Enucleation for benign or borderline tumors of the pancreas: comparing open and minimally invasive surgery

Laparoscopic pancreatic enucleation: how far should we go for parenchyma preservation? A study by the French National Association of Surgery

BACKGROUND

Pancreatic enucleation is indicated for selected patients and tumours with very low oncological risk to preserve a maximum of healthy pancreatic parenchyma. Minimally invasive pancreatic enucleation (MIPE) is increasingly performed. This study aims to assess the impact of tumor location and center experience on textbook outcomes (TBO) in patients undergoing MIPE.

METHODS

Retrospective nationwide multicentric cohort study including MIPE performed between 2010 and 2021. Tumor localization was classified as head/uncus, neck or body/tail (results are presented in this order). Centers were classified according to a mean volume of MI pancreatectomies performed per year: lower (< 5/year), intermediate (5 to 10/year) and higher volume (≥ 10/year). TBO was defined as meeting all 6 criteria: no postoperative pancreatic fistula (POPF), no post-pancreatectomy haemorrhage (PPH), no bile leak, no readmission, no mortality, and no severe morbidity.

RESULTS

27 participating centers performed 200 MIPE located in head/uncus (n = 65, 33%), neck (n = 26, 13%) and body/tail (n = 109, 55%), 8% of them performed by robotic approach. Mortality reached 1.5% (n = 3). Head/uncus lesions were larger (p = 0.03), frequently BD-IPMN (p = 0.04), with significant longer operative time (p = 0.002). TBO achievement was high across all tumor locations (52 vs. 73 vs. 67%, p = 0.09) with higher PPH (p = 0.03) or bile leaks (p = 0.03) for head/uncus lesions. In multivariate analysis, overweight (OR 0.49), preoperative biopsy (OR 0.41) and head/uncus lesion (OR 0.34) were independently associated with lower TBO. No independent risk factor was found for POPF or severe morbidity. While expertise level influenced indications, with more cystic lesions (p = 0.002), larger tumors (p = 0.003), 3D use (p = 0.001), and head/uncus lesions (p = 0.04) in high volume centers, TBO was not significantly different (p = 0.45).

CONCLUSIONS

MIPE is feasible with 1.5% mortality whatever its localization with higher morbidity for head/uncus lesions, justified by the will to avoid pancreaticoduodenectomy. High volume centers push the limits of MIPE without increasing morbidity.

Robotic versus laparoscopic surgery for sporadic benign insulinoma: Short- and long-term outcomes

BACKGROUND

Minimally invasive surgery is the optimal treatment for insulinoma. The present study aimed to compare short- and long-term outcomes of laparoscopic and robotic surgery for sporadic benign insulinoma.

METHODS

A retrospective analysis of patients who underwent laparoscopic or robotic surgery for insulinoma at our center between September 2007 and December 2019 was conducted. The demographic, perioperative and postoperative follow-up results were compared between the laparoscopic and robotic groups.

RESULTS

A total of 85 patients were enrolled, including 36 with laparoscopic approach and 49 with robotic approach. Enucleation was the preferred surgical procedure. Fifty-nine patients (69.4%) underwent enucleation; among them, 26 and 33 patients underwent laparoscopic and robotic surgery, respectively. Robotic enucleation had a lower conversion rate to laparotomy (0 vs. 19.2%, P = 0.013), shorter operative time (102.0 vs. 145.5 min, P = 0.008) and shorter postoperative hospital stay (6.0 vs. 8.5 d, P = 0.002) than laparoscopic enucleation. There were no differences between the groups in terms of intraoperative blood loss, the rates of postoperative pancreatic fistula and complications. After a median follow-up of 65 months, two patients in the laparoscopic group developed a functional recurrence and none of the patients in the robotic group had a recurrence.

CONCLUSIONS

Robotic enucleation can reduce the conversion rate to laparotomy and shorten operative time, which might lead to a reduction in postoperative hospital stay.

Short-term outcomes of laparoscopic and robotic limited resections of pancreatic neuroendocrine tumours of the uncinate process: Report of six cases and review of the literature

INTRODUCTION

Minimally invasive surgery (MIS) for limited resections for pancreatic uncinate lesions is not widely performed but can adequately treat benign or low-grade malignant lesions. The aim of this study was to evaluate the short-term outcomes of MIS-limited pancreatic resections for patients with suspected pancreatic neuroendocrine tumours (PNETs).

PATIENTS AND METHODS

This was a retrospective study of six consecutive patients who underwent MIS for PNET within a single institution between 2017 and 2022.

RESULTS

Six patients underwent limited pancreas-preserving MIS of the uncinate process (uncinectomy or enucleation), of which two were performed through the robotic approach and four through laparoscopic approach. The median operation time was 212.5 (175-338.75) min, and the median blood loss was 50 (50-112.5) ml. The median post-operative hospital length of stay was 5.5 (3.75-11.5) days. Two patients (33.3%) had major post-operative morbidities (Clavien-Dindo ≥Grade 3). There were no open conversions or post-operative mortalities. Five patients had histologically proven Grade 1 neuroendocrine tumours. One was T2 and four were T1.

CONCLUSIONS

This study suggests that limited MIS resections of pancreatic uncinate PNETs are a feasible procedure with good patient outcomes. It offers a safe alternative to radical surgical resections like pancreatoduodenectomies in selected patients with low-grade malignant or benign tumours.

Reconsidering the role of prophylactic pancreaticojejunostomy in pancreatic enucleation: balancing the benefits and risks

BACKGROUND

The incidence of postoperative pancreatic fistula (POPF) following enucleation is high, and prophylactic pancreaticojejunostomy (PPJ) is frequently performed. Minimally invasive enucleation (MEN) has been demonstrated to be safe and feasible, leaving most enucleation wounds exposed.

METHODS

The clinical data of 40 patients who underwent open enucleation with PPJ at our center between 2012 and 2021 were compared with those of 80 patients who underwent MEN.

RESULTS

The MEN group had better outcomes than the PPJ group in terms of intraoperative bleeding (50.0 versus 100.0 mL), postoperative semi-liquid diet recovery (2.0 versus 5.0 days), and postoperative length of stay (7.7 versus 12.5 days). While the MEN group had higher rates of complex enucleation (60.0% versus 40.0%), main pancreatic duct repair (32.5% versus 10.0%), discharge with drains (48.8% versus 25.0%), and grade B POPFs (47.5% versus 17.5%). Both surgical methods effectively preserved pancreatic function; however, two patients in the PPJ group experienced severe haemorrhaging and died. Additionally, during the follow-up period, gastrointestinal bleeding was found and discomfort in the surgical area was reported.

CONCLUSION

Pancreatic enucleation combined with PPJ should be avoided, and although a biochemical or grade B POPF may develop after MEN, it can be compensated for by preserving pancreatic function and ensuring a good long-term quality of life in the patients.

[Robotic pancreatic surgery]

Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.

Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications

Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.

Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area

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.

Minimally-invasive versus open pancreatic enucleation: systematic review and metanalysis of short-term outcomes

BACKGROUND

Minimally Invasive Pancreatic Enucleation, either laparoscopic or robot-assisted, is rarely performed. The aim of this study was to offer the current available evidence about the outcomes of minimally invasive pancreatic enucleations and explore the possible advantage of this approach over traditional surgery.

METHODS

PubMed (MEDLINE), Cochrane Library and Embase (ELSEVIER) medical databases were searched for articles published from January 1990 to March 2022. Studies which included more than 10 cases of minimally-invasive pancreatic enucleation were included. Data on the outcomes were synthetized and meta-analyzed when appropriate.

RESULTS

Twenty studies published between 2009 and 2022 with a total of 552 patients were included in the systematic review: three hundred fifty-one patients (63.5%) had a laparoscopic intervention, two hundred and one (36.5%) robot-assisted with a cumulative incidence of conversion rate of 5%. Minimally-invasive surgery was performed in 63% of cases on the body/tail of the Pancreas and in 37% of the cases on the head/uncinate process of the Pancreas. The cumulative post-operative 30 days - mortality rate was 0.2% and the major postoperative morbidity (Clavien-Dindo III-IV-V) 35%. Clinically relevant pancreatic fistula was observed in 17% of the patients. Compared with the standardized open approach (n: 366 patients), mean length of hospital stay was significantly reduced in patients undergoing minimally invasive pancreatic enucleation (2.45 days, p = 0.003) with a favorable trend for post-operative major morbidity (Clavien-Dindo III-IV) (- 24% RR, p: 0.13). Operative time, blood loss and clinically relevant pancreatic fistula rate were comparable between the two groups. One hundred and fourteen robot-assisted enucleations entered in a subgroup analysis with comparable results to open surgery.

CONCLUSION

Minimally-Invasive approach for pancreatic enucleation is safe, feasible and offers short-term clinical outcomes comparable with open surgery. The potential benefit of robotic surgery will need to be verified in further studies.

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula

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.

Central pancreatectomy prevents postoperative diabetes

BACKGROUND

Central pancreatectomy (CP) can be performed as an alternative surgical approach to distal pancreatectomy (DP) in the treatment of benign or low-grade malignant lesions located in the neck and body of the pancreas, aiming to reduce loss of parenchyma and therefore organ failure. The objective of this study was to evaluate the short- and long-term outcome of CP in comparison to DP.

METHODS

Patients who received CP in a large tertiary care pancreatic surgery center between 2001 and 2020 were identified from a prospectively maintained database and compared via propensity score matching with patients receiving DP during the same time period. Perioperative rate of complications and long-term outcome of pancreatic endocrine and exocrine function were evaluated.

RESULTS

One hundred and seven patients undergoing open CP were compared to 107 patients with open DP. No significant difference in rates or severity of most surgical complications could be found including postoperative pancreatic fistula, intraabdominal fluid collection, delayed gastric emptying and wound infection. However, patients receiving CP had a significantly higher risk of grade C postpancreatectomy hemorrhage (PPH) (CP: 10 patients, 9.3% versus DP: 1 patient, 0.9%; p = .0019). Perioperative mortality was comparable. Long-term follow-up of 60 matched pairs revealed significantly less patients with new-onset diabetes after CP (eight patients, 13.3%) compared to DP (22 patients, 36.7%, p = .0056).

CONCLUSION

CP offers an improved endocrine long-term outcome at the expense of a higher risk of PPH without increased perioperative mortality. As evidence on this parenchyma sparing surgical technique is sparse, more prospective data are needed.

Enucleation for low-grade branch duct intraductal papillary mucinous neoplasms: Long-term follow-up

BACKGROUND

Pancreatic enucleation allows resection of branch-duct intraductal papillary mucinous neoplasms with full parenchyma preservation. The aim of this study was to assess intraductal papillary mucinous neoplasms recurrence and functional outcomes during long-term follow-up after enucleation.

METHODS

Patient characteristics, as well as radiologic and clinicopathologic follow-up data of patients who underwent enucleation for branch-duct intraductal papillary mucinous neoplasms between 2004 and 2014, were analyzed. Quality of life was assessed using the EORTC QLQ-C30 and QLQ-PAN26 questionnaires.

RESULTS

Seventy-four patients underwent enucleation for low-grade branch-duct intraductal papillary mucinous neoplasms in 71 and high-grade branch-duct intraductal papillary mucinous neoplasms in 3 patients. Long-term follow-up data were available for 66 patients (89%; median follow-up: 87 months). Radiologic imaging (n = 56) showed intraductal papillary mucinous neoplasm recurrence in 10 patients (18%) including local recurrence at the site of enucleation in 3 patients (5%) and new onset intraductal papillary mucinous neoplasms manifestation in 7 patients (13%) at a distant site in the pancreatic remnant. Four patients (6%) underwent reoperation. Two of these patients had intraductal papillary mucinous neoplasm-associated carcinoma, one of them at the enucleation site. During the follow-up period, no intraductal papillary mucinous neoplasm-related deaths occurred and no new onsets of insulin-dependent diabetes mellitus were observed. QLQ-C30 revealed a global health status of 66.0% and overall functioning and symptom scores of 81.0% and 22.8%, respectively. Additionally, QLQ-PAN26 showed an overall symptom score of 26.5%.

CONCLUSION

Enucleation is an organ-preserving surgical treatment option for low-grade branch-duct intraductal papillary mucinous neoplasms with low local recurrence risk and excellent functional long-term outcome. However, postoperative life-long follow-up must be performed as for any type of partial pancreatectomy for intraductal papillary mucinous neoplasms due to the risk of recurrence and potential malignancy.

[Surgery of pancreatic neuroendocrine neoplasms: state of the art]

Pancreatic neuroendocrine neoplasms (pNEN) have a rising incidence and are increasingly diagnosed at early and thus potentially resectable stages. Due to the rarity of these neoplasms the recommendations of currently available guidelines are mainly based on retrospective data. Surgical and oncological treatment of these rare diseases should only be performed at specialized centers. In cases of resectability without indications of diffuse metastases, complete resection with curative intent should be the treatment of choice. For small nonfunctional pNENs < 2 cm watch and wait strategies are recommended as an alternative to surgical treatment. Recent data, however, also showed an increased survival even of small (1-2 cm) pNENs after resection. For benign insulinomas and small nonfunctional well-differentiated pNENs parenchyma-sparing procedures, such as enucleation and segmental resection are available. The question of the influence of lymph node metastases on long-term disease-free survival and overall survival and consequently the role of systematic lymphadenectomy is still a matter of debate. In pNENs > 2 cm formal resection with lymphadenectomy is considered the gold standard. Minimally invasive and robotic-assisted procedures are of increasing importance also for formal pancreatic resection.

Resektionsstrategien beim BD-IPMN - Enukleation oder onkologische Resektion?

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

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

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

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