Laparoscopic Pancreatic Enucleation Research Articles

6538 Find me if you can! A Case of a "Well Placed Solitary Insulinoma" in "The Center" of an SACST

Abstract Disclosure: R. Kennedy: None. D.A. D'Alessio: None. A.V. Vella: None. Introduction: Selective arterial calcium stimulation testing (SACST) can be utilized in patients to localize solitary insulinomas when imaging is non diagnostic. While a heterogenous stimulation pattern suggests NIPHS, or multiple insulinomas this case uniquely demonstrates such a pattern with a solitary insulinoma. Clinical Case: The patient is a 48 year old female who presented to the emergency department (ED) for bizarre behavior which resolved with a sweetened drink. Serum glucose was 62 mg/dL, she was treated with IV dextrose and was discharged from the ED. She was referred to outpatient endocrinology for further evaluation where continuous glucose monitoring confirmed predominantly fasting hypoglycemia. Adrenal insufficiency was excluded. She was admitted for a 72 hour inpatient fast where the patient achieved hypoglycemia within 24 hours, with glucose 46 mg/dL (associated with neuroglycopenic symptoms), beta hydroxybutyrate < 0.18 mmol/L, insulin 3.9 mcIU/mL, proinsulin 157pmol/L, c-peptide 1.4 ng/mL and a glucose rise greater than 25mg/dL after glucagon administration. Sulfonylurea screen and insulin antibodies were negative; IGF1 within normal limits. These labs were consistent with hyperinsulinemic hypoglycemia. An MRI pancreas however did not reveal an insulinoma. The patient therefore underwent a SACST, demonstrating a 10 fold response in the territory of the gastroduodenal artery and splenic artery, as well as a 3 fold response in the superior mesenteric artery. This heterogenous pattern in addition to the marked response in each arterial territory raised the possibility of multiple insulinomas. However as there were no tumors present on imaging, medical management was initiated with close follow up. She was trialed with months of somatostatin analogs and diazoxide with minimal improvement in the frequency and severity of her hypoglycemia. About a year after her initial diagnosis, repeat abdominal imaging (CT and MRI) revealed an 8 mm arterial hyper-enhancing lesion in the body of the pancreas concerning for neuroendocrine tumor. Repeat SACST was performed, this time showing a greater than 10 fold response in all three arterial territories. Angiography showed a tumor blush that was visible when each of the three major arteries were injected sequentially. She underwent laparoscopic pancreatic enucleation. The lesion was located on the body of the pancreas, with histology confirming an insulinoma. The patient responded promptly post operatively; her symptoms resolved without further need of medical management. Conclusion: Our case shows that the interpretation of an SACST should take into account the arterial anatomy before ascribing a non-focal response to multiple territories of insulin hypersecretion. Presentation: 6/1/2024

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula.

Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN. All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF. From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20mm (9-110); 30mm (20-110) for mucinous cystadenoma and 18mm (8-33) for NET. The median operative time was 90mn (30-330), median blood loss was 20ml (0-800)ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3mm. In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.

Laparoscopic pancreatic enucleation of a clear cell renal cell carcinoma metastasis

Authors present the case of a laparoscopic pancreatic enucleation of a clear cell renal cell carcinoma metastatic lesion of the uncinate process. A 43-year old female patient was admitted with a lesion in the uncinate process detected by abdominal ultrasound performed for mild epigastric pain she has been suffering from for 3 months prior to admission. Her past medical history is significant for right nephrectomy performed 9 years ago for clear cell renal cell carcinoma, which was confirmed by the histopathology report. A multidisciplinary investigation was performed. Pancreatic protocol CT-scan revealed a 2 cm hyper-enhancing round-shaped tumor, located within the uncinate process. Considering the CT-scan characteristics of the lesion and the past medical history of the patient, a clear cell renal cell metastasis was suspected. Transabdominal US-guided fine-needle aspiration biopsy (US-FNAB) was performed. Immunohistochemical examination using CD10 confirmed the suspicion. A laparoscopic pancreatic enucleation was planned with possible Whipple procedure in case the enucleation would turn out to be unfeasible due to such factors as intensive bleeding from an intrapancreatic vessel, unclear borders of the tumor, and high risk of postoperative pancreatic fistula formation. Nevertheless the attempt to perform enucleation succeeded. The postoperative course was uneventful. The drain was removed on postoperative day 3 after amylase level control. Final histopathological examination revealed a clear cell renal cell carcinoma (RCC) metastatic lesion to the pancreas with clear surgical margins. The purpose of the video is to demonstrate the feasibility of laparoscopic pancreatic enucleation, which is an organ-preserving procedure and is accompanied with better long-term results.

Is laparoscopic pancreatic enucleation appropriate for all pancreatic diseases?

Is laparoscopic pancreatic enucleation appropriate for all pancreatic diseases?

Is laparoscopic pancreatic enucleation appropriate for all pancreatic diseases?

Introduction: With the widespread of laparoscopic pancreatic surgery, enucleation is considered as an excellent indication to the laparoscopic approach. Our aim was to analyze our indications and results. Methods: From January 2008 to September 2017, among the 422 patients who underwent laparoscopic pancreatic resection, 41(10%) underwent laparoscopic enucleations and were studied retrospectively. Results: The mean age was 50 (17-74), mean BMI 25 (19-36) and 29 were females (71%). Main indications were neuroendocrine tumor (26; 63%); Mucinous cystadenoma (7; 17%), other benign cysts (7; 17%) and only one intra-ductal papillary mucinous neoplasia (IPMN) (3%). Lesions were located in the head (n=14; 34%).The mean size was 24 mm (9-80). The mean operative time was 110 mn (30-330), the mean blood loss was 64 ml (0-800) ml and no transfusion and one conversion. No 90 days mortality. Overall morbidity in 14 patients (34%), represented by pancreatic fistula of grades B and C (5;12%), bleeding (2;5%), one drained collection and no -intervention. Lymph nodes was harvested in 14 patients (34%) with a mean number 0.7(0-5) and negative in all. The mean hospital stay was 11 days (4–42). Conclusion: The excellent outcome of laparoscopic enucleation is explained by the low rate of enucleation for IPMN, which are theoretically at higher risk of complications. IPMN of good indications to the laparoscopic approach (peripheral branch ducts) do not necessary need surgery, and those who need surgery (small revealed by pancreatitis) are not good indications for the laparoscopic approach related to inflammation and difficult location (deep and small).

The lesser omentum approach for laparoscopic pancreatic enucleation

Objective: To evaluate the feasibility and strategy of the lesser omentum approach for laparoscopic pancreatic enucleation. Methods: Between June 2011 and October 2013, 6 laparoscopic pancreatic enucleations were performed by lesser omentum approach.The average age was 42 years, including 1 male and 5 female.The preoperation diagnosis of 6 cases were pancreatic islet cell tumors determined by abdominal CT/MRI, ultrasound and digital subtraction angiography.The tumors of 3 cases located in pancreatic neck, 2 tumors located in neck and body of pancreas, and 1 tumor located in pancreatic body.Their biggest tumor diameter were 0.8-2.5 cm. Results: Among the 6 cases, all laparoscopic pancreatic enucleations were successfully performed.None of the patients were converted to open operation.Eestimated blood loss was (26.7±18.6)ml, operating time was (82.5±19.4)minutes, and postoperative length of stay was (5.17±1.17)days.Additionally, postoperative complication included grade A pancreatic fistula in 1 case.After 36-64 months followed-up, there was no tumor recurrence and clinical symptom disappeared. Conclusion: For the islet cell tumors located in pancreatic neck and body, the lesser omentumapproach may contribute to good surgical view and operative space, which can make pancreatectomy safer and easier for clinical application.

Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis.

Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution. Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital-Rikshospitalet. Twenty-four (53.3%) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7%) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP). Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53-320) vs 102 (50-373) min, P=0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3%; P=0.19 and 20.8 vs 33.3%, P=0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2-80) vs 7 (2-52), P=0.49]. A case-matched analysis demonstrated shorter operating time [145 (90-350) vs 103 (50-233) min, P=0.02], but higher readmission rate following LLPE (25 vs 3.1%, P=0.037). LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.

A Critical Appraisal of Laparoscopic Pancreatic Enucleations

Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few small-sized series show encouraging results, especially after enucleations performed for lesions located in the left part of the pancreas. The outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected parameters. Results of right-sided (head/uncus) and left-sided (neck/body/tail) enucleations were compared. From 1997 to 2010, 25 patients underwent laparoscopic pancreatic enucleation. The conversion rate was 12%, mean operating time was 158 minutes, and mean blood loss was 106 mL. Morbidity was 56% and the rate of pancreatic fistula 32%. Outcome differed between patients undergoing right-sided and left-sided enucleations, the operative time being 178 versus 132 minutes, morbidity 64% versus 45%, and median hospital stay 26 versus 9 days, respectively. Pancreatic enucleation is feasible by laparoscopy, with a high success rate and no mortality but significant morbidity. Laparoscopy seems to be of no use in right-sided procedures. Pancreatic fistula is still the main cause of long-lasting morbidity.

Laparoscopic enucleation of pancreatic neoplasm

Enucleation is an alternative procedure for treating benign and borderline neoplasms of the pancreas, which preserves healthy parenchyma and pancreatic function. This study aimed to evaluate the postoperative and long-term results after laparoscopic enucleation. Data collected prospectively from 23 consecutive patients who underwent laparoscopic pancreatic enucleation were analyzed. Laparoscopic enucleation was achieved successfully for 21 patients (91.3%). One death (4%) occurred. A postoperative pancreatic fistula was observed in three cases (13%), and was clinically significant in one case (4%). Enucleation was performed for endocrine neoplasm in 15 patients (65%) and for cystic neoplasm in eight patients (35%). All the patients had benign tumors at the final histopathologic diagnosis. During a median follow-up period of 53months, no patient experienced tumor recurrence or new-onset exocrine or endocrine insufficiency. Laparoscopic enucleation is a safe and effective procedure for the radical treatment of benign and borderline pancreatic tumors. The laparoscopic approach seems to be associated with a decrease in operative time, hospital stay, and pancreatic fistula after enucleation. Laparoscopy should become the standard approach in the future for enucleation of presumed benign lesions.

Arterial Stimulation and Venous Sampling (ASVS) is Useful for Recurrent Lesions of Insulinoma

We encountered a recurrent case of benign solitary insulinoma in the pancreatic tail, which may have been caused by an inadequate surgical margin in the use of an ultrasonic dissector. A 45-year-old man was referred with hypoglycemia and diagnosed solitary insulinoma in the pancreas. Laparoscopic pancreatic enucleation was performed using an ultrasonic dissector. The tumor was extracted and the surgical margins were microscopically negative. Six years later, he presented with hypoglycemia again. Multiple small well-enhanced lesions were detected by computed tomography distant from the resection stump of the first operation. He underwent resection of all visible lesions with omentum and wide excision of the soft tissue surrounding the pancreas after preoperative arterial stimulation and venous sampling test. The postoperative course of the second operation was uncomplicated and the patient presents no sign of hypoglycemia after 12 months.

Neuroendocrine pancreatic tumors: the laparoscopic approach

BACKGROUND: Laparoscopic pancreatic procedures in patients with neuroendocrine pancreatic tumors are still at an evaluation stage with regard to their indications and techniques. The aim of this paper is to discuss the clinical and pathological features of a variety of neuroendocrine pancreatic tumors and the surgical approach by means of minimally access surgery. METHODS: We provide an overview of the different minimally access techniques for the treatment of neuroendocrine pancreatic tumors. This knowledge will provide the information needed to ascertain the suitability of the laparoscopic approach for any particular patient. RESULTS: Laparoscopic treatment consists of enucleation or distal pancreatectomy; the choice is based on the size, location and proximity of the lesion to the pancreatic duct. Splenic preservation is feasible when performing laparoscopic distal pancreatectomy. CONCLUSIONS: Laparoscopic pancreatic enucleation or laparoscopic pancreatic resection offers a clear benefit for patients with neuroendocrine pancreatic tumors in terms of reduction of hospital stay, a rapid recovery to initiate previous activities and excellent cosmesis. Careful selection of patients is essential to successful outcomes.