Central pancreatectomy for benign or low-grade malignant pancreatic lesions - A single-center retrospective analysis of 116 cases

BackgroundCentral pancreatectomy (CP) is a parenchyma-sparing surgery for benign or low-grade malignant pancreatic tumors. This study aimed to evaluate the safety of the procedure and to analyze the long-term pancreatic function. The age-specific incidence ratio (IR) was calculated based on the incidence of diabetes mellitus in the general Italian population of Italy.Materials and methodsPatients submitted to CP from January 1990 to December 2017 at the Department of General and Pancreatic Surgery of the Pancreas Institute of Verona, Italy, were evaluated.ResultsThe final population was composed of 116 patients. There was a clear prevalence of females (74.1%), the mean age was 48 ± 15 years and the main indication for surgery was a pancreatic neuroendocrine tumor (45.7%). A pancreojejunal anastomosis was performed more frequently than a pancreogastric anastomosis (78.4% vs 11.6%). The mean length of stay was 20 ± 33 days.The overall abdominal complications rate was 62%. The frequency of clinically relevant postoperative pancreatic fistula (grades B and C) was 26.7%. The mortality rate was 0%. The rate of R1-resection was 0.8%, as was the recurrence rate. After a mean follow-up of 12.8 years ±6.5, 6 patients developed new-onset diabetes (NODM, 7.5%), and the IR was 1.36 (95%CI 0.49–2.96).ConclusionsCP is associated with high rates of abdominal complications, however, considering the amount of the normal pancreas that was spared, it might be indicated for selected benign or low-malignancy pancreatic tumors. CP patients have the same incidence of diabetes than the general population.     

中段胰腺切除术治疗胰腺颈体部肿瘤

目的探讨中段胰腺切除术在胰腺颈、体部肿瘤等占位性病变治疗中的安全性和有效性。方法回顾性分析1999—2006年在中国医学科学院肿瘤医院实施中段胰腺切除术的14例患者的临床资料。结果12例患者为胰腺良性肿瘤，其中微囊性腺瘤2例、实性假乳头状瘤5例、无功能性胰岛细胞瘤2例、胰腺良性囊腺瘤1例、海绵状血管瘤1例、浆液性囊肿1例，1例为中分化腺鳞癌，1例为慢性胰腺炎。术后胰瘘4例（28．6％），腹腔感染1例（7．1％）。无术后死亡，无胰腺内、外分泌功能障碍的发生。无肿瘤复发和转移。结论中段胰腺切除术应用于胰腺良性、低度恶性肿瘤的外科治疗，可有效地保留胰腺内、外分泌功能和脾脏功能，是安全、有益和有效的手术方式。     

Robotic-assisted central pancreatectomy: A minimally invasive approach for benign and low-grade lesions

BackgroundCentrally located pancreatic lesions are often treated with extended pancreaticoduodenectomy or distal pancreatectomy resulting in loss of healthy parenchyma and a high risk of diabetes and exocrine insufficiency. Robotic central pancreatectomy (RCP) is a parenchyma sparring alternative that has been shown safe and feasible [[1], [2]].MethodsIn this article, we describe our operative technique and the perioperative outcomes of a series of RCP for low-grade or benign pancreatic tumors.ResultsSix patients (5 female and 1 man) with a median age of 51.5 (44–68) years underwent a RCP for 2 serous cystadenomas, 2 mucinous cystic tumors, 1 neuroendocrine tumor, and 1 autoimmune pancreatitis. There were no conversions, intraoperative complications, or perioperative transfusions. Median operative time and was 240 (230–291) minutes and median blood loss was 100 (100–400) ml. The median hospital stay was 8 (5–27) days. There were no mortalities, reoperations, or readmissions. One patient developed a grade B pancreatic fistula which was successfully managed conservatively. All resections had free margins and the median tumor size was 2.5 (1.5–3.5) cm. After a mean follow-up of 46 months, no patients presented new-onset diabetes or exocrine insufficiency.ConclusionsRCP represents the least invasive option for both the patient and the pancreatic parenchyma. With a standardized technique, RCP results in low postoperative morbidity and excellent long-term pancreatic function. Although our results are excellent, POPF still represents the main complication of central pancreatectomy with an incidence ranging from 0 to 80% depending on multiple factors such as the surgeon, technique, and pancreatic texture.     

Metastatic tumors to the pancreas: The role of surgery

Pancreatic metastases from other primary malignancies are a rare entity. By far, the most common primary cancer site resulting in an isolated pancreatic metastasis is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma. Only few data on the surgical outcome of pancreatic resections performed for metastases from other primary tumor have been published, and there are no guidelines to address the surgical treatment for these patients. In this study, we performed a review of the published literature, focusing on the early and long-term results of surgery for the most frequent primary tumors metastasizing to the pancreas. Results for the Literature’s analysis show that in last years an increasing number of surgical resections have been performed in selected patients with limited pancreatic disease. Pancreatic resection for metastatic disease can be performed with acceptable mortality and morbidity rates. The usefulness of pancreatic resection is mainly linked to the biology of the primary tumor metastasizing to the pancreas. The benefit of metastasectomy in terms of patient survival has been observed for metastases from renal cell cancer, while for other primary tumors, such as lung and breast cancers, the role of surgery is mainly palliative.     

Pancreatic resection for metastatic tumors to the pancreas

BACKGROUND AND OBJECTIVES: The incidence of metastases to the pancreas is very low. The benefit of resection of pancreatic metastasis is poorly defined. In this review we evaluated the outcome of patients undergoing pancreatic resection for metastatic tumors to the pancreas. METHODS: Eight patients underwent pancreatic resection for metastatic tumor from December 1980 to June 2001. The primary cancer was colon carcinoma (n = 4), renal cell cancer (n = 2), duodenal leiomyosarcoma (n = 1), and malignant fibrous histiocytoma (n = 1). The median interval between primary treatment and detection of pancreatic metastases was 36 months. In two cases pancreatic metastases were synchronous with the primary tumor. RESULTS: Four patients underwent pancreatoduodenectomy, two distal pancreatectomy, one total pancreatectomy, and one median pancreatectomy. Associated resection of extrapancreatic lesions was performed in four patients, including two left hepatectomy and two left colectomy. There was no postoperative mortality, but two patients had a pancreatic and a biliary fistula, respectively. Survival averaged 23 months (range 14-42 months): four patients died for metastatic disease from 14 to 42 months after operation, while four patients are alive and well 14 to 31 months after surgery. CONCLUSIONS: Pancreatic resection for metastatic disease to the pancreas should be considered even in selected patients with limited extrapancreatic disease. Long-term survival or good palliation may be achieved.     

Long term outcome after minimally invasive and open Warshaw and Kimura techniques for spleen-preserving distal pancreatectomy: International multicenter retrospective study

BackgroundThe Warshaw (WT) and the Kimura (KT) techniques are both used for open or minimally invasive (MI) spleen preserving distal pancreatectomy (SPDP). Multicenter studies on long-term outcome of WT and KT are lacking.MethodsMulticenter retrospective study with transversal follow-up moment, including patients who underwent SPDP from 2000 to 2017 at three high-volume centers in Italy and the Netherlands. Primary endpoint was the incidence of short and long term complications. Patients without regular follow-up were interviewed about symptoms and complications.ResultsIn total, 164 patients were enrolled, 55 WT (33.5%) and 109 kT (66.5%), of which 95 (57.9%) MI. There was no 30-day mortality (0%).The only significant difference in short-term outcome was more delayed gastric emptying (DGE) after WT (9.1% vs 1.8%, p = 0.043). MI-SPDP was associated with less blood loss (median 150 vs 250 ml, respectively, p < 0.001), less DGE (0% vs 10%, p = 0.002), less abdominal abscesses (8.4% vs 18.4%, p = 0.03) and less splenic infarctions (3.2% vs. 13%, p = 0.042), than open SPDP. Long-term follow-up (median 41 months) was available for 111 patients (67.7%) of whom 18 (16.2%) had an SPDP-related long-term sequela, mostly perigastric varices (n = 11, 9%) but without differences between WT and KT. Less long-term sequelae were reported after MI as compared to open SPDP (12.5% vs 21.2%, p = 0.032).ConclusionsIn this international retrospective study, the WT and KT had comparable short- and long-term outcomes. If a KT does not seem feasible during SPDP, a WT is recommended, rather than performing a splenectomy. MI-SPDP was associated with less short- and long term complications as compared to an open SPDP.     

Granular cell tumor of the pancreas: A case report and review of literature

Granular cell tumors, also called Abrikossof's tumors, were originally described by Abrikossof A in 1926. The first case of a pancreatic granular cell tumor was described in 1975 and only 6 cases have been reported. We describe a case of granular cell tumor in the pancreas showing pancreatic duct obstruction. Because imaging studies showed findings compatible with those of pancreatic carcinoma, the patient underwent distal pancreatectomy. Histological examination showed that the tumor consisted of a nested growth of large tumor cells with ample granular cytoplasm and small round nuclei. The tumor cells expressed S-100 protein and were stained with neuron-specific enolase and periodic acid-Schiff, but were negative for desmin, vimentin, and cytokeratin. The resected tumor was diagnosed as a granular cell tumor. To our knowledge, this is the seventh case of Granular cell tumor of the pancreas to be reported.     

Solid pseudopapillary tumor of the pancreas with liver metastasis: Clinical features and management

Objective

To summarize the diagnosis and management of metastatic pancreatic solid pseudopapillary tumors (SPTs).

Methods

We retrospectively analyzed the clinical data of patients with metastatic pancreatic SPTs who were admitted to Peking Union Medical College Hospital from November 2001 to September 2013.

Results

A total of 187 patients with pancreatic SPTs were admitted. Four patients had liver metastasis, and all four were female patients aged 20–72 years old. Each patient with metastases underwent surgical resection with good postoperative recovery. The mean follow-up period was 30 months (range, 1–64 months). None of the patients had obvious recurrence or distant metastasis.

Conclusions

Pancreatic SPT with liver metastasis is very rare, and surgical resection is an effective treatment option. The principle of surgical treatment is to resect the primary and metastatic lesions as completely as possible. The affected patients require long-term postoperative follow-up.     

Survival impact of pancreatic resection for metastases in the pancreas: A retrospective multi-center study

BackgroundPancreatic metastases from other primary malignancies are rare.There is no clear evidence for a treatment strategy for this condition. The purpose of this study was to assess the clinical outcomes, including prognostic factors for pancreatic resection of metastatic tumors in the pancreas, through a retrospective review.MethodsData of 35 patients who underwent pancreatic resection for pancreatic metastasis between 2005 and 2020 in eight Japanese institutions were included in this study. Survival analyses were performed using the Kaplan–Meier method, and comparisons were made using the Cox proportional hazards model.ResultsThe median follow-up period was 35 months (range, 5–102 months). Median duration from resection for primary tumor to resection for metastatic pancreatic tumor was 10.6 years (range, 0.6–29.2 years). The 3- and 5-year survival rates after resection for metastatic tumors in the pancreas were 89% and 69%, respectively. In contrast, the 3- and 5-year disease-free survival rates after resection for metastatic tumors in the pancreas were 48% and 21%, respectively. Performance status ≥1 at the time of resection for metastatic tumors in the pancreas (HR: 7.56, p = 0.036) and pancreatic metastasis tumor diameter >42 mm (HR: 6.39, p = 0.02) were significant poor prognostic factors only in the overall survival.ConclusionsThe prognosis of pancreatic resection for metastatic tumors in the pancreas is relatively good for selected patients. However, because it is prone to recurrence after radical surgery, it should only be considered in patients with good PS.     

Prospects and applications of enucleation in solid pseudopapillary neoplasms of the pancreas

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare, low-grade, malignant neoplasms that are mostly seen in young women in the second and third decades of life and are quite uncommon in children. Standard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as exocrine and endocrine function. Enucleation of SPNs has been increasingly reported to be feasible and safe for preserving the normal physiological function of the pancreas, especially in teenagers and children. This review summarizes findings published in recent years on the enucleation of SPNs as well as potential future developments and directions. Enucleation has undoubtedly come to stay as an alternative surgical procedure for SPNs. However, many questions remain unresolved, and future directions toward the best surgical indication, the prevention and intervention of complications, especially pancreatic fistula, intraoperative resection margin safety assessment, and long-term oncology prognosis remain to be evaluated and should be explored in future clinical trials.     

胰腺囊性良恶性病变的CT诊断

目的分析胰腺囊性病变的CT表现, 提高胰腺病变的CT诊断准确率。方法 回顾分析经手术、病理证实的22例胰腺囊性病变的CT表现。螺旋CT机为TOSHIBA Aquilion 16多层螺旋CT机, 采用平扫和双期(动脉期, 门静脉期)增强扫描, 层厚7.0mm, 螺距1.0, 非离子型碘对比剂总量100mL, 注射流率3mL/s, 动脉、门脉期扫描分别为30s和70s。结果 胰腺假性囊肿12例, 平扫为囊状水样密度影, 增强扫描囊壁轻度强化, 内无分隔。胰腺脓肿4例, 平扫为类圆形液性密度, CT值为24Hu左右, 内见小气泡影, 增强扫描囊壁呈环形明显强化。胰腺囊腺瘤4例, 平扫为类圆形的水样或肌肉样密度影, 增强扫描囊壁分隔及壁结节呈不规则强化, 囊壁厚度＜2mm。胰腺囊腺癌2例, 平扫呈囊状水样密度及壁结节, 其内有分隔, 增强扫描囊壁、壁结节及分隔可见不规则明显强化, 囊壁厚度＞2mm, 1例伴有肝内转移及腹膜后淋巴结转移。结论 胰腺囊性病变有各自的CT特征, 但相似之处较多, 结合临床病史、必要时密切随访加以鉴别, 可提高胰腺病变的CT诊断准确率。     

Radiofrequency ablation of the pancreas: Two-week follow-up in a porcine model

Objective

To determine the impact of radiofrequency ablation (RFA) in pancreas after two-week follow-up.

Background

RFA is a novel treatment strategy in patients with unresectable locally advanced pancreatic cancer. The histological effect and risk of postoperative complications has not been systematically addressed in an in-vivo animal model.

Methods

In a porcine model (n = 6), RFA was performed via laparotomy with previously determined optimal settings using a bipolar probe with 30 mm active length, at 30 W until a total energy of 15 KJ was administered. The probe was inserted in the pancreas at 10 mm distance from duodenum and portomesenteric vessels (PMV). RFA nearby duodenum was performed under continuous duodenal cooling using 100 ml/min saline of 5 °C. During two weeks the clinical condition was evaluated daily including blood analyses. After two weeks, total pancreatoduodenectomy was performed and the obtained tissue histopathologically assessed.

Results

No mortality occurred during or after RFA. Two animals had a serum amylase increase more than threefold the pre-intervention value without clinical manifestations. Histopathologic assessment showed total ablation within the ablation zone, with loss of normal pancreatic acinar cell outlines and necrosis. In one animal, focal necrosis of duodenal submucosa was seen and in another animal focal fibrosis in the muscular layer of the superior mesenteric vein without clinical manifestations.

Conclusion

No major morbidity and no mortality was seen during a period of two weeks after RFA with previously validated RFA settings including duodenal cooling and 10 mm distance to PMV. Future clinical studies should confirm safety of RFA using the settings established here.     

Low-dose radiotherapy as a chemopotentiator of gemcitabine in tumors of the pancreas or small bowel: a phase I study exploring a new treatment paradigm

PURPOSE: To determine the maximum tolerated dose of upper abdominal low-dose fractionated radiotherapy (<1.0 Gy per fraction) given in combination with, and as a chemopotentiator for, gemcitabine. METHODS AND MATERIALS: Gemcitabine was given at 1,250 mg/m(2) at 10 mg/m(2)/min on Days 1 and 8 of a 3-week cycle. Low-dose fractionated radiotherapy was tested at two dose levels: 60 cGy per fraction and 70 cGy per fraction. Radiotherapy was given b.i.d. on Days 1, 2, 8, and 9. Four cycles were planned. RESULTS: Twenty-seven patients have been put on study. Ten patients have been entered in Phase I: 6 with metastatic/recurrent pancreatic carcinoma and 4 with unresectable pancreatic/small bowel carcinoma. Two of four patients at Dose Level 2 experienced dose-limiting toxicity. The overall radiographic response was 30%, and median survival was 11 months (range, 4-37 months). CONCLUSION: Low-dose fractionated radiotherapy to the upper abdomen is well tolerated at 60 cGy per fraction when combined with gemcitabine. Phase II evaluation is ongoing.     

Analysis of 50 cases of solid pseudopapillary tumor of pancreas: Aggressive surgical resection provides excellent outcomes

IntroductionThis study reports the clinicopathological characteristics and the perioperative and long-term treatment outcomes after aggressive surgical resection in solid pseudopapillary tumor (SPT) of the pancreas performed at a high volume center for pancreatic surgery in India.Materials and methodsWe analyzed a prospectively maintained database of the patients operated for SPT at Tata Memorial Hospital, India over a period of 11 years from February 2007 to February 2018.ResultsFifty consecutive patients operated for SPT, during the study period were included. The median age at presentation was 24 years. Majority of the patients (43/50) were female (86%). Disease was predominantly localized in the head and uncinate process of pancreas (66%). Median tumor size was 7.7 cm (Range 1.6–15 cm). Tumor extent was radiologically defined as borderline resectable or locally advanced in 48% (n = 24) patients. Forty-six major pancreatic resections were performed, which included 10 (21%) vascular resections, 2 synchronous liver metastasectomies, 1 multi visceral resection and 5 total pancreaticosplenectomies. Five of these resections were reoperations in patients deemed inoperable on exploration at other centers. R0 resection was achieved in 47 patients (98%). Postoperative major morbidity was 19% and there was no mortality. At a median follow-up of 29 months (Range, 1–121 months), all patients were alive without any recurrence.ConclusionAggressive complete surgical resection of SPT achieves excellent long-term survival. Surgery, especially for large and borderline resectable tumors, can be potentially complex and should be performed at high-volume centers to provide the best chance of cure.     

Validation of the ISGLS classification of bile leakage after pancreatic surgery: A rare but severe complication

IntroductionHepaticoenterostomy is an important step of reconstruction during hepatopancreatobiliary (HPB) surgery with a subsequent bile leakage rate of up to 5%. The International Study Group of Liver Surgery (ISGLS) proposed a severity grading system for defining bile leakage after HPB surgery, which has not been validated after pancreatic surgery in a large patient cohort. The present study aimed to validate the ISGLS definition for bile leakage in pancreatic surgery and to investigate the postoperative outcomes of bile leakage after pancreatic resections.Materials and methodsData from the prospectively maintained database for pancreas surgery were extracted for any type of pancreatectomy with hepaticoenterostomy between 2006 and 2019. The severity of bile leakage was graded according to the ISGLS definition. The influence of our standardized hepaticoenterostomy technique and of the complexity of the surgical procedure on the rate of clinically relevant bile leakages (B and C) were assessed in three different timeframes.ResultsBile leakage was detected in 152 of 5,300 patients (2.9%). Clinically relevant bile leakages included seventy patients with grade B and eighty-two patients with grade C bile leakages (46.1% and 53.9%, respectively). During the study period, the overall rate of bile leakage showed to be stable (from 3.5% to 2.4%). Patients with grade C bile leakage had a higher rate of postoperative wound infection (P < 0.001) and longer ICU stays and hospital stays compared to patients with grade B bile leakage (P = 0.03 and P < 0.001 respectively). These parameters were significantly higher in patients with late grade C bile leakage but were similar between patients with grade B bile leakage and early grade C bile leakage (<5th day POD). In the whole patients’ cohort, the 90-day mortality rate was 3.2% (174/5,300), with a rate of 25% in patients with bile leakage (38/152).ConclusionThe ISGLS classification is a valid method for classifying postoperative bile leak after pancreas surgery. Standardization of our hepaticoenterostomy technique resulted in a stable rate of bile leakage. Although rare, bile leakage following pancreas surgery is a severe complication that has a major impact on patient outcomes and contributes significantly to morbidity and mortality, even in the absence of POPF.     

Predictors of postoperative pancreatic fistula after splenectomy with or without distal pancreatectomy performed as a component of cytoreductive surgery for advanced ovarian cancer

ObjectiveSplenectomy with or without distal pancreatectomy is occasionally performed during cytoreductive surgery for advanced ovarian cancer. We investigated pre-, intra-, postoperative risk factors and predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients who underwent cytoreductive surgery for advanced ovarian cancer.MethodsWe investigated 165 consecutive patients with ovarian, fallopian tube, and peritoneal carcinoma categorized as stage III/IV disease, who underwent splenectomy with or without distal pancreatectomy as a component of cytoreductive surgery performed as initial treatment at Chiba University Hospital. Patient characteristics, clinical factors, and surgical outcomes were compared between those with and without CR-POPF.ResultsCR-POPF occurred in 20 patients (12%). There were no significant intergroup differences in the characteristics between patients with CR-POPF and patients without CR-POPF except for operative time, intraoperative blood loss, amylase (AMY) levels in drain fluid on postoperative day (POD)1 and POD3, and pancreatic stump thickness. Multivariate analysis showed that the POD3 drain fluid AMY level was the only significant risk factor and predictor of CR-POPF in patients who underwent cytoreductive surgery for advanced ovarian cancer. The receiver operating characteristic curve of the POD3 drain fluid AMY level, which predicted development of CR-POPF showed an area under the curve of 0.77, and the optimal cut-off value of AMY was 808 U/L. A pancreatic fistula did not occur in patients with POD3 drain fluid AMY levels <130 U/L.ConclusionThe POD3 drain fluid AMY level can be early diagnostic predictor CR-POPF after splenectomy with or without distal pancreatectomy for advanced ovarian cancer.