Tag Archives: Pancreatic Neoplasms

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and arterial reconstruction: Techniques and outcomes

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Addeo P, Guerra M, Bachellier P. Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and arterial reconstruction: Techniques and outcomes. J Surg Oncol. 2021 Jun;123(7):1592-1598.

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Results: Sixty consecutive DP-CARs were reviewed. Most patients underwent induction chemotherapy (85%) based on FOLFIRINOX protocol (80.3%). The hepatic artery was reconstructed in 50 patients (83.3%). The left gastric artery was reconstructed in 4 and preserved in 14 patients. A venous resection was associated during 44 DP-CARs (36 segmental venous resections/8 lateral venous resections). Ninety days mortality was 5.0% with 48.3% (n = 29) overall rate of morbidity. Postoperative outcomes in term of mortality, morbidity, and ischemic events between patients with and without arterial reconstruction were similar despite a higher rate of venous resection (81% vs. 40%; p = 0.005) and more complex cases (Mayo clinic DP-CARs class 1B, 2A, and 3A) in the reconstructed group.

Conclusion: Arterial reconstruction represents a safe surgical option during DP-CAR to lessen postoperative ischemic events. This technique, reserved to high volume centers expert in vascular resection during pancreatectomy, deserves further comparison with standard technique in a larger setting.

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Solid pseudopapillary neoplasms (SPN) of the pancreas

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Gandhi D, et al. Solid pseudopapillary Tumor of the Pancreas: Radiological and surgical review. Clin Imaging. 2020 Nov;67:101-107.

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Highlights:

  • Solid Pseudopapillary Neoplasms of the pancreas are rare pancreatic tumors with low grade malignant potential, typically affecting young females.
  • Small SPNs (< 3cm in diameter) usually appear as completely solid tumors with sharp margins and gradually enhancing, well encapsulated masses in the pancreas and may demonstrate varying amounts of hemorrhage.
  • Large lesions have mixed solid – cystic components showing early weak enhancement with gradual increase in enhancement in the hepatic venous phase.
  • Atypical features including extracapsular, as well as parenchymal invasion, simulation of islet cell tumors, calcifications, ductal obstruction, and metastasis are suspicious for malignant degradation.
  • The tumor is considered unresectable in the event that it invades or encases the aorta, encases >180 degree of the SMA regardless of tumor location in the pancreas, abuts the celiac artery (when the tumor is located in the pancreatic head) or encases >180 degree of the celiac artery (when the tumor is located in the body/tail of the pancreas).
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Pancreatic cystic neoplasms

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Scholten L, et al. Pancreatic Cystic Neoplasms: Different Types, Different Management, New Guidelines. Visc Med. 2018 Jul;34(3):173-177.

Pancreatic cystic neoplasms (PCN) include different types of cysts with various biological behavior. The most prevalent PCN are intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and serous cystic neoplasm (SCN). Management of PCN should focus on the prevention of malignant progression, while avoiding unnecessary morbidity of surgery. This requires specialized centers with dedicated multidisciplinary PCN teams. The malignant potential of PCN varies enormously between the various types of PCN. A combination of computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography, and endoscopic ultrasound with or without fine needle aspiration is typically needed before a reliable diagnosis can be made. Several guidelines discuss the management of PCN; however, most of these are non-evidence-based without clear consensus on the optimal treatment and follow-up strategy. The 2018 European guidelines on PCN are the first evidence-based guidelines to include IPMN, MCN, SCN, and all other PCN. This guideline advises a more conservative approach to side-branch IPMN and MCN smaller than 40 mm and more often a surgical approach in IPMN with a main duct dilatation beyond 5 mm. The goal of this review is to summarize the different types and management of the most common PCN based on the current literature and guidelines.

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Surgical management of insulinomas

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Andreassen M, Ilett E, Wiese D, et al. Surgical Management, Preoperative Tumor Localization, and Histopathology of 80 Patients Operated on for Insulinoma. J Clin Endocrinol Metab. 2019 Dec 1;104(12):6129-6138.

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Results: Eighty patients were included. Seven had a malignant tumor. A total of 312 diagnostic examinations were performed: endoscopic ultrasonography (EUS; n = 59; sensitivity, 70%), MRI (n = 33; sensitivity, 58%), CT (n = 55; sensitivity, 47%), transabdominal ultrasonography (US; n = 45; sensitivity, 40%), somatostatin receptor imaging (n = 17; sensitivity, 29%), 18F-fluorodeoxyglucose positron emission tomography/CT (n = 1; negative), percutaneous transhepatic venous sampling (n = 10; sensitivity, 90%), arterial stimulation venous sampling (n = 20; sensitivity, 65%), and intraoperative US (n = 72; sensitivity, 89%). Fourteen tumors could not be visualized. Invasive methods were used in 7 of these 14 patients and localized the tumor in all cases. Median tumor size was 15 mm (range, 7 to 80 mm). Tumors with malignant vs benign behavior showed less staining for insulin (3 of 7 vs 66 of 73; P = 0.015) and for proinsulin (3 of 6 vs 58 of 59; P < 0.001). Staining for glucagon was seen in 2 of 6 malignant tumors and in no benign tumors (P < 0.001). Forty-three insulinomas stained negative for somatostatin receptor subtype 2a.

Conclusion: Localization of insulinomas requires many different diagnostic procedures. Most tumors can be localized by conventional imaging, including EUS. For nonvisible tumors, invasive methods may be a useful diagnostic tool. Malignant tumors showed reduced staining for insulin and proinsulin and increased staining for glucagon.

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Article of Interest: Avoiding Pitfalls in Insulinomas by Preoperative Localization with a Dual Imaging Approach

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Ramonell KM, Saunders ND, Sarmiento J, Bercu Z, Martin L, Weber CJ, Sharma J, Patel SG. Avoiding pitfalls in insulinomas by preoperative localization with a dual imaging approach. Am Surg. 2019 Jul 1;85(7):742-746.

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Graft reconstruction in pancreaticoduodenectomy: outcomes and survival

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One discussion this week included use of prosthetic graft reconstruction …

Reference: Chu CK, et al. Prosthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy: a multicenter analysis. Journal of the American College of Surgeons. 2010 Sep;211(3):316-324. doi: 10.1016/j.jamcollsurg.2010.04.005

Summary: Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. This paper (by Emory authors) review 33 patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique.

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Early vs late drain removal after pancreatectomy

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One discussion this week included early vs late drain removal in pancreatectomy.

References: Beane JD, et al. Variation of drain management after pancreatoduodenectomy: early versus delayed removal. Annals of Surgery. 2017 Oct. doi: 10.1097/SLA.0000000000002570

Deminski J, et al. Early removal of intraperitoneal drainage after pancreatoduodenectomy in patients without postoperative fistula at POD3: results of a randomized clinical trial. Journal of Visceral Surgery. 2019 Jan 31. pii: S1878-7886(18)30084-5. doi: 10.1016/j.jviscsurg.2018.06.006

Summary:  Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF).

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