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Pergolini I, Friess H, Demir IE. Resektionsstrategien beim BD-IPMN - Enukleation oder onkologische Resektion? Zentralbl Chir 2022; 147:155-159. [DOI: 10.1055/a-1759-4492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Hintergrund Das maligne Potenzial und die chirurgische Behandlung intraduktaler papillärer muzinöser Neoplasien der Seitengänge der Bauchspeicheldrüse (BD-IPMNs) bleiben umstritten.
Die Enukleation (EN) als parenchymsparende Resektion des Pankreas kann eine wertvolle Alternative zu Standardresektionen (SR), z. B. Whipple oder distale Pankreatektomie, für die Behandlung
von BD-IPMNs darstellen, ihre Rolle ist jedoch noch unzureichend definiert. Ziel dieser Übersichtsarbeit ist es, Indikationen und postoperative Ergebnisse nach Pankreas-Enukleation im
Vergleich zur Standardresektion (SR) zu vergleichen.
Methoden Es wurde eine selektive Literaturrecherche durchgeführt. Die postoperativen Kurz- und Langzeitergebnisse beider Operationsverfahren wurden ausgewertet.
Ergebnisse Die EN ist im Vergleich zur SR mit einer kürzeren Operationszeit und einem geringeren Blutverlust verbunden. Die chirurgische Gesamtmorbidität unterscheidet sich nicht
zwischen den beiden Verfahren. Obwohl die EN weniger invasiv ist, stellt die Entwicklung einer Pankreasfistel die häufigste Komplikation nach EN dar, und in mehreren Studien wird über eine
höhere Rate an Pankreasfisteln nach EN als nach SR berichtet. Die Unterschiede, bezogen auf die Pankreasfistel, werden zwischen den beiden Verfahren in High-Volume-Zentren abgemildert. Die
EN ermöglicht im Vergleich zur SR öfter den Erhalt der exokrinen und endokrinen Funktion der Bauchspeicheldrüse, dies ist der wichtigste Vorteil dieses Verfahrens.
Schlussfolgerungen Die EN scheint eine sichere und wirksame Alternative in der Behandlung der Seitengang-IPMN mit geringem Risiko zu sein, die den Erhalt der endokrinen und exokrinen
Funktion ermöglicht. Außerdem sind die postoperativen Komplikationen und Rezidivraten nach EN vergleichbar mit den wesentlich umfangreicheren chirurgischen Verfahren. Die EN der
Bauchspeicheldrüse sollte jedoch von erfahrenen Chirurgen durchgeführt werden. Da es sich um ein nicht onkologisches Verfahren handelt, muss die Auswahl der Patienten sehr genau erfolgen,
was die Bedeutung der Behandlung in Einrichtungen mit hohem Patientenaufkommen unterstreicht.
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Affiliation(s)
- Ilaria Pergolini
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - Ihsan Ekin Demir
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
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Enucleation for branch duct intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. HPB (Oxford) 2019; 21:1593-1602. [PMID: 31153837 DOI: 10.1016/j.hpb.2019.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/05/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN and compare it with pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy and central pancreatectomy). METHODS A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases. RESULTS Sixteen studies were included in the final analysis comprising 991 patients with 293 EN patients and 698 resected patients. EN was most often performed for low grade (77%, 151/197) BD-IPMN's (99%, 251/253) of the pancreatic head (64%, 106/165), with a pooled mean diameter of 21 mm (SD 28 mm). EN was a shorter procedure (MD -115.8 min, CI -142.2 to -89.5 min, P=<0.001) with a lower rate of post-pancreatectomy haemorrhage (EN 1% 2/144, Resection 5% 10/186, RR 0.32, CI 0.11 to 0.94, P = 0.043) and postoperative exocrine and endocrine insufficiency (P = <0.001 and P = 0.003 respectively) than resection. CONCLUSION EN for BD-IPMN's appears to be a reasonable alternative to resection in low risk BD-IPMN's, allowing preservation of exocrine and endocrine function with comparable reoperation and recurrence rates to resection. However, surveillance was indicated in these low risk patients based on current published guidelines.
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Pärli MS, Müller PC, Müller SA, Ruzza CM, Z'graggen K. Posterior enucleation of the pancreatic head: an alternative route of access for parenchyma-sparing pancreatic resection. Langenbecks Arch Surg 2019; 404:1023-1028. [PMID: 31712896 DOI: 10.1007/s00423-019-01835-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enucleation has become an alternative treatment in benign or low-malignant cystic tumors, including intraductal papillary mucinous neoplasms (IPMN). For enucleation to be a safe alternative to the standard procedures, there must be good access to the resection area. In this report, we present such a route for dorsally situated IPMNs. METHODS The head of the pancreas was exposed by an extended Kocher maneuver to the left lateral edge of the aorta. Stay sutures were placed along the second part of the duodenum to allow maximal rotation of the pancreatic head to the left, which exposed the posterior aspect of the pancreatic head. The cystic lesion was then enucleated followed by a protective pancreaticojejunostomy on the resection cavity. RESULTS Two consecutive patients with IPMNs of the dorsal pancreatic head successfully underwent dorsal enucleation. The postoperative course was uneventful in the first patient, while the course of the second patient was complicated by a clinically relevant pancreatic fistula, delayed gastric emptying, and hospital discharge on day 35. CONCLUSION This study shows the feasibility of a dorsal approach to the pancreatic head for enucleation as well as reconstruction by means of posterior Roux-en-Y pancreaticojejunostomy. In very selected cases in specialized centers, cystic lesions in the posterior aspect of the pancreatic head will become amenable to enucleation with preservation of pancreatic functionality. However, more research is needed to clarify postoperative outcomes of this approach.
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Affiliation(s)
- Michael S Pärli
- Department of Surgery, Klinik Beau-Site, Hirslanden, Schänzlihalde 1, 3013, Bern, Switzerland
| | - Philip C Müller
- Department of Surgery, Klinik Beau-Site, Hirslanden, Schänzlihalde 1, 3013, Bern, Switzerland.,Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Sascha A Müller
- Department of Surgery, Klinik Beau-Site, Hirslanden, Schänzlihalde 1, 3013, Bern, Switzerland
| | - Claudio M Ruzza
- Department of Surgery, Klinik Beau-Site, Hirslanden, Schänzlihalde 1, 3013, Bern, Switzerland
| | - Kaspar Z'graggen
- Department of Surgery, Klinik Beau-Site, Hirslanden, Schänzlihalde 1, 3013, Bern, Switzerland.
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Gerry JM, Poultsides GA. Surgical Management of Pancreatic Cysts: A Shifting Paradigm Toward Selective Resection. Dig Dis Sci 2017; 62:1816-1826. [PMID: 28421458 DOI: 10.1007/s10620-017-4570-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/04/2017] [Indexed: 12/13/2022]
Abstract
Due to the widespread use of high-quality cross-sectional imaging, pancreatic cystic neoplasms are being diagnosed with increasing frequency. Clinicians are therefore asked to counsel a growing number of patients with pancreatic cysts diagnosed incidentally at an early, asymptomatic stage. Over the last two decades, accumulating knowledge on the biologic behavior of these neoplasms along with improved diagnostics through imaging and endoscopic cyst fluid analysis have allowed for a selective therapeutic approach toward these neoplasms. On one end of the management spectrum, observation is recommended for typically benign lesions (serous cystadenoma), and on the other end, upfront resection is recommended for likely malignant lesions (main duct IPMN, mucinous cystadenoma, solid pseudopapillary tumor, and cystic pancreatic neuroendocrine tumors). In between, management of premalignant lesions (branch duct IPMN) is dictated by the presence of high-risk features. In general, resection should be considered whenever the risk of malignancy is higher than the risk of the operation. This review aims to describe the evolution and current status of evidence guiding the selection of patients with pancreatic cystic neoplasms for surgical resection, along with a specific discussion on the type of resection required and expected outcomes.
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Affiliation(s)
- Jon M Gerry
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Sauvanet A, Levy P, Gaujoux S. Comment on: Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms. Surgery 2017; 162:196-197. [PMID: 28196605 DOI: 10.1016/j.surg.2016.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Alain Sauvanet
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Clichy, France; Institut National de la Santé et de la Recherche Médicale, U773, Groupe Hospitalier Paris Nord Val de Seine, Paris, France; Université Paris Diderot, Paris, France.
| | - Philippe Levy
- Institut National de la Santé et de la Recherche Médicale, U773, Groupe Hospitalier Paris Nord Val de Seine, Paris, France; Université Paris Diderot, Paris, France; AP-HP, Hôpital Beaujon, Department of Gastroenterology, PMAD, Clichy, France
| | - Sébastien Gaujoux
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Clichy, France; AP-HP, Hôpital Cochin, Department of Hepato-Pancreato-Biliary and Endocrine Surgery, Paris, France; Université Paris Descartes, Paris, France
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Kaiser J, Fritz S, Klauss M, Bergmann F, Hinz U, Strobel O, Schneider L, Büchler MW, Hackert T. Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms. Surgery 2016; 161:602-610. [PMID: 27884612 DOI: 10.1016/j.surg.2016.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/06/2016] [Accepted: 09/16/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Small, asymptomatic, branch-duct intraductal papillary mucinous neoplasms of the pancreas are often kept under surveillance despite their malignant potential. The management of branch-duct intraductal papillary mucinous neoplasm is controversial with regard to indications and extent of any operative intervention. The present study aimed to evaluate enucleation as an alternative operative approach for branch-duct intraductal papillary mucinous neoplasms to exclude and prevent malignancy. METHODS For branch-duct intraductal papillary mucinous neoplasms of <30 mm in diameter and an acceptable distance from the main pancreatic duct, enucleation was considered as the operative approach of choice. All patients scheduled for enucleation of branch-duct intraductal papillary mucinous neoplasm on the basis of these features between January 2004 and September 2014 were analyzed. Among these, patients with successful enucleation were compared with those who were scheduled for enucleation but converted intraoperatively to pancreatic resection (intention-to-treat analysis). End points were hospital morbidity and mortality as well as histopathology and functional outcome at a mean follow-up of 32 months. RESULTS In the study, 115 patients with presumed branch-duct intraductal papillary mucinous neoplasm and the intention to perform pancreatic enucleation were included; 87 enucleations were performed in 74 patients. In 41 patients, enucleation was converted to a pancreatic resection (procedure-specific success rate 64%); indications for conversion included location or size (46%), presence of multicystic lesions (39%), or involvement of the main pancreatic duct (15%). Of the 74 patients with enucleation, 64 branch-duct intraductal papillary mucinous neoplasms revealed low- (85%), 11% moderate dysplasia-, and 4% high-grade dysplasia on histology. Among converted resections, 6 intraductal papillary mucinous neoplasms revealed high-grade dysplasia or invasive carcinoma (15%). Intention-to-treat analysis with patients converted to pancreatic resection showed that enucleations resulted in less blood loss (100 vs 400 mL) and a shorter operation time (146 vs 255 minutes; P < .001 each). Postoperative morbidity including postoperative pancreatic fistula was similar in both groups. No mortality occurred after enucleation; after formal resection, 1 patient died due to multiorgan failure. Both hospital stay (10 vs 14 days) and rates of postoperative endocrine and exocrine dysfunction rates were less after enucleation (P < .02 each). Intraductal papillary mucinous neoplasm-specific recurrence rates (3% vs 6%) were similar in both groups. CONCLUSION Enucleation is a safe procedure that can be performed successfully in a high proportion of branch-duct intraductal papillary mucinous neoplasms and should be considered instead of standard resections as an important function-preserving alternative. Limitations may occur due to malignancy, size, localization, multilocularity, or main-duct involvement requiring conversion to a formal, anatomic resection. Beside the advantages in the short-term course, functional outcome seems to be superior after enucleation, and intraductal papillary mucinous neoplasm-specific recurrence rates are not increased compared with standard resections, at least at a mean follow-up of 32 months.
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Affiliation(s)
- Joerg Kaiser
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefan Fritz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Department of General and Visceral Surgery, Katharinenhospital, Stuttgart, Germany
| | - Miriam Klauss
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lutz Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Chua TC, Yang TX, Gill AJ, Samra JS. Systematic Review and Meta-Analysis of Enucleation Versus Standardized Resection for Small Pancreatic Lesions. Ann Surg Oncol 2015; 23:592-9. [PMID: 26307231 DOI: 10.1245/s10434-015-4826-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The appropriate surgical strategy in patients with small pancreatic lesions of low malignant potential, such as pancreatic neuroendocrine tumors, remains unknown. Increasing reports suggest limited pancreatic surgery may be a safe option for parenchymal preservation. METHODS PubMed and MEDLINE were searched in the English literature for studies from January 2000 to February 2015 examining enucleation for pancreatic lesions that were single-arm and comparative studies (versus resection). Single-arm enucleation studies were systematically reviewed. Comparative studies were included for meta-analysis. Endpoints include safety, complications, mortality, survival, and parenchymal-related outcomes. RESULTS Thirteen studies comprising of 1101 patients undergoing enucleation were included. Seven studies were comparative studies of enucleation and standardized pancreatic resection. Enucleation was a shorter procedure (pooled mean differences (MD) = 109, 95 % confidence interval (CI) 105-114; Z = 46.37; P < 0.001) associated with less blood loss (pooled MD = 314, 95 % CI 297-330; Z = 37.47; P < 0.001). Both enucleation and resection had similar mortality and complication rates, but the rate of pancreatic fistula (all grades) (pooled odds ratio (OR) = 1.99; 95 % CI 1.2-3.4; Z = 2.57; P = 0.01] and rate of pancreatic fistula (grade B/C) (pooled OR = 1.58; 95 % CI 1.0-2.5; Z = 2.06; P = 0.04) was higher in the enucleation group. Enucleation resulted in lower rates of endocrine (pooled OR = 0.22; 95 % CI 0.1-0.5; Z = 3.21; P = 0.001) and exocrine (pooled OR = 0.07; 95 % CI 0.02-0.2; Z = 5.08; P < 0.001) insufficiency. The median 5-year survival was 95 % (range 93-98) and 84 % (range 79-90). CONCLUSIONS Enucleation appears to be a safe procedure and achieves parenchymal preservation for small pancreatic lesions of low malignant potential. Its oncologic efficacy compared with standardized pancreatic resection with respect to long-term survival and recurrences have not been reported adequately and hence may not be concluded as being comparable.
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Affiliation(s)
- Terence C Chua
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia. .,Discipline of Surgery, University of Sydney, Sydney, NSW, Australia.
| | - Timothy X Yang
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Discipline of Surgery, University of Sydney, Sydney, NSW, Australia
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,University of Sydney, Sydney, NSW, Australia.,Deparment of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jaswinder S Samra
- Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia. .,Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia.
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Thomas E, Matsuoka L, Alexopoulos S, Selby R, Parekh D. Laparoscopic Hand-Assisted Parenchymal-Sparing Resections for Presumed Side-Branch Intraductal Papillary Mucinous Neoplasms. J Laparoendosc Adv Surg Tech A 2015. [PMID: 26200132 DOI: 10.1089/lap.2014.0669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Elizabeth Thomas
- 1 Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Florida , Gainesville, Florida
| | - Lea Matsuoka
- 2 Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck Medical Center of University of Southern California , Los Angeles, California
| | - Sophoclis Alexopoulos
- 2 Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck Medical Center of University of Southern California , Los Angeles, California
| | - Rick Selby
- 2 Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck Medical Center of University of Southern California , Los Angeles, California
| | - Dilip Parekh
- 2 Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck Medical Center of University of Southern California , Los Angeles, California
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Hüttner FJ, Koessler-Ebs J, Hackert T, Ulrich A, Büchler MW, Diener MK. Meta-analysis of surgical outcome after enucleation versus standard resection for pancreatic neoplasms. Br J Surg 2015; 102:1026-36. [PMID: 26041666 DOI: 10.1002/bjs.9819] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/28/2015] [Accepted: 03/05/2015] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - J Koessler-Ebs
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - A Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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Song KB, Kim SC, Hwang DW, Lee JH, Lee DJ, Lee JW, Jun ES, Sin SH, Kim HE, Park KM, Lee YJ. Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients. Surgery 2014; 158:1203-10. [PMID: 25633730 DOI: 10.1016/j.surg.2014.10.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 10/12/2014] [Accepted: 10/17/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Standard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as pancreatic function. The aim of this study was to evaluate the postoperative clinical outcomes and long-term functional and oncologic results after pancreatic enucleation, and to compare the clinical results of laparoscopic and open enucleation. METHODS From March 2005 to December 2013, 65 cases of enucleation of benign tumors in the pancreas were identified through a retrospective review of medical records. RESULTS Most of the patients were women (73.8 %), and the median age was 52.7 years (interquartile range 43.1-60.9 years). Median tumor size was 2.5 cm (interquartile range 1.6-3.8 cm). The most common indication for enucleation was pancreatic neuroendocrine tumor (24, 36.9%). A clinically relevant pancreatic fistula (International Study Group on Pancreatic Fistula grade B, C) was reported in 6 patients (9.2%). The patients with tumors of the pancreatic neck had more complications after enucleation than those with tumors at other locations (3/4, 75%). There were no differences of clinical outcomes between open and laparoscopic enucleation groups. At a median follow-up of 58.7 months there was one case of new-onset diabetes, and there were no recurrences or deaths. CONCLUSION Enucleation is a safe and effective procedure for the treatment of benign and borderline pancreatic neoplasms. It preserves pancreatic function and is not associated with recurrence. The incidence of postoperative complications, including pancreatic fistula, is acceptable. Laparoscopic enucleation seems to be a feasible and safe approach associated with favorable perioperative outcomes for the selected patients.
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Affiliation(s)
- Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea.
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Dong Joo Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Jung Woo Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Eun Sung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Sang Hyun Sin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Heung En Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Kwang-Min Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
| | - Young-Joo Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea
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Parenchyma-Sparing Pancreatectomy for Presumed Noninvasive Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2014; 260:364-71. [DOI: 10.1097/sla.0000000000000601] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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12
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Abstract
INTRODUCTION AND PURPOSE Despite being technically challenging, minimally-invasive pancreatic surgery is increasingly being used to treat pancreatic diseases. Therefore, the evaluation of its oncological safety and its advantages arebecoming increasingly more important. This review focuses on these questions based on the currently available literature. MATERIAL AND METHODS The technically less demanding laparoscopic distal pancreatectomy has been evaluated in numerous meta-analyses. Minimally invasive pancreaticoduodenectomy has only been reported from a few centers worldwide. RESULTS AND CONCLUSION Minimally invasive pancreatic surgery, in particular laparoscopic distal pancreatectomy, is increasingly being used to treat pancreatic tumors. The advantages of laparoscopy, such as less intraoperative blood loss, reduced postoperative pain and a shorter length of stay have all been demonstrated in large trials. However, a sufficient oncological treatment was only assessed via indirect surrogate parameters, such as the number of lymph nodes obtained and R0 resection rates; therefore, larger prospective trials are needed to prove adequate oncological treatment. To date, minimally invasive techniques should only be employed in trials on treatment of pancreatic malignancies.
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Abstract
AbstractPancreatic cysts involve a wide spectrum of pathologies from post-inflammatory cysts to malignant neoplasms. Pancreatic pseudocysts, serous cystadenomas, mucinous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary tumors occur most frequently. Differential diagnosis involves the following imaging investigations: transabdominal ultrasonography (TUS), contrast enhanced ultrasonography (CEUS) and endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance (MR) and magnetic resonance cholangiopancretography (MRCP), endoscopic retrograde cholangiopancretography (ERCP). The cyst fluid cytology is performed in difficult differential diagnosis between pseudocysts and benign and potentially malignant or malignant tumors. Most frequently, viscosity, amylase, CEA and CA 19-9 levels are determined. Imaging findings should be correlated with cytology. The management depends on the cyst type and size. Small asymptomatic pseudocysts, serous cystadenomas and branchduct IPMNs should be carefully observed, whereas symptomatic large or uncertain serous cystadenomas and cystadenocarcinomas, mucinous cystadenomas and cystadenocarcinomas, main-duct IPMNs and large branch-duct IPMNs with malignant features, serous and mucinous cystadenocarcinomas, and solid pseudopapillary tumors require surgery. Pseudocysts are usually drained. Percutaneous / EUS-guided or surgical cyst drainage can be performed. Complicated and uncertain pseudocysts and cystic tumors need surgical resection. The type of surgery depends on cyst location and size and includes proximal, central, distal, total pancreatectomies and enucleation.
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Frankel TL, LaFemina J, Bamboat ZM, D'Angelica MI, DeMatteo RP, Fong Y, Kingham TP, Jarnagin WR, Allen PJ. Dysplasia at the surgical margin is associated with recurrence after resection of non-invasive intraductal papillary mucinous neoplasms. HPB (Oxford) 2013; 15:814-21. [PMID: 23782351 PMCID: PMC3791121 DOI: 10.1111/hpb.12137] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/11/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The significance of a positive margin in resected non-invasive pancreatic intraductal papillary mucinous neoplasms (IPMN) remains controversial. The aim of this study was to determine recurrence rates when dysplasia was present at the final surgical margin. METHODS A prospectively maintained database identified 192 patients undergoing resection of non-invasive IPMN. Pathological, peri-operative and recurrence data were analysed. RESULTS Ductal dysplasia was identified at the final surgical margin in 86 patients (45%) and defined as IPMN or Pancreatic Intraepithelial Neoplasia PanIN in 38 (20%) and 54 (28%) patients, respectively. At a median follow-up of 46 months, 40 (21%) patients recurred with 31 developing radiographical evidence of new cysts, 6 re-resected for IPMN and 3 diagnosed with pancreatic cancer within the remnant. Of those with margin dysplasia, 31% developed recurrent disease compared with 13% in those without dysplasia (P = 0.002). On multivariate analysis, margin dysplasia was associated with a three-fold increased risk of recurrence (P = 0.02). No relationship between dysplasia and development of pancreatic cancer was found. DISCUSSION In this study, dysplasia at the margin after a pancreatectomy for non-invasive IPMN was associated with recurrence in the remnant gland, but not at the resection margin. While this finding may warrant closer follow-up, it does not identify a gland at higher risk for the subsequent development of invasive disease.
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MESH Headings
- Aged
- Carcinoma in Situ/pathology
- Carcinoma in Situ/surgery
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Carcinoma, Papillary/pathology
- Carcinoma, Papillary/surgery
- Chi-Square Distribution
- Female
- Humans
- Kaplan-Meier Estimate
- Logistic Models
- Male
- Multivariate Analysis
- Neoplasm Recurrence, Local/etiology
- Neoplasm, Residual
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatectomy/adverse effects
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Risk Factors
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Timothy L Frankel
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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15
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Laparoscopic pancreatic resections. Langenbecks Arch Surg 2013; 398:939-45. [PMID: 24006117 DOI: 10.1007/s00423-013-1108-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade. METHODS In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide. RESULTS AND CONCLUSIONS Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.
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Mazza O, de Santibanes M, Cristiano A, Pekolj J, de Santibañes E. [Laparoscopic enucleation of a peripheral branch intraductal papillary mucinous neoplasm situated in the pancreatic head. A new alternative]. Cir Esp 2013; 92:291-3. [PMID: 23827930 DOI: 10.1016/j.ciresp.2012.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 10/01/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Oscar Mazza
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Martín de Santibanes
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Agustín Cristiano
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Sección de Cirugía Hepatobiliopancreática, Departamento de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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