Subtotal Pancreatic Resection Research Articles

Analysis of surgical treatment of patients with pancreatic cancer at the Samara Regional Clinical Oncological Dispensary

BACKGROUND: Surgery is the only treatment option for tumors of the head and tail. To date, the most optimal operations used for tumors of the head of the pancreas are gastro-pancreatoduodenal resection, and for tumors of the tail — distal subtotal resection of the pancreas and splenectomy. The main access for these operations is median laparotomy. In our article, we analyze the surgical interventions that have been performed for pancreatic cancer in our center, Samara Regional Clinical Oncological Dispensary.
 AIM: Analysis of surgical interventions for pancreatic cancer in the Samara Regional Clinical Oncological Dispensary to assess the immediate and long-term results of surgical treatment.
 METHODS: This article presents the results of treatment of 236 patients with pancreatic cancer in the Department of abdominal Oncology of the Samara Regional Clinical Oncology Dispensary from 2018 to 2023. Most patients underwent surgical interventions, including choledochal stenting, bile duct drainage, and cholecystostomy. In inoperable or unresectable processes, palliative surgery was performed, such as the formation of cholecystoenteroanastomosis and gastroenteroanastomosis. Most of the patients underwent radical surgery, and some of them were preceded by neoadjuvant polychemotherapy. In the postoperative period, various reconstruction methods were performed, including the formation of pancreato-gastro-anastomosis and pancreatoejunoanastomosis. Combined operations were also performed in some patients with tumor invasion of adjacent organs.
 RESULTS: The medical records of 99 patients who underwent radical surgery were examined. 30 of them had significant clinical complications according to the Clavien–Dindo classification and included pancreatic fistula, failure of pancreatoejunoanastomosis, failure of pancreato-gastro-anastomosis and subhepatic abscess. All patients underwent laparotomy, sanitation and drainage of the abdominal cavity, and continued treatment in intensive care units. Some patients required a relaparotomy to stop intra-abdominal erosive bleeding. The mortality rate was 12.02%, the cause of death in some cases was the failure of pancreatoenteroanastomosis together with pancreatic fistula and cardiopulmonary insufficiency caused by pulmonary embolism. The patients were divided into four groups depending on the operation performed. Mortality after distal subtotal pancreatic resection was 2.02%, after.
 CONCLUSION: Surgical intervention is the main method of treating pancreatic cancer. Radical surgery is a key factor that affects the prognosis of the disease. However, the lack of verification of pancreatic cancer before admission to the hospital does not allow chemotherapy to be performed in the mode of preoperative treatment for a common form of the disease. In about 70% of patients, the syndrome of mechanical jaundice becomes the first manifestation of the disease, which requires additional methods of diagnosis and treatment. The complexity of the operation lies in the proximity of the pancreas to vascular structures. Most patients are already inoperable at the time of diagnosis confirmation due to the spread of the tumor process. Due to the technical complexity of operations, the high number of complications and high postoperative mortality, treatment of pancreatic cancer should be carried out in large specialized centers. The treatment of the disease requires interdisciplinary cooperation to achieve optimal diagnosis.

Immediate results of spleen-preserving distal subtotal pancreatic resection

Aim. To assess the possibility of open spleen-preserving distal subtotal pancreatic resection for tumors of the body and tail of the pancreas.Material and methods. A retrospective comparative analysis of the immediate results of the spleen-preserving interventions in 41 patients was carried out. Mainly benign tumors or tumors with a low malignancy potential of the corpus and (or) the tail of the pancreas were detected. Distal subtotal pancreatectomy with splenectomy was performed in 53 patients with pancreatic tumors of different histogenesis with low malignancy potential (control group).Results. The duration of spleen-preserving distal subtotal pancreatectomy was 12 minutes shorter, compared with the distal subtotal pancreatectomy with splenectomy group (p = 0.180). Significantly lower volume of intraoperative blood loss during spleen-preserving procedure was noted – by 460 ml (p = 0.0001). The level of postoperative complications in the spleen-preserving pancreatectomy group was 15 (37%), while in the group of distal subtotal pancreatectomy with splenectomy was 26 (49%) (p = 0.227), respectively. External pancreatic fistula after spleenpreserving pancreatectomy was noted in 13 (32%) patients, in the other group in 21 (40%; p = 0.429). The duration of hospital stay did not statistically significantly differ in the compared groups and amounted to: 18.6 ± 6.9 and 20.3 ± 5.4 days (p = 0.123), respectively.Conclusion. Open spleen-preserving pancreatectomy is a relatively safe type of surgical treatment for patients with benign tumors and tumors with a low potential for malignancy of the body and/or tail of the pancreas. The surgery is shorter in time, accompanied by a lower level of complications, significantly less intraoperative blood loss, compared with a similar procedure involving splenectomy.

Evaluation of Outcomes Following Surgery for Locally Advanced Pancreatic Neuroendocrine Tumors

Although outcome of surgical resection of liver metastases from pancreatic neuroendocrine tumors (PNETs) has been extensively studied, little is known about surgery for locally advanced PNETs; it was listed recently by the European neuroendocrine tumor society as a major unmet need. To evaluate the outcome of patients who underwent surgery for locally aggressive PNETs. This retrospective single-center case series reviewed consecutive patients who underwent resection of T3/T4 PNETs at a single academic institution. Data collection occurred from 2003 to 2018. Data analysis was performed in August 2019. Disease-free survival (primary outcome) and overall mortality (secondary outcome) were assessed with Kaplan-Meier analysis. Recurrence risk (secondary outcome, defined as identification of tumor recurrence on imaging) was assessed with Cox proportional hazard models adjusting for covariates. In this case series, 99 patients with locally advanced nondistant metastatic PNET (56 men [57%]) with a mean (SEM) age of 57.0 (1.4) years and a mean (SEM) follow-up of 5.3 (0.1) years underwent surgically aggressive resections. Of those, 4 patients (4%) underwent preoperative neoadjuvant treatment (including peptide receptor radionuclide therapy and chemotherapy); 18 patients (18%) underwent pancreaticoduodenectomy, 68 patients (69%) had distal or subtotal pancreatic resection, 10 patients (10%) had total resection, and 3 patients (3%) had other pancreatic procedures. Additional organ resection was required in 86 patients (87%): spleen (71 patients [71%]), major blood vessel (17 patients [17%]), bowel (2 patients [2%]), stomach (4 patients [4%]), and kidney (2 patients [2%]). Five-year disease-free survival was 61% (61 patients) and 5-year overall survival was 91% (91 patients). Of those living, 75 patients (76%) had an Eastern Cooperative Oncology Group score of less than or equal to 1 at last followup. Lymph node involvement (HR, 7.66; 95% CI, 2.78-21.12; P < .001), additional organ resected (HR, 6.15; 95% CI, 1.61-23.55; P = .008), and male sex (HR, 3.77; 95% CI, 1.68-8.97; P = .003) were associated with increased risk of recurrence. Functional tumors had a lower risk of recurrence (HR, 0.23; CI, 0.06-0.89; P = .03). Required resection of blood vessels was not associated with a significant increase recurrence risk. In this case series, positive lymph node involvement and resection of organs with tumor involvement were associated with an increased recurrence risk. These subgroups may require adjuvant systemic treatment. These findings suggest that patients with locally advanced PNETs who undergo surgical resection have excellent disease-free and overall survival.

A LAPAROSCOPIC ACCESS IN THE SURGICAL TREATMENT OF CHILDREN WITH SOLID PSEUDOPAPILLARY TUMORS OF THE PANCREAS

Introduction. Solid-pseudopapillary tumors (SPT) of the pancreas are rare, not exceeding 1-2% of all exocrine pancreatic tumors. Treatment of patients with this pathology consists of the radical removal of the tumor which has to a favorable prognosis of the disease. If the tumor is localized only in the pancreas tail or in the body with invasion into the tail, distal subtotal splenopreserving or distal splenopreserving pancreatic resections are performed. Objective. To demonstrate potentials of laparoscopic access in the surgical treatment of children with SPT. Material and methods. The article discusses 9 patients with diagnosed SPT who had the abovementioned surgical interventions via laparoscopic access . Discussion. The researchers demonstrated that pancreatic resections can be performed laparoscopically. Conclusions. The laparoscopic access is a priority for distal, distal subtotal pancreatic resections. It reduces surgical time, minimizes surgical trauma, accelerates patients’ rehabilitation , improves cosmetic effects as well as makes hospital stay shorter. In addition, it does not worsen immediate and long-term outcomes of the treatment.

Middle Pancreatectomy - Own Experience

The aim of the study was to analyse early results after middle pancreatectomy based on our experience. During the period between 2008 and 2009, 154 pancreatic resections were performed at the Department of Gastrointestinal Surgery, Silesian Medical University in Katowice. The following procedures were performed: 109 (70.78%) pancreatoduodenectomies, 32 (20.78%) distal pancreatectomies, 9 (5.84%) middle pancreatectomies, 3 (1.94%) total pancreatic resections, and 1 (0.65%) subtotal pancreatic resection. Early results in case of nine middle pancreatectomies were subject to analysis. Average hospitalization period amounted to 24.28 days (ranging between 8 and 57 days). Mean hospitalization period after surgery amounted to 20.71 days (ranging between 6 and 54 days). Average duration of the surgical procedure amounted to 3.6 hours (ranging between 2.25 and 4 hours). Wirsung's duct required drainage in 4 (44.4%) patients. Pancreatoenterostomy was performed in 5 (55.5%) patients. Early postoperative complications were observed in three (33.3%) patients. The most common complications included wound suppuration and intra-abdominal abscess development observed in two (22.2%) patients. Pancreatic fistula development during the postoperative period was observed in case of one (11.1%) patient. Other early postoperative complications included peritoneal cavity hemorrhage (1-11.1%) and pancreatic necrosis (1-11.1%). Two (2.22%) reoperations were required. Early postoperative mortality amounted to 0%. Middle pancreatectomy operations performed in experienced centers are considered as safe procedures with a low rate of complications. The most common indication for middle pancreatectomy is the diagnosis of a benign pancreatic tumor.

RE: “Radical Subtotal Pancreatic Resection, Including Splenectomy, Is an Effective Form Of Treatment for Infected Pancreatic Necrosis”

RE: “Radical Subtotal Pancreatic Resection, Including Splenectomy, Is an Effective Form Of Treatment for Infected Pancreatic Necrosis”

Radical Subtotal Pancreatic Resection, Including Splenectomy, Is an Effective One‐off Treatment for Infected Pancreatic Necrosis

Pancreatic resection for severe acute necrotizing pancreatitis has been associated with prohibitive mortality rates and has been hence replaced by piecemeal debridement, either by the open or the laparoscopic technique. We report the results of deliberate subtotal pancreatectomy with splenectomy for infected pancreatic necrosis. Six-year prospective audit of patients treated by a single surgeon, with an interest in pancreatic disease, within a Low Volume Hospital (LVH) setting. Results are presented as median (IQR). During the study period 18 patients (9 males) with complicated severe acute pancreatitis underwent radical pancreatic resection. The median age was 61 years (range 36-69). The median time to operation after presentation was 27 days (range 2-74). Microbiological culture confirmed infection in 14 (78%) patients. Three patients (17%) died within 30 days of operation. Twelve of the 15 survivors (80%) underwent a single operative procedure. Three patients required a further laparotomy, of whom 2 required colectomy for ischemia. Median hospital and ICU stays were 43 (range 30-57) and 5 (range 4-6) days respectively. Six patients (40% of survivors) developed an infection of the left half of the chevron incision; however, all wounds were fully healed within 3 months. Long-term follow-up of survivors (n=14) revealed 8 (57%) to need at least occasional pancreatic enzyme supplementation and 5 (36%) to have diabetes mellitus. Two patients (14%) developed an incisional hernia. Radical resection of pancreas and spleen, combined with postoperative irrigation, was associated with comparatively low rates of morbidity and mortality for patients with infected pancreatic necrosis in a LVH setting.

Pancreatic resection for severe acute pancreatitis.

Non-operative management of acute necrotizing pancreatitis carries a mortality of up to 80 per cent. Over the last 6 years we have pursued an aggressive policy of intensive supportive therapy followed by pancreatic resection in those patients with this severe form of the disease. We have managed 15 patients in this way, 14 by subtotal pancreatic resection (usually body and tail of the gland) and one by total pancreatectomy; 7 had early overwhelming multi-system failure with a median of 4 positive prognostic factors whilst 8 were operated on later between 3 and 8 weeks (plus one at 32 weeks) and had varying clinical pictures. Eight patients had ischaemia of the transverse colon which was noted at operation in four, and presented postoperatively in the remainder. Re-operation was necessary in 13 patients to remove further slough or resect ischaemic bowel. Five patients (33 per cent) died between 10 days and 4 weeks postoperatively, death being due to sepsis and multi-system failure in four and a massive retroperitoneal haemorrhage in one. Of the ten survivors, four require insulin. Timely excision of necrotic pancreatic tissue combined with intensive supportive therapy may help reduce the high mortality in this condition.

Colonic complications of severe acute pancreatitis.

Colonic complications are rare in acute pancreatitis. Over the last 9 years at St. Mary's Hospital, London, UK, we have managed severe acute pancreatitis by intensive supportive therapy followed by sub-total pancreatic resection and/or debridement in those who fail to improve. Of the 22 patients who have undergone this form of surgery, nine were found to have colonic involvement in the form of either necrosis or perforation. In addition, one patient presenting at West Middlesex University Hospital, Isleworth, UK, had severe acute pancreatitis and almost total colonic necrosis as an unexpected finding at emergency laparotomy. These ten patients comprised seven men and three women of median age 59 years and with a median of four Ranson criteria. In seven patients, colonic involvement was discovered at the time of pancreatic surgery or laparotomy for pancreatitis and in the remainder it presented between 1 and 3 weeks later as either a faecal fistula (n = 2) or persistent abdominal sepsis (n = 1). The ascending colon was involved in one patient, the splenic flexure and descending colon in one, the transverse colon in three, the splenic flexure alone in four, and one patient had almost total colonic involvement. All patients underwent resection of the involved colon and exteriorization with either a proximal colostomy (n = 7) or ileostomy (n = 3) and a distal mucous fistula. Pathological examination of the resected colons revealed a spectrum of changes from pericolitis through to ischaemic necrosis suggesting at least two possible mechanisms. Six patients died from overwhelming sepsis between 1 day and 4 weeks (median 11 days) after colonic resection. Severe acute pancreatitis must be recognized as a cause of colonic ischaemia and necrosis; this complication is associated with a very poor prognosis despite surgical intervention.

Timing and extent of surgery in symptomatic and asymptomatic neuroendocrine tumors of the pancreas in MEN 1.

Pancreaticoduodenal tumors develop in a majority of patients with multiple endocrine neoplasia type 1 (MEN 1) and have a pronounced effect on life expectancy as the principal cause of disease related death. Previous discussion of therapy has focused mainly on syndromes of hormone excess and especially the management of MEN 1 associated Zollinger-Ellison syndrome (ZES). The syndromes of hormone excess, however, may be late features of the endocrinopathy and, when developed, indicate presence of metastases in more than one-third of patients. Recent possibilities for genetic diagnosis have emphasized requirements of prophylactic operation for prevention of malignant development. We recommend screening with biochemical markers and endoscopic ultrasound for early detection, and strong efforts of operative tumor removal before metastases have occurred. Surgery is generally recommended in patients with or without hormonal syndromes in the absence of spread hepatic metastases. Operative procedures include enucleation of tumors in the head of the pancreas, excision of duodenal gastrinomas together with clearance of lymph gland metastases, and as prophylaxis against tumor recurrence combination with distal 80% subtotal pancreatic resection. More extensive surgical tumor reduction is believed to reduce the risks for malignant progression of the pancreaticoduodenal tumors, but this requires further evaluation in MEN 1.

Pancreatic tumors in multiple endocrine neoplasia type 1: clinical presentation and surgical treatment.

Among 33 patients with endocrine pancreatic tumors due to multiple endocrine neoplasia type 1 (MEN-1), 19 (58%) patients had hypergastrinemia, 7 (21%) patients had hyperinsulinism, and 7 (21%) patients had clinically non-functioning lesions. At least one gross tumor was found in all patients undergoing pancreatic surgery, including those with negative localization studies prior to operation. The patients also had additional macroscopic tumors as well as numerous microadenomas, and the lesions frequently were positive for immunostaining with multiple hormones, mainly pancreatic polypeptide, insulin, glucagon, and somatostatin. Duodenal endocrine lesions were found in 4 of 5 investigated patients and stained with gastrin and somatostatin antibodies. Distal, mainly subtotal pancreatic resection, was performed in 18 patients, eventually combined with caput tumor enucleation or duodenotomy, while a few patients underwent only tumor enucleation or a Whipple procedure. The long-term outcome of operation was most favorable in patients with hyperinsulinism; only 1 patient had clinical recurrence. Patients with hypergastrinemia experienced only transitory lowering of serum gastrin values after pancreatic surgery and 47% of them had or developed metastases. Such tumor spread was seen in 57% of the patients with non-functioning lesions. Nine patients died from progressive tumor disease during follow-up. Consistent with previous studies, we found that surgery is indicated in MEN-1 patients with hyperinsulinism even if a lesion is not visualized by radiology. In addition, these indications should be extended to also include patients with only biochemical markers of disease, including elevations of gastrin, as these indicate the presence of gross tumors.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic pancreatitis: long-term surgical results of pancreatic duct drainage, pancreatic resection, and near-total pancreatectomy and islet autotransplantation.

Severe abdominal pain was the major indication for operation in 85 patients with chronic pancreatitis. Preoperative endoscopic retrograde cholangiopancreatography (50 patients) or intraoperative pancreatic ductograms (44 patients) demonstrated dilated or obstructed major pancreatic ducts in 50 patients (59%), nonvisualization of the distal duct in 10 patients (12%), and normal or small sized ducts in 34 patients (40%). Operative procedures, tailored according to duct morphology, included pancreatic duct drainage (46 patients), subtotal (40% to 80%) pancreatectomy (21 patients), near-total (85% to 95%) pancreatectomy alone (eight patients), and near-total or total pancreatectomy and intrahepatic islet autotransplantation (10 patients). Pancreatic duct drainage resulted in pain relief in 37/46 patients (80%) followed for 6 years. However, 20/46 patients (43%) had continued loss of pancreatic function after duct drainage as measured by the development of insulin-dependent diabetes (16 patients) or steatorrhea (seven patients). Seven years after subtotal pancreatectomy, pain relief was partial in 9/21 patients (43%) and complete in five patients (24%). A higher incidence of hypoglycemic or ketoacidotic complications was noted in patients treated by subtotal pancreatectomy (three patients, 14%) than by duct drainage (one patient, 2%). Near-total pancreatectomy was the most effective surgical procedure in relieving pain, but late sequelae in three patients (38%) included one hypoglycemic death and two ketoacidotic episodes. Five years after near-total pancreatectomy and islet autotransplantation, one patient remained permanently insulin independent; three patients were insulin independent for 4, 5, and 15 months, respectively, but subsequently developed nonketosis-prone diabetes (tested by insulin withdrawal) and require 15 to 30 U of insulin daily; three patients had immediate insulin requirements and currently need 20 to 30 U of insulin per day but are nonketosis prone; and two patients are ketosis prone and require 30 to 60 U of insulin daily. Our analysis suggests that 5-year survival of patients undergoing operation for chronic pancreatitis is similar after treatment by duct drainage, subtotal pancreatectomy, or near-total pancreatectomy, regardless of duct morphology. Five years after duct drainage or subtotal pancreatic resection, a high incidence of diabetes (59% and 48%) and/or continued pain (20%) and (35%) can be expected.(ABSTRACT TRUNCATED AT 400 WORDS)

Beta cell nesidioblastosis

Two patients with severe hypoglycemia since birth are described. In both hyperinsulinism was demonstrated during spontaneous hypoglycemic attacks or could be provoked by various tolerance tests. In case I considerable obesity and psychomotor retardation was present at the age of one year whereas in case II weight gain was normal and development unaffected. Immunofluorescence microscopic and electron microscopic examination of the pancreas after subtotal pancreatectomy revealed diffuse islet cell hyperplasia with nesidioblastosis in case I and β-cell nesidioblastosis in case II. The hyperplastic and nesidioblastotic areas consisted mainly of β-cells. In addition, an accumulation of somatostatin producing cells was observed in case I, and some cells were found with ultrastructural signs of both endocrine and exocrine function. In both cases, pancreatic insulin release was inhibited by a prolonged somatostatin infusion. The results of tolerance tests did not allow a diagnosis of the underlying pancreatic lesion. In case II, leucine-sensitive hypoglycemia detected soon after birth, was present even after subtotal pancreatic resection. Therapeutic trials with diazoxide in case I and a leucine-restricted diet in case II were only of temporary benefit. After subtotal pancreatectomy there was clinical improvement in both cases, but case II still needs a leucine-restricted diet. The familial occurrence of persistent hypoglycemia in both cases suggests that β-cell nesidioblastosis may be a hereditary disorder.

Islet cell tumors of the pancreas

During the last fifteen years at the Wilford Hall USAF Medical Center, ten patients with islet cell tumors of the pancreas underwent surgery. The age of these patients was much lower than that previously reported, with 50 per cent of the patients between 15 and 25 years of age. These tumors have been studied extensively with endocrinologic methods, and the following types of tumors were identified: Zollinger-Ellison syndrome in four cases, two of which were associated with multiple endocrine adenomatosis (MEA), type I; insulinoma in three cases; WDHA syndrome in one case; and nonfunctioning tumors in two cases. Two of the patients have died of progressive disease, one with the Zollinger-Ellison syndrome ten years after the original operative procedure. Three of the patients had immediate cessation of the endocrine symptoms after subtotal pancreatic resection. Six patients have been followed up more than five years, with only one death, that occurring in the previously mentioned patient with a Zollinger-Ellison syndrome. The good long-term results after surgical procedures make aggressive surgery in patients with these tumors mandatory.

Surgical aspects of spontaneous hypoglycemia due to occult insulinoma.

A DIAGNOSIS of an insulin-secreting tumor is tenable when the clinical symptom-complex conforms with the criteria set forth in Whipple's triad. These criteria are as follows: ( 1 ) signs and symptoms of insulin shock usually progressive, frequently induced by fasting or exercise; (2) repeated fasting bloodsugar concentrations below 50 mg. per 100 cc, and (3) symptomatic relief by dextrose administration. More than 400 cases of hypoglycemia due to pancreatic adenoma are reported in the literature, in half of which surgical treatment was employed. In about 45% of the patients explored, no tumor could be located by the surgeon. In more than one-half of these cases in which the surgeon did not find the tumor but proceeded with a subtotal pancreatectomy, the resected specimen was histologically normal. The over-all cure rate in patients is about 40% when the surgeon, in spite of finding no tumor, performs a subtotal pancreatic resection. 1 Reported