Section 6. Digestive organs: Minimally invasive endocrine surgery: laparoscopic resection of insulinomas

Pancreatic insulinomas are mostly benign and solitary tumors. Successful management of patients with insulinoma relies on accurate localization of the tumors and the use of appropriate surgical techniques. However, preoperative radiological imaging studies often fail to localize the insulinomas because of the small tumor sizes. Conventional intraoperative ultrasonography combined with palpation has been widely used as the best localization tool. Since contact ultrasonography, a new technique for localizing pancreatic lesions, became available as a laparoscopic study, several surgeons have utilized laparoscopy for not only localization but also resection of insulinomas. Previous reports of laparoscopic ultrasonography for intraoperative identification of insulinomas showed a 100% success rate in cases with insulinoma localized by preoperative imaging studies, but a less satisfactory rate in cases with occult insulinoma. Laparoscopic resection of insulinomas located in the head of the pancreas is often difficult because of its anatomical relationship with important adjacent structures such as pancreatic duct and mesenteric vessels. In contrast, insulinomas located in the body or tail of the pancreas are laparoscopically resectable even when they are in close proximity to the major pancreatic duct. Laparoscopic procedure is a feasible technique with low morbidity for surgical management of insulinomas. Accurate preoperative localization is essential for safe performance of this minimally invasive procedure.     

Successful laparoscopic distal pancreatectomy for a large solid pseudopapillary neoplasm: A case report

A 30‐year‐old Japanese woman presented at our hospital with a pancreatic tumor. Contrast‐enhanced CT revealed a tumor with a 12‐cm diameter in the pancreatic body and tail. In the preoperative setting, endoscopic ultrasound‐guided fine‐needle aspiration permitted a histopathological diagnosis of solid pseudopapillary neoplasm. Twhe patient underwent laparoscopic distal pancreatectomy with splenectomy. Our procedure involved three steps. Firstly, the splenic artery was occluded to block inflow of blood to the tumor. Then, we transected the neck of the pancreas using radical antegrade modular pancreatosplenectomy. Finally, hand‐assisted laparoscopic surgery allowed us to secure the operating field and easily handle the large tumor. This enabled us to accomplish laparoscopic distal pancreatectomy, and en‐bloc resection was completed. The patient was discharged without major complications. Laparoscopic distal pancreatectomy for huge solid pancreatic tumors can be completed safely.     

胰岛素瘤的诊断和外科治疗32例临床分析

目的 探讨胰岛素瘤的诊断及外科治疗方法.方法 回顾性分析我院收治的32例胰岛素瘤患者的临床资料,行单纯肿瘤摘除术19例,胰体、尾切除术10例,胰十二指肠切除术3例.结果 32例患者术前经腹部B超及增强螺旋CT初步诊断和定位20例,术中超声定位12例.肿瘤位于胰头部9例,胰体部15例,胰尾部8例.32例患者术后临床症状消失,包括2例胰瘘.术后病理示良性28例,恶性4例.结论 胰岛素瘤的主要临床表现为典型的Whipple三联征.根据临床表现和实验室检查行术前定性诊断不难,联合影像学检查有助于提高检出率,术中探查和术中B超是定位的主要手段.手术方式需根据肿瘤部位、大小、数目及深浅等情况具体决定.     

无功能性胰岛细胞肿瘤16例诊疗分析

目的：总结胰腺无功能性胰岛细胞肿瘤的诊治经验。方法：回顾分析近10年我院收治的16例无功能性胰岛细胞肿瘤的临床资料。男性5例，女性11例。平均年龄41．9岁。肿瘤位于胰头7例(44％)、胰颈部1例(6％)、胰体尾8例(50％)。良性5例(31．3％)，低度恶性6例(37．5％)，恶性5例(31．3％)。术前得到影像学定性诊断者7例(43．8％)，得到定位诊断13例(81．3)％。结果：14例接受了手术治疗。手术方式分别有肿瘤切除术、胰体尾切除术及肿瘤 部分胰腺切除术。主要并发症为胰瘘5例(35．7％)、腹腔脓肿2例(14．3％)、假性囊肿形成1例(7．1％)，无手术死亡，均获痊愈。结论：胰岛细胞肿瘤临床少见，易误诊和误治。CT和B超对定性和定位诊断准确率不高。加强对本病的认识并不断积累经验是诊断的关键。选择合理的手术方式和妥善的术后处理是预防并发症的关键。     

Arterial stimulation with simultaneous venous sampling for localizing insulinomas

Purpose: The present study aimed to assess the accuracies of arterial stimulation with simultaneous venous sampling (ASVS) in preoperative localization of insulinomas.Materials and Methods: A cohort consisting of 6 males and 14 females (median age, 48.5y; range, 28–62y) with pathologically proven insulinomas were included in this study. Selective angiographies were performed with the superior mesenteric artery (SMA), gastroduodenal artery (GDA), proximal splenic artery, and midsplenic artery in all individuals. Then ASVS procedures were followed after angiographies for these arteries. Clinical characteristics of the patient and the tumor number, location, and size were recorded. The accuracy of preoperative localization of insulinomas was tested.Results: A total of 22 tumors were identified by histopathological diagnosis. The mean size of the tumor was 1.40±0.60cm. Five tumors were in the head/neck region and 17 in the body/tail region. ASVS accurately localized 17/20 (85%) cases with only biochemical data and 19/20 (95%) cases with biochemical data and angiography images. Variant pancreatic arterial anatomy was revealed in 2 false cases with inferior pancreatic artery replaced by the superior mesenteric artery.Conclusion: ASVS was highly accurate in localizing insulinomas and should be performed in most of the patients with suspected insulinomas before the operation.     

Organic hyperinsulinism and endoscopic surgery

Summary BACKGROUND: Experience with minimally invasive surgery for organic hyperinsulinism is limited. No criteria for patient selection with special regard to sporadic, hereditary, multiple and malignant tumors have been defined. METHODS: The estimated success rate of endoscopic surgery was retrospectively calculated by analysing 34 consecutive patients with organic hyperinsulinism operated on by open surgery. A literature search was undertaken to better define indications for endoscopic procedures. Differences in postoperative outcome (morbidity) between endoscopic and open procedures were analysed. RESULTS: Twenty-eight of 31 patients (90%) with solitary insulinomas and one of three patients with multiple insulinomas were correctly localized preoperatively. Twenty-six enucleations (76%) and eight distal resections (24%) including one endoscopic tail resection were performed. Theoretically only 14 out of 34 patients (41%) would have been suitable for endoscopic surgery (8 enucleations and 6 patients for distal resections which were enucleated using an open approach). Pancreatic fistulas were documented in three patients (9%). Reviewing 34 publications, 49 enucleations, 36 distal resections and 15 conversions to open surgery were performed, showing a higher proportion of distal resections in endoscopic surgery. The spleen was preserved in 88% of cases. Fourteen fistulas occurred after enucleations. CONCLUSIONS: Only solitary insulinomas localized in the pancreatic tail or superficially in the body or head may be candidates for endoscopic procedures. Patients with multiple insulinomas, MEN-1 syndrome or malignancy should undergo open surgery.     

腹腔镜及其超声扫描判断胰头癌切除率的临床应用及意义

目的：探讨腹腔镜及其超声扫描技术(LUS)在判断胰头癌切除率中的应用及其价值。方法：对22例临床已确诊为胰头癌的病人在行剖腹探查手术前，采用腹腔镜超声进行前瞻性的肿瘤分期诊断，借此明确肝、腹膜有无微小转移，有无局部的血管侵犯(门静脉、肠系腰上动静脉、主动脉及下腔静脉)。结果：22例病人经腹腔镜及其超声扫描发现肝表面及腹膜转移癌灶3例，肝内转移灶1例，超声引导穿刺活检征实为胰腺炎1例，上述5例避免了开脱手术，余17例中8例发现腹腔、腹膜后及网膜有肿大淋巴结与局部血管或肿瘤本身与局部血管有侵犯，其中2例发现门静脉血栓，余9例腹腔镜超声检查提示可以手术切除。17例病人进行剖腹探查，8例成功进行胰十二指肠切除术。结论：腹腔镜及其超声扫描可以较为准确的判断胰头癌切除的可能性，可以避免不必要的剖腹探查以及由此而带来的并发症，有望成为胰头癌剖腹探查术前常规检查方法。     

Laparoscopy assisted middle‐segment–preserving pancreatectomy for multiple pancreatic neuroendocrine tumors: Report of a case

For multiple low‐grade malignant tumors located in the pancreatic head and tail, middle‐segment–preserving pancreatectomy (MSPP) is sometimes indicated. However, MSPP has rarely been performed laparoscopically. Here we report the first case of laparoscopic MSPP for multiple pancreatic neuroendocrine tumors diagnosed preoperatively under an endoscopic ultrasound‐guided fine‐needle aspiration biopsy. A 70‐year‐old man had multiple small tumors located in the pancreatic head, body and tail. Endoscopic ultrasound‐guided fine‐needle aspiration biopsy with immunohistochemical staining made a definitive diagnosis of a pancreatic neuroendocrine tumor (G1). To preserve the 5‐cm pancreas body, we successfully performed laparoscopic MSPP: subtotal stomach‐preserving pancreaticoduodenectomy followed by distal pancreatosplenectomy. Pathological examination revealed negative surgical margin after resection. Postoperative course was uneventful, and at 14 months after the operation, the patient remains tumor‐free. The patient has discontinued insulin supplement therapy but does use an oral hypoglycemic agent. Laparoscopy‐assisted MSPP, with reconstruction through a 6‐cm transverse incision, can be safely performed for selected cases of borderline and malignant lesions.     

腹腔镜超声在中央型肾肿瘤腹腔镜切除术中的应用价值

目的 探讨腹腔镜超声(laparoscopic ultrasonography,LUS)在中央型肾肿瘤腹腔镜切除术中的临床价值。方法 回顾分析行LUS协助肾肿瘤腹腔镜切除术的中央型肾肿瘤18例。LUS重点观察肿瘤的性质与大小、定位及肿瘤的肾表面投影,肿瘤距肾包膜、集合系统及肾门处肾血管的最短距离,肿瘤的血供。结果 18...     

Preoperative laparoscopic examination using surgical manipulation and ultrasonography for pancreatic lesions

BACKGROUND AND STUDY AIMS: Unnecessary laparotomies in patients with advanced pancreatic disease are unlikely to provide any benefits and may compromise both the quality and duration of survival. The purpose of this study was to determine the contribution of laparoscopy and laparoscopic ultrasound to the diagnosis or staging, or both, of pancreatic lesions. PATIENTS AND METHODS: Fifty-two patients were diagnosed preoperatively with pancreatic cancer. The diagnoses made by laparoscopic ultrasonography (LUS) were compared with those made prior to the operation. Laparoscopic visualization of the body of the pancreas was obtained via an infragastric approach. For the laparoscopic examination of the head of the pancreas, a retroduodenal approach was used. RESULTS: In 52 patients with cancer of the pancreatic head and body, unresectable findings were observed in 13 patients. Portal vein displacement without other unresectable findings was evident in six patients using LUS, and was confirmed at exploratory laparotomy in five patients. The surgical approaches were changed, with seven patients undergoing an open exploration for biliary drainage and the other six patients receiving endoscopic endoprostheses. In six of the 52 patients, LUS-guided needle biopsies and frozen-section examinations detected chronic pancreatitis (n = 4), a malignant lymphoma (n = 1), and an abdominal tuberculosis (n = 1), which were diagnosed preoperatively as pancreatic cancers and cysts. Only one patient undergoing the laparoscopic procedure had acute pancreatitis; this patient was treated conservatively. CONCLUSIONS: LUS, when combined with laparoscopic manipulations, may overcome many of the limitations of laparoscopy alone in the investigation of pancreatic lesions by providing an accurate diagnosis and assessment of the size and extent of the local dissemination.     

The importance of preoperative localisation procedures in organic hyperinsulinism — Experience in 67 patients

BACKGROUND: Preoperative localisation of insulinomas has been regarded unnecessary, given the significantly higher detection rates of intraoperative ultrasonography and bidigital palpation. These are mandatory before endoscopic surgery. METHODS: 67 patients operated on for organic hyperinsulinism were retrospectively analysed regarding tumour localisation within the pancreas, tumour size, histological findings, sensitivities of preoperative imaging methods, and surgical techniques. RESULTS: 59 patients (88%) had solitary insulinomas, four patients (6%) multiple insulinomas and four adult patients (6%) nesidioblastosis. Well-differentiated neuroendocrine tumours with benign behaviour (including four patients with nesidioblastosis) were diagnosed in 53 patients (79%), tumours with uncertain behaviour in nine patients (13%) and well-differentiated neuroendocrine carcinomas in five (8%). Tumours were evenly distributed throughout the pancreas. Endoscopic ultrasound localised tumours in 15 out of 21 patients (71%), conventional computed tomography (CT) in 7 out of 21 (33%), single-slice helical CT in 7 out of 12 (58%), multidetector CT in 5 out of 5 (100%), magnetic resonance imaging in 11 out of 13 (85%) and angiography in 15 out of 23 (65%). Various combinations of available methods achieved a sensitivity of 88% (49 patients true positive, 4 true negative, 7 false negative). Of 59 patients, solitary insulinomas were enucleated in 47 (80%), 11 patients underwent conventional open resection and one patient endoscopic distal pancreatic resection. Patients with nesidioblastosis or multiple tumours underwent pancreatic resections alone or in combination with enucleations. CONCLUSION: After biochemical diagnosis of organic hyperinsulinism, preoperative localisation is necessary for planning endoscopic pancreatic surgery, because of the possibility of multiple insulinomas, malignancy or nesidioblastosis in adults.     

胰腺CT可评估腹腔镜胰十二指肠切除术治疗胰头恶性肿瘤的效果

  目的  探讨腹腔镜胰十二指肠切除术对治疗胰头恶性肿瘤的效果，分析手术前后胰腺影像学特点。  方法  选取本院2020年1月~2021年6月收治的胰头恶性肿瘤患者110例，按手术方法的不同将患者分为两组，观察组:采用腹腔镜十二指肠切除术(n=61); 对照组:采用开腹十二指肠切除术(n=49)。分析两组患者围手术期指标、手术切除的完整性、炎性反应，并发症的发生率、术前与术后胰腺影像学特点。  结果  两组患者手术时间、手术切除的完整性及并发症的发生率差异无统计学意义(P > 0.05)，观察组术中出血量和住院时间均低于对照组，差异有统计学意义(P < 0.05); 观察组血清C-反应蛋白、白介素-6、肿瘤坏死因子-α水平低于对照组(P < 0.05); 术前CT显示胰头部可见不规则囊状低密度影，边缘分叶、内分隔、密度欠均匀，增强边界较清楚，术后有患者可见术区范围包裹性积液、局部密度稍高。  结论  腹腔镜胰十二指肠切除术治疗胰头恶性肿瘤可以减轻机体炎性反应，降低术中出血和缩短住院时间，其手术切除的完整性与开腹手术相当，且借助CT术前影像能有效指导手术过程和识别术后胰瘘等并发症。      

腹腔镜超声引导下冷循环射频治疗肝细胞癌的初步应用体会

目的 评估腹腔镜超声引导下射频消融治疗肝细胞癌的可行性、安全性及临床疗效.方法 对9例合并肝硬化的肝细胞癌患者进行腹腔镜超声引导下射频消融治疗.结果 9例患者共13个肿瘤均成功进行了腹腔镜超声引导下射频消融治疗.肿瘤直径0.7～4.2 cm,平均(2.4±1.1)cm.腹腔镜超声发现2个术前影像学未显示的病灶.3例患者同时进行腹腔镜胆囊切除术、粘连松解术以及腹壁转移灶切除术.术中无患者死亡及严重并发症发生.术后1个月增强CT显示12个病灶完全坏死.1例患者术后6个月死于肝功能衰竭,8例患者存活.结论 腹腔镜射频消融是一种安全可行的肝细胞癌治疗方法,腹腔镜超声在此过程中可准确地发现术前影像学漏诊的病灶.     

Preoperative localization of pancreatic insulinoma by super selective arterial stimulation with venous sampling

Although most insulinomas are small, they have been successfully detected by computed tomography and magnetic resonance imaging recently. However, preoperative localization of the insulinomas by arterial stimulation with venous sampling is crucial when they show atypical findings on these imaging modalities. We report a case of a large benign insulinoma located at the pancreatic tail; this tumor was diagnosed correctly by super selective arterial stimulation with venous sampling.     

Laparoscopy and biopsy in the diagnosis of malignant intra-abdominal tumors

Laparoscopic evaluation was effected in 298 patients with intra-abdominal tumors. Among 186 cases of liver tumor, 172 cases (92.5%) were diagnosed as tumors laparoscopically and malignant tissue was obtained in 71 cases (78.0%) out of 91 cases of liver tumors biopsied under laparoscopic guidance. Among 79 cases of pancreas tumors, laparoscopy led to the correct diagnosis in 32% (38 cases) of carcinoma of the head of the pancreas and 88% (41 cases) of carcinoma of the body and tail of the pancreas. The positive rate of biopsy in cases of tumor of the head of the pancreas and of the body and tail of the organ was 74.1% (20 out of 27 cases) and 84.6% (33 out of 39 cases), respectively. Laparoscopy supplemented by biopsy was useful for the diagnosis of submucosal tumors of the digestive tract and disseminated peritoneal tumors.     

胰岛素瘤的MSCT和MRI特征

目的 探讨胰岛素瘤的MSCT和MRI特征,提高对该肿瘤的定位和定性诊断能力.方法 回顾性分析经手术病理证实的18例胰岛素瘤患者的影像学资料,对12例行CT检查,1例仅行CT平扫,7例仅行三期动态增强扫描,4例同时行平扫和增强检查;16例行MR检查,其中4例同时行三期动态增强扫描;9例同时行CT和MR检查.结果 18例均为单发胰岛素瘤;8例发生在胰头(5例在钩突部),1例在胰颈,5例在胰体,4例在胰尾.CT平扫均为阴性;三期动态增强检查,11例中9例呈富血供表现,1例呈乏血供表现,1例漏诊.MR平扫肿瘤在T1WI上呈低信号,T2WI上呈等、稍高或混杂信号;4例行MR动态增强检查,均呈富血供表现.所有肿瘤边界清楚,均无血管、胰管和胆管受侵及肝转移表现.结论 胰岛素瘤有较为典型的MSCT和MRI表现,MSCT及MR检查对胰岛素瘤的定位和定性诊断有重要价值.     

Simultaneous laparoscopic left hemicolectomy and spleen‐preserving distal pancreatectomy for descending colon cancer with pancreatic invasion

Here, we describe laparoscopic colectomy with spleen‐preserving distal pancreatectomy for descending colon cancer with pancreatic tail invasion. A 69‐year‐old man with descending colon cancer staged as clinical state IIIC (cT4b [pancreas] N1M0) underwent definitive laparoscopic surgery that was performed in collaboration with surgeons who specialize in laparoscopic colorectal and hepatobiliary‐pancreatic laparoscopy. After the left colon was mobilized, tumor infiltration of the pancreas, but not the splenic vessels, was confirmed, and the spleen was preserved. The procedures were safely completed laparoscopically, without intraoperative and postoperative complications. Laparoscopic multivisceral resection could be a treatment option for similar patients but only when performed by multidisciplinary specialists.     

Pancreatic panniculitis and solid pseudopapillary tumor of the pancreas: A case report

Solid pseudopapillary tumor of the pancreas (SPTP), also known as solid and papillary epithelial neoplasm of the pancreas, is a rare pancreatic exocrine tumor that is difficult to diagnose before surgery. Pancreatic panniculitis is a rare type that occurs in less than 3% of all patients with pancreatic diseases. We here report a 19-year-old woman who presented with persistent left upper quadrant pain without obvious cause for 1 d. The patient also developed subcutaneous nodules involving lower abdomen bilaterally and lower limbs, and subcutaneous nodules were pathologically diagnosed as pancreatic panniculitis. Plain abdominal computed tomography revealed a soft-tissue mass in the body and tail of the pancreas, which was closely associated with the gastric wall. Contrast-enhanced ultrasound showed inhomogeneous echogenicity in the anterior pancreatic body, which had blurred parenchymal demarcation of the body and tail of the pancreas. Contrast-enhanced abdominal computed tomography revealed a mixed density mass with solid and cystic components in the body and tail of the pancreas, and the solid component was markedly enhanced. The lesion was pathologically diagnosed as SPTP after laparoscopic resection. Clinicians should be aware of the clinical manifestation, diagnosis, and treatment of pancreatic panniculitis and SPTP.     

晚期胰腺癌患者的肿瘤血供来源:218例患者的DSA评价

目的:探讨晚期胰腺癌患者的肿瘤血供来源。方法:对接受经导管动脉内灌注化疗(transcatheter arterial infusion chemotherapy,TAI)的218例晚期胰腺癌患者行数字减影血管造影(digital subtract angiography,DSA),以显示肿瘤血供来源。结果:晚期胰腺癌患者DSA造影可见血供来源146例(67.0%):其中,胰头颈部癌患者61例,其前3位供血动脉来源依次为:胰十二指肠动脉前上、后上弓(50例,82.0%),胰十二指肠动脉前下、后下弓(31例,50.8%),胰背动脉(14例,23.0%);胰体癌患者48例,主要供血动脉为:胰背动脉(35例,72.3%),肠系膜上动脉(9例,18.9%),胰大动脉(7例,14.6%);胰尾部癌患者37例,主要供血动脉为:胰尾动脉(29例,78.4%),胰大动脉(14例,38.8%),胰背动脉(3例,8.1%)。其中61例胰头颈部癌患者中有34例(55.7%)行DSA可见两支动脉血供。结论:胰腺癌患者的肿瘤血供与肿瘤位置相关:胰头颈部癌肿瘤血供大多来源于胰十二指肠动脉,胰体癌肿瘤血供多来源于胰背动脉,胰尾癌肿瘤血供多来源于胰尾动脉。     

胰腺囊性肿瘤的多层螺旋CT表现与病理对照

目的：探讨胰腺囊性肿瘤的多层螺旋CT（MSCT）表现和诊断价值。方法：回顾性分析21例经手术病理确诊的胰腺囊性肿瘤MSCT表现，其中浆液性囊腺瘤5例，黏液性囊腺肿瘤10例，导管内乳头状黏液瘤3例，实性假乳头状瘤3例。男5例，女16例，年龄14—78岁，平均52岁。使用4层和16层螺旋CT，平扫21例，同时增强20例。结果：①浆液性囊腺瘤多表现为多房囊性肿块，囊壁及分隔厚薄均匀，无壁结节。②黏液性囊腺肿瘤表现为多房或单房、边界清楚、无壁结节或壁结节小；而黏液性囊腺癌浸润周围组织、边界不清、壁结节较大。③导管内乳头状黏液瘤为多房或葡萄串样囊性肿块，与扩张的胰管相通。④实性假乳头状瘤边界清，可有较厚包膜，囊性成分与实性成分构成比例不一，实性部分逐步强化。结论：MSCT可以展示胰腺囊性肿瘤的病理特征，对诊断与鉴别诊断有较高的价值。