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Feasibility and outcome of spleen and vessel preserving total pancreatectomy (SVPTP) in pancreatic malignancies - a retrospective cohort study. Langenbecks Arch Surg 2022; 407:3457-3465. [PMID: 36169725 DOI: 10.1007/s00423-022-02690-7] [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: 05/23/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Total pancreatectomy (TP) is most commonly performed to avoid postoperative pancreatic fistula (POPF) in patients with high-risk pancreas or to achieve tumor-free resection margins. As part of TP, a simultaneous splenectomy is usually performed primarily for the reason of oncologic radicality. However, the benefit of a simultaneous splenectomy remains unclear. Likewise, the technical feasibility as well as the safety of spleen and vessel preserving total pancreatectomy in pancreatic malignancies has hardly been evaluated. Thus, the aims of the study were to evaluate the feasibility as well as the results of spleen and vessel preserving total pancreatectomy (SVPTP). MATERIAL AND METHODS Patient characteristics, technical feasibility, perioperative data, morbidity, and mortality as well as histopathological results after SVPTP, mainly for pancreatic malignancies, from patient cohorts of two European high-volume-centers for pancreatic surgery were retrospectively analyzed. Mortality was set as the primary outcome and morbidity (complications according to Clavien-Dindo) as the secondary outcome. RESULTS A SVPTP was performed in 92 patients, predominantly with pancreatic adenocarcinoma (78.3%). In all cases, the splenic vessels could be preserved. In 59 patients, the decision to total pancreatectomy was made intraoperatively. Among these, the most common reason for total pancreatectomy was risk of POPF (78%). The 30-day mortality was 2.2%. Major complications (≥ IIIb according to Clavien-Dindo) occurred in 18.5% within 30 postoperative days. There were no complications directly related to the spleen and vascular preservation procedure. A tumor-negative resection margin was achieved in 71.8%. CONCLUSION We could demonstrate the technical feasibility and safety of SVPTP even in patients mainly with pancreatic malignancies. In addition to potential immunologic and oncologic advantages, we believe a major benefit of this procedure is preservation of gastric venous outflow. We consider SVPTP to be indicated in patients at high risk for POPF, in patients with multilocular IPMN, and in cases for extended intrapancreatic cancers.
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Kauffmann EF, Napoli N, Genovese V, Ginesini M, Gianfaldoni C, Vistoli F, Amorese G, Boggi U. Feasibility and safety of robotic-assisted total pancreatectomy: a pilot western series. Updates Surg 2021; 73:955-966. [PMID: 34009627 PMCID: PMC8184722 DOI: 10.1007/s13304-021-01079-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 01/04/2023]
Abstract
This study was designed to demonstrate non-inferiority of robot-assisted total pancreatectomy (RATP) to open total pancreatectomy (OPT) based on an intention-to-treat analysis, having occurrence of severe post-operative complications (SPC) as primary study endpoint. The two groups were matched (2:1) by propensity scores. Assuming a rate of SPC of 22.5% (non-inferiority margin: 15%; α: 0.05; β: 0.20; power: 80%), a total of 25 patients were required per group. During the study period (October 2008–December 2019), 209 patients received a total pancreatectomy. After application of exclusion and inclusion criteria, matched groups were extracted from an overall cohort of 132 patients (OPT: 107; RATP: 25). Before matching, the two groups were different with respect to prevalence of cardiac disease (24.3% versus 4.0%; p = 0.03), presence of jaundice (45.8% versus 12.0%; p = 0.002), presence of a biliary drainage (23.4% versus 0; p = 0.004), history of weight loss (28.0% versus 8.0%; p = 0.04), and vein involvement (55.1% versus 28.0%) (p = 0.03). After matching, the two groups (OTP: 50; RATP: 25) were well balanced. Regarding primary study endpoint, SPC developed in 13 patients (26.0%) after OTP and in 6 patients (24.0%) after RATP (p = 0.85). Regarding secondary study endpoints, RATP was associated with longer median operating times [475 (408.8–582.5) versus 585 min (525–637.5) p = 0.003]. After a median follow-up time of 23.7 months (10.4–71), overall survival time [22.6 (11.2–81.2) versus NA (27.3–NA) p = 0.006] and cancer-specific survival [22.6 (11.2–NA) versus NA (27.3–NA) p = 0.02] were improved in patients undergoing RATP. In carefully selected patients, robot-assisted total pancreatectomy is non-inferior to open total pancreatectomy regarding occurrence of severe post-operative complications.
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Affiliation(s)
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Valerio Genovese
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
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Yang F, Jin C, Warshaw AL, You L, Mao Y, Fu D. Total pancreatectomy for pancreatic malignancy with preservation of the spleen. J Surg Oncol 2019; 119:784-793. [PMID: 30636049 DOI: 10.1002/jso.25377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Total pancreatectomy may be necessary to achieve margin-negative resection for pancreatic cancer. However, despite the desirability of saving the spleen, the feasibility, safety, and oncological outcomes of spleen-preserving total pancreatectomy have not been studied in patients with malignancy involving the pancreatic neck or proximal body. The aim of this study was to report the efficacy of spleen-preserving total pancreatectomy using the Warshaw technique for patients with pancreatic malignancies. METHODS A retrospective analysis of patients who underwent total pancreatectomy for malignant pancreatic diseases between December 2006 and January 2018 focused on comparing the clinical outcomes between conventional operations with splenectomy and spleen-preserving total pancreatectomy using the Warshaw technique. RESULTS Thirty-eight patients among a total of 59 total pancreatectomies had the spleen preservation by the Warshaw operation. In this series, the pancreatic ductal adenocarcinomas resected with the Warshaw technique were of smaller tumor size but had greater rates of vascular invasion, resulting in the more frequent vascular resection. No patients had splenic complications requiring splenectomy, but two patients intended to have the Warshaw operation were converted to splenectomy because of splenic malperfusion. Asymptomatic perigastric varices were noted in 4 patients. Postoperative morbidity and mortality were comparable between the Warshaw and conventional operation groups. Recurrence-free and overall survival was similar in both groups. CONCLUSION In patients with pancreatic malignancy, total pancreatectomy with preservation of the spleen using the Warshaw technique achieves outcomes comparable with conventional total pancreatectomy with splenectomy in selected patients.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Li You
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Yishen Mao
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
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Choi YJ, Lee JH, Lee CR, Han WK, Kang CM, Lee WJ. Laparoscopic total pancreatectomy for multiple metastasis of renal cell carcinoma of the pancreas: a case report and literature review. Ann Hepatobiliary Pancreat Surg 2017; 21:96-100. [PMID: 28567455 PMCID: PMC5449372 DOI: 10.14701/ahbps.2017.21.2.96] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 01/19/2017] [Accepted: 01/21/2017] [Indexed: 11/17/2022] Open
Abstract
Advances in surgical techniques and laparoscopic instruments have resulted in the development of laparoscopic pancreatic surgery. Total pancreaticoduodenectomy is performed for treating benign and borderline pancreatic disease involving the whole pancreas. Here, we report a case of metastatic renal cell carcinoma in the pancreas, treated by laparoscopic pylorus-preserving total pancreaticoduodenectomy. A 59-year-old woman was diagnosed with metastatic renal cell carcinoma. Multiple metastatic lesions were found on routine follow-up. She had a history of radical video-assisted right-nephrectomy for renal cell carcinoma (conventional type, pT1) in November 2003, without any recurrence. However, in 2014, a routine health checkup revealed multiple enhancing lesions throughout the pancreas. Positron emission tomography showed a suspicious 4-cm lesion in her left thyroid. Laparoscopic pylorus-preserving total pancreaticoduodenectomy with splenectomy was performed, along with simultaneous left total thyroidectomy with central compartment node dissection for metastatic renal cell carcinomas. The total operation time was 441 min, with an estimated blood loss of 150 ml; no transfusion was administered. Her hospital stay was 12 days. The histopath report confirmed metastatic renal cell carcinoma in the pancreas and left thyroid. Based on literature reviews, we further tried to estimate the oncologic outcome of total pancreatectomy in multiple pancreatic metastasis of renal cell carcinoma. Laparoscopic pylorus-preserving total pancreaticoduodenectomy is feasible and safe, even in cases of metastatic renal cell carcinoma.
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Affiliation(s)
| | - Jin Ho Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Cho Rok Lee
- Yonsei University College of Medicine, Seoul, Korea.,Division of Thyroid and Endocrine Surgery, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Surgery, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woong Kyu Han
- Yonsei University College of Medicine, Seoul, Korea.,Department of Urology, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Yonsei University College of Medicine, Seoul, Korea.,Division of Hepatobiliary and Pancreatic Surgery, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Surgery, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Yonsei University College of Medicine, Seoul, Korea.,Division of Hepatobiliary and Pancreatic Surgery, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Surgery, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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Analysis of prognostic factors in metastatic tumors of the pancreas: a single-center experience and review of the literature. Pancreas 2010; 39:135-43. [PMID: 19820422 DOI: 10.1097/mpa.0b013e3181bae9b3] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Pancreatic metastases are rare. The role of surgery is poorly defined, and data on long-term survival are lacking. METHODS Data from patients with pancreatic metastases observed in our division from 2003 to 2008 were retrospectively analyzed. In addition, the recent English medical literature was reviewed regarding series of patients with pancreatic secondary tumors. RESULTS Data from 234 patients including 9 consecutive patients observed in our division were retrieved. Metastasis from renal cell carcinoma accounted for 67.9% of all cases. Factors predictive of worse survival, as determined by multivariate analysis, were symptoms at diagnosis, synchronous tumors, radical-intent surgery not performed, and pathologic diagnosis of the primary tumor. Compared with pancreatic metastases from renal cell cancer, metastases from melanoma (P < 0.001) and lung cancer (P = 0.002) were associated with worse survival. The differences in survival of patients with renal cell cancer metastases and those with breast cancer, colorectal, or sarcoma metastases did not reach statistical significance. CONCLUSIONS There may be a subset of patients with pancreatic metastases who are able to benefit from surgery with respect to improved long-term survival. Symptoms at diagnosis, presentation with primary tumor, surgical resection, and pathologic diagnosis seem to be important prognostic factors.
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Hatori T, Kimijima A, Fujita I, Furukawa T, Yamamoto M. Duodenum-preserving total pancreatectomy for pancreatic neoplasms. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:824-30. [DOI: 10.1007/s00534-009-0225-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 11/28/2022]
Affiliation(s)
- Takashi Hatori
- Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; 8-1 Shinjuku-ku Tokyo 162-8666 Japan
| | - Akira Kimijima
- Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; 8-1 Shinjuku-ku Tokyo 162-8666 Japan
| | - Izumi Fujita
- Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; 8-1 Shinjuku-ku Tokyo 162-8666 Japan
| | - Toru Furukawa
- International Research and Educational Institute for Integrated Medical Sciences; Tokyo Women's Medical University; Tokyo 162-8666 Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; 8-1 Shinjuku-ku Tokyo 162-8666 Japan
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Fabbri C, Luigiano C, Collina G, Cennamo V, D'Imperio N, Jovine E. EUS-FNA diagnosis of single pancreatic metastasis of liposarcoma. Gastrointest Endosc 2009; 69:974-6. [PMID: 19152900 DOI: 10.1016/j.gie.2008.05.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Accepted: 05/27/2008] [Indexed: 02/07/2023]
Affiliation(s)
- Carlo Fabbri
- Gastrointestinal and Endoscopic Unit, S Orsola-Malpighi University Hospital, Bologna, Italy
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Bruzoni M, Sasson AR. Open and laparoscopic spleen-preserving, splenic vessel-preserving distal pancreatectomy: indications and outcomes. J Gastrointest Surg 2008; 12:1202-6. [PMID: 18437500 DOI: 10.1007/s11605-008-0512-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 03/26/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Spleen-preserving distal pancreatectomy has been described lately in order to reduce the risks associated with splenectomy. The aim of this study is to report a series of open and laparoscopic distal pancreatectomies with splenic vessel preservation. METHODS From June 2001 to April 2007, 11 spleen-preserving distal pancreatectomies were performed, utilizing open and laparoscopic techniques. The main variables recorded were demographics, intra- and postoperative complications, and final pathology results. RESULTS All 11 spleen-preserving distal pancreatectomies were performed successfully. Laparoscopic resection was possible in seven patients. Postoperative morbidity consisted of one pancreatic fluid collection. The overall incidence of pancreatic leak was 18%. The final pathology revealed serous cystadenoma in 36% of the cases, neuroendocrine tumor in two cases, three mucinous cystadenomas, one carcinoid tumor, and one intrapancreatic spleen. With a median follow-up of 26 months, no splenic vein thrombosis was detected. CONCLUSIONS Open or laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation is a feasible and safe procedure. In selected cases of cystic lesions and low grade neoplasms, distal pancreatectomy with splenic preservation is possible.
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Affiliation(s)
- Matias Bruzoni
- Department of Surgery, University of Nebraska Medical Center, 984030 Nebraska Medical Center, Omaha, NE 68198-4030, USA.
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Koukoutsis I, Tamijmarane A, Bellagamba R, Bramhall S, Buckels J, Mirza D. The impact of splenectomy on outcomes after distal and total pancreatectomy. World J Surg Oncol 2007; 5:61. [PMID: 17543130 PMCID: PMC1891298 DOI: 10.1186/1477-7819-5-61] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Accepted: 06/02/2007] [Indexed: 01/25/2023] Open
Abstract
Background Several authors advocate spleen preserving distal pancreatectomy, because of the increased complication rate after splenectomy. Methods Postoperative complications and survival after distal and total pancreatectomy, were recorded and retrospectively analyzed according to spleen preservation. Patients, who underwent distal and total pancreatectomy without histologically proven adenocarcinoma, or extrapancreatic disease, were included in the cohort which was divided into splenectomy and no splenectomy groups. Statistical analysis was performed using Fisher's test. Results The study group consisted of 62 patients who underwent distal and total pancreatectomy between 26/11/1987 to 6/1/2006. Splenectomy was performed in 35 out of 62 patients (56.5%), distal pancreatectomy was performed in 49 out of 62 patients (79%). Morbidity rate was 28.6% in splenectomy group and 14.8% in the no splenectomy group (p = 0.235), while 30 days mortality rate was 2.9%; one patient died in the splenectomy group (p = 1). Conclusion Spleen-preservation did not influence the outcomes after distal and total pancreatectomy in our series.
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Affiliation(s)
- Ilias Koukoutsis
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Appou Tamijmarane
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Riccardo Bellagamba
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Simon Bramhall
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Buckels
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius Mirza
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
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Inagaki M, Obara M, Kino S, Goto J, Suzuki S, Ishizaki A, Tanno S, Kohgo Y, Tokusashi Y, Miyokawa N, Kasai S. Pylorus-preserving total pancreatectomy for an intraductal papillary-mucinous neoplasm of the pancreas. ACTA ACUST UNITED AC 2007; 14:264-9. [PMID: 17520201 DOI: 10.1007/s00534-006-1146-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Accepted: 06/30/2006] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE Total pancreatectomy (TP) is rarely performed to treat invasive ductal carcinoma of the pancreas, due to the associated markedly impaired quality of life and poor prognosis after the resection. Intraductal papillary-mucinous neoplasm (IPMN) of the pancreas is characterized by extensive intraductal spread and a favorable outcome even when presenting at an invasive stage. We herein reappraise the role of pylorus-preserving total pancreatectomy (PPTP) as a viable alternative pancreatic resection modality for borderline and malignant IPMN. METHODS A total of five patients with IPMN underwent PPTP and their clinical follow-up data were reviewed. RESULTS TP was performed due to recurrent IPMN in the remnant pancreas after distal pancreatectomy in three patients and due to massive involvement of the entire pancreas in the others. All patients were treated by the pylorus-preserving method, while the spleen was also preserved in one patient. The surgical margins were negative and no metastasis to the resected lymph nodes was evident, based on histological examinations. One patient underwent a re-operation due to postoperative intraabdominal bleeding, while another patient required tubedrainage for left pleural effusion. Three of the four patients who underwent PPTP with a splenectomy experienced postoperative gastric ulcer, which were controlled by medication. One patient died due to suicide 16 months after the PPTP. All the others were doing well without recurrence at periods of 62 to 127 months after the PPTP. CONCLUSIONS PPTP is therefore considered to be indicated as an effective treatment for borderline or malignant IPMN with extensive involvement, when the patient's condition permits, in order to achieve complete resection of the IPMN.
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Affiliation(s)
- Mitsuhiro Inagaki
- Department of Surgery, Asahikawa Medical College, 2-1-1-1 Midorigaoka-Higashi, Asahikawa 078-8510, Japan
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Izard G, Zarski O. [Does ligation of the splenic vein during caudal pancreatectomy necessitate splenectomy?]. JOURNAL DE CHIRURGIE 2005; 142:124-5. [PMID: 15976640 DOI: 10.1016/s0021-7697(05)80877-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
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