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Gharios J, Hain E, Dohan A, Prat F, Terris B, Bertherat J, Coriat R, Dousset B, Gaujoux S. Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas. Best Pract Res Clin Endocrinol Metab 2019; 33:101294. [PMID: 31351817 DOI: 10.1016/j.beem.2019.101294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic neuroendocrine tumours (PanNET) are rare tumours, accounting for 1%-2% of all pancreatic neoplasms. These tumors are classified as functioning neuroendocrine tumours (F-PanNETs) or non-functioning (NF-PanNETs) depends on whether the tumour is associated with clinical hormonal hypersecretion syndrome or not. In the last decades, diagnosis of PanNETs has increased significantly due to the widespread of cross-sectional imaging. Whenever possible, surgery is the cornerstone of PanNETs management and the only curative option for these patients. Indeed, after R0 resection, the 5-year overall survival rate is around 90-100% for low grade lesions but significantly drops after incomplete resections. Compared to standard resections, pancreatic sparing surgery, i.e. enucleation and central pancreatectomy, significantly decreased the risk of pancreatic insufficiency. It should be performed in patients with good general condition and normal pancreatic function to limit the operative risk and enhance the benefit of surgery. Nowadays, due to many known advantages of minimally invasive surgery, there is an ongoing trend towards laparoscopic and robotic pancreatic surgery. The aim of this study is to describe the pre- and intraoperative diagnostic requirements for the management of PanNETs and the benefits and risks of minimally invasive surgery including laparoscopic and robotic approach in view of the recent literature.
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Affiliation(s)
- Joseph Gharios
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Elisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Anthony Dohan
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Radiology, Cochin Hospital, APHP, Paris, France
| | - Fréderic Prat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Benoit Terris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Pathology, Cochin Hospital, APHP, Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Endocrinology, Cochin Hospital, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Romain Coriat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France.
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Duan F, Bai YH, Cui L, Yan JY, Li XH, Wang XQ. CT during celiac artery angiography for localization of clinically suspected small insulinomas. Cancer Imaging 2018; 18:22. [PMID: 29941018 PMCID: PMC6020203 DOI: 10.1186/s40644-018-0155-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/13/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND To identify location and number of insulinomas before operation is very important for improving the cure rate. The objective of the study was to assess performance of CT during celiac artery angiography for preoperative localization of clinically suspected small insulinomas (< 2 cm in diameter). METHODS From January 2013 to November 2016, 42 patients with hypoglycemic symptoms underwent celiac artery angiography, superior mesenteric artery angiography and CT during celiac artery angiography by a combined CT/digital subtraction angiography system, MIYABI Angio CT plus an Artiszeeceiling (SIEMENS, Germany). Patient group consisted of 13 males and 29 females, age 17-69 years (average, 45.4 ± 13.5 y). After diagnosis, all 42 patients were operated. Obtained images were retrospectively analyzed and compared with findings from post-operation pathology. RESULTS All interventional radiology procedures were performed successfully with no complications. Sensitivity of angiography alone for insulinoma was 76.1% (32/42), at combined CT/digital subtraction angiography, 4 more nodules were found (sensitivity, 85.7%, 36/42), while 6 false-negatives were observed (all false negative lesions were less than 2 cm). A total of 64 ml to 80 ml contrast media was used per patient. CONCLUSION CT during celiac artery angiography is a sensitive diagnostic procedure for localizing insulinomas. Combined with angiography, it can prioritize the pancreatic region for exploration and guide a pancreatic resection. TRIAL REGISTRATION Ethical approval was obtained from the Hospital Research Ethics Committee. Informed consent was obtained from all patients included in the study. Duan Feng, Bai Yan-hua and Cui Li are co-first authors.
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Affiliation(s)
- Feng Duan
- Department of Interventional Radiology, the General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
| | - Yan-Hua Bai
- Department of Interventional Radiology, the General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Li Cui
- Department of Interventional Radiology, the General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Jie-Yu Yan
- Department of Interventional Radiology, the General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Xiao-Hui Li
- Department of Interventional Radiology, the General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Xiu-Qi Wang
- Department of Interventional Radiology, the General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
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Casadei R, Ricci C, D'Ambra M, Marrano N, Alagna V, Rega D, Monari F, Minni F. Laparoscopic versus open distal pancreatectomy in pancreatic tumours: a case-control study. Updates Surg 2016; 62:171-4. [PMID: 21052893 DOI: 10.1007/s13304-010-0027-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Laparoscopic distal pancreatectomy has become an increasingly used procedure in the surgical treatment of benign or borderline cystic and endocrine tumours. The feasibility and safety of this technique is well known but its results when compared with open distal pancreatectomy were rarely reported in literature. Data from 22 consecutive patients who underwent laparoscopic distal pancreatectomy were recorded in a prospective database from January 2006 to January 2010. These patients were matched with 22 patients who underwent open distal pancreatectomy from January 2000 to December 2005, regarding age, gender, American Society of Anesthesiologists score, pancreatic pathology. Intraoperative parameters and postoperative outcome were compared between the two groups. Blood loss, amount of analgesic drugs administered, postoperative mortality and morbidity and pancreatic fistula rate were similar in laparoscopic and open groups. Tumour size was significantly smaller in laparoscopic group (2.0 ± 3.3 vs. 5.0 ± 4.2 cm; P = 0.038). Operative time was significantly shorter in open group (145 ± 49 vs. 225 ± 83 min, P = 0.045). Time to adequate oral intake and length of postoperative hospital stay were significantly better in laparoscopic group than in open group (3.0 ± 0.8 vs. 4.0 ± 0.7 days; P = 0.030 and 8.0 ± 1.3 vs. 11.0 ± 3.0 days; P = 0.011, respectively). Laparoscopic distal pancreatectomy is a feasible and safe surgical approach as well as open distal pancreatectomy.
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Affiliation(s)
- Riccardo Casadei
- Dipartimento di Scienze Chirurgiche e Anestesiologiche, Chirurgia Generale-Minni, Alma Mater Studiorum, Università di Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti, 9, 40138, Bologna, Italy,
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4
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A systematic review and meta-analysis of spleen-preserving distal pancreatectomy with preservation or ligation of the splenic artery and vein. Surgeon 2016; 14:109-18. [DOI: 10.1016/j.surge.2015.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/24/2015] [Accepted: 11/20/2015] [Indexed: 01/19/2023]
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Fernandez Ranvier GG, Shouhed D, Inabnet WB. Minimally Invasive Techniques for Resection of Pancreatic Neuroendocrine Tumors. Surg Oncol Clin N Am 2015; 25:195-215. [PMID: 26610782 DOI: 10.1016/j.soc.2015.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Surgical resection remains the treatment of choice for primary pancreatic neuroendocrine tumors (PNETs), because it is associated with increased survival. Minimally invasive procedures are a safe modality for the surgical treatment of PNETs. In malignant PNETs, laparoscopy is not associated with a compromise in terms of oncologic resection, and provides the benefits of decreased postoperative pain, better cosmetic results, shorter hospital stay, and a shorter postoperative recovery period. Further prospective, multicenter, randomized trials are required for the analysis of these minimally invasive surgical techniques for the treatment of PNETs and their comparison with traditional open pancreatic surgery.
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Affiliation(s)
- Gustavo G Fernandez Ranvier
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 East 98 street, box 1259, New York, NY 10029, USA
| | - Daniel Shouhed
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 5 East 98 street, box 1259, New York, NY 10029, USA
| | - William B Inabnet
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, First Ave at 16th street, Baird Hall, Suite 16BH20, New York, NY 10003, USA.
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6
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Initial Experience in Total Laparoscopic Central Pancreatectomy with Pancreatogastrostomy. Cell Biochem Biophys 2014; 71:1023-8. [DOI: 10.1007/s12013-014-0304-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Björnsson B, Sandström P. Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas. World J Gastroenterol 2014; 20:13402-13411. [PMID: 25309072 PMCID: PMC4188893 DOI: 10.3748/wjg.v20.i37.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/11/2014] [Accepted: 04/23/2014] [Indexed: 02/07/2023] Open
Abstract
Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.
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8
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Matsushima H, Kuroki T, Adachi T, Kitasato A, Hirabaru M, Hidaka M, Soyama A, Takatsuki M, Eguchi S. Laparoscopic spleen-preserving distal pancreatectomy with and without splenic vessel preservation: the role of the Warshaw procedure. Pancreatology 2014; 14:530-5. [PMID: 25306307 DOI: 10.1016/j.pan.2014.09.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/18/2014] [Accepted: 09/19/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for low-grade malignant pancreas tumors was recently demonstrated. Although the procedure with splenic vessel preservation (SVP) is optimal for LSPDP, SVP is not always possible in patients with a large tumor or a tumor attached to splenic vessels. This study aimed to analyze the safety of two procedures: LSPDP without SVP, known as the Warshaw technique (lap-WT), and LSPDP with SVP (lap-SVP). METHODS Seventeen patients who underwent a lap-WT and seven patients who underwent a lap-SVP were investigated retrospectively. RESULTS The median follow-up duration was 45 (range 17-105) months. In the lap-WT and lap-SVP patients, the sizes of the tumors were 5 (1.3-12) and 1.5 (1-4) cm; the operative times were 304 (168-512) and 319 (238-387) min; the blood loss was 210 (5-3250) and 60 (9-210) gr; the length of the postoperative hospital stay was 15 (8-29) and 18 (5-24) days; the peak platelet counts were 37.2 (14.6-65.2) and 26.4 (18.8-41) × 10(4)/μL, and splenomegaly was observed in 10 (59%) and three (43%) patients, respectively. In both procedures, there was no local recurrence. In the lap-WT group, splenic infarctions were seen in four (24%) patients and perigastric varices were seen in two (12%) patients. All of these patients were observed conservatively. CONCLUSIONS Both the lap-WT and lap-SVP were found to be safe and effective, and in cases in which the tumor is relatively large or close to the splenic vessels, lap-WT can be used as the more appropriate procedure.
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Affiliation(s)
- Hajime Matsushima
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Tamotsu Kuroki
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Amane Kitasato
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Masataka Hirabaru
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Al-Kurd A, Chapchay K, Grozinsky-Glasberg S, Mazeh H. Laparoscopic resection of pancreatic neuroendocrine tumors. World J Gastroenterol 2014; 20:4908-4916. [PMID: 24803802 PMCID: PMC4009522 DOI: 10.3748/wjg.v20.i17.4908] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/06/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are a rare heterogeneous group of endocrine neoplasms. Surgery remains the best curative option for this type of tumor. Over the past two decades, with the development of laparoscopic pancreatic surgery, an increasingly larger number of PNET resections are being performed by these minimally-invasive techniques. In this review article, the various laparoscopic surgical options for the excision of PNETs are discussed. In addition, a summary of the literature describing the outcome of these treatment modalities is presented.
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Abstract
These authors conclude that laparoscopic distal pancreatectomy can be safely and effectively performed by surgeons skilled in basic laparoscopy and does not require specialized training or to be performed in a specialized center. Background: Laparoscopic management of distal pancreatic malignancies has been slow to gain a foothold in all but high-volume tertiary referral centers. The aim of this study was to assess the safety and outcomes of laparoscopic distal pancreatectomy (LDP) performed in a low-volume community hospital by a diverse group of surgeons, none of whom have a specialized laparoscopic background. Methods: We conducted a retrospective review of all patients who underwent open distal pancreatectomies (ODPs) and LDPs between August 2001 and June 2008. Data included type of surgery, open versus laparoscopy, demographics, operative time, blood loss, length of hospital stay, histopathologic diagnosis, postoperative complications, American Society of Anesthesiologists score, and mortality. Results: Twenty-seven patients with pancreatic masses underwent distal pancreatic resection during the study period. Fifty-nine percent (n = 16) underwent LDP, and 41% (n = 11) underwent ODP. Mean patient age was 66 y (range, 40 to 86) for the LDP group and 62 (range, 40 to 84) for the ODP group. Mean operative time was 231 min (range, 195 to 305) for LDP and 240 (range, 150 to 210) for the ODP technique. Mean length of stay for LDP and ODP was 8 (range, 3 to 22) and 12 d (range, 5 to 2), respectively. Morbidity was 25% (n = 4) in the LDP group and 36% (n = 4) in the ODP group. None of the differences between the LDP and ODP groups were statistically significant. No mortalities occurred in either group. Conclusion: This study supports the idea that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and may not require specialized training or a specialized center. Further data are required to make more definitive conclusions.
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Hartmann D, Michalski CW, Kleeff J. Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Pankreas - Kontra-Position. Visc Med 2013; 29:375-381. [DOI: 10.1159/000357173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
<b><i>Hintergrund: </i></b>Für eine Vielzahl von Erkrankungen der Bauchspeicheldrüse gilt die chirurgische Resektion als die Therapie der Wahl. In den vergangenen Jahren wurden die offenen Operationsmethoden für Pankreaserkrankungen zunehmend standardisiert und können mittlerweile mit hoher Sicherheit durchgeführt werden. Unabhängig davon wird zunehmend über laparoskopische Pankreasresektionen berichtet. <b><i>Methode: </i></b>In diesem Artikel stellen wir die aktuelle Literatur zur minimalinvasiven Chirurgie der Bauchspeicheldrüse vor, um sie mit offenen Operationsverfahren zu vergleichen. Besondere Berücksichtigung finden laparoskopische und roboterassistierte Duodenopankreatektomien sowie laparoskopische Pankreasschwanzresektionen bei Patienten mit chronischer Pankreatitis sowie mit gutartigen und bösartigen Tumoren. <b><i>Ergebnisse: </i></b>Laparoskopische und roboterassistierte Pankreaskopfresektionen sollten nur in ausgewählten Fällen angewandt werden und gelten als technisch äußerst anspruchsvoll - mit einer erhöhten Inzidenz von Pankreasfisteln. Laparoskopische Pankreasschwanzresektionen sind sichere Verfahren mit einem Trend zu einer kürzeren Krankenhausaufenthaltsdauer, sollten jedoch nur für gutartige Tumoren in Betracht gezogen werden. Im Rahmen der onkologischen Chirurgie sollte die offene Pankreasresektion bevorzugt werden. Werden onkologische Eingriffe laparoskopisch durchgeführt, ist eine ausgezeichnete präoperative Diagnostik und gegebenenfalls der Einsatz eines intraoperativen laparoskopischen Ultraschalls notwendig. <b><i>Schlussfolgerungen: </i></b>Obwohl laparoskopische Pankreasresektionen in ausgewählten Fällen von Nutzen sein können, werden sie zukünftig wohl eher die Ausnahme darstellen. Eine allgemeine Umstellung auf laparoskopische Pankreasschwanzresektionen wird aufgrund des Mangels an eindeutigen Vorteilen gegenüber dem offenen Verfahren höchstwahrscheinlich nicht stattfinden.
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Zhao YP, Du X, Dai MH, Zhang TP, Liao Q, Guo JC, Cong L, Chen G. Laparoscopic distal pancreatectomy with or without splenectomy: spleen-preservation does not increase morbidity. Hepatobiliary Pancreat Dis Int 2012; 11:536-41. [PMID: 23060401 DOI: 10.1016/s1499-3872(12)60220-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The indications for laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and its morbidity compared with laparoscopic distal pancreatectomy with splenectomy (LDPS) are ill-defined. This study aimed to share the indications for spleen-preservation and investigate the safety and outcome of LSPDP at our institution. METHODS A retrospective review of patients who were scheduled to receive laparoscopic surgery for distal pancreatic lesions was conducted. The indications, surgical procedures, intra-operative data, and outcomes of the two procedures were collected and compared by statistical analysis. RESULTS LDPS and LSPDP were successfully performed in 16 and 21 patients respectively, whereas they were converted to open surgery in 9 patients. There were no significant differences in age, gender, operation time, blood loss, and conversion rate between the LDPS and LSPDP groups. The mean tumor size showed an inter-group difference (5.05 vs 2.53 cm, P<0.001). There were no significant differences in complication and morbidity rates between the two groups. All patients remained alive without recurrence during a follow-up of 9 to 67 months (median 35). CONCLUSION LSPDP has a morbidity and outcome comparable to LDPS.
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Affiliation(s)
- Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
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Soh YF, Kow AWC, Wong KY, Wang B, Chan CY, Liau KH, Ho CK. Perioperative outcomes of laparoscopic and open distal pancreatectomy: our institution's 5-year experience. Asian J Surg 2012; 35:29-36. [PMID: 22726561 DOI: 10.1016/j.asjsur.2012.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/25/2011] [Accepted: 12/11/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Application of minimally invasive techniques in the surgical management of distal pancreatic lesions is increasing. Despite this, numbers of laparoscopic distal pancreatectomy remain low and limited to treatment of benign and premalignant lesions. METHODS Retrospective analysis of 31 patients who underwent distal pancreatectomy from 2005 to 2010. Patients were grouped according to mode of surgical access: open (ODP) or laparoscopic (LDP). Perioperative parameters were compared. RESULTS Twenty-one (67.7%) patients underwent ODP and 10 (32.3%) LDP (median age 61; 80.0% females in LDP group, p = 0.030). Postoperative morbidity rate were comparable between the two groups. In the LDP group, there were significantly lower estimated blood loss (p < 0.001) and amount of blood transfusion (p = 0.001), smaller tumor size (p = 0.010) and fewer lymph nodes harvested (p = 0.020), shorter postoperative length of stay (p = 0.020), and shorter length of stay in surgical high dependency (p = 0.001). CONCLUSION LDP is a safe, efficient technique for resection of benign and premalignant pancreatic lesions. Indices reflecting perioperative outcomes in this study are highly competitive with those in other major centers.
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Affiliation(s)
- Yu Feng Soh
- Department of Surgery, Digestive Disease Centre, Tan Tock Seng Hospital, Singapore
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Laparoscopic resection of epidermoid cyst arising from an intrapancreatic accessory spleen: a case report with a review of the literature. Surg Laparosc Endosc Percutan Tech 2012; 21:e275-9. [PMID: 22002295 DOI: 10.1097/sle.0b013e31822dd14a] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We describe a rare case of epidermoid cyst arising in an intrapancreatic accessory spleen that presented as a cystic mass in the tail of the pancreas, and for which laparoscopic distal pancreatectomy was performed successfully. A 36-year-old woman with a cystic mass in the tail of the pancreas, which had been discovered incidentally at a medical checkup, was referred to our department for further examination. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography and positron emission tomography demonstrated a multilocular cyst in the tail of the pancreas without any evidence of malignancy, although differential diagnosis was extremely difficult because of the neoplasm-like appearance of the lesion. Therefore, we performed laparoscopic distal pancreatectomy under a preoperative diagnosis of mucinous cystic neoplasm. Postoperative pathologic examination demonstrated an epidermoid cyst arising from a heterotopic spleen within the pancreas. This is the first report of successful laparoscopic distal pancreatectomy for an epidermoid cyst arising in an intrapancreatic accessory spleen. One virtually has no chance to diagnose an epidermoid cyst in an accessory spleen on the basis of preoperative diagnostic workup, and consequently the type of surgical resection (open vs. laparoscopic) would be conditioned by factors other than the clinical entity suspected at the preoperative period.
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15
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Zhang T, Du X, Zhao Y. Laparoscopic surgery for pancreatic lesions: current status and future. Front Med 2011; 5:277-82. [DOI: 10.1007/s11684-011-0147-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 07/05/2011] [Indexed: 02/08/2023]
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Richards ML, Thompson GB, Farley DR, Kendrick ML, Service JF, Vella A, Grant CS. Setting the bar for laparoscopic resection of sporadic insulinoma. World J Surg 2011; 35:785-9. [PMID: 21293961 DOI: 10.1007/s00268-011-0970-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Laparoscopic insulinoma resection (LIR) for sporadic disease is increasingly supported as a feasible and safe operation in small series of patients. To determine whether LIR is an acceptable alternative to the open operation, it is necessary to compare LIR to historical controls. The purpose of this study was to identify the skills and technology needed for LIR and establish outcome standards. METHODS A database of patients with benign sporadic insulinoma who underwent an open procedure at the Mayo Clinic was reviewed for demographics, imaging, operative/pathology reports, and outcomes. Outcomes were compared to a world-wide meta-analysis of patients who had undergone LIR reported in the English literature between 1996 and 2009. RESULTS Two hundred fifteen patients underwent a primary open operation for benign sporadic insulinoma. Solitary tumors were found in 97%. Meta-analysis identified 232 patients who underwent LIR. The open and LIR groups underwent comparable operations that included enucleations (64 vs. 68%) and distal pancreatectomies (28 vs. 35%) (p = 0.06). The mean estimated blood loss, operating time, and length of stay were comparable between the open and LIR groups (p = NS). Pancreatic fistula occurred more often in the LIR group (24 vs. 11%, p < 0.05). A curative operation was performed in 98% of control patients and in 99% of the LIR group (p = NS). CONCLUSIONS Multiple insulinomas are rare and a focused resection guided by imaging may be performed. LIR is associated with an increased incidence of pancreatic fistula. Success of LIR will depend on accurate multimodality preoperative imaging, skilled use of lap-US to replace palpation for localization, and safe methods to dissect the tumor adjacent to the pancreatic duct.
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Affiliation(s)
- Melanie L Richards
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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17
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Ammori BJ, Ayiomamitis GD. Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a UK experience and a systematic review of the literature. Surg Endosc 2011; 25:2084-99. [PMID: 21298539 DOI: 10.1007/s00464-010-1538-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 12/02/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Advances in operative techniques and technology have facilitated laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD). METHODS All distal pancreatectomies were attempted laparoscopically, while selected patients underwent LPD. The literature was systematically reviewed. RESULTS Between 2002 and 2008, 21 patients underwent LDP (n=14) or LPD (n = 7). The mean operating time, blood loss, and hospital stay after LDP were 265 min, 262 ml, and 7.7 days, respectively, and after LPD they were 628 min, 350 ml, and 11.1 days, respectively. The conversion, morbidity, pancreatic fistula, readmission, reoperation, and mortality after LDP were 7.1, 35.7, 28.4, 28.4, 0, and 7.1% respectively, and after LPD they were 0, 28.6, 14.3, 28.6, 0, and 0% respectively. The literature review identified 987 LDP and 126 LPD. Most LDP were for benign disease (83.9%) while most LPD were for malignancy (91.5%). The mean operating time, morbidity, pancreatic fistula, mortality, and hospital stay after LDP were 221.5 min, 24.7%, 16.4%, 0.4%, and 7.7 days, respectively, and after LPD they were 448.3 min, 28.6%, 11.6%, 2.1%, and 16 days, respectively. CONCLUSION LDP, particularly for benign disease and low-grade malignancy, is increasingly becoming the gold standard approach in experienced hands. In selected patients, LPD is feasible and safe. Long-term follow-up data are needed.
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Affiliation(s)
- Basil J Ammori
- Department of Hepato-Pancreato-Biliary Surgery, North Manchester General Hospital, and The University of Manchester, Delaunays Road, Manchester, UK.
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18
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Laparoscopic distal pancreatectomy for solid and cystic pancreatic neoplasms: outpatient postoperative management. Surg Laparosc Endosc Percutan Tech 2011; 19:470-3. [PMID: 20027089 DOI: 10.1097/sle.0b013e3181c4775f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy is a challenging procedure that has been reported in the last decade. The aim of this study is to describe our experience with laparoscopic distal pancreatectomy and an outpatient postoperative management after an early hospital discharge. METHODS Retrospective study of 11 laparoscopic distal pancreatectomies carried out at our institution between November 2005 and June 2007 for cystic and solid pancreatic neoplasms. Mean age was 55.5 years and 10 patients were females. A splenopancreatectomy was carried out in 9 cases, and a spleen-preserving resection was carried out in 2 cases. RESULTS Mean blood loss was 73.6 mL and mean operative time was 238.3 minutes. Patients were able to tolerate regular diet after a mean of 1.2 days and were discharged with a drain after a mean of 2.3 days. Two patients developed a mild pancreatic fistula that resolved with conservative management. One patient developed a pancreatic pseudocyst that was followed up with an MRI. CONCLUSIONS Laparoscopic distal pancreatectomy is feasible with a fast postoperative recovery. We recommend close follow-up of the patient in the outpatient clinic and maintaining the intraabdominal drain until a pancreatic fistula can be ruled out based on biochemical analysis of the fluid.
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Affiliation(s)
- Sam Pappas
- Medical College of Wisconsin, Department of Surgery and Froedtert Memorial Lutheran Hospital, Nutrition Services Department, Milwaukee, Wisconsin
| | - Elizabeth Krzywda
- Medical College of Wisconsin, Department of Surgery and Froedtert Memorial Lutheran Hospital, Nutrition Services Department, Milwaukee, Wisconsin
| | - Nadine Mcdowell
- Medical College of Wisconsin, Department of Surgery and Froedtert Memorial Lutheran Hospital, Nutrition Services Department, Milwaukee, Wisconsin
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20
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Katayama A, Iseda I, Tone A, Matsushita Y, Inoue K, Tsukamoto K, Yamashita H, Yamadori I, Wada J, Hida K. The usefulness of super-selective computed tomography angiography (CTA) for diagnosing and localizing a small insulinoma. Intern Med 2010; 49:1983-6. [PMID: 20847503 DOI: 10.2169/internalmedicine.49.3739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Localization of insulinomas by preoperative imaging is critical for successful surgical resection. However, the visualization and localization of small insulinomas by recent imaging modalities still remains a challenge. Here, we report a 77-year-old woman with a small insulinoma successfully localized by performing arterial stimulation and venous sampling (ASVS), and subsequent super-selective CTA (SSCTA). It was not visualized by routine non-invasive imaging tests such as digital subtraction angiography (DSA). The small size (1.0 cm) of the surgically removed tumor supports the usefulness of SSCTA for localizing very small insulinomas.
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Affiliation(s)
- Akihiro Katayama
- Department of Diabetology and Metabolism, National Hospital Organization, Okayama Medical Center, Okayama
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21
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Merchant NB, Parikh AA, Kooby DA. Should all distal pancreatectomies be performed laparoscopically? Adv Surg 2009; 43:283-300. [PMID: 19845186 DOI: 10.1016/j.yasu.2009.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.
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Affiliation(s)
- Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232-6860, USA.
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22
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Giger U, Michel JM, Wiesli P, Schmid C, Krähenbühl L. Laparoscopic surgery for benign lesions of the pancreas. J Laparoendosc Adv Surg Tech A 2009; 16:452-7. [PMID: 17004867 DOI: 10.1089/lap.2006.16.452] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Minimally invasive pancreatic surgery, although known to be feasible and safe, is still not considered a standard procedure. We report our experience with laparoscopic pancreatic surgery in a retrospective case series. MATERIALS AND METHODS Fifteen consecutive patients (3 male, 12 female) underwent primarily laparoscopic pancreatic surgery from February 2000 to June 2005. Histologically confirmed diagnoses were: neuroendocrine pancreatic tumors (n = 11), adult nesidioblastosis (n = 1), serous cystadenoma (n = 1), and pseudocysts due to chronic pancreatitis (n = 2). RESULTS Enucleation (n = 3) or left pancreatic resection with spleen preservation (n = 6) was performed laparoscopically in 9 patients. The mean (+/-standard deviation) operative time was 173 +/- 48 minutes (range, 120-250 minutes) and the mean postoperative hospital stay was 5.5 +/- 1.2 days (range, 5-8 days) for the laparoscopic cases. Conversion to open surgery was necessary in 6 patients because of: closeness of the lesion to the portal/mesenteric vein (n = 3), inadequate intraoperative tumor localization (n = 2), or stapler device dysfunction (n = 1). In these patients, open enucleation (n = 1), middle segment pancreatectomy (n = 2), left pancreatic resection (n = 2), and pylorus-preserving Whipple resection (n = 1) were performed. The mean operative time was 268 +/- 74 minutes (range, 150-360 minutes) with a mean postoperative hospital stay of 8 +/- 2 days (range, 6-10 days). Both operative time and hospital stay were significantly longer in patients with secondary open surgery compared to patients with successful laparoscopic operations. CONCLUSION Laparoscopic enucleation or distal pancreatectomy with spleen preservation for benign lesions located in the body or tail of the pancreas can be performed safely, with all the potential benefits of minimally invasive surgery. Preoperative tumor localization is of utmost importance to limit pancreatic mobilization and to avoid blind pancreatic resection and conversion to open surgery.
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Affiliation(s)
- Urs Giger
- Department of Surgery, Hôpital Cantonal Fribourg, Fribourg, Switzerland
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23
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Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, Praveen Raj P. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. ACTA ACUST UNITED AC 2009; 16:731-40. [PMID: 19652900 DOI: 10.1007/s00534-009-0157-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy is a technically demanding surgery performed only at few centers in the world. This article aims to describe the evolution of the technique and summarizes the results in our institute over the years. METHODS Prospective data of patients undergoing laparoscopic pancreaticoduodenectomy from March 1998 to January 2009 was retrospectively reviewed. RESULTS There were a total of 75 patients (22 females and 53 males) with a mean age of 62 (range, 28-76) years. Conversion rate was 0%, overall postoperative morbidity was 26.7% and mortality rate was 1. 33%. Pancreatic fistula was seen in 6.67%. The mean operating time was 357 min (range 270-650), and the mean blood loss was 74 ml (range 35-410). The average time to the first bowel movement was 3 days and mean hospital stay was 8.2 days (range 6-42). Resected margins were positive in 2.6% of cases. The mean number of retrieved lymph nodes for the malignant lesions was 14 (range 8-22). CONCLUSION Laparoscopic pancreaticoduodenectomy can be safely performed by highly skilled laparoscopic surgeons. This technique can achieve adequate margins and follow oncological principles. Randomized comparative trials are needed to establish the superiority of laparoscopy versus open surgery.
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Affiliation(s)
- C Palanivelu
- GEM Hospital, 45-A, Pankaja Mill Road, Ramnathapuram, Coimbatore, 641045, India.
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Abu Hilal M, Jain G, Kasasbeh F, Zuccaro M, Elberm H. Laparoscopic distal pancreatectomy: critical analysis of preliminary experience from a tertiary referral centre. Surg Endosc 2009; 23:2743-7. [PMID: 19462202 DOI: 10.1007/s00464-009-0499-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 02/20/2009] [Accepted: 03/25/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic pancreatic surgery has been slow to gain wide acceptance due to the complex pancreatic anatomy and physiology. The aim of this study was to analyze our preliminary results and highlight the impact of centralization on surgeon workload and pancreatic surgical innovation. METHODS A retrospective analysis was performed on all patients who underwent laparoscopic distal pancreatectomy from May 2007 to October 2008. RESULTS Laparoscopic distal pancreatectomy was performed in 17 patients during that period. Median operative time was 180 min (range 120-300 min). Median blood loss was 100 ml (range 50-500 ml). Splenectomy was performed in 12 patients. None of the patients was converted to open operation. All patients were kept in high-dependency unit for median duration of 1 day (range 0-1 day). One patient with previous cardiac disease was kept in intensive therapy unit for one night, but discharged home on 7th postoperative day without any complications. Postoperative recovery was uneventful in 13 patients, while four patients had pancreatic leak. One pancreatic leak was observed in the last 11 patients, in which pancreatic stump was oversewn. In three patients, pancreatic leaks (PL) were minor and settled with conservative management, while one patient needed a computed tomography (CT)-guided drainage and subsequent minilaparotomy for wash out of the intra abdominal collection. None of the patients died in this series. Median hospital stay was 5 days (range 4-7 days). CONCLUSIONS Laparoscopic distal pancreatic resection is feasible, safe, and efficient. However, this surgery should only be performed in specialized centres with extensive experience in pancreatic and laparoscopic surgery. Oversewing the pancreatic stump after transaction with Endostapler may reduce the incidence of pancreatic leak. Centralization of pancreatic surgery has a positive impact on building up surgical expertise, resulting in obvious benefits for both patients and institutions.
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Affiliation(s)
- Mohammed Abu Hilal
- Hepato pancreatico biliary Unit, Surgical Academic Unit, F Level Southampton General Hospital, Southampton, UK.
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25
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Martínez-Isla A, Griffith PS, Markogiannakis H, Clough R, Gandamihardja TAK, Qurashi K, Kekis PB. A novel laparoscopic approach to lesions related to the posterior aspect of the pancreatic head. Am J Surg 2009; 197:e51-3. [PMID: 19249742 DOI: 10.1016/j.amjsurg.2008.06.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 06/25/2008] [Accepted: 06/25/2008] [Indexed: 01/27/2023]
Abstract
The posterior aspect of the pancreatic head has proven to be a technically demanding region to approach laparoscopically. Previously, this region was approached through the gastrocolic ligament with the patient in a left semilateral position. We believe that this makes the laparoscopic approach to the posterior pancreatic head extremely difficult. In the technique presented here, which has been successfully used in 4 patients, the patient was in full left lateral position, and Nathanson retractors were used to retract the liver and right kidney. This allowed full exposure of the second part of the duodenum before any major dissection. The duodenum was then Kocherized, and the posterior aspect of the pancreatic head, along with the inferior vena cava, left renal vein, and aorta, was exposed. We describe here a safe and feasible laparoscopic method for access to and management of lesions related to the posterior aspect of the pancreatic head.
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Affiliation(s)
- Alberto Martínez-Isla
- Department of Upper Gastrointestinal and Laparoscopic Surgery, Ealing Hospital, Ealing Hospital NHS Trust, London, UK.
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26
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Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study. Surg Laparosc Endosc Percutan Tech 2009; 18:340-3. [PMID: 18716530 DOI: 10.1097/sle.0b013e3181705d23] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Although laparoscopic distal pancreatectomy (LDP) is technically feasible, its benefits remain uncertain. The purpose of this study was to compare the clinical results of LDP and open distal pancreatectomy (ODP). The medical records of 14 consecutive patients who underwent LDP were reviewed and compared with those of 19 patients who underwent ODP. All patients were treated for benign or borderline malignant disease of the pancreas. Operation time was longer for LDP than for ODP (290.7 vs. 213.8 min, P=0.0022), and postoperative analgesics were administered less frequently for patients who underwent LDP. Patients treated by LDP had earlier recovery of bowel function, shorter time to oral intake, and shorter postoperative hospital stay than those treated by ODP. No difference in morbidity or inflammatory response was observed between the 2 groups. LDP for benign or borderline malignant disease of the pancreas provides benefits without increasing morbidity.
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27
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Laparoscopic distal pancreatectomy: a retrospective review of 14 cases. Surg Laparosc Endosc Percutan Tech 2008; 18:254-9. [PMID: 18574411 DOI: 10.1097/sle.0b013e31816b4bd2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although the role of minimally invasive techniques in pancreatic surgery remains controversial, resection of the left pancreas for benign or endocrine lesions has been universally adopted as a routine technique over the last few years. This study was undertaken to assess feasibility and safety of minimal access resections of distal pancreas in benign, endocrine, and malignant diseases. Operative time, conversion rate, adequacy of dissection, respect for oncologic principles, morbidity rate, and short-term outcomes were analyzed. From the years 2002 to 2007, 14 patients affected by pancreatic neoplasm of body/tail region were approached by minimally invasive technique. Nine patients were affected by malignant neoplasms and distal splenopancreatectomy was successfully achieved by laparoscopy in 6. Five patients were affected by endocrine neoplasms; distal pancreatectomy with preservation of spleen and splenic vessels was achieved laparoscopically in 3, whereas 2 needed conversion to laparotomy. Four patients developed pancreatic leak after transection by linear cutting stapler plus oversewing, whereas no leak was observed within 30 days from surgery after transection by linear stapler with Seamguard reinforcement of the staple line (P<0.05 with Fisher exact test).
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28
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Goldin SB, Aston J, Wahi MM. Sporadically occurring functional pancreatic endocrine tumors: review of recent literature. Curr Opin Oncol 2008; 20:25-33. [PMID: 18043253 DOI: 10.1097/cco.0b013e3282f290af] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Pancreatic neuroendocrine tumors are rare neoplasms often associated with a clinical syndrome. Their rarity makes a comprehensive study difficult at any single institution, while their uniqueness makes them desirable for investigation. This review summarizes recent information and advancements concerning pancreatic neuroendocrine tumor diagnosis, imaging characteristics, treatment algorithms, and staging. RECENT FINDINGS Insulinomas and gastrinomas comprise the majority of functional pancreatic neuroendocrine tumors. Advances in their identification and diagnostic evaluation, imaging techniques, and treatment algorithms are presented. Furthermore, a new staging classification system has been proposed which may significantly improve the ability to conduct future multi-institutional investigations on pancreatic neuroendocrine tumors. SUMMARY Although rare, a thorough understanding of pancreatic neuroendocrine tumors is essential for all physicians due to the wide variety of symptoms with which patients present. Currently, patients are often misdiagnosed for extended periods of time. This review summarizes the recently published literature about diagnosis, imaging, treatment, and staging of pancreatic neuroendocrine tumors.
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Affiliation(s)
- Steven B Goldin
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida 33612, USA.
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Valente TODN, Bertevello PL, Waitzberg DL, Gama-Rodrigues J. [Laparoscopic surgical treatment of insulinomas with the use of intraoperative ultrasonography]. ARQUIVOS DE GASTROENTEROLOGIA 2008; 44:22-8. [PMID: 17639178 DOI: 10.1590/s0004-28032007000100006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 06/16/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Insulinoma are insulin productive tumors originated from the pancreatic beta cells with an incidence of 4/1 million persons. It is more prevalent between the 5th and 6th decade, in women (2:1) and from the endocrine pancreatic tumor is the more frequent (50% to 60%). Insulinoma behave as a benign tumor when the diameter is inferior to 2 cm. The diagnosis is mainly clinical and laboratorial. Surgery is the unique treatment with potential cure. AIM The present observation reports the use of simultaneous laparoscopic resection associated to intraoperative ultrasonography. METHODS Five patients were studied (3 man and 2 women) with age from 20 to 53 years old, clinically diagnosed with insulinoma. After image work out it was proposed nuclear resection of the insulinoma by laparoscopic technique associated to intraoperative ultrasonography. RESULTS The patients had a complete remission of tumor related hypoglycemia and one patient developed a pancreatic fistula and other a pancreatic pseudocist with good postoperative resolution. CONCLUSIONS The videolaparoscopic approach for the surgical treatment of insulinoma is feasible. The intraoperative ultrasonography helps to identify the lesions and check their complete resection with low complication rate.
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Affiliation(s)
- Tárik Olívar de Nunes Valente
- Serviço de Cirurgia Pro-Gastro - Coloproctologia, Gastroenterologia Clínica e Cirúrgica, Hospital São Joaquim, São Paulo, SP.
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30
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Taylor C, O'Rourke N, Nathanson L, Martin I, Hopkins G, Layani L, Ghusn M, Fielding G. Laparoscopic distal pancreatectomy: the Brisbane experience of forty-six cases. HPB (Oxford) 2008; 10:38-42. [PMID: 18695757 PMCID: PMC2504852 DOI: 10.1080/13651820701802312] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic distal pancreatectomy (LDP) is a safe alternative to conventional open distal pancreatectomy, with advantages that include smaller incisions, less pain, and shorter postoperative recovery. Despite these apparent advantages, however, uptake of the procedure has been slow, with only a handful of series published. MATERIAL AND METHODS All LDPs performed in Brisbane, Australia, over a 10-year period (May 1996 to June 2006) were retrospectively reviewed. RESULTS Forty-six consecutive LDPs were performed. A variety of lesions were resected, including nine cancers. Twelve patients were converted for oncological (6) or technical reasons (6). The spleen was retained in 14/29 patients, either by main splenic vessel preservation (9) or solely supported by the short gastric vessels (5), resulting in inferior pole infarction in 2 patients. Overall morbidity was 39%, including 15% pancreatic fistula. All fistulas resolved after a median of 6 weeks without re-operation. A non-significant trend toward fewer fistulas with stapled rather than sutured stump closure was observed (13% vs 19%; p=0.43). Median operative duration and hospital stay were 157 min and 7 days, respectively. There was no mortality. CONCLUSION LDP is a safe alternative to conventional resection for a wide range of lesions. As with open resection, pancreatic fistula is the dominant morbidity, but is generally indolent. While spleen preservation is often possible, care must be taken to avoid infarction of the inferior pole if the Warshaw technique is utilized.
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Affiliation(s)
- C. Taylor
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - N. O'Rourke
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - L. Nathanson
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - I. Martin
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - G. Hopkins
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - L. Layani
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - M. Ghusn
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
| | - G. Fielding
- Royal Brisbane HospitalHerston QLDAustralia,The Wesley HospitalAuchenflower QLDAustralia,Princess Alexandra HospitalWoolloongabba QLDAustralia,Holy Spirit HospitalChermside QLDAustralia,John Flynn HospitalTugun QLDAustralia
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31
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Norton JA. Tumors of the Endocrine System. Oncology 2007. [DOI: 10.1007/0-387-31056-8_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schraibman V, Goldenberg A, de Matos Farah JF, Apodaca FR, Goldman S, Lobo EJ. Laparoscopic enucleation of pancreatic insulinomas. J Laparoendosc Adv Surg Tech A 2007; 17:399-401. [PMID: 17705715 DOI: 10.1089/lap.2006.0110] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Insulinomas are rare endocrine pancreatic tumors whose incidence has been increasing in recent years owing to early detection by clinical and radiologic, such as remote neural monitoring, computed tomography (CT), and ultrasound (US) findings. The classical treatment consists of open surgical resection, which is associated with relative morbidity and mortality rates. The aim of this paper was to present 5 patients who were diagnosed with pancreatic insulinomas that were treated by laparoscopic resection. Five (5) patients, ranging from 14 to 45 years and presenting with classical Whipple Triad, had lesions ranging from 1.5 to 2.5 cm by CT (body and tail of the pancreas), which were subsequently diagnosed as insulinomas. An ecoendoscopy showed no combined lesions. They were treated by a laparoscopic resection. Glicemic levels were controlled during surgery with an expected glucose rise. All patients had an uneventfull recovery. The mean length of follow-up is 14 months. The laparoscopic resection of pancreatic insulinomas is a reliable procedure for superficial lesions in the body and tail of the pancreas.
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Affiliation(s)
- Vladimir Schraibman
- Department of Surgery, Discipline of Gastric Surgery of the Federal University of São Paulo, São Paulo, Brazil.
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33
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Honore C, Honore P, Meurisse M. Laparoscopic Spleen-Preserving Distal Pancreatectomy: Description of an Original Posterior Approach. J Laparoendosc Adv Surg Tech A 2007; 17:686-9. [PMID: 17907989 DOI: 10.1089/lap.2006.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We are describing in this paper the original and innovative technique we used to perform a spleen-preserving distal pancreatectomy. With the patient positioned on her right lateral side, we inserted four laparoscopic ports in the left subcostal region to enable an upper view on the spleen and its rear attachments. With this approach, we opened and dissected this plan located between the left kidney and the rear aspect of the spleen and of the pancreas. These structures, once liberated naturally, felt "en-bloc" out of the way because of the patient's lateral positioning and the gravity, exposing the operative field without any artificial retraction. Beyond this greater exposure, this new approach offers many other advantages, such as the easiness to be performed by only two operators and the preservation of the anterior abdominal cavity, the great omentum, the splenic vessels, and the short gastric vessels left untouched.
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Affiliation(s)
- Charles Honore
- Department of Abdominal Surgery, CHU Liège, Domaine Universitaire du Sart-Tilman, Liège, Belgium.
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34
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Matsutani T, Sasajima K, Miyamoto M, Yokoyama T, Hiroi M, Maruyama H, Suzuki S, Tajiri T. Pancreatic cyst associated with pancreas divisum treated by laparoscopy-assisted cystgastrostomy in the intragastric approach: a case report and a review of the literature. J Laparoendosc Adv Surg Tech A 2007; 17:317-20. [PMID: 17570778 DOI: 10.1089/lap.2006.0091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 39-year-old Japanese man was admitted to our hospital after experiencing recurrent episodes of pancreatitis over the previous 2 years. On the first episode, he had been admitted to our hospital with elevated serum amylase levels and epigastralgia. Abdominal computed tomography (CT) revealed a diffuse, uncircumscribed area with heterogeneous density in the pancreas. No previous history of pancreatitis, gallstones, drinking, or abdominal injury was elicited. Magnetic resonance cholangiopancreatography (MRCP) demonstrated that the Wirsung duct was unconnected to the Santorini's duct. Endoscopic retrograde cholangiopancreatography through the papilla of Vater and accessory papilla revealed an enlarged ventral pancreatic duct, pancreas divisum, and a cystic lesion in the pancreatic body. On the second and third episodes, endoscopic drainage of the pancreatic pseudocysts through the accessory papilla and ultrasonography-guided transmural drainage were unsuccessful. A follow-up CT and MRCP demonstrated that the pancreatic cyst had enlarged to 9 x 8 cm in diameter. A laparoscopy-assisted cystgastrostomy was performed with an intragastric approach. An anastomosis was performed using an endoscopic linear stapler through the small cystotomy and gastrotomy openings on the posterior wall of the stomach. The postoperative clinical course was uneventful. Over 6 months later, the patient remains well and with a good quality of life. A laparoscopy-assisted cystgastrostomy, using an intragastric surgical technique, offers a safe, less-invasive procedure for cyst drainage by the pancreas divisum.
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Affiliation(s)
- Takeshi Matsutani
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan.
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35
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Takaori K, Tanigawa N. Laparoscopic pancreatic resection: the past, present, and future. Surg Today 2007; 37:535-45. [PMID: 17593471 DOI: 10.1007/s00595-007-3472-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 01/11/2007] [Indexed: 02/06/2023]
Abstract
Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism, and neoplasms of the pancreas; e.g., insulinoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, etc. Laparoscopic pancreatic resections with an en bloc lymph node dissection have also been performed for invasive carcinomas. The long-term results after laparoscopic resections for invasive pancreatic cancer, however, are still not well defined. Laparoscopic distal pancreatectomies with or without spleen preservation may benefit patients with reduced postoperative pain, shorter hospital stay, a quicker recovery to normal activity, and better cosmetic appearances based on retrospective analyses of collective series and case reports. Prospective randomized controlled trials are needed to validate these benefits. In contrast, laparoscopic proximal pancreatectomies with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy and laparoscopic duodenum-preserving pancreatic head resection are technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences by highly skilled endoscopic surgeons. To justify the performance of laparoscopic proximal pancreatectomies, it is mandatory to demonstrate the potential clinical benefits and safety of these complicated procedures.
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Affiliation(s)
- Kyoichi Takaori
- Department of General and Gastroenterological Surgery, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
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36
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Diagnosis and Minimally Invasive Resection of an Insulinoma: Report of an Unusual Case and Review of the Literature. Am Surg 2007. [DOI: 10.1177/000313480707300521] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Insulinomas are rare endocrine tumors that are usually diagnosed by inappropriate elevations in insulin and C-peptide during hypoglycemia. We report a case of a surgically confirmed insulinoma diagnosed by a mild elevation in proinsulin with suppressed insulin and C-peptide at the time of hypoglycemia during a supervised fast. A supervised fast with serial measurements of plasma glucose, insulin, and C-peptide was performed in a patient with documented hypoglycemia. Proinsulin was measured at the beginning and end of the fast. Tumor localization was accomplished with spiral CT, magnetic resonance imaging, and endoscopic ultrasound. Minimally invasive tumor resection was performed. The presence of an insulinoma was confirmed on the basis of a minimally elevated proinsulin level with a suppressed insulin level at the time of symptomatic hypoglycemia. Tumor resection was performed without complications, resulting in resolution of the hypoglycemia. This case demonstrates the importance of measuring proinsulin as a routine component of the 72-hour fast for detection of an insulinoma. Even mild elevations in circulating proinsulin can be an independent indicator of aberrant insulin secretion during hypoglycemia. Once the diagnosis of insulinoma is made and tumor localization is achieved, minimally invasive tumor resection is a safe and effective treatment modality.
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37
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Gourgiotis S, Moustafellos P, Zavos A, Stratopoulos C, Vericouki C, Hadjiyannakis E. Localisation and surgical treatment of insulinomas. Int J Clin Pract 2007; 61:558-61. [PMID: 17394431 DOI: 10.1111/j.1742-1241.2006.00913.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Most insulinomas are solitary, benign and functional neuroendocrine pancreatic tumours which give rise to manifold symptoms. Their preoperative localisation is often unclear, but the cure rate after their excision is very high. It was the aim of this study to analyse and evaluate our group of patients with regard to preoperative tumour localisation and overall surgical results. Twelve patients with a biochemical diagnosis of organic hyperinsulinism were surgically treated. Diagnosis was made with the combination of magnetic resonance imaging, computed tomography, selective angiography and intraoperative portal vein sampling. In five patients, the tumour was enucleated, in three patients Whipple procedure was performed; while three patients underwent left pancreatectomy with spleen preserving in two cases. The twelfth patient underwent total pancreatectomy following Whipple procedure performed elsewhere. There was no postoperative death. The complications were two pancreatic fistulas and two wound infections. The fasting pre- and postoperative plasma glucose mean value was 2.8 mm/l and 4.9 mm/l, respectively; while the pre- and postoperative plasma insulin mean value was 282 pm/l and 72 pm/l, respectively. Accurate diagnosis, preoperative localisation and diligent surgical exploration by experienced surgeons are the key to a successful outcome in patients with insulinomas.
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Affiliation(s)
- S Gourgiotis
- Clinical Attachment in Division of General Surgery and Oncology, Royal Liverpool University Hospital, Liverpool, UK.
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38
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Aluka KJ, Long C, Rickford MS, Turner PL, McKenna SJ, Fullum TM. Laparoscopic distal pancreatectomy with splenic preservation for serous cystadenoma: a case report and literature review. Surg Innov 2007; 13:94-101. [PMID: 17012149 DOI: 10.1177/1553350606291339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A minimally invasive approach can be beneficial in a spleen-preserving distal pancreatectomy. This article reports a 71-year-old woman who presented to her internist with hypertension and persistent hypokalemia. A computed tomography scan to rule out a functional adrenal mass incidentally revealed a 4 cm x 3 cm x 2 cm serous cystadenoma of the distal pancreas and normal adrenal glands. The patient was referred to the general surgery service for resection of the distal pancreatic lesion. A laparoscopic spleen-preserving distal pancreatectomy was performed. The lesion was completely excised, and the pathology revealed serous cystadenoma with focal fibrosis and atrophic acini. The postoperative advantages of this approach were the early return of bowel function, minimal narcotic requirements, and early resumption of normal activities. This case illustrates the advantages of minimally invasive surgery in the performance of a spleen-preserving distal pancreatectomy.
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Affiliation(s)
- Kanayochukwu J Aluka
- Department of Surgery, Providence Hospital, Washington, District of Columbia, USA.
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39
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Hoffmann JN, Jauch KW. Chirurgische Therapie neuroendokriner nicht pankreatischer Tumoren des Gastrointestinaltrakts. Visc Med 2007. [DOI: 10.1159/000102600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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40
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Toniato A, Meduri F, Foletto M, Avogaro A, Pelizzo M. Laparoscopic treatment of benign insulinomas localized in the body and tail of the pancreas: a single-center experience. World J Surg 2006; 30:1916-9; discussion 1920-1. [PMID: 16855802 DOI: 10.1007/s00268-005-0645-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The increasingly widespread use of minimally invasive surgery has allowed surgeons to exploit this approach for complex procedures, such as pancreatic resections, though its actual role outside simple operations remains debated. METHODS This is a study of 12 consecutive patients, 5 men and 7 women, with pancreatic insulinoma who were treated at our institution from 2000 to September 2005. All patients presented with typical symptoms and laboratory findings of hyperinsulinism and were good candidates for laparoscopic surgery. Preoperative diagnostic work-up, operating time, postoperative complication rate, length of hospital stayd and clinical outcome were assessed. RESULTS Successful laparoscopic resection was performed in 11 out of 12 patients: 4 had tumor enucleation, and 7 had distal pancreatectomy; among these latter 5 had spleen-preserving distal pancreatectomy. In 1 case conversion to open surgery was necessary. Mean operative time was 170 minutes. The median tumor size was 18 mm, and all the insulinomas were benign. Four complications were observed in this group, and the median hospital stay was 8 days. CONCLUSIONS The laparoscopic approach proved to be feasible and safe, although the average operative time was longer and demanded good surgical skills as well as precise localization of the tumor and definition of its nature. Tumors located in the body or tail of the pancreas that are benign in nature can better benefit of laparoscopic approach.
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Affiliation(s)
- Antonio Toniato
- Surgical Pathology, Department of Clinical and Medical Science, University of Padua, Padua, Italy.
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41
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Uranues S, Alimoglu O, Todoric B, Toprak N, Auer T, Rondon L, Sauseng G, Pfeifer J. Laparoscopic resection of the pancreatic tail with splenic preservation. Am J Surg 2006; 192:257-61. [PMID: 16860642 DOI: 10.1016/j.amjsurg.2006.01.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Revised: 01/31/2006] [Accepted: 01/31/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Evaluation of feasibility and efficacy of left resection of the pancreas with preservation of the splenic vessels and spleen as a laparoscopic procedure. BACKGROUND Laparoscopic technique is used less often on the pancreas than on other organs. The most common indications are enucleation of endocrine-active tumors and distal resections for benign primary pancreatic lesions. An important premise of these operations is atraumatic removal of as little of the pancreas as possible and the preservation of the spleen and its main vessels. METHODS Five patients aged 16 to 56 years, all female, underwent laparoscopic left resection of the pancreas with preservation of the splenic vessels and the spleen. There were 4 cases of benign epithelial tumors of the pancreas and 1 case of a left-sided adrenal cyst, which pre- and intraoperatively gave the impression of a pancreatic cystadenoma. RESULTS In all 5 cases, the laparoscopic procedure was completed with preservation of the splenic vessels and the spleen itself. No patient required blood transfusion, and there was only 1 postoperative fluid collection at the site of the tumor resection, which was drained percutaneously on the fourth postoperative day. CONCLUSION Distal pancreas resection can be performed as a laparoscopic procedure, with the usual advantages that this techniques has for the patient. Optimal closure of the cut edge of the pancreas and the preservation of the spleen and its main vessels are the most important aspects of this operation.
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Affiliation(s)
- Selman Uranues
- Department of Surgery, Medical University of Graz, Austria.
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42
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Uranues S, Salehi B, Kornprat P, Todoric B. Technique of laparoscopic left pancreatic resection preserving the splenic vessels. Eur Surg 2006. [DOI: 10.1007/s10353-006-0246-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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43
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Orsenigo E, Baccari P, Bissolotti G, Staudacher C. Laparoscopic central pancreatectomy. Am J Surg 2006; 191:549-52. [PMID: 16531153 DOI: 10.1016/j.amjsurg.2006.01.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Revised: 04/25/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of mini-invasive surgery in pancreatic surgery is still being debated. Indications and results are still controversial. Only a few centers in the world report on laparoscopic pancreatic resections. With the aim of improving the use of minimally invasive surgery, we have devised a novel laparoscopic procedure for surgical treatment of neuroendocrine tumor of the neck of the pancreas. METHODS A central laparoscopic pancreatic resection was successfully performed. The pancreatic resection was performed using the harmonic scalpel. The duct was isolated and transected. The proximal duct stump was closed by an endoscopic stitch. The pancreaticojejunostomy was intracorporeally performed using a Roux-en-Y loop. RESULTS Histologic findings showed a well differentiated neuroendocrine tumor. Operating time was 330 minutes and blood loss 300 mL. The postoperative course was uneventful. CONCLUSIONS Laparoscopic central pancreatectomy is a feasible and safe procedure. The minimally invasive approach ensures an adequate treatment despite requiring the expertise of highly skilled laparoscopic surgeons.
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Affiliation(s)
- Elena Orsenigo
- Department of Surgery, University Vita-Salute, San Raffaele Scientific Institute, Via Olgettina, 60 20132 Milan, Italy.
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44
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Woeste G, Zapletal C, Golling M, Usadel KH, Vogl TJ, Bechstein WO, Wullstein C. Telerobotic-assisted laparoscopic spleen-preserving partial resection of the pancreatic tail for insulinoma. HPB (Oxford) 2006; 8:233-4. [PMID: 18333283 PMCID: PMC2131675 DOI: 10.1080/13651820510003753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Indexed: 12/12/2022]
Abstract
Laparoscopic pancreatic resection is rarely described. Telerobotic-assisted laparoscopy may offer some advantages for resection of the pancreatic tail. A 49-year-old woman was diagnosed with insulinoma located in the pancreatic tail. Telerobotic-assisted laparoscopic spleen-preserving resection of the pancreatic tail was performed. Operation time was 195 minutes. The postoperative course was uneventful. The previously described advantages of a telerobotic approach with extended range of motion and three-dimensional view make more complex operations like pancreatic resection possible and may offer extended indications for laparoscopic surgery.
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Affiliation(s)
- G. Woeste
- Departments of General and Vascular Surgery, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
| | - C. Zapletal
- Departments of General and Vascular Surgery, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
| | - M. Golling
- Departments of General and Vascular Surgery, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
| | - K. H. Usadel
- Departments of Internal Medicine I, Division of Endocrinology, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
| | - T. J. Vogl
- Departments of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
| | - W. O. Bechstein
- Departments of General and Vascular Surgery, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
| | - C. Wullstein
- Departments of General and Vascular Surgery, Johann Wolfgang Goethe-University FrankfurtFrankfurtGermany
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45
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D'Angelica M, Are C, Jarnagin W, DeGregoris G, Coit D, Jaques D, Brennan M, Fong Y. Initial experience with hand-assisted laparoscopic distal pancreatectomy. Surg Endosc 2005; 20:142-8. [PMID: 16333550 DOI: 10.1007/s00464-005-0209-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2005] [Accepted: 08/16/2005] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hand-assisted laparoscopic distal pancreatectomy, with or without splenectomy, is gradually gaining acceptance, although its ultimate benefit is yet to be confirmed. This study aimed to report our initial experience with hand-assisted laparoscopic distal pancreatectomy. METHODS A retrospective review of a prospectively collected database including 17 patients during the period 2002-2004 was conducted. The median age was 60 years (range, 29-85 years), and the female-to-male ratio was 13:4. The preoperative diagnoses included benign and malignant conditions. Besides two to three ports, a hand port was placed in the upper midline to aid in dissection. The pancreas was divided with a stapler in all the patients, and drains were placed in 10 patients (70%). RESULTS One patient was found to be unresectable because of celiac artery involvement, and 2 of the remaining 16 patients underwent conversion to an open procedure. The median operating time was 196 min (range, 128-235 min). The mean tumor size was 4 cm (range, 2-7 cm), and the estimated blood loss was 125 ml (range, 50-1,250 ml). The median time to resumption of a regular diet was 3.5 days (range, 2-9 days), and the time to conversion to oral pain medications was 3 days (range, 2-9 days). The length of hospital stay was 5.5 days (range, 4-18 days), with a majority of the patients (11 patients, 78%) staying less than 7 days. There were no mortalities. The overall postoperative morbidity rate was 25%, and the morbidities consisted of pancreatic leak/fistula (2 patients, 14%) and fever (1 patient). The margins were negative in 10 (76%) of the relevant 13 patients. At a median follow-up period of 3.8 months (range, 5-14 months), 11 (84%) of 13 patients had no evidence of disease recurrence. CONCLUSIONS The minimally invasive approach to pancreatic disease is safe and technically feasible. Further large studies with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the management of pancreatic disease.
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Affiliation(s)
- M D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, USA
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46
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Miura F, Takada T, Asano T, Kenmochi T, Ochiai T, Amano H, Yoshida M. Hemodynamic changes of splenogastric circulation after spleen-preserving pancreatectomy with excision of splenic artery and vein. Surgery 2005; 138:518-22. [PMID: 16213907 DOI: 10.1016/j.surg.2005.04.020] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Revised: 04/21/2005] [Accepted: 04/22/2005] [Indexed: 12/31/2022]
Abstract
BACKGROUND The safety of spleen conservation without preservation of the splenic artery and vein was proved on the basis of short-term observation, but the long-term results of this procedure have been uncertain. To clarify the hemodynamic changes of splenogastric circulation of patients undergoing spleen-preserving pancreatectomy with excision of the splenic artery and vein, we retrospectively analyzed patient outcome with particular reference to the assessment of hemodynamic changes of splenogastric circulation. METHODS Ten patients who had undergone spleen-preserving pancreatectomy with excision of the splenic artery and vein were retrospectively analyzed. In all patients both the short gastric and left gastroepiploic arteries and veins were preserved. All patients were observed for a minimum of 52 months. Collateral venous pathways were evaluated by computed tomography and endoscopy. RESULTS Early complications such as splenic infarction and atrophy did not occur in any of the patients, but computed tomography revealed perigastric varices in 7 patients (70%) and submucosal varices in 2 patients (20%). Endoscopy showed gastric varices in 2 patients in whom submucosal gastric varices were identified on computed tomography. Gastrointestinal bleeding from gastric varices occurred in 1 patient. In 1 patient without gastric varices, a gastrorenal shunt was demonstrated on computed tomography. CONCLUSIONS This study confirmed that gastric varices frequently occurred in patients who underwent spleen-preserving pancreatectomy with excision of the splenic artery and vein.
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Affiliation(s)
- Fumihiko Miura
- Department of Surgery, Teikyo University, School of Medicine, Tokyo, Japan
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47
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Root J, Nguyen N, Jones B, Mccloud S, Lee J, Nguyen P, Chang K, Lin P, Imagawa D. Laparoscopic Distal Pancreatic Resection. Am Surg 2005. [DOI: 10.1177/000313480507100910] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Laparoscopic resection is not an established treatment for pancreatic tumors. Previous reports, mainly in Europe and Japan, have demonstrated the potential utility of laparoscopic distal pancreatectomy (LDP). However, few reports have been published from the United States. We instituted a pilot program to assess LDP. A total of 11 patients were included from December 2003 to December 2004. All patients were staged with preoperative endoscopic ultrasound and received vaccinations for possible splenectomy. The indications for surgery were as follows: neuroendocrine tumor (n = 7), unspecified tumor (n = 1), and cystic neoplasm (n = 3). All procedures began with diagnostic laparoscopy and intraoperative ultrasound. Three patients underwent laparoscopic enucleation of a discrete pancreatic nodule. In eight patients, LDP was attempted. One patient required conversion to an open procedure. In the other seven patients, the procedure was completed laparoscopically, two with hand-assist. The average operative time was 5 hours and 3 minutes; average length of stay was 5 days; and the splenectomy rate was 57 per cent (n = 4). There was one complication of an infected hematoma. There were no pancreatic leaks, deaths, nor readmissions. LDP with or without splenectomy is feasible and can be performed with minimum morbidity and only slightly increased operative time.
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Affiliation(s)
- Jeff Root
- Division of Hepatobiliary and Pancreatic Surgery, UC Irvine Medical Center, Orange, California
| | - Ninh Nguyen
- Division of Gastrointestinal Surgery, UC Irvine Medical Center, Orange, California
| | - Blanding Jones
- Division of Hepatobiliary and Pancreatic Surgery, UC Irvine Medical Center, Orange, California
| | - Scott Mccloud
- Department of Radiology, UC Irvine Medical Center, Orange, California
| | - John Lee
- Division of Gastrointestinal Medicine, Chao Comprehensive Digestive Disease Center, UC Irvine Medical Center, Orange, California
| | - Phuong Nguyen
- Division of Gastrointestinal Medicine, Chao Comprehensive Digestive Disease Center, UC Irvine Medical Center, Orange, California
| | - Ken Chang
- Division of Gastrointestinal Medicine, Chao Comprehensive Digestive Disease Center, UC Irvine Medical Center, Orange, California
| | - Peter Lin
- Division of Hepatobiliary and Pancreatic Surgery, UC Irvine Medical Center, Orange, California
| | - David Imagawa
- Division of Hepatobiliary and Pancreatic Surgery, UC Irvine Medical Center, Orange, California
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48
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Varkarakis IM, Allaf ME, Bhayani SB, Inagaki T, Su LM, Kavoussi LR, Jarrett TW. Pancreatic injuries during laparoscopic urologic surgery. Urology 2005; 64:1089-93. [PMID: 15596174 DOI: 10.1016/j.urology.2004.06.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Accepted: 06/25/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To review our experience with pancreatic injury (PI) associated with urologic laparoscopy. PI associated with urologic laparoscopy is uncommon. METHODS From January 1999 to April 2004, 890 laparoscopic operations for upper urinary tract pathologic findings were performed, of which 574 were left-sided procedures. We reviewed the medical records for recognized intraoperative or postoperatively documented PI and recorded the patient demographic data and intraoperative and postoperative management. RESULTS Four PIs were identified, all associated with left-sided procedures. The overall rate of PI was 0.44%. Two injuries occurred during left radical nephrectomy (2.1%) and two during left adrenalectomy (8.6%). The mean tumor size was 6 +/- 3.4 cm. The diagnosis was made intraoperatively in 1 patient, postoperative midepigastric pain with elevated serum amylase levels was the clinical presentation in 2 patients, and the incidental finding of pancreatic tissue in the final pathologic specimen confirmed the injury in the fourth patient. A prolonged pancreatic fistula developed only in 1 case. Three patients were treated conservatively and computed tomography-guided drainage of a pancreatic collection was required in one. The mean hospital stay was 18 days (range 4 to 57). CONCLUSIONS PI is uncommon but can result in significant morbidity. Intraoperative detection and repair can minimize sequelae. Management with conservative measures and percutaneous drainage is usually successful, although a prolonged postoperative course can be expected.
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Affiliation(s)
- Ioannis M Varkarakis
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-8915, USA
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Abstract
Advances in minimally invasive surgery have revolutionized the field of surgery. Despite the great strides in equipment and experience, operative conduct remains confined by the limits of exposure. Retroperitoneal fat can be abundant and can contribute greatly to difficulty in exposure. Visceral organs ventral to the retroperitoneum preclude direct access and require optimal patient positioning to operate. Additionally, the major vascular pedicles all originate in the retroperitoneum off of the abdominal aorta or enter the inferior vena cava. The pancreas, in particular, is surrounded by the portal vein, celiac axis, superior mesenteric vein and artery, and splenic vein and artery. If injured during surgery, these vessels can present a life-threatening emergency. The issues related to the vasculature, coupled with the difficulty in resecting portions of the pancreas and the relative paucity of pancreatic procedures, have greatly concentrated these cases at tertiary care centers staffed by experienced laparoscopists. However, as surgical technology improves and fellowships train more surgeons with advanced laparoscopic skills, minimally invasive pancreatic surgery may diffuse with more community-based health care networks.
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Affiliation(s)
- Daniel Tseng
- Department of Surgery, Oregon Health and Science University, Portland, Oregon 97201, USA
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Molina WR, Desai MM, Ng CS, Spaliviero M, Gill IS. Retroperitoneoscopic radical nephrectomy with concomitant distal pancreatectomy: case report. J Endourol 2005; 18:665-7. [PMID: 15597658 DOI: 10.1089/end.2004.18.665] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Whereas laparoscopic radical nephrectomy has emerged as the standard of care for most low-stage renal tumors, laparoscopic pancreatic surgery remains uncommon. We describe a retroperitoneoscopic radical nephrectomy and concomitant distal pancreatectomy for a large left renal mass with suspected involvement of the adrenal gland and the distal pancreas.
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Affiliation(s)
- Wilson R Molina
- Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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