectomy, excavation of the pancreatic head, middle-preserving pancreatectomy, and other multiple segmental resections. All these procedures are technically feasible in experienced hands, with very low mortality, although with high morbidity rate when compared to standard procedures. Pancreatic endocrine and exocrine function is better preserved with good quality of life in most of the patients, and tumor recurrence is uncommon. Careful patient selection and expertise in pancreatic surgery are crucial to achieve the best results.

Clinicopathological features of pancreatic endocrine tumors: a prospective multicenter study in Italy of 297 sporadic cases

OBJECTIVES

Information on pancreatic endocrine tumors (PETs) comes mostly from small, retrospective, uncontrolled studies conducted on highly selected patients. The aim of the study was to describe the clinical and pathological features of PETs in a prospective, multicenter study.

METHODS

Newly diagnosed, histologically proven, sporadic PETs observed from June 2004 to March 2007 in 24 Italian centers were included in a specific data set.

RESULTS

Two hundred ninety-seven patients (mean age 58.6+/-14.7 years, females 51.2%, males 48.8%) were analyzed. In 73 cases (24.6%), the tumor was functioning (F) (53 insulinomas, 15 gastrinomas, 5 other syndromes) and in 232 (75.4%) it was non-functioning (NF); in 115 cases (38.7%), the diagnosis was incidental. The median tumor size was 20 mm (range 2-150). NF-PETs were significantly more represented among carcinomas (P<0.001). Nodal and liver metastases were detected in 84 (28.3%) and 85 (28.6%) cases, respectively. The presence of liver metastases was significantly higher in the NF-PETs than in the F-PETs (32.1% vs. 17.8%; P<0.05), and in the symptomatic than in the asymptomatic patients (34.6% vs. 19.1%; P<0.005). At the time of recruitment, the majority of patients (251, 84.5%) had undergone surgery, with complete resection in 209 cases (83.3%).

CONCLUSIONS

This study points out the high number of new cases of PETs observed in Italy, with a high prevalence of NF and incidentally discovered forms. The size of the tumor was smaller and the rate of metastasis was lower than usually reported, suggesting a trend toward an earlier diagnosis.

Parenchyma-preserving resections for small nonfunctioning pancreatic endocrine tumors

BACKGROUND

Parenchyma-preserving resections (PPRs), including enucleation and middle pancreatectomy (MP), are accepted procedures for insulinomas, but their role in the treatment of nonfunctioning pancreatic endocrine tumors (NF-PETs) is debated. The aim of this study was to evaluate perioperative and long-term outcomes after PPRs for NF-PETs.

METHODS

All patients who underwent PPRs for NF-PETs between 1990 and 2005 were included. Patients with multiple endocrine neoplasia type 1 were excluded.

RESULTS

Overall, 50 patients (23 men, 27 women, median age 59 years) underwent 26 enucleations and 24 MP. A total of 58% of NF-PETs were incidentally discovered. Median size of the tumors was 13.5 mm with no preoperative suspicion of malignancy in all patients. Overall morbidity and pancreatic fistula rates were 58 and 50%, respectively. Reoperation rate was 4%, with no mortality. Postoperative complications were higher in the MP group. At pathology, there were 34 (68%) benign lesions, 13 (26%) neoplasms of uncertain behavior, and 3 (6%) well-differentiated carcinomas. Forty-one patients (82%) had tumors < or =2 cm in size. Only eight patients (16%) had at least one lymph node removed. After a median follow-up of 58 months, no patient died of disease. Overall, four patients (8%) experienced tumor recurrence after a mean of 68 months. The incidence of exocrine/endocrine insufficiency was 8%.

CONCLUSIONS

PPRs are generally safe and effective procedures for treating small NF-PETs. However, better selection criteria must be identified, and lymph node sampling should be performed routinely to avoid understaging. Long-term follow-up evaluation (>5 years) is of paramount importance given the possible risk of late recurrence.

Middle pancreatectomy with pancreaticogastrostomy: a technique, operative outcomes, and long-term pancreatic function

BACKGROUND AND OBJECTIVES

Middle pancreatectomy is infrequently performed in selected patients. The rationale is to preserve pancreatic function. This study evaluates a technique, operative outcomes, and long-term exocrine and endocrine pancreatic function of the middle pancreatectomy procedure.

METHODS

Nineteen patients who underwent middle pancreatectomy between 1996 and 2008 were reviewed. Indications included eight intraductal papillary-mucinous neoplasms, five endocrine tumors, one serous and two mucinous cystadenomas, and three other benign lesions. Reconstruction of the distal pancreatic remnant was performed with pancreaticogastrostomy using the duct-to-mucosa method in 16 patients and with Roux-en-Y end-to-end pancreaticojejunostomy in 3 patients.

RESULTS

Median operative time was 215 min. Perioperative mortality was nil. Morbidity was 53%, including 9 (47%) pancreatic fistulas. One patient with hemorrhage, complicated by a pancreatic fistula was successfully treated by endovascular embolization. No patients required postsurgical reoperation. Only one patient had clinical exocrine insufficiency requiring pancreatic enzyme supplementation. None developed postresection new-onset insulin-dependent diabetes.

CONCLUSIONS

Middle pancreatectomy with pancreaticogastrostomy is feasible and reasonable technique. Although the incidence of pancreatic fistula formation may still be higher compared to conventional resection, long-term exocrine, and endocrine pancreatic function may be preserved. Thus, careful patient selection and experienced pancreatic surgeons in high-volume centers are of great importance.

Extended central pancreatic resection as an alternative for extended left or extended right resection for appropriate pancreatic neoplasms

BACKGROUND

Whether patients with focal pancreatic lesions of benign or borderline pathology should be treated by extended central pancreatectomy rather than by extended classic resectional procedures, such as extended right and left resections, is controversial.

METHODS

Between 1992 and 2007, 105 patients underwent operation for focal pancreatic lesions of borderline or benign neuroendocrine neoplasms, cystadenoma, intraductal papillary mucinous neoplasia (IPMN), and secondary metastasis. In all, 35 patients were subjected to extended central pancreatectomy, whereas the remaining 70 patients were treated by an extended classic right resection or an extended classic left resection. Groups were matched according to age, sex, and histopathology.

RESULTS

No peri-operative mortality occurred after extended central pancreatectomy and extended classic left resection (n = 35, each). Two (6%) patients died after extended classic right resection. Overall, in-hospital morbidity was 26% after extended central pancreatectomy, 43% after extended classic right resection, and 37% after extended classic left resection. After a median follow-up of 48 months, a local recurrence rate of 17% after extended central pancreatectomy was similar to the corresponding rates of 9% after extended classic left resection and 14% after extended classic right resection. Endocrine and exocrine impairment was less pronounced after extended central pancreatectomy (6% and 9%) than after extended classic left resection (34% and 29%) and extended classic right resection (28% and 24%; P < .05).

CONCLUSION

Extended central pancreatectomy for appropriate pancreatic neoplasms is associated with less peri-operative morbidity and mortality than after extended classic left and extended classic right resection. Long-term local recurrence after extended central pancreatectomy is similar to the recurrence rates after extended classic right and classic left resection. Our results suggest that appropriately selected patients will benefit from extended central pancreatectomy because of the maintenance of endocrine and exocrine function.

Middle pancreatectomy for pancreatic neoplasms

BACKGROUND

A middle pancreatectomy (MP) is a parenchyma-preserving procedure for benign or low-malignant neoplasms in the neck or body of the pancreas that reduces long-term endocrine and exocrine insufficiency. MP requires the handling of 2 (distal and proximal) pancreatic remnants, and therefore, the higher rates of pancreatic fistula and morbidity may occur after MP rather than after standard pancreatectomies, such as for a pancreaticoduodenectomy and distal pancreatectomy. Though there have so far been few reports regarding a high number of series in MP as opposed to standard pancreatic resections, recently reports describing more than 50 case outcomes of MP were published.

METHODS

A literature search, which examined articles related to MP, was performed using the PubMed database. Data were compiled to generate conglomerate results of mortality and morbidity rates, and the long-term pancreatic functional insufficiency and recurrence after MP.

RESULTS

The mortality rates varied from 0 to 3%, and the morbidity from 13 to 62%. The rates of pancreatic fistula in more than 50 cases of MP varied from 8 to 30%. The rates of endocrine and exocrine insufficiency were very low (range, 0-9% and 0-8%, respectively).

CONCLUSIONS

MP is a safe procedure for the treatment of benign or low-grade malignant neoplasms in the pancreatic neck or body, and in this procedure, the postoperative endocrine and exocrine functions are well preserved.

Parenchyma-sparing resections for pancreatic neoplasms

BACKGROUND/PURPOSE

In recent years there has been an increase in the indications for pancreatic resection of benign or low-grade malignant lesions, especially in young patients with long life expectancy. In this setting, patients may benefit from parenchyma-sparing resections in order to decrease the risk of development of exocrine/endocrine insufficiency.

METHODS

A review of the literature and authors experience was undertaken.

RESULTS

Parenchyma-sparing resections of the pancreas including enucleation, middle pancreatectomy (MP) and middle-preserving pancreatectomy are described. Short and long-term outcomes after surgery are analyzed with special regard to postoperative morbidity/mortality, and oncological and functional long-term results.

CONCLUSIONS

Parenchyma-sparing resections are safe and effective procedures for treatment of benign and low-grade malignant neoplasms. Despite a significant postoperative morbidity they are associated with good long-term functional and oncological results. Enucleation should preferentially be performed laparoscopically whenever possible.

[Middle segmental pancreatic resection: an organ-preserving option for benign lesions]

Benign and low malignant tumors of the middle pancreatic segment can be resected by extended pancreaticoduodenectomy or distal pancreatic resection. Both procedures involve unavoidably extensive loss of normal pancreatic parenchyma, leading to deteriorated endocrine and exocrine pancreatic function. Segmental pancreatic resection represents an organ-preserving surgical procedure. Normal pancreatic tissue can be preserved as only the tumor with a pancreatic segment is resected. Several reports confirm lower mortality and minimal risk of postoperative endocrine or exocrine insufficiency than with standard pancreatic resections. The indication should be limited exclusively to benign or low malignant pancreatic tumors, metastases from other tumors, and focal chronic pancreatitis, as this type of resection cannot be deemed oncologic. Segmental pancreatic resections are technically more demanding and therefore should be performed in experienced centers.

Small pancreatic and periampullary neuroendocrine tumors: resect or enucleate?

OBJECTIVE

The aim of this study was to compare the outcomes of enucleation versus resection in patients with small pancreatic, ampullary, and duodenal neuroendocrine tumors (NETs).

METHODS

Multi-institutional retrospective review identified all patients with pancreatic and peri-pancreatic NETs who underwent surgery from January 1990 to October 2008. Patients with tumors < or =3 cm and without nodal or metastatic disease were included.

RESULTS

Of the 271 patients identified, 122 (45%) met the inclusion criteria and had either an enucleation (n = 37) and/or a resection (n = 87). Enucleated tumors were more likely to be in the pancreatic head (P = 0.003) or functioning (P < 0.0001) and, when applicable, less likely to result in splenectomy (P = 0.0003). The rate of pancreatic fistula formation was higher after enucleation (P < 0.01), but the fistula severity tended to be worse following resection (P = 0.07). The enucleation and resection patients had similar operative times, blood loss, overall morbidity, mortality, hospital stay, and 5-year survival. However, for pancreatic head tumors, enucleation resulted in decreased blood loss, operative time, and length of stay compared to pancreaticoduodenectomy (P < 0.05).

CONCLUSION

These data suggest that most outcomes of enucleation and resection for small pancreatic and peri-pancreatic NETs are comparable. However, enucleation has better outcomes than pancreaticoduodenectomy for head lesions and the advantage of preserving splenic function for tail lesions.

A central pancreatectomy for benign or low-grade malignant neoplasms

INTRODUCTION

A central pancreatectomy is a parenchyma-sparing procedure that is performed to reduce long-term endocrine and exocrine insufficiency.

METHOD

In this study, we analyzed the perioperative course, the frequency of postoperative onset of diabetes mellitus, and long-term change of body weight in patients undergoing a central pancreatectomy, in comparison to the patients undergoing a distal pancreatectomy for low-grade neoplasms including cystic neoplasms and neuroendocrine tumors.

RESULTS AND DISCUSSION

The rate of postoperative complications including grade B/C pancreatic fistula was no different between both groups. Only one patient undergoing a central pancreatectomy (4.7%) developed new onset of mild diabetes, whereas 35% in the distal pancreatectomy group developed new onset or worsening diabetes (p = 0.0129). The body weight in the distal pancreatectomy group was significant lower than that in the central pancreatectomy group at 1 and 2 years after surgery (1 year; P < 0.0001, 2 years; P = 0.0055), and the body weight in the patients undergoing a central pancreatectomy improved to preoperative values within 2 years after surgery.

CONCLUSION

A central pancreatectomy is a safe procedure for the treatment of low-grade malignant neoplasms in the pancreatic body; the rate of onset of diabetes is minimal, and the body weight improves early in the postoperative course.

Conservative resection for benign tumors of the proximal pancreas

AIM: To evaluate the safety and long-term prognosis of conservative resection (CR) for benign or borderline tumor of the proximal pancreas.

METHODS: We retrospectively analyzed 20 patients who underwent CR at the Second Affiliated Hospital of Zhejiang University School of Medicine between April 2000 and October 2008. For pancreaticojejunostomy, a modified invagination method, continuous circular invaginated pancreaticojejunostomy (CCI-PJ) was used. Modified continuous closed lavage (MCCL) was performed for patients with pancreatic fistula.

RESULTS: The indications were: serous cystadenomas in eight patients, insulinomas in six, non-functional islet cell tumors in three and solid pseudopapillary tumors in three. Perioperative mortality was zero and morbidity was 25%. Overall, pancreatic fistula was present in 25% of patients. At a mean follow up of 42.7 mo, all patients were alive with no recurrence and no new-onset diabetes mellitus or exocrine dysfunction.

CONCLUSION: CR is a safe and effective procedure for patients with benign tumors in the proximal pancreas, with careful CCI-PJ and postoperative MCCL.

Middle pancreatectomy: safety and long-term results

BACKGROUND

Pancreaticoduodenectomy and distal pancreatectomy for lesions of the neck or body of the pancreas sacrifice a large amount of normal pancreatic tissue. Middle pancreatectomy (MP) is a parenchyma sparing technique that reduces the risk of postoperative endocrine and exocrine insufficiency. This study aims to evaluate the perioperative and long-term results of MP and to clarify whether MP can be performed with outcomes comparable with traditional pancreatectomies.

METHOD

Twenty-six patients who underwent MP for benign or low-grade malignant tumor of the pancreas between 1991 and 2006 at the Department of Surgery II, Nagoya University Graduate School of Medicine, were identified. Their outcomes were compared with 2 separate control groups, 35 left-side pancreatectomies (LSP) and 60 right-side pancreatectomies (RSP).

RESULTS

The mean operating time of the MP group was 295 minutes, which was significantly shorter than that for RSP (P=.0001). The rate of pancreatic fistula formation was higher in the MP group than in the 2 control groups, although the differences did not reach statistical significance. After a mean follow-up of 71 months, postoperative endocrine function was equivalent to the pre-operative values in the MP group, and none of the patients developed diabetes mellitus postoperatively. Only 1 patient in the MP group required enzyme substitution postoperatively for exocrine insufficiency. The MP group was inclined to be superior to the other 2 control groups in terms of postoperative nutritional status.

CONCLUSION

Middle pancreatectomy is a reasonable technique that is indicated for selected patients with benign or low malignant tumors in the neck and body of the pancreas. Middle pancreatectomy seems to result in better preservation of exocrine and endocrine functions as well as in better nutritional status postoperatively.

Intraductal papillary mucinous neoplasms of the pancreas: indication, extent, and results of surgery

In intraductal and papillary mucinous neoplasm (IPMN) of the pancreas, the aims of surgery differ according to the presence of malignancy. For malignant IPMN and especially for invasive malignancy, radical resection is essential, but entails a substantial operative risk and long-term pancreatic insufficiency. For benign IPMN, in theory, the operative risk and the loss of pancreatic function should be minimal. Thus, surgery for malignant and benign IPMN differs in patient selection, surgical technique, and accepted risk of long-term functional disorders. This article details the indications, surgical techniques, and results of surgery in IPMN.

Pancreatic insufficiency after different resections for benign tumours

BACKGROUND

Pancreatic resections for benign diseases may lead to long-term endocrine/exocrine impairment. The aim of this study was to compare postoperative and long-term results after different pancreatic resections for benign disease.

METHODS

Between 1990 and 1999, 62 patients underwent pancreaticoduodenectomy (PD), 36 atypical resection (AR) and 64 left pancreatectomy (LP) for benign tumours. Exocrine and endocrine pancreatic function was evaluated by 72-h faecal chymotrypsin and oral glucose tolerance test.

RESULTS

The incidence of pancreatic fistula was significantly higher after AR than after LP (11 of 36 versus seven of 64; P = 0.028). The long-term incidence of endocrine pancreatic insufficiency was significantly lower after AR than after PD (P < 0.001). Exocrine insufficiency was more common after PD (P < 0.001) and LP (P = 0.009) than after AR. The probability of developing both endocrine and exocrine insufficiency was higher for PD and LP than for AR (32, 27 and 3 per cent respectively at 1 year; 58, 29 and 3 per cent at 5 years; P < 0.001).

CONCLUSION

Different pancreatic resections are associated with different risks of developing long-term pancreatic insufficiency. AR represents the best option in terms of long-term endocrine and exocrine function, although it is associated with more postoperative complications.

Feasibility of en-bloc wedge resection of the pancreas and/or the duodenum as an alternative to pancreatoduodenectomy for advanced gallbladder cancer

Pancreatoduodenectomy has been described as a possible treatment for gallbladder cancer that presents with evidence of direct invasion to the pancreas and/or the duodenum. This procedure does, however, carry a significantly higher morbidity and mortality if performed with a hepatectomy. An alternative procedure, therefore, of wedge resection of the invaded organ(s) was investigated in this study. On recognition of infiltration of the tumor into the pancreas and/or the duodenum, an en-bloc wedge resection of the organ(s) combined with the original tumor was the intended procedure. However, a pancreatoduodenectomy was performed if the tumor was not resectable by an attempted wedge resection. Operative and long-term outcomes were compared between patients who underwent wedge resection (n = 9) and pancreatoduodenectomy (n = 8). One patient in each group was incorrectly diagnosed preoperatively as having cancer invasion, as opposed to inflammatory changes, as recognized by subsequent histology. All tumors were excised with tumor-free pancreatic and duodenal margins. Postoperative complications occurred in one patient with wedge resection and four with pancreatoduodenectomy. One in-hospital death occurred in each group; one patient died with wedge resection of sepsis and one patient with pancreatoduodenectomy died of a pancreatic leak. No local recurrence occurred in either group. There was no difference in cumulative survival rates between the groups. Wedge resection was considered to be a feasible surgical procedure, in terms of morbidity, respectability, and long-term outcome.