The potent somatostatin analogue vapreotide does not decrease pancreas-specific complications after elective pancreatectomy: a prospective,multicenter, double-blinded,randomized, placebo-controlled trial

BACKGROUND: Pancreatectomy can be complicated by pancreatic anastomotic leakage, causing major morbidity. STUDY DESIGN: Our aim was to determine if vapreotide, a potent long-acting somatostatin analogue, would decrease pancreas-related complications. This prospective, multicenter, randomized, double-blind, placebo-controlled trial involved 275 patients without preexisting chronic pancreatitis undergoing elective proximal, central, or distal pancreatectomy. Complications were defined by objective criteria before beginning the study. RESULTS: One hundred thirty-five patients received vapreotide; 140 patients received placebo. There were no statistically significant differences between vapreotide- and placebo-treated patients in either pancreas-related complications (30.4% versus 26.4%, respectively) or in other complications not directly related to the pancreas (40% versus 42%, respectively). CONCLUSIONS: The potent somatostatin analogue vapreotide does not appear to decrease postoperative complications after major pancreatectomy in patients without chronic pancreatitis.     

Nonstandard pancreatic resections for unusual lesions

BACKGROUND: Pancreatic resections including pancreaticoduodenectomy and distal pancreatectomy are the standard of care for patients with malignant tumors of the pancreas. Patients with benign disease or unusual tumors may benefit from other nonstandard resections. METHODS: A review of the literature and the author's experiences were undertaken. RESULTS: Parenchymal-sparing surgeries including pancreatic enucleation, central pancreatectomy, splenic-preserving distal pancreatectomy, and duodenal-preserving pancreatic head resection are described. The utility of each procedure is reviewed. Outcome results from published series are included. CONCLUSIONS: Nonstandard pancreatic resections should be considered in select patients with unusual lesions. Such procedures are safe and effective and may be associated with a reduced incidence of exocrine insufficiency.     

Pancreatectomy for chronic pancreatitis.

Of one hundred and forty-nine patients (101 male and 48 female) 4-67 years of age, 117 were alcoholics and underwent pancreatectomy because of episodic or continuous abdominal pain or complications or chronic pancreatitis. Nineteen patients underwent pancreaticoduodenectomy, seventy-seven 80-95% distal resection, anf fifty-three 40-80% distal pancreatic resection. There were 3 operative death and 30 late deaths 6 months to 11 years post pancreatectomy. Twenty-one patients were lost to followup, 1 to 11 years post pancreatectomy. Ninety-five patients are known to be alive, 4 of whom are institutionalized. Indications for pancreatectomy in addition to abdominal pain include recurrent or multiple pseudocysts, failure to relieve pain after decompression of a pseudocyst, pseudoaneurysm of the visceral arteries associated with a pseudocyst, recurrent attacks of pancreatitis unrelived by non-resective operations, duodenal stenosis and left side portal hypertension. The choice between pancreaticoduodenectomy or distal resection of 40-80% or 80-95% of the pancreas should be based on the principle site of inflammation whether proximal or distal in the gland, the size of the common bile duct, the ability to rule out carcinoma, and the anticipated deficits in exocrine and endocrine function. The risk of diabetes is very significant after 80-95% distal resection and of steatorrhea after pancreaticoduodenectomy. When the disease process can be encompassed by 40-80% distal pancreatectomy this is the procedure of choice.     

Indications and outcomes of surgical management of chronic pancreatitis: literature review

Surgical management of chronic pancreatitis remains a challenge for surgeons. Last decades, the improvement of knowledge regarding to pathophysiology of chronic pancreatitis, improved results of major pancreatic resections, and new diagnostic techniques in clinical practice resulted in significant changes in the surgical approach of this condition. Intractable pain, suspicion of malignancy, and involvement of adjacent organs are the main indications for surgery, while the improvement of patient's quality of life is the main purpose of surgical treatment. The surgical approach to chronic pancreatitis should be individualized based on pancreatic anatomy, pain characteristics, exocrine and endocrine function, and medical co-morbidity. The surgical treatment approach usually involves pancreatic duct drainage procedures and resectional procedures including longitudinal pancreatojejunostomy, pancreatoduodenectomy, pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Recently, non-pancreatic and endoscopic management of pain have also been described (splancnicectomy). Surgical procedures provide long-term pain relief, improve the patients? quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low mortality and morbidity rates. However, new studies are needed to determine which procedure is safe and effective for the surgical management of patients with chronic pancreatitis.     

Role of octreotide in the prevention of postoperative complications following pancreatic resection.

Though morbidity and mortality rates following pancreatic resection have improved in recent years, they are still around 35% and 5%, respectively. Typical complications, such as pancreatic fistula, abscess, and subsequent sepsis, are chiefly associated with exocrine pancreatic secretion. In order to clarify whether the perioperative inhibition of exocrine pancreatic secretion prevents complications, we assessed the efficacy of octreotide, a long-acting somatostatin analogue. We conducted a randomized, double-blind, placebo-controlled, multicenter trial in 246 patients undergoing major elective pancreatic surgery. Patients were stratified into a high-risk stratum (limited to patients with pancreatic and periampullary tumors) or low-risk stratum (patients with chronic pancreatitis). Patients received octreotide (3 x 100 micrograms) or placebo subcutaneously for 7 days perioperatively. Eleven complications were defined: death, leakage of anastomosis, pancreatic fistula, abscess, fluid collection, shock, sepsis, bleeding, pulmonary insufficiency, renal insufficiency, and postoperative pancreatitis. Two hundred patients underwent pancreatic head resection, 31 patients underwent left resection, and 15 patients had other procedures. The overall mortality rate within 90 days was 4.5%, with 3.2% in the octreotide group and 5.8% in the placebo group. The complication rate was 32% in the patients receiving octreotide (40 of 125 patients) and 55% in patients receiving placebo (67 of 121 patients) (p less than 0.005). In the patients in the high-risk stratum, complications were observed in 26 of the 68 (38%) patients treated with octreotide and in 46 of 71 (65%) patients given placebo (p less than 0.01). Whereas in patients in the low-risk stratum, the complication rate was 25% (14 of 57 patients) in those treated with octreotide and 42% (21 of 50 patients) in patients given placebo (p = NS). The perioperative application of octreotide reduces the occurrence of typical postoperative complications after pancreatic resection, particularly in patients with tumors.     

Long-term Outcome After Resection for Chronic Pancreatitis in 224 Patients

Introduction Organ complications like biliary or duodenal stenosis as well as intractable pain are current indications for surgery in patients with chronic pancreatitis (CP). We present here our experience with pancreatic resection for CP and focus on the long-term outcome after surgery regarding pain, exocrine/endocrine pancreatic function, and the control of organ complications in 224 patients with a median postoperative follow-up period of 56 months. Methods During 11 years 272 pancreatic resections were performed in our institution for CP. Perioperative mortality was 1%. Follow-up data using at least standardized questionnaires were available in 224 patients. The types of resection in these 224 patients were Whipple (9%), pylorus-preserving pancreato-duodenectomy (PD) (PPPD; 40%), duodenum-preserving pancreatic head resection (DPPHR; 41%, 50 Frey, 42 Beger), distal (9%) and two central pancreatic resections. Eighty-six of the patients were part of a randomized study comparing PPPD and DPPHR. The perioperative and follow-up (f/up) data were prospectively documented. Exocrine insufficiency was regarded as the presence of steatorrhea and/or the need for oral enzyme supplementation. Multivariate analysis was performed using binary logistic regression. Results Perioperative surgical morbidity was 28% and did not differ between the types of resection. At last f/up 87% of the patients were pain-free (60%) or had pain less frequently than once per week (27%). Thirteen percent had frequent pain, at least once per week (no difference between the operative procedures). A concomitant exocrine insufficiency and former postoperative surgical complications were the strongest independent risk factors for pain and frequent pain at follow-up. At the last f/up 65% had exocrine insufficiency, half of them developed it during the postoperative course. The presence of regional or generalized portal hypertension, a low preoperative body mass index, and a longer preoperative duration of CP were independent risk factors for exocrine insufficiency. Thirty-seven percent of the patients without preoperative diabetes developed de novo diabetes during f/up (no risk factor identified). Both, exocrine and endocrine insufficiencies were independent of the type of surgery. Median weight gain was 2 kg and higher in patients with preoperative malnutrition and in patients without abdominal pain. After PPPD, 8% of the patients had peptic jejunal ulcers, whereas 4% presented with biliary complications after DPPHR. Late mortality was analyzed in 233 patients. Survival rates after pancreatic resection for CP were 86% after 5 years and 65% after 10 years. Conclusions Pancreatic resection leads to adequate pain control in the majority of patients with CP. Long-term outcome does not depend on the type of surgical procedure but is in part influenced by severe preoperative CP and by postoperative surgical complications (regarding pain). A few patients develop procedure-related late complications. Late mortality is high, probably because of the high comorbidity (alcohol, smoking) in many of these patients.     

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.     

The lasso technique for laparoscopic distal pancreatectomy

Background Laparoscopic distal pancreatectomy with or without splenectomy is becoming an acceptable alternative to open resection for selected pancreatic lesions. One of the difficulties with this approach is manipulating the pancreas with laparoscopic instruments to avoid unnecessary injury to the pancreas, and yet obtain adequate margins. The described technique accomplishes these goals. Methods Data from all patients who underwent laparoscopic distal pancreatectomy (always with splenectomy) were reviewed for age, gender, laparoscopic completion of the resection, postoperative complications, length of hosptial stay, and pathology. The essential component of the technique is use of a Penrose drain around the neck or proximal body of the pancreas as a “lasso” for atraumatic manipulation. This technique is described in detail. Results A total of 11 patients have undergone laparoscopic distal pancreatectomy with splenectomy using the lasso technique. Two patients (18%) underwent conversion to an open laparotomy: the because of bleeding from the pancreatic parenchyma and the other due to local invasion of a pancreatic adenocarcinoma. The average operating time was 162 ± 39 min, and the median length of hosptial stay was 3 days. There were two (18%) pancreatic leaks, both of which were treated conservatively with resolution. Pathologic examination, found six cystic neoplasms, two neuroendocrine tumors, two masses of chronic pancreatitis, and one adenocarcinoma. Conclusions The lasso technique simplifies intraoperative manipulation of the pancreas during laparoscopic distal pancreatectomy. It allows for safe manipulation of the pancreas and may expand the indications for the laparoscopic approach to pancreatic resection. This article contains a supplementary video. Presented in part at the 2004 Scientific Session of the Society of American Gastrointestinal Endoscopic Surgeons, (SAGES), Denver, Colorado, 31 March to 2 April, 2004     

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.     

Postobstructive chronic pancreatitis: results with distal resection

HYPOTHESIS: For most patients with chronic obstructive pancreatitis, distal pancreatectomy confers pain relief. DESIGN: Retrospective case series. Follow-up was complete in 80% of study subjects (mean follow-up, 6.7 years). SETTING: Tertiary care center. PATIENTS: Among 484 patients with chronic pancreatitis undergoing operation from 1976 to 1997, 40 with postobstructive chronic pancreatitis were identified. Criteria for selection included an isolated, dominant major pancreatic duct stricture or cutoff, changes of chronic pancreatitis in the distal pancreas, and ostensibly normal parenchyma without calcification in the proximal gland. The patients were reviewed with regard to operative procedure, postoperative course, and outcome. MAIN OUTCOME MEASURES: Outcome measures included degree of pain relief, morbidity and mortality of operation, survival, rates of endocrine and exocrine insufficiency, and ability to return to work and/or normal activities. RESULTS: All but 1 of the 40 patients had abdominal pain, and 20 (50%) had recurrent episodes of acute pancreatitis. Suspicion of malignancy was a concern in 16 patients (40%). Thirty-eight patients underwent distal pancreatectomy; 1 had a central resection and another a Roux-en-Y cystojejunostomy. There was no operative mortality, but significant morbidity occurred in 15%. Among 31 patients with preoperative pain in whom long-term follow-up was available, complete or significant pain relief was achieved in 25 (81%); 74% returned to normal social function, but about half had some element of pancreatic insufficiency. CONCLUSIONS: Distal pancreatectomy is a safe procedure and achieves pain relief and good quality of life in a large percentage of patients (80%) with presumed postobstructive chronic pancreatitis. However, some of these patients with chronic pancreatitis involving the entire gland have disease masquerading as postobstructive chronic pancreatitis secondary to an ostensibly isolated dominant pancreatic ductal stricture.     

Multivisceral central pancreatectomy for pancreatic neuroendocrine tumor: A case report on a novel surgical technique

IntroductionCentral pancreatectomy (CP) is considered a viable alternative to subtotal distal pancreatectomy, for lesions involving the neck or proximal pancreatic body. Multivisceral central pancreatectomy (MVCP) for locally advanced tumors of the pancreatic body remains unreported.Presentation of caseWe hereby report a case of locally advanced pancreatic neuroendocrine tumor (NET) with gastric involvement. The patient underwent successful central pancreatectomy with subtotal gastrectomy for locally advanced NET of the pancreas. In the follow up period, relevant complications like pancreatic insufficiency or pancreatic fistula were not encountered. The patient is doing well more than ten months after resection.DiscussionA MVCP can be considered in patients with limited pancreatic involvement, as long as sufficient pancreatic parenchyma can be preserved. Additional organ involvement mandating resection should not be considered a contra indication to this procedure. With careful surgical planning and meticulous technique, risk of post operative complications after MVCP can be minimized with added benefit of long term endocrine and exocrine integrity.ConclusionsCP is a viable alternative and can be performed with adjacent organ resection, with acceptable post operative outcomes.     

Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization

HYPOTHESIS: Experience with pancreatic resection for the last 10 years has resulted in new trends in patient characteristics and, for pancreaticoduodenectomy (PD), a decrease in the length of stay (LOS). This decrease is due in part to the implementation of case management and clinical pathways. DESIGN: Retrospective case series of patients undergoing pancreatic resection. SETTING: A university-affiliated, tertiary care referral center. PATIENTS: The study comprised 733 consecutive patients undergoing pancreatic resection for benign or malignant disease at the Massachusetts General Hospital in Boston from April 1990 to March 2000. INTERVENTIONS: Of the 733 pancreatic resections, 489 were PD; 190, distal pancreatectomy; 40, total pancreatectomy; and 14, middle-segment pancreatectomy. MAIN OUTCOME MEASURES: Length of stay; occurrence of delayed gastric emptying, pancreatic fistula, reoperation, readmission, or other complications; mortality; and comparison of patients in 3 periods according to the implementation of case management (July 1995) and clinical pathways (September 1998). RESULTS: For PD, patients in group 1 (April 1990 to June 1995) were significantly younger (mean +/- SD, 57 +/- 15 years) than those in group 2 (July 1995 to August 1998; mean +/- SD, 62 +/- 13 years) and group 3 (September 1998 to October 2000; mean +/- SD, 65 +/- 13 years)(P <.01). Over time, the proportion of PD for cystic tumors increased from 9.9% to 20% (P =.01), and the proportion of PD for chronic pancreatitis decreased from 23% to 10% (P <.01). Use of pylorus-preserving PD decreased from 45% to 0% (P <.001). Delayed gastric emptying decreased from 17% to 6.1% (P <.01). Pancreatic fistula, reoperation, and mortality were unchanged. Length of stay for PD decreased from 16.1 +/- 0.6 to 9.5 +/- 0.4 days (mean +/- SE) (P <.001). Multivariate analysis showed that period, case volume, pylorus-preserving PD, and presence of complications are all independent predictors of LOS (P <.05 for all). For distal pancreatectomy, patients in groups 2 and 3 were older than those in group 1 (mean +/- SD, 57 +/-14 vs 52 +/- 17 years) (P <.05). Resections for cystic tumors increased from 26% to 52% (P <.05), and resections for chronic pancreatitis decreased from 32% to 14% (P =.06). Median LOS decreased from 9 days to 6. For total pancreatectomy, resections for cystic tumors increased from 18% to 43%. Median LOS decreased from 14.5 days to 11. For all resections, case volume increased from 4 resections per month in 1990 to 5.8 in 1995 and 12 in 2000 (r = 0.83; P <.001). CONCLUSIONS: Older patients are increasingly being selected for pancreatic resection. This reflects an increasing frequency of operations performed for cystic tumors and fewer for chronic pancreatitis. With the exception of delayed gastric emptying, complications and mortality have remained the same or decreased slightly during the past 10 years. However, there has been a significant decrease in LOS; this is the result of implementation of case management and clinical pathways, increasing case volume, decreasing incidence of delayed gastric emptying, and decreasing use of pylorus-preserving PD.     

Surgical treatment of chronic pancreatitis by distal pancreatectomy

No consensus exists on the best surgical treatment for chronic pancreatitis. In a retrospective study on 29 patients it was found that pain caused by chronic pancreatitis can be treated effectively by a 95% DP or a 40-80% DP. However, after a 40-80% DP the incidence of endocrine and exocrine pancreatic insufficiency is less frequent than after a 95% DP. Therefore, distal pancreatectomy can be advised as a treatment of pain, caused by chronic pancreatitis. In order to minimize the chance of pancreatic insufficiency resection should be done as conservatively as possible.     

Central pancreatectomy with pancreaticogastrostomy for benign pancreatic pathology

Benign lesions of the neck and proximal body of the pancreas pose an interesting surgical challenge. If the lesions are not amenable to simple enucleation, surgeons may be faced with the choice of performing a right-sided resection (pancreaticoduodenectomy) or a left-sided resection (distal pancreatectomy) to include the lesion, resulting in resection of a substantial amount of normal pancreatic parenchyma. Central pancreatic resection has been reported with Roux-en-Y pancreaticojejunostomy reconstruction; however, this interrupts small bowel continuity and obligates an additional anastomosis.We have reviewed our experience with central pancreatectomy with pancreaticogastrostomy (PG) for benign central pancreatic pathology. Between January 1999 and December 2002, 14 central pancreatectomies were performed with PG reconstruction. There were 7 women and 7 men with a mean age of 60.9 years. Five resections were performed for islet cell tumors, three were performed for noninvasive intraductal papillary mucinous neoplasms, two were performed for serous cystadenoma, and one each was performed for a simple cyst, pseudocyst, mucinous metaplasia, and focal chronic pancreatitis. Seven out of 14 patients experienced a total of 10 complications. Pancreatic fistulae manifested by drainage of amylase-rich fluid from the operatively placed drains developed in 5 patients (36%). Reoperation or interventional radiologic procedures were not required in any patient with a fistula. Postoperative follow-up demonstrated 13 out of 14 patients to be alive and well without evidence of pancreatic insufficiency. One patient died at home on postoperative day 57 of cardiac pathology. Central pancreatectomy withPGis a safe and effective procedure that allows for preservation of pancreatic endocrine and exocrine function without disruption of enteric continuity. The complication of pancreatic fistula was managed conservatively via maintenance of operatively placed drains. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (poster presentation).     

Use of lanreotide in the prevention of pancreatic fistula after cephalic duodeno-pancreatectomy. Preliminary study

STUDY AIM: Dehiscence of pancreatic anastomosis is the main complication after pancreatoduodenectomy. The efficacy of somatostatin analogue to prevent complications after pancreatic resections is at present well-established by several randomized trials. The aim of this preliminary prospective study was to assess the role of lanreotide (a long acting somatostatin analogue) in this field. PATIENTS AND METHOD: Forty patients with pancreatic head tumour have been included in a prospective study. Criteria for pancreatic fistula were: high concentration of amylase in the drainage fluid (> 3 times that in the serum), or intra-abdominal fluid collection adjacent to the pancreatic anastomosis, or reoperation (or postmortem verification) showing an anastomotic dehiscence. The patients received 12 h before the operation 30 mg of lanreotide intramuscularly. RESULTS: Of the 40 patients included prospectively, 34 underwent a pancreatic resection. Parenchyma of pancreatic remnant was crumbly in 28 cases. Six patients experienced a pancreatic fistula (17.6%) which healed in all cases. CONCLUSION: This preliminary study shows clearly the feasibility of a long acting somatostatin analogue (lanreotide) to prevent pancreatic fistula after pancreatectomy. This agent appears simple to use and its efficacy needs obviously to be assessed by randomized trials.     

Middle segmental pancreatic resection: An option to treat benign pancreatic body lesions

OBJECTIVE: To clarify whether middle segmental pancreatic resection can be performed with comparable morbidity and mortality to classic pancreatic resections for lesions in the mid-portion of the pancreas. SUMMARY BACKGROUND DATA: Pancreaticoduodenectomies or distal pancreatectomy, traditionally used to treat lesions of the pancreatic body, sacrifice a significant amount of normal pancreatic tissue. Middle segmental pancreatic resection has therefore been introduced to minimize loss of functioning pancreatic tissue. PATIENTS AND METHODS: In a prospective 4-year single-center study, 40 consecutive patients with lesions of the neck or the body of the pancreas underwent a middle segmental pancreatic resection. A matched-pairs analysis comparing middle segmental pancreatic resection with pp-Whipple and distal pancreatectomy was included. RESULTS: Seventeen patients had neoplastic lesions (4 solid malignancies, 9 cystic lesions, 4 neuroendocrine tumors) and 23 patients had focal chronic pancreatitis. Postoperative surgical morbidity was 27.5% and mortality 2.5%. The reoperation rate was 5.0%. Three patients (7.5%) developed pancreatic fistula. Median postoperative hospital stay was 11 days (range, 6-62 days). After a median follow-up of 29 months, 97.4% (38 patients) of the patients were satisfied with the operation. The mean quality of life status (EORTC QLQ-C30) was comparable to a normal control population. Matched-pairs analysis revealed no differences of perioperative parameters (except operation time), morbidity, and mortality. However, endocrine pancreatic function was better preserved (P < 0.05) in patients with middle segmental pancreatic resection. CONCLUSIONS: Middle segmental pancreatic resection is an appropriate procedure for selected patients with tumorous lesions in the mid-portion of the pancreas. It preserves pancreatic parenchyma and function and has a mortality and morbidity rate comparable to other pancreatic resection procedures.     

Long-term results of distal pancreatectomy for chronic pancreatitis in 90 patients

OBJECTIVE: To determine the indications for distal pancreatectomy for chronic pancreatitis and to evaluate the risks, functional loss, and outcome of the procedure. SUMMARY BACKGROUND DATA: Chronic pancreatitis is generally associated with continued pain, parenchymal and ductal hypertension. and progressive pancreatic dysfunction, and it is a cause of premature death in patients who receive conservative treatment. Good results have recently been reported by the authors and others for resection of the pancreatic head in this disease, but distal pancreatectomy is a less popular option attended by variable success rates. It remains a logical approach for patients with predominantly left-sided pancreatic disease, however. METHODS: A personal series of 90 patients undergoing distal pancreatectomy for chronic pancreatitis over the last 20 years has been reviewed, with a mean postoperative follow-up of 34 months (range 1-247). Pancreatic function was measured before and after operation in many patients. RESULTS: Forty-eight of 84 patients available for follow-up had a successful outcome in terms of zero or minimal, intermittent pain. There was one perioperative death, but complications developed in 29 patients, with six early reexplorations. Morbidity was unaffected by associated splenectomy or right-to-left dissection. Late mortality rate over the follow-up period was 10%; most of these late deaths occurred because of failure to abstain from alcohol. Preoperative exocrine function was abnormal in two thirds of those tested and was unchanged at follow-up. Diabetic curves were seen in 10% of patients preoperatively, while there was an additional diabetic morbidity rate of 23% related to the procedure and late onset of diabetes (median duration 27 months) in another 23%. Diabetic onset was related to percentage parenchymal resection as well as splenectomy. Outcome was not clearly dependent on the etiology of pancreatitis or on disease characteristics as assessed by preoperative imaging. However, patients with pseudocyst disease alone did better than other groups. Twenty-one of 36 patients who failed to respond to distal pancreatectomy required further intervention, including completion pancreatectomy, neurolysis, and sphincteroplasty. Thirteen of these 21 patients achieved long-term pain relief after their second procedure. CONCLUSIONS: Distal pancreatectomy for chronic pancreatitis from any etiology can be performed with low mortality and a good outcome in terms of pain relief and return to work in approximately 60% of patients. Little effect is seen on exocrine function of the pancreas, but there is a diabetic risk of 46% over 2 years. Pseudocyst disease is associated with the best outcome, but other manifestations of this disease, including strictures, calcification, and limited concomitant disease in the head of the pancreas, can still be associated with a good outcome.     

Intraperitoneal drainage after pancreatic resection: a review of the evidence

Background

Despite a growing body of literature supporting the limited use of prophylactic intra-abdominal drainage for many procedures, drain placement after pancreatic resection remains commonplace and highly controversial.

Materials and methods

Literature available in the PubMed was systematically reviewed by searching using combinations of keywords and citations in review articles regarding prophylactic drainage after pancreatic resection, early removal of intraoperatively placed drains after pancreatic resections, and risk factors and predictive tools for pancreatic fistula.

Results

Prospective randomized studies on prophylactic drainage after pancreaticoduodenectomy or distal pancreatectomy have not shown any benefit in decreasing pancreatic fistula, total complications, length of hospital stay, or readmission rates. Frequency of complications was significantly higher in patients receiving routine drainage. This was recently supported by retrospective studies; however, patients with risk factors for pancreatic fistula (soft pancreatic texture, prolonged operative times, and increased blood loss) were more likely to have prophylactic intra-abdominal drainage. Alternatively, if a drain is placed, prospective randomized studies demonstrate that early removal is safe in patients with postoperative day 1 drain amylase values <5000 U/L and associated with a lower rate of fistula.

Conclusions

The current literature supports a strategy of selective drainage and early drain removal after pancreatic resection in low-risk patients.     

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.     

Laparoscopic distal 70% pancreatectomy and splenectomy for chronic pancreatitis.

OBJECTIVE: The authors performed an initial clinical evaluation of laparoscopic pancreatectomy with splenectomy for chronic pancreatitis. SUMMARY BACKGROUND DATA: Severe intractable pain is the most common indication for resection in chronic pancreatitis. Localized accentuation of the pathology, usually in the head of the organ, is the basis for localized proximal resection, often with preservation of a rim of pancreas and the duodenum, although some favor total pancreatectomy. The reported results for distal pancreatectomy have been variable. Distal resections are limited to those patients in whom the gross pathology is maximal in the left hemipancreas. METHODS: A consecutive series of five patients with intractable pain due to chronic pancreatitis have been treated with laparoscopic 70% distal pancreatectomy and splenectomy using a 5-port technique. RESULTS: The procedure was completed in all with an average operating time of 4.5 hours and a mean intraoperative blood loss of 400 mL. There was one minor pancreatic leak, which resolved spontaneously. The median postoperative hospital stay was 6 days. CONCLUSIONS: Laparoscopic distal pancreatectomy for chronic pancreatitis is feasible, the procedure appears to be safe, and it is accompanied by an accelerated recovery.