Management of left pancreatic trauma

Left pancreatic traumas (LPTs) are rare but serious lesions occurring in 1 to 6 per cent of abdominal trauma patients and mainly resulting from blunt traumas. LPT severity is primarily dependent on the associated injuries and secondarily related to main pancreatic duct injury responsible for complications: acute pancreatitis, pseudocysts, pancreatic fistulas, or abscesses. The guidelines for blunt LPT management can be presented as follows. In case of emergency laparotomy, pancreas exploration is mandatory to detect pancreatic duct lesions. In the absence of main pancreatic duct lesions, simple drainage is advocated. In case of distal injury to the main pancreatic duct, a left pancreatectomy is mandatory. In the absence of initial laparotomy, the diagnosis is more and more based on CT and magnetic resonance cholangiopancreatography, which tend to replace endoscopic retrograde cholangiopancreatography (ERCP) as a first-intent diagnostic modality. In case of distal injury to the main pancreatic duct, spleen-preserving distal pancreatectomy is recommended. In the absence of main pancreatic duct lesions, nonoperative treatment is advocated. When LPTs are discovered at the time of complications, pancreatic fistulas and/or pseudocysts are associated with main pancreatic lesions, which can be treated by pancreatic duct stenting at ERCP and/or internal endoscopic cystogastrostomy. However, in such cases, spleen-preserving distal pancreatectomy remains the treatment of choice. Pancreatic ductal lesions resulting from LPT have to be diagnosed early to avoid late complications. Distal pancreatectomy remains the treatment of choice in case of severe pancreatic ductal lesions because the role of ERCP stenting and endoscopic techniques needs further evaluation.     

Ductal branch-oriented minimal pancreatectomy: Two cases of successful treatment

Two patients with intraductal papillary-mucinous adenoma of the pancreas were successfully treated by ductal branch-oriented minimal pancreatectomy. We propose this novel less invasive ductal branch-oriented pancreatectomy, as indicated for benign ductal ectasia of the pancreas. The cystically dilated branch duct is identified by intraoperative ultrasonography, intraoperative balloon pancreatography, and injection of indigocarmine into the cyst. The cystically dilated branch is resected from the surrounding pancreas together with minimal removal of the pancreatic parenchyma. The communicating duct and cutting margins are tightly ligated to prevent pancreatic juice leakage and fistula. A drainage tube is placed in the main pancreatic duct whenever possible. Histopathologic examination of the transected branch duct is necessary to check for mucosal extension of dysplastic epithelium. This ductal branch-oriented minimal pancreatectomy is the least invasive pancreatectomy and a suitable operation for branch-type ductal ectasia of the pancreas, which is usually benign. Received for publication on Jan. 5, 1998; accepted on April 3, 1998     

Nonfunctioning pancreatic endocrine tumor with extension into the main pancreatic duct: report of a case

Pancreatic endocrine tumors (PETs) rarely involve the main pancreatic duct. We report a case of malignant nonfunctioning pancreatic endocrine tumor (NFPET) with prevalent intraductal growth. A 47-year-old woman was referred to us after ultrasonography at a routine health check showed diffuse swelling of the pancreas. Preoperative imaging showed a solid mass in the tail of the pancreas and a bulging intraductal mass in the main pancreatic duct. We performed total pancreatectomy because the tumor occupied almost the entire lumen of the main pancreatic duct. Histological examination confirmed well-differentiated endocrine carcinoma. We review reported cases of the intraductal growth of NFPETs and discuss the pathogenesis of these unusual tumors.     

Closure of the distal pancreatic stump with a seromuscular flap

We describe herein our new method for transecting the pancreas and closing its stump in distal pancreatectomy, devised to decrease the risk of pancreatic fistula formation. With this technique, the pancreas is transected in such a way that a convex stump is left, whereby the pancreatic secretions from the parenchyma near the pancreatic stump are fully drained into the main pancreatic duct. A pedicled seromuscular flap of the stomach or jejunum is then used to cover the cut surface of the pancreas. This new technique provides tight closure of the pancreatic stump after distal pancreatectomy.     

慢性胰腺炎的治疗策略:内镜治疗与外科干预

慢性胰腺炎是由多种病因导致的胰腺慢性炎症性和纤维化病变,其基本治疗原则为去除病因、缓解症状、改善胰腺分泌功能不足及防治并发症等。目前,对于慢性胰腺炎治疗策略的探讨日趋增多,创伤递进式策略与早期外科手术干预是共性治疗理念。临床实践中,对于出现胰腺假性囊肿、胰管结石、胆管狭窄等并发症,内镜干预可作为优选治疗方式;无胰头部病变的主胰管扩张,可首选Partington术;合并胰头部病变,可行Beger术或Frey术;无主胰管扩张,应根据具体病变部位行胰腺切除术;全胰炎性病变或多发部位病变,可行全胰腺切除术。外科医师在诸多手术方式的选择中,应遵循个体化与多学科化的整体治疗理念与策略,尤其对于干预指征、时机及方式的掌控。笔者综合分析国内外研究进展,阐述慢性胰腺炎的内镜治疗与外科干预策略,以期进一步优化慢性胰腺炎病人的整体疗效。     

The role of magnetic resonance cholangiopancreatography (MRCP) after resection of the pancreas

Magnetic resonance cholangiopancreatography (MRCP) was performed in 35 patients to evaluate the feasibility of its use as a postsurgical imaging technique after resection of the pancreas. The surgical procedures performed were: pancreatoduodenectomy in 22 patients, segmental pancreatectomy in 1, distal pancreatectomy in 7, and pyroluspreserving pancreatoduodenectomy in 5. The pancreatic duct was shown in its entirety in 24 of the 35 patients (68.6%) and was partially visualized in 8 patients (22.9%), but the intrahepatic and extrahepatic bile ducts were visualized completely in all patients. Furthermore, MRCP was able to demonstrate lesions in 3 of 6 patients who had shown clinical evidence of recurrence. The visualization of the pancreatic and bile duct system was satisfactory despite anatomical changes brought about by resection of the pancreas. Thus, we conclude that MRCP is an appropriate follow-up screening test for patients with suspected abnormalities of the biliary and pancreatic duct system.     

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??Prevention and treatment for pancreatic fistula after distal pancreatectomy YANG Ming??WANG Chun-you. Department of Pancreatic Surgery, Union Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan 430022??China
Corresponding author: WANG Chun-you, E-mail: chunyouwang52@126.com
Abstract The incidence of pancreatic fistula after distal pancreatectomy is higher. Some of the main risk factors associated with pancreatic fistula after distal pancreatectomy include soft pancreatic texture, smaller pancreatic duct diameter and the handling of the pancreatic stump. Surgical techniques should been selected reasonably according to the pancreas texture and pathology, which is the key to decrease the incidence of pancreatic fistula. The optimal surgical method for a thick or edema pancreas is still a standardized hand-sewn closure technique of the pancreatic remnant. An anastomosis of the remnant to the intestine should be considered to prevent pancreatic fistula in the case of proximal duct obstruction associated with dilatation of the main pancreatic duct. The stapler technique should be recommended as the preferred method of pancreatic stump closure for a soft and flat pancreas. Most cases of pancreatic fistula could be cured by conservative treatment. Effective drainage plays an important role in the management of pancreatic fistula and in prevention of abdominal infection and bleeding. Pancreatic stent placement should be considered on the principle of failure of conservative treatment. Some of cases need fistulojejunostomy for refractory pancreatic fistulas.     

Favorable Response After Gemcitabine-Radiotherapy for Invasive Pancreatic Intraductal Papillary Mucinous Neoplasm: A Case Report

The efficacy of chemoradiotherapy for invasive pancreatic ductal carcinoma derived from an intraductal papillary mucinous neoplasm (IPMN) has not been established. The subject of the present report was a 53-year-old man admitted for the treatment of IPMN. The tumor, located in the pancreatic body, was of the mixed type of IPMN, and it involved the branch duct, where it was 38 mm in diameter, and the main duct, where it was 6 mm in diameter. Distal pancreatectomy was performed and the postoperative course was uneventful; however, histopathologic diagnosis revealed invasive ductal carcinoma with a positive surgical margin in the pancreatic duct. Although total pancreatectomy was recommended, chemoradiotherapy (50.4-Gy irradiation and gemcitabine) was preferred by the patient. At 9-month follow up, computed tomography and magnetic resonance imaging showed a cystic mass at the surgical margin of the pancreas. Endoscopic ultrasonography showed a 44-mm cystic lesion with nodules in the remnant pancreas, on the basis of which he underwent total pancreatectomy. Pathologic examination of the resected specimen revealed absence of the epithelium at the surgical margin of the main pancreatic duct, and malignant cells were not detected.     

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??Clinical application of endoscopic retrograde cholangiopancreatography in the treatment of pancreatic fistula after distal pancreatectomy: A report of 8 cases WU Wen-guang*??ZHANG Wen-jie??GU Jun??et al. *Department of General Surgery??Institute of Biliary Tract Disease??Xinhua Hospital??Affiliated to Shanghai Jiao Tong University School of Medicine??Shanghai 200092??China
Corresponding author??WANG Xue-feng??E-mail??wxxfd@live.cn
Abstract Objective To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic fistula after distal pancreatectomy. Methods A retrospective review of 8 cases with ongoing symptoms related to the pancreatic fistula after distal pancreatectomy was conducted from November 2010 to February 2014 at Department of General Surgery and Laboratory of General Surgery??Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Results ERCP was performed and demonstrated clear extravasation of contrast from the main pancreas duct at the site of pancreas transection in all eight cases. Pancreatic duct stents were placed in all patients at a median time of 15.8 days (range??9-26 days)postoperation and the pancreatic fistula resolved in all patients after a median duration of 16.0 days(range??12-25 days) from the index ERCP. Pancreatic duct stent were removed in all patients three months after discharge??and no patient has developed recurrent pancreatic fistula after stent removal. There was no episodes of pancreatitis??perforation??or other complications associated with pancreatic duct stent placement or removal. Conclusion ERCP with pancreatic duct stent may have a beneficial role in the management of patients with pancreatic fistula after distal pancreatectomy and the approach should be considered in patients not responsive to traditional management strategies.     

Simplified distal pancreatectomy with the Auto Suture stapler: preliminary clinical observations.

The most serious complication following distal pancreatectomy is the development of a pancreatic fistula or subphrenic abscess. These complications are particularly prone to occur following distal pancreatectomy for trauma. The injured pancreas is divided in a contaminated field, often in the presence of hemorrhage and partly devitalized tissues, in which identification and secure closure of the transected pancreatic duct may be difficult. A review of 12 surgical publications describing experience with 234 distal pancreatectomies performed for trauma found the average pancreatic fistula rate to be 13% an in some reports as high as 25% to 30%. In an attempt to decrease the high postoperative fistula rate after distal pancreatectomy, transection of the gland with the autosuture has been investigated. There are at least three theoretical advantages of this technique. The pancreas is transected through healthy tissue, the pancreatic duct is closed securely, and stainless steel sutures are used, which probably are more resistant to the development of infection than other suture material. This report describes a technique of distal pancreatectomy for both trauma surgery and elective surgery with the TA-55 Auto Suture stapler. TA-55 Auto Suture stapler, with 3.5 mm staples, is placed across the mobilized pancreas, and two rows of staggered stainless steel staples are laid down. The gland distal to the stapler then is amputated. At present this technique has been used in a total of 12 cases--four for trauma and eight during elective procedures. One fistula related to pancreatectomy performed with the Auto Suture stapler developed, for a complication rate of 8.3%. This preliminary experience indicates that a more widespread evaluation of this technique is indicated.     

Pancreatic duct anatomy in the corpus area: implications for closure and anastomotic technique in pancreas surgery

Purpose  

Pancreatic anastomosis and stump closure after partial pancreatectomy is the most critical step in pancreas surgery due to a high percentage of postoperative fistulas. Whether transverse cut side branches or the main pancreatic duct presents the source of this leak is still unknown. Thus, better understanding of the anatomy of the pancreatic duct system in the resection area could significantly improve the surgical technique and reduce complications.     

Primary repair of blunt pancreatic transection

A 19-year-old female patient with blunt traumatic transection of the pancreas underwent successful primary repair of the pancreas and main pancreatic duct. A literature review revealed 14 previously reported such cases. Primary repair of the main pancreatic duct is feasible in selected patients. A wider experience will help to determine the method's role among such established surgical procedures as distal pancreatectomy, internal drainage, and minimally invasive transpapillary stent techniques.     

ERCP辅助治疗胰体尾切除术后胰瘘8例报告

目的 探讨内镜逆行胰胆管造影（ERCP）辅助治疗胰体尾切除术后胰瘘的疗效。 方法 回顾性分析上海交通大学医学院附属新华医院普外科2010年11月至2014年2月间行胰体尾切除术后因胰瘘相关症状而采用ERCP辅助治疗的8例病人临床资料,并分析其术后疗效。结果 8例病人在ERCP下均见胰腺主胰管有明显的造影剂外渗出,均行胰管支架置入术,支架置入距手术日的平均时间为15.8（9～26）d,ERCP术后胰瘘愈合时间平均为16.0（12～25）d。所有病人的胰管支架在出院3个月后拔除,支架拔除后无胰瘘复发病例。治疗期间均未发生胰腺炎、穿孔及其他并发症。结论 对常规方法无效的胰体尾切除合并胰瘘病人,ERCP辅助行胰管支架置入可改善治疗效果。     

Organ-preserving surgery in chronic pancreatitis: the duodenum-preserving pancreatic head resection

Chronic pancreatitis is a inhomogeneous disease of multifactorial genesis and a variable clinical course. Upper abdominal pain is the leading clinical symptom of the majority of the patients. The primary treatment of these patients is conservative, but if the treatment fails in pain relief or organ complications occur surgical treatment is indicated. The most common organ complications due to chronic pancreatitis are stenosis of the common bile duct and the pancreatic duct, duodenal stenosis, stenosis of the portal vein with portal hypertension, pancreatic pseudocysts and the development of pancreatic fistula. Due to the pathophysiological concept of an elevated duct pressure as a source of pain, duct decompression by drainage procedures is the favored surgical procedure by many surgeons. Nevertheless, even in patients with a dilated pancreatic main duct, only half of the patients will benefit from drainage operations. Long-term severe upper abdominal pain and complications of the neighboring organs due to an inflammatory mass in the head of the pancreas should be indicative for resective procedures which should be organ-preserving as much as possible and take into account the endocrine function of the pancreatic gland. Simultaneous multiple organ resections like pylorus-preserving partial duodenopancreatectomy or total pancreatectomy are not necessary for a benign disease and should be only performed in patients with proven malignancy. The aim of the surgical procedure is to reduce pain and frequency of relapsing pancreatitis without impairing the endocrine function of the pancreatic gland.     

Repeated Pancreatectomy after Pancreatoduodenectomy

Background When pancreatic duct dilatation is found in the patient having undergone pancreatoduodenectomy (PD), observation is chosen in most cases. Similarly, recurrent tumor in the remnant pancreas of invasive ductal carcinoma (IDC) of the pancreas is seldom indicated for resection. We have aggressively performed repeated pancreatectomy for these cases and obtained good results. Methods Repeated pancreatectomy after PD was performed for three types of circumstances: (1) pancreatodigestive anastomotic stricture; (2) neoplasm after intraductal papillary mucinous neoplasm (IPMN); and (3) recurrence of IDC of the pancreas. Results Resection of anastomosis and reanastomosis was performed for pancreatodigestive stricture in four patients. Symptoms derived from pancreatitis in three patients resolved by the second operation and did not recur during follow-up. None of the four patients required pancreatic enzyme substitution because of clinically overt malabsorption, and the defecation frequency of the four patients was within twice a day. Mild diabetes mellitus has been identified in only one patient who had diabetes mellitus before the second surgery. Completion pancreatectomy and pancreatic tail resection was performed for recurrence in two patients and IDC in one patient, respectively, after PD for IPMN. Intrapancreatic recurrences of IPMN in two patients existed in the main pancreatic ducts. As CT revealed pancreatic duct dilatation but not intraductal tumors, recurrences were not correctly diagnosed before the second operation. Completion pancreatectomy was performed for recurrence of IDC in two patients. One patient who underwent completion pancreatectomy for recurrence of IDC survived 66/44 months after the first/second operation. Conclusion Repeated pancreatectomy should be performed for patients with pancreatodigestive anastomotic stricture to preserve remnant pancreatic function and for patients with neoplasm or pancreatic duct dilatation after PD for IPMN, and repeated pancreatectomy for recurrence of IDC might be indicated for selected patients.     

Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy

BACKGROUND: Pancreatoenterostomic leakage after pancreatoduodenectomy may be caused partly by pancreatic juice leakage from transected branch pancreatic ducts on the pancreatic cut surface that do not drain into the main pancreatic duct after pancreatectomy. METHODS:We devised a new technique of pancreatic transection using an ultrasonic dissector followed by duct-to-mucosa pancreatojejunostomy, in order to prevent pancreatoenterostomic leakage after pancreatoduodenectomy in patients with a soft pancreas and a small main pancreatic duct. During pancreatic transection, branch pancreatic ducts and blood vessels are adequately skeletonized and securely ligated. The pancreatic duct is anastomosed to the full thickness of the jejunum with four to six interrupted sutures. RESULTS: Ten patients with a nondilated pancreatic duct (2 to 3 mm) underwent pancreatoduodenectomy by the present method. During pancreatic transection, 24 to 35 ducts including the pancreatic ducts and blood vessels were skeletonized and ligated. Postoperatively, no patients developed pancreatojejunostomic leakage. The present method may prevent pancreatoenterostomic leakage after pancreatoduodenectomy.     

胰管结石的手术治疗

目的 探讨胰管结石的手术治疗方式.方法 对1997-2007年间24例胰管结石患者的手术治疗方式进行回顾性分析.结果 24例胰管结石中行胰管纵行切开取石、胰管空肠Roux-en-Y吻合17例,其中附加主胰管外引流2例,附加胆管空肠吻合3例,附加胰腺囊肿空肠吻合1例,1例术后并发胰肠吻合口出血,1例术后早期出现应激性溃疡,均经保守治疗治愈;胰十二指肠切除3例,1例并发吻合口出血,经保守治疗治愈;胰体尾切除2例,保留十二指肠胰头切除1例,胰管切开取石、Ⅰ期缝合1例,术后均无并发症.全组21例得到随访,17例效果优良.结论 胰管纵行切开取石、胰管空肠Roux-en-Y吻合是治疗胰管结石的合理术式,保留十二指肠的胰头切除和胰管切开取石、Ⅰ期缝合用于治疗胰管结石是可行的.     

MANAGEMENT OF TRANSECTED PANCREAS IN CHILDREN

The pancreas is the fourth most commonly injured intra-abdominal organ in children who sustain blunt abdominal trauma. Appropriate management of the injured pancreas has been controversial. With the advent of the computerized tomography scan, paediatric surgeons have tended to manage pancreatic injuries non-operatively. However. if pseudocysts develop. non-operative management may necessarily entail a long hospital course involving total parenleral nutrition. drainage procedures and attendant morbidity. The critical element in planning therapy is to determine the status of the pancreatic duct. We have recently encountered five children who suffered blunt pancreatic injury where the main pancreatic duct was determined to have been transected. These children underwent spleen preserving distal pancreatectomy with resultant shorter hospital stays and minimal long-term morbidity. We suggest that in children with pancreatic injury where the main pancreatic duct has been transected early operative management rather than non-operative therapy is the procedure of choice. Endoscopic retrograde cholangiopancreatography should be used to determine the status of the pancreatic duct. This modality can be both diagnostic and therapeutic in appropriate circumstances.     

Hand-assisted laparoscopic total pancreatectomy for a main duct intraductal papillary mucinous neoplasm of the pancreas

The laparoscopic approach to pancreatectomy entails a number of restrictions in performing major pancreatic surgery. This report describes a hand-assisted laparoscopic total pancreatectomy performed for a main duct intraductal papillary mucinous neoplasm of the pancreas. Dissection of the gastroduodenal artery and splenic artery, and the transection of the duodenum were done through the midline mini-laparotomy, while mobilization of the spleen and the pancreatic tail and body, and Kocher’s maneuver were performed using the hand-assisted laparoscopic approach. Furthermore, dissection of lymph nodes in the hepatoduodenal ligament, removal of the gallbladder, division of the hepatic duct, tunneling of the pancreas, and dissection of the pancreas from the superior mesenteric vein and superior mesenteric artery were possible to perform safely under a pure laparoscopic technique with an excellent laparoscopic view. The reconstruction procedures were performed through the mini-laparotomy. The hand-assisted laparoscopic total pancreatectomy should be considered for the treatment of selected patients because it has various advantages as one type of minimally invasive surgery.     

胰体尾切除术后胰瘘预防及处理

胰体尾切除术术后胰瘘发生率较高,主要与胰腺质地、胰管直径及胰腺残端的处理方式等有关。依据胰腺质地及病理检查结果合理选择胰腺残端处理方式是减少胰瘘发生的关键。胰腺肥厚或水肿质脆者胰瘘发生率较高,推荐残端手工缝合;如近端胰管存在梗阻并伴胰管扩张,建议行胰管-空肠吻合;对于胰腺扁平且质地柔软者,推荐使用直线切割闭合器。胰体尾切除术术后胰瘘经非手术治疗多可治愈。通畅引流可有效预防腹腔感染和出血的发生,是促进胰瘘愈合的关键。非手术治疗无效时可考虑胰管支架置入,部分难治性胰瘘病人须行窦道-空肠吻合。