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Salirrosas O, Vega EA, Panettieri E, Harandi H, Kozyreva O, Ghanta S, Conrad C. Solid Pseudopapillary Tumor of the Pancreas: Is Enucleation Safe? Ann Surg Oncol 2024; 31:4105-4111. [PMID: 38480561 DOI: 10.1245/s10434-024-15119-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/14/2024] [Indexed: 05/09/2024]
Abstract
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.
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Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shree Ghanta
- Department of Medicine, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Patrone R, Mongardini FM, Conzo A, Cacciatore C, Cozzolino G, Catauro A, Lanza E, Izzo F, Belli A, Palaia R, Flagiello L, De Vita F, Docimo L, Conzo G. Pancreatic Neuroendocrine Tumors: What Is the Best Surgical Option? J Clin Med 2024; 13:3015. [PMID: 38792555 PMCID: PMC11121769 DOI: 10.3390/jcm13103015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used ("NET", "pancreatic", "surgery", "laparoscopic", "minimally invasive", "robotic", "enucleation", "parenchyma sparing") and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body-tail, while laparoscopic enucleation is better for head pNETs.
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Affiliation(s)
- Renato Patrone
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Alessandra Conzo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Chiara Cacciatore
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Giovanni Cozzolino
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Antonio Catauro
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Eduardo Lanza
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Francesco Izzo
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Andrea Belli
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Raffaele Palaia
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Luigi Flagiello
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.M.M.); (A.C.); (C.C.); (G.C.); (A.C.); (E.L.); (L.F.)
| | - Ferdinando De Vita
- Division of Medical Oncology, Department of Internal and Experimental Medicine ‘F. Magrassi’, Università della Campania ‘Luigi Vanvitelli’, 80138 Naples, Italy;
| | - Ludovico Docimo
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
| | - Giovanni Conzo
- Hepatobiliary Surgical Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy; (F.I.); (A.B.); (R.P.); (L.D.); (G.C.)
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Jürgensen C, Eckart M, Haberbosch L, Tacke F, Sandforth A, Birkenfeld AL, Overkamp D, Daniels M, Mogl M, Goretzki P, Strasburger C, Mai K, Spranger J, Jumpertz von Schwartzenberg R. Endoscopic ultrasound-guided ethanol ablation versus surgical resection of insulinomas. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 37931914 DOI: 10.1055/a-2204-5814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE Insulinoma is a rare tumor of the pancreas that can lead to hypoglycemia. To date, the standard therapy is surgical resection. After the first case report of successful endoscopic ultrasound-guided (EUS) ethanol injection 16 years ago, the need for establishing an alternative treatment method remains unchanged given the high morbidity rates of surgery and its unsuitability in some patients. MATERIALS AND METHODS Here, we provide retrospective data from 33 insulinoma patients that were treated at our center between 2010 and 2021. Of these, 9 patients were treated with EUS-guided ethanol injection and 24 underwent pancreatic surgery. RESULTS The ethanol group was older (ethanol: mean ± SE 67.8±11.2 years vs. surgery: 52.3±15.7, p=0.014) with a higher Charlson Comorbidity Index (3.0 (1.0;4.0) vs. 1.0 (0.0;2.0), p=0.008). The lowest glucose values were similar between groups before (ethanol: 2.09±0.17 mmol/l vs. surgery: 1.81±0.08, p=0.158) and after (4.95±0.74 vs. 5.41±0.28, p=0.581) the respective treatments. Complications occurred more frequently in the surgery group (11 % vs. 54 %, p=0.026). One patient after prior partial pancreatectomy died postoperatively. The hospitalization time was significantly shorter in the ethanol group (4.78±0.78 days vs. 19.88±4.07, p<0.001). CONCLUSION EUS-guided ethanol injection can be similarly effective for the treatment of hyperinsulinemic hypoglycemia compared with pancreatic surgery but seems to be associated with less severe complications. This implies the need for prospective randomized trials in insulinoma patients with a low risk for malignancy.
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Affiliation(s)
- Christian Jürgensen
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Marius Eckart
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Linus Haberbosch
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Arvid Sandforth
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
| | - Andreas L Birkenfeld
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
| | - Dietrich Overkamp
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Martin Daniels
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Martina Mogl
- Department of Surgery, Charité University Medicine, Berlin, Germany
| | - Peter Goretzki
- Department of Surgery, Charité University Medicine, Berlin, Germany
| | - Christian Strasburger
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Knut Mai
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
| | - Joachim Spranger
- Department of Endocrinology and Metabolic Diseases (including Lipid Metabolism), Charité University Medicine, Berlin, Germany
- Berlin Institute of Health at Charite, Berlin, Germany
| | - Reiner Jumpertz von Schwartzenberg
- Department of Internal Medicine IV, Division of Diabetology, Endocrinology and Nephrology, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
- German Center for Diabetes Research, München-Neuherberg, Germany
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Bell-Allen N, McKay B, Kilburn D, Waters P, Cavallucci D. Robotic enucleation & uncinectomy of complex lesions of the proximal pancreas. ANZ J Surg 2023; 93:2897-2903. [PMID: 37795900 DOI: 10.1111/ans.18719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Malignant tumours within the proximal pancreas traditionally require pancreaticoduodenectomy (PD) for cure. For smaller lesions with borderline malignant potential the risk/benefit of PD becomes difficult to justify. Robotic approaches to these lesions allow for parenchymal preserving resection with reduced complication profile without oncological compromise. METHODS A review of a single surgeons prospectively collated database across two institutions of consecutive robotic enucleations or parenchyma preserving resections of the proximal pancreas was performed between July 2018 and October 2021. Standard demographic data, preoperative variables, intraoperative parameters, post-operative outcomes, morbidity and mortality were recorded. RESULTS Thirteen patients (8 female and 5 male) underwent robotic enucleation (EN) (8) and/or uncinectomy (UN) (5) in the proximal pancreas. Mean BMI was 32(kg/m2 ). Three patients (21%) underwent preoperative prophylactic pancreatic duct stenting. One patient required conversion to open. The median operative time in the EN group was 170 min (108-224 min) and the UN group was 160 min (110-204 min). The majority (8) of lesions were pNETs. Three lesions were IPMNs, with 1 solitary fibrous tumour and a serous cystic neoplasm (SCN) respectively. Median tumour size was 23 mm (11-58 mm) in the EN group, and 27 mm (17-38 mm) in the UN group. Ten of 13 patients had an R0 resection. There was no mortality in our series. Four (31%) patients across both groups developed clinically relevant POPF while none developed new endocrine or exocrine insufficiency. Average outpatient follow-up has been 6 months (1-18 months). CONCLUSION A robotic approach in proximal parenchymal preserving pancreatectomy is expanding, safe and feasible.
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Affiliation(s)
- Nicholas Bell-Allen
- Department of HPB Surgery, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Bartholomew McKay
- Department of HPB Surgery, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Daniel Kilburn
- Department of HPB Surgery, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Peadar Waters
- Department of HPB Surgery, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
- Department of Surgery, Cork University Hospital, Cork, Ireland
| | - David Cavallucci
- Department of HPB Surgery, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
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Li Z, Zhuo Q, Shi Y, Chen H, Liu M, Liu W, Xu W, Chen C, Ji S, Yu X, Xu X. Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area. Heliyon 2023; 9:e21917. [PMID: 38027678 PMCID: PMC10658339 DOI: 10.1016/j.heliyon.2023.e21917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation. Methods Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed. Results Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up. Conclusions The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.
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Affiliation(s)
- Zheng Li
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Qifeng Zhuo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Yihua Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Haidi Chen
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Mengqi Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Wensheng Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Wenyan Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Chen Chen
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Shunrong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Xiaowu Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China
- Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
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Sulciner ML, Clancy TE. Surgical Management of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2023; 15:cancers15072006. [PMID: 37046665 PMCID: PMC10093271 DOI: 10.3390/cancers15072006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are relatively uncommon malignancies, characterized as either functional or nonfunctional secondary to their secretion of biologically active hormones. A wide range of clinical behavior can be seen, with the primary prognostic indicator being tumor grade as defined by the Ki67 proliferation index and mitotic index. Surgery is the primary treatment modality for PNETs. While functional PNETs should undergo resection for symptom control as well as potential curative intent, nonfunctional PNETs are increasingly managed nonoperatively. There is increasing data to suggest small, nonfunctional PNETs (less than 2 cm) are appropriate follow with nonoperative active surveillance. Evidence supports surgical management of metastatic disease if possible, and occasionally even surgical management of the primary tumor in the setting of widespread metastases. In this review, we highlight the evolving surgical management of local and metastatic PNETs.
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Giuliani T, De Pastena M, Paiella S, Marchegiani G, Landoni L, Festini M, Ramera M, Marinelli V, Casetti L, Esposito A, Bassi C, Salvia R. Pancreatic Enucleation Patients Share the Same Quality of Life as the General Population at Long-Term Follow-Up: A Propensity Score-Matched Analysis. Ann Surg 2023; 277:e609-e616. [PMID: 33856383 DOI: 10.1097/sla.0000000000004911] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Tommaso Giuliani
- Department of General and Pancreatic Surgery, Verona Hospital Trust, University of Verona, Verona, Italy
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Aussilhou B, Ftériche FS, Bouquot M, Lesurtel M, Sauvanet A, Dokmak S. Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula. Surg Endosc 2023; 37:544-555. [PMID: 36002687 DOI: 10.1007/s00464-022-09527-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 07/31/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN. METHODS AND PATIENTS All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF. RESULTS From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51 years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20 mm (9-110); 30 mm (20-110) for mucinous cystadenoma and 18 mm (8-33) for NET. The median operative time was 90 mn (30-330), median blood loss was 20 ml (0-800) ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7 days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24 months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3 mm. CONCLUSION In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.
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Affiliation(s)
- Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, AP-HP, Hôpital Beaujon, Clichy, France
| | - Fadhel Samir Ftériche
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, AP-HP, Hôpital Beaujon, Clichy, France
| | - Morgane Bouquot
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, AP-HP, Hôpital Beaujon, Clichy, France.,University of Paris Cité, Paris, France
| | - Mickael Lesurtel
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, AP-HP, Hôpital Beaujon, Clichy, France.,University of Paris Cité, Paris, France
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, AP-HP, Hôpital Beaujon, Clichy, France.,University of Paris Cité, Paris, France
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, DMU DIGEST, AP-HP, Hôpital Beaujon, Clichy, France.
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9
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Yin F, Wu ZH, Lai JP. New insights in diagnosis and treatment of gastroenteropancreatic neuroendocrine neoplasms. World J Gastroenterol 2022; 28:1751-1767. [PMID: 35633912 PMCID: PMC9099195 DOI: 10.3748/wjg.v28.i17.1751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/06/2022] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare epithelial neoplasms derived from pluripotent endocrine cells along the gastrointestinal tract and pancreas. GEP-NENs are classified into well-differentiated neuroendocrine tumors and poorly differentiated neuroendocrine carcinomas. Despite overlapping morphological features, GEP-NENs vary in molecular biology, epigenetic, clinical behavior, treatment response, and prognosis features and remain an unmet clinical challenge. In this review, we introduce recent updates on the histopathologic classification, including the tumor grading and staging system, molecular genetics, and systemic evaluation of the diagnosis and treatment of GEP-NENs at different anatomic sites, together with some insights into the diagnosis of challenging and unusual cases. We also discuss the application of novel therapeutic approaches for GEP-NENs, including peptide receptor radionuclide therapy, targeted therapy, and immunotherapy with immune checkpoint inhibitors. These findings will help improve patient care with precise diagnosis and individualized treatment of patients with GEP-NENs.
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Affiliation(s)
- Feng Yin
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, MO 65212, United States
| | - Zi-Hao Wu
- Department of Surgery, University of Missouri, Columbia, MO 65212, United States
| | - Jin-Ping Lai
- Department of Pathology, Kaiser Permanente Sacramento Medical Center, Sacramento, CA 95825, United States
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10
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Gupta V, Bhandare MS, Chaudhari V, Parray A, Shrikhande SV. 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. Langenbecks Arch Surg 2022; 407:1507-1515. [PMID: 35298681 DOI: 10.1007/s00423-022-02491-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 03/09/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Vikas Gupta
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India.
| | - Vikram Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Amir Parray
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
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11
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Li YQ, Pan SB, Yan SS, Jin ZD, Huang HJ, Sun LQ. Impact of parenchyma-preserving surgical methods on treating patients with solid pseudopapillary neoplasms: A retrospective study with a large sample size. World J Gastrointest Surg 2022; 14:174-184. [PMID: 35317543 PMCID: PMC8908337 DOI: 10.4240/wjgs.v14.i2.174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/09/2021] [Accepted: 01/25/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Yu-Qiong Li
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China
| | - Shu-Bo Pan
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China
- Department of Gastroenterology, Suzhou Science and Technology Town Hospital, Suzhou 215000, Jiangsu Province, China
| | - Shu-Shu Yan
- Department of Anesthesiology, Changhai Hospital, Shanghai 200433, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China
| | - Hao-Jie Huang
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China
| | - Li-Qi Sun
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China
- Department of Gastroenterology, 72nd Group Army Hospital, Huzhou University, Huzhou 313000, Zhejiang Province, China
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12
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Shen X, Yang X. Comparison of Outcomes of Enucleation vs. Standard Surgical Resection for Pancreatic Neoplasms: A Systematic Review and Meta-Analysis. Front Surg 2022; 8:744316. [PMID: 35155544 PMCID: PMC8825491 DOI: 10.3389/fsurg.2021.744316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/09/2021] [Indexed: 01/04/2023] Open
Abstract
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.
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13
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Naples R, Thomas JD, Orabi DA, Reynolds JP, Robertson S, Siperstein AE, Walsh RM, Simon R, Shin JJ, Jin J, Krishnamurthy VD, Berber E. A critical analysis of laparoscopic and open approaches to sporadic pancreatic insulinoma resection in the modern era. Am J Surg 2021; 223:912-917. [PMID: 34702489 DOI: 10.1016/j.amjsurg.2021.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. METHODS Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. RESULTS The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). CONCLUSIONS Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.
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Affiliation(s)
- Robert Naples
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jonah D Thomas
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Danny A Orabi
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Scott Robertson
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | | | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Joyce J Shin
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Judy Jin
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA.
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14
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Prediction of Recurrence of Completely Resected Pancreatic Solid Pseudopapillary Neoplasms in Pediatric Patients: A Single Center Analysis. CHILDREN-BASEL 2021; 8:children8080632. [PMID: 34438523 PMCID: PMC8391822 DOI: 10.3390/children8080632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/12/2021] [Accepted: 07/23/2021] [Indexed: 12/14/2022]
Abstract
Background: Many previous studies have investigated the risk factors for the recurrence of pancreatic solid pseudopapillary neoplasms (SPNs), although a consensus has not yet been reached, despite this effort. We aimed to identify the predictive factors for recurrence in patients with SPNs who underwent complete surgical resection of the tumor. Methods: We retrospectively analyzed the records of pediatric patients with SPNs who underwent surgical resection at a single center between 2001 and 2018. Results: During the study period, 47 patients with SPNs underwent radical resection of the tumor. The median age of the patients was 14 (8–18) years. R0 resection was confirmed in every case and none of the patients presented with systemic metastasis at the time of diagnosis. The median follow-up period was 53.1 (30.8–150.8) months. Of the 47 patients, only two (4.2%) experienced recurrence. Using comparative analysis, we found that some factors such as a large tumor size, peripancreatic tissue invasion, and capsule invasion did not increase the risk of recurrence of SPNs. Lymph node metastasis was the only significant factor for recurrence in our study (p = 0.043). Conclusion: During our single center analysis, we found that only lymph node metastasis was a predictive factor for recurrence of SPNs among patients who underwent complete tumor resection. Long-term follow-up is required to determine whether SPNs will recur if lymph node metastasis is observed after surgery. Furthermore, therapeutic benefits of routine lymphadenectomy or sentinel lymph node biopsy should be investigated in future studies to reduce the risk of recurrence in patients with SPNs.
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15
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Schulte Am Esch J, Krüger M, Barthlen W, Förster C, Mohnike K, Empting S, Benhidjeb T, Vossschulte H. Technical aspects of paediatric robotic pancreatic enucleation based on a case of an insulinoma. Int J Med Robot 2021; 17:e2317. [PMID: 34297475 DOI: 10.1002/rcs.2317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Insulinomas are rare insulin-producing pancreatic neuroendocrine tumours leading to severe episodes of hypoglycaemia. Surgery is the predominant curative therapy. METHODS We report here the first paediatric case of an insulinoma of the pancreatic body resected completely robotically under ultrasound guidance in a 10-year-old male with multiple endocrine neoplasia type 1. The port set-up was adapted for the narrowed dimensions of the paediatric peritoneal space. We comment on technical key steps for the organ-preserving procedure that was performed in close proximity to critical anatomic structures, with supporting video. Preoperative diagnostics, including endoscopic ultrasound, to determine surgical management are highlighted. RESULTS Following an uneventful post-operative course, the boy was discharged on day 11 with normalised glucose-metabolism. A pseudocyst developing after 4 weeks was treated with endoscopic stenting. CONCLUSIONS The applicability of a robotic surgical system in limited space conditions such as found in the paediatric abdominal cavity is demonstrated here for pancreatic surgery.
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Affiliation(s)
- Jan Schulte Am Esch
- Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Martin Krüger
- Department of Internal Medicine and Gastroenterology, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Christine Förster
- Institute of Pathology, KRH Hospital Nordstadt, affiliated with the University Hospital of the University of Bielefeld, Campus Bielefeld-Bethel, Hannover, Germany
| | | | - Susann Empting
- Department of Pediatrics, University Hospital Magdeburg, Magdeburg, Germany
| | - Tahar Benhidjeb
- Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
| | - Hendrik Vossschulte
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Bielefeld, Germany
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16
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Beane JD, Borrebach JD, Billderback A, Onuma AE, Adam MA, Zureikat AH, Pitt HA. Small pancreatic neuroendocrine tumors: Resect or enucleate? Am J Surg 2021; 222:29-34. [DOI: 10.1016/j.amjsurg.2020.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 12/18/2022]
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17
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Abudalou M, Vega EA, Dhingra R, Holzwanger E, Krishnan S, Kondratiev S, Niakosari A, Conrad C, Stallwood CG. Solid pseudopapillary neoplasm-diagnostic approach and post-surgical follow up: Three case reports and review of literature. World J Clin Cases 2021; 9:1682-1695. [PMID: 33728313 PMCID: PMC7942041 DOI: 10.12998/wjcc.v9.i7.1682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/23/2020] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Solid pseudopapillary neoplasm (SPN) is a rare tumor that was first described by Frantz in 1959. Although this tumor is benign, some may have malignant potential that can be predicted based on demographics, imaging characteristics, and pathologic evaluation. This case series presents 3 SPN cases with discussion on gender differences, preoperative predictors of malignancy, and a suggested algorithm for diagnostic approach as well as post-surgical follow up.
CASE SUMMARY Three adult patients in a tertiary hospital found to have SPN, one elderly male and two young females. Each of the cases presented with abdominal pain and were discovered incidentally. Two cases underwent endoscopic ultrasound with fine needle aspiration and biopsy to assess tumor markers and immuno-histochemical staining (which were consistent with SPN before undergoing surgery), and one case underwent surgery directly after imaging. The average tumor size was 5 cm. Diagnosis was confirmed by histology. Two patients had post-surgical complications requiring intervention.
CONCLUSION Demographic and imaging characteristics can be sufficient to establish diagnosis for SPN, while malignant cases require pre-operative evaluation with endoscopic ultrasound fine needle aspiration/fine needle biopsy.
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Affiliation(s)
- Mohammad Abudalou
- Department of Internal Medicine, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Eduardo A Vega
- Department of General Surgery, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Rohit Dhingra
- Department of Gastroenterology, Tufts Medical Center, Boston, MA 02111, United States
| | - Erik Holzwanger
- Department of Gastroenterology, Tufts Medical Center, Boston, MA 02111, United States
| | - Sandeep Krishnan
- Department of Gastroenterology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Svetlana Kondratiev
- Department of Pathology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Ali Niakosari
- Department of Radiology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Claudius Conrad
- Department of General Surgery, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Christopher G Stallwood
- Department of Gastroenterology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
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18
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Chen J, Yang Y, Liu Y, Kan H. Prognosis analysis of patients with pancreatic neuroendocrine tumors after surgical resection and the application of enucleation. World J Surg Oncol 2021; 19:11. [PMID: 33436017 PMCID: PMC7805225 DOI: 10.1186/s12957-020-02115-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate the prognostic factors of patients with pancreatic neuroendocrine tumor (pNETs) after surgical resection, and to analyze the value of enucleation for pNETs without distant metastasis that are well-differentiated (G1) and have a diameter ≤ 4 cm. Methods Data from pNET patients undergoing surgical resection between 2004 and 2017 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier analysis and log-rank testing were used for the survival comparisons. Adjusted HRs with 95% CIs were calculated using univariate and multivariate Cox regression models to estimate the prognostic factors. P < 0.05 was regarded as statistically significant. Results This study found that female, cases diagnosed after 2010, and pancreatic body/tail tumors were protective factors for good survival, while histological grade G3, a larger tumor size, distant metastasis, AJCC 8th stage III-IV and age over 60 were independent prognostic factors for a worse OS/CSS. For the pNETs that were well-differentiated (G1) and had a tumor diameter ≤ 4 cm, the type of surgery was an independent factor for the long-term prognosis of this group. Compared with pancreaticoduodenectomy and total pancreatectomy, patients who were accepted enucleation had better OS/CSS. Conclusion For pNETs patients undergoing surgical resection, sex, year of diagnosis, tumor location, pathological grade, tumor size, distant metastasis, race, and age were independent prognostic factors associated with the OS/CSS of patients. For pNETs patients with G1 and a tumor diameter less than 4 cm, if the tumor was located over 3 mm from the pancreatic duct, enucleation may be a wise choice.
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Affiliation(s)
- Junzhang Chen
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Ave, Guangzhou, 510515, Guangdong Province, China
| | - Yongyu Yang
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Ave, Guangzhou, 510515, Guangdong Province, China
| | - Yuanhua Liu
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Ave, Guangzhou, 510515, Guangdong Province, China
| | - Heping Kan
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Ave, Guangzhou, 510515, Guangdong Province, China.
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19
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Sahara K, Tsilimigras DI, Moro A, Mehta R, Dillhoff M, Heidsma CM, Lopez-Aguiar AG, Maithel SK, Rocha FG, Kanji Z, Abbott DE, Fisher A, Fields RC, Krasnick BA, Idrees K, Smith PM, Poultsides GA, Makris E, Cho CS, Beems M, Endo I, Pawlik TM. Long-Term Outcomes after Spleen-Preserving Distal Pancreatectomy for Pancreatic Neuroendocrine Tumors: Results from the US Neuroendocrine Study Group. Neuroendocrinology 2021; 111:129-138. [PMID: 32040951 PMCID: PMC10182897 DOI: 10.1159/000506399] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The adoption of spleen-preserving distal pancreatectomy (SPDP) for malignant disease such as pancreatic neuroendocrine tumors (pNETs) has been controversial. The objective of the current study was to assess the impact of SPDP on outcomes of patients with pNETs. METHODS Patients undergoing a distal pancreatectomy for pNET between 2002 and 2016 were identified in the US Neuroendocrine Tumor Study Group database. Propensity score matching (PSM) was used to compare short- and long-term outcomes of patients undergoing SPDP versus distal pancreatectomy with splenectomy (DPS). RESULTS Among 621 patients, 103 patients (16.6%) underwent an SPDP. Patients who underwent SPDP were more likely to have lower BMI (median, 27.5 [IQR 24.0-31.2] vs. 28.7 [IQR 25.7-33.6]; p = 0.005) and have undergone minimally invasive surgery (n = 56, 54.4% vs. n = 185, 35.7%; p < 0.001). After PSM, while the median total number of lymph nodes examined among patients who underwent an SPDP was lower compared with DPS (3 [IQR 1-8] vs. 9 [5-13]; p < 0.001), 5-year overall survival (OS) and recurrence-free survival (RFS) were comparable (OS: 96.8 vs. 92.0%, log-rank p = 0.21, RFS: 91.1 vs. 84.7%, log-rank p = 0.93). In addition, patients undergoing SPDP had less intraoperative blood loss (median, 100 mL [IQR 10-250] vs. 150 mL [IQR 100-400]; p = 0.001), lower incidence of serious complications (n = 13, 12.8% vs. n = 28, 27.5%; p = 0.014), and shorter length of stay (median: 5 days [IQR 4-7] vs. 6 days [IQR 5-13]; p = 0.049) compared with patients undergoing DPS. CONCLUSION SPDP for pNET was associated with acceptable perioperative and long-term outcomes that were comparable to DPS. SPDP should be considered for patients with pNET.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Charlotte M Heidsma
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Flavio G Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Zaheer Kanji
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alexander Fisher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Paula M Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | - Clifford S Cho
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan Beems
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA,
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20
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Chao J, Zhu C, Jia Z, Zhang X, Qin X. Prophylactic active irrigation drainage reduces the risk of post-operative pancreatic fistula-related complications in patients undergoing limited pancreatic resection. J Minim Access Surg 2021; 17:197-201. [PMID: 33047685 PMCID: PMC8083757 DOI: 10.4103/jmas.jmas_290_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective of this study is to evaluate the efficacy of prophylactic active irrigation drainage in preventing post-operative pancreatic fistula (POPF) and POPF-related complications in patients undergoing limited pancreatic resection (LPR). Materials and Methods: Patients who underwent LPR for benign or borderline pancreatic lesions between February 2014 and March 2019 were enroled in this retrospective study. Patients were divided into two groups according to the type of intraperitoneal drainage used: closed-suction drainage (CSD) or continuous active irrigation drainage (CAID). Data regarding the outcomes and complications of surgery were collected and analysed. Results: A total of 50 patients (33 women; age, 50.1 ± 10.8 years) were included in this study. Twenty-nine patients were treated with CSD, and 21 patients were treated with CAID. Clinically relevant POPF and POPF-related complications occurred in 11 patients in the CSD group and in two patients in the CAID group (P = 0.024). Patients in the CSD group demonstrated a longer tube indwelling time than those in the CAID group (17.1 ± 10.2 days vs. 13.7 ± 7.5 days; P = 0.044). Mean post-operative hospital stay was also longer in the CSD group than in the CAID group (20.6 ± 7.9 days vs. 16.1 ± 6.3 days; P = 0.039). Conclusions: Prophylactic CAID appears to be an effective alternative for the management of POPF and POPF-related complications in patients undergoing LPR.
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Affiliation(s)
- Jiadeng Chao
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Chunfu Zhu
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Zhongzhi Jia
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Xudong Zhang
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Xihu Qin
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
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21
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Advances in the management of pancreatic cystic neoplasms. Curr Probl Surg 2020; 58:100879. [PMID: 34144739 DOI: 10.1016/j.cpsurg.2020.100879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/09/2020] [Indexed: 12/11/2022]
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22
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Giuliani T, Marchegiani G, Girgis MD, Crinò SF, Muthusamy VR, Bernardoni L, Pea A, Ramera M, Paiella S, Landoni L, Gabbrielli A, Salvia R, Donahue TR, Bassi C. Endoscopic placement of pancreatic stent for "Deep" pancreatic enucleations operative technique and preliminary experience at two high-volume centers. Surg Endosc 2020; 34:2796-2802. [PMID: 32180000 DOI: 10.1007/s00464-020-07501-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of "deep" PE preceded by endoscopic stenting of the MPD. METHODS From January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3 weeks before surgery, depending on the participating institute. RESULTS Ten patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases. CONCLUSION In the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.
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Affiliation(s)
- Tommaso Giuliani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Mark D Girgis
- Division of Surgical Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Stefano Francesco Crinò
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | | | - Laura Bernardoni
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Marco Ramera
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy.
| | - Armando Gabbrielli
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Timothy R Donahue
- Division of Surgical Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
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23
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Ore AS, Klompmaker S, Stackhouse K, Solis-Velasco M, Francken M, Callery MP, Kent TS, Moser AJ. Does surgical approach affect outcomes of enucleation for benign and low-grade pancreatic tumors? An ACS-NSQIP evaluation. HPB (Oxford) 2019; 21:1585-1591. [PMID: 31076257 DOI: 10.1016/j.hpb.2019.03.375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/19/2018] [Accepted: 03/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enucleation of low-grade pancreatic tumors achieves oncological outcomes equivalent to resection but conserves parenchyma. Given strict selection criteria, we hypothesized that minimally-invasive (MI) enucleation is associated with decreased composite major morbidity (CMM) compared to open. METHODS Pancreas-targeted ACS NSQIP (2014 -2016) was queried for enucleation (CPT code: 48120) and analyzed by intended surgical approach regardless of conversion. The primary outcome was CMM, a validated 30-day composite metric of adverse events. RESULTS Enucleation was performed using an open (n = 71; 62.3%) or MI (n = 43; 37.7%) approach with 7 conversions (16.2%). Both cohorts had interchangeable baseline characteristics. No selection factors governing MI were identified. MI-enucleation reduced median length of stay (4 vs. 5 days; p = 0.003), whereas rates of CMM after open (24; 34%) and MIenucleation (12; 28%) were equivalent (p = 0.541). Multivariable analysis demonstrated an association between CMM and prolonged operative time (OR 2.7, 95% CI 1.14 -6.74), female sex (OR 0.38, 95% CI 0.16 -0.94), and ASA score <3 (OR 0.39, 95% CI 0.16 -0.96) but not surgical approach. CONCLUSION MI-enucleation was not associated with reduced 30-day CMM compared to open, whereas prolonged operating time and unmodifiable patient factors were correlated with adverse outcomes.
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Affiliation(s)
- Ana Sofia Ore
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sjors Klompmaker
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kathryn Stackhouse
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Monica Solis-Velasco
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michiel Francken
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark P Callery
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tara S Kent
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A James Moser
- The Pancreas and Liver Institute at Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Andreasi V, Partelli S, Capurso G, Muffatti F, Balzano G, Crippa S, Falconi M. Long-Term Pancreatic Functional Impairment after Surgery for Neuroendocrine Neoplasms. J Clin Med 2019; 8:jcm8101611. [PMID: 31623399 PMCID: PMC6832294 DOI: 10.3390/jcm8101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Radical surgery represents the only curative treatment for pancreatic neuroendocrine neoplasms (PanNEN). The aim of this study was to evaluate the postoperative onset of diabetes mellitus (DM) and/or pancreatic exocrine insufficiency (PEI) in surgically treated PanNEN. Consecutive PanNEN patients, without preoperative DM, who underwent partial pancreatic resection, were included. After a median follow-up of 72 months, overall 68/276 patients (24%) developed DM. Patients who developed DM were significantly older (p = 0.002) and they had a higher body mass index (BMI) (p < 0.0001) than those who did not; they were more frequently male (p = 0.017) and with nonfunctioning neoplasms (p = 0.019). BMI > 25 Kg/m2 was the only independent predictor of DM (p = 0.001). Overall, 118/276 patients (43%) developed a PEI, which was significantly more frequent after pancreaticoduodenectomy (p < 0.0001) and in patients with T3-T4 tumors (p = 0.001). Pancreaticoduodenectomy was the only independent predictor of PEI (p < 0.0001). Overall, 54 patients (20%) developed disease progression. Patients with and without DM had similar progression free survival (PFS), whereas patients without PEI had better five-year-PFS (p = 0.002), although this association was not confirmed in multivariate analysis. The risk of DM and PEI after surgery for PanNEN is relatively high but it does not affect PFS. BMI and pancreatic head resection are independent predictors of DM and PEI, respectively.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Gabriele Capurso
- Biliopancreatic Endoscopy Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
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Chong JU, Kang CM. Robotic Single-Site Plus One Port: Pancreas Enucleation. J Gastrointest Surg 2019; 23:1527-1528. [PMID: 30887291 DOI: 10.1007/s11605-019-04183-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/25/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE Laparoscopic approaches to enucleation of the pancreas have been frequently described. Here we present a case of robotic single-site plus one port pancreas enucleation. To our knowledge, this enucleation surgical technique is the first to be reported in the medical literature. METHODS A 46-year-old male patient without previous medical or surgical history was incidentally diagnosed with a pancreatic mass during evaluation of intermittent right flank pain. Robotic single-site plus one port pancreas enucleation was performed using the Da Vinci single-site surgical platform with one additional port on November 16, 2016. Usual robotic instruments such as hook, bipolar, and vessel sealer with endo-wrist function could be used to facilitate effective surgical procedure with the additional port. The resected specimen was delivered through the umbilicus and a drain was not inserted. RESULTS Total operation time was 124 min with total console time of 73 min. Estimated blood loss was 50 cm3. Final pathology result was neuroendocrine tumor, grade 1. The patient was discharged without any complications on postoperative day #4. CONCLUSIONS Robotic single-site plus one port pancreas enucleation seems feasible with acceptable perioperative outcomes.
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Affiliation(s)
- Jae Uk Chong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei Ro, Seodaemun gu, Seoul, 03722, South Korea. .,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea.
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26
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Werner RA, Ilhan H, Lehner S, Papp L, Zsótér N, Schatka I, Muegge DO, Javadi MS, Higuchi T, Buck AK, Bartenstein P, Bengel F, Essler M, Lapa C, Bundschuh RA. Pre-therapy Somatostatin Receptor-Based Heterogeneity Predicts Overall Survival in Pancreatic Neuroendocrine Tumor Patients Undergoing Peptide Receptor Radionuclide Therapy. Mol Imaging Biol 2019; 21:582-590. [PMID: 30014345 DOI: 10.1007/s11307-018-1252-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Early identification of aggressive disease could improve decision support in pancreatic neuroendocrine tumor (pNET) patients prior to peptide receptor radionuclide therapy (PRRT). The prognostic value of intratumoral textural features (TF) determined by baseline somatostatin receptor (SSTR)-positron emission tomography (PET) before PRRT was analyzed. PROCEDURES Thirty-one patients with G1/G2 pNET were enrolled (G2, n = 23/31). Prior to PRRT with [177Lu]DOTATATE (mean, 3.6 cycles), baseline SSTR-PET computed tomography was performed. By segmentation of 162 (median per patient, 5) metastases, intratumoral TF were computed. The impact of conventional PET parameters (SUVmean/max), imaging-based TF, and clinical parameters (Ki67, CgA) for prediction of both progression-free survival (PFS) and overall survival (OS) after PRRT were evaluated. RESULTS Within a median follow-up of 3.7 years, tumor progression was detected in 21 patients (median, 1.5 years) and 13/31 deceased (median, 1.9 years). In ROC analysis, the TF entropy, reflecting derangement on a voxel-by-voxel level, demonstrated predictive capability for OS (cutoff = 6.7, AUC = 0.71, p = 0.02). Of note, increasing entropy could predict a longer survival (> 6.7, OS = 2.5 years, 17/31), whereas less voxel-based derangement portended inferior outcome (< 6.7, OS = 1.9 years, 14/31). These findings were supported in a G2 subanalysis (> 6.9, OS = 2.8 years, 9/23 vs. < 6.9, OS = 1.9 years, 14/23). Kaplan-Meier analysis revealed a significant distinction between high- and low-risk groups using entropy (n = 31, p < 0.05). For those patients below the ROC-derived threshold, the relative risk of death after PRRT was 2.73 (n = 31, p = 0.04). Ki67 was negatively associated with PFS (p = 0.002); however, SUVmean/max failed in prognostication (n.s.). CONCLUSIONS In contrast to conventional PET parameters, assessment of intratumoral heterogeneity demonstrated superior prognostic performance in pNET patients undergoing PRRT. This novel PET-based strategy of outcome prediction prior to PRRT might be useful for patient risk stratification.
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Affiliation(s)
- Rudolf A Werner
- The Russell H. Morgan Department of Radiology and Radiological Science, Division of Nuclear Medicine and Molecular Imaging, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Harun Ilhan
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Lehner
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
- Ambulatory Healthcare Center Dr. Neumaier & Colleagues, Radiology, Nuclear Medicine, Radiation Therapy, Regensburg, Germany
| | - László Papp
- Department of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Imke Schatka
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk O Muegge
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Mehrbod S Javadi
- The Russell H. Morgan Department of Radiology and Radiological Science, Division of Nuclear Medicine and Molecular Imaging, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Takahiro Higuchi
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
- Department of Bio Medical Imaging, National Cardiovascular and Cerebral Research Center, Suita, Japan
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Frank Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Constantin Lapa
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Ralph A Bundschuh
- Department of Nuclear Medicine, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
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Central pancreatectomy for early-stage pancreatic ductal adenocarcinoma: a single-center case–control study. Langenbecks Arch Surg 2019; 404:175-182. [DOI: 10.1007/s00423-019-01766-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/18/2019] [Indexed: 02/08/2023]
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28
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Cho YJ, Namgoong JM, Kim DY, Kim SC, Kwon HH. Suggested Indications for Enucleation of Solid Pseudopapillary Neoplasms in Pediatric Patients. Front Pediatr 2019; 7:125. [PMID: 31001506 PMCID: PMC6456698 DOI: 10.3389/fped.2019.00125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/15/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Solid pseudopapillary neoplasms (SPNs) are rare, low-grade, malignant neoplasms that can occur in pediatric patients. Although complete resection of the tumor is the principle treatment, SPN enucleation (EN) has been reported to be effective in children. This study aimed to examine the feasibility and safety of EN by comparing it with conventional pancreatectomy (CP), and to present the indications for its use in pediatric patients. Methods: We retrospectively reviewed the medical records of 66 patients who underwent surgery for SPN at our institution from October 1992 to April 2018. Surgical methods, postoperative complications, hospital stay, and recurrence were compared. Results: Of the 66 patients, 15 (22.7%) were treated with EN and 51 (77.3%) were treated with CP. The mean duration of EN operation was 262 min (±145 min) and of CP was 345 min (±195 min). There was no statistically significant difference between the two methods (P = 0.13). To objectively compare the mass size between patients, we introduced a tumor size/intraperitoneal width ratio, which also revealed no significant difference between the 2 surgery groups (P = 0.21). The EN group had one case of recurrence at the resection site. The complications observed were fluid collection, splenic infarctions, hematomas, pancreatic fistulas, portal vein thromboses, and chylous drainage, among which pancreatic fistulas were the most frequent followed by moderate-severe fistulas in the EN group (P < 0.001). The mean postoperative fasting time (EN 17.0 ± 8.7 days vs. CP 5.1 ± 3.3 days, P < 0.001) and mean hospital stay (EN 23.4 ± 10.0 days vs. CP 13.2 ± 6.5 days, P = 0.002) showed statistically significant differences. Conclusion: Compared with CP treatment, EN of SPNs in children has the disadvantages of prolonged fasting times and hospital stays to recover from moderate pancreatic fistulas. However, if appropriate indications are applied, EN can be considered a safe and effective surgical procedure for children.
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Affiliation(s)
- Yu Jeong Cho
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyun Hee Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
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Bartolini I, Bencini L, Bernini M, Farsi M, Calistri M, Annecchiarico M, Moraldi L, Coratti A. Robotic enucleations of pancreatic benign or low-grade malignant tumors: preliminary results and comparison with robotic demolitive resections. Surg Endosc 2018; 33:2834-2842. [PMID: 30421079 DOI: 10.1007/s00464-018-6576-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/02/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND The incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. The surgical management of these patients is still under debate. The aim of this paper is to evaluate the safety and feasibility of robotic enucleations and to compare the outcomes with non-parenchymal sparing robotic resections. METHODS The study included a total of 25 patients. Nine of them underwent a robotic enucleation (EN Group) and 16 patients received a robotic demolitive resection (DR Group). Perioperative and medium-term outcomes were compared between the two groups. RESULTS Patients' baseline characteristics were similar in the two groups except for presence of symptoms and tumor size, due to the inclusion criteria. Operative time was significantly shorter and postoperative results were better for EN group, including a significant shorter hospitalization (5 vs. 8 days, p = 0.027), reduced pancreatic leaks (22% vs. 50%, p = 0.287) and a better preservation of glandular function (100% vs. 62.5%, p = 0.066). Mortality rate was zero in both groups, with all patients free from disease at a median follow-up of 18 months. CONCLUSIONS The risks of under/overtreatment remain still unavoidable for benign to low-grade malignant small pancreatic neoplasms. Simple enucleation should be performed whenever oncological appropriate, to achieve the best postoperative outcomes. The adoption of robotic technique might widen the indications for parenchymal sparing, minimally invasive surgery.
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Affiliation(s)
- Ilenia Bartolini
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy. .,Department of Surgery and Translational Medicine, Hepatobiliary Surgery Unit, University of Florence-AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy.
| | - Lapo Bencini
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Marco Bernini
- Department of Oncology, Division of Oncologic and Reconstructive Breast Surgery, Breast Unit, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Marco Farsi
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Massimo Calistri
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Mario Annecchiarico
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Luca Moraldi
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Andrea Coratti
- Department of Oncology, Division of Surgical Oncology and Robotics, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy
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Duconseil P, Marchese U, Ewald J, Giovannini M, Mokart D, Delpero JR, Turrini O. A pancreatic zone at higher risk of fistula after enucleation. World J Surg Oncol 2018; 16:177. [PMID: 30157952 PMCID: PMC6116563 DOI: 10.1186/s12957-018-1476-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
Background To determine predictive factors of postoperative pancreatic fistula (POPF) in patients undergoing enucleation (EN). Methods From 2005 to 2017, 47 patients underwent EN and had magnetic resonance imaging available for precise analysis of tumor location. Three pancreatic zones were delimited by the right side of the portal vein and the main pancreatic head duct (zone #3 comprising the lower head parenchyma and the uncinate process). Results The mortality and morbidity rates were 0% and 62%, respectively. POPF occurred in 23 patients (49%) and was graded as B or C (severe) in 15 patients (32%). Four patients (8.5%) developed a postoperative hemorrhage, and 5 patients (11%) needed a reintervention. In univariate and multivariate analyses, the pancreatic zone was the unique predictive factor of overall (P = .048) or severe POPF (P = .05). We did not observe any difference in postoperative courses when comparing the EN achieved in zones #1 and #2. We noted a longer operative duration (P = .016), higher overall (P = .017) and severe POPF (P = .01) rates, and longer hospital stays (P = .04) when comparing the EN achieved in zone #3 versus that in zones #1 and #2. Patients who underwent EN in zone #3 had a relative risk of developing a severe POPF of 3.22 compared with patients who underwent EN in the two other pancreatic zones. Conclusion Our study identifies the lower head parenchyma and the uncinate process as a high-risk zone of severe POPF after EN. Patients with planned EN in this zone could be selected and benefit from preoperative and/or intraoperative techniques to reduce the severe POPF rate. Electronic supplementary material The online version of this article (10.1186/s12957-018-1476-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Marc Giovannini
- Department of Endoscopy, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Department of Intensive Care, Institut Paoli-Calmettes, Marseille, France
| | | | - Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CNRS, Inserm, CRCM, Marseille, France.
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Di Benedetto F, Magistri P, Ballarin R, Tarantino G, Bartolini I, Bencini L, Moraldi L, Annecchiarico M, Guerra F, Coratti A. Ultrasound-Guided Robotic Enucleation of Pancreatic Neuroendocrine Tumors. Surg Innov 2018; 26:37-45. [PMID: 30066609 DOI: 10.1177/1553350618790711] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management. METHODS We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. RESULTS Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5). CONCLUSIONS Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity.
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Affiliation(s)
| | - Paolo Magistri
- 1 University of Modena and Reggio Emilia, Modena Italy.,2 Sapienza-University of Rome, Rome, Italy
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Bartolini I, Bencini L, Risaliti M, Ringressi MN, Moraldi L, Taddei A. Current Management of Pancreatic Neuroendocrine Tumors: From Demolitive Surgery to Observation. Gastroenterol Res Pract 2018; 2018:9647247. [PMID: 30140282 PMCID: PMC6081603 DOI: 10.1155/2018/9647247] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/29/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Ilenia Bartolini
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Lapo Bencini
- Department of Oncology, AOU Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Matteo Risaliti
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Maria Novella Ringressi
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Luca Moraldi
- Department of Oncology, AOU Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Antonio Taddei
- Department of Surgery and Translational Medicine, AOU Careggi, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
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Liang M, Jiang J, Dai H, Hong X, Han X, Cong L, Tong A, Li F, Luo Y, Liu W, Zhou L, Di W, Wu W, Zhao Y. Robotic enucleation for pediatric insulinoma with MEN1 syndrome: a case report and literature review. BMC Surg 2018; 18:44. [PMID: 29921249 PMCID: PMC6009035 DOI: 10.1186/s12893-018-0376-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/11/2018] [Indexed: 01/20/2023] Open
Abstract
Background A patient with a rare pediatric insulinoma and MEN1 syndrome was treated by robotic enucleation surgery. Case presentation We present a case of a 9-year-old girl presenting with repeated loss of consciousness, concomitant with a pale face, palpitations, and convulsions, which had persisted for 2 years and had been aggravated during the previous 2 months. She was previously misdiagnosed with epilepsy in another hospital. We further examined her while she was hospitalized. By combining her medical history and imaging examination and lab test results, a diagnosis of insulinoma was confirmed. Sanger-directed sequencing on a peripheral blood sample revealed an MEN1 gene mutation, indicating pediatric insulinoma with MEN1 syndrome. The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system with intraoperative ultrasound (IOUS) connected. The surgery was successfully completed within 65 min, and the girl recovered well postoperatively and no longer experienced symptoms of hypoglycemia. Conclusion This is the first report of a case of pediatric insulinoma treated using robotic enucleation. This experience demonstrates the feasibility and safety of combining robotic surgery with the enucleation procedure as an excellent strategy for pediatric insulinoma.
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Affiliation(s)
- Mei Liang
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jialin Jiang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Hongmei Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiafei Hong
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Lin Cong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Anli Tong
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Fang Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yaping Luo
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Weinan Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Liangrui Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Wenyu Di
- Department of Pathology, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
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Lu WJ, Cai HL, Ye MD, Wu YL, Xu B. Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections. J Zhejiang Univ Sci B 2018; 18:906-916. [PMID: 28990381 DOI: 10.1631/jzus.b1600597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Wen-Jie Lu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Hao-Lei Cai
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Ma-Dong Ye
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Yu-Lian Wu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Bin Xu
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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Guerra F, Giuliani G, Bencini L, Bianchi PP, Coratti A. Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes. J Surg Oncol 2018; 117:1509-1516. [PMID: 29574729 DOI: 10.1002/jso.25026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/23/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Francesco Guerra
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery; Misericordia Hospital; Grosseto Italy
| | - Lapo Bencini
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Paolo P. Bianchi
- Division of General and Minimally Invasive Surgery; Misericordia Hospital; Grosseto Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
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Neophytou H, Wangermez M, Gand E, Carretier M, Danion J, Richer JP. Predictive factors of endocrine and exocrine insufficiency after resection of a benign tumour of the pancreas. ANNALES D'ENDOCRINOLOGIE 2018. [PMID: 29526248 DOI: 10.1016/j.ando.2017.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the present study is to evaluate the risk factors of endocrine and exocrine insufficiency occurring few years after pancreatic resections in a consecutive series of patients who underwent pancreatoduodenectomy (PD), left pancreatectomy (LP) or enucleation for benign neoplasms at a referral centre. METHODS Pancreatic exocrine insufficiency (PEI) was defined by the onset of steatorrhea associated with weight loss, and endocrine insufficiency was determinate by fasting plasma glucose. Association between pancreatic insufficiency and clinical, pathological, and perioperative features was studied using univariate and multivariate Cox regression analysis. RESULTS A prospective cohort of 92 patients underwent PD (48%), LP (44%) or enucleation (8%) for benign tumours, from 2005 to 2016 in the University Hospital in Poitiers (France). The median follow-up was 68.6±42.4months. During the following, 54 patients developed exocrine insufficiency whereas 32 patients presented endocrine insufficiency. In the Cox model, a BMI>28kg/m2, being a man and presenting a metabolic syndrome were significantly associated with a higher risk to develop postoperative diabetes. The risks factors for the occurrence of PEI were preoperative chronic pancreatitis, a BMI<18.5kg/m2, tumours located in the pancreatic head, biological markers of chronic obstruction and fibrotic pancreas. Undergoing LP or enucleation were protective factors of PEI. Histological categories such as neuroendocrine tumours and cystadenomas were also associated with a decreased incidence of PEI. CONCLUSION Men with metabolic syndrome and obesity should be closely followed-up for diabetes, and patients with obstructive tumours, pancreatic fibrosis or chronic pancreatitis require a vigilant follow up on their pancreatic exocrine function.
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Affiliation(s)
- Hélène Neophytou
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France.
| | - Marc Wangermez
- CHU de Poitiers, service d'hépato-gastro-entérologie et assistance nutritive, Poitiers, France
| | - Elise Gand
- CHU de Poitiers, pôle DUNE, Poitiers, France
| | - Michel Carretier
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France
| | - Jérôme Danion
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France
| | - Jean-Pierre Richer
- CHU de Poitiers, service de chirurgie viscérale, 2, rue de la Milétrie, 86000 Poitiers, France
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Wang X, Chen YH, Tan CL, Zhang H, Xiong JJ, Chen HY, Ke NW, Liu XB. Enucleation of pancreatic solid pseudopapillary neoplasm: Short-term and long-term outcomes from a 7-year large single-center experience. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018. [PMID: 29525465 DOI: 10.1016/j.ejso.2018.01.085] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jun-Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong-Yu Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Neng-Wen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
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Ohtsuka T, Mori Y, Fujimoto T, Miyasaka Y, Nakata K, Ohuchida K, Nagai E, Oda Y, Shimizu S, Nakamura M. Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection. Am Surg 2018. [DOI: 10.1177/000313481808400138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with ( n = 10) and without ( n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer ( P < 0.01) and blood loss significantly greater ( P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent ( P = 0.02) and postoperative hospital stay was significantly longer ( P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study.
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Affiliation(s)
- Takao Ohtsuka
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, Fukuoka, Japan
| | - Yasuhisa Mori
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takaaki Fujimoto
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Miyasaka
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohei Nakata
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenoki Ohuchida
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eishi Nagai
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shuji Shimizu
- Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, Fukuoka, Japan
- Department of International Medical Department, Kyushu University Hospital, Fukuoka, Japan
| | - Masafumi Nakamura
- Departments of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Wang X, Tan CL, Zhang H, Chen YH, Yang M, Ke NW, Liu XB. Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: A single-center experience of 142 patients. J Surg Oncol 2017; 117:182-190. [PMID: 29281757 DOI: 10.1002/jso.24804] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 07/18/2017] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Min Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Neng-Wen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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40
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Robotic Enucleation for Benign or Borderline Tumours of the Pancreas: A Retrospective Analysis and Comparison from a High-Volume Centre in Asia. World J Surg 2017; 40:3009-3020. [PMID: 27491323 DOI: 10.1007/s00268-016-3655-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enucleation is increasingly performed for benign or borderline tumours of the pancreas because it is a parenchyma-sparing and less invasive procedure compared to conventional pancreatectomy, which reduces the risk of exocrine and endocrine insufficiency. This study retrospectively evaluated and compared the pre-, intra-, and post-operative clinical characteristics after open and robotic approaches for pancreatic enucleation. METHODS Fifty-six cases of enucleation for benign or borderline tumours of the pancreas treated from March 2010 to July 2015 were identified by a retrospective search. These included 25 patients who underwent an open approach and 31 patients who underwent a robotic approach. The clinical characteristics were extracted and compared. RESULTS The two groups had a similar location and pathology of the tumour. The robotic group had a significantly shorter operation time and significantly less blood loss than the open group. The rates of clinical pancreatic fistula (PF) formation and major complications were similar. The robotic approach could be applied for a tumour on the right side of the pancreas without increasing the incidence of clinical PF or other major complications. The patients with clinical PF had a significantly shorter distance between the lesion and the main pancreatic duct (MPD). CONCLUSION Robotic enucleation appears to be a feasible and safe approach for benign or borderline tumours of the pancreas and was associated with similarly favourable surgical outcomes as the open approach. Identifying and avoiding the MPD is an important step during enucleation.
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41
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Kaiser J, Büchler MW, Hackert T. [Branch duct intraductal papillary mucinous neoplasm - surgical approach]. Chirurg 2017; 88:927-933. [PMID: 28801818 DOI: 10.1007/s00104-017-0491-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Due to increasing precision of modern imaging modalities, intraductal papillary mucinous neoplasms (IPMN) of the pancreas are found with increasing prevalence. Despite their malignant potential IPMN are often kept under surveillance and are not immediately resected. The 2012 International Consensus Guidelines of Fukuoka have been widely accepted for the management of IPMN. They recommend surgical resection for branch duct IPMN with "high risk stigmata", while branch duct IPMN with "worrisome features" should undergo observation without immediate resection. Consequently, patients with asymptomatic branch duct IPMN and a presumed low malignant potential mostly undergo primary surveillance to avoid surgery-related morbidity and mortality following pancreatic resection; however, with respect to the cumulative risk of malignant transformation over time, surgical resection might also be indicated for patients with branch duct IPMN with "worrisome features". This article discusses the indications for surgery and different options of resection of branch duct IPMN.
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Affiliation(s)
- J Kaiser
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M W Büchler
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - T Hackert
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Yeh R, Steinman J, Luk L, Kluger MD, Hecht EM. Imaging of pancreatic cancer: what the surgeon wants to know. Clin Imaging 2017; 42:203-217. [DOI: 10.1016/j.clinimag.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/14/2016] [Accepted: 10/03/2016] [Indexed: 02/07/2023]
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Ge W, Zhou D, Xu S, Wang W, Zheng S. Surveillance and comparison of surgical prognosis for asymptomatic and symptomatic non-functioning pancreatic neuroendocrine tumors. Int J Surg 2017; 39:127-134. [PMID: 28137555 DOI: 10.1016/j.ijsu.2017.01.088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/21/2017] [Accepted: 01/23/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND The treatment of non-functioning pancreatic neuroendocrine tumors (NF-PNETs) still remains controversial. It is uncertain whether asymptomatic patients have better prognosis than symptomatic patients and whether surgery is necessary for asymptomatic patients. METHODS Patients with NF-PNETs who were managed surgically or by surveillance between June 2007 and December 2013 were retrospectively studied. The choice of surgery or surveillance was based entirely on the patient's desire. Survival prognosis was compared between asymptomatic and symptomatic patients, and evaluated among patients who were under surveillance. RESULTS Of the 53 patients with NF-PNETs, 48 (90%) were treated surgically. 25 patients (47%) were symptomatic patients, 23 (43%) asymptomatic, and five (10%) detected by surveillance. Among the latter group, one patient suffered from tumor progression and four had stable disease. When compared with symptomatic NF-PNETs, asymptomatic NF-PNETs showed lower pathology grades (P = 0.006), better 3-year cumulative progression-free survival and overall survival after surgical treatment. Parenchyma-preserving resection was associated with a higher risk of pancreatic fistula (71 vs. 17%, P = 0.007). A positive lymph node status (P = 0.003) and perineural or vascular invasion (P = 0.01) were significant predictors of tumor recurrence or metastasis. Patients with grade G3 disease (P = 0.005) or a tumor size >4 cm (P = 0.019) had poor prognosis. CONCLUSIONS Compared with symptomatic NF-PNETs, asymptomatic NF-PNETs had a lower degree of malignancy and better prognosis. Surveillance for small asymptomatic NF-PNETs needs to be further studied.
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Affiliation(s)
- Wenhao Ge
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Dongkai Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Shaoyan Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China; Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, 79 Qingchun Road, Hangzhou, 310003, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, 79 Qingchun Road, Hangzhou, 310003, China.
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China; Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, 79 Qingchun Road, Hangzhou, 310003, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, 79 Qingchun Road, Hangzhou, 310003, China.
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Abstract
Pancreatic neuroendocrine tumors (PNETs) are a rare, heterogeneous group of neoplasms infamous for their endocrinopathies. Up to 90% of PNETs, however, are nonfunctional and are frequently detected incidentally on axial imaging during the evaluation of vague abdominal symptoms. Surgery remains the mainstay of therapy for patients diagnosed with both functional and nonfunctional PNETs. However, the multifaceted nature of PNETs challenges treatment decision making. In general, resection is recommended for patients with acceptable perioperative risk and amenable lesions.
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Affiliation(s)
- Jason B Liu
- Department of Surgery, University of Chicago Hospitals, Chicago, IL, USA
| | - Marshall S Baker
- Department of Surgery, University of Chicago Hospitals, Chicago, IL, USA; Division of Surgical Oncology, Department of Surgery, NorthShore University Health System, Evanston, IL, USA.
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Abstract
Management of cystic neoplasms of the pancreas is challenging as it relies on radiologic and cyst fluid markers to discriminate between benign and pre-cancerous lesions, however their ability to predict malignancy is limited. While asymptomatic serous cystadenomas can be managed conservatively, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms are more difficult to manage. A selective approach, based on the preoperative likelihood of high-grade dysplasia or invasive disease, is the standard of care. Research is focusing on the development of pre-operative markers for identifying high risk lesions, which will spare patients with low-risk or benign lesions the risks of pancreatectomy.
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Affiliation(s)
- Mohammad Al Efishat
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA; Department of Surgery, Johns Hopkins Hospital, 600 N Wolfe Street, Baltimore, MD 21287, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor. World J Surg 2016; 40:715-28. [PMID: 26608956 PMCID: PMC4746212 DOI: 10.1007/s00268-015-3341-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Either enucleation or more extended resection is performed to treat patients with pancreatic neuroendocrine tumor (pNET). Aim was to analyze the postoperative complications for each operation separately. Furthermore, independent risk factors for complications and incidence of pancreatic insufficiency were analyzed. Methods Retrospective all resected patients from two academic hospitals in The Netherlands between 1992 and 2013 were included. Postoperative complications were scored by both ISGPS and Clavien–Dindo criteria. Based on tumor location, operations were compared. Independent risk factors for overall complications were identified. During long-term follow-up, pancreatic insufficiency and recurrent disease were analyzed. Results Tumor enucleation was performed in 60/205 patients (29 %), pancreatoduodenectomy in 65/205 (31 %), distal pancreatectomy in 72/205 (35 %) and central pancreatectomy in 8/205 (4 %) patients. Overall complications after tumor enucleation of the pancreatic head and pancreatoduodenectomy were comparable, 24/35 (69 %) versus 52/65 (80 %). The same was found after tumor enucleation and resection of the pancreatic tail (36 vs.58 %). Number of re-interventions and readmissions were comparable between all operations. After pancreatoduodenectomy, 33/65 patients had lymph node metastasis and in patients with tumor size ≤2 cm, 55 % had lymph node metastasis. Tumor in the head and BMI ≥25 kg/m2 were independent risk factors for complications after enucleation. During follow-up, incidence of exocrine and endocrine insufficiency was significant higher after pancreatoduodenectomy (resp. 55 and 19 %) compared to the tumor enucleation and distal pancreatectomy(resp. 5 and 7 % vs.8 and 13 %). After tumor enucleation 19 % developed recurrent disease. Conclusion Since the complication rate, need for re-interventions and readmissions were comparable for all resections, tumor enucleation may be regarded as high risk. Appropriate operation should be based on tumor size, location, and functional status of the pNET.
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Sahakyan MA, Røsok BI, Kazaryan AM, Barkhatov L, Haugvik SP, Fretland ÅA, Ignjatovic D, Labori KJ, Edwin B. Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis. Surg Endosc 2016; 31:2310-2316. [PMID: 27620912 DOI: 10.1007/s00464-016-5233-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/30/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution. METHODS Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital-Rikshospitalet. Twenty-four (53.3 %) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7 %) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP). RESULTS Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53-320) vs 102 (50-373) min, P = 0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3 %; P = 0.19 and 20.8 vs 33.3 %, P = 0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2-80) vs 7 (2-52), P = 0.49]. A case-matched analysis demonstrated shorter operating time [145 (90-350) vs 103 (50-233) min, P = 0.02], but higher readmission rate following LLPE (25 vs 3.1 %, P = 0.037). CONCLUSION LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway.
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
- Department of Surgery No 1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Bård Ingvald Røsok
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Leonid Barkhatov
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Sven-Petter Haugvik
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Knut Jørgen Labori
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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Intraductal Papillary Mucinous Neoplasm of the Pancreas: Current State of the Art and Ongoing Controversies. Ann Surg 2016; 263:908-17. [PMID: 26727096 DOI: 10.1097/sla.0000000000001567] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the widespread use and advances in radiographic imaging, Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas are identified with increasing frequency. Although many studies have addressed its biology and treatment, true understanding of its natural history continues to elude us. Its malignant potential places careproviders in a clinical dilemma of balancing the morbidity of pancreatectomy against the risk of malignant transformation while under continuous surveillance. Recently, there have been conflicting data published in the literature, generating more uncertainty in the field. In this article, we critically analyze the contrasting consensus guidelines from the International Association of Pancreatology and the American Gastroenterology Association, and address lingering questions and controversies. We also synthesize newly published data in the context of current standard of care, and provide a comprehensive review and recommendations for the clinical diagnosis, treatment, and follow-up strategy in the management of patients with Intraductal Papillary Mucinous Neoplasms.
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Short- and long-term outcomes after enucleation of pancreatic tumors: An evidence-based assessment. Pancreatology 2016; 16:1092-1098. [PMID: 27423534 DOI: 10.1016/j.pan.2016.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Enucleation of pancreatic tumors is rarely performed. The aim of this study was to evaluate the published evidence for its short- and long-term outcomes. METHODS PubMed (MEDLINE) and EMBASE databases were searched from 1990 to March 2016. Studies including at least ten patients who underwent enucleation of pancreatic lesions were included. Data on the outcomes were synthesized and meta-analyzed where appropriate. RESULTS Twenty-seven studies involving 1316 patients were included in the systematic review. The postoperative mortality was 0.3%, and the postoperative morbidity was 50.3%, mainly represented by pancreatic fistula (38.1%). Endocrine insufficiency, exocrine insufficiency and tumor recurrence was observed in 2.4%, 1.1% and 2.3% of the patients respectively. Compared with typical resection, the operation time, blood loss, length of hospital stay, and the incidence of endocrine and exocrine insufficiency were all significantly reduced after enucleation. The occurrence of pancreatic fistula was significantly higher in enucleation group, but overall morbidity, the reoperation rate and mortality were comparable between the two groups. There was no significant difference in disease recurrence between the two groups. Compared with central pancreatectomy, enucleation had a shorter operation time, lower blood loss, less morbidity, and better pancreatic function. Compared with open enucleation, minimally invasive enucleation had a shorter operation time and a shorter length of hospital stay. CONCLUSIONS Enucleation is an appropriate surgical procedure in selected patients with benign or low-malignant lesions of the pancreas. The benefits of minimally invasive approach need to be validated in further investigations with larger groups of patients.
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Lim PW, Dinh KH, Sullivan M, Wassef WY, Zivny J, Whalen GF, LaFemina J. Thirty-day outcomes underestimate endocrine and exocrine insufficiency after pancreatic resection. HPB (Oxford) 2016; 18:360-6. [PMID: 27037206 PMCID: PMC4814621 DOI: 10.1016/j.hpb.2015.11.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term incidence of endocrine and exocrine insufficiency after pancreatectomy is poorly described. We analyze the long-term risks of pancreatic insufficiency after pancreatectomy. METHODS Subjects who underwent pancreatectomy from 2002 to 2012 were identified from a prospective database (n = 227). Subjects who underwent total pancreatectomy or pancreatitis surgery were excluded. New post-operative endocrine and exocrine insufficiency was defined as the need for new pharmacologic intervention within 1000 days from resection. RESULTS 28 (16%) of 178 subjects without pre-existing endocrine insufficiency developed post-operative endocrine insufficiency: 7 (25%) did so within 30 days, 8 (29%) between 30 and 90 days, and 13 (46%) after 90 days. 94 (43%) of 214 subjects without pre-operative exocrine insufficiency developed exocrine insufficiency: 20 (21%) did so within 30 days, 29 (31%) between 30 and 90 days, and 45 (48%) after 90 days. Adjuvant radiation was associated with new endocrine insufficiency. On multivariate regression, pancreaticoduodenectomy and chemotherapy were associated with a greater risk of exocrine insufficiency. CONCLUSION Reporting 30-day functional outcomes for pancreatic resection is insufficient, as nearly 45% of subjects who develop disease do so after 90 days. Reporting of at least 90-day outcomes may more reliably assess risk for post-operative endocrine and exocrine insufficiency.
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Affiliation(s)
- Pei-Wen Lim
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate H. Dinh
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mary Sullivan
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Wahid Y. Wassef
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jaroslav Zivny
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Giles F. Whalen
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer LaFemina
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA,Correspondence: Jennifer LaFemina, Department of Surgery, University of Massachusetts Medical School, 119 Belmont Street, Swift House, Worcester, MA 01605, USA. Tel: +508 334 5274 (office). Fax: +508 334 5089.
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