Is Enucleation Safe When the Distance Between the Tumor and the Main Pancreatic Duct Is Less Than 3 mm? Results from a Multi-Institutional Retrospective Study
Stefano PartelliVolker FendrichStefano CrippaCaroline LopezLetizia BoninsegnaK. DietzelDetlef K. BartschMassimo Falconi
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Abstract:
Background Enucleation of small tumors can prevent pancreatic function impairment although the incidence of postoperative pancreatic fistula is relatively high. It has been suggested that this procedure should be avoided when the distance between the tumor and the main pancreatic duct is less than 3 mm. Objective To evaluate the safety of pancreatic enucleation for tumors distant less than 3 mm from the main pancreatic duct. Methods We reviewed the databases of the Department of Surgery of Marburg University (MU) and “Sacro Cuore” (SCH) Hospital of Negrar (1990-2012). All patients underwent intra-operative ultrasound (US) to measure the distance between the main pancreatic duct and the tumor. Binary logistic regression analysis of predictors of pancreatic fistula was performed. Results Sixty patients underwent enucleation in the two institutions. There were 21 males (35%) and 39 females (65%) with a median age of 50 years. The main reason for surgery was insulinomas (60%) followed by nonfunctioning neuroendocrine tumors (22%), gastrinomas (8%) and other tumors (6%). The median operative time was 137 minutes (IQR: 120-160). The overall rate of pancreatic fistula was 48% whereas the mortality was nil. The rate of pancreatic fistula was similar among the two institutions (55% in the SCH versus 42% in the MU; P=0.305). Overall, 31 patients (52%) had a distance between the tumor and the main pancreatic duct less than 3 mm. Re-exploration was necessary in 5 patients (8%) who had a tumor distant less than 3 mm from main pancreatic duct whereas the rate of grade C pancreatic fistula was similar among the two groups (25% vs . 29%; P=0.257). The only variable associated with a higher risk of pancreatic fistula was the distance between the tumor and main pancreatic duct less than 3 mm (odds ratio: 5.51; P=0.003). Conclusions Although the distance between the main pancreatic duct and tumor less than 3 mm is associated with a higher risk of pancreatic fistula, enucleation remains acceptably safe also in this group of patients. An intra-operative US is always mandatory to improve the post-operative management other than preventing main pancreatic duct injuries.Keywords:
Pancreatic fistula
Pancreatic tumor
In Brief Objective: To evaluate the usefulness and long-term results with pancreatic head resection with segmental duodenectomy (PHRSD; Nakao’s technique) in patients with branch-duct type intraductal papillary mucinous neoplasms (IPMNs). A prospective study from Nagoya (Japan) and Barcelona (Spain). Summary Background Data: Surgery should be the first choice of treatment of IPMNs. An aggressive surgery (eg, pancreatoduodenectomy) should be questioned in patients with an indolent disease or with noninvasive tumors. Recently, organ-preserving pancreatic resections for benign and noninvasive IPMN located in the head of the pancreas have been described. We have PHRSD in which the pancreatic head can be completely resected and the major portion of the duodenum can be preserved by this procedure. There have been only 4 reports concerning PHRSD with <8 patients (each one) in the English literature. Methods: Thirty-five patients underwent PHRSD (20 men, 15 women), mean age 65.1 ± 9.0 (range, 55–75). Mean maximal diameter of the cystic lesion was 26.4 ± 5.3 mm (range, 20–33 mm) and mean diameter of the main pancreatic duct was 3.3 ± 0.5 mm (range, 3.0–4.0 mm). Alimentary tract reconstruction was performed in 20 patients by pancreatogastrostomy, duodenoduodenostomy, and choledochoduodenostomy (type A) and 15 patients by pancreaticojejunostomy, duodenoduodenostomy and choledochojejunostomy (Roux-en-Y; type B). Surgical parameters, postoperative complications, endocrine function, exocrine function, and long-term outcomes were evaluated. To compare the perioperative factors, a matched-pairs analysis between PHRSD patients and patients with pylorus preserving pancreaticoduodenectomy (PPPD) was performed. In the latter group were included 32 patients with branch-duct type of IPMN operated during the same time period that patients with PHRSD. The mean follow-up period was 48.8 months. Results: Mean operative time after PHRSD was 365 ± 50 and mean surgical blood loss was 615 ± 251 mL. There was no mortality. Pancreatic fistula occurred in 10% and 13% with types (alimentary tract reconstruction) A and B, respectively. Noninvasive IPMN was found in 31 patients and invasive IPMN in 4 patients (11.4%). In the matched-pairs analysis between PHRSD and PPPD, the 2 procedures were comparable in regard to operation time and intraoperative blood loss. The overall incidence of pancreatic fistula was higher after PPPD than after PHRSD; the difference was not statistically significant. When fistulas occurred after PHRSD they were grade A (biochemical). In contrast, pancreatic fistulas after PPPD were grade A in 78% of cases and grade B in 22% (clinically relevant fistula). The incidence of delayed gastric emptying was significantly higher in the PPPD group compared with the PHRSD group (P < 0.01). Endocrine pancreatic function, measured by fasting blood glucose levels and HbA1, levels was unchanged in 94.28% of patients, in the PHRSD group, and in 87.87% in the PPPD group. Body weight was unchanged in 80% after PHRSD and in 59% after PPPD. Postoperative enzyme substitution was needed in 20% of patients after PHRSD and in 40% patients after PPPD. The 5-year survival rate was 100% in patients with benign IPMN and 42% in patients with invasive IPMN. Conclusion: PHRSD is a safe and reasonable technique appropriate for selected patients with branch-duct IPMN. The major advantages of PHRSD are promising long-term results in terms of pancreatic function (exocrine and endocrine) with important consequences in elderly patients. Long-term outcome was satisfactory without tumor recurrence in noninvasive carcinoma. PHRSD should therefore be considered as an adequate operation as an organ-preserving pancreatic resection for branch-duct type of IPMN located at the head of the pancreas. This prospective study from Nagoya (Japan) and Barcelona (Spain) evaluates the usefulness and long-term results with pancreatic head resection with segmental duodenectomy (PHRSD; Nakao’s technique) in patients with branch-duct type IMPT. The major advantages of PHRSD are promising long-term results in terms of pancreatic function (exocrine and endocrine) with important consequences in elderly patients. PHRSD should be considered as an organ-preserving pancreatic resection for the branch-duct type of intraductal papillary mucinous neoplasm located at the head of the pancreas.
Segmental resection
Pancreatic head
Pancreatic Disease
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Objective
To explore the clinical application value of central pancreatectomy in the treatment of benign and low-grade pancreatic malignant neoplasms.
Methods
Clinical data of 23 patients (9 males, 14 females, age range: 16-59 years old, median age: 46 years old), who underwent central pancreatectomy and were diagnosed as benign or low-grade malignant neoplasms by postoperative pathological examinations in Department of General Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University from January 2006 to December 2011 were retrospectively analyzed. Five cases were insulinomas, 4 cases were solid pseudopapillary tumors, 4 cases were mucinous cystadenomas, 3 cases were serous cystadenomas, 3 cases were intraductal papillary mucinous tumors, 2 cases were pancreatic cysts, 1 case was nonfunctioning endocrine tumor and 1 case was hemangioma. The informed consents of all patients were obtained and the ethical committee approval was received. All patients received central pancreatectomy under tracheal intubation general anesthesia. The pancreas was transected about 1 cm away from both sides of neoplasm. The proximal end of pancreas was closed by U shape-suture or mattress-suture, and the main pancreatic duct was ligatured separately. The distal end of pancreas was anastomosed with stomach or jejunum. The volume of intraoperative blood loss, blood transfusion, operation length, postoperative blood glucose level and pancreatic fistula were observed. The patients were followed up after operation about tumor recurrence, quality of life and blood glucose level.
Results
The median volume of intraoperative blood loss was 159 ml(50-400 ml). One case received blood transfusion during operation. The median operation length was 225 min(149-386 min). No severe complication was observed in all patients. Elevated blood glucose level was found in 1 case after operation and remitted after symptomatic treatment. Pancreatic fistula was found in 11 cases(48%) with 10 cases of grade A pancreatic fistula and 1 case of grade B pancreatic fistula. The patients with grade A pancreatic fistula were self-cured without any treatment. The patient with grade B pancreatic fistula was cured by peritoneal lavage and anti-infective treatment. The postoperative follow-up length was 6 months to 5 years with the median of 23 months. One case was lost to follow-up, the other 22 cases survived without tumor recurrence. One case suffered from elevated blood glucose level 6 months after operation. The patient received oral hypoglycemic agents for 1 year and then stopped, the blood glucose level was kept normal. Three cases failed to regain body weight within half a year after operation, but no symptoms of dyspepsia were observed and no exogenous pancreaticenzyme replacement was used.
Conclusion
Central pancreatectomy is a safe and reasonable procedure for patients with benign or low-grade pancreatic malignant neoplasms.
Key words:
Pancreatectomy; Pancreatic neoplasms; Pancreatic fistula; Hyperglycemia; Neoplasm recurrence, local
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To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage.Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage.Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) developed postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical significance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy.Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.
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Objective To investigate the risk factors for pancreatic fistula after pancreatoduodenectomy (PD). Methods Data of patients received PD in our hospital in the recent 6 years was analyzed. Risk factors for pancreatic fistula after PD were analyzed. Additionally, the independent risk factors were screened and included in a multivariate Logistic regression for analysis. Results A total of 202 cases were included in this analysis , among whom 26 cases had postoperative pancreatic fistula (12.87%). There were significant differences on terms of age, BMI, ASA score, pancreatic duct diameter and soft pancreas between the two groups (P0.05). A further multivariate Logistic regression revealed that the pancreatic duct diameter smaller than 3 mm and soft pancreas could be treated as the independent risk factors for postoperative pancreatic fistula (pancreas texture OR=4.90, 95%CI: 1.12～18.91,P=0.02; pancreatic duct diameter OR = 3.76, 95% CI:1.51 ～ 12.41,P=0.03). Conclusion Pancreatic duct diameter smaller than 3 mm and soft pancreas were the independent risk factors for postoperative pancreatic fistula after PD.
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【Objective 】The aim of the current study was to analyze factors which may affect the risk of pancreatic fistula formation.【Methods】All consecutive distal pancreatectomies prospectively registered in the Third Affiliated Hospital of Inner Mongolia Medical College database from 2001 to 2009 were included.Clini-cally relevant pancreatic fistula grades B and C,defined according to the International Study Group on Pan-creatic Fistula definition were assessed.The impact of patient,tumor,and surgery-related factors on the risk of pancreatic fistula formation were assessed by univariate and multivariate analyses.【Results】A distal pan-createctomy was performed in 51 patients(median age: 60 years;range: 31~75 years),23 of whom had malig-nant and 28 benign or premalignant disease.Pancreatic fistulas were diagnosed in 17(33.3%) of the patients.An additional three patients had a local abscess without apparent but assumed pancreatic leakage.Multivariate analysis showed that pancreatic fistulas occurred more frequently after hand suturing of the transection area versus the use of a stapler(OR: 41.2,95% CI: 3.36~486;P =0.004) and a large volume of the pancreatic remnant(greater,or equal to,34 cm3) increased the subsequent risk of pancreatic fistula(OR: 7.28,95% CI: 1.14~39.0;P =0.035).【Conclusions】Development of pancreatic fistula after distal pancreatectomy remains a challenge.The volume of the remaining pancreas and the technique of closure of the transected pancreas were found to affect this risk,thus allowing future preventive measures to be explored and evaluated in clinical tri-als.
Pancreatic fistula
Univariate analysis
Distal pancreatectomy
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To determine predictive factors of postoperative pancreatic fistula (POPF) in patients undergoing enucleation (EN). 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). 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. 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.
Pancreatic fistula
Univariate analysis
Pancreatic head
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Objective To evaluate the pancreaticojejunostomy procedures selection strategy after pancreaticoduodenectomy.Methods The clinical data of 305 cases who received pancreaticoduodenetomy at Shanghai Renji Hospital from Jan 2010 to Jan 2013 were retrospectively analyzed.For patients with pancreatic duct diameter≥3 mm,duct-to-mucosa pancreaticojejunostomy was applied(120 cases).For duct diameter ＜ 3 mm,modified Child pancreaticojejunostomy was applied to 80 cases when pancreatic stump was large,or binding pancreaticojejunostomy procedures was applied to 105 cases while pancreatic stump was small.Results The diameter of the pancreatic stump in modified Child group was significantly larger than that in the binding group (F =5.78,P ＜ 0.05).The overall incidence of pancreatic fistula was 11.1％ (34/305).There were no significant differences in the incidences of pancreatic fistula,peritoneal bleeding,abdominal infection,digestive dysfunction rate,the mean duration of hospital and the death cases among the three groups (x2 =1.51,2.78,1.16,3.75,1.94,F=2.13,P＞0.05).Conclusions Three different pancreaticojejunostomies based on the size of pancreatic duct and pancreatic stump are equally safe and effective as a reconstructive method after pancreaticoduodenectomy.
Key words:
Pancreaticoduodenectomy ; Anatosmosis, surgical ; Postoperative complications ; Pancreatic fistula
Pancreatic fistula
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Objective
To analyze the curative effect and prognosis of pancreatic ductal stone treated by pancreatectomy, pancreatic duct drainage or combined procedures.
Methods
The clinical data of 296 pancreatic ductal stone patients who received surgical treatment in First Affiliated Hospital of the Army Medical University between January 2008 and June 2017 were retrospectively analyzed. The cases were divided into pancreatectomy group (162 cases), pancreatic duct drainage group (104 cases) and combined procedures group (30 cases) according to their surgical procedures. The clinical characteristics and short-term and long-term outcomes of surgical treatment between the three groups were analyzed. Kaplan-Meier method was used to estimate the survival rate of no recurrence of pain after operation. Log-rank test and Cox-proportional hazard model were used to analyze the influencing factors on the recurrent pain free survival after surgery.
Results
The ratio of male patients was highest in pancreatectomy group, and the incidence of pancreatic exocrine insufficiency was highest in pancreatic duct drainage group. Of 296 patients, Ⅰ type pancreatic stone was most in pancreatectomy group and combined procedures group (80.2%, 70.0%), and Ⅲ type pancreatic stone was most in pancreatic duct drainage group(46.2%). Medium size pancreatic stone was most in pancreatectomy group (52.5%), and medium and large size pancreatic stone was most in pancreatic duct drainage group (80.8%). Obvious pancreatic atrophy was most in pancreatic duct drainage group.Pancreatic head swelling, bile ductal dilation or compression, combined with pancreatic or surrounding organ complications were most in pancreatectomy, and all the differences were statistically significant (all P<0.05). In the short-term effect, the overall rate of pain relief was 99.3%, and there was no statistical difference among three groups. Pancreatic duct drainage group was superior to the other two groups in terms of operative time, bleeding volume, postoperative hospitalization days and postoperative complications (all P<0.05), but the total incidence of residual stones after operation in drainage group (64.8%) was higher than that in the other two groups, and the difference was statistically significant (all P<0.05). In the long-term effect, there were no significant differences in pain recurrence, stone recurrence reoperation, postoperative pancreatic function, body weight and quality of life recovery among the three groups. The 1-year, 3-year and 5-year no recurrent pain after operation was 89.0%, 79.2% and 68.9%, respectively. Univariate and multivariate analysis showed that the course of CP ≥5 years(HR=2.113, 95% CI 1.160-3.848, P=0.014) and postoperative long-term alcohol consumption (HR=1.971, 95% CI 1.073-3.620, P=0.029) were independent risk factors affecting pain recurrence after surgery.
Conclusions
Surgery is still an important means for the treatment of pancreatic ductal stone. The short-term and long-term effect of pancreatectomy, pancreatic duct drainage and combined procedures for pancreatic ductal stones are definitely effective. However, none of the three methods can prevent the continued loss of pancreatic function in some patients. According to the preoperative clinical features, surgery strategy should be formulated individually, and the postoperative health guidance and follow-up should be emphasized, which can help to improve the prognosis of the patients with pancreatic ductal stones.
Key words:
Pancreatitis, chronic; Calculi; Surgical procedures, operative; Treatment outcome; Prognosis
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