Median pancreatectomy for tumors of the neck and body of the pancreas

Background: When enucleation is too risky because of possible damage of the main pancreatic duct, benign tumors located in the neck or body of the pancreas are usually removed by a left (spleno)-pancreatectomy or by a pancreatoduodenectomy. But standard pancreatic resection results in an important loss of normal pancreatic parenchyma and may cause impairment of exocrine and endocrine function. The aim of this study was to evaluate early and longterm results of median pancreatectomy, a limited resection of the midportion of the pancreas, in selected patients with benign or borderline tumors of the pancreas.

Study Design: Records of patients at Ospedale Busonera between November 1985 and September 1998 were reviewed. Ten patients with tumors of the neck or body of the pancreas underwent median pancreatectomy; the cephalic stump was sutured and the distal stump was anastomosed with a Roux-en-Y jejunal loop. Followup included clinical evaluation and routine laboratory tests: abdominal ultrasonography, exocrine and endocrine pancreatic function with fecal chymotrypsin, and an oral glucose tolerance test.

Results: Pathologic examination showed: insulinoma (n = 3), mucinous cystadenoma (n = 3), nonfunctioning endocrine tumor (n = 1), papillary-cystic neoplasm (n = 1), serous cystadenoma (n = 1), and intraductal mucinous tumor (n = 1). Operative mortality and morbidity were 0% and 40%, respectively; pancreatic fistula occurred in three patients. At mean followup of 62.7 months, no recurrence was found and no patient had exocrine insufficiency or glucose metabolism impairment.

Conclusions: Median pancreatectomy is a safe and effective alternative to major pancreatic resection in selected patients with benign or low-malignant lesions of the pancreas. This procedure carries a surgical risk similar to that of the standard operation, but avoids extensive pancreatic resection and pancreatic function impairment.     

Management of blunt major pancreatic injury

BACKGROUND: Major duct injury is the principal determinant of outcome for patients with pancreatic trauma, and there are a number of therapeutic choices available specific to the location of the insult. We report a series of blunt major pancreatic injury cases, with a review of the different procedures used and a discussion of the results. METHODS: A total of 48 cases of blunt major pancreatic injury treated during a 10-year period at one trauma center were reviewed retrospectively. Diagnosis and assessment of injury severity were based on imaging studies and proved by surgical findings. Charts were reviewed to establish the mechanism of injury, surgical indications and imaging studies, management strategy, and outcome. RESULTS: Of the 32 grade III patients, 19 underwent distal pancreatectomy with splenectomy, 8 had pancreatectomy with preservation of the spleen, and 2 received a pancreatic duct stent, with the remaining 3 individuals undergoing nonsurgical treatment, pancreaticojejunostomy, and drainage alone, respectively. The grade III complication rate was 60.6%. Of the 14 grade IV patients, 4 underwent drainage alone because of the severity of the associated injuries, 4 underwent pancreaticojejunostomy, 3 had distal pancreatectomy with splenectomy, and 1 underwent distal pancreatectomy. The two remaining patients received a pancreatic duct stent. The grade IV complication rate was 53.8%. The Whipple procedure was performed for two grade V patients; one died subsequently. For all 48 patients, intraabdominal abscess was the most common morbidity (n = 11) followed, in order of prevalence, by major duct stricture (n = 4), pancreatitis (n = 2), pseudocyst (n = 2), pancreatic fistula (n = 1), and biliary fistula (n = 1). All stented cases developed complications, with one dying and three experiencing major duct stricture. CONCLUSION: The complication rate for our cases of blunt major pancreatic injury was high (62.2%), especially when treatment was delayed more than 24 hours; the same result was also noted for cases transferred from other institutions. Distal pancreatectomy with spleen preservation had a lower complication rate (22.2%) compared with other procedures and is suggested for grade III and grade IV injuries. Magnetic resonance pancreatography was unreliable early after injury but was effective in the chronic stage. Although pancreatic duct stenting can be used to treat posttraumatic pancreatic fistula and pseudocyst, the major duct stricture in the chronic stage of recovery and the risk of sepsis in the acute stage must be overcome.     

Medial pancreatectomy: a multi-institutional retrospective study of 53 patients by the French Pancreas Club

BACKGROUND: The results of medial pancreatectomy have been previously reported anecdotally. The purpose of the study was to provide short- and long-term results of MP in a large multicenter collective series. METHODS: From 1990 to 1998, 53 patients (mean age +/- SD = 49 +/- 15 years) underwent medial pancreatectomy for primary cystic neoplasms of pancreas (n = 19), endocrine neoplasms (n = 17), intraductal papillary mucinous neoplasms (IPMN) (n = 6), fibrotic stenosis of the Wirsung's duct (n = 4), or other benign (n = 4) or malignant (n = 3) diseases. The proximal (right) pancreatic remnant was sutured (n = 53), and the distal (left) remnant was either anastomosed to a jejunal loop (n = 26), to the stomach (n = 25), or oversewn (n = 2). Medial pancreatectomy was indicated in 3 patients (6%) because of failed enucleation, in 3 (6%) to prevent worsening of preexisting diabetes, or to prevent de novo diabetes in a patient with chronic pancreatitis, and deliberately in the 47 others. RESULTS: The length of the resected pancreas was 5.0+/- 2.2 cm (range, 2-15). One patient (2%) died from a pancreatic fistula and portal thrombosis. Three patients were reoperated on because of complications related to the left pancreas, which was partially or totally resected. Pancreatic fistula developed in 16 patients (30%). Mean delay for the return of oral feeding was related to the presence of a pancreatic fistula. At follow-up (median = 26 months, range, 12-131), 1 pancreatic recurrence and 1 de novo diabetes occurred in patients without IPMN. In patients with IPMN, the rates of pancreatic recurrence and diabetes were 40% (2/5), respectively. CONCLUSIONS: Medial pancreatectomy effectively preserves long-term endocrine function and is associated with a low risk of local recurrence, except in patients with IPMN. However, there is a high risk (30%) of PF after medial pancreatectomy.     

ERCP������������β�г���������8������

??Clinical application of endoscopic retrograde cholangiopancreatography in the treatment of pancreatic fistula after distal pancreatectomy: A report of 8 cases WU Wen-guang*??ZHANG Wen-jie??GU Jun??et al. *Department of General Surgery??Institute of Biliary Tract Disease??Xinhua Hospital??Affiliated to Shanghai Jiao Tong University School of Medicine??Shanghai 200092??China
Corresponding author??WANG Xue-feng??E-mail??wxxfd@live.cn
Abstract Objective To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic fistula after distal pancreatectomy. Methods A retrospective review of 8 cases with ongoing symptoms related to the pancreatic fistula after distal pancreatectomy was conducted from November 2010 to February 2014 at Department of General Surgery and Laboratory of General Surgery??Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Results ERCP was performed and demonstrated clear extravasation of contrast from the main pancreas duct at the site of pancreas transection in all eight cases. Pancreatic duct stents were placed in all patients at a median time of 15.8 days (range??9-26 days)postoperation and the pancreatic fistula resolved in all patients after a median duration of 16.0 days(range??12-25 days) from the index ERCP. Pancreatic duct stent were removed in all patients three months after discharge??and no patient has developed recurrent pancreatic fistula after stent removal. There was no episodes of pancreatitis??perforation??or other complications associated with pancreatic duct stent placement or removal. Conclusion ERCP with pancreatic duct stent may have a beneficial role in the management of patients with pancreatic fistula after distal pancreatectomy and the approach should be considered in patients not responsive to traditional management strategies.     

Management of left pancreatic trauma

Left pancreatic traumas (LPTs) are rare but serious lesions occurring in 1 to 6 per cent of abdominal trauma patients and mainly resulting from blunt traumas. LPT severity is primarily dependent on the associated injuries and secondarily related to main pancreatic duct injury responsible for complications: acute pancreatitis, pseudocysts, pancreatic fistulas, or abscesses. The guidelines for blunt LPT management can be presented as follows. In case of emergency laparotomy, pancreas exploration is mandatory to detect pancreatic duct lesions. In the absence of main pancreatic duct lesions, simple drainage is advocated. In case of distal injury to the main pancreatic duct, a left pancreatectomy is mandatory. In the absence of initial laparotomy, the diagnosis is more and more based on CT and magnetic resonance cholangiopancreatography, which tend to replace endoscopic retrograde cholangiopancreatography (ERCP) as a first-intent diagnostic modality. In case of distal injury to the main pancreatic duct, spleen-preserving distal pancreatectomy is recommended. In the absence of main pancreatic duct lesions, nonoperative treatment is advocated. When LPTs are discovered at the time of complications, pancreatic fistulas and/or pseudocysts are associated with main pancreatic lesions, which can be treated by pancreatic duct stenting at ERCP and/or internal endoscopic cystogastrostomy. However, in such cases, spleen-preserving distal pancreatectomy remains the treatment of choice. Pancreatic ductal lesions resulting from LPT have to be diagnosed early to avoid late complications. Distal pancreatectomy remains the treatment of choice in case of severe pancreatic ductal lesions because the role of ERCP stenting and endoscopic techniques needs further evaluation.     

Management of pancreatic trauma

BACKGROUND: Pancreatic injury can pose a formidable challenge to the surgeon, and failure to manage it correctly may have devastating consequences for the patient. Management options for pancreatic trauma are reviewed and technical issues highlighted. METHOD: The English-language literature on pancreatic trauma from 1970 to 2006 was reviewed. RESULTS AND CONCLUSIONS: Most pancreatic injuries are minor and can be treated by external drainage. Injuries involving the body, neck and tail of the pancreas, and with suspicion or direct evidence of pancreatic duct disruption, require distal pancreatectomy. Similar injuries affecting the head of the pancreas are best managed by simple external drainage, even if there is suspected pancreatic duct injury. Pancreaticoduodenectomy should be reserved for extensive injuries to the head of the pancreas, and should be practised as part of damage control. Most complications should initially be treated by a combination of nutrition, percutaneous drainage and endoscopic stenting.     

Surgical treatment of benign and borderline neoplasms of the pancreatic body

BACKGROUND: Conventional operations for benign and borderline tumors of the pancreatic body are distal pancreatectomy and enucleation. An unusual operation allowing the preservation of the proximal and distal pancreas is median pancreatectomy. METHOD: A retrospective analysis of prospectively collected data on 67 patients with nonmalignant neoplasms of the pancreatic body was performed. The operations were: 32 median pancreatectomies (22 with duct occlusion of the distal pancreas, 10 with pancreaticojejunostomy), 21 distal pancreatectomies, and 14 enucleations. The operative and long-term outcomes of the different operations were compared. RESULTS: Enucleation had a shorter operative time and less blood loss than the other operations. No mortality was observed. The pancreatic fistula rate was 50% after median pancreatectomy (59% in case of distal duct occlusion, 30% in case of pancreaticojejunostomy), 14% after distal pancreatectomy and 14% after enucleation. Diabetes appeared in 3 patients after distal pancreatectomy and 3 patients after median pancreatectomy with duct occlusion. CONCLUSIONS: When indicated, enucleation is the operation of choice for a nonmalignant neoplasm of the pancreatic body. With respect to distal resection, the higher fistula rate of median pancreatectomy with pancreaticojejunostomy could be the price for a better long-term endocrine function; median pancreatectomy with duct occlusion had worse operative results and no long-term advantages.     

ERCP辅助治疗胰体尾切除术后胰瘘8例报告

目的 探讨内镜逆行胰胆管造影（ERCP）辅助治疗胰体尾切除术后胰瘘的疗效。 方法 回顾性分析上海交通大学医学院附属新华医院普外科2010年11月至2014年2月间行胰体尾切除术后因胰瘘相关症状而采用ERCP辅助治疗的8例病人临床资料,并分析其术后疗效。结果 8例病人在ERCP下均见胰腺主胰管有明显的造影剂外渗出,均行胰管支架置入术,支架置入距手术日的平均时间为15.8（9～26）d,ERCP术后胰瘘愈合时间平均为16.0（12～25）d。所有病人的胰管支架在出院3个月后拔除,支架拔除后无胰瘘复发病例。治疗期间均未发生胰腺炎、穿孔及其他并发症。结论 对常规方法无效的胰体尾切除合并胰瘘病人,ERCP辅助行胰管支架置入可改善治疗效果。     

Pancreatic Trauma Revisited*

Abstract Pancreatic trauma is rare with an incidence between one and two percent in patients with abdominal trauma. Morbidity and mortality, however, are significant with rates approaching 40–45% in some reports. The majority of patients with injuries to the pancreas have associated trauma to other organs which are primarily responsible for the high mortality rate. The continuity of the main pancreatic duct is the most important determinant of outcome after injury to the pancreas. If there is no evidence of ductal injury on fine-cut CT or on ERCP, nonoperative management is chosen. The indications for operative management are as follows: (1) peritonitis on physical examination; (2) hypotension and a positive FAST; and (3) evidence of disruption of the pancreatic duct on fine-cut CT or on ERCP. After exposure and evaluation of the extent of injuries to the pancreas and duodenum, a decision must be made on the procedure. For pancreatic contusions, hematomas, or small lacerations, simple external drainage or pancreatorrhaphy with drainage can be performed. For ductal transection at the neck, body, or tail, the procedure of choice is a distal pancreatectomy or Roux-en-Y distal pancreatojejunostomy. If the patient has suffered a ductal transection at the head of the pancreas without injury to the duodenum, a Roux-en-Y distal pancreatojejunostomy or anterior Roux-en-Y pancreatojejunostomy is the operation of choice. For combined pancreatoduodenal injuries, the options are repair and drainage, diversion via a pyloric exclusion procedure, or pancreatoduodenectomy. Complications of pancreatic injuries include fistulas and intra-abdominal abscesses, and an occasional pancreatic pseudocyst. Key Words *Please see related articles in Eur J Trauma Emerg Surg 33;3:221–37     

Central pancreatectomy: single-center experience of 50 cases

Central pancreatectomy is a nonstandard operation for unusual lesions. This study reports a single-center experience of central pancreatectomy. Thirty-eight women and 12 men with a mean age of 49.4 years (range, 13.4-79.2 years) underwent central pancreatectomy from January 1987 to October 2005. Indications included 18 neuroendocrine tumors (11 nonfunctioning), 10 serous and 10 mucinous cystadenomas, 5 intraductal papillary mucinous neoplasms, 3 main pancreatic duct strictures, 2 solid cystic papillary tumors, 1 hydatid cyst, and 1 acinar cell carcinoma. The proximal pancreatic remnant was suture ligated. The distal pancreatic end was anastomosed to a Roux-en-Y jejunal loop (n = 6) or to the stomach (n = 44). Three patients had associated procedures, 1 each for metastatic liver cytoreduction (VIPoma), hydatid liver disease, and pancreatic resection for multifocal mucinous cystadenoma. The median operative time was 3 hours 21 minutes (range, 1 hour 50 minutes to 6 hours). The mean length of the resected pancreas was 45 mm (range, 20-80 mm) and the mean tumor size was 23 mm (5-60 mm). The perioperative mortality was nil. Complications included the following: 4 patients (8%) had pancreatic anastomotic leak, 5 patients (10%) had acute pancreatitis, 7 patients (14%) had intra-abdominal collection, and 3 patients (6%) had bleeding. Six patients (12%) required a reoperation during the postoperative period. Eight patients (16%) required endoscopic (1 with biliary endoscopic stent) or radiological (7 with percutaneous drainage) intervention. No patients developed de novo diabetes. On long-term follow-up, 2 patients with invasive intraductal papillary mucinous neoplasia had recurrence; one was treated successfully by completion pancreatectomy and the other died at 20 months. One patient with serous cystadenoma died at 16.8 years without recurrence. One patient with metastatic VIPoma had a liver transplant 9 years postoperatively and is alive. The median follow-up was 55 months (range, 2 months to 16.8 years). The actuarial 5-year patient and pancreatic remnant survival rates were 98% and 95%, respectively. In our series, central pancreatectomy led to effective preservation of both cephalic and distal pancreatic remnants without a significant increase in postoperative morbidity compared with conventional pancreatectomy.     

Contribution of endoscopic retrograde pancreatography in management of complications following distal pancreatic trauma.

Pancreatic trauma is associated with high morbidity and mortality. Treatment of this condition is controversial. This retrospective study aimed to evaluate the management of distal pancreatic trauma and its complications, assessing the role of endoscopic retrograde cholangiopancreatography (ERCP). The clinical course and surgical management of 38 patients with distal pancreatic trauma were analyzed in a university hospital in Paris, France. Twenty-five patients were referred after initial treatment elsewhere. As initial treatment, patients underwent external drainage (n = 25), pancreatic resection (n = 6), laparotomy alone (n = 5), and no surgery (n = 2). Nineteen patients with pancreatic duct injury and no pancreatic resection developed fistulae (n = 14) or pseudocysts (n = 5). Only four of these patients recovered without a subsequent pancreatic resection or internal drainage procedure. In the absence of duct injury, patients recovered without the need for pancreatic resection. ERCP was performed in 16 cases and provided critical information on duct status influencing surgical management. We conclude that the presence of pancreatic trauma duct injury is a major determinant of complications and outcome after pancreatic trauma. It is optimally managed by pancreatic resection. ERCP is valuable in providing a definitive diagnosis of duct injury, thereby directing treatment.     

Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings

BACKGROUND: The purpose of this study was to determine the utility of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of pancreatic duct trauma and pancreas-specific complications. METHODS: Ten hemodynamically stable patients with clinically suspected pancreatic injury related to blunt abdominal trauma (n = 8), penetrating trauma (n = 1), or iatrogenic trauma (n = 1) underwent MRCP. Two abdominal radiologists conducted a review of the MRCPs to assess for the presence or absence of pancreatic duct trauma and pancreas-specific complications such as pseudocysts. The MRCP findings were correlated with endoscopic retrograde cholangiopancreatograms (n = 2), surgical findings (n = 1), computed tomographic scans (n = 10), and with clinical, biochemical or imaging follow-up (n = 10). RESULTS: Diagnostic quality MRCPs were obtained in each of the 10 patients. A mean imaging time of 5 minutes was required to perform the MRCPs. Pancreatic duct injuries were detected in four patients; pseudocysts were detected in three of these four patients. The pancreatic duct injuries in three patients were acute or subacute. In one of the three patients, disruption of a side branch of the pancreatic duct diagnosed with MRCP was not detected with endoscopic retrograde cholangiopancreatography but was confirmed surgically. In the fourth patient, the pancreatic duct injury was chronic; MRCP revealed a posttraumatic stricture in this patient who had sustained blunt abdominal trauma 17 years previously. In the remaining six patients, pancreatic duct trauma was excluded with MRCP. The information derived from the MRCPs was used to guide clinical decision-making in all 10 patients. CONCLUSIONS: MRCP enables noninvasive detection and exclusion of pancreatic duct trauma and pancreas-specific complications and provides information that may be used to guide management decisions.     

Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre

IntroductionThe aim of this study was to present our surgical experience of isolated blunt major pancreatic injury (IBMPI), and to compare its characteristic outcomes with that of multi-organ injury.Materials and methodsFrom 1994–2015, 31 patients with IBMPI and 54 patients with multi-organ injury, who underwent surgery, were retrospectively studied.ResultsOf the 31 patients with IBMPI, 22 were male and 9 were female. The median age was 30 years (interquartile range, 20–38). Twenty-one patients were classified as the American Association for the Surgery of Trauma–Organ Injury Scale Grade III, and 10 patients as Grade IV. Patients with IBMPI had significantly lower shock-at-triage rates, lower injury severity scores, longer injury-to-surgery time, and shorter length of hospital stay than those with multi-organ injury. There were no statistically significant differences in sex, age, trauma mechanism, laboratory data, surgical procedures, and complications between the two groups. Eight patients with IBMPI underwent endoscopic retrograde pancreatography, and 5 patients with complete major pancreatic duct (MPD) disruption underwent pancreatectomy eventually. The remaining 3 patients had partial MPD injury and two of them received a pancreatic duct stent for the treatment of existing postoperative pancreatic fistula. Spleen-sacrificing distal pancreatectomy (SSDP) was performed in 13 patient with IBMPI, followed by spleen-preserving distal pancreatectomy (n = 12), peripancreatic drainage (n = 4), and central pancreatectomy with Roux-en-Y reconstruction (n = 2). The overall complication rates, related to the SSDP, SPDP, peripancreatic drainage, and central pancreatectomy, were 10/13 (77%), 4/12 (33%), 3/4 (75%), and 2/2 (100%), respectively. Three patients died resulting in a 10% mortality rate, and the other 16 patients developed intra-abdominal complications resulting in a 52% morbidity rate. In the subgroup analysis of the 25 patients who underwent distal pancreatectomy, SPDP was associated with a shorter injury-to-surgery time than SSDP.ConclusionsPatients with IBMPI have longer injury-to-surgery times, compared to those with multi-organ injury. Of the distal pancreatectomy patients, the time interval from injury to surgery was a significant associated factor in preserving or sacrificing the spleen.     

Distal pancreatectomy with and without splenectomy

Splenectomy is performed routinely during distal pancreatectomy, yet the spleen has an important role in host defence and can often be preserved. A personal series of 100 distal pancreatectomies undertaken for pancreatic disease between 1978 and 1990 included 23 patients undergoing total pancreatic resection. The remaining 77 patients, who form the basis of the present report, underwent primary distal pancreatectomy and comprised 34 women and 43 men with a median age of 41 years (range 17-78 years). Conventional distal pancreatectomy including splenectomy was performed in 42 patients (55 per cent) for chronic pancreatitis (34 patients), pancreatic neoplasia (six patients), suspected pancreatitis (one patient) or pancreatitic trauma (one patient). Conservative resection with splenic preservation was performed in 35 patients (45 per cent) for chronic pancreatitis (12 patients), suspected pancreatitis (13 patients, including eight patients with pancreas divisum), pancreatic neoplasia (six patients), recurrent acute pancreatitis (two patients) and pancreatic trauma (two patients). There were no postoperative deaths in either group. Early complications followed conventional resection in 10 patients (24 per cent) and conservative resection in seven patients (20 per cent). In five patients the splenic vessels were ligated away from the splenic hilum and the spleen was left in situ, but subsequent isotope scans and haematological indices showed no hyposplenism. The spleen can safely be preserved in many distal pancreatic resections, including those for inflammatory disease, and we now prefer a retrograde technique for dissecting the pancreas off the splenic vessels.     

Central pancreatectomy revisited

Central pancreatectomy is a surgical procedure that removes the middle segment of the pancreas and preserves the distal pancreas and spleen. This limited resection has the advantage of conserving normal, uninvolved pancreatic parenchyma, thus reducing the possibility of postoperative exocrine and endocrine dysfunction. While the incidence of postoperative endocrine insufficiency may be as low as 4%, procedural morbidity, specifically pancreatic fistula, appears to exceed the published rates for standard resections (i.e., distal/subtotal pancreatectomy or pancreaticoduodenectomy). We have reviewed our prospective pancreatic cancer database to determine the utilization of central pancreatectomy in a major cancer center with expertise in pancreatic surgery. We identified only 10 cases of central pancreatectomy over the past 13 years. Six (60%) had postoperative complications including three cases (30%) of pancreatic fistula. No patients died as a result of the procedure. At a median follow-up of 13.6 months (mean, 25.2 months), only one patient had mild endocrine insufficiency and no patients had clinically significant exocrine dysfunction. The associated morbidity of central pancreatectomy may outweigh any potential benefit in long-term pancreatic secretory function. We suggest that such a procedure be used selectively, where preservation of the pancreas appears essential.     

Conservative pancreatectomy

By convention, resection of the proximal pancreas includes the distal stomach (and duodenum) and resection of the distal pancreas includes the spleen. In 28 patients the stomach and spleen were preserved to minimize functional disability. In 13 patients with proximal pancreatectomy (7 men, median age 39 years) the pylorus and first 3 cm of duodenum were preserved. Indications were chronic pancreatitis (n = 9) and localized neoplasia (ampulla 2, duodenum 1, insulinoma 1). One patient died (aged 81 years), and 2 required re-operation for a pancreatic abscess or stenosed choledochojejunostomy. The 12 survivors are well at a median of 1.25 years (range 0.25-3.25 years). In 15 patients with distal pancreatectomy (6 men, median age 44 years) the spleen was preserved. Indications were islet cell tumour in 2 and chronic abdominal pain in 13,9 of whom had an isolated dorsal pancreas and 6 of whom had histological evidence of chronic pancreatitis. Recovery was uneventful apart from 2 patients with a fluid collection in the lesser sac, 1 needing percutaneous aspiration. In the absence of gross inflammatory adherence, partial pancreatectomy need not entail removal of the adjacent stomach or spleen.     

Management of pancreatic trauma

The majority of patients who sustain penetrating blunt trauma to the pancreas can be managed with sump drainage, including those with gunshot wounds to the head of the pancreas. Pancreatico-duodenectomy may be indicated in 2 to 3 percent of cases of pancreatic injury. Patients who require resection of 80 percent or more of the pancreas and do not have splenic injury should be considered for a Roux-Y anastomosis to the distal pancreas after ductal injury has been proved. Severe injuries to the body of the pancreas are best managed by distal pancreatectomy. The mortality rate due to pancreatic injury has been less than 3 percent and rarely is the cause of death. To support this conclusion, few normotensive patients die, and no patient with an isolated pancreatic injury in our series died. The severity of injury often dictates the appropriate treatment. A conservative approach is indicated for most pancreatic injuries, resulting in shorter operating time and less blood loss in the unstable patient with multiple injuries. Most important is identification of ductal injury at the initial operation and institution of surgical drainage.     

Outcome of duodenum-preserving resection of the head of the pancreas for intraductal papillary-mucinous neoplasm

BACKGROUND: The standard surgical procedure for intraductal papillary-mucinous neoplasm of the pancreatic head is pylorus-preserving pancreatoduodenectomy. A less extensive resection may be justified because most intraductal papillary-mucinous neoplasms are benign or of low-grade malignancy. AIMS AND METHODS: The outcome of duodenum-preserving pancreatic head resection with preservation of the main bile duct was evaluated retrospectively in 13 patients with a branch-type intraductal papillary-mucinous neoplasm in the head of the pancreas and with a median (range) follow-up of 60.0 (0.3-99.5) months. RESULTS: Post-operative complications included anastomotic leakage (n=3), bile duct perforation (n=1), intra-abdominal bleeding (n=3), delayed gastric emptying (n=2) and death (n=2). All the resection margins were clear of tumour on histological examination. Ten of 11 patients maintained over 90% of their pre-operative body weight. Glucose tolerance improved in 4 of 11 evaluable patients, was unchanged in 6 and worsened in 1 patient. Biliary scintigraphy showed that bile flow was delayed compared with that before surgery (8.8 +/- 1.1 vs. 19.6 +/- 4.6 min; p = 0.03). Neither recurrence nor metastasis was observed. CONCLUSION: The results of duodenum-preserving pancreatic head resection for branch duct-type intraductal papillary-mucinous neoplasm were satisfactory and provided a good quality of life.     

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。     

慢性胰腺炎伴胰管结石外科治疗体会

目的 探讨慢性胰腺炎伴胰管结石外科治疗的术式选择.方法 对1991年6月至2006年6月收治的17例慢性胰腺炎伴胰管结石手术治疗的患者进行回顾性分析,总结不同类型的胰管结石的手术方式及结果.结果 本组17例中胰头部胰管结石13例,胰体尾部胰管结石4例,合并胆石症6例,其中6例行胰管切开取石胰管空肠吻合术(Partington法);4例行胰管胃吻合术(Warren法);3例行保留十二指肠胰头次全切除术(Beger法);3例行胰尾切除胰腺空肠吻合术(Duval法);1例行胰尾、脾切除胰腺空肠吻合术.17例临床治愈,其中上腹部顽固性疼痛完全缓解15例,血糖控制2例,胰漏2例,1例术后11个月死于胰腺癌.结论 针对慢性胰腺炎合并胰管结石患者的不同状况采取的手术方式应高度个体化,有主胰管扩张者采取引流术,无胰管扩张及局部胰腺病变者采取胰腺部分切除联合内引流术,同时注意尽量保存胰腺组织功能,可明显改善患者生活质量.