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。     

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。     

Laparoscopic resection of the pancreatic tail with splenic preservation

OBJECTIVE: Evaluation of feasibility and efficacy of left resection of the pancreas with preservation of the splenic vessels and spleen as a laparoscopic procedure. BACKGROUND: Laparoscopic technique is used less often on the pancreas than on other organs. The most common indications are enucleation of endocrine-active tumors and distal resections for benign primary pancreatic lesions. An important premise of these operations is atraumatic removal of as little of the pancreas as possible and the preservation of the spleen and its main vessels. METHODS: Five patients aged 16 to 56 years, all female, underwent laparoscopic left resection of the pancreas with preservation of the splenic vessels and the spleen. There were 4 cases of benign epithelial tumors of the pancreas and 1 case of a left-sided adrenal cyst, which pre- and intraoperatively gave the impression of a pancreatic cystadenoma. RESULTS: In all 5 cases, the laparoscopic procedure was completed with preservation of the splenic vessels and the spleen itself. No patient required blood transfusion, and there was only 1 postoperative fluid collection at the site of the tumor resection, which was drained percutaneously on the fourth postoperative day. CONCLUSION: Distal pancreas resection can be performed as a laparoscopic procedure, with the usual advantages that this techniques has for the patient. Optimal closure of the cut edge of the pancreas and the preservation of the spleen and its main vessels are the most important aspects of this operation.     

腹腔镜下脾囊肿的保脾术探讨

目的探讨腹腔镜下脾囊肿保脾手术的可行性。方法应用腹腔镜微创器械和镜下单人双手操作缝合技术为8例脾囊肿施行保脾手术,根据囊肿所处的部位、大小、性质,采用囊肿完整剥除4例,脾部分切除2例,囊肿去顶开窗引流2例。结果8例脾囊肿都成功地完成了腹腔镜下去除囊肿和脾脏的保留,手术时间60～120min,平均100min;术中出血量60～120ml,平均80ml。术后无出血、感染等并发症,4～6d出院。8例术后随访1～72个月,平均38个月,恢复良好,无复发。结论腹腔镜下去除囊肿而保存脾脏的术式可行。     

腹腔镜保留脾脏胰体尾切除术的关键技术

腹腔镜保留脾脏胰体尾切除术适用于胰体尾部良性或低度恶性病变,避免了脾切除术后近、远期并发症,手术方式包括保留脾动静脉的Kimura手术和切除脾动静脉主干、保留胃网膜左血管等侧枝循环的Warshaw手术。腹腔镜下Kimura手术视野清晰,安全可行,术后并发症发生率低,应为保脾胰体尾切除手术的首选。术前检查或术中探查可疑为浸润性恶性病变或病灶与脾血管、脾门关系密切者,应果断放弃保脾术式,改行胰体尾联合脾切除术。     

Spleen-preserving Distal Pancreatectomy with Excision of Splenic Artery and Vein: A Case-matched Comparison with Conventional Distal Pancreatectomy with Splenectomy

Background The value of spleen preservation during distal pancreatectomy (DP) still remains controversial. Spleen-preserving DP with excision of the splenic artery and vein is a simplified technique for spleen preservation. The aim of this study was to compare the postoperative course of DP with or without splenectomy. Patients and Methods From 1990 to 2005, 38 consecutive patients with benign or low-grade malignant disease underwent a spleen-preserving DP operation with excision of the splenic artery and vein (Conservative Group). They were compared with 38 patients who underwent conventional DP with splenectomy over the same time period (Splenectomy Group) and who had been matched for age, American Society of Anesthesiologists (ASA) score, and pathological diagnosis. Postoperative courses were analyzed and compared between the Conservative Group and Splenectomy Group. Results Spleen preservation was effective in 36 of the 38 attempts (95%). Postoperative complications – in particular, infectious intra-abdominal complications – were significantly higher in the Splenectomy Group (34 and 18%, respectively) than in the Conservative Group (13 and 3%, respectively) (P = 0.03 and P = 0.02, respectively). The length of the surgery, perioperative blood loss or transfusions, perioperative mortality and length of hospital stay did not differ between the two groups. Univariate analysis showed that splenectomy was the only risk factor for postoperative complication. Conclusions Spleen-preserving DP with excision of the splenic artery and vein is a fast, safe and effective procedure associated, in this series, with a reduction of postoperative complications relative to conventional DP with splenectomy. This technique should be considered in patients with benign or low-grade malignant disease of the pancreas. The authors declare that there are no competing interests.     

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)     

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。     

腹腔镜辅助全胃、胰体尾、脾脏联合脏器切除术

全麻后取倒Y体位,5孔法。进腹后探查未见广泛转移。医用胶在左肝表面喷涂,将肝脏粘在腹壁上(悬吊肝脏)。提起胃结肠韧带,超声刀分离。清扫幽门下区淋巴结。处理胃网膜右血管。分离胰腺上缘,显露肝总动脉及胃十二指肠动脉,处理胃左血管,清扫胰腺上缘及腹腔动脉淋巴结。切除小网膜直至贲门右侧,清扫区域淋巴结。分离胃大弯及脾门区淋巴结,处理胃短血管,游离食管胃连接部。分离胃胰皱襞,发现胰腺体尾部结节较硬考虑转移。决定行全胃、胰体尾、脾脏切除术。游离胰床,离断脾周韧带,超声刀削薄胰腺,直线型切割器离断,微乔间断加固。用直线型切割器离断十二指肠。上腹正中切口5cm,辅助行消化道Roux-Y重建。     

Laparoscopic partial splenectomy

Background The immunologic function of the spleen and its important role in immune defense has led to splenic-preserving surgery. This study aimed to evaluate whether laparoscopic partial splenectomy is safe. Methods Data on consecutive patients presenting with localized benign or malignant disease of the spleen were included in a prospective database. The surgical technique consisted of six steps: patient positioning and trocar placement, mobilization of the spleen, vascular dissection, parenchymal resection, sealing/tamponading of the transected edge, and removal of the specimen. Results From 1994 to 2005, 38 patients underwent laparoscopic partial splenectomy. The indications included splenomegaly of unknown origin, splenic cysts, benign tumors (hamartoma), and metastasis from ovarian carcinoma and schwannoma. The median operating time was 110 min (range, 65–148 min). The median length of hospital stay was 5 days (range, 4–7 days). There was no postoperative mortality. Postoperative pleural effusion occurred in two patients. There were no reoperations. Three patients required blood transfusions. Conclusion Laparoscopic partial splenectomy is safe for patients with localized benign or malignant disease of the spleen.     

Modified Laparoscopic Splenic Vessel-Preserving Distal Pancreatectomy: Matador Assistance and Peel-Away Technique

Background

Laparoscopic splenic vessel-preserving distal pancreatectomy (lap-SVPDP) is a popular procedure in pancreatic surgery. However, postoperative complications include false aneurysms of the splenic artery, splenic vein stenosis and thrombosis, pancreatic fistulas, abscess, and perigastric varices.

Methods

Eight patients (three men, five women, average age 66.1 years) with benign tumors underwent lap-SVPDP. Lap-SVPDP was performed in the lithotomy position with the head slightly elevated. The splenic vein was peeled longitudinally toward the pancreatic tail. A vessel-sealing system was used to detach the pancreatic body from the greater omentum, and the pancreas was transected using a surgical stapler.

Results

Mean operation time was 254 min; mean blood loss was 163 ml; and mean post-surgical hospitalization time was 13 days. No postoperative bleeding from the preserved splenic vessels occurred, and there were no splenic infarcts or splenic abscesses.

Conclusions

For safe performance of lap-SVPDP, the posterior surface of the pancreas should be completely exposed. The splenic vein should be ‘peeled away’, starting from its central rear, enabling easy detection of its course to avoid inadvertent sealing. With improved operational techniques, lap-SVPDP can be adopted as a standard procedure in pancreatic surgery.     

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.     

Laparoscopic Distal Pancreatectomy in Children: Case Report and Review of the Literature

Background Laparoscopic resection of benign tumors of the pancreas has been reported in adults, but only four cases of partial laparoscopic pancreatectomy in children have been described in the English-language literature. Methods We describe the case of an 11-year-old girl with a solid pseudopapillary tumor who was treated with a laparoscopic, spleen-preserving, distal pancreatectomy. The specimen was extracted in an endoscopic bag retrieval system through a Pfannenstiel incision. Operative time was 120 minutes, and minimal blood loss occurred. The literature is reviewed. Results The postoperative course was uneventful. Twenty-two months after the operation, clinical follow-up (including assessment of exocrine and endocrine pancreatic function) revealed nothing abnormal. The functional and aesthetic results were satisfactory. Conclusions The technique used for our case is simple and reproducible, was completed safely within a reasonable operative time, and yielded a good result.     

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.     

Perioperative Outcomes for Open Distal Pancreatectomy: Current Benchmarks for Comparison

Background  

Open distal pancreatectomy (ODP) outcomes have largely relied on single-institution data from high-volume, tertiary centers. To provide contemporary, national benchmarks of ODP outcomes, we examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.     

Role of Laparoscopic Distal Pancreatectomy for Solid Pseudopapillary Tumor

Background:

Since the first case report regarding laparoscopic distal pancreatectomy (DP) for solid pseudopapillary tumor (SPT), few additional articles have been published. The objective of this study was to evaluate the feasibility, safety, and long-term outcome of the laparoscopic DP based on a series of adult SPT patients.

Methods:

In a single-center study, we screened all adult patients undergoing a laparoscopic DP for SPT. Preoperative, operative, and postoperative data were retrospectively analysed and compared to the results of open DP for SPT published in the medical literature.

Results:

From April 2000 to June 2010, 5 adult female patients (median age 34 y) underwent a laparoscopic DP for an SPT. No conversion to open surgery was required. The median size of the tumor was 45 mm. The postoperative mortality rate was 0%, and serious complications (Dindo IV) occured in 2 patients. The postoperative quality of life was not significantly altered by the laparoscopic procedure. At a median follow-up of 60 mo, all patients were alive and without evidence of local recurrence, distant metastasis, diabetes, or exocrine insufficiency.

Conclusion:

Laparoscopy may offer an alternative to open surgery in the treatment of SPT of the distal pancreas in adult female patients. The laparoscopic procedure impacts neither the oncologic outcome nor the quality of life. However, due to the risk of postoperative complications, this procedure should be reserved for specialized centers.     

Laparoscopic Spleen-Preserving Distal Pancreatectomy in a Solitary True Pancreatic Cyst

Background:

Solitary true pancreatic cysts (STPCs), or epithelial cysts, are benign lesions that are extremely rare in adult patients. Advances in radiographic techniques have improved the ability to identify pancreatic cystic lesions. We report a case of a large and symptomatic STPC in a 47-year-old female patient who was treated successfully with spleen-preserving laparoscopic distal pancreatectomy. We also review the clinical and pathologic features of all reported STPCs within the past 25 years.

Database:

To compose the review, we did a search of the international literature for STPCs that had occurred in adults. Fourteen related articles were found describing cases of STPCs. Clinical and pathologic information was collected for all of the reported pancreatic cysts, and a database was formed. STPCs are detected more frequently in women than in men. The mean age of occurrence is 43.2 years, and the mean cyst size is 5.6 cm. Fifty percent of true cysts are located in the head of the pancreas. Size and site are responsible for the symptoms caused, although 22.8% were asymptomatic. Diagnosis was made postoperatively in all cases by histopathologic studies. No case of malignancy was reported in any STPC.

Conclusions:

STPCs are rare and benign lesions commonly discovered incidentally during abdominal imaging. Surgical treatment is considered the appropriate therapy for large and symptomatic STPCs. The definitive diagnosis is established by histopathologic and immunohistochemical studies.     

Laparoscopic Spleen-Preserving Distal Pancreatectomy: Comparative Study of Spleen Preservation with Splenic Vessel Resection and Splenic Vessel Preservation

Background

Spleen-preserving laparoscopic distal pancreatectomy (SPLDP) can be performed with splenic vessel resection (SVR) or splenic vessel preservation (SVP). The purpose of this comparative study was to evaluate the clinical outcomes of patients who underwent SPLDP with SVR or SVP at a single institution.

Methods

We retrospectively reviewed the records of 246 patients who underwent SPLDP at Asan Medical Center, Seoul, Korea, for benign or low-grade malignant tumors found in the body or tail of the pancreas between November 2005 and November 2011.

Results

In total, 206 patients (83.7 %) were managed by SVP. SVR was performed in the remaining 40 (16.3 %) cases. There were no significant differences between the SVP and SVR groups in terms of intraoperative blood loss (378 ± 240 vs. 328 ± 204 ml, respectively; P = 0.240) and operating time (193.4 ± 59.1 vs. 204.4 ± 51.8 min, respectively; P = 0.492). Sixty-seven (32.5 %) and 10 patients (25 %) had complications in the SVP and SVR groups, respectively (P = 0.347). At 3 days after surgery, the rates of splenic infarction were 16.0 % (33/206) in the SVP group and 52.5 % (21/40) in the SVR group, but all recovered within 12 months on postoperative computed tomography. The time of recovery from splenic infarction was 3.6 ± 3.1 and 4.7 ± 3.7 months in the SVP and SVR groups, respectively. At 6 months, the rates of gastric varices were 1.9 % in the SVP group and 35 % in the SVR group (P < 0.001) with no progression at 12 months. No gastrointestinal bleeding occurred at a median follow-up of 34 months (range = 12–84).

Conclusions

SPLDP with SVR can be used for patients with large and benign or low-grade malignant tumors that distort and compress vessel course, as the higher rate of early splenic ischemia and perigastric varices is acceptable.