A novel technique for multiple pancreatectomies: removal of unicinate process of the pancreas combined with medial pancreatectomy

Preservation of normal pancreatic tissue in the surgical treatment of benign tumors of the pancreas offers advantages over more extended pancreatic resections. Removal of the uncinate process of the pancreas with the preservation of Wirsung's duct allows resection of a localized tumor within the uncinate process of the pancreas, maintains the flow of pancreatic juice into the duodenum, and preserves the dorsal part of the head of the gland. A pancreatic duct stent is particularly useful to identify the pancreatic duct (Wirsung's duct) intraoperatively to avoid injury which causes postoperative pancreatic leak. We have developed and employed a novel technique whereby tumors are completely excised, in combination with medial pancreatectomy, for the management of multiple mucin-producing tumors of the pancreas localized in the uncinate process and in the body of the pancreas. The cut end of the head of the pancreas is closed by interrupted sutures. Reconstruction for the distal pancreas is effected with a Roux-en-Y pancreatico-jejunostomy to the tail of the pancreas. Recovery was uncomplicated in our patient, with no endocrine or exocrine pancreatic insufficiency after 2-year follow-up. Received for publication on July 1, 1999; accepted on Aug. 17, 1999     

Partial pancreatic head resection for intraductal papillary mucinous carcinoma originating in a branch of the duct of santorini

We report partial pancreatic head resection of intraductal papillary mucinous carcinoma originating in a branch of the duct of Santorini. The tumor was located in the ventral part of pancreatic head at a distance from the Wirsung duct. Magnetic resonance cholangiopancreatography accurately showed the communication between the duct of Santorini and the cystic tumor, and was useful for determining the part of the pancreas to be resected. Both the duct of Wirsung and the duct of Santorini were preserved. Partial pancreatic head resection would play an important role in surgical management of low-grade malignant neoplasm.     

Use of bromthymol blue, a pH indicator, for detecting the pancreatic duct orifice after resection of the head of the pancreats

Postoperative pancreatography after resection of the head of the pancreas often provides important morphologic information. However, the orifice of the residual pancreatic duct is often difficult to detect endoscopically. We evaluated the use of bromthymol blue (BTB), a pH indicator that changes color from orange to a purplish-blue when exposed to alkaline conditions, to assist in the detection of the postoperative orifice. Pancreatography was performed in 46 patients who underwent resection of the head of the pancreas, and the utility of BTB in identifying the orifice of the pancreatic duct during endoscopy was studied. Twenty-one patients underwent endoscopy with the use of BTB. The series consisted of 8 patients who had received a pyloruspreserving pancreaticoduodenectomy with a pancreaticogastrostomy (PPPD-PG), 6 patients who had had pyloruspreserving pancreaticoduodenectomy with a pancreaticojejunostomy (PPPD-PJ), and 7 patients who had undergone a duodenum-preserving resection of the head of the pancreas with a pancreaticoduodenostomy (DPPHR-PD). The remaining 25 patients underwent conventional pancreatography without the use of BTB. This group consisted of 12 patients given a PPPD-PG, 6 patients who had received a PPPD-PJ, and 7 patients who had undergone a DPPHR-PD. The success of the postoperative endoscopic pancreatography was compared in the two groups. In all 21 patients, postoperative pancreatography with BTB resulted in a success rate of 100%, compared to success in only 10 patients who had conventional endoscopy (success rate 40%). This study demonstrated that the use of BTB significantly enhanced the success rate of endoscopic retrograde pancreatography after resection of the head of the pancreas.     

Ventral pancreatic resection for adenoma and low-grade malignancies of the head of the pancreas

The head of the pancreas can be anatomically divided into two sections, one drained by the duct of the Santorini system, and the other drained by the ventral pancreatic duct. This study was undertaken to determine whether independent resection of the ventral pancreas drained by the ventral pancreatic duct could be performed safely and effectively, by employing the following method in four patients. First, the duodenum and pancreas were sufficiently separated preserving the mesoduodenum and the posterior pancreaticoduodenal artery. Next, the main pancreatic duct was divided at the papillary portion, and sectioned at its junction with the duct of Santorini, ensuring preservation of the intrapancreatic bile duct. After the ventral pancreas had been detached from the glistening intrapancreatic bile duct, the ventral pancreas was connected with the dorsal pancreas by only the pancreatic parenchyma. The ventral pancreatic resection was completed following the incision of this border. A pancreatic fistula developed in one patient postoperatively, but this healed within 30 days. The hospital stay after surgery ranged from 35 to 58 days, and a good quality of life was maintained in all four patients. Thus, we conclude that ventral pancreatic resection can be safely performed and is especially valuable for treating the increasingly frequent adenomas and borderline malignancies in the main pancreatic duct system of the head of the pancreas.     

Pancreatic head resection with segmental duodenectomy for intraductal papillary mucinous tumors of the pancreas

Various modifications of organ-preserving pancreatic resections have been performed for intraductal papillary mucinous tumor (IPMT) of the pancreas. The aim of this study was to evaluate usefulness of pancreatic head resection with duodenal segmentectomy (PHRSD), which is one of the organpreserving pancreatic resections for IPMT. Pancreatic head resection with duodenal segmentectomy was indicated for the branch duct type of IPMT. Eight patients underwent PHRSD. The mean operative time was 390 minutes, and the mean blood loss was 1270 ml. Duodenal ischemia was prevented by preserving the duodenal branches of the gastroduodenal artery and the anterior inferior pancreaticoduodenal artery. Complications occurred in four patients: one with pancreatic leak, one with choledochoduodenal anastomotic stenosis, and two with delayed gastric emptying. However, no deaths occurred. The final pathologic diagnosis was adenoma in seven patients and carcinoma in situ in one patient. Six of eight patients had an adenoma with papillary growth in the main pancreatic duct. Postoperative pancreatic endocrine and exocrine functions were satisfactory. All patients were alive without recurrent disease at a median follow-up of 30 months. Pancreatic head resection with duodenal segmentectomy appears to be a useful procedure as an organ-preserving pancreatic resection for the branch duct type of IPMT, because this procedure allows a safe and complete resection of the pancreatic head without ischemia of the common bile duct and the duodenum.     

Pancreatic head resection with second-portion duodenectomy for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head region.

BACKGROUND: Preservation of arterial blood supply to the duodenum and common bile duct during duodenum-preserving total resection of the pancreatic head is a major problem. We describe here a new procedure comprising pancreatic head resection with second-portion duodenectomy to overcome it. METHODS: The procedure was performed in 18 patients with benign lesions, low-grade malignancies, or early stage carcinomas involving the pancreatic head and with carcinoma of the middle bile duct or the gallbladder. The technique preserves the third portion of the duodenum by conserving the anterior inferior pancreaticoduodenal artery. The second portion of the duodenum is divided, followed by division of the lower bile duct and pancreatic neck. After resection followed by duodenoduodenostomy, there is a choice of two procedures: type A, pancreaticoduodenostomy and choledochoduodenostomy; or type B, pancreaticojejunostomy and hepatodochojejunostomy. RESULTS: There were no operative or hospital deaths (type A, 6; type B, 12). Postoperative complications occurred in 2 patients, but the others had an uneventful postoperative course. The quality of life of all patients has been satisfactory up to 36 months postoperatively. CONCLUSION: This procedure is a reliable option as an organ-preserving procedure for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head.     

Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure?

BACKGROUND: Less extensive resection of the head of the pancreas has been the procedure of choice recently for low-grade malignant neoplasms. The anatomical detail of the head of the pancreas is currently insufficient for segmental resection along the embryological fusion plane. METHODS: The anatomy of the head of the pancreas was analyzed in 31 consecutive autopsy specimens. An anterior (n = 10) or posterior (n = 10) segmentectomy of the head of each pancreas was performed along the macroscopically found fusion plane. The pancreatic arteries, the portal vein, the bile duct, and the pancreatic duct were visualized by injecting 3 silicon dyes of different colors. Another 11 specimens were examined by pancreatography before and after anterior (n = 5) or posterior (n = 6) segmentectomy. Eight of these 11 specimens were stained immunohistochemically to reveal the distribution of pancreatic polypeptide cells after segmentectomy. RESULTS: The cleavage between the anterior and posterior segments was discovered at the anterior inferior edge or at the posterior superior edge of the head of the pancreas. Anterior segmentectomy was accomplished while preserving the anterior and posterior pancreaticoduodenal arcades and the lower bile duct in the posterior segment. Posterior segmentectomy involved the removal of the lower bile duct and the posterior pancreaticoduodenal arcades. Pancreatography after segmentectomy showed the division of the ducts of Wirsung and Santorini with the peripheral branches. The immunohistochemical boundary of pancreatic polypeptide cells coincided with the surgical plane. These results showed the anterior and posterior segments were originated from the embryologically dorsal and ventral primordia, respectively. CONCLUSIONS: The current anterior or posterior segmentectomy of the head of the pancreas corresponded to the resection of the embryologically dorsal or ventral primordium, respectively. Anterior segmentectomy of the head of the pancreas might be a clinically applicable procedure; however, posterior segmentectomy involving the resection of the lower bile duct may be impractical.     

胰头区恶性肿瘤术后预后因素的研究进展

目的探讨包含壶腹部、胆管下段、胰头部、钩突部和胰颈部5个部位在内的胰头区恶性肿瘤术后的预后影响因素。方法对近年国内外有关该区域恶性肿瘤研究的文献结果进行归纳综述。结果壶腹部、胆管下段、胰头部、钩突部和胰颈部恶性肿瘤的预后与其病变部位、肿瘤直径、神经侵犯、血管侵犯、淋巴转移、病理学及组织学分型和切缘状态存在相关性。肿瘤位置及病理学分型的不同使其神经血管侵犯率、淋巴转移率和R0切除率存在差异。结论通过对肿瘤病变部位、肿瘤直径、神经侵犯、血管侵犯、淋巴转移、病理及组织学分型和切缘状态的总结分析,可提高对该区域肿瘤的临床预判准确性,有利于术前选择恰当的手术方式,术后制定更为合理的辅助治疗方案,提高人们对该区域肿瘤治疗的针对性,改善预后,以便更好地服务于临床工作。     

Duodenum-preserving resection of the head of the pancreas

Summary. Duodenum-preserving resection of the head of the pancreas was developed 25 years ago by Beger. This procedure is indicated in patients suffering from chronic pain in combination with inflammation of the head of the pancreas, common bile duct obstruction, pancreatic duct obstruction and/or obstruction of the retropancreatic vessels. At the Inselspital in Berne, 74 patients underwent this operation between 1993 and 1996. The median length of the operation was 380 min, with the need for transfusion in a median of 0 units (0–6). There was no postoperative mortality. Total postoperative morbidity was 13 %. One patient needed relaparotomy on day 17 for small bowel obstruction. Median length of hospital stay was 11 days. Postoperatively, two patients developed diabetes. Duodenum-preserving resection of the head of the pancreas represents an organ-preserving principle of surgery. This procedure treats the complications of chronic pancreatitis and provides long-term pain relief in more than 80 % of patients.      

胰腺钩突部根治性完整切除的新方法(附306例报告)

目的 探讨壶腹部周围恶性肿瘤患者胰腺钩突部根治性完整切除的技巧和方法.方法 2005年3月至2010年3月共连续完成了306例壶腹部周围恶性肿瘤的根治性胰十二指肠切除(RPD),男性169例,女性137例;发病年龄37～79岁,平均58岁.其中胰头颈部肿瘤151例,胆总管下端肿瘤48例,壶腹部肿瘤55例,十二指肠乳头部肿瘤52例.采用肠系膜上血管交换和胰腺钩突部血流控制法顺利完成所有患者的钩突部根治性完整切除;消化道重建均采用Child法;胰肠吻合均采用简化的捆绑式胰肠吻合术.结果 306例接受RPD的患者中,手术时间4～6 h,出血量200～600 ml,无术中及术后胰腺钩突部位的出血.术后患者出血发生率和病死率分别为3.3%和0.9%;术后胰瘘和胆瘘发生率分别为1.6%和0.6%,胆瘘、胰瘘患者均在B超引导下经穿刺引流等保守治疗后痊愈.随访至2010年3月,未见因肠系膜上血管周围肿瘤复发死亡患者.结论 采用肠系膜上血管交换和胰腺钩突部血流控制法可顺利完成壶腹部周围恶性肿瘤患者胰腺钩突部的根治性完整切除;并可减少术中出血量,缩短手术时间,减少肠系膜上静脉和(或)肠系膜上动脉的误切,可避免因胰腺钩突部残留引起的术后胰腺组织坏死脱落、感染和出血;还可从理论上减少肿瘤细胞播散的机会.     

Uncinatectomy: a novel surgical option for the management of intraductal papillary mucinous tumors of the pancreas

An intraductal papillary mucinous tumor (IPMT) is a rare cystic lesion of the pancreas, comprising only 1% of all pancreatic exocrine neoplasms. The prognosis for these lesions is typically favorable as compared with invasive ductal carcinomas. Nevertheless, the management of IPMTs involves surgical resection due to their malignant potential. When located in the pancreatic head, the conventional treatment for IPMT is pancreatoduodenectomy. Some authors have advocated limited pancreatectomy for low-grade IPMTs of the pancreas, thereby decreasing the morbidity of more extensive resection. In this report, we describe our technique of minimal pancreatectomy, whereby the uncinate process and associated branch duct were completely extirpated while preserving remainder of the pancreatic head, duodenum, and pancreatic ducts. The case presented underscores the feasibility and advantages of minimal pancreatic resection in the management of such tumors.     

Mucin-producing tumors of the pancreas: clinicopathological features, surgical treatment, and outcome

Mucin-producing tumors (MPTs) of the pancreas are increasingly being recognized. To evaluate the appropriate surgical treatment and predict the prognosis of MPTs, we performed a retrospective clinicopathological study in 51 patients, 27 with benign tumors and 24 with borderline/malignant tumors. Three of the malignant tumors showed stromal invasion and lymph node metastasis on histological examination. Of the 24 patients with borderline/malignant tumors, 2 died of MPTs and 4 died of other diseases. At the last follow-up, 35 patients were alive and well. The 5-year postoperative survival rate was 90% for patients with benign tumors, and 78% of these with borderline/malignant tumors. Five of the patients with borderline/malignant tumors had multicentric tumors. Three of these patients underwent resection of the rest of the pancreas, 5, 6, and 8 years, respectively, after the first operation. Extended radical resection is required for malignant MPT with invasion of the pancreatic stroma. We prefer to perform pancreatogastrostomy or Imanaga's procedure to allow examination of the body and tail of the pancreas by endoscopic retrograde pancreatography after resection of the pancreatic head. Careful follow-up for a long period may be the most prudent approach for detecting multiple MPTs in the residual pancreas after surgical treatment. Received for publication on June 30, 1998; accepted on March 3, 1999     

胰头十二指肠切除术71例分析

目的探讨如何提高胰头壶腹部恶性肿瘤的手术切除率和手术成功率。方法对1981～1997年收治的71例胰头十二指肠切除术患者的术后并发症、病死率及术前术中诊断情况进行分析。结果71例中恶性肿瘤61例,良性疾病10例（14．2％）,有并发症24例（33．8％）,死亡8例（11．2％）。结论要提高胰头壶腹恶性肿瘤的手术切除率和治愈率,关键是早期诊断、妥善的围手术期处理和精湛的手术技巧。     

Duodenal-preserving resection of the head of the pancreas and pancreatic head resection with second-portion duodenectomy for benign lesions,low-grade malignancies,and early carcinoma involving the periampullary region

HYPOTHESIS: Duodenal-preserving resection of the head of the pancreas (DPRHP) and pancreas head resection with segmental duodenectomy (PHRSD) can be alternatives to standard pancreaticoduodenectomy for benign periampullary lesions. DESIGN: Retrospective analysis of patients requiring surgery for benign and borderline malignant tumors of the periampullary region. SETTING: Tertiary care referral center. PATIENTS: Duodenal-preserving resection of the head of the pancreas (n = 8) and PHRSD (n = 7) were performed in 15 patients with a preoperative diagnosis of benign and borderline malignant tumors of the periampullary region (ie, 11 pancreas head lesions [2 intraductal papillary mucinous tumors, 4 serous cystadenomas, 2 insulinomas, 1 epidermal cyst, 1 metastatic renal cell carcinoma, 1 nonfunctioning islet cell tumor/parapaillary] and 4 duodenal lesions [3 adenomas and 1 adenocarcinoma]). MAIN OUTCOME MEASURES: Surgical factors (operation time and blood loss), postoperative complication, postoperative pancreatic insufficiency (eg, development of diabetes mellitus and steatorrhea or elevated stool elastase values), weight change, and recurrence of disease. RESULTS: No differences were noted in the mean operation time and estimated blood loss between the 2 procedures. Major postoperative complication constituted the following: bile duct stricture (n = 1) in DPRHP and delayed gastric emptying (n = 1) and postoperative bleeding (n = 1) in PHRSD. Newly developed diabetes mellitus occurred in 1 patient. Exocrine pancreatic insufficiency (steatorrhea) was observed in 1 patient after PHRSD. Patients with early duodenal carcinoma and intraductal papillary mucinous tumors with a borderline malignancy are still alive without evidence of recurrence. There was no hospital or long-term mortality. CONCLUSIONS: Duodenal-preserving resection of the head of the pancreas is recommended first for a benign or low-grade, early malignant pancreatic head lesion; PHRSD can be an option for a lesion of the ampullary-parapapillary duodenal area as well as the pancreatic head. Duodenal-preserving resection of the head of the pancreas can be converted to PHRSD if ischemia of the second portion of the duodenum occurs. We found benign periampullary lesions could be conservatively treated with DPRHP and PHRSD, which could substitute for classic pancreaticoduodenectomy.     

Resection of the head of the pancreas in three patients with anomalous arrangement or occlusive diseases of the major abdominal visceral arteries

We resected the head of the pancreas in three patients with occlusive diseases or anomalous arrangement of the abdominal visceral arteries. The first patient who was diagnosed with cancer of the head of the pancreas; pancreatoduodenectomy (PD) was performed. Preoperative celiac angiography showed no significant occlusion of the celiac axis, while superior mesenteric arteriography visualized the common hepatic artery, with delayed retrograde filling. At the completion of the PD, an unsuspected atherosclerotic celiac occlusion was identified. Celiac reconstruction was performed. The second patient was diagnosed with cystadenoma of the head of the pancreas and had congenital ostial occlusion of the superior mesenteric artery (SMA), with dilated pancreaticoduodenal (PD) arcades as a celiacomesenteric collateral pathway. Duodenum-preserving resection of the head of the pancreas was performed, with preservation of the PD arcades. The third patient was diagnosed with cancer of the common bile duct, and exhibited a replaced common hepatic artery that arose from the SMA and formed PD arcades. PD was performed, with revascularization of the common hepatic artery. Following surgery, the three patients have done well for 18, 27, and 9 months, respectively. Careful preoperative investigation to identify abnormalities of the visceral arteries is necessary before resection of the head of the pancreas is performed.     

The surgical treatment of pancreatic disease

Periampullary carcinoma and chronic pancreatitis are the most frequent indications for operations on the pancreas. Exploration and resection by pancreaticoduodenectomy is the preferred method of treatment for carcinoma of the periampullary region when the malignancy is localized to this area and when it does not invade the superior mesenteric vein. A direct anastomosis of the remaining pancreatic duct to the side of the jejunum is performed when possible. Total pancreatectomy has been utilized for extensive carcinomas of the pancreas and for early lesions with an essentially normal pancreatic parenchyma to avoid the hazards of the pancreaticojejunal anastomosis. Chronic pancreatitis has been treated by various operative procedures. Duct stenosis and calculi, fibrosis and inflammation, and occasional pseudocyst formation commonly occur in the head of the gland. This area seems to act as a site of origin and perpetuation of the disease process. Proximal pancreatic resection by pancreaticoduodenectomy is being performed more frequently with anastomosis of five to 15 per cent of the pancreatic tail to the jejunum. Diabetes may be prevented and some external pancreatic enzyme function may thereby be preserved. In any pancreaticoduodenectomy, preservation of the entire stomach and first portion of the duodenum and intact pylorus should be considered. Preliminary observations suggest that the presence of an intact stomach and a functioning pylorus tend to lessen the digestive disturbances following this resection. After total pancreatectomy, further efforts should be made to extract and regraft the patient's viable islet of Langerhans cells from the excised pancreas. A reliable method of restoring insulin production would extend the use of total pancreatectomy for both malignant and benign pancreatic disease.     

Complete duodenum-preserving resection of the head of the pancreas with preservation of the biliary tract

A complete resection of the head of the pancreas, with preservation of the duodenum and biliary tract was performed for 14 patients: 8 with chronic pancreatitis, 3 with mucin-producing cancer of the head of the pancreas, 2 with pancreas divisum, and 1 with cystadenoma of the head of the pancreas. With our technique, duodenal blood flow is maintained, and no pancreatic parenchyma is left on the duodenal side. For these patients, a pancreaticoduodenostomy without resection of the digestive tract was provided; however, for those in whom an anastomosis between the caudal side of the pancreas and the duodenum was too difficult, due to distance, a pancreaticojejunostomy, using a Roux-en-Y jejunal loop, was performed as an alternative method. The digestive tract was reconstructed by a pancreaticoduodenostomy in 8 patients and by a pancreaticojejunostomy in the remaining 6. The operation time for the former procedure was 5h, and for the latter, 5h and 40 min; the mean blood loss in both groups was similar, being 926 and 940 ml, respectively. The successful results in all cases indicate that maintenance of the duodenal blood flow is significantly related to complete resection of the head of the pancreas. Thus, it appears that the use of Kocher's maneuver should be avoided and that the preservation of the posterior superior pancreaticoduodenal artery is important.     

Laparoscopic resection of uncinate process of the pancreas

Background  Solid pseudopapillary neoplasm of the pancreas is an uncommon but distinctive pancreatic neoplasm with low metastatic potential [1]. Therefore, whenever feasible, an organ-preserving operation should be performed. As previously reported, women with solid pseudopapillary neoplasm of the pancreas may be best treated by more conservative procedures [2]. Recently, laparoscopic pancreatic resections became more common and are being performed in highly specialized centers. There are only six cases of laparoscopic resection for solid pseudopapillary neoplasm of pancreas published in the English literature and, to our knowledge, laparoscopic resection of uncinate process of the pancreas has never been reported [3–6]. This video demonstrates the technical aspects of a totally laparoscopic resection of the uncinate process of the pancreas in a patient with solid pseudopapillary neoplasm. Methods  A 26-year-old woman with a 4-cm solid pseudopapillary pancreatic neoplasm was referred for surgical treatment. According to preoperative echoendoscopy, there was a safe margin between neoplasm and main pancreatic duct. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, one 10-mm and three 5-mm, were used. At inspection, the inferior vena cava, transverse colon, duodenum, and pancreas are clearly identified. A Kocher maneuver was performed with complete exposure of pancreatic head and uncinate process. The uncinate process was dissected from the superior mesenteric vein and venous branches were divided between metallic clips or by use of laparoscopic coagulation shears (LCS; Ethicon Endo Surgery Industries, Cincinnati, OH, USA). Blood supply of the duodenum was preserved by ligature of small pancreatic branches from inferior pancreatoduodenal artery. Transection of pancreatic parenchyma was performed using laparoscopic coagulation shears, which is an effective tool for cutting the pancreas [7, 8]. Surgical specimen was removed through a suprapubic incision inside a retrieval bag. A hemostatic absorbable tissue (Surgicel; Ethicon Inc., Cincinnati, OH) was placed in the cutting pancreatic surface, and one round 19F Blake abdominal drain (Ethicon) was left in place. Results  Operative time was 180 minutes and blood loss estimated in 40 ml with no blood transfusion. Hospital stay was 4 days. The patient did not have postoperative pancreatitis or pancreatic leakage, and the abdominal drain was removed on the tenth postoperative day. Final pathology confirmed the diagnosis of solid pseudopapillary neoplasm of pancreas with free surgical margins. The patient was well and asymptomatic 2 months after the procedure. Conclusions  Laparoscopic resection of uncinate process of the pancreas is safe and feasible and should be considered for patients suffering from pancreatic neoplasms. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.