Parenchyma-sparing resections for pancreatic neoplasms

Solid Pseudopapillary Tumor of the Pancreas: Is Enucleation Safe?

BACKGROUND

While solid pseudopapillary tumor (SPT) of the pancreas are oncologically low-risk tumors, their resection with pancreaticoduodenectomy (PD) or partial pancreatectomy (PP) carries a significant risk for morbidity. To balance the favorable prognosis with the surgical morbidity of pancreas resection, this study explores the oncologic safety of enucleation (EN).

PATIENTS AND METHODS

The National Cancer Database (NCDB) was queried for resected SPT from January 2004 through December 2020. Perioperative outcomes and survival were analyzed with Kruskal-Wallis tests, and Kaplan-Meier analysis (with log-rank test). Survival analysis was performed to compare patients with and without lymph node (LN) metastases and binary logistic regression for predictors of LN metastasis.

RESULTS

A total of 922 patients met inclusion criteria; 18 patients (2%) underwent EN, 550 (59.6%) underwent PP, and 354 (38.4%) underwent PD. Mean tumor size was 57.6 mm. Length of hospital stay was significantly shorter for EN compared with PP and PD groups (3.8 versus 6.2 versus 9.4 days, p < 0.001). There was a nonsignificant improvement in unplanned readmission [0% versus 8% versus 10.7% (p = 0.163)], 30-day mortality [0% versus 0.5% versus 0% (p = 0.359)], and 90-day mortality [0% versus 0.5% versus 0% (p = 0.363)] between EN, PP, and PD groups. Survival analyses showed no difference in OS when comparing EN versus PP (p = 0.443), and EN versus PD (p = 0317). Patients with LN metastases (p < 0.001) fared worse, and lymphovascular invasion, higher T category (T3-4) and M1 status were found as predictors for LN metastasis.

CONCLUSIONS

EN may be considered for select patients leading to favorable outcomes. Because survival was worse in the rare cohort of patients with LN metastases, the predictors for LN metastasis identified here may aid in stratifying patients to EN versus resection.

Younger Age and Parenchyma-Sparing Surgery Positively Affected Long-Term Health-Related Quality of Life after Surgery for Pancreatic Neuroendocrine Neoplasms

(1) Background: Patients with pancreatic Neuroendocrine Neoplasms (PanNENs) often have a long overall survival. We evaluated determinants of quality of life (QoL) after surgery for PanNENs. (2) Methods: Patients operated on for a PanNEN in our center (1990-2021) received three EORTC QoL questionnaires (QLQ-C30, QLQ-GI.NET21, QLQ-PAN26). Six domains were selected as outcome variables (global QoL, physical function -PF, social function -SF, disease-related worries -DRWs, pain, upper-gastrointestinal (GI) symptoms) and evaluated in relation to the clinical variables. Statistical analysis was performed using R software v 4.2.2. (3) Results: One hundred and four patients enrolled showed a good global QoL (median 83.3). Old age was a determinant of worse global QoL (p 0.006) and worse PF (p 0.003). Multiple comorbidities (p 0.002) and old age (p 0.034) were associated with pain, while male gender was related to better PF (p 0.007) and less pain (p 0.012). Patients who had undergone parenchyma-sparing surgery demonstrated better PF (p 0.037), better SF (p 0.012), and less upper-GI symptoms (p 0.047). At multivariable analysis, age (p 0.005) and type of surgery (p 0.028) were confirmed as determinants of global QoL. (4) Conclusions: In patients operated on for a PanNEN, a good HRQoL is generally reported; notably, younger age and parenchyma-sparing surgery seem to positively affect HRQoL.

Laparoscopic parenchyma-sparing resections for solid pseudopapillary tumors located in the head of pancreas

BACKGROUND

Solid pseudopapillary tumor (SPT) of the pancreas is a rare low-grade malignant tumor. Here, we aimed to determine the safety and feasibility of laparoscopic parenchyma-sparing pancreatectomy for SPT located in the pancreatic head.

METHODS

From July 2014 to February 2022, 62 patients with SPT located in the pancreatic head were operated laparoscopically in two institutions. These patients were divided into two groups according to the operative strategy: laparoscopic parenchyma-sparing pancreatectomy (27 patients, group 1) and laparoscopic pancreaticoduodenectomy (35 patients, group 2). The clinical data were retrospectively collected and analyzed in terms of demographic characteristics, perioperative variables, and long-term follow-up outcomes.

RESULTS

The demographic characteristics of the patients in the two groups were comparable. Compared to the patients in group 2, those in group 1 required less operative time (263.4 ± 37.2 min vs. 332.7 ± 55.6 min, p < 0.001) and experienced less blood loss (105.1 ± 36.5mL vs. 188.3 ± 150.7 mL, p < 0.001). None of the patients in group 1 had tumor recurrence or metastasis. However, 1 (2.5%) patient in group 2 showed liver metastasis.

CONCLUSION

Laparoscopic parenchyma-sparing pancreatectomy is a safe and feasible approach for SPT located in the pancreatic head, with favorable long-term functional and oncological results.

Pancreatic Enucleation Patients Share the Same Quality of Life as the General Population at Long-Term Follow-Up: A Propensity Score-Matched Analysis

OBJECTIVE

The aim of this study was to assess short- and long-term outcomes including quality of life (QoL) following pancreatic enucleation (PE).

BACKGROUND

PE is deemed to preserve both the endocrine and the exocrine function while ensuring radicality. However, to assess whether this reflects an actual benefit perceived by patients, QoL has to be considered.

METHODS

Data from all consecutive patients undergoing PE from January 2010 to December 2019 were retrospectively analyzed. Surgical outcomes were graded according to the Clavien-Dindo classification, and EORTC-C30 and the EORTC-Pan26 were administered as a cross-sectional assessment of QoL. A control group consisting of healthy individuals from the general population was obtained and matched using the propensity score matching method.

RESULTS

Eighty-one patients underwent PE using the open (59.3%), laparoscopic (27.2%), or robot-assisted (13.5%) approach. Sixty-five (80.2%) patients exhibited functioning/nonfunctioning pancreatic neuroendocrine tumors at final pathology.Surgical morbidity and complications of a Clavien-Dindo grade ≥3 were 48.1% and 16.0%, respectively. In-hospital mortality was 0%. Postoperative pancreatic fistula, post-pancreatectomy hemorrhage, and delayed gastric emptying rates were 21.0%, 9.9%, and 4.9%, respectively.Patients returned the questionnaires after a median of 74.2 months from the index surgery. Postoperative new onset of diabetes mellitus (NODM) was observed in 5 subjects (7.1%), with age being an independent predictor. Seven patients (10.0%) developed postoperative exocrine insufficiency. At the analysis of QoL, all function and symptom scales were comparable between the 2 groups, except for 2 of the EORTC-Pan 26 symptom scales, ("worries for the future" and "body image", P < 0.05).

CONCLUSIONS

Despite being associated with significant postoperative morbidity, PE provides excellent long-term outcomes. The risk of NODM is low and related to patient age, with QoL being comparable to the general population. Such information should drive surgeons to pursue PE whenever properly indicated.

Short and long-term outcomes of minimally invasive central pancreatectomy: Comparison with minimally invasive spleen-preserving subtotal distal pancreatectomy

BACKGROUND

Central pancreatectomy(CP) is more complex surgery and higher complication rate than distal pancreatectomy(DP). However, with the development of minimally invasive surgery, CP has become a safer surgery technique. In this study, we compare minimally invasive CP(MI-CP) and Minimally invasive spleen-preserving subtotal DP(MI-SpSTDP) to figure out the short-term and long-term outcomes of MI-CP.

METHODS

From March 2007 to June 2020, 36 cases of MI-SpSTDP and 23 cases of MI-CP were performed for benign and borderline malignant pancreatic tumors in Severance hospital. The occurrence of postoperative pancreatic fistula(POPF) and Clavian-Dindo classification grade 3 or more in the two group was investigated, and the Controlling nutritional status scores(CONUT score) before and 1-year after surgery were compared to determine the long-term outcomes of exocrine function.

RESULTS

There was no difference in postoperative complications including POPF between the two groups(17.4% vs 5.1%, p = 0.294). And there were no statistical differences in either the MI-CP group (0.74 ± 0.75 vs. 0.78 ± 0.99, p = 0.803) or the MI-SpSTDP group (0.86 ± 0.83 to 0.61 ± 0.59, p = 0.071).

CONCLUSIONS

MI-CP had longer operation time and hospital stay and is safe and effective in preserving endocrine and exocrine functions in treatment of benign or borderline tumors located at the neck or proximal body of the pancreas.

Mind the tributary of the canal: Are stents necessary for insulinoma enucleation in proximity to a prominent Duct of Santorini: A case report and literature review

RATIONALE

We describe a case of insulinoma located extremely close to the accessory pancreatic duct (APD), but away from the main pancreatic duct (MPD). Previous studies showed insulinoma enucleation is a safe procedure for small benign tumors >3 mm distant from the MPD. However, in this case enucleation of the tumor led to unanticipated APD injury and grade B post-operative pancreatic fistula (POPF). We provide detailed records of clinical management and argue that enucleation of tumors near APD needs to be carefully weighed.

PATIENT CONCERNS

The patient experienced a sudden increase of abdominal drain fluid and prolonged drainage time after a regular insulinoma enucleation surgery.

DIAGNOSIS

APD damage during the enucleation.

INTERVENTIONS

Drain fluid amylase concentration were regularly recorded and prolonged somatostatin analogs were administered.

OUTCOMES

Amount of abdominal drain gradually decreased and the drain tube was removed on postoperative 37.

LESSONS

Benign pancreatic tumor close to the APD need to be evaluated carefully and clinical evidence is warranted to affirm the necessity of placing a pancreatic duct stent before the surgery.

Intraoperative Ultrasound Guided Robotic Pancreatic Enucleation, Does a Distance of 3mm Still Matters?

Background: A minimal distance of 3 mm to main pancreatic duct (MPD) was generally considered to be necessary for pancreatic enucleation (PE). This study was designed to report the safety and feasibility of PE for tumors located in 3 mm to MPD Under the intraoperative ultrasound (IOUS) guidance.Methods: The data of patients who received IOUS guided robotic PE from January 2018 to May 2019 in the second department of hepato-pancreato-biliary surgery were reviewed in this study. According to the distance to MPD (less than 3 mm or not), patients were divided in 2 groups, and the short-term operative outcomes were compared.Statistics: Students' t-test and Mann-Whitney U test were used for comparing continuous variables, and Chi-squared test was used for comparing categorical variables.Results: And a total of 56 patients were analyzed, and a minimal distance less than 3 mm between the tumor and pancreatic duct measured by IOUS was found in 12 patients. The tumors and MPD were clearly revealed intraoperatively in all the cases. The operative duration was significantly longer in patients with tumors located in 3 mm from MPD (143.25 ± 40.89 min vs 107.14 ± 37.73 min, t = 2.756, P=.014). There was no significant difference between the rate of post-operative pancreatic fistula and other complications in the different groups (χ² =.924, P=.48).Discussion and conclusion: robotic PE could be safely performed under IOUS guidance for benign or low-grade malignant tumors located less than 3 mm to the MPD.

Laparoscopic Enucleation of Pancreatic Neoplasms: A Single-Center Experience and Outcomes

Background: Laparoscopic technique has been increasingly applied in the treatment of selected pancreatic tumors. The aim of this study is to evaluate the experience with laparoscopic enucleation of pancreatic neoplasms (LEPNs), for selected pancreatic diseases, at a high-volume referral center. Methods: Between May 2012 and October 2020, LEPNs was attempted in 16 patients with selected pancreatic neoplasms. The localization of tumors, etiology, indications, and clinical outcomes were analyzed. Results: Sixteen patients were included. LEPN was successfully performed in 13 patients, 3 conversions to open procedure were required. The definitive histopathological result of the resected pieces showed prevalence of intraductal papillary mucinous neoplasms. Postoperative major complications occurred for 3 patients (18.7%), the 3 of them presented postoperative pancreatic fistula (POPF). The median hospital stay was 4.5 days (range 2-7) for patients without POPF and 14.6 days (3-30) for those who presented with POPF. No deaths were registered. During a median follow-up of 43.8 months (0.2-109), no new-onset exocrine or endocrine insufficiency was diagnosed, no patient experienced tumor recurrence and, the 4 patients who underwent LEPN for insulinoma, remained asymptomatic. Conclusion: LEPNs has become a valuable alternative for patients with benign or low risk of malignancy tumors. Appropriate preoperative imaging is key for localization. Whenever feasible, this technique not only reduces the risks of exocrine and endocrine insufficiency, but also adds the well-known advantages of minimally invasive techniques, making it a safe and feasible treatment.

Laparoscopic clamp-crushing enucleation with a pancreatic duct stent for tumors located close to the main pancreatic duct

The perioperative management and technical details of laparoscopic clamp-crushing enucleation for low-malignant-potential pancreatic neuroendocrine neoplasms (PNENs) located close to the main pancreatic duct (MPD) in the body/tail of the pancreas using a perioperative MPD stent are reported. The procedure was performed in two patients with PNEN (13 and 10 mm in diameter) in the body/tail of the pancreas. A naso-pancreatic stent (NPS) was placed preoperatively in both patients. Resection was performed using Maryland-type bipolar forceps. The surgical duration was 139 and 55 min, and the estimated blood loss was 5 and 0 mL, respectively. One patient was discharged uneventfully on postoperative day (POD) 12. The other patient developed a grade B pancreatic fistula, but was discharged on POD 22. Laparoscopic clamp-crushing enucleation with an NPS might be a viable treatment option for tumors located close to the MPD.

Resektionsstrategien beim BD-IPMN - Enukleation oder onkologische Resektion?

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

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

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

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

Organ preserving pancreatic resections offer better long-term conservation of pancreatic function at the expense of high perioperative major morbidity: a fair trade-off for benign or low malignant potential pancreatic neoplasms-a single-center experience

BACKGROUND

Standard pancreatic resections (SPRs) might have long-term deleterious effects on pancreatic function, without added oncological advantage in low malignant potential (LMP) or benign neoplasms. This study aimed to evaluate outcomes following organ-preserving pancreatic resections (OPPARs) and SPRs.

METHOD

Post hoc analysis of patients undergoing OPPAR or SPR for benign or LMP pancreatic tumors from January 2011 to January 2020 at Tata Memorial Hospital, Mumbai.

RESULTS

Thirty-six and 114 patients were identified in OPPAR and SPR groups respectively. The overall morbidity (58.3% vs 43.9%, p-0.129) was comparable. Major morbidity (41.7% vs 21.9%, p-0.020), post-operative pancreatic fistula (POPF) (63.9% vs 35.1%, p-0.002), and clinically relevant POPF (41.7% vs 20.2%, p-0.010) were significantly higher with OPPAR. Post-operative endocrine insufficiency (14.9% vs 11.1%, p-0.567), exocrine insufficiency (19.3% vs 0%, p-0.004), and requirement of long-term pancreatic enzyme replacement (17.5% vs 0%, p-0.007) were higher in SPRs. Comparing left-sided and right-sided resections in the entire cohort, incidence of endocrine insufficiency was 17.1% vs 11.2% (p-0.299) and that of exocrine insufficiency was 8.6% vs 20% (p-0.048) respectively.

CONCLUSION

OPPAR is associated with high post-operative major morbidity and pancreatic fistula rate but offers long-term benefit due to better preservation of pancreatic function than SPR. The incidence of exocrine insufficiency is higher in right sided as compared to left-sided pancreatic resections.

Impact of parenchyma-preserving surgical methods on treating patients with solid pseudopapillary neoplasms: A retrospective study with a large sample size

BACKGROUND

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that mainly affects young women.

AIM

To evaluate the impact of parenchyma-preserving surgical methods (PPMs, including enucleation and central pancreatectomy) in the treatment of SPN patients.

METHODS

From 2013 to 2019, patients who underwent pancreatectomy for SPNs were retrospectively reviewed. The baseline characteristics, intraoperative index, pathological outcomes, short-term complications and long-term follow-up data were compared between the PPM group and the conventional method (CM) group.

RESULTS

In total, 166 patients were included in this study. Of them, 33 patients (19.9%) underwent PPM. Most of the tumors (104/166, 62.7%) were found accidentally. Comparing the parameters between groups, the hospital stay d (12.35 vs 13.5 d, P = 0.49), total expense (44213 vs 54084 yuan, P = 0.21), operation duration (135 vs 120 min, P = 0.71), and intraoperative bleeding volume (200 vs 100 mL, P = 0.49) did not differ between groups. Regarding pathological outcomes, tumor size (45 vs 32 mm, P = 0.07), Ki67 index (P = 0.53), peripheral tissue invasion (11.3% vs 9.1%, P = 0.43) and positive margin status (7.5% vs 6%, P = 0.28) also did not differ between groups. Moreover, PPM did not increase the risk of severe postoperative pancreatic fistula (3.8% vs 3.0%, P = 0.85) or tumor recurrence (3.0% vs 6.0%, P = 0.39). However, the number of patients who had exocrine insufficiency during follow-up was significantly lower in the PPM group (21.8% vs 3%, P = 0.024). CM was identified as an independent risk factor for pancreatic exocrine insufficiency (odds ratio = 8.195, 95% confident interval: 1.067-62.93).

CONCLUSION

PPM for SPN appears to be feasible and safe for preserving the exocrine function of the pancreas.

Comparison of Outcomes of Enucleation vs. Standard Surgical Resection for Pancreatic Neoplasms: A Systematic Review and Meta-Analysis

Background

With advancement in health technology, the detection rate of pancreatic neoplasms is increasing. Tissue sparing surgery (enucleation) as well as standard surgical resection are two commonly used modalities of management. There are studies comparing clinical outcomes between these two modalities; however, there is lack of studies that systematically pool the available findings to present conclusive and reliable evidence.

Methods

A systematic search was conducted using the PubMed, Scopus, and Google Scholar databases. Studies that were randomised controlled trials or cohort based or analysed retrospective data were considered for inclusion. Studies should have been done in adult patients with pancreatic neoplasms and should have examined the outcomes of interest by the two management modalities i.e., enucleation and standard surgical resection. Statistical analysis was performed using STATA software.

Results

A total of 20 studies were included in the meta-analysis. The operation time (in minutes) (WMD −78.20; 95% CI: −89.47, −66.93) and blood loss (in ml) (WMD −204.30; 95% CI: −281.70, −126.90) for enucleation was significantly lesser than standard surgical resection. The risk of endocrine (RR 0.32; 95% CI: 0.18, 0.56) and exocrine insufficiency (RR 0.16; 95% CI: 0.07, 0.34) was lower whereas the risk of post-operative pancreatic fistula (RR 1.46; 95% CI: 1.22, 1.75) was higher in enucleation, compared to standard surgical resection group. There were no differences in the risk of reoperation, readmission, recurrence, mortality within 90 days and 5-years overall mortality between the two groups.

Conclusions

Enucleation, compared to standard surgical resection, was associated with better clinical outcomes and therefore, might be considered for selected pancreatic neoplasms. There is a need for randomised controlled trials to document the efficacy of these two management techniques.

Short- and Long-Term Outcomes of Laparoscopic Organ-Sparing Resection for Pancreatic Neuroendocrine Neoplasms

BACKGROUND

Pancreatic neuroendocrine neoplasms (PNENs) are rare neoplasms associated with a long life expectancy after resection. In this setting, patients may benefit from laparoscopic organ-sparing resection. Studies of laparoscopic organ-sparing resection for PNENs are limited. The aim of this study was to evaluate the short- and long-term outcomes of laparoscopic organ-sparing resection for PNENs.

METHODS

A retrospective study was performed for patients with PNENs who underwent laparoscopic organ-sparing pancreatectomy between March 2005 and May 2018. The patients' demographic data, operative results, pathological reports, hospital courses and morbidity, mortality, and follow-up data (until August 2018) were analysed.

RESULTS

Thirty-five patients were included in the final analysis. There were 9 male and 26 female patients, with a median age of 46 years (range 25-75 years). The mean BMI was 24.6 ± 3.3 kg/m². Nine patients received laparoscopic enucleation (LE), 20 received laparoscopic spleen-preserving distal pancreatectomy (LSPDP), and 6 received laparoscopic central pancreatectomy. The operative time, intraoperative blood loss, transfusion rate, and postoperative hospital stay were 186.4 ± 60.2 min, 165 ± 73.0 ml, 0 days, and 9 days (range 5-23 days), respectively. The morbidity rate, grade ≥ III complication rate, and grade ≥ B pancreatic fistula rate were 34.2%, 11.4%, and 8.7%, respectively, with no mortality. The rate of follow-up was 94.3%, and the median follow-up time was 55 months (range 3-158 months). One patient developed recurrence 36 months after LE and was managed with surgical resection. The other patients survived without metastases or recurrence during the follow-up. One patient had diabetes after LSPDP, and no patients had symptoms of pancreatic exocrine insufficiency. Nineteen patients who underwent LSPDP (16 with the Kimura technique and 3 with the Warshaw technique) were followed. Normal patency of the splenic artery and vein was observed in 14 and 14 patients within 1 month of surgery and in 15 and 14 patients 6 months or more after the operation, respectively. Partial splenic infarction was observed in 3 patients within 1 month of surgery and in no patients 6 months or more after the operation. Three patients eventually developed collateral venous vessels around the gastric fundus and reserved spleen, with one case of variceal bleeding.

CONCLUSIONS

Laparoscopic organ-sparing resection for selected cases of PNENs is safe and feasible and has favourable short- and long-term outcomes.

Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas

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.

Minimally-invasive versus open enucleation for pancreatic tumours: A propensity-score adjusted analysis

BACKGROUNDS/AIMS

This study aims to evaluate the perioperative outcomes of minimally-invasive enucleation (MIEn) of the pancreas versus open enucleation (OEn).

METHODS

This is a retrospective review of 20 consecutive patients who underwent pancreatic enucleation at a single institution.

RESULTS

Seven patients underwent MIEn, of which 3 were robotic and 4 were laparoscopic. After propensity-adjusted analysis, the only significant difference was a reduced rate of readmissions within 30 days in the MIEn group versus the OEn group [0 vs 4 (30.8%), p=0.0464]. There were no conversions to open in the MIEn group, and median operation time was similar in both groups. There was no difference in median EBL in both groups, and none of the patients in our series required blood transfusions. The overall morbidity rate was 45.0% and the major complication (Clavien-Dindo>2) rate was 15%; which was similar between both groups. Seven (35%) patients had a Grade B/C POPF, and there was no significant difference between the two groups for this. The MIEn group had a shorter median length of stay compared to OEn [5 days (range, 3-24) vs 8.5 days (range, 5-42)] this was not significant on propensity-adjusted analysis (p=0.3195). There was no post-operative 90-day/in-hospital mortality in all 20 patients.

CONCLUSIONS

Our experience demonstrates that MIEn was associated with similar perioperative outcomes and fewer readmissions compared to OEn.

Management of asymptomatic, well-differentiated PNETs: results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association

BACKGROUND

Variation in the management of PNETs exist due to the limited high-level evidence to guide clinical practice. The aim of this work is to generate consensus guidelines with a Delphi process for managing PNETs.

METHODS

A panel of experts reviewed the surgical literature and scored a set of clinical case statements using a web-based survey to identify areas of agreement and disagreement. Results of the survey were discussed after each round of review. This cycle was repeated until no further likelihood of reaching consensus existed.

RESULTS

Twenty-two case statements related to surgical indications, preoperative biopsy, extent of resection, type of surgery, and tumor location were scored. Using a pre-defined definition of consensus, the panel achieved consensus on the following: i) resection is not recommended for <1 cm lesions; ii) resection is recommended for lesions greater than 2 cm; iii) lymph node dissection is recommended for radiographically-suspicious nodes with splenectomy for distal lesions; iv) tumor enucleation and central pancreatectomy are acceptable when technically feasible. No consensus was reached regarding issues of preoperative biopsy or 1-2 cm tumors.

CONCLUSIONS

Using a structured, validated system for identifying consensus, an expert panel identified areas of agreement regarding critical management decisions for patients with PNET. Issues without consensus warrant additional clinical investigation.

Current Management of Pancreatic Neuroendocrine Tumors: From Demolitive Surgery to Observation

Incidental diagnosis of pancreatic neuroendocrine tumors (PanNETs) greatly increased in the last years. In particular, more frequent diagnosis of small PanNETs leads to many challenging clinical decisions. These tumors are mostly indolent, although a percentage (up to 39%) may reveal an aggressive behaviour despite the small size. Therefore, there is still no unanimity about the best management of tumor smaller than 2 cm. The risks of under/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery. The importance of the Ki-67 index as a prognostic factor is still debated as well. Whenever technically feasible, parenchyma-sparing surgeries lead to the best chance of organ preservation. Lymphadenectomy seems to be another important prognostic issue and, according to recent findings, should be performed in noninsulinoma patients. In the case of enucleation of the lesion, a lymph nodal sampling should always be considered. The relatively recent introduction of minimally invasive techniques (robotic) is a valuable option to deal with these tumors. The current management of PanNETs is analysed throughout the many available published guidelines and evidences with the aim of helping clinicians in the difficult decision-making process.

Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections

OBJECTIVE

The aim of this study was to evaluate the safety and efficiency of enucleation (EU) for proximal pancreatic non-invasive neoplasms.

METHODS

Patients with solitary non-invasive neoplasms in the proximal pancreas from January 1998 to April 2014 at the Second Affiliated Hospital of Zhejiang University, Hangzhou, China were included. Different operations and outcomes were analyzed.

RESULTS

A total of 123 patients were enrolled. Forty patients (32.5%) underwent EU including 18 patients who had tumors close to the main pancreatic duct (MPD). Sixty-one patients (49.6%) had pancreaticoduodenectomy (PD) performed and 22 (17.9%) underwent central pancreatectomy (CP). Pathological outcomes included neuroendocrine tumors, cystic lesions, and solid pseudopapillary tumors. Operation time, intra-operative blood loss, and duration of hospital stay were significantly reduced in the EU group. PD was associated with the greatest complication rate (55.7%), followed by EU (50%) and CP (40.9%), though the pancreatic fistula rate after EU was the highest (50%), especially in patients with tumors larger than 3 cm and tumors close to the MPD. EU had advantages in the preservation of pancreatic parenchyma and endocrine and exocrine function.

CONCLUSIONS

EU can be carried out safely and effectively for tumors in the proximal pancreas with improved outcomes compared with standard resections, even if the tumor is larger than 3 cm and close to the MPD.

Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation.

Enucleation of pancreatic solid pseudopapillary neoplasm: Short-term and long-term outcomes from a 7-year large single-center experience

BACKGROUND

Enucleation is increasingly used for pancreatic solid pseudopapillary neoplasm (SPN) to preserve function of the pancreas. The data was limited due to rarity of this low-grade neoplasm. We sought to describe the indications, operative technique, short and long-term outcomes after enucleation with largest series of enucleated SPNs.

METHODS

Data collected retrospectively from 110 patients with SPN who underwent pancreatectomy between 2009 and 2016 in our institution were reviewed. Thirty-one patients underwent enucleation were identified for analysis, and compared with the 70 patients underwent conventional pancreatic resection.

RESULTS

Of the 31 patients, 27 (87.1%) were women, and the mean age was 29.8 years (range, 11-49 years). Enucleated SPNs were mostly located in the head/uncinate process of the pancreas (38.7%). Overall morbidity was 25.8%, mainly due to POPF (19.4%), and severe morbidity was only 6.5% with no death. Compared with conventional pancreatic resection, enucleation had a shorter duration of surgery (P < 0.001), less blood loss (P < 0.001), lower rate of exocrine insufficiency (P = 0.033) and comparable morbidity (P = 1), with no increased risk of tumor recurrence (P = 1). The rate of endocrine insufficiency after enucleation seemed lower (Nil vs. 4.5%, P = 0.55).

CONCLUSIONS

Enucleation of SPN of the pancreas appears to be feasible and safe for preserving exocrine and endocrine function of the gland. Enucleation with negative surgical margin seems adequate with no increased risk of tumor recurrence. Enucleation could be seriously considered as an alternative to conventional resection for this frequently young population.

Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: A single-center experience of 142 patients

BACKGROUND

Enucleation is increasingly used for benign or low-grade pancreatic neoplasms. Enucleation preserves the pancreatic parenchyma as well as decreases the risk of long-term endocrine and exocrine dysfunction, but may be associated with a higher rate of postoperative pancreatic fistula (POPF). The aim of this study was to assess short-term outcomes, in particular, POPF.

METHODS

Data were collected retrospectively from all 142 patients who underwent pancreatic enucleation between 2009 and 2014 in our institution were analyzed.

RESULTS

Lesions were most frequently located in the head and uncinate process of the pancreas (60.6%), and the most common types were neuroendocrine neoplasms (52.1%). Overall morbidity was 66%, mainly due to POPF (53.5%), and severe morbidity was only 8.4%, including one death (0.7%). Clinical POPF (Grade B or C) occurred in 22 patients (15.5%). Independent risk factors for clinical POPF were age ≥60 years, an episode of acute pancreatitis, and cystic morphology. Tumor size, coverage, histological differentiation, and prolonged operative time were not associated with the risk of POPF.

CONCLUSIONS

Enucleation is a safe and feasible procedure for benign or low-grade pancreatic neoplasms. The rate of clinical POPF is acceptable, and clinical POPF occurs more frequently in elderly patients (≥60 years of age), patients with cystic neoplasms, or patients with an episode of acute pancreatitis.

Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference

BACKGROUND

Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients.

METHODS

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey.

RESULTS

LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe.

CONCLUSIONS

LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.

Islet Cell Tumors of the Pancreas

Islet cell tumors of the pancreas, also known as pancreatic neuroendocrine tumors, constitute less than 5% of pancreatic tumors, and 7% of all neuroendocrine tumors. Most are non-functional, and patients often present with metastatic disease. Functional tumors present with distinct clinical syndromes. Accurate staging is critical as surgery is both the cornerstone of treatment, and the only hope for cure. Medical management involves treating the manifestations of hormonal excess, and using somatastatin analogues when appropriate. Systemic chemotherapy, targeted molecular therapy, and peptide receptor radiotherapy may be used for refractory disease in lieu of or as an adjunct to surgery.

Minimally invasive surgical approach to pancreatic malignancies

Pancreatic surgery for malignancy is recognized as challenging for the surgeons and risky for the patients due to consistent perioperative morbidity and mortality. Furthermore, the oncological long-term results are largely disappointing, even for those patients who experience an uneventfully hospital stay. Nevertheless, surgery still remains the cornerstone of a multidisciplinary treatment for pancreatic cancer. In order to maximize the benefits of surgery, the advent of both laparoscopy and robotics has led many surgeons to treat pancreatic cancers with these new methodologies. The reduction of postoperative complications, length of hospital stay and pain, together with a shorter interval between surgery and the beginning of adjuvant chemotherapy, represent the potential advantages over conventional surgery. Lastly, a better cosmetic result, although not crucial in any cancerous patient, could also play a role by improving overall well-being and patient self-perception. The laparoscopic approach to pancreatic surgery is, however, difficult in inexperienced hands and requires a dedicated training in both advanced laparoscopy and pancreatic surgery. The recent large diffusion of the da Vinci(®) robotic platform seems to facilitate many of the technical maneuvers, such as anastomotic biliary and pancreatic reconstructions, accurate lymphadenectomy, and vascular sutures. The two main pancreatic operations, distal pancreatectomy and pancreaticoduodenectomy, are approachable by a minimally invasive path, but more limited interventions such as enucleation are also feasible. Nevertheless, a word of caution should be taken into account when considering the increasing costs of these newest technologies because the main concerns regarding these are the maintenance of all oncological standards and the lack of long-term follow-up. The purpose of this review is to examine the evidence for the use of minimally invasive surgery in pancreatic cancer (and less aggressive tumors), with particular attention to the oncological results and widespread reproducibility of each technique.

Intraductal Papillary Mucinous Neoplasms and the Risk of Diabetes Mellitus in Patients Undergoing Resection Versus Observation

OBJECTIVE

The aim of this study is to determine the prevalence of diabetes mellitus (DM) in patients with intraductal papillary mucinous neoplasm of the pancreas (IPMN) and compare rates of new/progressive DM between IPMN patients undergoing pancreatectomy versus observation.

METHODS

Patients diagnosed with IPMN were identified from institutional databases, divided into two groups based on treatment type, pancreatectomy versus clinical observation, and subsequently evaluated. Standard demographic and clinicopathologic variables, fasting glucose, diabetic status, and pancreatic volume data, were obtained and compared between groups.

RESULTS

One hundred thirty-four IPMN patients were identified; 103 (77 %) underwent pancreatectomy and 31 (23 %) were observed. Baseline DM rate was 18 % (24/134). This was not different between groups [17 % (17/103) resected vs. 23 % (7/31) observed, p = 0.51]. Median follow-up was 53 months and new/progressive DM occurred in 37 (28 %) patients with no difference between groups [29 (28 %) resected vs. 8 (26 %) observed, p = 0.74]. Among resected patients, degree of dysplasia was associated with increase risk of new/progressive DM [moderate dysplasia OR 5.76 (1.24-26.79) and severe dysplasia OR 9.43 (1.54-57.74), p = 0.04], while procedure type and remnant volume were not.

CONCLUSIONS

The incidence and prevalence of DM among patients with IPMN was high and did not differ between resected and observed groups. Degree of dysplasia, not the amount of resected pancreas, was associated with increased risk of DM, suggesting that the presence or development of DM may be a marker of malignant progression. Confirmatory studies are required.

Laparoscopic versus open enucleation for pancreatic neoplasms: clinical outcomes and pancreatic function analysis

BACKGROUND

The studies comparing laparoscopic enucleation (LE) with open enucleation (OE) are limited. This study aimed to compare perioperative outcomes of patients undergoing LE and OE and to assess the pancreatic function after LE.

METHODS

Between February 2001 and July 2014, patients who underwent enucleation were reviewed. Patients were divided into two groups as LE and OE. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and long-term follow-up (including pancreatic function).

RESULTS

Thirty-seven patients (15 LE and 22 OE) were included in the final analysis. Baseline characteristics were similar in the two groups. LE group showed significantly shorter operating time (118.2 ± 33.1 vs. 155.2 ± 44.3 min, p = 0.009), lower estimated blood loss (80.0 ± 71.2 vs. 195.5 ± 103.4 ml, p = 0.001), shorter first flatus time (1.8 ± 1.0 vs. 3.4 ± 1.8 days, p = 0.004), shorter diet start time (2.4 ± 1.0 vs. 4.4 ± 2.0 days, p = 0.001), shorter postoperative hospital stay (7.9 ± 3.4 vs. 11.2 ± 5.7 days, p = 0.046). Postoperative outcomes, including morbidity (40.0 vs. 45.5 %, p = 1.000), grade B/C pancreatic fistula rates (20.0 vs. 13.6 %, p = 0.874), and mortality, were similar in the two groups. The median follow-up period was 47 months (range 7-163 months). No local recurrence or distant metastasis was detected in either group. Only one patient (4.8 %) underwent OE developed new-onset diabetes, in comparison with none in the LE group. One patient (7.1 %) had weight loss and received pancreatic enzyme supplementation in the LE group, in comparison with two patients (9.5 %) in the OE group.

CONCLUSIONS

LE is a safe and feasible technique for the benign or low malignant-potential pancreatic neoplasms. Compared to OE, LE had shorter operating time, lower estimated blood loss, and faster recovery. LE could preserve the pancreatic function as the OE.

Pancreatic Neuroendocrine Tumors: an Update

Pancreatic neuroendocrine tumors (pNETs) are rare and comprise only 1-2 % of all pancreatic neoplastic disease. Although the majority of these tumors are sporadic (90 %), pNETs can arise in the setting of several different hereditary genetic syndromes, most commonly multiple endocrine neoplasia type 1 (MEN1). The presentation of pNETs varies widely, with over 60 % having malignant distant disease at the time of initial diagnosis involving the liver or other distant sites. Functioning pNETs represent approximately 10 % of all pNETs, secrete a variety of peptide hormones, and are responsible for several clinical syndromes caused by profound hormonal derangement. Surgery remains the cornerstone of therapy and the only curative approach. It should be pursued for localized disease and for metastatic lesions amenable to resection. Multimodality therapies, including liver-directed therapies and medical therapy, are gaining increasing favor in the treatment of advanced pNETs. Their utility is multifold and spans from ameliorating symptoms of hormonal excess (functional pNETs) to controlling the local and systemic disease burden (non-functional pNETs). The recent introduction of target molecular therapy has promising results especially for the treatment of progressive well-differentiated G1/G2 tumor. In this review, we summarize the current knowledge and give an update on recent advancements made in the therapeutic strategies for pNETs.

Parenchyma-sparing pancreatectomies for pancreatic neuroendocrine tumors

Parenchyma-sparing pancreatectomy, including enucleation and central pancreatectomy, has been investigated as an alternative to standard resection (pancreaticoduodenectomy or left/distal pancreatectomy) for pancreatic neuroendocrine tumor (PNET). In selected patients, with small (<2 cm) and low-grade tumors, PSP are associated with excellent both overall and disease-free survivals. These procedures are associated with an increased postoperative morbidity but an excellent long-term postoperative pancreatic function. Therefore, they should be considered as a valid therapeutic option in selected well-differentiated PNET.

Meta-analysis of surgical outcome after enucleation versus standard resection for pancreatic neoplasms

BACKGROUND

Pancreatic enucleation is a tissue-sparing approach to pancreatic neoplasms and may result in better postoperative pancreatic function than standard pancreatic resection. The objective of this review was to compare the postoperative outcome after pancreatic enucleation versus standard resection.

METHODS

MEDLINE, Embase and the Cochrane Library were searched systematically until February 2015 to identify studies comparing the outcome of enucleation versus standard resection for pancreatic neoplasms. After critical appraisal, meta-analysis was performed and the findings were presented as odds ratios or weighted mean differences with corresponding 95 per cent c.i.

RESULTS

Twenty-two observational studies (1148 patients) were included. Duration of surgery (P < 0.001), blood loss (P < 0.001), length of hospital stay (P = 0.04), and postoperative endocrine (P < 0.001) and exocrine (P = 0.01) insufficiency were lower after enucleation than after standard resection. Mortality (P = 0.44), overall complications (P = 0.74), reoperation rate (P = 0.93) and delayed gastric emptying (P = 0.15) were not significantly different between the two approaches. The overall rate of postoperative pancreatic fistula (POPF) was higher after enucleation than after standard resection (P < 0.001). However, the raised POPF rate did not result in higher mortality or overall morbidity. Sensitivity analysis of high-volume studies (total of more than 20 enucleations and more than 4 per year) showed that, in specialized centres, enucleation can be performed with no increased risk of POPF (P = 0.12).

CONCLUSION

Compared with standard resection, pancreatic enucleation can be performed effectively and with comparable safety in high-volume institutions. Enucleation should be considered instead of standard resection for selected pancreatic neoplasms.

Pancreatic fistulae after pancreatic resections for neuroendocrine tumours compared with resections for other lesions

BACKGROUND

Resection for pancreatic neuroendocrine tumours (PNET) is suggested to be associated with an increased risk of a post-operative pancreatic fistula (POPF). The aim of this study was to describe morbidity after resections for PNET, focusing on POPF. Outcomes were compared with resections for other lesions.

METHODS

Patients undergoing an elective pancreatic resection during a 12-year period were retrospectively analysed. Morbidity was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definitions.

RESULTS

Eighty-eight out of 832 patients (10.6%) underwent a resection for PNET. Atypical pancreatic resections (enucleation and central pancreatectomy) and distal pancreatectomies were more frequently performed for PNET. The POPF rate was 22.7% in patients operated for PNET compared with 17.2% in other patients (P = 0.200). In univariate analysis, body mass index (BMI), pancreatic duct diameter, somatostatin analogue administration, type of resection and type of pathology were associated with a POPF. In multivariate analysis, BMI, a pancreatic duct diameter <3 mm and central pancreatectomy remained independent risk factors [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.22-3.07 and OR 3.04, 95% CI 1.05-8.82, respectively].

CONCLUSIONS

High rates of POPF were found in patients operated for PNET. However, this was mainly owing to the fact that atypical resections, known to be associated with a higher fistula rate, were performed more frequently in these patients.

Update on pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (pNETs) are relatively rare tumors comprising 1-2% of all pancreas neoplasms. In the last 10 years our understanding of this disease has increased dramatically allowing for advancements in the treatment of pNETs. Surgical excision remains the primary therapy for localized tumors and only potential for cure. New surgical techniques using laparoscopic approaches to complex pancreatic resections are a major advancement in surgical therapy and increasingly possible. With early detection being less common, most patients present with metastatic disease. Management of these patients requires multidisciplinary care combining the best of surgery, chemotherapy and other targeted therapies. In addition to surgical advances, recently, there have been significant advances in systemic therapy and targeted molecular therapy.

A rare case of mixed mucinous cystadenoma with serous cystadenoma of the pancreas treated by laparoscopic central pancreatectomy

Mixed mucinous cystadenoma with serous cystadenoma of the pancreas is rare. There have been only two previous case reports in the English-language literature. We present a case of a 46-year-old woman who was diagnosed with mixed mucinous cystadenoma with serous cystadenoma of the pancreas. Computed tomography and magnetic resonance imaging showed a cystic neoplasm in the dorsal/proximal body of the pancreas with a clear-margin multilocular cavity and enhanced internal septum. The patient underwent laparoscopic central pancreatectomy. The diagnosis of mixed mucinous cystadenoma with serous cystadenoma of the pancreas was confirmed by pathological examination. The patient was followed up for 3 months and there were no signs of recurrence, or pancreatic exocrine or endocrine insufficiency. To the best of our knowledge, this is the first reported case treated by laparoscopic central pancreatectomy.

Extent of Surgery and Implications of Transection Margin Status after Resection of IPMNs

Appropriate surgical strategies for management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a matter of debate. Preoperative and intraoperative evaluation of malignant potential of IPMN and of patient's comorbidities is of paramount importance to balance potential complications of surgery with tumors' risk of being or becoming malignant; the decision about the extent of pancreatic resection and the eventual total pancreatectomy needs to be determined on individual basis. The analysis of frozen-section margin of pancreas during operation is mandatory. The goal should be the complete resection of IPMN reaching negative margin, although there is still no agreed definition of “negative margin.” Of note, the presence of deepithelization is often wrongly interpreted as absence of neoplasia. Management of resection margin status and stratification of surveillance of the remnant pancreas, based on characteristics of primary tumour, are of crucial importance in the management of IPMNs in order to decrease the risk of tumor recurrence after resection. Although risk of local and distant recurrence for invasive IPMNs is increased even in case of total pancreatectomy, also local recurrence after complete resection of noninvasive IPMNs is not negligible. Therefore, a long-term/life-time follow-up monitoring is of paramount importance to detect eventual recurrences.

Middle-preserving pancreatectomy for multifocal intraductal papillary mucinous neoplasms of the pancreas: report of a case

Multifocal or continuous pancreatic lesion is identified frequently but finding an appropriate surgical approach is quite challenging. Total pancreatectomy is a useful procedure. However, postoperative endocrine and exocrine disturbance is inevitable. Recently, the safety and feasibility of parenchyma preserving pancreatectomy, including middle-preserving pancreatectomy (MPP), have been reported. MPP is a combined procedure of pancreaticoduodenectomy and distal pancreatectomy, while preserving the body of the pancreas, for cases of multifocal pancreatic lesions. So far, there have only been a few reports that have described MPP. We report a case of MPP for multifocal intraductal papillary mucinous neoplasms of the pancreas, describe the surgical procedure, and discuss the feasibility of MPP as parenchyma-preserving pancreatectomy with reference to the literature.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

Enucleation of pancreatic lesions: indications, outcomes, and risk factors for clinical pancreatic fistula

BACKGROUND

There are few large samples and single-center series that focus on the outcomes of pancreatic enucleation and risk factors for clinical pancreatic fistula (PF). This study aimed to evaluate the indications, short- and long-term results, and risk factors for clinical PF after pancreatic enucleation.

METHODS

Patients who underwent pancreatic enucleation from January 2005 to April 2011 at the Peking Union Medical College Hospital in China were included. Clinical data were collected and analyzed.

RESULTS

A total of 119 patients underwent enucleation. PF was the most common complication; the incidence of clinical PF (grades B and C) was 27.7 %. The most common indications were endocrine neoplasms (76.5 %). During a median follow-up of 41 months, no patient developed exocrine insufficiency. Three elderly patients developed non-insulin-dependent diabetes mellitus. One patient with VIPoma developed recurrence and liver metastasis. New York Heart Association (NYHA) class II or III (P = 0.009; hazard ratio (HR) 3.191; 95 % confidence interval (CI) 1.334-7.632), operative time ≥180 min (P = 0.025; HR 2.664; 95 % CI 1.112-6.386) were the independent risk factors for clinical PF.

CONCLUSION

Enucleation is a safe and effective treatment for benign and low malignant lesions of the pancreas. NYHA class II or III and operation time of ≥180 min are independent risk factors for clinical PF.

Laparoscopic parenchyma-sparing pancreatectomy

In recent years laparoscopic pancreatic procedures have developed rapidly, and reports of laparoscopic resection including laparoscopic distal pancreatectomy and laparoscopic pancreaticoduodenectomy have increased in number. On the other hand, many benign and low-grade malignant pancreatic lesions have recently been detected by the improved diagnostic modalities. Parenchyma-sparing pancreatectomy is a preferred surgical procedure for such benign and low-malignancy pancreatic lesions, because parenchyma-sparing pancreatectomy can avoid the unnecessary resection of the normal pancreatic parenchyma, thereby preserving the endocrine and exocrine functions of the pancreas. Simultaneously, laparoscopic surgery has contributed to minimally invasive approaches for various pancreatic surgical procedures. The combination of laparoscopic surgery and parenchyma-sparing pancreatectomy is an ideal surgical procedure for benign and low-grade malignant pancreatic lesions. For laparoscopic parenchyma-sparing pancreatectomy to become more widely known and its indications clarified, it is necessary to demonstrate the clinical benefits, technical feasibility, and safety of this complex and difficult surgical procedure.

Advancements in pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PanNETs) have increased in incidence in the USA over the last 20 years. Although PanNETs are often misconceived as being indolent tumors as they have a far more favorable prognosis over pancreatic adenocarcinoma, roughly 60-70% of patients have metastatic disease at the time of diagnosis due to presentation late in the disease process. While improvements in imaging modalities allow for early detection and better tumor localization, recent advancements in basic science, as well as surgical and medical management of PanNETs have further improved the prognosis. The mainstay of therapy for localized PanNETs is surgical intervention, which has become safer and is slowly shifting towards a more minimally invasive approach. However, the prognosis still remains relatively bleak for patients with unresectable disease. Fortunately, novel molecular targeted therapies, such as everolimus and sunitinib, have recently come into the limelight and have shown significant promise for the treatment of locally advanced and metastatic disease.

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

BACKGROUND/AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Parenchyma-sparing resections for pancreatic neuroendocrine tumors

BACKGROUND

Parenchyma-sparing pancreatectomy (PSP), including enucleation and central pancreatectomy, has been investigated as an alternative to standard resection for pancreatic endocrine neoplasm, but the benefit/risk of these procedures remains little known.

METHODS

From 1998 to 2010, among 197 patients operated for well-differentiated pancreatic neuroendocrine tumors, 67 underwent PSP (45 enucleations and 22 central pancreatectomies) and 66 standard resections (35 pancreaticoduodenectomies and 31 distal pancreatectomies) for a tumor below 4 cm, without synchronous distant metastasis. Groups were compared regarding postoperative morbidity, mortality, long-term pancreatic function, and survival calculated using the Kaplan-Meier method.

RESULTS

Tumors operated by PSP had a median size of 15 mm, were mainly incidentally diagnosed (n = 46, 69 %), and nonfunctioning (n = 55, 82 %). Overall morbidity rate was higher after PSP than standard resection (SR) (76 vs 58 %, p = 0.0028), including more frequent pancreatic fistulas (69 vs 42 %, p = 0.003). Postoperative diabetes was less frequent following PSP than pancreaticoduodenectomy (5 vs 21 %; p = 0.022) but equivalent to the one observed after distal pancreatectomy (4 %, p = 1). Exocrine insufficiency was significantly less frequent after PSP than SR (3 vs 32 %; p < 0.0001). The overall and recurrence-free 5-year survival after PSP for nonfunctioning tumors was 96 and 98 %, respectively.

CONCLUSION

In selected patients, with small and low-grade tumors, PSP are associated with excellent overall and recurrence-free survivals. These procedures are associated with an increased postoperative morbidity but an excellent postoperative pancreatic function. Therefore, they should be considered as a valid therapeutic option in selected well-differentiated pancreatic neuroendocrine tumors.

Laparoscopic pancreatectomy for malignancy

Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.

Place of surgical resection in the treatment strategy of gastrointestinal neuroendocrine tumors

Neuroendocrine tumors (NET) are usually slow-growing neoplasms carrying an overall favorable prognosis. Surgery, from resection to transplantation, remains the only potential curative option for these patients, and should always be considered. Nevertheless, because of very few randomized controlled trials available, the optimal treatment for these patients remains controversial, especially regarding the place of surgery. We herein discuss the place of surgical resection in the treatment strategy in neuroendocrine tumors of the digestive tract.

Middle-preserving pancreatectomy for synchronous ampullary carcinoma and solid-pseudopapillary tumor of distal pancreas

INTRODUCTION

Total pancreatectomy is the treatment of choice for multicentric diseases involving the pancreas. Middle-preserving pancreatectomy is a recently reported alternative procedure when the pancreatic body is spared from disease.

PRESENTATION OF CASE

We report a 63-year old lady who underwent a combined Whipple's operation and distal splenopancreatectomy for her synchronous ampullary carcinoma and solid-pseudopapillary tumor of the distal pancreas.

DISCUSSION

For multiple tumors of the pancreas, the choice of surgery should be based on the nature of pathology and follow the principle of oncological resection.

CONCLUSION

Middle-preserving pancreatectomy is a safe and feasible option for patient with multicentric or synchronous pancreatic pathologies.

Postoperative pancreatic fistula

Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically. The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.