Low-grade Malignant Lesions Research Articles

A Giant Sacrococcygeal Chordoma: Case Report and Literature Review

Introduction: Chordomas are rare low-grade malignant lesions that are mostly seen in the spine. They constitute about 1% of intracranial tumors and 3-4% of all primary bone tumors. The principal spinal location is usually the sacrococcygeal and infrequently the sphenooccipital and cervical areas. Case Presentation: We present a 74-year-old man with a huge sacrococcygeal mass extending to both buttocks. Computerized tomography (CT-scan) and magnetic resonance imaging (MRI) as well as computerized tomographic angiography (CTA) evaluations were suggestive to chordoma. Immunohistochemical analysis confirmed the diagnosis after the patient was successfully operated on. All aggravating symptoms resolved after the operation. Conclusion: The management of giant sacrococcygeal chordomas can be very challenging but with all-inclusive treatment, complete cure is achievable although recurrence can occur. In our case, surgery alone was curative. Preoperative CTA aided us in achieving total tumor resection.

Postoperative nutritional benefits of proximal parenchymal pancreatectomy for low-grade malignant lesions in the pancreatic head

BackgroundOutcomes of proximal parenchymal pancreatectomy (PPP) as compared to pancreatoduodenectomy (PD) have not been reported. The aim of this study was to describe the short- and long-term outcomes of patients with low-grade pancreatic head lesions who underwent PPP or PD. MethodsPatients who underwent PPP or PD for low-grade lesions between 2009 and 2017 were included. Operative factors including postoperative complications and nutritional indicators during the first-year postoperatively were compared. ResultsA total of 13 and 14 patients underwent PPP and PD respectively. The PPP group demonstrated significantly less intraoperative blood loss and shorter postoperative hospital stay than the PD group. No significant differences were noted in the incidence of postoperative complications between the two groups. Nutritional indices were significantly better in the PPP group at 3 months post-surgery, but these nutritional indices were not significantly different at 6 months and 1-year. None of 12 patients who underwent PPP and did not require biliary resection developed postoperative cholangitis. None of the 12 PPP patients without preoperative diabetes developed impaired glucose tolerance after surgery. DiscussionThe complication rate of PPP is equivalent to that of PD. PPP demonstrated better short-term nutritional status than PD. Moreover, preservation of the total duodenum and bile duct may reduce the risk of developing postoperative diabetes and cholangitis.

Central pancreatectomy for benign or low-grade malignant pancreatic lesions - A single-center retrospective analysis of 116 cases

BackgroundCentral pancreatectomy (CP) is a parenchyma-sparing surgery for benign or low-grade malignant pancreatic tumors. This study aimed to evaluate the safety of the procedure and to analyze the long-term pancreatic function. The age-specific incidence ratio (IR) was calculated based on the incidence of diabetes mellitus in the general Italian population of Italy. Materials and methodsPatients submitted to CP from January 1990 to December 2017 at the Department of General and Pancreatic Surgery of the Pancreas Institute of Verona, Italy, were evaluated. ResultsThe final population was composed of 116 patients. There was a clear prevalence of females (74.1%), the mean age was 48 ± 15 years and the main indication for surgery was a pancreatic neuroendocrine tumor (45.7%). A pancreojejunal anastomosis was performed more frequently than a pancreogastric anastomosis (78.4% vs 11.6%). The mean length of stay was 20 ± 33 days.The overall abdominal complications rate was 62%. The frequency of clinically relevant postoperative pancreatic fistula (grades B and C) was 26.7%. The mortality rate was 0%. The rate of R1-resection was 0.8%, as was the recurrence rate. After a mean follow-up of 12.8 years ±6.5, 6 patients developed new-onset diabetes (NODM, 7.5%), and the IR was 1.36 (95%CI 0.49–2.96). ConclusionsCP is associated with high rates of abdominal complications, however, considering the amount of the normal pancreas that was spared, it might be indicated for selected benign or low-malignancy pancreatic tumors. CP patients have the same incidence of diabetes than the general population.

Surgical therapy of benign and low-grade malignant intramedullary chondroid lesions of the distal femur: intralesional resection and bone cement filling with or without osteosynthesis

Surgical treatment of benign and low-grade malignant intramedullary chondroid lesions at the distal femur is not well analyzed compared to higher-grade chondrosarcomas. Localization at the distal femur offers high biomechanical risks requiring sophisticated treatment strategy, but scientific guidelines are missing. We therefore wanted to analyze a series of equally treated patients with intralesional resection and bone cement filling with and without additional osteosynthesis. Twenty-two consecutive patients could be included with intralesional excision and filling with polymethylmethacrylate bone cement alone (n = 10) or with compound bone cement osteosynthesis using a locking compression plate (n = 12). Clinical and radiological outcome was retrospectively evaluated including tumor recurrences, complications, satisfaction, pain, and function. Mean follow-up was 55 months (range 7–159 months). Complication rate was generally high with lesion-associated fractures both in the osteosynthesis group (n = 2) and in the non-osteosynthesis group (n = 2). All fractures occurred in lesions that reached the diaphysis. No fractures were found in meta-epiphyseal lesions. No tumor recurrence was found until final follow-up. Clinical outcome was good to excellent for both groups, but patients with additional osteosynthesis had significantly longer surgery time, more blood loss, longer postoperative stay in the hospital, more complications, more pain, less satisfaction, and worse functional outcome. Intralesional resection strategy was oncologically safe without local recurrences but revealed high risk of biomechanical complications if the lesion reached the diaphysis with an equal fracture rate no matter whether osteosynthesis was used or not. Additional osteosynthesis significantly worsened final clinical outcome and had more overall complications. This study may help guide surgeons to avoid overtreatment with additional osteosynthesis after curettage and bone cement filling of intramedullary lesions of the distal femur. Meta-epiphyseal lesions will need additional osteosynthesis rarely, contrary to diaphyseal lesions with considerable cortical thinning.

Three Skulls Dating from the French Revolutionary Years Diagnosed with Tinea Capitis: A Paleopathologic Approach.

The Musée Dupuytren was a Parisian pathology museum established in 1835. This museum hosted 3 skulls with severe craniofacial lesions initially tagged as aggressive forms of tinea capitis. The aim of this study was to investigate these specimens and discuss the initial diagnosis. Historical investigations were conducted based on the biographic data from the tags of the 3 skulls and entries on the catalog of the museum. Age was determined using dentition and the patency of cranial base synchondroses. The computed tomography scans were performed using standard medical devices. The 3 skulls were from the late 18th to early 19th century. Skull № 1 was a 5-year-old child and presented with microcephaly and extensive vault osteolysis compatible with an aggressive benign lesion, a malignant tumor, or a chronic infection. Skull № 2 was a 12- to 18-year-old teenager and presented with symmetrical porotic hyperostosis compatible with undernutrition and various hematologic conditions causing prolonged anemia, but also with chronic inflammation and/or infection. Skull № 3 was also from a 12- to 18-year-old teenager and presented with focal temporal osteolysis compatible with an aggressive benign or a low-grade malignant temporal soft-tissue lesion or with chronic infection. These skulls contribute to the understanding of the concept of tinea in the 19th century. They are furthermore windows on the sanitary and social conditions in Paris in the years following the French revolution and during the Napoleonian wars.

Robotic single-site plus ONE-port distal pancreatectomy

Laparoscopic distal pancreatectomy (DP) is regarded as an appropriate surgical option to treat benign and low-grade malignant lesions in the left side of the pancreas. Some expert surgeons tried to reduce the number of trocars in conventional laparoscopic surgery to enhance DP’s cosmetic and minimally invasive effects. However, it is thought to be too difficult to generalize this approach in clinical practice. In theory, robotic surgical system was introduced to overcome limitations of laparoscopic surgery. More specialized robotic surgical system has been introduced for single site minimally invasive surgery. If an additional robotic arm is used to this robotic surgical system, a wrist-like motion of instrument can be used, allowing for a more effective surgical movement during robotic single site surgery. In this paper, preoperative preparations and surgical techniques for robotic single-site plus ONE-port DP will be discussed.

Parosteal osteosarcoma of the maxilla: A case report and review of the literature

This study reports a rare case of parosteal osteosarcoma, a low-grade malignant lesion diagnosed in a 67-year-old female who presented with a slow growing oval-shaped, well circumscribed, bony hard, left maxillary swelling of 4 months' duration; extending from the region of the left upper lateral incisor tooth (22) to the left upper first molar tooth (26) and fixed to the overlying gingival. Oblique lateral radiograph showed the left maxillary alveolar ridge with lobulated ossified mass. The clinical differential diagnoses of the lesion were osteoma, and fibrous dysplasia histopathological diagnosis of parosteal osteosarcoma was made after incisional biopsy of the lesion. Surgical resection (with a wide margin) of the affected maxillary segment and the associated teeth was performed, and postsurgical biopsy confirmed the diagnosis of parosteal osteosarcoma. Parosteal osteosarcoma shares similar clinicopathological characteristics with some periosteal lesions. However, special imaging techniques and histopathological evaluation remain the most reliable tools for definitive diagnosis of these lesions.

Minimally Invasive Surgical Approaches for Pancreatic Adenocarcinoma: Recent Trends.

Pancreatic resection for cancer represents a real challenge for every surgeon. Recent improvements in laparoscopic experience, minimally invasive surgical techniques and instruments make now the minimally invasive approach a real "triumph." There is no doubt that minimally invasive surgery has replaced with great success conventional surgery in many fields, including surgical oncology. However, its progress in pancreatic resection for adenocarcinoma has been dramatically slow. Recent evidence supports the notion that minimally invasive distal pancreatectomy is safe and feasible and that is becoming the procedure of choice mainly for benign or low-grade malignant lesions in the distal pancreas. On the other side, minimally invasive pancreatoduodenectomy has not yet been widely accepted and there is enormous skepticism when applied for pancreatic head adenocarcinoma. In this review, we summarize the current evidence on the potential applications of minimally invasive surgical approaches for this aggressive, heterogeneous, and enigmatic type of cancer. Moreover, the potential future applications of these approaches are discussed with the hope to improve the quality of life as well as the survival rates of pancreatic cancer patients.

Indications for prophylactic osteosynthesis associated with curettage in benign and low-grade malignant primitive bone tumors of the distal femur in adult patients: a case series.

BackgroundThe aim of the study was to evaluate whether the use of preventive osteosynthesis after curettage in benign and primitive low-grade malignant bone tumor localized in the distal femur in adult patients provides sufficient mechanical stability to the system as to allow weight-bearing and reduce the risk of postoperative fracture. Additionally, lower limb function after curettage and preventive osteosynthesis was evaluated.Materials and methodsWe analyzed twelve cases of benign and low-grade malignant bone lesions of the distal femur in adult patients treated in our orthopedic department between 2008 and 2011 with curettage, bone filling and preventive osteosynthesis. All patients were treated with curettage with the use of high-speed cutters, plus liquid nitrogen as local adjuvant in low-grade malignant lesions, and filling of the lesion with bone graft or allograft or acrylic cement, followed by osteosynthesis.ResultsNo fractures or major complications were observed; good function of the knee was observed.ConclusionWe recommend preventive osteosynthesis after curettage in patients with very large lesions (>5 cm, >60 cm3) or high functional requirements, in obese patients, and when local adjuvants are used.Level of evidenceLevel IV retrospective case-series study.

Multifocal Pyogenic Granuloma-Like Kaposi Sarcoma

Background: Kaposi sarcomais a low-grade malignant vascular lesion, which has different histological variants. Pyogenic granuloma-like Kaposi sarcoma is an unusual type of this tumor, which presents as anexophytic small nodule surrounded by an epidermal collaret mimicking pyogenic granuloma yet it has immunohistopathologic features of Kaposi sarcoma. Case Presentation: A 57-year old male with 2 exophytic lesions on the left hand and left foot for 3 months was presented to our center. Both lesions were excised and diagnosis of Kaposi sarcoma was confirmed by histopathology and immunohistochemistry. Human herpesvirus 8 DNA was detected by the polymerase chain reaction in the lesions. Conclusions: Immunostaining methods should be considered in pyogenic granuloma-like lesions with unusual presentation.

Pigmented epitheloid melanocytoma: a low grade/intermediate/ borderline melanoma

Pigmented epitheloid melanocytoma is a recently described entity, low grade malignant lesion, encompassing epitheloid blue nevus of carney complex and animal type melanoma, from which they are histologically indistinguishable. Excision biopsy of skin and lymph node were subjected to histopathological processing and IHC studies. The characteristic histomorphology and positive melanocytic marker in spindle, polygonal and epitheloid cellular components of both the skin and left supraclavicular lymph nodal lesions confirmed the diagnosis. We report a rare case of pigmented epitheloid melanocytoma of the anterior chest wall with metastasis to left supraclavicular lymph node.

Caveolin-1-ROS feedforward in PSC induces stroma-tumor metabolic coupling in pancreatic cancer

Objective: To investigate the clinical application of binding pancreaticogastrostomy (BPG) anastomosis in medial pancreatectomy(MP). Methods: The clinical data of 62 patients with benign and low-grade malignant lesions in neck and body of pancreas who received medial pancreatectomy combined with binding pancreaticogastrostomy anastomosis from January 2010 to October 2014 were retrospectively analyzed. MP: Several surgical approaches were combined used to finish the pass-through of the neck of pancreas as the common hepatic artery, portal vein, superior mesenteric vein and splenic vein for the anatomic axis. The pancreas was transected apart from the tumor 1 cm. The proximal stump was closed by interrupted sutures after the main pancreatic duct was ligated. Dissecting the tumor-burdened pancreas and ligating the branch vessels between the splenic vessels and pancreas exactly. After identification of the distal main pancreatic duct, a stent was implanted and fixed. BPG: The reconstruction began with a mobilization of distal pancreatic stump for 3-4cm. After evaluating the size and position of pancreatic stump, a purse-string suture was preset around the sero-muscular layer of the posterior gastric wall. A small gastrostomy was performed in this area with a size equivalent to accommodate the pancreatic stump. An incision was made at the anterior gastric wall. The pancreas remnant was pulled into the gastric cavity. The purse-string, as the outer binding, was tied just enough for anastomosis and the endogastric mucosa and pancreatic capsule were interrupted sutured. The incision on the anterior gastric wall was closed with a closure device. Results: Operation was successfully performed on all patients. The mean operation time was 155 min, the mean blood loss was 300 ml and the mean postoperative length of hospital stay was 10.5 days. 6 patients had postoperative pancreatic fistula (2 were Grade B and 4 were Grade A). The follow-up range time was 3 ~ 36 months. None of the 62 patients were found to have pancreatic endocrine or exocrine insufficiency or formation of pseudo pancreatic cyst. Conclusion: Medial pancreatectomy showed trauma little, quick recovery and maximum protection the pancreatic exocrine and endocrine function which should be realized as a preferred treatment for pancreas injury and the benign or low-grade malignant tumor in neck and body of pancreas. Binding pancreaticogastrostomy anastomosis could effectively reduce the incidence of pancreatic fistula which should be a ideal reconstruction mode in medial pancreatectomy.

Clinical application of binding pancreaticogastrostomy anastomosis in medial pancreatectomy

Objective: To investigate the clinical application of binding pancreaticogastrostomy (BPG) anastomosis in medial pancreatectomy(MP). Methods: The clinical data of 62 patients with benign and low-grade malignant lesions in neck and body of pancreas who received medial pancreatectomy combined with binding pancreaticogastrostomy anastomosis from January 2010 to October 2014 were retrospectively analyzed. MP: Several surgical approaches were combined used to finish the pass-through of the neck of pancreas as the common hepatic artery, portal vein, superior mesenteric vein and splenic vein for the anatomic axis. The pancreas was transected apart from the tumor 1 cm. The proximal stump was closed by interrupted sutures after the main pancreatic duct was ligated. Dissecting the tumor-burdened pancreas and ligating the branch vessels between the splenic vessels and pancreas exactly. After identification of the distal main pancreatic duct, a stent was implanted and fixed. BPG: The reconstruction began with a mobilization of distal pancreatic stump for 3-4cm. After evaluating the size and position of pancreatic stump, a purse-string suture was preset around the sero-muscular layer of the posterior gastric wall. A small gastrostomy was performed in this area with a size equivalent to accommodate the pancreatic stump. An incision was made at the anterior gastric wall. The pancreas remnant was pulled into the gastric cavity. The purse-string, as the outer binding, was tied just enough for anastomosis and the endogastric mucosa and pancreatic capsule were interrupted sutured. The incision on the anterior gastric wall was closed with a closure device. Results: Operation was successfully performed on all patients. The mean operation time was 155 min, the mean blood loss was 300 ml and the mean postoperative length of hospital stay was 10.5 days. 6 patients had postoperative pancreatic fistula (2 were Grade B and 4 were Grade A). The follow-up range time was 3 ~ 36 months. None of the 62 patients were found to have pancreatic endocrine or exocrine insufficiency or formation of pseudo pancreatic cyst. Conclusion: Medial pancreatectomy showed trauma little, quick recovery and maximum protection the pancreatic exocrine and endocrine function which should be realized as a preferred treatment for pancreas injury and the benign or low-grade malignant tumor in neck and body of pancreas. Binding pancreaticogastrostomy anastomosis could effectively reduce the incidence of pancreatic fistula which should be a ideal reconstruction mode in medial pancreatectomy.

Perineural invasion and pancreatic cancer

Objective: To investigate the clinical application of binding pancreaticogastrostomy (BPG) anastomosis in medial pancreatectomy(MP). Methods: The clinical data of 62 patients with benign and low-grade malignant lesions in neck and body of pancreas who received medial pancreatectomy combined with binding pancreaticogastrostomy anastomosis from January 2010 to October 2014 were retrospectively analyzed. MP: Several surgical approaches were combined used to finish the pass-through of the neck of pancreas as the common hepatic artery, portal vein, superior mesenteric vein and splenic vein for the anatomic axis. The pancreas was transected apart from the tumor 1 cm. The proximal stump was closed by interrupted sutures after the main pancreatic duct was ligated. Dissecting the tumor-burdened pancreas and ligating the branch vessels between the splenic vessels and pancreas exactly. After identification of the distal main pancreatic duct, a stent was implanted and fixed. BPG: The reconstruction began with a mobilization of distal pancreatic stump for 3-4cm. After evaluating the size and position of pancreatic stump, a purse-string suture was preset around the sero-muscular layer of the posterior gastric wall. A small gastrostomy was performed in this area with a size equivalent to accommodate the pancreatic stump. An incision was made at the anterior gastric wall. The pancreas remnant was pulled into the gastric cavity. The purse-string, as the outer binding, was tied just enough for anastomosis and the endogastric mucosa and pancreatic capsule were interrupted sutured. The incision on the anterior gastric wall was closed with a closure device. Results: Operation was successfully performed on all patients. The mean operation time was 155 min, the mean blood loss was 300 ml and the mean postoperative length of hospital stay was 10.5 days. 6 patients had postoperative pancreatic fistula (2 were Grade B and 4 were Grade A). The follow-up range time was 3 ~ 36 months. None of the 62 patients were found to have pancreatic endocrine or exocrine insufficiency or formation of pseudo pancreatic cyst. Conclusion: Medial pancreatectomy showed trauma little, quick recovery and maximum protection the pancreatic exocrine and endocrine function which should be realized as a preferred treatment for pancreas injury and the benign or low-grade malignant tumor in neck and body of pancreas. Binding pancreaticogastrostomy anastomosis could effectively reduce the incidence of pancreatic fistula which should be a ideal reconstruction mode in medial pancreatectomy.

Clinical application of binding pancreaticogastrostomy in the central pancreatectomy

Objective To investigate the clinical application of binding pancreaticogastrostomy (BPG) in the central pancreatectomy (CP). Methods The clinical data of 62 patients with benign and low-grade malignant lesions in the neck and body of pancreas who received CP combined with BPG from January 2010 to October 2014 were retrospectively analyzed. Fifty-six patients with space-occupying lesions of the head and neck of pancreas were confirmed by postoperative pathological examinations, including 21 solid pseudopapillary tumors of pancreas (SPTPs), 19 pancreatic neuroendocrine neoplasms (PNENs) (13 non-functional islet cell tumors), 16 pancreatic cystic tumors (12 serous cystadenomas and 4 mucinous cystadenomas) and 6 ruptures in the head and neck of pancreas. CP combined with BPG was performed. The central pancreas was resected via upper and anterior approaches after surgical exploration, and digestive tract reconstruction was applied using BPG. The operation time, volume of intraoperative blood loss, time of postoperative gastrointestinal function recovery, drainage tube removed time, duration of hospital stay and postoperative complications were recorded. Patients were followed up by outpatient examination and telephone interview up to January 2015, and follow-up included the level of blood glucose, conditions of pancreatic exocrine function and with or without pancreatic pseudocyst. Results All the patients underwent successful operation without perioperative death. The average operation time, average volume of intraoperative blood loss, average time of postoperative gastrointestinal function recovery, average drainage tube removal time and average duration of postoperative hospital stay were 155 minutes (range, 125-230 minutes), 300 mL (range, 210-425 mL), 3.0 days (range, 2.0-5.0 days), 6.0 days (range, 4.0-10.0 days) and 10.5 days (range, 9.0-21.0 days), respectively. Seven patients with delayed gastric emptying were cured by non-surgical treatment. Of 6 patients complicated with pancreatic fistula, 4 patients (Grade A) had healed pancreatic fistulas during hospitalization, 2 patients (Grade B) with drainage tubes were discharged from hospital and then drainage tubes were removed after confirming healed pancreatic fistula by imaging examination. Of 2 patients with intraperitoneal hemorrhage, 1 underwent under gastroscope cauterisation for hemostasis and 1 underwent open reoperation for hemostasis. All the patients were followed up for 3-36 months with a median time of 25 months and without high blood glucose, pancreatic exocrine function insufficiency and pancreatic pseudocyst. Conclusions CP with the advantages of minimal invasion and quick recovery can be used as a priority surgical method for benign or low-grade malignant tumors and injures in the neck and body of pancreas. BPG is safe and feasible as well as reduce the incidence of pancreatic fistula after CP, and it is an ideal reconstruction. Key words: Pancreatic neoplasms; Pancreatic trauma; Central pancreatectomy; Binding pancreatico-gastrostomy; Pancreatic fistula

Central pancreatectomy: 129 patients treated in two European pancreatic centers

Introduction: Central pancreatectomy (CP) is a parenchima-sparing surgical procedure to remove benign and/or low grade malignant lesions from the neck/body of the pancreas. Aims: We reported the experience of two high-volume pancreatic centers (Padua and Heidelberg), regarding indications, postoperative outcome and follow up (FU) of 129 patients submitted to CP in the last 14 years. Patients & methods: Data of 129 patients operated from March 2000 to January 2014 were retrieved retrospectively, and evaluated in terms of complications and post-operative pancreatic function. FU to July 2014. Results: Average 50.5 years (range 6-80), 57 M/72 F. Mean operation time was 274 minutes (range 98-490) and intraoperative blood loss 484.3 mL (range 50-2500). Median hospital stay: 13 days (range 7-63). Histology: 73 pancreatic tumors (33 serous cystadenoma, 26 neuroendocrine tumor, 8 IPMN, 4 solid-pseudopapillary tumor, 2 other tumor), 44 chronic pancreatitis, 5 other neoplasms, 7 other pancreatic pathology. Mean tumor size: 1.3 cm (range 0.2-8.0). Forty-three patients (33.3%) had a pancreatic fistula (POPF): 22 grade C, 20/22 treated by interventional radiology. Thirteen patients had a hemorrage (PPH), eight having a grade C POPF; 7/ 13 underwent re-operation and three died (mortality rate 2.3%). Median FU was 95months (range 6-172). Disease recurrence occurred in 3 patients (2.4%). Post-operatively, only 7 new onset mild diabetes, and 28 exocrine insufficiency (18 chronic pancreatitis) occurred. Conclusion: CP is an alternative option to distal pancreatectomy to treat benign and/or low-grade malignant lesions. CP has a high morbidity rate, but preserves endocrine and exocrine pancreatic function in longterm FU.

Mo1667 Central Pancreatectomy for Benign or Low-Grade Malignant Tumors: A Single Center Experience

BACKGROUND: Central pancreatectomy is used for select benign and low-grade malignant neoplasms located in the neck and proximal body of the pancreas. There is limited data describing the technique and elucidating the risks and benefits when compared to the standard subtotal pancreatectomy or pylorus preserving pancreaticoduodenectomy. METHODS: A single tertiary institutional experience was retrospectively studied from January 2004 to August of 2014. Twenty-seven patients underwent central pancreatectomy (CP), 49 patients distal pancreatectomy (DP), and 20 patients had a pylorus preserving pancreaticoduodenectomy (PPPD) for benign or low-grade malignant lesions located specifically in the neck or proximal body of the pancreas. Primary endpoints included operative time, estimated blood loss and length of hospital stay. Secondary endpoints included postoperative complications such as new onset or worsening of pre-existing diabetes and pancreatic fistula rates. RESULTS: Operative time was significantly longer in CP vs DP, yet shorter than PPPD (273.8 ± 59 versus 192.1 ± 41.8 versus 365.5 ± 50.6 minutes, respectively; p 0.5). Those who developed new diabetes or worsening of pre-existing diabetes among DP patients tended to be those with more parenchyma resected (not statistically significant). Pancreatic fistula rates were 37% and 40% for CP and PPPD as opposed to only 18% for DP. CONCLUSIONS: Central pancreatectomy is a feasible option for certain pancreatic neoplasms situated in the neck or proximal body of the pancreas. The potential benefits of this limited resection are preservation of parenchyma, decreased length of stay compared to PPPD and a trend towards conservation of endocrine function, in addition to allowing for preservation of the spleen. Nonetheless, similar to PPPD, CP has a higher pancreatic leak rate than DP.

Pancreas-Preserving Duodenectomy Is a Safe Alternative to High-Risk Pancreatoduodenectomy for Premalignant Duodenal Lesions

BackgroundPancreas-preserving duodenectomy (PPD) can be considered a technical alternative to pancreaticoduodenectomy for the treatment of premalignant/low-grade malignant lesions of the duodenum. However, no many data are available comparing surgical results and costs of these two procedures. MethodsProspectively collected data from the Karolinska University Hospital’s electronic database was analyzed retrospectively for patients who underwent PD and PPD between January 2006 and December 2011. The demographics, length of stay (LOS), postoperative morbidity and mortality, and hospital costs were analyzed. ResultsTwenty patients operated with PPD and 369 with PD were identified. Of the PDs, 81 were classified as HR-PDs, based on the intraoperative assessment of the gland. PPD patients were younger than those with HR-PD (50 vs 62 years; p = 0.0003), and with slight prevalence of overweight, BMI ≥25 (60 vs 45.7 %; p = 0.2). No differences were found in overall morbidity (55 vs 68 %; p = 0.3), in severe postoperative complications—Dindo-Clavien grade ≥3b (20 vs 30 %; p = 0.3), in delayed gastric emptying (10 vs 12 %, ns), and postpancreatectomy hemorrhage (10 vs 7.4 %, ns) between PPD and HR-PDs. However, the incidence of POPF was marginally lower in the PPD group (15 vs 37 %; p = 0.06) and was treated conservatively, while ten patients in the HR-PD group were reoperated and with POPF-associated mortality of 40 %. Also, shorter ICU stay (5 vs 12.%, ns), lower reoperation rate (10 vs 21 %, ns), lower mortality (0 vs 6.2 %), and shorter LOS (16.9 vs 24.6 days) were observed with PPD compared to HR-PD, but the numbers did not reach statistical significance. PPD was performed with shorter operative time (319 vs 418 min; p < 0.0001) and less intra-operative blood loss than HR-PD (521 vs 1027 ml; p = 0.003). The hospital costs for PPD were significantly lower than for HR-PD (29,170 vs 53,080 Euro, p = 0.03) ConclusionsPPD for resection of premalignant and low-grade malignant duodenal lesions in this small series shows to be an equivalent alternative to HR-PD, as it can be performed with shorter operative time, less intraoperative blood loss, and comparable, even slightly better, postoperative outcome and with lower costs.

Robot-Assisted Middle Pancreatectomy for Elderly Patients: Our Initial Experience.

BackgroundThe aim of this study was to evaluate the indications, safety, feasibility, and short- and long-term outcomes for elderly patients who underwent robot-assisted middle pancreatectomies (MPs).Material/MethodsTen patients (≥60 years) underwent robot-assisted middle pancreatectomies from 2012 to 2015. The perioperative data, including tumor size, operating time, rate of postoperative pancreatic fistula (POPF), postoperative morbidity, and other parameters, were analyzed. We collected and analyzed the follow-up information.ResultsThe mean age of patients was 64.30 years (range, 60–73 years). The average tumor size was 2.61 cm. The 10 cases were all benign or low-grade malignant lesions. The mean operating time was 175.00 min. The mean blood loss was 113.00 ml with no blood transfusion needed. Postoperative fistulas developed in 5 patients; there were 2 Grade A fistulas and 3 grade B fistulas. There were 3 patients who underwent postoperative complications, including 2 Grade 1 or 2 complications and 1 Grade 3 complication. No reoperation and postoperative mortality occurred. The mean hospital stay was 19.91 days. After a median follow-up of 23 months, new onset of diabetes mellitus developed in 1 patient and none suffered from deterioration of previously diagnosed diabetes or exocrine insufficiency, and no tumor recurrence happened.ConclusionsRobot-assisted middle pancreatectomy was safe and feasible for elderly people. It had low risk of exocrine or endocrine dysfunction and benefited patients’ long-term outcomes. Incidence of POPF was relatively high but we could prevent it from resulting in bad outcomes by scientific perioperative care and systemic treatment.

Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients

Standard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as pancreatic function. The aim of this study was to evaluate the postoperative clinical outcomes and long-term functional and oncologic results after pancreatic enucleation, and to compare the clinical results of laparoscopic and open enucleation. From March 2005 to December 2013, 65 cases of enucleation of benign tumors in the pancreas were identified through a retrospective review of medical records. Most of the patients were women (73.8 %), and the median age was 52.7 years (interquartile range 43.1-60.9 years). Median tumor size was 2.5 cm (interquartile range 1.6-3.8 cm). The most common indication for enucleation was pancreatic neuroendocrine tumor (24, 36.9%). A clinically relevant pancreatic fistula (International Study Group on Pancreatic Fistula grade B, C) was reported in 6 patients (9.2%). The patients with tumors of the pancreatic neck had more complications after enucleation than those with tumors at other locations (3/4, 75%). There were no differences of clinical outcomes between open and laparoscopic enucleation groups. At a median follow-up of 58.7 months there was one case of new-onset diabetes, and there were no recurrences or deaths. Enucleation is a safe and effective procedure for the treatment of benign and borderline pancreatic neoplasms. It preserves pancreatic function and is not associated with recurrence. The incidence of postoperative complications, including pancreatic fistula, is acceptable. Laparoscopic enucleation seems to be a feasible and safe approach associated with favorable perioperative outcomes for the selected patients.