Laparoscopic fenestration of pancreatic serous cystadenoma: Minimally invasive approach for symptomatic benign disease

Pancreatic Serous Cystadenoma: A Continuing Diagnostic Challenge

OBJECTIVE

To understand the natural history of serous cystadenoma (SCA), and the diagnostic accuracy of SCA and identify possible factors that lead to the correct diagnosis.

BACKGROUND

SCA is a benign cystic pancreatic neoplasm of the pancreas, accounting for ~15% of resected pancreatic cysts. Current recommendations are to proceed with surgical resection in symptomatic patients or when there is uncertainty regarding diagnosis. The latter continues to be a challenge since intentional resection of an SCA accounts for only a minority of resected cases.

METHODS

Retrospective single-institution review of patients who on final pathology had a diagnosis of pancreatic SCA and of patients who had this diagnosis and were managed nonoperatively. Demographic data, cyst characteristics, and growth rate were collected for analysis.

RESULTS

A total of 250 patients were analyzed. Median age was 62 (range: 22-89), 65% were females, and 34% had symptoms. Tumor size ranged from 0.6 to 20, with a median of 3.4 cm. The morphologic appearance was microcystic in 58%, macrocystic in 16%, mixed-type in 23%, and solid in 3%. Pancreatic duct dilation and pancreatic atrophy were found in 22% and 14%, respectively. The average growth rate was 1.8 mm/year regardless of tumor size. Of the 172 patients who underwent surgery, SCA was the preoperative diagnosis in only 33%. A correct diagnosis was independently associated with large tumors and cyst fluid carcinoembryonic antigen analysis. Pancreatic duct dilation was independently associated with an in-growing cyst and the presence of calcification.

CONCLUSIONS

SCA is a slow-growing pancreatic cystic neoplasm that is mostly asymptomatic but can lead to pancreatic duct dilation and atrophy in some patients. A surprisingly small number of correct preoperative diagnoses confirms that this entity continues to be a diagnostic challenge. A more thorough preoperative workup that includes endoscopic ultrasonography should improve the rate of misdiagnosis.

[Minimally invasive and robot-assisted surgery for pancreatic cystic tumors]

BACKGROUND

The indications for resection of pancreatic cystic lesions (PCL) are often complex and the operative risk has to be balanced against the risk of malignant transformation. The aim of the study was to provide a synopsis of the current treatment results of minimally invasive surgery for PCL.

METHODS

A systematic literature search was performed using the Medline database (PubMed). Subsequently, the retrieved literature was selectively reviewed.

RESULTS

No published prospective randomized controlled trials have yet addressed the comparison of open and minimally invasive surgery of PCL; however, retrospective case studies have demonstrated the feasibility, safety and a comparable morbidity after minimally invasive distal pancreatectomy (DP), pancreatoduodenectomy (PD), central (CP) or total pancreatectomy and enucleation. Whereas most DPs are performed laparoscopically, the experience of minimally invasive PD has been consolidated for the robot-assisted approach but is concentrated in only a few centers. The number of published reports on minimally invasive organ-sparing pancreas procedures (e. g. CP or enucleation) for PCL is scarce; however, the available (selected) results are promising.

CONCLUSION

Minimally invasive surgery for PCL has the potential to reduce the operative trauma to the patients, while at the same time causing comparable or less morbidity. This requires an increasing specialization of complex minimally invasive resections. The clinical use of robotic systems will grow for the latter cases. A prospective registry of the results should be mandatory for quality management.

Giant Serous Cystadenoma of the Pancreas (⩾10 cm): The Clinical Features and CT Findings

Purpose. To report the clinical features and CT manifestations of giant pancreatic serous cystadenoma (≥10 cm). Methods. We retrospectively reviewed the clinical features and CT findings of 6 cases of this entity. Results. All 6 patients were symptomatic. The tumors were 10.2 cm–16.5 cm (median value, 13.0 cm). CT imaging revealed that all 6 cases showed microcystic appearances (n = 5) or mixed microcystic and macrocystic appearances (n = 1). Five patients with tumors at the distal end of the pancreas received distal pancreatectomy. Among these 5 patients, 2 patients underwent partial transverse colon resection or omentum resection due to close adhesion. One patient whose tumor was located in the pancreatic head underwent pancreaticoduodenectomy; however, due to encasement of the portal and superior mesenteric veins, the tumor was incompletely resected. One patient had abundant draining veins on the tumor surface and suffered large blood loss (700 mL). After 6–49 months of follow-up the 6 patients showed no tumor recurrence or signs of malignant transformation. Conclusions. Giant pancreatic serous cystadenoma necessitates surgical resection due to large size, symptoms, uncertain diagnosis, and adjacent organ compression. The relationship between the tumors and the neighboring organs needs to be carefully assessed before operation on CT image.