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The British Journal of Surgery Jul 2021Multimodal treatment concepts enhance options for surgery in locally advanced pancreatic ductal adenocarcinoma (PDAC). This review provides an overview of technical... (Review)
Review
BACKGROUND
Multimodal treatment concepts enhance options for surgery in locally advanced pancreatic ductal adenocarcinoma (PDAC). This review provides an overview of technical advances to facilitate curative-intent resection in PDAC.
METHODS
A review of the literature addressing current technical advances in surgery for PDAC was performed, and current state-of-the-art surgical techniques summarized.
RESULTS
Artery-first and uncinate-first approaches, dissection of the anatomical triangle between the coeliac and superior mesenteric arteries and the portomesenteric vein, and radical antegrade modular pancreatosplenectomy were introduced to enhance the completeness of resection and reduce the risk of local recurrence. Elaborated techniques for resection and reconstruction of the mesenteric-portal vein axis and a venous bypass graft-first approach frequently allow resection of PDAC with venous involvement, even in patients with portal venous congestion and cavernous transformation. Arterial involvement does not preclude surgical resection per se, but may become surgically manageable with recent techniques of arterial divestment or arterial resection following neoadjuvant treatment.
CONCLUSION
Advanced techniques of surgical resection and vessel reconstruction provide a toolkit for curative-intent surgery in borderline resectable and locally advanced PDAC. Effects of these surgical approaches on overall survival remain to be proven with high-level clinical evidence.
Topics: Humans; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy
PubMed: 34046668
DOI: 10.1093/bjs/znab133 -
Annals of Surgery Jan 2020The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the... (Review)
Review
OBJECTIVE
The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).
SUMMARY BACKGROUND DATA
MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking.
METHODS
The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.
RESULTS
After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.
CONCLUSION
The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.
Topics: Congresses as Topic; Evidence-Based Medicine; Florida; Humans; Minimally Invasive Surgical Procedures; Pancreatectomy; Pancreatic Diseases; Practice Guidelines as Topic; Societies, Medical
PubMed: 31567509
DOI: 10.1097/SLA.0000000000003590 -
Bratislavske Lekarske Listy 2024Distal pancreatectomy is a standard surgical procedure for selected benign, premalignant, and malignant lesions localized in the pancreatic body or tail. Surgical...
NTRODUCTION
Distal pancreatectomy is a standard surgical procedure for selected benign, premalignant, and malignant lesions localized in the pancreatic body or tail. Surgical resection remains the only curative option for patients diagnosed with adenocarcinoma of the pancreas.
PATIENTS AND METHODS
Perioperative and postoperative clinical courses were retrospectively assessed in patients, who underwent distal pancreatectomy during the 2011‒2021 period.
RESULTS
During the 2011‒2021 period, a total of 112 distal pancreatectomies were performed. 67 patients (59.8%) underwent laparoscopic distal pancreatectomy, and 45 patients (40.2%) open laparotomy. The conversion was necessary for 13 patients (11.6%). Distal pancreatectomies performed laparoscopically were associated more often with biochemical leak and the development of grade B fistula, on the other hand grade C fistula developed only in patients operated by open laparotomy (LPT). The mean operating time was slightly longer in the laparoscopic group (227.1 min vs 214.6 min). The mean estimated blood loss was significantly higher in the LPT group (540.4 ml vs 191.9 ml). The mean hospitalization time was slightly longer in the LPT group (11.8 days vs 9.3 days). The rates of early reoperations were comparable between both groups (6 vs 5).
CONCLUSION
Laparoscopic techniques are preferred in centers around the world to bring patients benefits by using a minimally invasive approach. These techniques are also preferred in our center, in nearly 60% of all distal pancreatectomies performed during 10 years, but on the other hand, there is a much more careful approach chosen in cases of malignant disease to achieve adequate radicality (Tab.4, Ref. 20).
Topics: Humans; Pancreatectomy; Pancreatic Neoplasms; Retrospective Studies; Pancreas; Laparoscopy; Fistula; Treatment Outcome; Postoperative Complications
PubMed: 38526860
DOI: 10.4149/BLL_2024_36 -
Expert Review of Endocrinology &... 2023Chronic pancreatitis and recurrent acute pancreatitis comprise a spectrum of disease that results in complications related to exocrine and endocrine insufficiency and... (Review)
Review
INTRODUCTION
Chronic pancreatitis and recurrent acute pancreatitis comprise a spectrum of disease that results in complications related to exocrine and endocrine insufficiency and chronic pain with narcotic dependence and poor quality of life. The mainstay of therapy has been medical and endoscopic therapy; surgery, especially total pancreatectomy, was historically reserved for few select patients as the obligate exocrine insufficiency and pancreatogenic diabetes (type 3C) are challenging to manage. The addition of islet cell autotransplantation after total pancreatectomy helps to mitigate brittle type 3c diabetes and prevents mortality related to severe hypoglycemic episodes and hypoglycemic unawareness. There have been more recent data demonstrating the safety of surgery and the beneficial long-term outcomes.
AREAS COVERED
The purpose of this review is to describe the current practices in the field of islet cell autotransplantation including the selection and evaluation of patients for surgery, their preoperative work up and management, surgical approach, post-operative management and outcomes.
EXPERT OPINION
Total pancreatectomy and islet cell autotransplantation has the ability to drastically improve quality of life and prevent brittle diabetes for patients suffering with chronic pancreatitis.
Topics: Humans; Transplantation, Autologous; Quality of Life; Acute Disease; Treatment Outcome; Islets of Langerhans Transplantation; Pancreatitis, Chronic; Pancreatectomy; Diabetes Mellitus, Type 1; Islets of Langerhans; Hypoglycemic Agents
PubMed: 37680038
DOI: 10.1080/17446651.2023.2256407 -
Scientific Reports Jun 2023Chronic pancreatitis is a debilitating disease affecting millions worldwide. These patients suffer from bouts of severe pain that are minimally relieved by pain...
Chronic pancreatitis is a debilitating disease affecting millions worldwide. These patients suffer from bouts of severe pain that are minimally relieved by pain medications and may necessitate major surgeries with high morbidity and mortality. Previously, we demonstrated that "chemical pancreatectomy," a pancreatic intraductal infusion of dilute acetic acid solution, ablated the exocrine pancreas while preserving the endocrine pancreas. Notably, chemical pancreatectomy resolved chronic inflammation, alleviated allodynia in the cerulein pancreatitis model, and improved glucose homeostasis. Herein, we extensively tested the feasibility of a chemical pancreatectomy in NHPs and validated our previously published pilot study. We did serial computed tomography (CT) scans of the abdomen and pelvis, analyzed dorsal root ganglia, measured serum enzymes, and performed histological and ultrastructural assessments and pancreatic endocrine function assays. Based on serial CT scans, chemical pancreatectomy led to the loss of pancreatic volume. Immunohistochemistry and transmission electron microscopy demonstrated exocrine pancreatic ablation with endocrine islet preservation. Importantly, chemical pancreatectomy did not increase pro-nociceptive markers in harvested dorsal root ganglia. Also, chemical pancreatectomy improved insulin secretion to supranormal levels in vivo and in vitro. Thus, this study may provide a foundation for translating this procedure to patients with chronic pancreatitis or other conditions requiring a pancreatectomy.
Topics: Animals; Pancreatectomy; Pilot Projects; Pancreatitis, Chronic; Primates; Pain; Chronic Disease
PubMed: 37277426
DOI: 10.1038/s41598-023-35820-2 -
Seminars in Pediatric Surgery Jun 2022Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures... (Review)
Review
Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).
Topics: Child; Cholangiopancreatography, Endoscopic Retrograde; Humans; Pancreas; Pancreatectomy; Pancreatitis, Chronic
PubMed: 35725058
DOI: 10.1016/j.sempedsurg.2022.151190 -
Chirurgie (Heidelberg, Germany) Feb 2024Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last... (Observational Study)
Observational Study
Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2-3 years.
Topics: Humans; Robotic Surgical Procedures; Retrospective Studies; Pancreas; Robotics; Pancreatectomy
PubMed: 38095648
DOI: 10.1007/s00104-023-02001-w -
Islets Dec 2023Patients with chronic pancreatitis (CP) often have severe and intractable abdominal pain, leading to decreased quality of life (QOL), inability to work or attend school,...
BACKGROUND
Patients with chronic pancreatitis (CP) often have severe and intractable abdominal pain, leading to decreased quality of life (QOL), inability to work or attend school, and increased health care costs due to repeated emergency room visits and hospitalizations.
METHODS
We evaluated the efficacy of total pancreatectomy and islet autotransplantation (TPIAT) in terms of pain control and QOL in CP patients treated at our center in Japan. To evaluate QOL, we used the Short-Form 36 Health Survey version 2 (SF-36v2 Standard, Japanese), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), and Quality of Life Questionnaire-Pancreatic Modification (QLQ-PAN28).
RESULTS
Between August 2016 and June 2019, we performed this procedure in 5 patients. All patients were followed up for 12 months and all transplanted islets were still functioning at the 1-year follow-up. The major adverse events were abdominal wall hemorrhage, intestinal obstruction, intra-abdominal abscess, and abdominal pain requiring hospitalization; no case had sequelae. No major complications were due to islet transplantation. Pain scores improved postoperatively in all patients. Three QOL item dimensions role-physical ( = 0.03125), general health perception ( = 0.03125) and vitality ( = 0.03125) in the SF-36 were significantly improved 12 months after TPIAT. Mean values of many other QOL items improved, though not significantly.
CONCLUSION
The QOL improvement after TPIAT for CP suggests its effectiveness in the Japanese population.
Topics: Humans; Pancreatectomy; Transplantation, Autologous; Quality of Life; Japan; Treatment Outcome; Pancreatitis, Chronic; Islets of Langerhans Transplantation; Abdominal Pain
PubMed: 37087752
DOI: 10.1080/19382014.2023.2202092 -
Annals of Surgery Apr 2021
Review
Topics: Football; Humans; Pancreatectomy; Pancreatic Fistula; Risk Factors
PubMed: 32976277
DOI: 10.1097/SLA.0000000000004228 -
Minerva Surgery Dec 2023Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are...
Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are insufficient for digestion because of gastrointestinal (GI) surgery involving the upper GI tract, biliary ducts, or the pancreas, and and leading to potential malnutrition and deterioration in quality of life. Age, obesity, history of tobacco use, family history of diabetes, surgery due to a malignant tumor, presence of steatorrhea, jaundice, weight loss, and intraoperative findings of hard pancreatic texture have been associated with a higher risk of PSP. Pancreatoduodectomy (PD) has demonstrated an increased risk of developing PSP, with a prevalence between 19-100%. Distal pancreatectomy (DP) and central pancreatectomy (CenP) are associated with less risk of PSP, with a prevalence of 0-82% and 3.66-8.7%, respectively. In patients with chronic pancreatitis (CP), PSP was associated with 80% in Partington-Rochelle procedure, 86% in Frey procedure, 80% in duodenum preserving pancreatic head procedure, >60% in PD and 27.5-63% in DP. Fecal elastase-1 (FE-1) is a generally accepted tool for diagnosis. Treatment is recommended to start as soon as a diagnosis is achieved, or clinical suspicion is high. Pancreatic enzyme replacement therapy improves symptoms of malabsorption, facilitates weight gain, and ultimately improves patients' quality of life. Starting dosage is between 10,000-50,000 units in snacks and 50,000-75,000 units in main meals, administered throughout food intake, though further data specifically on PSP are needed. Follow-up in PSP is recommended on an on-demand basis, where malnutrition should be assessed.
Topics: Humans; Quality of Life; Exocrine Pancreatic Insufficiency; Pancreas; Pancreatectomy; Malnutrition
PubMed: 38059441
DOI: 10.23736/S2724-5691.23.10125-0