Pancreatic Enucleation Research Articles

Robotic-assisted pancreatic enucleation: Posterior uncinate approach.

Functional pancreatic neuroendocrine tumors (pNET) necessitate surgical resection. Enucleation is the preferred surgical method for well-differentiated pNETs that measure less than 2cm in diameter, as it offers a greater likelihood of enhancing post-operative recovery and decreasing morbidity and mortality. Insulinomas are particularly suitable for enucleation when such a procedure is viable. However, enucleating tumors within the uncinate process of the pancreas, especially on its posterior aspect, can present substantial challenges. The accompanying video illustrates a robotic-assisted enucleation of an insulinoma in the uncinate process, performed on a 41-year-old male with recurrent hypoglycemia. This intervention led to the resolution of symptoms and incurred minimal post-operative morbidity.

An innovative surgical approach for solid pseudopapillary neoplasm with duodenal invasion in a pediatric patient: a case report

BackgroundPediatric pancreatic tumors, especially with duodenal invasion, are exceptionally rare and a strategy for their treatment has not been established. A pancreaticoduodenectomy is often the desired treatment, but may be over-invasive for solid pseudopapillary neoplasm (SPN). This study reports an innovative surgical approach for SPN with duodenal invasion using pancreatic enucleation and endoscopically guided partial duodenectomy.Case presentationAn 11-year-old girl complained of malaise and presented with severe anemia; imaging revealed a tumor of undetermined origin, involving the pancreatic head and descending duodenum. Intraoperative findings showed tumor adherence to the pancreatic head and endoscopy revealed invasion of the duodenum. The tumor was enucleated from the pancreatic head, and partial duodenectomy was performed under endoscopically guided direct visualization. Pathology confirmed SPN with duodenal invasion, and no residual tumor. Although a Grade B pancreatic fistula occurred postoperatively, it was managed conservatively. At the 15-month follow-up, no signs of tumor recurrence, duodenal stenosis, or pancreatic dysfunction were evident.ConclusionsGiven the good prognosis of SPN, we believe that enucleation from the pancreatic head combined with an endoscopically guided partial duodenectomy could be a useful and less invasive alternative to pancreaticoduodenectomy for cases with duodenal invasion.

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

The outcomes of robotic-assisted enucleation for tumors located in uncinate process of pancreas in 16 cases

Objective: To summarize the experience of robot-assisted enucleation of tumors located in uncinate process of pancreas. Methods: This is a retrospective case series study. The clinical data of patients with robot-assisted enucleation of tumors located in the uncinate process of pancreas at the Department of Gastroenterology and Pancreatic Surgery,Zhejiang Provincial People's Hospital from June 2019 to December 2023 were retrospectively analyzed. A total of 16 cases were enrolled,including 10 males and 6 females,with an age(M(IQR)) of 56(21)years (range: 28 to 77 years),and body mass index of 22.4(2.3)kg/m2 (range:19.8 to 25.6 kg/m2). Follow-up was asked every 6 to 12 months after the first 3-month postoperative follow-up through out-patient service or via telephone. Results: In total 16 cases,there were 11 cases with pancreatic enucleation,and 5 cases with resection of the uninate process. The operation time was 70(60) minutes (range: 40 to 165 minutes),and the blood loss was 30(13)ml (range: 10 to 80 ml). The rate of pancreatic fistula was 5/16. The length of stay was 8(6)days (range: 5 to 33 days). The pathological finding included non-functional neuroendocrine tumor(n=3),insulinoma(n=2),introductal papillary mucinous neoplasm (n=5),solid pseudopapillary neoplasm (n=2),mucinous cystadenoma (n=1),serous cystadenoma (n=2),pseudocyst (n=1). Follow-up as of March 12, 2024, the follow-up time was 16(12)months (range: 3 to 41 months). All patients had no new onset diabetes and no dyspepsia. Conclusion: Robot-assisted surgical system can be used for local resection of uncinate process tumors of pancreas,and the quality of life of patients can be improved.

Main pancreatic duct 360° denudation technique for local resection of solid pseudopapillary tumor: a case report

Pancreatic enucleation is a reasonable surgical procedure for small pancreatic solid pseudopapillary tumors (SPTs). For patients with tumors close to the main pancreatic duct, enucleation surgery was previously considered contraindicated. We reported a 36-year-old Asian woman with SPT of 1.8×1.5 cm which contacting with part of the main pancreatic duct, that was once considered contraindicated for enucleation. We adopted the "main pancreatic duct approach" surgical method, and denuded main pancreatic duct with a length of about 2 cm for 360°, to locally resect the tumor, successfully preserving the continuity of the pancreatic duct in this patient. The patient did not complain of discomfort, had no symptoms of indigestion, normal blood sugar levels, and no dilation of the main pancreatic duct was seen on CT and MRI examinations in the 1st month and 3rd month after surgery.

Main duct-first approach: A potential expansion of indications for pancreatic enucleation in benign and low-grade malignant lesions.

Main duct-first approach: A potential expansion of indications for pancreatic enucleation in benign and low-grade malignant lesions.

Robotic‑assisted minimally invasive pancreas surgery. Review

The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Minimally invasive techniques have been increasingly used in oncologic surgery and pancreatic surgery in particular. Minimally invasive pancreatectomy (MIP) has been performed with increasing frequency in all pancreatic pathologies, including pancreatic neuroendocrine tumors (PNETs), including pancreaticoduodenectomy (PD), distal pancreatectomy (DP), and pancreatic enucleation. Robotic‑assisted surgery using the DaVinci platform has accelerated the adoption of MIP. The proportion of robotic DP between 2015 and 2016 was nearly 4 times greater than between 2010 and 2012 (16% vs 4%), with a similar increase in proportion of robotic PD (7% vs 2%) over the same time frame. Advantages of robotic surgery over laparoscopy include three‑dimensional visualization, increased degrees of motion with endo‑articulation, stable camera platform, surgeon ergonomics, and single surgeon’s ability to control four instruments. Systematic adoption of MIP has been facilitated by the creation of multiple multicenter training programs in robotic DP and PD, aiming to standardize the oncologic safety and technical performance of these operations. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are PD and DP. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes.

Short-term and Long-term Outcomes of Robotic Enucleation of Tumors Located in the Pancreatic Head and Uncinate Process.

To assess short-term and long-term outcomes following robotic enucleation (REn) of tumors in the proximal pancreas. Despite the advantages of preserving function via pancreatic enucleation, controversies persist, since this can be associated with severe complications, such as clinically relevant postoperative pancreatic fistula, especially when performed near the main pancreatic duct. The safety and efficacy of REn in this context remain largely unknown. A retrospective analysis was performed of all patients who underwent REn for benign and low-grade malignant neoplasms in the pancreatic head and uncinate process between January 2005 and December 2021. Clinicopathologic, perioperative, and long-term outcomes were compared with a similar open enucleation (OEn) group. Of 146 patients, 92 underwent REn with a zero conversion-to-open rate. REn was superior to OEn in terms of shorter operative time (90.0minutes vs 120.0minutes, P<0.001), decreased blood loss (20.0mL vs 100.0min, P=0.001), and lower clinically relevant postoperative pancreatic fistula rate (43.5% vs 61.1%, P=0.040). Bile leakage rate, major morbidity, 90-day mortality, and length of hospital stay were comparable between groups. No post-REn grade C POPF or grade IV/V complication was identified. Subgroup analyses for uncinate process tumors and proximity to the main pancreatic duct did not demonstrate inferior postoperative outcomes. In a median follow-up period of 50 months, REn outcomes were comparable to OEn regarding recurrence rate and pancreatic endocrine or exocrine function. REn for pancreatic head and uncinate process tumors improved clinically relevant outcomes without increased major complications compared to OEn, while demonstrating comparable long-term oncological and functional outcomes.

Reconsidering the role of prophylactic pancreaticojejunostomy in pancreatic enucleation: balancing the benefits and risks.

The incidence of postoperative pancreatic fistula (POPF) following enucleation is high, and prophylactic pancreaticojejunostomy (PPJ) is frequently performed. Minimally invasive enucleation (MEN) has been demonstrated to be safe and feasible, leaving most enucleation wounds exposed. The clinical data of 40 patients who underwent open enucleation with PPJ at our center between 2012 and 2021 were compared with those of 80 patients who underwent MEN. The MEN group had better outcomes than the PPJ group in terms of intraoperative bleeding (50.0 versus 100.0 mL), postoperative semi-liquid diet recovery (2.0 versus 5.0 days), and postoperative length of stay (7.7 versus 12.5 days). While the MEN group had higher rates of complex enucleation (60.0% versus 40.0%), main pancreatic duct repair (32.5% versus 10.0%), discharge with drains (48.8% versus 25.0%), and grade B POPFs (47.5% versus 17.5%). Both surgical methods effectively preserved pancreatic function; however, two patients in the PPJ group experienced severe haemorrhaging and died. Additionally, during the follow-up period, gastrointestinal bleeding was found and discomfort in the surgical area was reported. Pancreatic enucleation combined with PPJ should be avoided, and although a biochemical or grade B POPF may develop after MEN, it can be compensated for by preserving pancreatic function and ensuring a good long-term quality of life in the patients.

Minimally invasive enucleation versus open enucleation for benign or low-grade malignant pancreatic neoplasms: Effects on clinical outcomes and quality of life.

The efficacy and safety of minimally invasive pancreatic enucleation (PE) have rarely been investigated. This study aimed to compare the perioperative and long-term outcomes of minimally invasive enucleation (MIEn) with those of open enucleation (OEn) for benign/low-grade malignant pancreatic neoplasms. Data collected from patients who underwent PE between January 2011 and June 2020 at our centre were analysed. Forty-two patients who underwent MIEn (10 - robot-assisted and 32 - laparoscopic) and 47 who underwent OEn were included in this study. Compared with the OEn group, the MIEn group showed shorter operation time (147.6 ± 71.3 min vs. 183.1 ± 64.3 min), shorter post-operative hospital stay (11.5 ± 3.9 days vs. 13.4 ± 4.2 days), shorter off-bed activity time (2.9 ± 0.9 days vs. 3.7 ± 1.0 days) and lower estimated blood loss (EBL) (118.5 ± 59.2 mL vs. 153.1 ± 85.0 mL). Overall complication rate (47.6% vs. 55.3%), overall post-operative pancreatic fistula (POPF) rate (40.5% vs. 44.7%) and Grade B + C POPF rate (11.9% vs. 19.1%) were similar in both the groups. For neoplasms located in the proximal pancreas, MIEn showed more favourable perioperative outcomes than OEn. Unlike MIEn for superficial neoplasms, MIEn for neoplasms deeply embedded in the pancreas resulted in a longer operative time and tended to increase EBL and the incidence of complications and POPF. During the follow-up period, no significant differences were observed between these two groups in terms of pancreatic function or quality of life. Compared to OEn, MIEn is effective and safe for patients with benign or low-grade malignant pancreatic neoplasms. However, MIEn for embedded pancreatic neoplasms is recommended only in experienced centres because of the high rates of complications and POPF.

Robotic Pancreatic Enucleations

Robotic Pancreatic Enucleations

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.

Robotic parenchymal-sparing pancreatectomy and pancreas-sparing duodenectomy avoid pancreaticoduodenectomy for benign and low-grade malignant tumours.

Parenchymal-sparing pancreatectomy (PSP) or pancreas-sparing duodenectomy (PSD) is an alternative method for patients with benign or low-grade malignant tumours at the pancreatic head or duodenum. It avoids traumatic pancreaticoduodenectomy (PD) with pancreatic function preservation and improves quality of life. However, few studies have reported on robotic PSP (RPSP) or robotic PSD (RPSD). A retrospective analysis of 17 patients with benign and low-grade malignant pancreatic head and duodenal tumours who underwent RPSP or RPSD from January 2018 to February 2022 was conducted. The demographic, perioperative, and postoperative data of all patients were collected and analysed. The operations were successful for all seventeen patients without conversion, including 10 cases of RPSP and 7 cases of RPSD. For RPSP, eight patients underwent pancreatic enucleation, and two patients underwent uncinate process resection. For RPSD, five patients underwent local duodenectomy, and two patients underwent segmental duodenectomy, with five simultaneous jejunostomies and two distal gastrectomies. The median OT and EBL were 135min and 50mL for RPSP and 220min and 100mL for RPSD, respectively. The median LOS was 8days for RPSP and 19days for RPSD. The main postoperative complications for RPSP included POPF (grade B, 6 cases), DGE (grade B, 1 case), PPH (1 case), and intra-abdominal infection (1 case). The main postoperative complications for RPSD included DGE (grade B, 1 case, grade C, 3 cases), postoperative haemorrhage (1 case), intra-abdominal infection (1 case), and duodenal fistula (1 case). One patient underwent interventional drain placement after RPSP because of POPF. RPSP or RPSD is feasible for highly selected patients with benign and low-grade malignant pancreatic head and duodenal tumours, avoiding potential pancreaticoduodenectomy.

Single-port (SP) robotic pancreatic surgery using the da Vinci SP system: A retrospective study on prospectively collected data in a consecutive patient cohort

BackgroundSingle-port (SP) robotic systems have the advantages of multi-jointed wristed instruments and a fully wristed three-dimensional high-definition camera. SP robotic pancreatic surgery (SPRPS) is rarely reported because of its complexity and technical challenges. This study aimed to evaluate the feasibility of SPRPS using the new da Vinci SP system. MethodsThe demographics and short-term outcomes of a consecutive series of patients who underwent SP robotic pancreatic enucleation, distal pancreatectomy, and pancreaticoduodenectomy between December 24, 2021, and February 23, 2022, were analyzed. ResultsTwenty-three patients (eight men and 15 women; mean age, 39.7 years) were included in the study; 11 underwent SP robotic pancreatic enucleation, 11 underwent SP robotic distal pancreatectomy, and one underwent SP robotic pancreaticoduodenectomy. The mean operative time was 156.5 min, and the median estimated blood loss was 40.0 (interquartile range, 20.0–50.0) mL. No patient required conversion to laparotomy or blood transfusions. One patient in each of the three groups had grade B postoperative pancreatic fistula (POPF) and abdominal infection; they all recovered after conservative treatment. No patient had postoperative complications of grade C POPF, pancreatectomy hemorrhage, or major complications (Clavien grade ≥3). The mean length of postoperative length of hospital stay was 4.0 days. Pathological examination showed that all tumors were benign, and the mean largest tumor diameter was 2.8 cm. ConclusionsSPRPS using the da Vinci SP system is safe and feasible in selected patients. Further research and more surgical experience are needed to determine the indications for SPRPS.

Intraoperative Ultrasound Guided Robotic Pancreatic Enucleation, Does a Distance of 3mm Still Matters?

Background: A minimal distance of 3mm to main pancreatic duct (MPD) was generally considered to be necessary for pancreatic enucleation (PE). This study was designed to report the safety and feasibility of PE for tumors located in 3mm to MPD Under the intraoperative ultrasound (IOUS) guidance.Methods: The data of patients who received IOUS guided robotic PE from January 2018 to May 2019 in the second department of hepato-pancreato-biliary surgery were reviewed in this study. According to the distance to MPD (less than 3mm or not), patients were divided in 2 groups, and the short-term operative outcomes were compared.Statistics: Students' t-test and Mann-Whitney U test were used for comparing continuous variables, and Chi-squared test was used for comparing categorical variables.Results: And a total of 56 patients were analyzed, and a minimal distance less than 3mm between the tumor and pancreatic duct measured by IOUS was found in 12 patients. The tumors and MPD were clearly revealed intraoperatively in all the cases. The operative duration was significantly longer in patients with tumors located in 3mm from MPD (143.25 ± 40.89min vs 107.14 ± 37.73min, t = 2.756, P=.014). There was no significant difference between the rate of post-operative pancreatic fistula and other complications in the different groups (χ2 =.924, P=.48).Discussion and conclusion: robotic PE could be safely performed under IOUS guidance for benign or low-grade malignant tumors located less than 3mm to the MPD.

Case-matched analysis of robotic versus open surgical enucleation for pancreatic tumours: A comparative cost-effectiveness study.

Enucleation has widely spread as an alternative strategy in the treatment of small pancreatic tumours and cystic lesions. To date there are limited data on perioperative outcomes after pancreatic enucleation performed using a minimally invasive robotic technique, particularly regarding the risk factors associated with postoperative pancreatic fistula (POPF). We perform a comparative study of robotic pancreatic enucleation (RPE) and open enucleation (OPE) with the aim of evaluating clinical and cost-effective outcomes. This is a case-matched analysis of patients who underwent robotic and open pancreatic enucleation performed at Sanchinarro University Hospital, Madrid, from October 2014 to December 2021. Patient data were obtained retrospectively. Clinicopathologic characteristics and perioperative and postoperative outcomes were recorded and analysed. Two groups of demographically similar patients were analysed: the robotic group (n=20) and the open group (n=20). The patient characteristics of the two groups have been compared. From February 2015, quality-adjusted life years (QALYs) are also included and prospectively recorded in the database and used to measure the effectiveness of the treatment. A total of 20 RPE and 20 OPE have been included. The incremental cost of the robotic approach versus open was €2617.85(CI 95% 1601.48; 3634.24) and the incremental utility was 0.0879 QALYs (CI 95% 0.0834; 0.0925). The estimated ICER for patients was €29,782.13 (CI 95% 17,313.29; 43,576.01) per QALY gained. Robotic resection resulted a shorter postoperative hospital stay, less wound infections, faster recovery diet and a similar operating time. The two groups had similar complication rates. Pathological data were similar for both procedures. RPE resulted in a shorter hospital stay and less blood loss and morbidity, comparable with the outcomes of open enucleation. RPE may also be acceptable in terms of cost-effectiveness.

Robotic Assisted Pancreatic Enucleation. Clinical Outcomes and Cost Effectiveness Analysis

Background and Aims: This is a prospective comparative study of robotic enucleation (RE) and open enucleation (OE) of evaluating clinical and cost-effective outcomes. Study Design: Data of RE and OE from February 2010 to March 2020, at the Sanchinarro University Hospital, Madrid. Demographics, pathological characteristics, perioperative outcome were collected . Surgical and post-operative costs, quality adjusted life years (QALY), and incremental cost per QALY gained, or the incremental cost effectiveness ratio (ICER) were calculated and compared in RE and OE goups. A willingness-to-pay of 20,000 € and 30,000 € per QALY was used as a threshold to recognize which treatment was most cost-effective. Results: A total of 20 RE and 20 OE have been included. The overall rate of pancreatic leak was 27.7% in the RE group and 29.4% in the OE group (p > 0.5). The mean number of hospital stay days was significative higher in the OE (8.9 days vs 10.9 days, p = 0.03). The mean operative time was higher in the RE group. The overall mean total cost was superior in the robotic group (RE: 11,569.81 € versus OE: 8,951.96 €; P > 0.5). Mean QALYs at 1 year for RE (0.802) was higher than that associated with OE (0.714) (p<0.001). There was a 88.5% to 90.1% probability that RE was cost-effective relative to OE. Conclusion: RE offers better postoperative outcomes with respect to the open resection and this study provides data of cost-effectiveness between the RE and OE approaches showing a benefit for RE.

Clarifying the Role of Observation in the Management of Poorly Differentiated Pancreatic Neuroendocrine Tumors

Introduction: The management of pancreatic neuroendocrine tumors (PNET) varies between observation (O), pancreatic resection (PR) and enucleation (E). Currently, size, grade and location are used to determine which treatment strategy may be employed. We sought to evaluate each strategy and further clarify the role for surgery with regards to patients with poorly differentiated (PD) PNET. Method: Utilizing the National Cancer Database we identified patients with poorly differentiated PNET and stratified based upon size and management. Pearson’s Chi-square test was used to compare categorical variables. Survival analyses were performed using the Kaplan-Meier method. Multivariate analysis (MVA) was performed to identify predictors of survival. A p-value of <0.05 was considered significant. Results: We identified 3,187 patients diagnosed with poorly differentiated pancreatic neuroendocrine tumors. The median age of the cohort was 61 (18-90). Patients with tumors > 2cm demonstrated a higher incidence of node positivity compared to other cohorts p=0.01. Patients with <2cm tumors demonstrated a 5-year survival of 65% in those undergoing surgery vs 16% in those who did not, p<0.001. There was no difference in survival in those patients undergoing pancreatic enucleation vs those undergoing pancreatic resection, (median survival 102.2 months PR, vs 107.9 months PE, p=0.16). Multivariate analysis revealed age, tumor location, size, surgery, and clinical stage were predictors of survival. Conclusions: Poorly differentiated pancreatic neuroendocrine tumors exhibit high incidence of node positivity. Surgery improves survival in all patients with poorly differentiated PNET. Thus, observation has no role in the management of PD PNET.

Risk factors and prevention of postoperative pancreatic fistula after insulinoma enucleation:a retrospective study from a high-volume center

Background/ObjectivesEnucleation is an effective surgical method to treat pancreatic insulinoma, however, the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) is high. We aim to investigate the risk factors for CR-POPF which have not been well characterized and develop effective methods to prevent CR-POPF after enucleation. MethodsThis retrospective cohort study included 161 patients diagnosed with insulinoma from June 2016 to July 2020 in Peking Union Medical College Hospital. The risk factors for CR-POPF were evaluated and the role of prophylactic pre-operative pancreatic stent to prevent the occurrence of CR-POPF after enucleation of pancreatic insulinoma were explored. ResultsA cohort of 161 insulinoma cases were reviewed. The CT or MRI imaging reports could be tracked in 108 cases. A total of 96 patients underwent surgery, while 81 experienced pancreatic enucleation. Univariate and multivariate analyses showed that the distance from insulinoma to the main pancreatic duct (MPD) ≤2 mm was an independent risk factor for CR-POPF (p = 0.003, OR = 6.011, 95% Cl 1.852–19.512). The pre-operative pancreatic stent substantially reduced the incidence of CR-POPF in patients with tumor located in proximity to (distance ≤2 mm) the MPD (CR-POPF of the stented group vs the non-stented group: 37.5% vs 71.4%, p = 0.028). ConclusionsThe distance from insulinoma to MPD ≤2 mm is a predictive factor for CR-POPF after enucleation. Pancreatic duct stenting may benefit patients with insulinoma in proximity to the MPD by enabling a lower CR-POPF rate, so it should be considered before the enucleation of the insulinoma in proximity to the MPD (distance ≤2 mm).

Pancreatic Enucleation Patients Share the Same Quality of Life as the General Population at Long-Term Follow-Up: A Propensity Score-Matched Analysis.

The aim of this study was to assess short- and long-term outcomes including quality of life (QoL) following pancreatic enucleation (PE). PE is deemed to preserve both the endocrine and the exocrine function while ensuring radicality. However, to assess whether this reflects an actual benefit perceived by patients, QoL has to be considered. Data from all consecutive patients undergoing PE from January 2010 to December 2019 were retrospectively analyzed. Surgical outcomes were graded according to the Clavien-Dindo classification, and EORTC-C30 and the EORTC-Pan26 were administered as a cross-sectional assessment of QoL. A control group consisting of healthy individuals from the general population was obtained and matched using the propensity score matching method. Eighty-one patients underwent PE using the open (59.3%), laparoscopic (27.2%), or robot-assisted (13.5%) approach. Sixty-five (80.2%) patients exhibited functioning/nonfunctioning pancreatic neuroendocrine tumors at final pathology.Surgical morbidity and complications of a Clavien-Dindo grade ≥3 were 48.1% and 16.0%, respectively. In-hospital mortality was 0%. Postoperative pancreatic fistula, post-pancreatectomy hemorrhage, and delayed gastric emptying rates were 21.0%, 9.9%, and 4.9%, respectively.Patients returned the questionnaires after a median of 74.2 months from the index surgery. Postoperative new onset of diabetes mellitus (NODM) was observed in 5 subjects (7.1%), with age being an independent predictor. Seven patients (10.0%) developed postoperative exocrine insufficiency. At the analysis of QoL, all function and symptom scales were comparable between the 2 groups, except for 2 of the EORTC-Pan 26 symptom scales, ("worries for the future" and "body image", P < 0.05). Despite being associated with significant postoperative morbidity, PE provides excellent long-term outcomes. The risk of NODM is low and related to patient age, with QoL being comparable to the general population. Such information should drive surgeons to pursue PE whenever properly indicated.