Pylorus-preserving Pancreatic Head Resection Research Articles

Surgical Strategy Based on Radiological 3D Reconstruction in a Giant Metastatic Neuroendocrine Tumor of the Pancreas: A Case Report of an Interdisciplinary Approach

Background Neuroendocrine tumors (NETs) are a rare entity and are most commonly found in the gastroenteropancreatic tract. The clinical outcome depends on the potential resectability, grade, and stage. Here, we report a case of a tumor debulking in a metastatic NET of the pancreas. A 25-year-old woman with stable metastatic NET of the pancreas G2 T4N1M1 (hepatic, extrahepatic) already underwent several therapies. Case Presentation. A 25-year-old woman with stable metastatic NET of the pancreas G2 T4N1M1 (hepatic, extrahepatic) already underwent several pharmaceutical therapies. Due to the young age, the G2 characteristic, and the stable liver disease, the decision for debulking was made. Based on a 3D CT scan, an embolization was successfully performed directly prior to a pylorus-preserving pancreatic head resection, advanced interaortocaval lymph node dissection, and an atypical liver resection within segment VI. Histological workup revealed a stage pT3, G2, pN1 (29/34), pM1c (hepatic and extrahepatic), L1, V0, Pn0 with complete surgical resection of the primary tumor (180 mm). The excision of the liver segment V showed a completely resected metastasis. Conclusions In this patient, extensive surgery of a pancreatic NET with the aim of a prolonged progression-free survival was performed. Close cooperation between different disciplines is absolutely mandatory. Modern imaging allowed a precise therapy plan to be worked out.

Comparative analysis of the revenues of pylorus-preserving pancreatic head resections and laparoscopic cholecystectomies as prototypic surgical procedures in the German health-care system

Although centralization of complex surgical procedures such as pancreaticoduodenectomies is associated with a reduction in morbidity and mortality rates, it is unclear whether such surgeries are adequately represented in the German disease-related group (DRG) system. Out of all patients who underwent pancreatic resections (n = 450) at our institution between January 2008 and November 2011, 76 patients who underwent a pylorus-preserving pancreatic head resection due to pancreatic head adenocarcinoma were selected for analysis. The revenues generated by these surgical procedures were compared with those of 144 patients who had undergone elective laparoscopic cholecystectomies for symptomatic gallstone disease between January 2009 and September 2010 in our hospital. In patients undergoing pylorus-preserving pancreaticoduodenectomy, revenues per case were 1,585.55 Euros, with an average length of hospital stay (ALOS) of 19.9days (range 7-55days) and an average postoperative hospital stay of 16days; however, if the ALOS was exceeded, expenditures increasingly exceeded returns. Analysis of the cohort of patients with pylorus-preserving pancreaticoduodenectomies demonstrated average revenues per day of 79.27 Euros. In contrast, for laparoscopic cholecystectomy, which was treated with high surgical standardization and stringent case management, the ALOS was only 2.8days, producing average revenues of 288.80 Euros per day and total revenues of 817.53 Euros per case. At university hospitals, cost-effective realization of major pancreatic surgery is difficult, while highly standardized surgeries such as laparoscopic cholecystectomies can be performed at a favorable balance. This may be due to, firstly, an underrepresentation of university hospitals in the German DRG calculation basis and, secondly, to a relatively long preoperative hospital stay as a result of extensive diagnostic measures. We consider this kind of preoperative assessment paramount for an academic pancreatic center and thus argue for an increased reimbursement for these procedures.

Pankreatojejunostomie bei der Pankreaskopfresektion unter Verwendung eines resorbierbaren monofilen Fadens zur inneren Schienung der Anastomose - klinische Erfahrungen und perioperative Ergebnisse

Pancreatic fistulas are relevant in perioperative outcome, morbidity and mortality after pancreatic head resection. We analysed the potential benefit of an internal pancreatic duct draining technique by a resorbable monofilament suture if performing a two-layer duct-to-mucosa pancreatojejunostomy. From 2006 to 2010, 139 pancreatic head resections were performed in our department (124 pylorus-preserving, 15 Whipple). Indications for surgery were malignancies (n = 97), chronic pancreatitis (n = 24) or others (n = 18). In 64 cases, internal drainage of the pancreatic anastomosis was performed as described. Perioperative results were evaluated by the ISGPF classification (International Study Group for Pancreatic Fistula, type A-C) and Accordion classification (degree 1-6). Pancreatic anastomosis was performed in 99 cases as pancreatojejunostomy and in 41 cases as pancreatogastrostomy. Morbidity (Accordion 1-6) was 48 %, and mortality was 5.8 %. Pancreatic fistulas (A-C) occurred in 27 (19.4 %) cases. Only one patient died as a direct consequence of a pancreatic fistula (type C fistula after pylorus-preserving pancreatic head resection and pancreatogastrostomy). In the subgroup of patients with a two-layer duct-to-mucosa pancreatojejunostomy with internal pancreatic duct drainage by a resorbable monofilament suture (n = 64), a pancreatic fistula occurred in 20.3 % (n = 13). According to the ISGPF classification, they were type A (n = 10), type B (n = 2) and type C fistulas (n = 1). In this subgroup with pancreatic duct drainage, morbidity (Accordion 1-6) was 55 % (n = 35) and mortality (Accordion 6) was 6.2 % (n = 4). Complications due to the pancreatic duct drainage were not observed. Internal drainage of the duct-to-mucosa pancreatojejunostomy using monofilament suture material is a safe and feasible method. Pancreatic fistula occurred in 20 % both in the entire group as well as in subgroups with or without pancreatic duct drainage. A reduction of the rate of pancreatic fistula could not be achieved by internal drainage of the pancreatojejunostomy.

Laparoskopische Pankreaskopfresektion

Whereas pancreatic tail resection is routinely and safely performed in several institutions, laparoscopic resection of the pancreatic head is only performed by a handful of surgeons worldwide, none of them in Germany. We review our experience with 9 laparoscopic pancreatic head resections (lap-PPPD) performed between March and September 2010. The operations were performed using a hybrid approach with complete laparoscopic pylorus-preserving pancreatic head resection and successive reconstruction via a small retrieval incision. Perioperative outcome was compared to 605 open pancreatic head resections (1997-2010). In the group lap-PPPD 3 out of 9 conversions had to be performed due to oncologic reasons. There were no significant differences in perioperative outcome when comparing open-PPPD to lap-PPPD. Laparoscopic pancreatic head resection with hybrid open reconstruction combines the potential advantages of laparoscopic resection with the safety of an open pancreatic anastomosis. Even at the beginning of the learning curve the procedure can be performed with no concessions to safety or duration of the operation.

Jejunokolische Fisteln nach pyloruserhaltender Pankreaskopfresektion: eine ungewöhnliche Ursache für chronische Diarrhö

In patients with a history of pancreatic surgery, chronic diarrhea is mainly caused by exocrine pancreatic insufficiency. The authors report, for the first time, a case of jejunocolic fistulae as a cause of diarrhea and weight loss after pancreatic head resection. A 55-year-old patient presented with chronic diarrhea and cachexia. He had undergone pylorus-preserving pancreatic head resection for chronic pancreatitis 8 years earlier. A recent colonoscopy showed an uncommon anatomy of the colon. Gastroscopy and computed tomography revealed several jejunocolic fistulae as the cause of chronic diarrhea. The patient underwent surgery and the fistula-carrying parts of jejunum and colon were resected. After surgery, his clinical status improved and he gained weight. Interenteric fistulae after pylorus-preserving pancreatic head resection have not been reported so far. Impaired synchronization of gastric emptying and bile secretion could be a possible cause of autodigestion in the anastomosis region.

Pyloruserhaltende Pankreaskopfresektion

Traverso-Longmire pylorus-preserving pancreatic head resection is regarded as the standard surgical procedure for pancreatic head tumors. The mortality, morbidity, and oncological radicality are as low as with the classic Kausch-Whipple resection, with the additional advantage of shorter operating time and reduced blood loss. Important for long-term survival is, however, not the resection of the stomach but the early diagnosis with subsequent R0 tumor resection. Patients can benefit fundamentally from this procedure if it is carried out at a specialized center.

Morbid Obesity and Subsequent Pancreatic Cancer: Pylorus-Preserving Pancreatoduodenectomy after Laparoscopic Sleeve Gastrectomy

Morbid obesity is a recognized risk factor for gastrointestinal cancer. Little is known about pancreatic cancer developing after gastric bypass surgery or about surgery for this type of tumor following bariatric surgery. This report describes a case of pancreatic head cancer identified 3 months after laparoscopic sleeve gastrectomy for morbid obesity. During routine follow-up, mild abdominal pain and elevated pancreatic enzymes prompted computed tomography, which revealed mild edematous pancreatitis. Hyperbilirubinemia developed, and magnetic resonance imaging showed a pancreatic head tumor. CA19-9 was elevated. After a pylorus-preserving pancreatic head resection, the postoperative course was uneventful. The patient received adjuvant chemotherapy. Unfortunately, at the time of writing (9 months postoperatively), a local recurrence and hepatic metastases were diagnosed. Patients treated with bariatric surgery who develop new symptoms or report constant mild symptoms should be evaluated using endoscopy and radiomorphological imaging. Interdisciplinary obesity treatment can then offer significant benefits for the patient, particularly in the case of pancreatic cancer, which is still difficult to diagnose. In addition, there is a need for epidemiological studies of patients who undergo bariatric surgery and subsequently develop cancer.

Pancreatic head resection: the risk for local and systemic complications in 1315 patients—a monoinstitutional experience

Pancreatic head resection is a major surgical procedure and even today is linked to considerable risk for severe complications. In high-volume centers, morbidity and mortality after pancreatic head resection decreased to below 5%. In the authors’ monoinstitutional experiences including 1315 patients with malignant lesion and benign tumor, the frequency and severity of local as well as systemic complications after pancreatic head resection are reported. Between 1982 and 2004, 1315 patients underwent several types of pancreatic head resections including 549 patients with periampullary cancer, 57 with cystic neoplastic lesions, 61 with neoplasia of the papilla, 18 with endocrine tumors, and 630 with inflammatory head tumors in chronic pancreatitis. Kausch-Whipple resection was applied in 208 patients, pylorus-preserving pancreatic head resection in 412, duodenum-preserving pancreatic head resection in 571, total pancreatectomy in 36, and ampullectomy in 61 patients. Pancreatic fistula was observed in 6.8% and a breakdown of pancreaticojejunostomosis in 2.5% of the patients. Gastrointestinal leakage occurred in 0.5%. Pancreatic fistula was managed nonsurgically in 84 of 89 patients. However, the breakdown of pancreatic anastomosis requiring completion pancreatectomy developed in 29 of 33 patients. The hospital mortality of the breakdown of pancreaticojejunostomosis rose up to 34.5%; hospital mortality in patients with pancreatic fistula was 3.6%. The total hospital mortality in 1315 patients after head resection was 2.05%. Risk factors with significant relation to outcome criteria on nonsurvival are the breakdown of pancreaticojejunostomosis, severe intra-abdominal bleeding, intra-abdominal abscess, and postoperative multiorgan dysfunction syndrome. Pancreatic fistula as well as biliary leakage did not significantly determine outcome. Pancreatic head resection for neoplastic and benign tumor lesions of the pancreatic head using different resection techniques is still a major surgical procedure but with a low risk for severe complications in a high-volume center. Pancreatic fistula is a local complication that results in a prolongation of hospital stay but does not contribute to mortality and reoperation. However, the breakdown of pancreaticojejunostomosis is a life-threatening complication causing abdominal sepsis.

Randomised trial of organ- vs. pylorus-preserving pancreatic head resection

Introduction: In chronic pancreatitis, enlargement of the head of the pancreas develops in consequence of inflammatory alterations. In a prospective, randomized, control trial organ-preserving pancreatic head resection (OPPHR) was compared with pylorus-preserving pancreatoduodenectomy (PPPHR) to assess the advantages and disadvantages of each type of operation.