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Distal Pancreatectomy (distal + pancreatectomy)

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Medical Sciences	100%

Selected Abstracts

Laparoscopic Donor Distal Pancreatectomy for Living Donor Pancreas and Pancreas,Kidney Transplantation

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 8 2005
Miguel Tan
With the proliferation and expanding applications of laparoscopic techniques, we determined the applicability of the laparoscopic approach to living pancreas donation. We performed the first laparoscopic donor distal pancreatectomy in 1999. We herein present our initial experience with five hand-assisted laparoscopic donor pancreatectomies. Three donors underwent distal pancreatectomy alone; two underwent a simultaneous left nephrectomy. The mean donor age was 48.4 ± 8.7 years with a body mass index of 23.7 kg/m2. The donor and recipient survival rate was 100% at up to 3 years of follow-up. There were no episodes of pancreatitis, leaks, or pseudocysts. All donors returned to their preoperative state of health and to work. None of the donors have required oral anti-diabetic medications or insulin. We conclude that laparoscopic donor distal pancreatectomy is a safe and efficient procedure; hand-assisted laparoscopic distal pancreatectomy appears to be preferable, because of the added margin of safety from increased tactile feedback and ease of pancreatic dissection. The procedure can be accomplished with a single 6-cm periumbilical incision and only two 12-mm ports, resulting in excellent cosmesis and high donor satisfaction. [source]

Diagnostic usefulness of laparoscopic fine-needle aspiration for intraductal papillary tumor of the pancreas

DIGESTIVE ENDOSCOPY, Issue 4 2001
Tomonori Akagi
A 67-year-old man who was followed up for 20 years for a diagnosis of chronic pancreatitis developed a unilocular cystic lesion in the pancreatic body and a gallstone. The cystic lesion (3.0 cm in diameter) was considered to be a pseudocyst with suspicion of a mucinous cystic tumor. Laparoscopic ultrasonography and fine-needle aspiration (FNA) were performed following laparoscopic cholecystectomy. Under laparoscopic observation, the pinhole puncture was immediately closed. Analysis of the fluid revealed clusters of epithelial cells with mild atypia, remarkably elevated tumor markers (carcinoembryonic antigen and CA19-9) and a K- ras oncogene mutation. Distal pancreatectomy was performed 3 months after laparoscopic FNA and the pancreatic mass was diagnosed as an intraductal papillary tumor. The patient's postoperative course was uneventful and he continues to do well without signs of recurrence. Laparoscopic FNA appears useful and safe for the diagnosis of cystic masses in the pancreas. [source]

Laparoscopic pancreatic surgery: a review of present results and future prospects

HPB, Issue 4 2010
Omer S. Al-Taan
Abstract Pancreatic surgery is still associated with a relatively high morbidity and mortality compared with other specialties. This is a result of the complex nature of the organ, the difficult access as a result of the retroperitoneal position and the number of technically challenging anastomoses required. Nevertheless, the past two decades have witnessed a steady improvement in morbidity and a decrease in mortality achieved through alterations of technique (particularly relating to the pancreatic anastomoses) together with hormonal manipulation to decrease pancreatic secretions. Recently minimally invasive pancreatic surgery has been attempted by several centres around the world which has stimulated considerable interest in this approach. The majority of the cases attempted have been distal pancreatectomies, because of the more straightforward nature of the resection and the lack of a pancreatic ductal anastomosis, but more recently reports of laparoscopic pancreaticoduodenectomy have started to appear. The reports of the series to date have been difficult to interpret and although the results are claimed to be equivalent or better than those associated with a traditional approach a careful examination of the literature and comparison with the best results previously reported does not presently support this. In the present review we examined all the reports of pancreatic procedures performed laparoscopically and compared the results with those previously achieved at open surgery. [source]

Pancreatic fistula after distal pancreatectomy: incidence, risk factors and management

ANZ JOURNAL OF SURGERY, Issue 9 2010
Chiow Adrian Kah Heng
Abstract Background:, Pancreatic fistulae post distal pancreatectomy still leads to significant morbidity and if not properly managed, may lead to mortality. The identification of risk factors and effective management of patients with pancreatic fistulae is important in the prevention of these complications. Methods:, There were 75 open consecutive distal pancreatectomies in the Department of Surgery, Changi General Hospital from May 2001 to May 2007. Results:, The indications for operation were neuroendocrine tumours (n= 15), adenocarcinoma (n= 20), Intraductal papillary mucinous tumour (IPMT) (n= 20), serous cysts (n= 15) and trauma (n= 5). There were 20 patients (27%) who developed pancreatic fistulae in the whole series. On univariate analysis, the patients with pancreatic fistulae had significantly more pre-morbidities, softer pancreas and use of staplers as a method of closure of the pancreatic remnant. On multivariate analysis, the use of staplers and soft pancreas were significant independent risk factors for the development of pancreatic fistulae in our patient population. All of the patients with pancreatic fistulae were successfully treated non-surgically with no mortality in the whole series. Conclusions:, The use of stapler on soft pancreas leads to a higher risk for pancreatic fistulae after distal pancreatectomies. Most pancreatic fistulae can be managed non-surgically with good outcome. [source]

Epidermoid cyst of the intrapancreatic accessory spleen producing CA19-9

DIGESTIVE ENDOSCOPY, Issue 3 2004
Hiroyuki Watanabe
We report a rare case of an epidermoid cyst in an accessory spleen at the pancreatic tail with producing CA19-9. A 55-year-old female was admitted to our hospital, Cancer Research Institute, Kanazawa University, for close examination of a cystic lesion at the pancreatic tail and a high serum CA19-9-value (176 U/mL). There were almost no abdominal symptoms related to the cystic lesion. A cystic tumor approximately 3 cm in diameter and composed of multilocular cysts without a protruding portion of the inner surface was found at the pancreatic tail by ultrasound sonography, computed tomography, and magnetic resonance imaging. Endoscopic retrograde pancreatography revealed that the main pancreatic duct shifted at the pancreatic tail and there was no communication between the main pancreatic duct and cystic lesion. Based on a preoperative diagnosis of mucinous cystic tumor, distal pancreatectomy with splenectomy was performed. Histological ,ndings suggested an epidermoid cyst (3.5 × 3.0 cm) originating from an intrapancreatic accessory spleen. Immunohistochemical analysis of CA19-9 in the epidermoid cyst showed clear staining of the inner epithelium of the cyst and amorphous or hyalinous cystic contents. The serum CA19-9 value was con,rmed to decline to normal 2 months after resection. Physicians should not forget this disease during differential diagnosis related to pancreatic cystic lesions with elevated levels of serum tumor markers, such as CA19-9 or carcinoembryonic antigen, although this disease is extremely rare. [source]

Haemosuccus pancreaticus: diagnostic and therapeutic challenges

HPB, Issue 4 2009
Velayutham Vimalraj
Abstract Background:, Haemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. The objective of our study was to highlight the challenges in the diagnosis and management of HP. Methods:, The records of 31 patients with HP diagnosed between January 1997 and June 2008 were reviewed retrospectively. Results:, Mean patient age was 34 years (11,55 years). Twelve patients had chronic alcoholic pancreatitis, 16 had tropical pancreatitis, two had acute pancreatitis and one had idiopathic pancreatitis. Selective arterial embolization was attempted in 22 of 26 (84%) patients and was successful in 11 of the 22 (50%). Twenty of 31 (64%) patients required surgery to control bleeding after the failure of arterial embolization in 11 and in an emergent setting in nine patients. Procedures included distal pancreatectomy and splenectomy, central pancreatectomy, intracystic ligation of the blood vessel, and aneurysmal ligation and bypass graft in 11, two, six and one patients, respectively. There were no deaths. Length of follow-up ranged from 6 months to 10 years. Conclusions:, Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. Diagnosis is based on investigations that should be performed in all patients, preferably during a period of active bleeding. These include upper digestive endoscopy, contrast-enhanced computed tomography (CECT) and selective arteriography of the coeliac trunk and superior mesenteric artery. Contrast-enhanced CT had a high positive yield comparable with that of selective angiography in our series. Therapeutic options consist of selective embolization and surgery. Endovascular treatment can control unstable haemodynamics and can be sufficient in some cases. However, in patients with persistent unstable haemodynamics, recurrent bleeding or failed embolization, surgery is required. [source]

D2 gastrectomy , a safe operation in experienced hands,

INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 6 2005
R.S. Date
Summary In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler. [source]

Is there an indication for initial conservative management of pancreatic cystic lesions?,

JOURNAL OF SURGICAL ONCOLOGY, Issue 5 2009
Stephen R. Grobmyer MD
Abstract Background The management of small pancreatic cystic lesions presents a clinical challenge. Methods We reviewed our experience with 78 patients who presented with a cystic pancreatic lesion who underwent operative management between 1995 and 2005. Data on cyst characteristics were analyzed in the context of pathologic findings following resection. Results Among 78 patients, there were 55 (71%) females; median age 63 years. Patients presented with: an incidental finding (48%), pain (40%), acute pancreatitis (4%), other (8%). Operations were distal pancreatectomy (n,=,47), pancreaticoduodenectomy (n,=,16), and other (n,=,15). Most patients had a non-malignant lesion (n,=,65, 83%) (mucinous cystadenoma (n,=,29), serous cystadenoma (n,=,15), IPMN without invasion (n,=,8), pseudocyst (n,=,8), other benign (n,=,5)). Malignant lesions (adenocarcinoma, neuroendocrine tumor, and other) were found in 13 patients (17%). The risk of malignancy increased with size: <3 cm (n,=,25), 4%; 3,5 cm (n,=,23), 13%; and >5 cm (n,=,30), 30%. Pre-operative cyst fluid cytology was performed in 41 patients. The negative predictive value (NPV) of cytology for malignancy was 88% and the positive predictive value (PPV) was 80%. The NPV of CA 19-9 for malignancy was 90%; the PPV was 50%. Conclusions Initial conservative management of small cystic pancreatic lesions may be indicated in selected patients. J. Surg. Oncol. 2009;100:372,374. © 2009 Wiley-Liss, Inc. [source]

Mucinous cystadenoma of the pancreas with huge mural hematoma

PATHOLOGY INTERNATIONAL, Issue 10 2009
Takeshi Hisa
A 60-year-old woman was referred for evaluation of a cystic mass in the pancreatic body that extended to the tail. Transabdominal ultrasonography demonstrated an oval cystic mass 24 cm in diameter, filled with debris. On the cyst wall there was a wide-based, smooth-surfaced, heterogeneous high-echoic protrusion that was 5 cm in diameter. On CT the protrusion showed internal enhancement. Endoscopic pancreatography showed no intraductal mucin or communication with the cyst. A distal pancreatectomy was performed under the diagnosis of mucinous cystadenocarcinoma. Grossly there was a brownish, hemispherical protrusion into the thin monolocular cyst. The cut surface of the protrusion showed a peripheral yellow-brownish area and an internal wine-colored area. Histopathologically the cyst wall consisted of tall columnar cells without atypical nuclei, ovarian-type stroma beneath the epithelium, and fibrotic tissue with abundant capillary vessels, suggestive of a mucinous cystadenoma. The protrusion was composed of peripheral organized hematoma without a covering epithelium, and internal hemorrhage and many capillary vessels, with no evidence of tumor cell necrosis. These histopathological findings appear to be similar to those of chronic expanding hematoma. The formation of a huge mural hematoma in a mucinous cystic neoplasm can occur as a repair process after the breaking of intrawall vessels. [source]

Laparoscopic Donor Distal Pancreatectomy for Living Donor Pancreas and Pancreas,Kidney Transplantation

Pancreatic fistula after distal pancreatectomy: incidence, risk factors and management

Novel approach to laparoscopic resection of tumours of the distal pancreas

ANZ JOURNAL OF SURGERY, Issue 4 2009
Soumen Das De
Abstract Background:, Laparoscopic resection for small lesions of the pancreas has recently gained popularity. We report our initial experience with a new approach to laparoscopic spleen-preserving distal pancreatectomy so that the maximum amount of normal pancreas can be preserved while ensuring adequate resection margins and preservation of the spleen and splenic vessels. Methods:, Three patients underwent laparoscopic distal pancreatectomy with spleen and splenic vessel preservation over a 2-month period. Surgical techniques and patient outcomes were examined. Results:, All three patients were females, with ages ranging from 31 to 47 years. Two patients underwent resection using the conventional medial-to-lateral dissection as the lesion was close to the body or proximal tail of the pancreas. The third patient had a lesion in the distal tail of the pancreas and surgery was carried out in a lateral-to-medial manner. This new approach minimized excessive sacrifice of normal pancreatic tissue for such distally located lesions. The splenic artery and vein were preserved in all cases and there was no significant difference in clinical outcome, operative time or intraoperative blood loss. Conclusion:, Laparoscopic distal pancreatectomy with preservation of the spleen and splenic vessels is a feasible surgical technique with acceptable outcome. We have shown that a tailored approach to dissection and pancreatic transection based on the location of the lesion allows the maximum amount of normal pancreatic tissue to be preserved without additional morbidity. Although the conventional ,medial-to-lateral' approach is recommended for more proximal tumours of the pancreas, distal lesions can be safely addressed using the ,lateral-to-medial' approach. [source]

Clinical features and morphological characterization of 10 patients with noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS)

CLINICAL ENDOCRINOLOGY, Issue 5 2006
Justin G. S. Won
Summary Objective, Noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS), characterized by postprandial neuroglycopaenia, negative prolonged fasts and negative perioperative localization studies for insulinoma, but positive selective arterial calcium stimulation tests and nesidioblastosis in the gradient-guided resected pancreas, is a rare hypoglycaemic disorder of undetermined aetiology. We analysed the clinical, morphological and immunohistological features to further clarify the aetiology and pathogenesis of this rare disease. Patients, Ten consecutive patients with NIPHS (nine men and one woman, aged 29,78 years) were included in the study. Six of the 10 received a gradient-guided subtotal (70%) or distal (50%) pancreatectomy. In the remaining four patients, diazoxide treatment was initiated and the precise mechanism of its action was assessed by meal tests. Results, All of the patients showed a combination of postprandial neuroglycopaenia, negative prolonged fasts (except one patient) and negative localization studies for insulinoma, but positive calcium stimulation tests and nesidioblastosis in the gradient-guided resected pancreas. Immunohistological studies of the resected pancreatic tissues revealed neither an increased rate of proliferation of ,-cells nor an abnormal synthesis and/or processing of either proinsulin or amylin. Evidence of overexpression of the two pancreatic differentiation factors, PDX-1 and Nkx-6·1, as well as the calcium sensing receptor (CaSR) was absent. Nevertheless, abnormal expression of islet neogenesis-associated protein (INGAP), a human cytokine expressed only in the presence of islet neogenesis, in ducts and/or islets, was identified in three of the five patients studied. All of the six patients who received a surgical operation were relieved of further neuroglycopaenic attacks, but one patient who received a subtotal pancreatectomy developed diabetes. In the remaining four patients who received diazoxide treatment, hypoglycaemic episodes were satisfactorily controlled with an attenuated response of ,-cell peptides to meal stimulation. Conclusions, Our results strengthen the existence of this unique clinical hypoglycaemic syndrome from ,-cell hyperfunction as well as the value of the selective arterial calcium stimulation test in its correct diagnosis and localization. The mechanisms underlying ,-cell hyperfunction and release of insulin to calcium, however, remain poorly characterized. Nevertheless, in a subset of patients with NIPHS, there exists some, as yet undefined, pancreatic humoral/paracrine factor(s) other than proinsulin, amylin, PDX-1, Nkx-6·1 and possibly glucagon-like peptide-1 (GLP-1) that are capable of inducing the INGAP gene and, if activated, will initiate ductal proliferation and islet neogenesis. As for the treatment, we recommend that diazoxide be tried first in each patient and, should it fail, a gradient-guided subtotal or distal pancreatectomy be attempted. [source]