Distal Pancreatic Resection Research Articles

An updated systematic review and meta-analysis of the use of octreotide for the prevention of postoperative complications after pancreatic resection.

Background:The use of octreotide prophylaxis following pancreatic surgery is controversial. We aimed to evaluate the effectiveness of octreotide for the prevention of postoperative complications after pancreatic surgery through this systematic review and meta-analysis.Methods:Literature databases (including the MEDLINE, EMBASE, and Cochrane databases) were searched systematically for relevant articles. Only randomized controlled trials (RCTs) were eligible for inclusion in our research. We extracted the basic information regarding the patients, intervention procedures, and all complications after pancreatic surgery and then performed the meta-analysis.Results:Thirteen RCTs involving 2006 patients were identified. There were no differences between the octreotide group and the placebo group with regard to pancreatic fistulas (PFs) (relative risk [RR] = 0.79, 95% confidence interval [CI] = 0.62–0.99, P = .05), clinically significant PFs (RR = 1.01, 95% CI = 0.68–1.50, P = .95), mortality (RR = 1.21, 95% CI = 0.78–1.88, P = .40), biliary leakage (RR 0.84, 95% CI = 0.39–1.82, P = .66), delayed gastric emptying (RR = 0.83, 95% CI = 0.54–1.27, P = .39), abdominal infection (RR = 1.00, 95% CI = 0.66–1.52, P = 1.00), bleeding (RR = 1.16, 95% CI = 0.78–1.72, P = .46), pulmonary complications (RR = 0.73, 95% CI = 0.45–1.18, P = .20), overall complications (RR = 0.80, 95% CI = 0.64–1.01, P = .06), and reoperation rates (RR = 1.18, 95% CI = 0.77–1.81, P = .45). In the high-risk group, octreotide was no more effective at reducing PF formation than placebo (RR = 0.81, 95% CI = 0.67–1.00, P = .05). In addition, octreotide had no influence on the incidence of PF (RR = 0.38, 95% CI = 0.14–1.05, P = .06) after distal pancreatic resection and local pancreatic resection.Conclusion:The present best evidence suggests that prophylactic use of octreotide has no effect on reducing complications after pancreatic resection.

Outcomes, risk of recurrence and chronic pancreatitis after a first episode of idiopathic acute pancreatitis: a retrospective cohort study

Centralization of pancreatic surgery has proceeded in the last few years in many countries. However, information on the effect of hospital volume specifically on distal pancreatic resections (DP) is lacking.To investigate the effect of hospital volume on postoperative complications in DP patients in Finland.All DP performed in Finland during the period 2012–2014 were analyzed, information having been retrieved from the appropriate national registers. Hospital volumes, postoperative pancreatic fistulae (POPF) and overall complications were graded. High volume centre (HVC) was defined as performing > 10 DPs, median volume centre (MVC) 4–9 DPs and low volume centre (LVC) fewer than 4 DP annually.A total of 194 DPs were performed at 18 different hospitals. Of these 42% (81) were performed in HVCs (2 hospitals), 43% (84) in MVCs (6 hospitals) and the remaining 15% (29) in LVCs (10 hospitals). Patient demographics did not differ between the hospital volume groups. The overall rate of clinically relevant POPF, Clavien-Dindo grade 3–5 complications, and 90-day mortality showed no significant differences between the different hospital volumes. Grade C POPF was found more often in LVCs, being 1.2% in HVCs, 0% in MCVs and 6.9% in LVCs, p = 0.030. More reoperations were performed in LVCs (10.3%) than in HVCs (1.2%) or MVCs (1.2%); p = 0.025.Even though the rate of postoperative complications after DP is not affected by hospital volume, reoperations were performed ten times more often in the low-volume centres. Optimal management of postoperative complications may favour centralization not only of PD, but also of DP.

The impact of minimally invasive surgery and robot-assisted surgery on distal pancreatic resection: a snapshot on literature review and future technical innovations

The distal pancreatectomy (DP) with or without splenectomy, has to be considered the standard of care for the treatment of benign, borderline, and malignant lesions of the pancreatic body and tail.

Spleen-preserving laparoscopic distal pancreatectomy: is it worthwhile?

Distal pancreatic resection has been standardized in the 1990s, and since then favourable short-term results have been reported in high-volume centers (1). Later on, with the advent of minimally invasive surgery, the issue of spleen preservation has become more and more important given the implications of this organ in the regulation of body immunocompetency.

Etiology, clinical presentation and management of pancreatic pseudocyst

Background: The clinical presentation of pseudocyst is varied among individuals and so does the spectrum of management ranging from resolution to open or minimal access/ endoscopic drainage procedures. This study aims to review the various etiological factors, mode of clinical presentation of pseudocyst in relation to age and sex, and to study various modalities of investigation & management of pseudocysts.Methods: In this prospective study, 31 diagnosed patients of pseudocyst of pancreas were included who underwent different biochemical and radiological investigations. The study duration was 2 years from November 2016 to October 2018 carried out at a tertiary care hospital and the management and outcome of these patients were studied.Results: Males (93.54%) were the predominating gender suffering from pseudocyst and alcohol consumption (70.96%) was the most common etiological factor. 67.74% of patients had pseudocyst formation after recurrent attacks of pancreatitis. 20 patients (64.51%) patients were managed conservatively with complete resolution of pseudocyst in 10 patients. In rest of the 11 patients, 7 patients underwent open internal drainage, 2 patients underwent endoscopic internal drainage and pancreatic duct stenting; in one patient, external drainage was performed and another patient distal pancreatic resection was done.Conclusions: Pseudocyst of pancreas is predominantly seen in males with alcohol consumption being the commonest etiological factor. Spontaneous resolution of pseudocyst occurs in most of the patients and symptomatic patients can be managed by intervention by open/endoscopic internal drainage with or without pancreatic stenting and external drainage should be reserved for infected pseudocysts.

SOLID PSEUDOPAPILLARY TUMOR OF THE PANCREAS IN CHILDREN: 10 YEARS OF EXPERIENCE

Introduction: a solid pseudopapillary tumor (SPPT) of the pancreas is an extremely rare disease occurring in 0.13-2.7% of all pancreatic tumors. This tumor is characterized by a fairly favorable clinical course, with low metastasis potential. The clinical picture is highly non-specific, it is more common in girls of puberty and young women under 30 years of age. The main treatment method is surgical. The purpose of the study is to study the clinical and pathological characteristics of this disease and the possibilities of surgical treatment of patients with this pathology. Material and methods. The analysis of clinical data of patients diagnosed with SPPT in our Institute over the past 10 years (2007-2017). And also therу was reviewed the morphological data of SPPT, types of surgical treatment, results, and complications. Results. For 10 years, SPPT was detected in 24 patients. All patients were girls of puberty from 9 to 17 years. In most cases, the disease was asymptomatic and was diagnosed as an "accidental find" during a medical examination. Two patients had liver metastases. All patients underwent surgical treatment in a different volume: 8 patients - laparoscopic distal pancreatic resection, 3 - gastropancreatoduodenal resections, 3 - pancreatoduodenal resection, 6 - central pancreatic resections, 3 - distal subtotal pancreas resection and 1 - resection of uncinate process of the pancreas with resection of the duodenal wall. Complications occurred in 6 patients: in 4 - postoperative pancreatitis with the formation of pancreatic fistula and in one case - bleeding from the pancreatic branch of the splenic artery and bleeding from the wound surface. The follow-up period lasted from 3 months to 11 years. All patients are alive. Conclusion. SPPT is a rare tumor with a benign course potential. Clinical signs and symptoms are relatively nonspecific. Surgical treatment is the main method of treatment, although it is characterized by a high risk of postoperative complications. In general, the prognosis of this disease is favorable, even in the presence of distant metastases.

Modern principles of surgical treatment of chronic pancreatitis

We reviewed the charts of 752 patients, who have undergone surgery for various forms of chronic pancreatitis at “Shalimov’s National Institute of Surgery and Transplantation of the NAMS of Ukraine” in the years from 2007 to 2017. The average age of the 591 males (78,6 %) and 161 females (22,4 %) was 43,0 ± 3,2 years. Out of these, 446 (62,4 %) patients with pseudocysts and pancreatic fistula and also with isolated main pancreatic duct lithiasis underwent drainage procedures. The 269 (37.6%) patients were subjected to different types of resection, including the Frey operation, pancreatoenterostomy with artificial pancreatic duct formation, the Berne technique, the Beger procedure, pancreatoduodenectomy, distal-pancreatic resection and other procedures. After pancreatic resections, the patients did not require repeated surgical interventions for chronic pancreatitis. In some cases of chronic pancreatitis, there was an isolated lesion of the pancreas: in such cases (13 patients), we performed distal resection of the pancreas. Among the observed patients here were no fatal cases. Satisfactory results were obtained in 92.6 % of cases at longterm follow-up. Post-operative complications occurred in 27 patients (4.6 %), in 6 (1.03 %) patients there was a need for repeated surgery. Progression of the disease in patients previously operated in our clinic was observed in 32 (5.5 %), and 72 patients, initially operated in other medical institutions. Patients after direct resection of the pancreas did not require repeated surgery for chronic pancreatitis. The main causes of unsatisfactory results of the surgical treatment for chronic pancreatitis have been found to be: false indications for initial surgery, improper primary surgical techniques, insufficient use of drainage procedures, as well as, performing a drainage procedure instead of a resection. Key words: chronic pancreatitis, surgical treatment, resection and drainage procedures. For citation: Usenko OY, Kopchak VM, Nychytailo MY, Duvalko OV, Khanenko VV, Trachuk VI, Khomiak AI. Modern principles of surgical treatment of chronic pancreatitis. Journal of the National Academy of Medical Sciences of Ukraine. 2019;25(3):306–12

Long term oncological outcome of laparoscopic techniques in pancreatic cancer.

The laparoscopic technique in distal pancreatic resection (LDP) has been widely accepted, and outcome data support the hypothesis that survival is improved, partly due to improved postoperative safety and recovery, thus optimizing treatment with adjuvant chemotherapy. But laparoscopic pancreaticoduodenectomy (LPD or Whipple-procedures) has spread more slowly, due to the complexity of the procedure. Surgical safety has been a problem in hospitals with low patient volume, resulting in raised postoperative mortality, requiring careful monitoring of outcome during the surgical learning curve. Robotic assistance is expected to improve surgical safety, but data on long term oncological outcome of laparoscopic Whipple procedures with or without robotic assistance is scarce. Future research should still focus surgical safety, but most importantly long term outcome, recorded as recurrence at maximal follow up or - at best - overall long term survival (OS). Available data show median survival above 2.5 years, five year OS more than 30% after LDP even in series with suboptimal adjuvant chemotherapy. Also after LPD, long term survival is reported equal to or longer than open resection. However, surgical safety during the learning curve of LPD is a problem, which hopefully can be facilitated by robotic assistance. Patient reported outcome should also be an endpoint in future trials, including patients with pancreatic ductal adenocarcinoma.

Management of postoperative complications may favour the centralization of distal pancreatectomies. Nationwide data on pancreatic distal resections in Finland 2012–2014

BackgroundCentralization of pancreatic surgery has proceeded in the last few years in many countries. However, information on the effect of hospital volume specifically on distal pancreatic resections (DP) is lacking. AimTo investigate the effect of hospital volume on postoperative complications in DP patients in Finland. MethodsAll DP performed in Finland during the period 2012–2014 were analyzed, information having been retrieved from the appropriate national registers. Hospital volumes, postoperative pancreatic fistulae (POPF) and overall complications were graded. High volume centre (HVC) was defined as performing > 10 DPs, median volume centre (MVC) 4–9 DPs and low volume centre (LVC) fewer than 4 DP annually. ResultsA total of 194 DPs were performed at 18 different hospitals. Of these 42% (81) were performed in HVCs (2 hospitals), 43% (84) in MVCs (6 hospitals) and the remaining 15% (29) in LVCs (10 hospitals). Patient demographics did not differ between the hospital volume groups. The overall rate of clinically relevant POPF, Clavien-Dindo grade 3–5 complications, and 90-day mortality showed no significant differences between the different hospital volumes. Grade C POPF was found more often in LVCs, being 1.2% in HVCs, 0% in MCVs and 6.9% in LVCs, p = 0.030. More reoperations were performed in LVCs (10.3%) than in HVCs (1.2%) or MVCs (1.2%); p = 0.025. ConclusionsEven though the rate of postoperative complications after DP is not affected by hospital volume, reoperations were performed ten times more often in the low-volume centres. Optimal management of postoperative complications may favour centralization not only of PD, but also of DP.

Characteristics and Outcomes of 79 Patients with an Insulinoma: A Nationwide Retrospective Study in Finland.

Objective Insulinomas are rare pancreatic tumours. Population-based data on their incidence, clinical picture, diagnosis, and treatment are almost nonexistent. The aim of this study was to clarify these aspects in a nationwide cohort of insulinoma patients diagnosed during three decades. Design and Methods Retrospective analysis on all adult patients diagnosed with insulinoma in Finland during 1980–2010. Results Seventy-nine patients were diagnosed with insulinoma over the research period. The median follow-up from diagnosis to last control visit was one (min 0, max 31) year. The incidence increased from 0.5/million/year in the 1980s to 0.9/million/year in the 2000s (p = 0.002). The median diagnostic delay was 13 months and did not change over the study period. The mean age at diagnosis was 52 (SD 16) years. The overall imaging sensitivity improved from 39% in the 1980s to 98% in the 2000s (p < 0.001). Seventy-one (90%) of the patients underwent surgery with a curative aim, two (3%) had palliative surgery, and 6 (8%) were inoperable. There were no significant differences in the types of surgical procedures between the 1980s, 1990s, and 2000s; tumour enucleations comprised 43% of the operations, distal pancreatic resections 45%, and pancreaticoduodenectomies 12%, over the whole study period. Of the patients who underwent surgery with a curative aim, 89% had a full recovery. Postoperative complications occurred in half of the patients, but postoperative mortality was rare. Conclusions The incidence of insulinomas has increased during the past three decades. Despite the improved diagnostic options, diagnostic delay has remained unchanged. To shorten the delay, clinicians should be informed and alert to consider the possibility of hypoglycemia and insulinoma, when symptomatic attacks are investigated in different sectors of the healthcare system. Developing the surgical treatment is another major target, in order to lower the overall complication rate, without compromising the high cure rate of insulinomas.

Етіопатогенетичні чинники ендокринної дисфункції підшлункової залози у хворих на хронічний панкреатит

Introduction. The risk of developing diabetes mellitus in patients with chronic pancreatitis is 25-75 % throughout life and depends on the method of surgical treatment, the etiology of the disease and the degree of damage of the pancreas.The purpose of the study was to determine the features of the functional status of the pancreas in case of chronic pancreatitis, to study its influence on the endocrine function and various methods of surgical interventions on the pancreas, and to determine the terms of surgery.Materials and methods. The study included 105 patients, which were divided into groups: group I (n=14) – resection operations; group II (n=47) –duodenopreserving operation of head of the pancreas with draining of the main pancreatic duct; group III (n=44) – drainage, in which the parenchyma of the pancreas has not been removed. Laboratory blood glucose levels, glycated hemoglobin and C-peptide were measured, glucose tolerance test was performed in the pre- and postoperative period. In the preoperative period, the prevalence of endocrine insufficiency was 27,6 %. In the postoperative period, the prevalence of endocrine insufficiency (non-corrected over the duration of the observation) was 42,9 % (n=45) of patients, among them: 30 – glucose tolerance and 15 – diabetes mellitus.Results.The largest increase in endocrine insufficiency was observed among patients undergoing resection surgery, especially in patients with distal pancreatic resection, while organo-preserving procedures and isolated removal of head of the pancreas had a smaller increase (p = 0,001). Reducing the level of C-peptide in blood plasma in patients with pancreatic parenchymal calcinosis after surgery can predict the development of carbohydrate metabolism disturbances up to and including diabetes mellitus. In the histological study, progressive fibrosis of the parenchyma of the pancreas with inflammatory and degenerative changes has been detected, which leads to a decrease in the ganglia cells and β-cells of the Langegars islets. It was noted that in patients with chronic pancreatite, who had surgery while the duration of the disease was up to 1 year, the incidence of carbohydrate metabolism in the postoperative period was less frequent than in patients with anamnesis over 1 year (p = 0,02).Conclusion.Therefore, we proposed a policy of early surgical intervention – before the development of irreversible functional disorders, which leads to endocrine or exocrine insufficiency.

Which method of distal pancreatectomy is cost-effective among open, laparoscopic, or robotic surgery?

The aim of this study was to analyze the clinical and economic impact of robotic distal pancreatectomy, laparoscopic distal pancreatectomy, and open distal pancreatectomy. All consecutive patients who underwent distal pancreatic resection for benign and malignant diseases between January 2012 and December 2015 were prospectively included. Cost analysis was performed; all charges from patient admission to discharge were considered. There were 21 robotic (RDP), 25 laparoscopic (LDP), and 43 open (ODP) procedures. Operative time was longer in the RDP group (RDP =345 minutes, LDP =306 min, ODP =251 min, P=0.01). Blood loss was higher in the ODP group (RDP =192 mL, LDP =356 mL, ODP =573 mL, P=0.0002). Spleen preservation was more frequent in the RDP group (RDP =66.6%, LDP =61.9%, ODP =9.3%, P=0.001). The rate of patients with Clavien-Dindo > grade III was higher in the ODP group (RDP =0%, LDP =12%, ODP =23%, P=0.01), especially for non-surgical complications, which were more frequent in the ODP group (RDP =9.5%, LDP =24%, ODP =41.8%, P=0.02). Length of hospital stay was increased in the ODP group (ODP =19 days, LDP =13 days, RDP =11 days, P=0.007). The total cost of the procedure, including the surgical procedure and postoperative course was higher in the ODP group (ODP =30,929 Euros, LDP =22,150 Euros, RDP =21,219 Euros, P=0.02). Cost-effective results of RDP seem to be similar to LDP with some better short-term outcomes.

The early and late results of distal pacreatic resection

Objective. To study up the early and late results of distal pancreatic resection with the aim to improve diagnosis and surgical treatment of the distal pancreatic segment disease.&#x0D; Маterials and methods. Resectional interventions on distal pancreatic segment were performed in 19 patients in Department of General Surgery of Ivano-Frankivsk Regional Clinical Hospital in 2013 - 2017 yrs. In 12 (63.2%) patients the complicated forms of chronic pancreatitis (CHP) were diagnosed, and in 7 (36.8%) – pancreatic neoplasia. For diagnosis of pathological changes in corpora-caudal pancreatic segment there were applied laboratory investigations, ultrasound investigation, computed tomography, magnet-resonance tomography, pathohistological investigation of operational material.&#x0D; Results. In CHP a DR, using anterior operative access, was performed in 7 patients, and using a posterior one - in 5. For pancreatic neoplasia a standard DR was done in 3 patients, a radical one – in 1, radical antegrade module (RAMPS) - 2, and applying a laparoscopic operative access – in 1 woman-patient. Postoperative complications have occurred in 6 (31.6%) patients. Late results were followed-up in 13 (68.4%) patients in 6 mo – 5 yrs terms: after DR for CHP – in 9, after DR for tumors – in 4. Good late results were obtained in 7 (77.7%) patients after DR for CHP and in 2 (50.0%) – for tumors, satisfactory results – in 2 (22.3%) and in 1 (25.0%) patients, accordingly, and poor result - in 1 (25.0%) after pancreatic DR, performed for malignant tumor.&#x0D; Conclusion. Complex diagnosis of the distal pancreatic segment diseases with obligatory application of computed tomography gives possibility to establish strict indications for operation and to select a mostly adequate method of surgical intervention individually. Laparoscopic pancreatic DR constitutes a perspective method of surgical treatment in patients with CHP and locally-spread pancreatic neoplasia, it has good and fair early and late results. Resectional interventions on distal pancreatic segment leads to the diabetes mellitus occurrence in 16.6% of the patients.

ВИКОНАННЯ РОЗШИРЕНОЇ РЕЗЕКЦІЇ ПІДШЛУНКОВОЇ ЗАЛОЗИ В ЛІКУВАННІ ХВОРИХ З ПРИВОДУ ЇЇ ПУХЛИН

Мета. Оцінити результати виконання розширеної резекції підшлункової залози (ПЗ) у лікуванні хворих з приводу її пухлин.&#x0D; Матеріали і методи. За період 2010 – 2016 рр. оперовані 545 пацієнтів з приводу аденокарциноми ПЗ, дистальна резекція (ДР) ПЗ виконана у 127 (23,3%) з них, панкреатодуоденальна резекція (ПДР) – у 402 (73,8%), тотальна панкреатектомія (ТПЕ) – у 16 (2,9%).&#x0D; Розширена резекція ПЗ виконана у 121 (22,2%) хворого, в тому числі ПДР – у 65 (53,7%), ДР ПЗ – у 46 (38%), панкреатектомія – у 10 (8,3%).&#x0D; Результати. Ускладнення виникли у 167 (39,4%) пацієнтів після стандартної резекції ПЗ та у 51 (42,1%) – розширеної (c2 = 0,29, p = 0,58). Летальність становила 2,6% (померли 14 хворих), з них 5 (4,1%) – після розширеної резекції ПЗ, 9 (2,1%) – стандартної (c2 = 1,52, p = 0,22). Медіана виживання та показники 5–річного загального виживання недостовірно менші у пацієнтів після розширеної резекції ПЗ, ніж стандартної – відповідно 21 міс і 26% та 28 міс і 29% (c2 = 0,15, p = 0,69).&#x0D; Висновки. Летальність, частота післяопераційних ускладнень, віддалені результати після розширеної резекції ПЗ зіставні з такими після її стандартної резекції.

Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection.

Endocrine and exocrine insufficiency after partial pancreatectomy affect quality of life, cardiovascular health, and nutritional status. However, their incidence and predictors are unknown. To identify the incidence and predictors of new-onset diabetes and exocrine insufficiency after partial pancreatectomy. We retrospectively reviewed 1165 cases of partial pancreatectomy, performed from 1998 to 2010, from a large population-based database. Incidence of new onset diabetes and exocrine insufficiency RESULTS: Of 1165 patients undergoing partial pancreatectomy, 41.8% had preexisting diabetes. In the remaining 678 patients, at a median 3.6 months, diabetes developed in 274 (40.4%) and pancreatic insufficiency developed in 235 (34.7%) patients. Independent predictors of new-onset diabetes were higher Charlson Comorbidity Index (CCI; hazard ratio [HR] = 1.62 for CCI of 1, p = 0.02; HR = 1.95 for CCI ≥ 2, p < 0.01) and pancreatitis (HR = 1.51, p = 0.03). There was no difference in diabetes after Whipple procedure vs distal pancreatic resections, or malignant vs benign pathologic findings. Independent predictors of exocrine insufficiency were female sex (HR = 1.32, p = 0.002) and higher CCI (HR = 1.85 for CCI of 1, p < 0.01; HR = 2.05 for CCI ≥ 2, p < 0.01). Distal resection and Asian race predicted decreased exocrine insufficiency (HR = 0.35, p < 0.01; HR = 0.54, p < 0.01, respectively). In a large population-based database, the rates of postpancreatectomy endocrine and exocrine insufficiency were 40% and 35%, respectively. These data are critical for informing patients' and physicians' expectations.

Operation for insulinomas in multiple endocrine neoplasia type 1: When pancreatoduodenectomy is appropriate

Distal pancreatectomy is the most frequent operation for insulinomas complicating multiple endocrine neoplasia type 1 insulinoma, although there are conditions for which a different operative approach might be preferable. In this article, we report the operative experience of a referral center for multiple endocrine neoplasia type 1 insulinoma. Twelve patients underwent operations between 1992 and 2015: 8 underwent a distal pancreatic resection, and 4 underwent a pancreatoduodenectomy. Enucleation of other macroadenomas present in the remnant pancreas was performed in 9 out of these 12 patients. Operative complications (2 pancreatic fistulas and 2 cases of pancreatitis) occurred in 4 of the 8 distal pancreatic resections. In 1 patient, reoperation was required to resolve the complications of the first operation. At pathologic analysis, multiple insulinomas were found in 5 patients, lymph-nodal metastasis positive for insulin in 2 patients, multiple nonfunctioning pancreatic tumors in all patients, glucagonoma in 4 patients, and gastrinoma in the duodenum or lymph nodes in 4 patients. All the patients were treated successfully for the hypoglycemic/hyperinsulinemic syndrome with no clinical recurrence at a mean follow-up of 85months (range 4-242months). Recurrent nonfunctioning pancreatic tumor macroadenomas in the remnant pancreas occurred in only 1 of the 12 patients, and no progression of the gastrinomas was observed. None of the patients developed diabetes mellitus. Resection of the most severely affected part of the pancreas, whether left or right, associated with enucleation of concomitant macroadenomas in the preserved pancreas is recommended for the treatment of hypoglycemic/hyperinsulinemic syndrome and to prevent malignant progression of nonfunctioning pancreatic tumors in patients with multiple endocrine neoplasia type 1. If the head of the pancreas is the most affected site and the Zollinger-Ellison syndrome is concomitant, then pancreatoduodenectomy should be preferred over distal pancreatectomy.

Current South African clinical Practice in Debulking Surgery for Ovarian Cancer.

The aim of this study was to assess practice patterns and rationale with regard to debulking surgery for advanced epithelial ovarian carcinoma among South African Gynaecological oncologists. A survey was distributed to all practicing gynecological oncologists in South Africa. It was structured to assess definitions of optimal debulking, procedures used to achieve optimal debulking, and reasons for not performing specific procedures. Respondents were also asked to report on experience and additional surgical training to improve skill in performing ultra-radical debulking surgery. Eighty percent of gynecological oncologists completed the survey. Sixty percent of respondents reported that they view optimal debulking as no visible disease, and this was achieved in 63% of surgical cases. The most common barriers to optimal debulking were medical comorbidities (85%), followed by lack of expertise in ultra-radical debulking surgery (55%) and advanced patient age (40%). At operation, the most common disease findings precluding optimal debulking were large volume confluent peritoneal disease and confluent diaphragmatic disease. All of the surgeons perform excision of bulky pelvic and lower paraaortic nodes themselves. Bowel resections are often performed with the help of a colleague, but more than half of the respondents never perform diaphragmatic stripping, resection of liver metastases, distal pancreatic resection, or ablation of peritoneal metastases. Overall, most participants seem to regularly perform debulking procedures in the pelvis but are less comfortable with resection of upper abdominal or peritoneal disease. Most common reasons for not performing procedures were concerns about patient morbidity and concerns regarding benefit. Fifty percent of respondents also reported a lack of personal expertise in performing ultra-radical debulking procedures. The progression of South African Gynaecological Oncologist towards more aggressive debulking surgery is following international trends, but many of the surgeons report a lack of experience in ultra-radical debulking surgery, especially in the upper abdomen.

Total laparoscopic pancreaticoduodenectomy.

Total laparoscopic pancreaticoduodenectomy (TLP) represents perhaps one of the most challenging abdominal operations. This procedure is gaining popularity in recent years, mostly due to the numerous reports underling its safety and feasibility in the setting of several benign and malignant pancreatic pathologies. Minimal-invasive pancreatic surgery is rapidly becoming a reality in many centers around the globe and its benefits, compared to the traditional open approach, have been extensively proven in the setting of distal pancreatic resection. The many advantages of a laparoscopic approach, such as the improved visual magnification, the theoretical improved tissue exposure, and the potential for a more delicate manipulation of tissues are reasonably expected to be applicable to other pancreatic procedures including TLP. Herein we describe a technique for a TLP; we provide some suggestions on patient selection, pre-operative preparation, equipment, postoperative management, and finally discuss some of the most common pitfalls encountered during the procedure.

Effects of exocrine pancreatic insufficiency on serum levels of branched chain amino acids under conditions of completely standardized diet – Study in pancreatic duct ligated pigs used as a model for humans

s / Pancreatology 16 (2016) S1eS130 S3 next arteries: lienalis (46), gastroduodenalis (51), hepatic (6), pancreatoduodenalis (5), left gastric (2). They are manifestated as recurrent wirsungorragia or arrosive duodenal bleeding. 36 selective arterial embolisations of PA by coils were performedwith definitive haemostasis (94,4%) and partial success (5,6%). All patients are survived. In other 74 cases (67,3%) we performed next open procedures: pancreatoduodenectomy (33); distal pancreatic resection with splenectomy (18), including combined gastric or colon resection (72,2%); pancreatic head resection (6), suture or PA resection (17). 3 patients (4,1%) died after open surgery. Conclusion: Interventional radiology is a successful way in treatment of intestinal bleeding due to pseudoaneuryzms after acute necritizing pancreatitis. Digestive organ's resections with their arrosive defects in one block with pancreas may be performed effectively in the specialized surgical centres with good short-term results.

An Analysis of Complications, Quality of Life, and Nutritional Index After Laparoscopic Distal Pancreatectomy with Regard to Spleen Preservation.

Whether splenectomy is adverse or spleen preservation offers significant advantages in distal pancreatic resection is unclear. The aim was to compare the early/late clinical results and the functional outcomes in terms of quality of life (QoL) and nutrition between conventional laparoscopic distal pancreatectomy (LDP) and laparoscopic spleen-preserving distal pancreatectomy (LSPDP). Clinical data and computed tomography findings of 111 laparoscopic distal resections (79 LDPs and 32 LSPDPs) between 1999 and 2012 were retrospectively reviewed. QoL was assessed by the EORTC QLQ-C30. Body mass index and biochemical tests were examined as nutritional indices. Comparative analysis was done. The mean follow-up was 25 months. The operation time was shorter in LSPDP (127.9 minutes vs. 158.0 minutes, P < .001). The lesion size was larger in LDP (36.8 mm vs. 27.2 mm, P < .01). Mucinous cystic neoplasm (MCN) was the most common diagnosis in LDP and intraductal papillary mucinous neoplasm (IPMN) in LSPDP. Early results showed similar hospital days and infection episodes. Nonvascular complications were more frequent in LDP owing to more fluid collections (43.0% vs. 21.9%, P = .04). The ISGPF grade B/C pancreatic fistula rates were similar (27.8% in LDP vs. 25.0% in LSPDP, P = .760). Vascular complications were more frequent in LSPDP (64.5% vs. 26.0%, P < .01). Excluding some fluid collections, none required a specific treatment. Late results demonstrated no differences in nonvascular results. Vascular complications were more frequent in LSPDP (65.6% vs. 4.2%, P < .01). The vascular complications did not require any specific treatment or have any serious sequelae. There was no overwhelming postsplenectomy infection. QoL and nutritional indices showed no difference. QoL decreased at discharge and recovered from 3 months thereafter. Nutritional indices showed a similar pattern. LDP is associated with more fluid collections and LSPDP with more vascular complications, all with a minimal clinical impact. Both methods had similar functional outcomes. Either LDP or LSPDP could be performed depending on the indication and surgeon's experiences considering the comparable results.