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
Objective
To compare the clinical results of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and open spleen-preserving distal pancreatectomy (OSPDP).
Methods
From Jan 2014 to Aug 2017, the clinical results of 30 patients undergoing LSPDP were compared with those of 20 OSPDP patients.The postoperative pancreatic fistula rate was the main observation index.
Results
There was significant difference in operation time [(140.33±55.93)min vs. (182.71±43.51) min], blood loss [(175.61±180.78)ml vs. (253.51±176.06)ml], postoperative hospital stay [(6.16±7.22)d vs. (8.85±9.36)d], postoperative exhaust [(2.17±1.43)d vs. (3.10±1.89)d], and postoperative feeding time [(2.26±1.78)d vs. (3.42±2.01)d] between LSPDP and OSPDP. LSPDP group was better than OSPDP group (all P<0.05). The rate of postoperative pancreatic fistula (66.7% vs. 70.0%) and overall complications (80% vs. 90.0%) were not statistically different between the two groups. Pancreatic leakage occurred in 20 cases, lung infection in 1 case, peritoneal infection in 1 case and chylous leakage in one case in LSPDP group, while pancreatic leakage in 14 cases, lung infection in 2 cases, and peritoneal infection in 2 cases in OSPDP group, all were cured by conservative therapy.
Conclusions
LSPDP is a safe, effective, less traumatic and more economic surgical approach for benign cystic tumors located at the body or tail of the pancreas.
Key words:
Pancreatectomy; Pancreatic fistula; Spleen preservation; Laparoscopes
Pancreatic fistula
Distal pancreatectomy
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Objective
To investigates the role of duodenum and bile duct preserving pancreatic head resection (DBPPHR) in treatment of benign or low-grade malignant diseases located in the head of pancreas.
Methods
The clinical data of 31 patients who underwent DBPPHR between April 2012 to May 2016 in Zhejiang Provincial People's Hospital and Zhangzhou Municipal Hospital of Fujian Province were analyzed retrospectively.
Results
Of the 31 patients, 4 patients underwent laparoscopic DBPPHR. One patient in the open group was converted to pancreaticoduodenectomy. For the open group, the mean operation time was (165.3±63.6) min; the mean estimated blood loss was (258.1±156.9) ml; and the mean postoperative stay was (11.7±6.3) days. The postoperative complications included 1 reoperation due to postoperative bleeding, 1 bile leakage and 13 patients developed grade A pancreatic fistula (48.2%). For the laparosco-pic group, the mean operation time was 350.0 (280.0~450.0) min; the mean estimated blood loss was 425.0 (250.0~600.0) ml; and the mean postoperative stay was 14 days. Three patients developed post-operative pancreatic fistula (grade A). The pathological diagnosis were: 12 patients with pancreatolithiasis, 8 patients with serous cystadenoma, 4 patients with branched intraductal papillary mucinous neoplasm, 5 patients with neuroendocrine tumor and 2 patients with mucinous cystadenoma. The follow-up period was 1~48 month, and there was no patient with diabetes or diarrhea.
Conclusions
DBPPHR was safe and efficacious. It is less invasive to treat benign or low-grade malignant diseases located in the head of pancreas.
Key words:
Pancreatic duct stone; Cystic-solid lesion, pancreas; Chronic pancreatitis; Duodenum preserving pancreatic head resection; Laparoscopic surgery
Serous Cystadenoma
Pancreatic fistula
Mucinous cystadenoma
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Objective To analyze the influence of pancreatic fistula in middle segmental pancreatic resection and summarize the experience in dealing with the stump. Methods The data of 40 cases undergoing middle pancreatectomy were reviewed retrospectively to analyze the curative effect and pancreatic fistula between April 2003 and December 2009. Of these, 36 patients with benign cases outcomes were compared with 2 separate control groups, 44 pancreaticoduodenectomy (PD) and 26 extended distal pancreatectomy (EDP). Results The mean operating time of group MSP was 222 min, which was significantly shorter than that of group PD. The mean blood loss of group MSP was 316 ml,which was less than that of others. Otherwise, the postoperative nutritional status and blood sugar control in group MSP was superior to the other 2 groups. Through long-term follow-up,the patients in group MSP retained endocrine and exocrine function better. Only 1 patient developed new-onset diabetes mellitus after operation, and no patient required enzyme substitution. No lesion recurred. The rate of pancreatic fistula was highest(42％) ,but didn't result in the significant deference of overall discharge time with group PD and EDP. The pancreatic fistula level and the mean postoperative time in hospital didn't differ significantly from the other 2 groups.Conclusions Middle segmental pancreatectomy is a safe and feasible technique that is indicated for selected patients with benign or low malignant lesion in the neck and body of the pancreas. Though the rate of pancreatic fistula is higher,the risk of which is reduced by the marked curative effect It is very important to deal with the stump reasonably.
Key words:
Pancreatic neoplasms; Postoperative complications; Middle segmental pancreatic resection; Pancreatic fistula
Pancreatic fistula
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This study was conducted to explore the feasibility of partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of benign tumors of the pancreatic head (BTPH).From November 2006 to February 2009, four patients (three female and one male) with a mean age of 34.3 years (range: 21-48 years) underwent partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of BTPH (diameters of 3.2-4.5 cm) using small incisions (5.1-7.2 cm).Preoperative symptoms include one case of repeated upper abdominal pain, one case of drowsiness and two cases with no obvious preoperative symptoms.All four surgeries were successfully performed.The mean operative time was 196.8 min (range 165-226 min), and average blood loss was 138.0 mL (range: 82-210 mL).The mean postoperative hospital stay was 7.5 d (range: 7-8 d).In one case, the main pancreatic duct was injured.Pathological examination confirmed that one patient suffered from mucinous cystadenoma, one exhibited insulinoma, and two patients had solid-pseudopapillary neoplasms.There were no deaths or complications observed during the perioperative period.All patients had no signs of recurrence of the BTPH within a follow-up period of 48-76 mo and had good quality of life without diabetes.Partial pancreatic head resection with Roux-en-Y pancreatic jejunostomy is feasible in selected patients with BTPH.
Jejunostomy
Pancreatic head
Roux-en-Y anastomosis
Mucinous cystadenoma
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Although duct-to-mucosa pancreatojejunostomy has been considered safer than other techniques, this procedure is particularly difficult when the pancreatic duct is small. It has therefore become increasingly necessary to develop a simple mucosal sutureless pancreatojejunostomy technique to replace the conventional hand-sewing one. Two hundred fourteen patients who underwent mucosal sutureless pancreatojejunostomy were classified into two groups: those with a normal pancreatic duct diameter (less than 3 mm, n = 97) and those with a dilated pancreatic duct (3 mm or greater, n = 117). The rate of clinically significant pancreatic fistula (Grade B or C by the International Study Group on Pancreatic Fistula definition) among the patients as a whole was 8 per cent. The overall incidence of pancreatic fistula was significantly higher in the patients with a pancreatic duct diameter of less than 3 mm than in those with a pancreatic duct diameter of 3 mm or greater. However, the incidence of clinically significant pancreatic fistula did not differ between the groups (less than 3 mm, 11%; 3 mm or greater, 5%; P = 0.09). Grade C pancreatic fistula developed in one patient with a pancreatic duct diameter of less than 3 mm and in two with a pancreatic duct diameter 3 mm or greater. Although two patients required reoperation, all of the fistulas were cured and the postoperative mortality rate related to pancreatoduodenectomy was zero. Mucosal sutureless pancreatojejunostomy combined with pancreatic duct stenting is associated with a low rate of clinically significant pancreatic fistula even in patients with a small pancreatic duct diameter less than 3 mm.
Pancreatic fistula
Pancreatic juice
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Context It is well-known that a soft pancreatic stump is related to an increased incidence of postoperative pancreatic fistula (POPF) after pancreatic resection. Objectives To evaluate the presence of preoperative factors predicting soft pancreas in patients who underwent pancreaticoduodenectomy (PD) or left pancreatectomy (LP). Methods From January 2004 to June 2012, data regarding 208 consecutive patients whom underwent PD or LP were collected in a prospective database. For each patients we recorded sex, age, co-morbidities, BMI, ASA score, preoperative diagnosis, type of resection, characteristics of pancreatic remnant, pathological diagnosis and POPF rate. Univariate and multivariate analyses were carried out in order to evaluate the preoperative factors predicting a soft pancreatic stump. Results There were 102 (49%) female and 106 (51%) male with a mean age of 64.5±13.2 years. Co-morbidities were present in 128 (61.5%) patients; 64 patients (30.8%) were ASA II, 128 (61.5%) ASA III and 16 (7.7%) ASA IV. Mean BMI was 25.3±4.4 kg/m 2 . A pancreatic cancer or a chronic pancreatitis (CP) were suspected in 85 (40.9%) cases. One-hundred and twenty-five (60.1%) patients underwent PD and 83 (39.9%) LP. Pancreatic stump was soft in 129 (62%) cases and Wirsung duct was dilated in 55 cases (26.4%). Sixty-one patients (29.3%) had POPF (9.1% grade A; 19.2% grade B; and 1% grade C). Univariate analysis showed that a non dilated Wirsung duct (P 24 kg/m 2 , a non dilated Wirsung duct and a pancreatic lesion different from pancreatic cancer or CP can predict a soft pancreas and subsequently a major risk of POPF.
Pancreatic fistula
Univariate analysis
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Although much is known about the long-term outcome of patients undergoing left (distal) pancreatectomy for malignancy, comparatively little is known about the optimal management strategy for the residual transected pancreatic parenchyma and the divided pancreatic duct. Clinicopathological and operative factors that may contribute to postoperative pancreatic leak were evaluated.A retrospective review of the medical records of 126 patients who underwent left pancreatectomy between June 1990 and December 1999 at the University of Texas M. D. Anderson Cancer Center was performed.Indications for left pancreatectomy included pancreatic neoplasms (n = 42; 33.3 per cent), en bloc resection for management of retroperitoneal sarcoma (n = 21; 16.7 per cent), gastric adenocarcinoma (n = 14; 11.1 per cent), renal cell carcinoma (n = 11; 8.7 per cent) and other tumours or benign conditions (n = 38; 30.2 per cent). Pancreatic parenchymal closure was accomplished by a hand-sewn technique, mechanical stapling, or a combination of the two in 83, 20 and 15 patients respectively. No form of parenchymal closure was used in eight patients. Identification of the pancreatic duct and suture ligation was performed in 73 patients (57.9 per cent). Twenty-five patients (19.8 per cent) developed a pancreatic leak. For subgroups having duct ligation or no duct ligation, pancreatic leak rates were 9.6 per cent (seven of 73 patients) and 34.0 per cent (18 of 53 patients) respectively (P < 0.001). Multivariate analysis including clinicopathological and operative factors indicated that failure to ligate the pancreatic duct was the only feature associated with an increased risk for pancreatic leak (odds ratio 5.0 (95 per cent confidence interval 2.0 to 10.0); P = 0.001).Pancreatic leak remains a common complication after left pancreatectomy. The incidence of leak is reduced significantly when the pancreatic duct is identified and directly ligated during left pancreatectomy.
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Objective To investigate the risk factors and management of pancreatic fistula(PF) after (pancreaticoduodenectomy)(PD).Methods Two hundred and eighteen patients who underwent PD(consecutively) at our hospital from February 1994 to December 2005 were reviewed retrospectively.The(management) and outcomes of patients with PF were also evaluated.Sixteen factors which potentially affect the incidence of PF were analyzed with univariate and multivariate logistic regression model.Results Of the 218 patients,the overall morbidity and hospital mortality were 29.8%(65/218)and 4.1%(9/218)(respectively),and PE occurred in 30 patients(13.8%).PE was account for 46.1% in the overall(morbidity).Of the 30 patients with PE,25 had successful management conservatively with effective drainage including under B-ultrasonography guided or CT-guided percutaneous drainage.In the other 5 patients who had intra-abdominal abscess,two patients refused reoperation died of multiple organ failure,and one died of combination of intra-abdominal massive hemorrhage;the other two underwent reoperation for wide drainage,one survived,another died.The mortality of PF was 13.3%(4/30),which was account for 44.4% of overall mortality.Patients with PF had significantly higher morbidity(P0.01)and in-hospital mortality(P0.05)than those without PF.In univariate analysis,texture of the remnant pancreas,pancreatic duct size,drainage of pancreatic duct,duration of operation,perioperative nutrition support and use of prophylactic somatostatin analogues were related to occurrence of PF.Multivariate logistic regression analysis revealed that normal texture of the remnant pancreas and pancreatic duct size(≤3mm) were independent risk factors(OR=(9.394) and 4.232).Conclusions Pancreatic duct size and texture of the remnant pancreas are the independent risk factors of occurrence of PF after PD.If the optimal pancreatojejunal anastomotic technique is selected according to pancreatic duct size,texture of the remnant pancreas and experience of the surgeon,the incidence of PF can be reduced(effectively).Early diagnosis and management of PE and other severe complications associated with PF are important to improve its outcome.
Pancreatic fistula
Univariate analysis
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Parenchyma-sparing pancreatic resections are used in low-grade malignant tumors, but result in a high incidence of pancreatic fistula. Pancreaticojejunostomy to the site of resection might decrease the risk of pancreatic fistula. The purpose of this study was to evaluate the influence of pancreaticojejunostomy on the outcomes of parenchyma-sparing resections.The study group consisted of 21 patients (M/F = 4:17, mean age = 47 years). Local tumor resection with a pancreaticojejunostomy was performed in 11 patients and enucleation in 10 patients. Both groups were compared retrospectively with regard to perioperative variables.The operative time was significantly shorter in the enucleation group (median 180 min vs. 222 min, P = 0.005). The overall surgical morbidity was similar in both groups (81% vs. 70%, P = 0.64). The rate of clinically significant pancreatic fistula (64% vs. 40%, P = 0.39), hemorrhagic complications (27% vs. 10%, P = 0.59) and wound infection (18% vs. 40%, P = 0.36) were comparable in both groups. One patient died after central pancreatectomy. There were no new-onset cases of diabetes mellitus postoperatively.Local resection combined with pancreaticojejunostomy is an option to avoid extensive resection of the pancreatic parenchyma, but is still associated with a high incidence of pancreatic fistula which is comparable to that after enucleation.
Pancreatic fistula
Parenchyma
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