Middle-preserving pancreatectomy: an interesting procedure for pancreas-sparing resection (original) (raw)
Related papers
Clinical journal of gastroenterology, 2014
Multifocal or continuous pancreatic lesion is identified frequently but finding an appropriate surgical approach is quite challenging. Total pancreatectomy is a useful procedure. However, postoperative endocrine and exocrine disturbance is inevitable. Recently, the safety and feasibility of parenchyma preserving pancreatectomy, including middle-preserving pancreatectomy (MPP), have been reported. MPP is a combined procedure of pancreaticoduodenectomy and distal pancreatectomy, while preserving the body of the pancreas, for cases of multifocal pancreatic lesions. So far, there have only been a few reports that have described MPP. We report a case of MPP for multifocal intraductal papillary mucinous neoplasms of the pancreas, describe the surgical procedure, and discuss the feasibility of MPP as parenchyma-preserving pancreatectomy with reference to the literature.
Annals of Surgery, 2014
Objective: To assess the feasibility and outcomes of parenchyma-sparing pancreatectomy (PSP), including enucleation (EN), resection of uncinate process (RUP), and central pancreatectomy (CP), as an alternative to standard pancreatectomy for presumed noninvasive intraductal papillary and mucinous neoplasms (IPMNs). Background: Pancreaticoduodenectomy and distal pancreatectomy are associated with significant perioperative morbidity, a substantial risk of pancreatic insufficiency, and may overtreat noninvasive IPMNs. Methods: From 1999 to 2011, PSP was attempted in 91 patients with presumed noninvasive IPMNs, after complete preoperative work-up including computed tomography, magnetic resonance imaging, and endoscopic ultrasonography. Intraoperative frozen section examination was routinely performed to assess surgical margins and rule out invasive malignancy. Follow-up included clinical, biochemical, and radiological assessments. Results: Overall PSP was achieved with a feasibility rate of 89% (n = 81), including 44 ENs, 5 RUPs, and 32 CPs. Postoperative mortality rate was 1.3% (n = 1), and overall morbidity was noteworthy (61%; n = 47). Definitive pathological examination confirmed IPMN diagnosis in 95% of patients (n = 77), all except 2 (3%), without invasive component. After a median follow-up of 50 months, both pancreatic endocrine/exocrine functions were preserved in 92% of patients. Ten-year progression-free survival was 76%, and reoperation for recurrence was required in 4% of patients (n = 3). Conclusions: In selected patients, PSP for presumed noninvasive IPMN in experienced hands is highly feasible and avoids inappropriate standard resections for IPMN-mimicking lesions. Early morbidity is greater than that after standard resections but counterbalanced by preservation of pancreatic endocrine/exocrine functions and a low rate of reoperation for tumor recurrence.
Journal of the American College of Surgeons, 2015
Because of its known malignant potential, precise histologic diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN) during intraoperative pancreatoscopy (IOP) is essential for complete surgical resection. The impact of IOP on perioperative IPMN patient management was reviewed over 20 years of practice at Cliniques universitaires Saint-Luc, Brussels, Belgium. Among 86 IPMN patients treated by pancreatectomy between 1991 and 2013, 21 patients had a dilated main pancreatic duct enabling IOP and were retrospectively reviewed. The IOP was performed using an ultrathin flexible endoscope and biopsy forceps, and specimens of all suspicious lesions underwent frozen section examination. Complete IOP with intraductal biopsies was easily and safely performed in 21 patients, revealing 8 occult IPMN lesions. In 5 cases (23.8%), initially planned surgical resection was modified secondary to IOP: 3 for carcinoma in situ and 2 for invasive carcinoma. The postoperative morbidity rate at 3 months was 25.0% (5 of 20); 1 patient died from septic shock postoperatively and was excluded. Median follow-up was 93 months (range 13 to 248 months). Nineteen of 21 patients were still alive and free of disease at last follow-up (90.5%); there was 1 patient with invasive carcinoma at initial pathology (pT3 N1) who died of pulmonary recurrence 21 months after surgery. Intraoperative pancreatoscopy of the main pancreatic duct combined with intraductal biopsies plays a significant role in the surgical management of IPMN patients and should be used in all patients presenting a sufficiently dilated main pancreatic duct.
Comparison of Resected and Non-resected Intraductal Papillary Mucinous Neoplasms of the Pancreas
World Journal of Surgery, 2005
By comparing the clinicopathological features and survivals between the resected and non-resected intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, this study tried to clarify the natural history of IPMNs, to provide a strategy for treatment, and to determine the justification of not performing resection for some patients. A total of 57 patients with IPMN, including 39 resected and 18 non-resected IPMNs, were recruited for study. Data on demographics, clinical presentations, diagnostic work-up, treatment modality, clinical course, and outcomes were evaluated and compared between the resected and non-resected IPMNs. The most common clinical presentation was abdominal pain (57% in total IPMNs, 67% in resected, 33% in non-resected), followed by body weight loss (32% in total IPMNs, 33% in resected, 28% in non-resected). The sensitivity in the diagnosis of IPMN was highest by magnetic resonance cholangiopancreatography (MRCP) (88%), followed by endoscopic retrograde cholangiopancreatography (ERCP) (68%), and computed tomography scan (CT scan) (42%) and sonography (10%). The median survival was 21.5 months for patients with resected IPMNs, ranging from 2 to 124 months, and 14 months in non-resected IPMN patients, ranging from 5.5 to 70 months. There is no significant survival difference between the resected and non-resected groups, with a 5-year survival of 69.8% in resected IPMNs and 59.8% in non-resected IPMNs, P = 0.347. The survival outcome of the unresectable non-resected IPMNs was much inferior to the resected IPMNs, P = 0.002 and resectable non-resected IPMNs, P = 0.001. Thus, the prime prognostic factor in predicting the survival outcome of IPMNs is resectability, instead of resection itself. Long-term survival could also be expected in resectable IPMNs without resection. No resection for the IPMN may be justified for patients with high surgical risks, especially for those who are asymptomatic and very aged.
Surgical Management of Intraductal Papillary Mucinous Tumors of the Pancreas
Archives of Surgery, 2001
Hypothesis: Resection of intraductal papillary mucinous tumors of the pancreas (IPMTP) should be tailored to longitudinal spreading into the pancreatic ductal system and the presence of malignant transformation. Objective: To review a single institutional experience with IPMTP, focusing on the operative strategy of tailoring resection to the extent of disease. Design: Retrospective study. Setting: Academic tertiary referral center. Patients: Thirteen patients with IPMTP were referred for resection during the past 10 years. Malignant growth was present in 7 patients (54%). According to the determination of tumor extent, distal pancreatic resection was performed in 3 patients, pancreatoduodenectomy was done in 9 patients, and total pancreatectomy was performed in 1 patient. The median follow-up time in this series was 46 months (range, 3-104 months). Main Outcome Measures: Preoperative and perioperative diagnosis, final pathologic results, and longterm outcome. Results: A correct preoperative or perioperative diagnosis of IPMTP was achieved in 9 patients (69%). Routine frozen section of the surgical margin was used in all patients, changing the operative strategy in 3 (23%) of
Inferior head resection of the pancreas for intraductal papillary mucinous neoplasms
Journal of hepato-biliary-pancreatic sciences, 2010
Previous reports have suggested that patients with intraductal papillary mucinous neoplasm (IPMN) have a favorable prognosis after surgical resection. Thus, a variety of types of partial pancreatic resections have been advocated for treating these low-grade malignant tumors. However, the surgical outcome of IPMN after such limited pancreatectomy has not been fully clarified. We performed a retrospective review of the clinicopathologic features and surgical outcome in 15 patients who underwent inferior head resection for IPMN at the Chiba University Hospital and National Cancer Center Hospital East between July 1994 and January 2007. There were 13 patients with noninvasive IPMNs (10 adenomas and 3 noninvasive carcinomas) and 2 patients with minimally invasive intraductal papillary mucinous carcinoma (minimally invasive IPMN). Complete tumor removal (R0 resection) was performed in four patients (80%) with intraductal papillary mucinous carcinoma. Subsequent pancreatoduodenectomy was p...
Management of intraductal papillary mucinous tumours of the pancreas
European Journal of Surgery, 1999
Objective: To focus attention on the management and outcome of patients with intraductal papillary mucinous tumours of the pancreas. Design: Retrospective study and analysis of published reports. Setting: University hospital, France. Subjects: 111 patients (101 published cases and our own 10 cases) divided in two groups: the first including malignant tumours (n = 46), and the second group benign or in situ tumours (n = 61). In 4 patients the type of tumour was not known. Main outcome measure: Resectability, mortality and recurrence. Results: More men had benign or in situ tumours [48/61 (79%) compared with 28/46 (61%), p = 0.054]. Pancreatitis was more common among benign than malignant tumours [34/61 (58%) compared with 21/46 (46%), p = 0.33]. In group I, 39 patients had diabetes. A total of 107 patients were operated on: pancreaticoduodenectomy (n = 54, 50%), distal pancreatectomy (n = 25, 23%), total pancreatectomy (n = 4, 4%), bypass (n = 2, 2%). The type of resection was not mentioned in 22 records (21%). Four patients were not operated on because of their poor general condition. The resectability rate was 98% (105/107). Eleven patients had died at the time of publication. Hospital mortality rate was 3% (n = 3), mainly because 2 of the 4 who had total pancreatectomy died. With a median follow-up of 37 months, recurrence was 5% (n = 5). Conclusion: Intraductal papillary mucinous tumours of the pancreas are well known distinctive pancreatic tumours that are usually intraductal but may develop into invasive carcinoma. They should be resected, and have a good prognosis and low recurrence rate.
American Journal of Surgical Pathology, 2006
external beam radiation. Six were found to have peritoneal metastasis. Total pancreatectomy with mesenteric vein +/À arterial resection and reconstruction was the most common procedure in the PEAR group. Celiac and SMA resection and reconstruction were carried out in 2 patients each. The 30-day morbidity and mortality was 30% and 0% respectively. The median OS and DFS were 47 and 39 weeks respectively. In the upfront resection group the median OS and DFS was 48 and 32 weeks respectively, while in the PEAR group, the median OS and DFS were 47 and 34 weeks respectively (p = 0.74). Conclusion: In summary, our findings support upfront resection of LAPC without arterial or extensive portalmesenteric venous involvement and the use of neoadjuvant therapy to select LAPC cases, including limited arterial involvement, for resection.