Pancreatico-jejunostomy decreases post-operative pancreatic fistula incidence and severity after central pancreatectomy

Central pancreatectomy: An uncommon but potentially optimal choice of pancreatic resection

Benign, premalignant or low-grade malignant pancreatic tumors are increasingly diagnosed owing to the widespread uptake of cross-sectional imaging. Surgical excision is a potential treatment option for these tumors. Pancreatoduodenectomy and distal pancreatectomy are the standard resections for tumors located in the pancreatic head-neck or body-tail, respectively, and not uncommonly sacrifice a significant amount of healthy pancreatic parenchyma. Central pancreatectomy (CP) is a parenchyma-sparing procedure, initially performed by Dagradi and Serio in 1982, in a patient with pancreatic neck insulinoma. Since then, an increasing number of cases are being performed worldwide, either via open or minimally invasive surgical access. Additionally, pancreatic enucleation is reserved for tumors < 3 cm, without involvement of the main pancreatic duct. CP remains an alternative approach in selected cases, albeit in the presence of some controversies, such as its use in early pancreatic ductal adenocarcinoma or metastatic deposits to the central aspect of the pancreas from other malignancies. In recent years, clarity is lacking as regards indications for CP, and despite accumulating evidence in favor of limited resections for suitable pancreatic tumors, no evidence-based consensus guidelines are yet available. Nevertheless, it appears that appropriate patient selection is of paramount importance to maximize the advantages of preservation of endocrine and exocrine pancreatic functions as well as to mitigate the risks of higher complication rates. In this comprehensive review, we explore the role of CP in the treatment of lesions located in the neck and proximal body of the pancreas.

Clinical outcomes of interlocking main pancreatic duct-jejunal internal bridge drainage in middle pancreatectomy: A comparative study

BACKGROUND

Middle pancreatectomy (MP) is a surgical procedure that removes non-invasive lesions in the pancreatic neck and body, allowing for the preservation of pancreatic function. However, MP is associated with a higher risk of postoperative complications, and there's no clear consensus on which anastomotic method is preferable. In recent years, our team has developed a new method called interlocking main pancreatic duct-jejunal (IMPD-J) internal bridge drainage to MP.

AIM

To compare perioperative and postoperative outcomes in patients who underwent IMPD-J bridge drainage and those underwent traditional duct-to-mucosa pancreatojejunostomy.

METHODS

Patients who underwent MP in our hospital between October 1, 2011 and July 31, 2023 were enrolled in this study. Patients were divided into two groups based on their pancreatojejunostomy technique: IMPD-J bridge drainage group and duct-to-mucosa pancreatojejunostomy group. Demographic data (age, gender, body mass index, hypertension, diabetes, etc.) and perioperative indicators [operation time, intraoperative bleeding, clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying, etc.] were recorded and analyzed statistically.

RESULTS

A total of 53 patients were enrolled in this study, including 23 in the IMPD-J Bridge Drainage group and 30 in the traditional duct-to-mucosa pancreatojejunostomy group. There were no significant differences in demographic or preoperative characteristics between the groups. Compared to traditional duct-to-mucosa pancreaticojejunostomy, IMPD-J bridge drainage had a significant shorter operation time (4.3 ± 1.3 hours vs 5.8 ± 1.8 hours, P = 0.002), nasogastric tube retention days (5.3 ± 1.7 days vs 6.5 ± 2.0 days, P = 0.031), lower incidence of delayed gastric emptying (8.7% vs 36.7%, P = 0.019), and lower incidence of CR-POPF (39.1% vs 70.0%, P = 0.025). Multivariate logistic regression analysis showed that pancreaticojejunostomy type (odds ratio = 4.219, 95% confidence interval = 1.238-14.379, P = 0.021) and plasma prealbumin (odds ratio = 1.132, 95% confidence interval = 1.001-1.281, P = 0.049) were independent risk factor for CR-POPF. In IMPD-J bridge drainage group, only one patient experienced recurrent pancreatitis due to the large diameter of the silicone tube and had it removed six months after surgery.

CONCLUSION

Compared to traditional duct-to-mucosa pancreatojejunostomy, IMPD-J bridge drainage has the advantages of simplicity and fewer perioperative complications, with favorable long-term outcomes.

Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy?

(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.

Laparoscopic versus open central pancreatectomy: a propensity score-matched analysis in a single centre

PURPOSE

Laparoscopic central pancreatectomy (LCP) has been implemented in pancreatic surgery; however, open surgery is still the predominant approach for central pancreatectomy (CP). Our objective was to compare LCP with open CP (OCP).

METHODS

Data were collected from patients with tumours located in the pancreatic neck and proximal body who underwent CP in the Department of Pancreatic Surgery West China Hospital from January 1, 2010, to June 30, 2019. A comparison between the LCP and OCP groups was performed.

RESULTS

Fifteen patients underwent CP via the laparoscopic approach, and 96 patients underwent CP via the open approach. Using 1:2 propensity score matching (PSM), 12 patients in the LCP group were matched to 21 in the OCP group. Regarding safety, postoperative pancreatic fistula (POPF) was not significantly different between the two groups (13.3% vs. 12.5%, P = 1.000), even with PSM (16.7% vs. 14.3%, P = 1.000). However, regarding effectiveness, the operative time in the OCP group was significantly shorter than that in the LCP group before (307.0 ± 92.3 ml vs. 220.6 ± 63.6 ml, P < 0.000) and after (300.3 ± 90.2 ml vs. 212.7 ± 44.4 ml, P = 0.002) PSM. Regarding length of stay (LOS), there was no difference between the two groups before (13.1 ± 13.7 days vs. 12.7 ± 10.1 days, P = 0.376) and after PSM (14.4 ± 15.1 days vs. 14.5 ± 16.2 days, P = 0.985). The length of the resected pancreas was shorter in the OCP group than in the LCP group before PSM (50.0 ± 13.2 mm vs. 41.1 ± 11.1 mm, P = 0.043). However, there was no difference between the two groups after PSM (47.9 ± 12.5 mm vs. 37.9 ± 10.4 mm, P = 0.084). Moreover, the other variables showed no difference between the two groups before and after PSM.

CONCLUSION

LCP can demonstrate similar safety and effectiveness to OCP, even in the early stages of the learning curve.

Risk Factor Identification for Delayed Gastric Emptying after Distal Pancreatectomy-An Evaluation of 1688 Patients Based on the German StuDoQ|Pancreas Registry

Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.

Resection of the splenic vessels during laparoscopic central pancreatectomy is safe and does not compromise preservation of the distal pancreas

BACKGROUND

The diagnosis of low potential malignant diseases is increasingly frequent, and laparoscopic central pancreatectomy can be indicated in these patients. Laparoscopic central pancreatectomy that usually preserves the splenic vessels results in a low risk of new-onset diabetes but high morbidity, mainly due to postoperative pancreatic fistula and postpancreatectomy hemorrhage. In this study, we evaluated the short and long-term complications after laparoscopic central pancreatectomy with splenic vessel resection.

METHODS

This retrospective single-center cohort study included 650 laparoscopic pancreatic resections from 2008 to 2020 with 84 laparoscopic central pancreatectomy; 15 laparoscopic central pancreatectomy with splenic vessel resection; and 69 laparoscopic central pancreatectomy with preservation of the splenic vessels. Pancreaticogastrostomy was routinely performed, and the patients were discharged after complications had been treated. The 15 laparoscopic central pancreatectomy with splenic vessel resection were matched for age, sex, body mass index, and tumor characteristics [1:2] and compared with 30 laparoscopic central pancreatectomy with the preservation of the splenic vessels.

RESULTS

In the laparoscopic central pancreatectomy with splenic vessel resection group, resection of splenic vessels was performed due to tumoral or inflammatory adhesions (n = 11) or accidental vascular injury (n = 4). The demographic characteristics of the groups were similar. Tumors were larger in the laparoscopic central pancreatectomy with splenic vessel resection group (40 vs 21 mm; P = .008), and right transection on the body of the pancreas (53% vs 13%; P = .01) was more frequent. There were no differences in the characteristics of the pancreas (Wirsung duct size or consistency). The median operative time (minutes) was longer in the laparoscopic central pancreatectomy with splenic vessel resection group than in the laparoscopic central pancreatectomy with preservation of the splenic vessels group (210 vs 180, respectively; P = .15) with more blood loss (100 mL vs 50 mL, respectively; P = .012). The lengths (mm) of the resected pancreas and remnant distal pancreas in the 2 groups were 65 vs 50 (P = .053) and 40 vs 65 (P = .006), respectively. There were no differences in postoperative mortality (0% vs 3%; P = .47), grade B-C postoperative pancreatic fistula (27% vs 27%; P = 1), reintervention (7% vs 13%; P = .50), grade B-C postpancreatectomy hemorrhage (0% vs 13%; P = .13), length of hospital stay (20 days vs 22 days; P = .15), or new-onset diabetes (7% vs 10%; P = .67) between the 2 groups.

CONCLUSION

Laparoscopic central pancreatectomy with splenic vessel resection is a safe technical modification of central pancreatectomy that does not prevent preservation of the distal pancreas and does not influence postoperative pancreatic fistula or endocrine insufficiency. Furthermore, it could reduce the risk of postpancreatectomy hemorrhage.

Solid pancreatic masses in children: A review of current evidence and clinical challenges

Pancreatic tumors in children are infrequently encountered in clinical practice. Their non-specific clinical presentation and overlapping imaging characteristics often make an accurate preoperative diagnosis difficult. Tumors are categorized as epithelial or non-epithelial, with epithelial tumors further classified as tumors of the exocrine or endocrine pancreas. Although both are tumors of the exocrine pancreas, solid pseudopapillary neoplasm is the most prevalent solid pancreatic tumor in children, while pancreatoblastoma is the most common malignant tumor. Insulinoma is the most common pediatric pancreatic tumor of the endocrine pancreas. Malignant tumors require a complete, often radical, surgical resection. However, pancreatic parenchyma-sparing surgical procedures are utilized for benign tumors and low-grade malignancy to preserve gland function. This review will discuss the epidemiology, pathophysiology, clinical and diagnostic characteristics, and management options associated with both common and rare solid pancreatic masses in children. We will also discuss current challenges encountered in their evaluation and treatment.

Laparoscopic spleen-preserving distal versus central pancreatectomy for tumors in the pancreatic neck and proximal body

For benign and borderline tumors in the pancreatic neck and proximal body, laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic central pancreatectomy (LCP) are alternative surgical procedures. Choosing between LSPDP and LCP is difficult. This retrospective cohort study was looking forward to provide evidence for clinical decision.A total of 59 patients undergoing LSPDP (Kimura procedure) and LCP between June 2013 and March 2017 were selected. The clinical outcomes of patients were compared by χ test or Fisher exact test and Student t test.This study included 36 patients in LSPDP group, and 23 patients in LCP group. The overall complications incidence in LCP group was significantly higher than LSPDP group (35 vs 6%, P = .004), and the postoperative pancreatic fistula (POPF) (grade B and C) rate and abdominal infection rate in LCP group were still significantly higher than LSPDP group (POPF 22 vs 3%, P = .019; abdominal infection 35 vs 3%, P = .001, respectively). The length of resected pancreas was significantly longer in LSPDP group (9.8 ± 2.0 vs 5.3 ± 1.1 cm, P = .007). The median follow-up was 39 months (range 12-57 months). No patient was confronted by tumor recurrence. The proportion of postoperative pancreatin and insulin treatment in LCP group were similar to LSPDP group (9 vs 17%, P = .383; 0 vs 3%, P = 1.000, respectively).For patients with poor general condition, the safety of LCP needs to be taken seriously; in some ways, LSPDP may be more secure, physiological, and easier operation for tumor located in pancreatic neck and proximal body.

The role of central pancreatectomy in pancreatic surgery: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP) and pancreaticoduodenectomy (PD).

METHODS

A systematic literature research in PubMed/Medline, Embase and Cochrane Library was performed to identify articles reporting CP from January 1983 to November 2017.

RESULTS

Fifty studies with 1305 patients undergoing CP were identified. The overall morbidity, mortality, pancreatic fistula (PF) rate and reoperation rate was 51%, 0.5%, 35% and 4% respectively. Endocrine and exocrine insufficiency were occurred in 4% and 5% of patients after CP. Meta-analysis of CP versus DP favored CP with regard to less blood loss (WMD = -143.4, P = 0.001), lower rates of endocrine (OR = 0.13, P < 0.001) and exocrine insufficiency (OR = 0.38, P < 0.001). CP was associated with higher morbidity and PF rate. In comparison with PD, CP had a lower risk of endocrine (OR = 0.14, P < 0.001) and exocrine insufficiency (OR = 0.14, P < 0.001), but a higher PF rate (OR = 1.6, P = 0.015).

CONCLUSIONS

CP maintains pancreatic endocrine and exocrine function better than DP and PD, but is associated with a higher PF rate.

Postoperative pancreatic fistula: a review of traditional and emerging concepts

Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.