Laparoscopic Resection of Pediatric Solid Pseudopapillary Tumors of the Pancreas

Background Solid pseudopapillary tumors (SPTs) of the pancreas arise rarely in children, are often large, and can associate intimately with splenic vessels. Splenic preservation is a fundamental consideration when resecting distal SPT. Occasionally, the main splenic vessels must be divided to resect the SPT with negative margins, but the spleen can be preserved if the short gastric vessels remain intact (ie, Warshaw procedure). The purpose of this study was to evaluate outcomes of distal pancreatectomy (DP) for SPT in children and to highlight 2 cases of splenic preservation using the Warshaw procedure. Methods Patients 19 years and younger who were treated at a single children’s hospital between July 2004 and January 2021 were examined. Patient characteristics were collected from the electronic medical record. A pediatric radiologist calculated SPT and pre- and post-operative (ie, non-infarcted) splenic volumes. Results Eleven patients received DP for SPT. Six DPs were performed open and 5 laparoscopically. The spleen was preserved in 3 open and 4 laparoscopic DPs. A laparoscopic Warshaw procedure was performed in 2 patients. Laparoscopic resection associated with less frequent epidural use ( P = .015), shorter time to full diet ( P = .030), and post-operative length of stay ( P = .009), compared to open resection. Average residual splenic volume after the laparoscopic Warshaw procedure was 70% of preoperative volume. Discussion Laparoscopic DP for pediatric SPT achieved similar oncologic goals to open resection. Splenic preservation was feasible with laparoscopy in most cases and was successfully supplemented with the Warshaw procedure, which has not been previously reported for SPT resection in children.

Ten Reasons for Laparoendoscopic Repair of Hiatal Hernia

Laparoendoscopic hiatal hernia repair (LEHHR) involves laparoscopic repair of hiatal hernia with concomitant transoral incisionless fundoplication (TIF). The objective of this case presentation is to highlight the benefits of LEHHR in a patient with long term follow up. This patient is a 56-year-old woman with symptoms of gastroesophageal reflux disease for 40 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm hiatal hernia. DeMeester score was 21.3. She underwent LEHHR 33 months ago. The patient underwent laparoscopic cholecystectomy for symptomatic biliary dyskinesia. This provided the opportunity to examine the operative anatomy. There were minimal adhesions to the liver. The partial fundoplication was intact. The angle of His was preserved. The fundus was spared from any adhesions as TIF utilizes the cardia rather than the fundus to create the wrap. The plane behind the stomach was undisturbed. LEHHR has 10 main benefits. Anatomical benefits result from the preservation of the angle of His. Functional benefits relate to a partial fundoplication which normalizes pH values. LEHHR avoids bleeding from short gastric vessels and the creation of a wrap when anatomical obstacles present. Strategic benefits are directed toward any subsequent revisional reflux surgery. The lack of adhesions, easy access to the base of left crus, and sparing the fundus render revisional surgery straightforward.

PS01.052: OUR STANDARD PROCEDURE IN LAPAROSCOPIC NISSEN FUNDOPLICATION FOR GERD PATIENTS

Background Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated by many surgeons. We have established our simple procedure. Methods: SURGICAL PROCEDURE Setting Our 5-trocar setting with patients is as follows: 12 mm trocar just below the navel (A), 5 mm trocar at the upper right abdomen for pulling up lateral segment of the liver, 5 mm trocar at the upper right abdomen, 12 mm trocar at the upper left abdomen (B), 5 mm trocar at the middle left abdomen (C). Step 1 Under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus of the diaphragma has been dissected free from the soft tissue around the stomach. In this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid unnecessary bleeding. After cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. Then the inside margin of the left crus of the diaphragma was recognized from right side. In this part, laparoscope: trocar (A), the assistant: trocar (B), the operator's right hand: trocar (C). Step 2 The branches of left gastroepiploic vessels and the short gastric vessels were divided. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. In this part, laparoscope: trocar (A) at the beginning of dividing left gastroepiploic vessels, trocar (B) when dividing short gastric vessels. Step 3 The both crus are sutured with interrupted stitches to reduce the hiatus. From the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. Then the fundus of the stomach is pulled to obtain a 360 degree ‘stomach-wrap’ around the abdominal esophagus. Using 2–0 non-absorbable braided suture, stitches are placed between both gastric flaps. Results We have performed this procedure in 90 cases. The mean operation time of recent 20 cases was 90 min. Conclusion We have established our standard anti-reflux surgery procedure with less bleeding and less operative time. Disclosure All authors have declared no conflicts of interest.

Splenic Bed Laparoscopic Splenectomy Approach for Massive Splenomegaly Secondary to Portal Hypertension and Liver Cirrhosis

This study was performed to evaluate the feasibility of the splenic bed laparoscopic splenectomy approach (SBLS) for massive splenomegaly (≥30 cm) in patients with hypersplenism secondary to portal hypertension and liver cirrhosis. Patients who underwent laparoscopic splenectomy (LS) from January 2012 to December 2016 were retrospectively reviewed. We performed LS in 83 patients with massive splenomegaly (≥30 cm) secondary to portal hypertension and liver cirrhosis. Of these patients, 37 underwent the SBLS and 46 underwent anterior LS (ALS). Five patients in the ALS group and none in the SBLS group underwent conversion to open surgery. The operation time, intraoperative blood loss volume, transfusion volume, frequency of transfusion, hemorrhage of short gastric vessels, conversion rate, postoperative hospital stay, and incidence of pancreatic fistula were all significantly lower in the SBLS than ALS group (all P < 0.05). No death or postoperative bleeding occurred in the two groups, and there were no significant differences in age, gender, spleen size, hemoglobin level, platelet count, prothrombin time, Child-Pugh class, hypoproteinemia, or ascites (all P > 0.05). The SBLS is more feasible and effective than ALS in patients with massive splenomegaly (≥30 cm) secondary to portal hypertension and liver cirrhosis.

Predictive factors for short gastric vessels division during laparoscopic total fundoplication

<sec><title>OBJECTIVE:</title><p>to determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels.</p></sec><sec><title>METHODS:</title><p> we analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B).</p></sec><sec><title>RESULTS:</title><p> the section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B.</p></sec><sec><title>CONCLUSION:</title><p> the division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.</p></sec>

DYSPHAGIA AFTER LAPAROSCOPIC TOTAL FUNDOPLICATION: anterior or posterior gastric wall fundoplication?

ContextThe occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease.ObjectivesCompare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF).MethodsAnalysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF – n = 160) and Group 2 (Nissen LTF – n = 129).ResultsThe overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF.ConclusionsThe overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

Asymptomatic Partial Splenic Infarction In Laparoscopic Floppy Nissen Fundoplication And Brief Literature Review

Short gastric vessels are divided during the laparoscopic Nissen fundoplication resulting in splenic infarct in some cases. We report a case of laparoscopic floppy Nissen fundoplication with splenic infarct that was recognized during the procedure and provide a brief literature review. The patient underwent a laparoscopic floppy Nissen fundoplication. We observed a partial infarction of the spleen. She reported no pain. A follow-up computed tomography scan showed an infarct, and a 3-month abdominal ultrasound showed complete resolution. Peripheral splenic arterial branches have very little collateral circulation. When these vessels are occluded or injured, an area of infarction will occur immediately. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from splenic infarct. In conclusion, we believe that the real incidence is probably much higher because many cases of SI may have gone undiagnosed during or following an operation, because some patients are asymptomatic. We propose to check spleen carefully for the possibility of splenic infarct.