Laparoscopic Spleen-preserving Distal Pancreatectomy Research Articles

Laparoscopic antegrade spleen-preserving distal pancreatectomy with conservation of the splenic vessels: A prospective multicenter case series (with Video)

Introduction: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with conservation of the splenic artery and vein (Kimura’ technique) is considered a technically challenging procedure that requires a high level of expertise in laparoscopic and pancreatic surgery. Methods: A prospective descriptive study on 18 patients with laparoscopic “antegrade” spleen-preserving distal pancreatectomy with Kimura’ technique from 2018 to 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Results: The mean age was 39.4±13.3. Only 2 male patients accounted for 11.1%. The average operating time is 171±23 minutes. The average blood loss is 65.7±43 ml. The average tumor size is 4.1cm. The average hospitalization is 9.4 days. The rate of pancreatic fistula is 66.7%. There is no case of transferring open surgery or blood transfusion during surgery. The results of pathological after surgery, there were 8 cases of solid pseudopapillary tumors, 4 cases of mucinous cystadenoma, 6 cases of neuroendocrine tumors. Conclusion: Kimura’s technique for laparoscopic spleen-preserving distal pancreatectomy is safe and feasible, which can be applied to benign tumors in the body and tail of pancreas. However, this is a difficult technique in laparoscopic surgery that requires surgeons to have a lot of experience and equipment need to be adequate.

Clinical application of laparoscopic spleen-preserving distal pancreatectomy in patients with situs inversus totalis.

Clinical application of laparoscopic spleen-preserving distal pancreatectomy in patients with situs inversus totalis.

Laparoscopic spleen-preserving distal pancreatectomy: A novel technique with splenic artery resection and splenic vein preservation.

Laparoscopic spleen-preserving distal pancreatectomy (LSDP) is widely performed to treat benign and low-grade malignant diseases. Although preservation of splenic vessels may be desirable considering the risk of postoperative complications, it is sometimes difficult due to tumor size, inflammation, and proximity of the tumor and splenic vessels. Herein, we present the first case of LSDP with splenic artery resection and splenic vein preservation. A 40-year-old woman with a pancreatic tumor was referred to our hospital. Contrast-enhanced computed tomography (CT) revealed a tumor in the pancreatic tail that was in contact with the splenic artery and distant from the splenic vein. The splenic artery and vein were separated from the pancreas near the dissection line. The splenic artery was resected after pancreatic dissection using a linear stapler. After the pancreatic tail was separated from the splenic hilum while preserving the splenic vein, the distal side of the splenic artery was resected, and the specimen was removed. The postoperative course was uneventful and the patient was discharged on postoperative Day 9. Four months after surgery, postoperative follow-up CT findings showed neither splenic infarction nor gastric varices. This technique is an alternative method of splenic preservation when there is no attachment of the tumor to the splenic vein or uncontrolled expected bleeding of the splenic artery using the Kimura technique.

Minimally invasive vessel-preservation spleen preserving distal pancreatectomy-how I do it, tips and tricks and clinical results

BackgroundMinimally invasive spleen-preserving distal pancreatectomy (SPDP) has emerged as a parenchyma-preserving approach and has become the standard treatment for pancreatic benign and low-grade malignant lesions. Nevertheless, minimally invasive SPDP is still technically challenging, especially when vessel preservation is intended. This study aims to describe the technique and outcomes of laparoscopic (LSPDP) and robot-assisted spleen-preserving distal pancreatectomy (RSPDP) with intended vessel preservation, highlighting the important tips and tricks to overcome technical obstacles and optimize surgical outcomes.MethodsA retrospective observational study of consecutive patients undergoing LSPDP and RSPDP with intended vessel preservation by a single surgeon in two different centers. A video demonstrating both surgical techniques is attached.ResultsA total of 50 patients who underwent minimally invasive SPDP were included of which 88% underwent LSPDP and 12% RSPDP. Splenic vessels were preserved in 37 patients (74%) while a salvage vessel-resecting technique was performed in 13 patients (26%). The average surgery time was 178 ± 74 min for the vessel-preserving and 188 ± 57 for the vessel-resecting technique (p = 0.706) with an estimated blood loss of 100 mL in both groups (p = 0.663). The overall complication rate was 46% (n = 23) with major complications (Clavien Dindo ≥ III) observed in 14% (n = 7) of the patients. No conversions occurred. The median length of hospital stay was 4 days.ConclusionThis study presented the results after minimally invasive SPDP with intended vessel preservation by a highly experienced pancreatic surgeon. It provided tips and tricks to successfully accomplish a minimally invasive SPDP, which can contribute to quick patient rehabilitation and optimal postoperative results.Graphical

Spleen-Preserving Retrograde Distal Pancreatectomy for Malignant Insulinoma

Introduction: Distal pancreatectomy is performed primarily for malignant and premalignant diseases of the pancreas. Neuroendocrine tumors within the body and tail of the pancreas can be resected or enucleated depending upon the size and relationship of the tumor with the pancreatic duct.1,2 This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy using a retrograde dissection (Kimura technique) for malignant pancreatic neuroendocrine tumor treatment. Operative Technique: A 47-year-old woman with medical history of hypertension and hypothyroidism comes to endocrinology presenting 3 months history of lumbar pain and 6 months history of neuroglycopenic symptoms. The work-up demonstrated hyperinsulinemic hypoglycemia produced by a 2.7 cm insulin-producing tumor of the body of the pancreas. A 1 cm cyst of the tail of the pancreas, a 5 mm sellar mass, and an adenoma of one parathyroid gland with elevated parathyroid hormone and calcium are seen as well, indicatory of a multiple endocrine neoplasia type 1.3–5 A five-trocar laparoscopic distal pancreatectomy was performed with one surgeon between the legs and two more surgeons on each side of the patient. The liver was retracted for better visibility and started with the section of splenocolic ligament to release the splenic angle of the colon and move it to the midline. Short gastric vessels of the gastrosplenic ligament are sectioned to address the posterior face of the stomach, through the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreas. The insulinoma became visible on the anteroinferior margin and was well delimited with intraoperative manipulation. Pancreas is accessed through the retroperitoneum. Splenic vessels are dissected. The splenic artery and vein are identified and referred to be able to dissect along the upper edge of the pancreas, in a retrograde approach to preserve vascular structures. Ligaclips are placed on the branches of the splenic vessels. Transection is performed at the level of the junction of the head and neck of the pancreas, leaving enough space between the mass using a linear stapler capable of 60 mm long cuts and with 3.5 mm open staple height. The integrity of the piece is verified and is extracted with a laparoscopic specimen retrieval bag. In the case of this patient with previous surgery, an existing Pfannenstiel-type scar is used to avoid extension of the laparoscopic scars. Blake-type drain is placed in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding postoperatively was well tolerated. The patient was discharged home 3 days after surgery with a placed drain. Histology analysis confirmed the full resection of the intrapancreatic neuroendocrine tumor. No competing financial interests exist. Runtime of video: 9 mins 24 secs

Giant mucinous cystadenoma of the pancreas in a young female

Cystic tumors of the pancreas are rare and may be confused with hydatid cysts, especially in endemic areas. The incidence of cystic neoplasms of the pancreas is relatively rare in the pediatric population and young adults. We present a 21-year-old female with a well-defined giant multiloculated cystic lesion in the body and tail of the pancreas, which was diagnosed as a hydatid cyst elsewhere. The patient underwent laparoscopic spleen-preserving distal pancreatectomy. There was no visible communication between the mucinous cystic neoplasm and the pancreatic duct. Histopathology confirmed the diagnosis of benign mucinous cystadenoma of the pancreas. Ambiguity in the management of the lesion arises when mucinous cystadenoma is commonly misdiagnosed as pancreatic pseudocyst because the surgical management is entirely different.

Laparoscopic gastric wedge resection and spleen-preserving distal pancreatectomy performed on a 6-cm gastric desmoid tumour with pancreatic invasion.

Desmoid tumours are rare tumours originating from fibroblasts, and are characterised by local infiltration and no metastasis. When complete resection is possible, surgical resection is considered a first-line treatment. In the case of large desmoid tumours, it is mainly performed by laparotomy, not laparoscopy. We report a case of a 43-year-old female patient presenting with a hypodense mass of approximately 5 cm in the posterior wall of the gastric antrum on computed tomography. There was no history of familial adenomatous polyposis, trauma or abdominal surgery. The patient underwent laparoscopic gastric wedge resection and spleen-preserving distal pancreatectomy without peri-operative complications. Pathological analysis revealed a desmoid tumour, which originated from the stomach and invaded the pancreas. Despite the large size and the locally infiltrative characteristics of these tumours, laparoscopic surgery can be an optimal treatment option due to its advantages.

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# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Benchmarking of robotic and laparoscopic spleen-preserving distal pancreatectomy by using two different methods.

Benchmarking is an important tool for quality comparison and improvement. However, no benchmark values are available for minimally invasive spleen-preserving distal pancreatectomy, either laparoscopically or robotically assisted. The aim of this study was to establish benchmarks for these techniques using two different methods. Data from patients undergoing laparoscopically or robotically assisted spleen-preserving distal pancreatectomy were extracted from a multicentre database (2006-2019). Benchmarks for 10 outcomes were calculated using the Achievable Benchmark of Care (ABC) and best-patient-in-best-centre methods. Overall, 951 laparoscopically assisted (77.3 per cent) and 279 robotically assisted (22.7 per cent) procedures were included. Using the ABC method, the benchmarks for laparoscopically assisted and robotically assisted spleen-preserving distal pancreatectomy respectively were: 150 and 207 min for duration of operation, 55 and 100 ml for blood loss, 3.5 and 1.7 per cent for conversion, 0 and 1.7 per cent for failure to preserve the spleen, 27.3 and 34.0 per cent for overall morbidity, 5.1 and 3.3 per cent for major morbidity, 3.6 and 7.1 per cent for pancreatic fistula grade B/C, 5 and 6 days for duration of hospital stay, 2.9 and 5.4 per cent for readmissions, and 0 and 0 per cent for 90-day mortality. Best-patient-in-best-centre methodology revealed milder benchmark cut-offs for laparoscopically and robotically assisted procedures, with operating times of 254 and 262.5 min, blood loss of 150 and 195 ml, conversion rates of 5.8 and 8.2 per cent, rates of failure to salvage spleen of 29.9 and 27.3 per cent, overall morbidity rates of 62.7 and 55.7 per cent, major morbidity rates of 20.4 and 14 per cent, POPF B/C rates of 23.8 and 24.2 per cent, duration of hospital stay of 8 and 8 days, readmission rates of 20 and 15.1 per cent, and 90-day mortality rates of 0 and 0 per cent respectively. Two benchmark methods for minimally invasive distal pancreatectomy produced different values, and should be interpreted and applied differently.

Laparoscopic spleen-preserving distal pancreatectomy with splenic vessels resection (laparoscopic Warshaw procedure).

Laparoscopic spleen-preserving distal pancreatectomy with splenic vessels resection (laparoscopic Warshaw procedure).

Microcystic serous cystadenoma mimicking pancreatic neuroendocrine neoplasm: report of a resected case with preoperative diagnostic difficulty and review of the literature

BackgroundMicrocystic pancreatic serous cystadenoma (SCA) can be managed without surgery in selected patients. However, the preoperative diagnosis of microcystic SCA remains challenging, and it is potentially misdiagnosed as other pancreatic cystic neoplasms or solid tumors, especially small microcystic SCA.Case presentationThis was a case of a 27-year-old male patient with microcystic SCA causing difficulty in the differential diagnosis from pancreatic neuroendocrine neoplasm (pNEN). A pancreatic tail mass was incidentally discovered on abdominal ultrasound (US). A contrast-enhanced computed tomography (CT) scan revealed a solid tumor measuring 13 mm with early enhancement in the arterial phase at the pancreatic tail. The tumor showed low intensity on T1-weighted magnetic resonance image, high intensity on T2-weighted image, and a slightly hyperechoic mass on endoscopic US (EUS). EUS-fine needle aspiration (EUS-FNA) did not lead to a definitive diagnosis. The tumor was clinically diagnosed as a pNEN, and a laparoscopic spleen-preserving distal pancreatectomy using the Warshaw technique was performed. The final histopathological diagnosis was microcystic SCA.ConclusionSmall microcystic SCA is difficult to distinguish from a hypervascular pancreatic tumor such as pNEN on imaging studies, and it is necessary to focus on the tumor echogenicity of EUS to differentiate microcystic SCA from pNEN preoperatively.

A novel second-stage surgical strategy for severely obese patient with pancreatic neuroendocrine tumor: a case report

BackgroundSeverely obese patients can have other diseases requiring surgical treatment. In such patients, bariatric surgeries are considered a precursor to operations targeting the original disease for the purpose of reducing severe perioperative complications. Pancreatic ectopic fat deposition increases pancreas volume (PV) and thickness, which can worsen insulin resistance and islet β cell function. To address this problem, we present a novel two-stage surgical strategy performed on a severely obese patient with pancreatic neuroendocrine tumor (PNET) consisting of laparoscopic sleeve gastrectomy (LSG) as a metabolic surgery followed by laparoscopic spleen-preserving distal pancreatectomy (LSPDP).Case presentationA 56-year-old man was referred to our hospital for further investigation of a pancreatic tumor. His initial body weight and body mass index (BMI) were 94.0 kg and 37.2 kg/m2, respectively. Contrast computed tomography revealed an enhanced tumor measuring 15 mm on the pancreatic body. The pancreas thickness and PV were 32 mm and 148 mL, respectively. An endoscopic ultrasonographic fine needle aspiration identified the tumor as PNET-G1. We first performed LSG, the patient’s body weight and BMI had decreased dramatically to 64.0 kg and 25.3 kg/m2 at 6 months after LSG. The pancreas thickness and PV had also decreased to 17 mm and 99 mL, respectively, with no tumor growth. Since LSG has been shown to reduce the perioperative risk factors of LSPDP, and to improve insulin resistance and recovery of islet β cell function, we performed LSPDP for PNET-G1 as a second-stage surgery. The postoperative course was unremarkable, and the patient was discharged on postoperative day 14 without symptomatic postoperative pancreatic fistula (POPF). He was followed without recurrence or type 2 diabetes (T2D) onset for 6 months after LSPDP.ConclusionsWe present a novel two-stage surgical strategy for a severely obese patient with PNET, consisting of LSG as a metabolic surgery for severe obesity, followed by LSPDP after confirmation of good weight loss and metabolic effects. LSG before pancreatectomy may have a potential to reduce pancreas thickness and recovery of islet β cell function in severely obese patients, thereby reducing the risk of clinically relevant POPF and post-pancreatectomy T2D onset.

Indocyanine green fluorescence angiography-guided simultaneous laparoscopic distal gastrectomy and spleen-preserving distal pancreatectomy for conserving the gastrosplenic ligament: A case report.

Introduction and importanceIndocyanine green (ICG) fluorescence angiography is being increasingly performed intraoperatively to detect restricted blood flow intraoperatively for the prevention of postoperative organ ischemia and anastomotic leakage. This is the first case report of simultaneous laparoscopic distal gastrectomy (LDG) and spleen-preserving distal pancreatectomy (LSPDP) involving ICG angiography use to avoid the remnant stomach ischemia.Case presentationA 55-year-old man was diagnosed with early cancer of the stomach body and intraductal papillary mucinous neoplasms of the pancreatic tail. We performed simultaneous LDG with D2 dissection and LSPDP to conserve the gastrosplenic ligament and preserve blood supply to the remnant stomach. Intraoperatively, blood flow to the remnant stomach was visualized using ICG fluorescence angiography, after which Roux-en-Y reconstruction was performed. There was no perioperative remnant stomach ischemia.Clinical discussionDespite the preserved splenic artery and vein, complete splenic infarction occurs after LSPDP possibly due to thrombus formation during surgical procedures. In this patient, we conserved the gastrosplenic ligament for the short gastric artery, which supplied blood to the remnant stomach; however, remnant stomach ischemia may occur. Therefore, we performed ICG fluorescence angiography during this operation to ensure that sufficient blood supply to the remnant stomach was maintained.ConclusionOur experience demonstrates that ICG angiography may be useful for the prevention of remnant stomach ischemia.

Laparoscopic Spleen Preserving Distal Pancreatectomy: Is There a Better Technique?

Introduction: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection or preservation of the splenic vessels. Our study aims to compare the Warshaw Technique with the preservation of the splenic vessels in LSPDP. Methods: We performed a retrospective chart review of adults undergoing laparoscopic spleen preserving distal pancreatectomy at a single institution from 2009 to 2021. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of hospital stay, and 30-day major morbidity (Clavien-Dindo grade 3, 4, and 5). Results: We retrieved 105 cases (median age 63.2 years) of LSPDP (60 Warshaw Technique, 45 vessel preservation). Median operative time was shorter with the Warshaw Technique (140 vs. 177 minutes, p<0.05). The rate of successful spleen preservation was greater with the Warshaw Technique group (77% vs. 69%, p<0.05). There was no significant difference in the median blood loss, or length of hospital stay between the two techniques. Seven cases required conversion to open laparotomy (3 in the Warshaw Technique group). Postoperative complications of grade 3 or greater occurred in a total of thirteen cases (9 in the Warshaw Technique Group). Conclusion: Our preliminary results suggest both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique is not inferior to the vessel sparing technique for LSPDP and may be more efficient with respect to use of hospital resources.

A Prognostic Impact of Splenectomy in Laparoscopic Distal Pancreatectomy on Benign/Borderline Pancreatic Tumors: A Change of the Era.

PurposeIn the past, spleen preservation during distal pancreatectomy (DP) was preferred; however, more recent studies reported comparable results between splenectomy and spleen preserving. We retrospectively reviewed patients in a single center who underwent laparoscopic DP with/without splenectomy, and evaluated the chronologic changes of surgical outcomes of the two procedures.Materials and MethodsPatients who underwent laparoscopic DP with or without splenectomy due to benign/borderline tumor from 2005 to 2019 were included in this study. We divided this period into Era 1 (2005–2012) and Era 2 (2013–2019), and compared the chronological evolution of surgical outcomes of laparoscopic distal pancreatosplenectomy (LDPS) to those of laparoscopic spleen-preserving distal pancreatectomy (LSpDP), including the long-term postoperative immunologic profiles.ResultsA total of 198 cases were included (LSpDP: 80 cases; LDPS: 118 cases). As the period changed from Era 1 to Era 2, the ratio of LSpDP decreased and the surgical outcomes of LDPS improved. In Era 1, LSpDP group showed superior results compared to LDPS group in terms of hospital days and postoperative pancreatic fistula ratio; however, in Era 2, the surgical outcomes showed no statistical differences. No significant differences were observed in all of the immunologic markers.ConclusionWe carefully conclude that during laparoscopic DP, combined splenectomy can be equivalent to spleen preserving in surgical and immunological outcomes, and inevitable splenectomy can be safely conducted.

Fate of Small Remnant Pancreas Tail in Splenic Hilum after Laparoscopic Spleen Preserving Distal Pancreatectomy

Introduction: Laparoscopic spleen preserving distal pancreatectomy (LSPDP) has been shown to be safe and readily feasible. However, we sometimes encounter anatomically challenging patients with the pancreas tail deep into the splenic hilum. The purpose of this study was to discuss the experience of the surgical technique leaving a deep pancreas tail of the splenic hilum in these patients. Methods: There were ten patients who underwent LSPDP with remnant pancreas tail between November 2019 and July 2021 at Samsung Medical Center, Seoul, Korea. Their short-term postoperative outcomes were analyzed retrospectively. Results: Mean operative time was 180.7 ± 18.9 min, estimated blood loss was 192.9 ± 105.8 ml, and postoperative length of stay was 6.3 ± 1.0 days. All ten lesions were in the body or tail of the pancreas and included: 4 intraductal papillary mucinous neoplasms (IPMNs), 4 neuroendocrine tumors, a chronic pancreatitis and a metastatic renal cell carcinoma. Among ten patients, pancreas tail in nine patients were left only on the splenic hilum at distal portion inside branching of the splenic vessel, and there was intraabdominal fluid collection which was naturally resolved. But other one patient with remnant pancreas tail above the hilar vessels re-admitted due to postoperative pancreatic fistula with fever, and underwent internal drainage. Conclusions: In spleen preservation, leaving small pancreas tail inside the splenic hilum would be feasible and more beneficial to the patient, rather than performing splenectomy in anatomically challenging patients.Tabled 1EP02E-00664/FPre-Op. : R/O PNETPost-Op. : Chronic pancreatitisSplenic vessel LigatedNo POPF5 days (Hosp. stay)X (Re-admission)49/MPNETPreservedBCL6X45/MIPMNLigatedBCL6X41/MPNETLigatedBCL7X56/FPNETPreservedNo5X38/MPNETLigatedBCL6X50/MIPMNLigatedGrade B8O74/MIPMNLigatedBCL10X61/MMetastatic renal cell ca.LigatedBCL7X25/FIPMNPreservedBCL7X Open table in a new tab

Laparoscopic Spleen Preserving Distal Pancreatectomy: A Single Surgeon’s Experience

Introduction: Laparoscopic distal pancreatectomy (LDP) has performed for left-sided pancreatic tumors and spleen preservation has been performed recently for benign or low-grade malignant tumors due to its advantages. Herein, we describe our experience for laparoscopic spleen preserving distal pancreatectomy (LSPDP) and compare the postoperative outcomes according to two spleen preservation techniques.

Laparoscopic pancreatectomy for benign or low-grade malignant pancreatic tumors: outcomes in a single high-volume institution

ObjectiveTo investigate the perioperative and long-term outcomes of laparoscopic pancreatectomy for benign and low-grade malignant pancreatic tumors, and further compare the outcomes between different surgical techniques.MethodsWe retrospectively collected clinical data of consecutive patients with benign or low-grade malignant pancreatic tumors underwent surgery from February 2014 to February 2019. Patients were grouped and compared according to different surgical operations they accepted.ResultsTotally 164 patients were reviewed and 83 patients underwent laparoscopic pylorus-preserving pancreaticoduodenectomy (LPPPD), 41 patients underwent laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and 20 patients underwent laparoscopic central pancreatectomy (LCP) were included in this study, the rest 20 patients underwent laparoscopic enucleation were excluded. There were 53 male patients and 91 female patients. The median age of these patients was 53.0 years (IQR 39.3–63.0 years). The median BMI was 21.5 kg/m2 (IQR 19.7–24.0 kg/m2). The postoperative severe complication was 4.2% and the 90-days mortality was 0. Compare with LCP group, the LPPPD and LSPDP group had longer operation time (300.4 ± 89.7 vs. 197.5 ± 30.5 min, P < 0.001) while LSPDP group had shorter operation time (174.8 ± 46.4 vs. 197.5 ± 30.5 min, P = 0.027), more blood loss [140.0 (50.0–1000.0) vs. 50.0 (20.0–200.0) ml P < 0.001 and 100.0 (20.0–300.0) vs. 50.0 (20.0–200.0 ml, P = 0.039, respectively), lower rate of clinically relevant postoperative pancreatic fistula [3 (3.6%) vs. 8 (40.0%), P < 0.001 and 3 (7.3%) vs. 8 (40.0%), P = 0.006, respectively], lower rate of postpancreatectomy hemorrhage [0 (0%) vs. 2 (10.0%), P = 0.036 and (0%) vs. 2 (10.0%) P = 0.104, respectively] and lower rate of postoperative severe complications [2 (2.4%) vs.4 (20.0%), P = 0.012 and 0 (0%) vs. 4 (20.0%), P = 0.009, respectively], higher proportion of postoperative pancreatin and insulin treatment (pancreatin: 39.8% vs., 15% P = 0.037 and 24.4%vs. 15%, P = 0.390; insulin: 0 vs. 18.1%, P = 0.040 and 0 vs. 12.2%, P = 0.041).ConclusionsOverall, laparoscopic pancreatectomy could be safely performed for benign and low-grade malignant pancreatic tumors while the decision to perform laparoscopic central pancreatectomy should be made carefully for fit patients who can sustain a significant postoperative morbidity and could benefit from the excellent long-term results even in a high-volume center.

A case of peripancreatic plexiform schwannoma

BackgroundPlexiform schwannoma is one of the least common variants of schwannoma, accounting for only 5% of all schwannoma cases. It generally occurs in the skin and subcutaneous tissues and is uncommon in deep soft tissue or viscera. We present an extremely rare case of plexiform schwannoma arising from the peripancreatic plexus.Case presentationA 29-year-old man presented with hyperglycemia detected during a medical checkup. He was diagnosed with type 1 diabetes based on the clinical findings and laboratory tests. During the diagnostic process for diabetes, a 2.5 cm mass was incidentally detected in the pancreas by abdominal ultrasound. Contrast-enhanced computed tomography revealed a mass that was gradually enhanced at the body and tail of the pancreas. Magnetic resonance imaging revealed low signal intensity of the mass on T1-weighted images and high signal intensity on T2-weighted and diffusion-weighted images. Magnetic resonance cholangiopancreatography showed no abnormal findings in the main pancreatic duct. Endoscopic ultrasonography (EUS) showed a lobulated, low-echoic mass with a clear boundary. EUS-guided fine needle biopsy was performed, and spindle-shaped cells that were diffusely immunopositive for S-100 and negative for c-kit and desmin were detected, resulting in a diagnosis of a neurogenic tumor arising from the pancreas or the peripancreatic nerve plexus. The patient underwent laparoscopic spleen-preserving distal pancreatectomy. Although the tumor was connected to the splenic plexus, the splenic artery could be divided along its adventitial plane. Macroscopic findings of the excised tumor consisted of multiple yellowish-white nodules, and its histopathological features were consistent with plexiform schwannoma. There was no pancreatic tissue on the dorsal surface of the tumor, which suggested that the tumor arose from the peripancreatic nerve plexus.ConclusionsThe findings documented herein can aid in the differential diagnosis of peripancreatic schwannoma and in planning appropriate treatment.

Short-Term Outcomes of the Tail-First Approach in Laparoscopic Spleen-Preserving Distal Pancreatectomy: a Single Center Experience

BackgroundSeveral approaches have been reported during laparoscopic spleen-preserving distal pancreatectomy (LSPDP), such as medial, lateral, and posterior approaches. This study reports a tail-first approach that is mobilization of the pancreatic gland from tail to neck followed by division. The short-term outcomes are described. MethodsCases which underwent LSPDP from 2014 to 2020 at Qilu Hospital of Shandong University were included. Clinical parameters were collected and analyzed. ResultsOne hundred five cases were collected, including 54 Kimura, 45 Warshaw, and 6 modified-Warshaw procedures. Seventy-seven patients (73.3%) underwent LSPDP by a tail-first approach (TFA-LSPDP) and 28 (26.7%) by a medial approach (M-LSPDP). Compared with the M-LSPDP, the TFA-LSPDP group had a lower incidence of splenic infraction (9.1 VS 25.0%, P = 0.05) and a higher frequency of Kimura procedure (55.8 VS 39.3%, P = 0.053). ConclusionTFA-LSPDP is feasible and safe for treatment of benign and low malignant lesions of the distal pancreas, which has a lower incidence of splenic infraction and a higher frequency of splenic vessel preservation compared with the traditional medial approach.