True Solitary Pancreatic Cyst in an Adult: Report of a Case

The differential diagnosis of cystic neoformations in the pancreas is challenging. We report a case of a true solitary cyst of the pancreas in a 26-year old woman. Abdominal magnetic resonance imaging and computed tomography showed a unilocular neoformation in the head of the pancreas, without obstruction of Wirsung's duct. We excised the cyst and performed Roux-en-Y loop pancreaticojejunostomy, but the patient suffered recurrent acute pancreatitis from Wirsung's duct stenosis. Thus, a new Roux-en-Y loop pancreaticojejunostomy was successfully done 6 months later. Histologically, the cyst was lined by cuboidal epithelium, immunohistochemically positive to anti-carbohydrate antigen 19-9 antibodies. To our knowledge, only 11 cases of solitary true cyst of the pancreas in adults have been reported, so the characteristics of this unusual entity are not well known. We propose a scheme for the differential diagnosis of cystic neoformations of the pancreas, starting from the histopathological definition of a true solitary cyst.     

Spleen-Preserving Distal Pancreatectomy Combined with Distal Gastrectomy for Distal Pancreatic Lesion and Gastric Cancer: Report of a Case

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein was recently devised as a feasible operation. We report the case of a patient who underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein, combined with distal gastrectomy, for gastric cancer and a distal pancreatic lesion. Thus, unnecessary total gastrectomy was avoided. The operative blood loss and operative time were 630 ml and 465 min, respectively. The patient's postoperative course was complicated by a minor pancreatic fistula, which required daily irrigation and drainage, but she recovered and was discharged from hospital. This case report demonstrates that spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein combined with distal gastrectomy can be performable synchronously and is a feasible alternative to avoid unnecessary total gastrectomy.     

保留脾脏的胰体尾切除术的选择与方法

目的研究保留脾脏的胰体尾切除术(SpDP)的可行性、安全性,探讨其选择及具体方法。方法对上海交通大学附属新华医院2004年1月至2007年12月期间施行的7例SpDP患者的临床资料进行回顾性分析。结果 6例成功施行保留脾血管的SpDP,1例成功施行部分脾血管切除的SpDP,手术时间(2.93±0.38)h,术中失血量为(392.86±109.65)ml。术后发生胰瘘1例,经保守治疗后好转出院。全组患者术后血小板计数最高值为(273±43.76)×109/L,术后住院时间为(17.86±8.07)d,住院期间无死亡病例。6例肿瘤患者术后随访(49.2±14.4)个月(30～70个月),未见肿瘤复发、转移征象。结论 SpDP是一种安全、可行的术式,对于胰体尾良性占位等合适的病例有一定的临床应用价值。     

Laparoscopic Spleen-Preserving Distal Pancreatectomy as Treatment for Nesidioblastosis after Gastric Bypass Surgery

Nesidioblastosis is characterized by hyperfunction of pancreatic islets caused by hypertrophic beta cells. Postprandial symptoms of hypoglycemia are the clinical presentation of the disease. A female patient with diabetes mellitus who underwent a Roux-en-Y gastric bypass began to present postprandial symptoms of hypoglycemia. There was no radiologic (MRI) evidence of insulinoma. Selective arterial calcium-stimulation test identified hyperfunction only in the splenic artery. Laparoscopic spleen-preserving distal pancreatectomy was performed.The patient has been entirely free of any postprandial symptoms for 10 months after the partial pancreatectomy.     

Robotic Spleen-Preserving Distal Pancreatectomy. A Case Report

Distal pancreatectomy (DP) is the removal of the pancreatic tissue at the left side of the superior mesenteric vein and it is traditionally approached by an open or laparoscopic exposure. Preservation of the spleen is optional but appears to have a better immunological outcome. We present the case of a 53-year old patient with a 2.4/2.2 tumor located in the tail of the pancreas, with high tumour marker values for whom we decided to perform a robotic spleen-preserving distal pancreatectomy (RSPDP). The postoperative outcome was satisfactory. In conclusion, we recommend this type of approach for small pancreatic tail lesions.     

Decreasing Pancreatic Leak After Distal Pancreatectomy: Saline-coupled Radiofrequency Ablation in a Porcine Model

Despite marked improvements in pancreatic surgery, the high incidence and morbidity of pancreatic leak after resection has remained unchanged. The objective of this study was to evaluate the role of saline-coupled radiofrequency ablation (TissueLink) as an alternative to traditional methods of stump closure in an animal model of distal pancreatectomy. Forty swine were randomized after pancreatic transection and remnant stump was either oversewn in a traditional fashion (control) or treated with the device alone (TissueLink). Animals were killed and necropsied at 3 or 5 weeks postoperatively. Primary endpoints were the development of a pancreatic fistula defined as dye extravasation from the remnant duct, presence of undrained amylase-rich fluid collections/abscess, and greater than threefold drain/serum amylase after the third postoperative day. The incidence of pancreatic leak in the TissueLink group was 5.5 vs 42% in the control group (p = 0.01). There were no differences in operative time or other clinical parameters measured. Histologic analysis of the remnant pancreatic stumps confirmed our results. These data support our hypothesis that saline-coupled radiofrequency ablation leads to obliteration of ducts with a resultant decrease in pancreatic leak and subsequent complications. This technology may play a substantial role in preventing this dreaded complication in the clinical setting. This study was presented at the Pancreas Club on May 21, 2006 and at the Society for Surgery of the Alimentary Tract during Digestive Disease Week on May 22, 2006 in Los Angeles, CA, USA, as a poster presentation.     

经脐单一部位腹腔镜胰体尾切除术的初步体会

目的探讨经脐单一部位腹腔镜胰体尾切除术的可行性。方法 2009年6月～2011年10月对8例胰体尾部良性病变施行经脐单一部位腹腔镜胰体尾切除手术,其中保留脾脏3例,联合脾切除5例。超声刀游离周围韧带及远端胰腺,切割闭合器将胰体尾及脾血管切断,标本经脐取出。结果 7例经脐单一部位腹腔镜胰体尾切除术成功,1例因胰尾囊肿与周围粘连严重中转为多孔手术。手术时间130～240 min,(155±38)min;出血量50～250 ml,(101.3±71.6)ml;住院时间6～9 d,(7.4±1.1)d。所有患者均无术后出血、静脉血栓、发热感染等并发症。1例持续性胰漏,开腹手术修补。术后脐部切口愈合良好,美容效果明显。8例术后随访3～28个月,(14.3±8.6)月,均恢复正常工作及生活,预后良好。结论对于有经验的腹腔镜外科医生,经脐单一部位腹腔镜胰体尾切除术是可行的,并具有极佳的美容效果。     

Laparoscopic and Open Distal Pancreatic Resection for Benign Pancreatic Disease

The aim of the study is to provide comparisons of the perioperative outcomes between open and laparoscopic distal pancreatic resection (DPR) for benign pancreatic disease. From 2002 and 2005, there were 28 patients (16 open, 12 laparoscopic) with a mean age of 52 who had presumptive diagnoses of benign pancreatic lesions. Pathology was neuroendocrine tumor (nine and five), mucinous cystic neoplasm (three and three), symptomatic pancreatic pseudocyst (two and two), and others (two and two). The mean operative time was 278 vs 212 min (p = 0.05), the estimated blood lost was 609 vs 193 ml (p = 0.01), and the success rate of preoperative intent for splenic preservation was 17 vs 62% (p = 0.08) in the open and laparoscopic groups, respectively. Two patients (16%) were converted to an open procedure. There was no perioperative mortality. The mean hospital stay and total perioperative morbidity were 10.6 vs 6.2 days (p = 0.001) and nine vs two events (p = 0.03) in the open and laparoscopic groups, respectively. Ten of 12 patients (83%) with laparoscopic DPR had adequate oral intake within 72 h post operatively in contrast to 2 of 16 (12.5%) patients in the open DPR group (p = 0.0001). Laparoscopic DPR is technically feasible, safe, and associated with less perioperative morbidity and a shorter hospital stay than open DPR. In centers with the appropriate expertise, laparoscopic DPR should be considered the procedure of choice for putative benign lesions of the pancreatic body and tail. Presented at the AHPBA Spring Meeting, Miami Beach, FL March 9–12, 2006 (oral presentation)     

Laparoscopic Donor Distal Pancreatectomy for Living Donor Pancreas and Pancreas–Kidney Transplantation

With the proliferation and expanding applications of laparoscopic techniques, we determined the applicability of the laparoscopic approach to living pancreas donation. We performed the first laparoscopic donor distal pancreatectomy in 1999. We herein present our initial experience with five hand-assisted laparoscopic donor pancreatectomies. Three donors underwent distal pancreatectomy alone; two underwent a simultaneous left nephrectomy. The mean donor age was 48.4+/-8.7 years with a body mass index of 23.7 kg/m2. The donor and recipient survival rate was 100% at up to 3 years of follow-up. There were no episodes of pancreatitis, leaks, or pseudocysts. All donors returned to their preoperative state of health and to work. None of the donors have required oral anti-diabetic medications or insulin. We conclude that laparoscopic donor distal pancreatectomy is a safe and efficient procedure; hand-assisted laparoscopic distal pancreatectomy appears to be preferable, because of the added margin of safety from increased tactile feedback and ease of pancreatic dissection. The procedure can be accomplished with a single 6-cm periumbilical incision and only two 12-mm ports, resulting in excellent cosmesis and high donor satisfaction.     

Absorbable Mesh Reinforcement of a Stapled Pancreatic Transection Line Reduces the Leak Rate with Distal Pancreatectomy

Pancreatic leak remains a significant cause of morbidity after distal pancreatectomy. We report the use of an absorbable mesh to reinforce a stapled pancreatic transection line for distal pancreatectomy. Forty consecutive distal pancreatectomies (33 open and 7 laparoscopic) were performed since the introduction of mesh reinforcement. We utilized an inclusive definition of pancreatic leak to critically evaluate the staple line reinforcement material. In addition, we compared the pancreatic leak rate for this case series with the antecedent 40 cases where mesh reinforcement was not available. In the prospective series there was 1 leak in 29 cases (3.5%) in which mesh reinforcement was utilized, and 4 leaks in 11 cases (36%) when mesh was not utilized (p < 0.005). The 12.5% leak rate for the 40 cases during the prospective period, compared favorably to the 27.5% leak rate for the 40 cases preceding the study period (p = 0.09). Twenty-nine cases receiving mesh compared favorably to the 23 stapled cases in the control series, reducing leak rate from 22 to 3.5% (p = 0.04). Mesh reinforcement of the stapled pancreatic transection line reduced the pancreatic leak rate after distal pancreatectomy. Mesh reinforcement was possible with open or laparoscopic resections. No complications were attributable to the use of absorbable mesh. This study was presented in part at the 2006 American Hepato-Pancreato-Biliary Association annual meeting, March, 2006, Miami Beach, Florida.     

保留脾脏的胰体尾部良性肿瘤切除

目的探讨保留脾脏胰体尾切除的可行性和安全性以及并发症预防。方法回顾性分析总结2009年1月至2011年12月行保留脾脏胰体尾切除术5例资料,其中保留脾脏血管的开腹保脾胰体尾切除3例,切断(或切除)脾脏血管的保脾胰体尾切除术1例,腔镜下保脾胰体尾部切除术1例。结果本组无手术死亡,术后均未发生胰瘘、脾梗死、脾脓肿及脾出血等。随访3～6月,无并发症发生。结论胰体尾部良性肿瘤,应首选保留脾脏的胰体尾切除方法,手术安全,效果好,且避免了脾脏的不必要切除。     

Kimura法保留脾脏的腹腔镜胰体尾切除术

目的探讨Kimura法保留脾脏的腹腔镜胰体尾切除术的安全性和可行性。方法回顾性分析2016年8月~2019年3月Kimura法保留脾脏的腹腔镜胰体尾切除术11例资料。均为胰体尾部单发病灶,直径2.0~5.0 cm,平均3.5 cm。结果11例手术均顺利完成,无中转开腹。手术时间125~185 min,平均155 min;出血量35~100 ml,平均65 ml,术中均未输注血制品;围手术期无死亡,无腹腔出血、B级或C级胰漏、脾梗死等严重并发症发生。术后住院6~12 d,平均7.8 d。11例随访1~32个月,中位数16个月,均未见肿瘤复发、转移及脾梗死。结论Kimura法保留脾脏的腹腔镜胰体尾切除术安全、可行。     

腹腔镜胰腺远端切除术26例

目的探讨腹腔镜胰腺远端切除术的安全性、可行性。方法2005年9月～2008年6月,对26例胰腺体尾部肿物行腹腔镜胰腺远端切除术。术前25例诊断为胰腺体尾部良性肿物,1例不除外恶性,肿物中位直径5cm（1.2～10cm）。结果所有手术均在全腹腔镜下完成。15例行保留脾脏的胰体尾切除（10例保留脾动静脉,5例未保留脾动静脉）,10例行胰体尾加脾切除,1例既往行胰体尾及脾切除者行胰体部切除。手术中位时间268.5min（129～400min）,中位出血量100ml（50～800ml）,术后中位住院时间9d（6～21d）。无胰漏或脾梗死发生,2例包裹性积液,均保守治疗治愈,1例引流管口感染。26例中位随访时间15.5月（1～35个月）,均无复发。结论胰腺体尾部良性肿物行腹腔镜胰腺远端切除术安全、可行。     

Efficacy of the Electrothermal Bipolar Vessel Sealer in Laparoscopic Spleen-Preserving Distal Pancreatectomy with Conservation of the Splenic Artery and Vein

Introduction  Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with conservation of the splenic artery and vein has recently been performed as a minimally invasive surgery to retain splenic function in the treatment of pancreatic diseases. As the branches of the splenic vessels are very delicate, division of these branches increases the risk of bleeding. Materials and Methods  To overcome this problem, we have used the electrothermal bipolar vessel sealer (EBVS) to divide branches of the splenic vessels in LSPDP while conserving the splenic vessels themselves. Results  The EBVS reliably provided excellent and safe hemostasis, minimizing the risk of serious blood loss. Conclusion  Use of the EBVS is safe and efficient in LSPDP with conservation of the splenic vessels.     

Laparoscopic Pancreatic Resections for Cancer: Pushing the Boundaries

Laparoscopic pancreatic resection (distal pancreatectomy, pancreaticoduodenectomy, including pancreaticoduodenectomy with vascular resections) for pancreatic ductal adenocarcinoma is a technically demanding procedure, and the available evidence from selected high-volume centers suggest it to be well within the oncological principles of surgery for cancer, though this remains to be proven in a randomized study. This review summarizes the present status of laparoscopic resections for pancreatic cancer.     

Preservation or Ligation of Splenic Vessels During Spleen-Preserving Distal Pancreatectomy: A Meta-Analysis

ABSTRACT

Purpose/aim: Spleen preservation distal pancreatectomy (SPDP) can be achieved by either splenic vessel preservation distal pancreatectomy (SVP-DP) or Warshaw technique (WT). Although studies comparing SVP-DP with WT have been reported, controversies exist. The aim of our study is to assess and compare the safety and feasibility of SVP-DP and WT. Materials and methods: Two authors searched the online database independently till April 30, 2017. Data extraction and quality assessment were performed independently by two authors. Short- and long-term outcomes of WT and SVP-DP were evaluated. Subgroup analysis was performed on laparoscopic surgery. Odds ratios (OR) with 95% confidence interval (CI) and mean difference (MD) with 95% CI were estimated. Results: A total of 664 patients from 11 retrospective cohort studies were included. Meta-analysis showed the WT group had a significantly higher incidence of splenic infarction (OR = 0.12; 95% CI: 0.07–0.20; p < 0.00001) and gastric/epigastric varices (OR = 0.11; 95% CI: 0.05–0.24; p < 0.00001). And more patients suffering from splenic infarction from WT group needed further splenectomy (OR = 0.13; 95% CI: 0.02–0.84; p = 0.03). While there was no difference between the two procedures in terms of pancreatic fistula (OR = 0.55; 95% CI: 0.25–1.19; p = 0.13), overall morbidity (OR = 0.87; 95% CI: 0.59–1.30; p = 0.50) and hospital stay (MD = ?0.45; 95% CI: ?1.73-0.82; p = 0.49). Conclusions: Due to relatively higher risk of postoperative splenic infarction, gastric/epigastric varices and Clavien–Dindo III–V complications, WT is not as safe as SVP-DP. However, well-conducted randomized clinical trials are still needed due to the limitations of current studies.     

Distal Pancreatectomy and Splenectomy: A Robotic or LESS Approach

Introduction:The role and application of robotic surgery are debated, particularly given the expansion of laparoscopy, especially laparoendoscopic single-site (LESS) surgery. This cohort study was undertaken to delineate differences in outcomes between LESS and robotic distal pancreatectomy and splenectomy.Methods:With Institutional Review Board approval, patients undergoing LESS or robotic distal pancreatectomy and splenectomy from September 1, 2012, through December 31, 2014, were prospectively observed, and data were collected. The results are expressed as the median, with the mean ± SD.Results:Thirty-four patients underwent a minimally invasive distal pancreatectomy and splenectomy: 18 with robotic and 16 with LESS surgery. The patients were similar in sex, age, and body mass index. Conversions to open surgery and estimated blood loss were similar. There were two intraoperative complications in the group that underwent the robotic approach. Time spent in the operating room was significantly longer with the robot (297 vs 254 minutes, P = .03), although operative duration (i.e., incision to closure) was not longer (225 vs 190 minutes; P = .15). Of the operations studied, 79% were undertaken for neoplastic processes. Tumor size was 3.5 cm for both approaches; R0 resections were achieved in all patients. Length of stay was similar in the two study groups (5 vs 4 days). There was one 30-day readmission after robotic surgery.Conclusions:Patient outcomes are similar with LESS or robotic distal pancreatectomy and splenectomy. Robotic operations require more time in the operating room. Both are safe and efficacious minimally invasive operations that follow similar oncologic principles for similar tumors, and both should be in the surgeon''s armamentarium for distal pancreatectomy and splenectomy.     

腹腔镜下保留脾脏的胰体尾切除术23例

目的探讨完全腹腔镜下保留脾脏的胰体尾切除术在治疗胰腺体尾部占位的安全性、可行性及操作技巧。方法2008年6月至2013年4月,我院对23例胰体尾良性肿瘤病人施行腹腔镜下保留脾脏的胰体尾切除术,男性7例,女性16例,平均年龄42.4岁。按Kimura法完成13例,按Warshaw法完成10例。结果全部23例无一例中转开腹。平均手术时间253 min;平均出血量245 ml;术后平均住院日7.3天;平均随访期46.3月。无一例复发。结论对胰体尾部的良性肿瘤行腹腔镜下保留脾脏的胰体尾切除术是安全可行的。     

Laparoscopic Treatment of a Huge Mesenteric Chylous Cyst

Mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. The preoperative diagnosis requires all the common abdominal imaging techniques, but usually the correct diagnosis may be made only at the operation stage or during the histological examination. The treatment of choice is the complete surgical excision that may be safely performed by laparoscopy. A 58-year-old man underwent laparoscopic excision of a huge mesenteric chylous cyst. The technique entails the perfect control of the major abdominal vessels running near the tumor and the complete sealing of the chylous and blood vessels to and from the cyst.