Laparoscopic central pancreatectomy with gastro-pancreatic anastomosis for symptomatic serous cystadenoma:A case report and literature review

Surgery for lesions of the proximal part of the pancreatic body or neck can be challenging,and when enucleation is not possible,central pancreatectomy is an option.Laparoscopic central pancreatic resection is rarely described worldwide;it is considered a difficult procedure mainly because of the risk of double pancreatic fistula developing at two sites of resection.However,it seems to be an excellent alternative to distal pancreatectomy or pancreaticoduodenectomy,with the advantages of preserving functioning parenchyma and reducing endocrine and exocrine failure.Nevertheless,patients with pancreatic lesions requiring central resection are often managed with the open approach in many hospitals due to the complexity of total laparoscopic central pancreatectomy,which requires advanced laparoscopic skills,expertise and experience.Here,we report a case of a 29-year-old female who underwent total laparoscopic central pancreatic resection with gastro-pancreatic anastomosis for symptomatic serous cystadenoma.We discuss the details of case management and review the relevant literature.

Central pancreatectomy: The Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach

Central pancreatectomy(CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection(SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot(1957) and Letton and Wilson(1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came.

Pancreatic fistula after central pancreatectomy: case series and review of the literature

BACKGROUND: Postoperative pancreatic fistula is one of the most common complications after pancreatectomy. This study aimed to assess the occurrence and severity of pancreatic fistula after central pancreatectomy.METHODS: The medical records of 13 patients who had undergone central pancreatectomy were retrospectively studied together with a literature review of studies including at least five cases of central pancreatectomy. Pancreatic fistula was defined and graded according to the recommendations of the International Study Group on Pancreatic Fistula (ISGPF).RESULTS: No death was observed in the 13 patients. Pancreatic fistula developed in 7 patients and was successfully treated nonoperatively. None of these patients required re-operation. A total of 40 studies involving 867 patients who underwent central pancreatectomy were reviewed. The overall pancreatic fistula rate of the patients was 33.4% (0-100%). Of 279 patients, 250(89.6%) had grade A or B fistulae of ISGPF and were treated nonoperatively, and the remaining 29 (10.4%) had grade C fistulae of ISGPF. In 194 patients, 15 (7.7%) were re-operated upon. Only one patient with grade C fistula of ISGPF died from multiple organ failure after re-operation.CONCLUSION: Despite the relatively high occurrence, most pancreatic fistulae after central pancreatectomy are recognized a grade A or B fistula of ISGPF, which can be treated conservatively or by mini-invasive approaches.

Central pancreatectomy for benign or low-grade malignant pancreatic tumors in the neck and body of the pancreas

BACKGROUND For tumors in the neck and body of the pancreas,distal pancreatectomy(DP)has been the standard surgical procedure for the last few decades and central pancreatectomy(CP)is an alternative surgical option.Whether CP better preserves remnant pancreatic endocrine and exocrine functions after surgery remains a subject of debate.AIM To evaluate the safety and efficacy of CP compared with DP for benign or lowgrade malignant pancreatic tumors in the neck and body of the pancreas.METHODS This retrospective study enrolled 296 patients who underwent CP or DP for benign and low-malignant neoplasms at the same hospital between January 2016 and March 2020.Perioperative outcomes and long-term morbidity of endocrine/exocrine function were prospectively evaluated.RESULTS No significant difference was observed in overall morbidity or clinically relevant postoperative pancreatic fistula between the two groups(P=0.055).Delayed gastric emptying occurred more frequently in the CP group than in the DP group(29.4%vs 15.3%;P<0.005).None of the patients in the CP group had new-onset or aggravated distal metastasis,whereas 40 patients in the DP group had endocrine function deficiency after surgery(P<0.05).There was no significant difference in the incidence of diarrhea immediately after surgery,but at postoperative 12 mo,a significantly higher number of patients had diarrhea in the DP group than in the CP group(0%vs 9.5%;P<0.05).CONCLUSION CP is a generally safe procedure and is better than DP in preserving long-term pancreatic endocrine and exocrine functions.Therefore,CP might be a better option for treating benign or low-grade malignant neoplasms in suitable patients.

Central pancreatectomy:a new technique for resection of selected pancreatic tumors

BACKGROUND:Pancreatic tumors located in the neck region usually require pancreaticoduodenectomy or splenopancreatectomy.For small benign tumors enucleation is not usually feasible due to their size and localization;then pancreatectomy is often needed.Central pancreatectomy consists of a limited resection of the midportion of the pancreas and can be offered in benign and low-grade malignant tumors of the neck of the pancreas.The study aimed to evaluate whether central pancreatectomy has a place in pancreatic surgery. METHODS:In this study,which covered a period of 14 months,we performed central pancreatectomy in four selected patients.Preoperative evaluation and operative frozen section biopsy in indicated cases allowed proper selection for the procedure.Operative details,complications and follow-up were recorded. RESULTS:Four patients,two with serous cystadenoma,and one with an islet cell tumor,and one with a hydatid cyst, were identified for the procedure.The mean tumor size was 3 cm,the mean operative time was 217.5 minutes,and the mean blood loss was 382.5 ml.There was no morbidity or mortality in this series.No endocrine or exocrine deficiency was observed in any patient during a mean follow-up of 22.7 months. CONCLUSIONS:Central pancreatectomy is a procedure that offers excellent results in benign and low-grade malignant tumors.It preserves functional elements(endocrine and exocrine)of the pancreas and also eliminates the infective and hematological effects of splenectomy.Thus,central pancreatectomy should be included in the armamentarium of pancreatic surgery,and in order to obtain good results,proper indications and adequate experience are recommended.

Optimizing prediction models for pancreatic fistula after pancreatectomy:Current status and future perspectives

Postoperative pancreatic fistula(POPF)is a frequent complication after pancre-atectomy,leading to increased morbidity and mortality.Optimizing prediction models for POPF has emerged as a critical focus in surgical research.Although over sixty models following pancreaticoduodenectomy,predominantly reliant on a variety of clinical,surgical,and radiological parameters,have been documented,their predictive accuracy remains suboptimal in external validation and across diverse populations.As models after distal pancreatectomy continue to be pro-gressively reported,their external validation is eagerly anticipated.Conversely,POPF prediction after central pancreatectomy is in its nascent stage,warranting urgent need for further development and validation.The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance.Moreover,there is potential for the development of personalized prediction models based on patient-or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF.In the future,prospective multicenter studies and the integration of novel imaging technologies,such as artificial intelligence-based radiomics,may further refine predictive models.Addressing these issues is anticipated to revolutionize risk stratification,clinical decision-making,and postoperative management in patients undergoing pancre-atectomy.

Quality of life after pancreatic surgery

BACKGROUND Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas.Increasing attention has been paid to changes in quality of life(QOL)after pancreatic surgery.AIM To summarize and analyze current research results on QOL after pancreatic surgery.METHODS A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Relevant studies were identified by screening the references of retrieved articles.Studies on patients’QOL after pancreatic surgery published after January 1,2012,were included.These included prospective and retrospective studies on patients'QOL after several types of pancreatic surgeries.The results of these primary studies were summarized inductively.RESULTS A total of 45 articles were included in the study,of which 13 were related to pancreaticoduodenectomy(PD),seven to duodenum-preserving pancreatic head resection(DPPHR),nine to distal pancreatectomy(DP),two to central pancre-atectomy(CP),and 14 to total pancreatectomy(TP).Some studies showed that 3-6 months were needed for QOL recovery after PD,whereas others showed that 6-12 months was more accurate.Although TP and PD had similar influences on QOL,patients needed longer to recover to preoperative or baseline levels after TP.The QOL was better after DPPHR than PD.However,the superiority of the QOL between patients who underwent CP and PD remains controversial.The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL.Minimally invasive surgery could improve patients’QOL in the early Core Tip:This review summarizes and analyzes current research results on quality of life(QOL)after pancreatic surgery.The article covers the discussion and analysis of the QOL of various pancreatic surgeries.Which kind of surgical procedure has better QOL is controversial.The long-term benefits on QOL of minimally invasive surgery over open surgery are contro-INTRODUCTION The pancreas,located in the retroperitoneum,is a glandular organ with endocrine and exocrine functions.It can be divided into four main parts:Head,neck,body,and tail.Pancreatic surgery can be divided into pancreaticoduoden-ectomy(PD),duodenum-preserving pancreatic head resection(DPPHR),distal pancreatectomy(DP),central pancre-atectomy(CP),and total pancreatectomy(TP).Pancreatic surgery is challenging due to the organ’s complex anatomical structure,peripheral vascularity,and intractable postoperative complications.Following the standardization of surgical steps and improvements in relevant medical techniques and surgical instruments,the safety of pancreatic surgery has significantly improved.Perioperative morbidity,mortality,and other related indicators have become more acceptable.However,owing to the organ’s essential role in digestion,absorption,and blood glucose regulation,changes in the quality of life(QOL)of patients after pancreatic surgery have attracted the attention of surgeons.More patients with non-malignant pancreatic diseases are willing to undergo surgical treatment because of the acceptable safety.In this case,from the perspective of the patient postoperatively,the significance of rehabilitation reflects the traditional perioperative outcome and QOL[1].The QOL is a new concept that extends beyond health.Although there is no consensus on its conception[2],we can consider it a multi-dimensional architecture that incorporates objective and individual subjective views of aspects of one’s physical,psychological,and social well-being[3-5].It includes evaluating physical health,and many subscales,such as emotion,job,culture,family,sociability,economy,cognition,happiness,sex,and some symptoms[6].Since people have realized the importance of QOL,many QOL scales have emerged,including the European Organization for Research and Treatment of Cancer QLQ-C30,European Quality of Life 5-dimension,36-item Short,etc.However,it is challenging to follow up on patients’QOL once they are discharged from the hospital.Consequently,most relevant studies had small sample sizes or lacked long-term follow-up results.Moreover,a summary of studies on QOL after pancreatic surgery is lacking.This study assessed the QOL in patients who underwent PD,DPPHR,DP,CP and TP.We conducted this study to describe the existing findings on the QOL after pancreatic surgery to make it easier for surgeons and patients to decide on a surgical approach.In addition,we attempted to identify controversial results to encourage further targeted research.

Minimally invasive pancreatic surgery:An upward spiral

Minimally invasive techniques have been widely applied in general surgery for decades,but the generalization in pancreatic resection underwent a hard process for the complexity of the procedure.The current studies suggested that the safety and feasibility of minimally invasive pancreatic surgery(MIPS)were approximately equivalent to that of open surgery,but the overall benefit and the oncological outcomes of MIPS remained to be verified.Inferior outcomes were observed in the initial learning curve phase and low-volume hospitals,thus establishing a program that can well assess the learning process and minimize the harm to patients was essential.To ensure safety,the patients should be strictly selected in the early phase of the learning curve,and a careful and judicious stepwise should be considered to broaden the indications.

Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections

Objective： The aim of this study was to evaluate the safety and efficiency of enucleation（EU） for proximal pancreatic non-invasive neoplasms.Methods： Patients with solitary non-invasive neoplasms in the proximal pancreas from January 1998 to April 2014 at the Second Affiliated Hospital of Zhejiang University, Hangzhou, China were included.Different operations and outcomes were analyzed.Results： A total of 123 patients were enrolled.Forty patients（32.5%） underwent EU including 18 patients who had tumors close to the main pancreatic duct（MPD）.Sixty-one patients（49.6%） had pancreaticoduodenectomy（PD） performed and 22（17.9%） underwent central pancreatectomy（CP）.Pathological outcomes included neuroendocrine tumors, cystic lesions, and solid pseudopapillary tumors.Operation time, intra-operative blood loss, and duration of hospital stay were significantly reduced in the EU group.PD was associated with the greatest complication rate（55.7%）, followed by EU（50%） and CP（40.9%）, though the pancreatic fistula rate after EU was the highest（50%）, especially in patients with tumors larger than 3 cm and tumors close to the MPD.EU had advantages in the preservation of pancreatic parenchyma and endocrine and exocrine function.Conclusions： EU can be carried out safely and effectively for tumors in the proximal pancreas with improved outcomes compared with standard resections, even if the tumor is larger than 3 cm and close to the MPD.