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 Table of Contents     
ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 3  |  Page : 167-171
 

Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients


1 Department of Hepato Pancreatico Biliary surgery, Gem Hospital and Research Center, Coimbatore, Tamil Nadu, India
2 Department of Upper GI and Bariatric surgery, Gem Hospital and Research Center, Coimbatore, Tamil Nadu, India
3 Director and Head, Gem Hospital and Research Center, Coimbatore, Tamil Nadu, India

Date of Submission13-Feb-2014
Date of Acceptance01-Jan-2015
Date of Web Publication2-Jul-2015

Correspondence Address:
Shiekh Imran Gul
Gem Hospital and Research Center, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.158967

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 ¤ Abstract 

Introduction: Conventional pancreatic resections may be unnecessary for benign tumours or for tumours of low malignant potential located in the neck and body of pancreas. Such extensive resections can place the patient at increased risk of developing postoperative exocrine and endocrine insufficiency. Central pancreatectomy is a plausible surgical option for the management of tumours located in these locations. Laparoscopic approach seems appropriate for such small tumours situated deep in the retroperitoneum. Aims: To assess the technical feasibility, safety and long-term results of laparoscopic central pancreatectomy in patients with benign and low malignant potential tumours involving the neck and body of pancreas. Settings and Design: This study was an observational study which reports a single-centre experience with laparoscopic central pancreatectomy over a 9-year period. Materials and Methods: 14 patients underwent laparoscopic central pancreatectomy from October 2004 to September 2013. These included patients with tumours located in the neck and body of pancreas that were radiologically benign-looking tumours of less than 3 cm in size. Statistical Analysis Used: The statistical analysis was done using GraphPad Prism software. Results: The mean age of patients was 48.93 years. The mean operative time was 239.7 min. Mean blood loss was 153.2 ml. Mean postoperative ICU stay was 1.2 days and overall mean hospital stay was 8.07 days. There were no mortalities and no major postoperative complications. Margins were negative in all cases and with a median follow-up of 44 months, there was no recurrence. Conclusions: Laparoscopic central pancreatectomy is a feasible procedure with acceptable morbidity. In the long term, there were no recurrences and pancreatic function was well preserved.


Keywords: Laparoscopic central pancreatectomy, median pancreatectomy, pancreaticojejunal anastomosis


How to cite this article:
Senthilnathan P, Gul SI, Gurumurthy SS, Palanivelu PR, Parthasarathi R, Palanisamy NV, Natesan VA, Palanivelu C. Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients. J Min Access Surg 2015;11:167-71

How to cite this URL:
Senthilnathan P, Gul SI, Gurumurthy SS, Palanivelu PR, Parthasarathi R, Palanisamy NV, Natesan VA, Palanivelu C. Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients. J Min Access Surg [serial online] 2015 [cited 2019 Nov 14];11:167-71. Available from: http://www.journalofmas.com/text.asp?2015/11/3/167/158967



 ¤ Introduction Top


Pancreas is a vital organ having both exocrine and endocrine functions. Major pancreatic resection is thus inherently accompanied by its associated exocrine and/or endocrine deficiencies. Standard procedures like pancreaticoduodenectomy and distal pancreatectomy are associated with long-term morbidities which primarily include an exocrine deficiency after pancreaticoduodenectomy and diabetes in distal pancreatic resections. [1],[2] It is thus implied that whenever possible, pancreatic resections should be as limited as possible, especially in benign lesions of the gland. In this search of pancreatic preserving surgery, pancreatic enucleation may seem an enticing approach for benign tumours in pancreatic neck and body. However, proximity of the tumours to the main pancreatic duct and large size of the tumour limit the indications for successful enucleation. [3],[4] Thus, central pancreatectomy offers an alternative approach to left pancreatectomy, with the advantages of preserving the pancreatic parenchyma and the spleen. [5]

Minimally invasive pancreatic surgery has grown over the last two decades with complex operations like pancreaticoduodenectomy being performed successfully by skilled laparoscopic surgeons. [6] Moreover, in recent times, with advances in imaging, diagnosis of small lesions within the pancreas has further allowed localised resections of the pancreas. It is thus not surprising that other forms of pancreatic resections have also been accomplished by laparoscopy. Central pancreatectomy is one such operation which has been performed with increasing frequency in recent years. However, laparoscopic adaptation of this procedure has been slow in view of the technical expertise required and concerns for safety. With proper selection of patients, laparoscopic central pancreatectomy remains a safe procedure with acceptable morbidity.


 ¤ Materials and methods Top


We report a single institution experience of laparoscopic central pancreatectomy performed for 14 cases (8 females and 6 males) over a period of 9 years from October 2004 to September 2013. All patients underwent contrast-enhanced CT scan of the abdomen to find out the characteristics of the lesion. In the last few years, we have added endoscopic ultrasound examination in suspected patients to further qualify the lesion regarding its nature and relation to the pancreatic duct. Tumours located in the body and neck of pancreas were chosen. Exclusion criteria were tumours more than 3 cm in size or with radiological suspicion of malignancy. After following these criteria, a total of 21 patients were selected to undergo the procedure. Seven patients out of 21 were converted intraoperatively to laparoscopic distal pancreatectomy due to large tumour/small distal segment in five patients and difficult splenic vein dissection in two patients. All patients were followed up 3 monthly in the first year and 6 monthly in the second year and yearly thereafter. During the follow-up visit, exocrine function was evaluated by history suggestive of steatorrhoea. The endocrine function was evaluated along with estimation of fasting blood sugar and Hb1Ac. A yearly ultrasound examination was also done in all the patients.

Operative technique

Patient and team setup

Patient is placed in supine with split leg position. The surgeon operates standing in between the legs. The camera assistant stands on the left side of the surgeon. The retracting assistant and scrub nurse stand on the right side of the surgeon.

Port placement

  1. Umbilical (10 mm) - Camera.
  2. Left midclavicular (10 mm) - Right hand working port.
  3. Right midclavicular (5 mm) - Left hand working port.
  4. Subxiphoid (5 mm) - Stomach retracting port.
  5. Left lumbar (5 mm) - Colon retracting port.


After general inspection of the peritoneal cavity, the lesser sac is entered by dividing the gastrocolic omentum from distal antrum up to the fundus of stomach including the short gastric vessels, so as to expose the tail of pancreas. Adhesions between the posterior wall of stomach and pancreas are released completely.

Dissection of the inferior border of the pancreas and mobilisation of its posterior surface are performed by retracting the transverse colon downwards and dividing the anterior layer of the transverse mesocolon. This opens the areolar tissue at the back of the pancreas. Dissection is continued until the splenic vein is identified. The junction of the splenic vein and the superior mesenteric vein is identified by opening the fascial layer using scissors. Care is taken not to injure the splenic vein and splenic artery at the upper border of the pancreas. The splenic artery is dissected away from the pancreatic parenchyma and it is secured. The pancreas along with the tumour-containing segment is dissected from the splenic artery and vein, so as to have a 1 cm margin distally and proximally. Mobilisation of the body of the pancreas is done beyond the portal vein if necessary. At this juncture, a laparoscopic intraoperative ultrasound is used to determine the extent of tumour.

Pancreatic branches supplying the mobilised pancreas are divided. Endo GIA 60 mm stapler is used to divide the pancreas proximal to the tumour [Figure 1]. A blue (45 mm/60 mm) cartridge or a golden (60 mm) cartridge can be used depending upon the pancreatic parenchymal volume. Distally the pancreas is divided using ultrasonic shears and the central portion with the tumour is removed [Figure 2]. However, care is taken not to use ultrasonic shears in the area of presumed duct where scissors are used instead to cut the pancreatic parenchyma. The distal stump is mobilised for 2 cm. Distal pancreatic stump is anastomosed to Roux-en-Y limb of the jejunum intracorporeally. We use dunking as our standard anastomotic technique for soft undilated pancreatic ducts [Figure 3]. However, in two patients, a duct to mucosa anastomotic technique was applied in view of firm pancreas with a dilated pancreatic duct. A drain is placed near the site of anastomosis.
Figure 1: Proximal pancreatic division using Endo GIA stapler

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Figure 2: Distal pancreatic division using ultrasonic shears

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Figure 3: Completion of laparoscopic pancreaticojejunostomy

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 ¤ Results Top


The results are tabulated in [Table 1]. There were no major postoperative complications except for grade B ISGPF (International Study Group of Pancreatic Fistula ) fistula in two patients. These patients were discharged with a drain. The drain was cut short and a bag applied over the drain site for convenience. Subsequently, the drains were removed on the 21 st and 28 th day, respectively, on follow-up. In addition two patients developed clinically insignificant ISGPF grade A fistula. All postoperative pancreatic fistulae were managed conservatively. The patients with grade B fistula also had a delayed gastric emptying. On histopathological examination, the margins were negative in all cases.
Table 1: Intraoperative and postoperative data

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Follow-up

The patients were followed up for a median duration of 44 months (range 12-60). On long-term follow-up, two patients developed diabetes mellitus; however, their C-peptide levels were normal. None of the patients developed any detectable exocrine deficiency or steatorrhoea. Two patients were lost to follow-up at 20 and 21 months of surgery. In rest of the patients, no recurrence was seen on follow-up.


 ¤ Discussion Top


Classically, surgery for pancreatic tumours usually entails either pancreatoduodenectomy or distal pancreatectomy depending on the location of the lesion. Such extensive procedures are justified for malignant lesions in order to achieve an adequate oncological clearance. However, these conventional pancreatic resections performed for benign or borderline malignant lesions incur unnecessary resection of normal pancreatic tissue, placing the patient at risk of both immediate and long-term complications. Many clinical and experimental studies have been published about the relations between resected pancreatic volume and diabetic control. Yasugi et al. found that when 80% or more of the pancreas was removed, hyperglycaemia occurred immediately, and diabetes did not occur when less than 70% was removed. [7] These concerns have brought central pancreatectomy into focus and it is increasingly being reported as a feasible procedure for small benign and borderline tumours of the body and pancreatic neck. [8] Enucleation as a procedure for small lesions has very limited indications and the procedure has accompanying complications like pancreatic fistula and pseudocyst formation. [9]

It was as late as 1984 that Dagradi and Serio removed a benign insulinoma by a central pancreatectomy, making it the first such resection for a pancreatic neoplasm. [10] Later, this procedure was popularised by Serio and Iacono. Thus, the procedure was named as the Dagradi-Serio-Iacono operation (central pancreatectomy). Since then, many series of open central pancreatectomy have been reported. However, laparoscopic approach to central pancreatectomy is still a new one with very few cases of totally laparoscopic central pancreatectomy reported in literature. [11] One of the reasons for limited reports on laparoscopic central pancreatectomy is the technical difficulty a surgeon faces in laparoscopic pancreatic surgery. The other important reason is a limited group of tumours of pancreas which form an indication for central pancreatectomy. The main factor for offering this type of procedure hinges on the ability to predict the pathological nature of the lesion preoperatively. In recent years, there has been a dramatic increase in the utilisation of various preoperative radiological investigations. Their application has proved to be successful in accurately identifying cystic and solid lesions of the pancreas, [12] although at times, it is difficult to distinguish a benign cystic lesion from its malignant counterpart. In such a situation, addition of endoscopic ultrasonography, fine needle aspiration (FNA) and sometimes intraoperative frozen section may be helpful. Higher leak rates which are thought to be associated with central pancreatectomy may further push surgeons to opt for an alternate surgical approach. [13],[14],[15] However, some authors believe that these high leak rates are a result of soft pancreatic parenchyma and two pancreatic stumps left after resection. Again, some authors have concluded that neither the approach nor the anastomotic technique appears to affect the occurrence of pancreatic fistula. [16] Moreover, the majority of these leaks are clinically insignificant grade A fistulae, with grades B and C being comparable to extended resections. [8] In our experience, we had 3 patients out of 14 (21.4%) with clinically significant postoperative pancreatic fistula.

The pancreatic reconstruction in laparoscopic cases may be a Roux-en-Y pancreaticojejunostomy or a pancreaticogastrostomy. Some authors believe that the leak rates are lower with pancreaticogastrostomy, citing better blood supply to the anastomosis and inactivation of pancreatic enzymes with gastric juice preventing erosion of the anastomosis as a possible reason. [17],[18],[19],[21] Pancreaticogastrostomy is easier to fashion and takes less operative time, but is thought to delay oral feeding, which in turn can lead to a prolonged hospital stay. Pancreaticojejunostomy is done in a duct to mucosa fashion or dunking technique and is thought to have a better long-term outcome. [22] Nevertheless, both the anastomotic techniques have been reported with almost equal frequency. While a nonrandomised trial favoured pancreaticogastrostomy as regards pancreatic leak rates when compared to pancreaticojejunostomy, a few studies and randomised trials failed to show any significant differences in this regard. [23],[24] Central pancreatectomy has been reported to be associated with negligible mortality but with a high postoperative morbidity, and above all, consisting of pancreatic fistula. [25] In our series, the pancreatic fistula was seen in 4 out of 14 patients (28.57%). However, these were ISGPF grade A and grade B in two and three patients, respectively, and were managed conservatively.

As far as the incidence of exocrine dysfunction is concerned, it is minimal in patients of central pancreatectomy. [8],[26] In our series, there was no worsening of exocrine function of the pancreas, as evident by the absence of steatorrhoea on history.

There was no tumour recurrence in our series. It has been recommended that when in doubt, all patients being considered for central pancreatectomy should have a frozen section analysis of the lesion and resected margins. From a technical perspective, central pancreatectomy requires meticulous dissection and anastomotic technique and advanced laparoscopic skills. These skills, coupled with the rare circumstances in which the need for such resections arises, support the recommendation that this is an operation to be performed by surgeons with experience in pancreatic surgery.


 ¤ Conclusion Top


Laparoscopic central pancreatectomy is a feasible and safe procedure with excellent overall long-term outcomes as far as endocrine and exocrine functions are concerned. The minimally invasive approach ensures an adequate treatment in benign and low malignant potential tumours with proper preoperative selection of cases. However, standardisation of technique is essential to compare the overall data in multicentric trials.

 
 ¤ References Top

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Shikano T, Nakao A, Kodera Y, Yamada S, Fujii T, Sugimoto H, et al. Middle pancreatectomy: Safety and long-term results. Surgery 2010;147:21-9.  Back to cited text no. 1
    
2.
Goldstein MJ, Toman J, Chabot JA. Pancreaticogastrostomy: A novel application after central pancreatectomy. J Am Coll Surg 2004;198:871-6.  Back to cited text no. 2
    
3.
Falconi M, Zerbi A, Crippa S, Balzano G, Boninsegna L, Capitanio V, et al. Parenchyma-preserving resections for small nonfunctioning pancreatic endocrine tumors. Ann Surg Oncol 2010;17:1621-7.  Back to cited text no. 3
    
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Casadei R, Ricci C, Rega D, D'Ambra M, Pezzilli R, Tomassetti P, et al. Pancreatic endocrine tumors less than 4 cm in diameter: Resect or enucleate? A single-center experience. Pancreas 2010;39:825-8.   Back to cited text no. 4
    
5.
Iacono C, Verlato G, Ruzzenente A, Campagnaro T, Bacchelli C, Valdegamberi A, et al. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg 2013;100:873-85.   Back to cited text no. 5
    
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Boggi U, Amorese G, Vistoli F, Caniglia F, De Lio N, Perrone V, et al. Laparoscopic pancreaticoduodenectomy: A systematic literature review. Surg Endosc 2014 [In Press].  Back to cited text no. 6
    
7.
Yasugi H, Mizumoto R, Sakurai H, Honjo I. Changes in carbohydrate metabolism and endocrine function of remnant pancreas after major pancreatic resection. Am J Surg 1976;132:577-80.  Back to cited text no. 7
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Crippa S, Bassi C, Warshaw AL, Falconi M, Partelli S, Thayer SP, et al. Middle pancreatectomy: Indications, short- and long-term operative outcomes. Ann Surg 2007;246:69-76.  Back to cited text no. 8
    
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Talamini MA, Moesinger R, Yeo CJ, Poulose B, Hruban RH, Cameron JL, et al. Cystadenomas of the pancreas: Is enucleation an adequate operation?. Ann Surg 1998;227:896-903.  Back to cited text no. 9
    
10.
Dagradi A, Serio G. Pancreatectomia intermedia. Enciclopedia Medica Italiana, vol XI: pancreas. Firenze: USES Edizioni Scientifiche; 1984. pp. 850-51.  Back to cited text no. 10
    
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Machado MA, Surjan RC, Epstein MG, Makdissi FF. Laparoscopic central pancreatectomy: A review of 51 cases. Surg Laparosc Endosc Percutan Tech 2013;23:486-90.  Back to cited text no. 11
    
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Christein JD, Smoot RL, Farnell MB. Central pancreatectomy: A technique for the resection of pancreatic neck lesions. Arch Surg 2006;141:293-9.   Back to cited text no. 13
    
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Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82:1590-7.   Back to cited text no. 17
    
18.
Poon RT, Lo SH, Fong D, Fan ST, Wong J. Prevention of pancreatic anastomostic leakage after pancreaticoduodenectomy. Am J Surg 2002;183:42-52.   Back to cited text no. 18
    
19.
Takada T, Yasuda H, Uchiyama K, Hasegawa H, Misu Y, Iwagaki T. Pancreatic enzyme activity after pylorus-preserving pancreaticoduodenectomy reconstructed with pancreaticogastrostomy. Pancreas 1995;11:276-82.   Back to cited text no. 19
    
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Mason GR. Pancreatogastrostomy as reconstruction for pancreatoduodenectomy: Review. World J Surg 1999;23:221-6.   Back to cited text no. 20
    
21.
Goldstein MJ, Toman J, Chabot JA. Pancreaticogastrostomy: A novel application after central pancreatectomy. J Am Coll Surg 2004; 198:871-6.  Back to cited text no. 21
    
22.
Rotellar F, Pardo F, Montiel C, Benito A, Regueira FM, Poveda I, et al. Totally laparoscopic Roux-en-Y duct-to-mucosa pancreaticojejunostomy after middle pancreatectomy: A consecutive nine-case series at a single institution. Ann Surg 2008;247:938-44.  Back to cited text no. 22
    
23.
Moritz NW, Shailesh VS, Michael WM, Markus KD, Christoph MS, Helmut F, et al. Pancreaticojejunostomy versus pancreaticogastrostomy: Systematic review and meta-analysis. Am J Surg 2007;193:171-83.  Back to cited text no. 23
    
24.
Du ZY, Chen S, Han BS, Shen BY, Liu YB, Peng CH. Middle segmental pancreatectomy: A safe and organ-preserving option for benign and low-grade malignant lesions. World J Gastroenterol 2013;19:1458-65.  Back to cited text no. 24
    
25.
Goudard Y, Gaujoux S, Dokmak S, Cros J, Couvelard A, Palazzo M, et al. Reappraisal of central pancreatectomy a 12-year single-center experience. JAMA Surg 2014;149:356-63.   Back to cited text no. 25
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26.
Allendorf JD, Schrope BA, Lauerman MH, Inabnet WB, Chabot JA. Postoperative glycemic control after central pancreatectomy for mid-gland lesions. World J Surg 2007;31:164-70.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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