Laparoscopic pancreatectomy for benign or low-grade malignant pancreatic tumors: outcomes in a single high-volume institution

Objective To investigate the perioperative and long-term outcomes of laparoscopic pancreatectomy for benign and low-grade malignant pancreatic tumors, and further compare the outcomes between different surgical techniques. Methods We retrospectively collected clinical data of consecutive patients with benign or low-grade malignant pancreatic tumors underwent surgery from February 2014 to February 2019. Patients were grouped and compared according to different surgical operations they accepted. Results Totally 164 patients were reviewed and 83 patients underwent laparoscopic pylorus-preserving pancreaticoduodenectomy (LPPPD), 41 patients underwent laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and 20 patients underwent laparoscopic central pancreatectomy (LCP) were included in this study, the rest 20 patients underwent laparoscopic enucleation were excluded. There were 53 male patients and 91 female patients. The median age of these patients was 53.0 years (IQR 39.3–63.0 years). The median BMI was 21.5 kg/m2 (IQR 19.7–24.0 kg/m2). The postoperative severe complication was 4.2% and the 90-days mortality was 0. Compare with LCP group, the LPPPD and LSPDP group had longer operation time (300.4 ± 89.7 vs. 197.5 ± 30.5 min, P < 0.001) while LSPDP group had shorter operation time (174.8 ± 46.4 vs. 197.5 ± 30.5 min, P = 0.027), more blood loss [140.0 (50.0–1000.0) vs. 50.0 (20.0–200.0) ml P < 0.001 and 100.0 (20.0–300.0) vs. 50.0 (20.0–200.0 ml, P = 0.039, respectively), lower rate of clinically relevant postoperative pancreatic fistula [3 (3.6%) vs. 8 (40.0%), P < 0.001 and 3 (7.3%) vs. 8 (40.0%), P = 0.006, respectively], lower rate of postpancreatectomy hemorrhage [0 (0%) vs. 2 (10.0%), P = 0.036 and (0%) vs. 2 (10.0%) P = 0.104, respectively] and lower rate of postoperative severe complications [2 (2.4%) vs.4 (20.0%), P = 0.012 and 0 (0%) vs. 4 (20.0%), P = 0.009, respectively], higher proportion of postoperative pancreatin and insulin treatment (pancreatin: 39.8% vs., 15% P = 0.037 and 24.4%vs. 15%, P = 0.390; insulin: 0 vs. 18.1%, P = 0.040 and 0 vs. 12.2%, P = 0.041). Conclusions Overall, laparoscopic pancreatectomy could be safely performed for benign and low-grade malignant pancreatic tumors while the decision to perform laparoscopic central pancreatectomy should be made carefully for fit patients who can sustain a significant postoperative morbidity and could benefit from the excellent long-term results even in a high-volume center.

SURGICAL OPTIONS FOR NONPARASITIC SPLENIC CYSTS

Nonparasitic splenic cysts (NPSCs) are uncommon lesions of the spleen,clinically, they may be asymptomatic. Their classification includes two basic groups: the true cysts or primary cysts and false or pseudo cysts based on the presence or absence of an epithelial lining. The need for surgery of nonparasitic cysts is due to the development of complications: suppuration, hemorrhage into the cavity of the cyst and its rupture. Historically, the conventional surgical method was splenectomy, however, complete removal of the organ, especially at a young age, often led to life-threatening infectious complications. Spleen-preserving surgeryis considered to be analternative to classicalsplenectomy: partial resection of the spleen and fenestration with excisionof extra-hepaticcyst wall. However, as clinical practice has shown, these methods can be effectively used exclusively for the treatment of superficial cysts, and during the operation the ruptures of the capsule of the pathological focus with bleeding are observed. According to the general tendency in surgery to reduce the traumatization all patients were worked up with an ultrasound and X-Ray examination of the abdomen to look for the size and location of the splenic cysts. These operations include: drainage with sclerosing of the cyst and deepithelialization with superselective arterial embolization of the feeding vascular pedicle of the pathological focus. The study of these techniques revealed their weak points: the recurrence rate of cysts after sclerosis was 30-50%, and the use of embolizing agents in 50% of cases is complicated by ischemia of an organ segment with possible formation of an infarction zone in the early postoperative period. Nowadays the most promising method is considered to be a microwave ablation. Its thermal effect creates coagulation necrosis of the pathological focus and surrounding tissues with minimal toxic effects. This approach decidedly requires further research.

Giant complex non-parasitic splenic cyst in a young boy: is laparoscopic spleen-preserving surgery safe?

Non-parasitic splenic cysts are an uncommon finding in pediatric patients. We report on a 14-year-old male presenting with a giant abdominal mass. Imaging documented a giant splenic cyst, and preoperative blood tests revealed high levels of CA125. Minimally invasive unroofing of the cyst was performed. Notably, the cyst content was hematic, but histopathological studies described a mesothelial cyst lining. To date, no recurrence has been noted. Laparoscopic spleen-preserving surgery appears to be a valid and safe treatment option in children with complex non-parasitic splenic cyst to preserve the splenic parenchyma.

Symptomatic pancreatic body endometrial cyst requiring en bloc distal pancreatectomy

Pancreatic endometriosis is an extremely rare condition, with only a few cases described in the literature. Definitive diagnosis is often difficult to elucidate and will almost always require biopsy or surgical resection. We present a case of a female in her early thirties with a well-known history of widespread endometriosis presenting with vague epigastric pain. CT imaging showed an 11 cm well-circumscribed simple-appearing cyst in the lessor sac. Its origin could not be determined preoperatively but it appeared to involve the parenchyma of the body of the pancreas. Due to the associated pain and indeterminate nature, subtotal surgical resection of the extrapancreatic cyst was performed with the intrapancreatic cyst being managed by a cystogastrostomy to the adjacent stomach in a planned pancreas-sparing procedure following intraoperative confirmation it was arising within the pancreas. Pathological evaluation of the resected cyst confirmed it to be an endometrial cyst. The cystogastrostomy anastomosis subsequently obstructed a few weeks postoperatively and symptoms recurred from cyst enlargement. Redo robotic resection with resection of the remnant cyst, cystogastrostomy and en bloc spleen-preserving distal pancreatectomy was performed. The patient had an uneventful recovery. She has had no recurrence of cyst or symptoms since. A procedure video is included in the report.

Laparoscopic spleen-preserving dome resection for a giant primary epithelial splenic cyst

Non-parasitic splenic cysts are rare and are seldom diagnosed outside the paediatric surgical practice. Giant true primary epithelial cysts greater than 14 cm in diameter are even rarer. Laparoscopic surgery is preferable; however, bleeding, splenectomy and recurrence are recognised risks. Here, we report a young female patient with a 21 cm symptomatic primary splenic cyst. The patient underwent a spleen-preserving laparoscopy and was followed up for 2 years when she had an MRI of the abdomen. Surgical, technical and perioperative treatment aspects are discussed here, in the context of the current literature.