Laparoscopic Duodenum and Spleen-Preserving Subtotal or Total Pancreatectomy: A Parenchyma-Sparing Strategy for Main Duct Intraductal Papillary Mucinous Neoplasms (with Video)

Overview

Journal Ann Surg Oncol

Publisher Springer

Specialty Oncology

Date 2024 Sep 23

PMID 39312053

Authors

Zheng Li

Yihua Shi

Wenjie Tang

Chen Chen

Wensheng Liu

Qifeng Zhuo

Shunrong Ji

Chenjie Zhou

Xianjun Yu

Xiaowu Xu

Affiliations

Soon will be listed here.

Abstract

Background: For premalignant main duct intraductal papillary mucinous neoplasms (MD-IPMN), laparoscopic duodenum and spleen-preserving subtotal or total pancreatectomy (LDSP-STP/TP) seems to be a viable option for parenchyma-sparing pancreatectomy.

Patients And Methods: On the basis of the imaging features, family history, genomic alterations, intraoperative ultrasound examination, and frozen section evaluation, we have proposed patient selection strategies for the LDSP-STP/TP technique for the first time. Additionally, a comprehensive step-by-step overview of this technique has been provided. To date, we have performed five LDSP-STP procedures and one LDSP-TP procedure.

Results: We successfully performed selective resection of the affected pancreatic parenchyma while preserving the duodenum, common bile duct (CBD), spleen, and splenic artery and vein. The operation time ranged from 295 to 495 min, with blood loss ranging from 100 to 300 mL. Postoperative pathological results revealed low-grade dysplasia in the resected pancreatic samples and margins. The patients resumed eating within 3-5 days after surgery, and all postoperative complications were classified as grade I according to the Clavien-Dindo classification. At the 3-month follow-up, there were no cases of CBD ischemic stenosis, splenic ischemia, or pseudocyst formation observed. For patients who received LDSP-STP, the longitudinal diameter of the remaining pancreatic tail ranged from 2.2 to 4.6 cm, and they demonstrated satisfactory long-term blood glycemic control.

Conclusions: LDSP-STP/TP demonstrates technical feasibility and safety. It allows for the selective resection of the affected pancreatic parenchyma, thereby minimizing the impact of pancreatic functional impairment. However, it is crucial to validate this technique through long-term prospective observations.

References

You L, Yao L, Mao Y, Zou C, Jin C, Fu D . Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes. World J Gastrointest Surg. 2021; 12(12):491-506. PMC: 7769744. DOI: 10.4240/wjgs.v12.i12.491. View

Pollini T, Wong P, Maker A . The Landmark Series: Intraductal Papillary Mucinous Neoplasms of the Pancreas-From Prevalence to Early Cancer Detection. Ann Surg Oncol. 2023; 30(3):1453-1462. PMC: 9908620. DOI: 10.1245/s10434-022-12870-w. View

Chen S, Gao P, Cai H, Cai Y, Wang X, Peng B . Indocyanine Green-Enhanced Fluorescence in Laparoscopic Duodenum-Preserving Pancreatic Head Resection: Technique with Video. Ann Surg Oncol. 2020; 27(10):3926-3927. DOI: 10.1245/s10434-020-08360-6. View

Kiritani S, Iwano T, Yoshimura K, Saito R, Nakayama T, Yamamoto D . New Diagnostic Modality Combining Mass Spectrometry and Machine Learning for the Discrimination of Malignant Intraductal Papillary Mucinous Neoplasms. Ann Surg Oncol. 2023; 30(5):3150-3157. PMC: 10085898. DOI: 10.1245/s10434-022-13012-y. View

Matthaei H, Schulick R, Hruban R, Maitra A . Cystic precursors to invasive pancreatic cancer. Nat Rev Gastroenterol Hepatol. 2011; 8(3):141-50. PMC: 3236705. DOI: 10.1038/nrgastro.2011.2. View

Paniccia A, Polanco P, Boone B, Wald A, McGrath K, Brand R . Prospective, Multi-Institutional, Real-Time Next-Generation Sequencing of Pancreatic Cyst Fluid Reveals Diverse Genomic Alterations That Improve the Clinical Management of Pancreatic Cysts. Gastroenterology. 2022; 164(1):117-133.e7. PMC: 9844531. DOI: 10.1053/j.gastro.2022.09.028. View

Giuliani T, De Pastena M, Paiella S, Marchegiani G, Landoni L, Festini M . Pancreatic Enucleation Patients Share the Same Quality of Life as the General Population at Long-Term Follow-Up: A Propensity Score-Matched Analysis. Ann Surg. 2021; 277(3):e609-e616. DOI: 10.1097/SLA.0000000000004911. View

Hatori T, Kimijima A, Fujita I, Furukawa T, Yamamoto M . Duodenum-preserving total pancreatectomy for pancreatic neoplasms. J Hepatobiliary Pancreat Sci. 2009; 17(6):824-30. DOI: 10.1007/s00534-009-0225-0. View

Beger H, Mayer B, Poch B . Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis. Ann Surg Oncol. 2024; 31(7):4637-4653. PMC: 11164799. DOI: 10.1245/s10434-024-15222-y. View

10.

Singhi A, Koay E, Chari S, Maitra A . Early Detection of Pancreatic Cancer: Opportunities and Challenges. Gastroenterology. 2019; 156(7):2024-2040. PMC: 6486851. DOI: 10.1053/j.gastro.2019.01.259. View

11.

Marchegiani G, Salvia R . Guidelines on Pancreatic Cystic Neoplasms: Major Inconsistencies With Available Evidence and Clinical Practice- Results From an International Survey. Gastroenterology. 2021; 160(7):2234-2238. DOI: 10.1053/j.gastro.2021.02.026. View

12.

Lawrence S, Attiyeh M, Seier K, Gonen M, Schattner M, Haviland D . Should Patients With Cystic Lesions of the Pancreas Undergo Long-term Radiographic Surveillance?: Results of 3024 Patients Evaluated at a Single Institution. Ann Surg. 2017; 266(3):536-544. DOI: 10.1097/SLA.0000000000002371. View

13.

Kimura W . [Anatomy of the head of the pancreas and various limited resection procedures for intraductal papillary-mucinous tumors of the pancreas]. Nihon Geka Gakkai Zasshi. 2003; 104(6):460-70. View

14.

Wu J, Hu Q, Jin L, Yao W, Zhang C, Hu Z . Laparoscopic duodenum and spleen-preserving total pancreatectomy: A novel surgical technique for pancreatic intraductal papillary mucinous neoplasms. Biosci Trends. 2019; 13(5):456-460. DOI: 10.5582/bst.2019.01271. View

15.

Marchegiani G, Pollini T, Andrianello S, Tomasoni G, Biancotto M, Javed A . Progression vs Cyst Stability of Branch-Duct Intraductal Papillary Mucinous Neoplasms After Observation and Surgery. JAMA Surg. 2021; 156(7):654-661. PMC: 8135059. DOI: 10.1001/jamasurg.2021.1802. View

16.

Ohtsuka T, Fernandez-Del Castillo C, Furukawa T, Hijioka S, Jang J, Lennon A . International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas. Pancreatology. 2024; 24(2):255-270. DOI: 10.1016/j.pan.2023.12.009. View

17.

Beger H, Krautzberger W, Bittner R, Buchler M, Limmer J . Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery. 1985; 97(4):467-73. View

18.

. European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 2018; 67(5):789-804. PMC: 5890653. DOI: 10.1136/gutjnl-2018-316027. View

19.

Marchegiani G, Andrianello S, Morbin G, Secchettin E, DOnofrio M, De Robertis R . Importance of main pancreatic duct dilatation in IPMN undergoing surveillance. Br J Surg. 2018; 105(13):1825-1834. DOI: 10.1002/bjs.10948. View

20.

Kimura W, Fuse A, Hirai I, Suto K, Suzuki A, Moriya T . Spleen-preserving distal pancreatectomy with preservation of the splenic artery and vein for intraductal papillary-mucinous tumor (IPMT): three interesting cases. Hepatogastroenterology. 2003; 50(54):2242-5. View