Noninvasive pancreatic cystic neoplasms can be safely and effectively treated by limited pancreatectomy

Agenesis of Dorsal Pancreas and Solid Pseudopapillary Tumor: Ventral Pancreas Preserving Portal Vein Resection and Reconstruction Using a Peritoneal Graft

A diabetic lady in her 40s was referred to surgical oncologists with epigastric pain associated with vomiting. Computed Tomography (CT) Abdomen with contrast demonstrated a mass arising from the head of the pancreas with the absence of dorsal pancreas, confirmed on magnetic resonance cholangio-pancreatography (MRCP). A core needle biopsy was done, and the tumor was revealed to be a solid pseudopapillary epithelial neoplasm. She underwent sub-total pancreatectomy preserving the duodenum and ventral pancreas as there was adequate free margin; however due to the tumor abutting the anterior wall of the portal vein, it was resected, and reconstruction was done using a peritoneal graft. The patient made a good recovery without any significant post-operative events.

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.

Management of serous cystic neoplasms of the pancreas

Pancreatic serous cystadenomas are uncommon benign tumours that are often found incidentally on routine imaging examinations. Radiological imaging techniques alone have proven to be suboptimal to fully characterize cystic pancreatic lesions. Endoscopic ultrasound, with the addition of fine-needle aspiration in difficult cases, has showed greater diagnostic accuracy than conventional imaging techniques. The best management strategy of these neoplasms is still debated. Surgery should be limited only to symptomatic and highly selected cases and most of the patients should only be strictly monitored. In the current paper, we provide an updated overview on pancreatic serous cystadenomas, focusing our attention on epidemiology, clinical characteristics and diagnostic evaluation; finally, we also discuss different management strategies and areas for future research.

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.

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.

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Cystic pancreatic lesions: current evidence for diagnosis and treatment

Pancreatic cystic neoplasms are detected at an increasing frequency due to an increased use and quality of abdominal imaging. There are well known differential diagnostic difficulties concerning these lesions. The aim is to review current literature on the diagnostic options and the following treatment for cystic lesions in the pancreas focusing on serous cystadenomas, primary mucinous neoplasm of the pancreas and mucinous cystadenocarcinomas, as well as intraductal papillary mucinous neoplasms, starting with excluding pseudocysts. A conservative approach is feasible in patients with a clinical presentation suggestive of an asymptomatic serous cystadenoma. Surgical management, as well as follow-up, is discussed for each of the types of neoplastic lesions, including an uncharacterized cyst, based on patient data, symptoms, serum analysis, cyst fluid analysis and morphological features. Aspects for future diagnostics and management of these neoplasia are commented upon.

Management of mucinous cystic neoplasms of the pancreas

The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words “pancreatic mucinous cystic neoplasm”, “pancreatic mucinous cystic tumour”, “pancreatic mucinous cystic mass”, “pancreatic cyst”, and “pancreatic cystic neoplasm” to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.

Surgical treatment of cystic neoplasms of the pancreas

CONTEXT: Diagnosis and treatment of cystic neoplasms of the pancreas increased significantly in the last decades. There are only a few Brazilian publications on these tumors. The majority of them are limited to reports of one or few cases. OBJECTIVE: To present our experience with 27 patients with cystic neoplasms of the pancreas. METHODS: Demographic data, clinical manifestations, diagnostic exams, surgical procedures, postoperative complications, and follow-up data of 27 patients with cystic neoplasms of the pancreas were analyzed, according to the histological type of the tumor. RESULTS: There were 10 (37%) serous cystic tumors, 10 (37%) mucinous cystic tumors, 4 (15%) intraductal papillary mucinous tumors, and 3 (11%) solid pseudopapillary tumors or Frantz tumor. All serous cystic tumors, 6 (60%) mucinous tumors, 2 (50%) intraductal papillary mucinous tumors, and 2 (67%) solid pseudopapillary tumors were benign. The age of the patients varied from 31 to 82 years and all tumors were more common in female. Two patients had been treated previously as a pseudocyst. Surgical procedures depended on the location and extension of the tumor. Two patients underwent only laparotomy with tumor biopsy, one cholecystectomy with Roux-en-Y hepaticojejunostomy for jaundice treatment, 6 pancreatoduodenectomy, and 18 partial pancreatectomy. The most common postoperative complication was pancreatic fistula (n = 5; 19%). One patient died of necrotic pancreatitis. Of the 10 patients with serous cystic tumor, only 1 had tumor recurrence at the section border. The three patients with mucinous cystoadenocarcinoma in which was not possible to resect the tumor, died 6 to 24 months after laparotomy. The six patients with benign mucinous tumors did not have tumor recurrence. CONCLUSIONS: The most common cystic neoplasms of the pancreas are serous and mucinous cysts. These tumors are more frequent in female. Although almost all serous cysts are benign, 40% of mucinous cysts are malign. Misdiagnosis may delay appropriate treatment and increase mortality.