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Digestive Surgery 2016An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for... (Review)
Review
An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pancreatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers.
Topics: Diabetes Mellitus; Humans; Malabsorption Syndromes; Organ Sparing Treatments; Pancreatectomy; Pancreatic Neoplasms; Patient Selection; Pylorus; Spleen; Stomach
PubMed: 27215746
DOI: 10.1159/000445018 -
Asian Journal of Surgery Mar 2018This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic... (Comparative Study)
Comparative Study Review
This review describes the recent advances in, and current status of, minimally invasive pancreatic surgery (MIPS). Typical MIPS procedures are laparoscopic pancreaticoduodenectomy (LPD), laparoscopic distal pancreatectomy (LDP), laparoscopic central pancreatectomy (LCP), and laparoscopic total pancreatectomy (LTP). Some retrospective studies comparing LPD or LDP and open procedures have demonstrated the safety and feasibility as well as the intraoperative outcomes and postoperative recovery of these procedures. In contrast, LCP and LTP have not been widely accepted as common laparoscopic procedures owing to their complicated reconstruction and limited indications. Nevertheless, our concise review reveals that LCP and LTP performed by expert laparoscopic surgeons can result in good short-term and long-term outcomes. Moreover, as surgeons' experience with laparoscopic techniques continues to grow around the world, new innovations and breakthroughs in MIPS will evolve. Well-designed and suitably powered randomized controlled trials of LPD, LDP, LCP, and LTP are now warranted to demonstrate the superiority of these procedures.
Topics: Disease-Free Survival; Female; Humans; Laparoscopy; Length of Stay; Male; Operative Time; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Prognosis; Risk Assessment; Survival Analysis; Treatment Outcome
PubMed: 27688035
DOI: 10.1016/j.asjsur.2016.09.003 -
The Journal of Surgical Research Jul 2022The initial settings on an intravenous patient-controlled analgesia (IV-PCA) pump can represent a significant source of postoperative opioid exposure. The primary aim of...
INTRODUCTION
The initial settings on an intravenous patient-controlled analgesia (IV-PCA) pump can represent a significant source of postoperative opioid exposure. The primary aim of this study was to evaluate the impact of first day IV-PCA use on total inpatient opioid use after open pancreatectomy, before and after standardization of initial dosing.
METHODS
Inpatient oral morphine equivalents (OMEs) were reviewed for pancreatectomy patients treated with IV-PCA at a single institution before and after (3/2016-8/2017 versus 3/2019-11/2020) implementation of a standardized initial IV-PCA dosing regimen (initial limit 0.1 mg hydromorphone, or 1 mg OME, every 10 min as needed). IV-PCA OME in the first 24 h and the total inpatient OME were compared between cohorts.
RESULTS
Of 220 total patients, 132 were in the prestandardization (PRE) historical cohort. A first-24-h IV-PCA use was different (PRE median 95 mg versus poststandardization [POST] 15 mg, P < 0.001). The median total inpatient OME was different (P < 0.001) between PRE (525 mg, interquartile range [IQR] 239-951 mg) and POST patients (129 mg, IQR 65-204 mg) with 77% (median 373 mg) of total inpatient OMEs contributed by IV-PCA in the PRE and 56% (median 64 mg) in the POST cohorts. There were similar patient-reported pain scores between groups.
CONCLUSIONS
Standardizing initial IV-PCA settings was associated with a reduced first-24-h opioid exposure, proportional and absolute total IV-PCA use, and total inpatient OMEs. Because of the contribution of an IV-PCA to the total inpatient opioid exposure, purposeful reduction or omission of an IV-PCA is critical to perioperative opioid reduction strategies.
Topics: Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Inpatients; Morphine; Opioid-Related Disorders; Pain, Postoperative; Pancreatectomy
PubMed: 35306260
DOI: 10.1016/j.jss.2022.02.031 -
Current Opinion in Gastroenterology Sep 2017Critical review of the indications for total pancreatectomy and highlight limitations in current diagnostic criteria for chronic pancreatitis. (Review)
Review
PURPOSE OF REVIEW
Critical review of the indications for total pancreatectomy and highlight limitations in current diagnostic criteria for chronic pancreatitis.
RECENT FINDINGS
The diagnosis of noncalcific chronic pancreatitis remains controversial because of an overreliance on nonspecific imaging and laboratories findings. Endoscopic ultrasound, s-magnetic resonance cholangiopancreatography, and/or endoscopic pancreatic function testing are often used to diagnose noncalcific chronic pancreatitis despite the fact that there is no gold standard for this condition. Abdominal pain is not specific for chronic pancreatitis and is more likely to be encountered in patients with functional gastrointestinal disorders based on the high incidence of these conditions. The duration of pain and opioid analgesic use results in central sensitization that adversely affects pain outcomes after total pancreatectomy. An alcoholic cause is associated with poorer pain outcomes after total pancreatectomy.
SUMMARY
The lack of a gold standard for noncalcific chronic pancreatitis limits the diagnostic accuracy of imaging and laboratory tests. The pain of chronic pancreatitis is nonspecific and is affected by duration, preoperative opioid use, and cause. These factors will need to be considered in the development of future selection criteria for this morbid surgery.
Topics: Abdominal Pain; Acute Disease; Alcoholism; Analgesics, Opioid; Cholangiopancreatography, Endoscopic Retrograde; Chronic Disease; Humans; Pain, Postoperative; Pancreatectomy; Pancreatitis; Patient Selection; Practice Guidelines as Topic; Recurrence; Smoking
PubMed: 28700371
DOI: 10.1097/MOG.0000000000000390 -
Cell Transplantation 2021Circulating microRNAs (miRNAs) can be biomarkers for diagnosis and progression of several pathophysiological conditions. In a cohort undergoing total pancreatectomy with...
Circulating microRNAs (miRNAs) can be biomarkers for diagnosis and progression of several pathophysiological conditions. In a cohort undergoing total pancreatectomy with islet autotransplantation (TPIAT) from the multicenter Prospective Observational Study of TPIAT (POST), we investigated associations between a panel of circulating miRNAs (hsa-miR-375, hsa-miR-29b-3p, hsa-miR-148a-3p, hsa-miR-216a-5p, hsa-miR-320d, hsa-miR-200c, hsa-miR-125b, hsa-miR-7-5p, hsa-miR-221-3p, hsa-miR-122-5p) and patient, disease and islet-isolation characteristics. Plasma samples ( = 139) were collected before TPIAT and miRNA levels were measured by RTPCR. Disease duration, prior surgery, and pre-surgical diabetes were not associated with circulating miRNAs. Levels of hsa-miR-29b-3p ( = 0.03), hsa-miR-148a-3p ( = 0.04) and hsa-miR-221-3p ( = 0.01) were lower in those with genetic risk factors. Levels of hsa-miR-148a-3p ( = 0.04) and hsa-miR-7-5p ( = 0.04) were elevated in toxic/metabolic disease. Participants with exocrine insufficiency had lower hsa-miR-29b-3p, hsa-miR-148a-3p, hsa-miR-320d, hsa-miR-221-3p ( < 0.01) and hsa-miR-375, hsa-miR-200c-3p, and hsa-miR-125b-5p ( < 0.05). Four miRNAs were associated with fasting C-peptide before TPIAT (hsa-miR-29b-3p, = 0.18; hsa-miR-148a-3p, = 0.21; hsa-miR-320d, = 0.19; and hsa-miR-221-3p, = 0.21; all < 0.05), while hsa-miR-29b-3p was inversely associated with post-isolation islet equivalents/kg and islet number/kg ( = -0.20, = 0.02). Also, hsa-miR-200c ( = 0.18, = 0.03) and hsa-miR-221-3p ( = 0.19, = 0.03) were associated with islet graft tissue volume. Further investigation is needed to determine the predictive potential of these miRNAs for assessing islet autotransplant outcomes.
Topics: Adult; Female; Humans; Islets of Langerhans; Islets of Langerhans Transplantation; Male; MicroRNAs; Pancreatectomy; Prospective Studies; Transplantation, Autologous
PubMed: 33902338
DOI: 10.1177/0963689721999330 -
HPB : the Official Journal of the... May 2023No consensus was reached with regard to the effect of EDR on postoperative outcomes after pancreatic surgery. The meta-analysis was designed to explore the efficacy and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
No consensus was reached with regard to the effect of EDR on postoperative outcomes after pancreatic surgery. The meta-analysis was designed to explore the efficacy and safety of early drain removal (EDR).
METHODS
Systematic literature search was performed. Data extraction and correction were performed by three researchers. For dichotomous and continuous outcomes, we calculated the pooled risk difference and mean difference with 95% confidence intervals, respectively. The heterogeneity of included studies was evaluated using Cochran's Q and I test. The stratified analyses of pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) were performed.
RESULTS
A total of 10 studies including 3 RCTs and 7 non RCTs were included for meta-analysis, among which 1780 patients with EDR and 5613 patients with late drain removal (LDR) were enrolled. The meta-analysis of both all the available studies and studies only with selected low risk patients indicated that EDR group had significantly lower incidences of Grade B/C postoperative pancreatic fistula (POPF) and total complications for both PD and DP. However, no advantages of EDR were observed in the meta-analysis of the 3 RCTs. In addition, EDR was associated with a lower incidence of intra-abdominal infection after PD. While for DP, EDR group had decreased risk of delayed gastric emptying and re-operation, and shorter postoperative in-hospital stay.
CONCLUSIONS
The meta-analysis demonstrates that EDR is effective and safe for both PD and DP considering POPF and total complications, especially for patients with low concentration of postoperative drain fluid amylase.
Topics: Humans; Pancreatectomy; Pancreas; Pancreaticoduodenectomy; Pancreatic Fistula; Device Removal; Postoperative Complications; Drainage
PubMed: 36822926
DOI: 10.1016/j.hpb.2023.02.005 -
Current Opinion in Gastroenterology Sep 2013We review selected important clinical observations reported in 2012. (Review)
Review
PURPOSE OF REVIEW
We review selected important clinical observations reported in 2012.
RECENT FINDINGS
Celiac disease is a risk factor for pancreatitis. Patients with recurrent acute pancreatitis likely have chronic pancreatitis, do not benefit from pancreatic sphincterotomy, and may not benefit from biliary sphincterotomy. Analysis of endoscopic ultrasonography (EUS) images with an artificial neural network (ANN) program may improve chronic pancreatitis diagnosis compared with clinical interpretation of images. In a multicenter, randomized controlled trial of chronic pancreatitis patients, 90 000 USP U of pancreatin with meals decreased fat malabsorption compared with placebo. Detection of visceral pain in chronic pancreatitis predicts pain relief from various treatments, but nonvisceral pain due to altered central pain processing may respond to agents such as pregabalin. Predictors of surgical pain relief include onset of symptoms less than 3 years and preoperatively no opioid use and less than five endoscopic procedures. Total pancreatectomy for presumed painful chronic pancreatitis remains controversial.
SUMMARY
Celiacs are at risk for pancreatitis. The diagnosis of chronic pancreatitis may be enhanced by ANN analysis of EUS imaging. Treatment of fat malabsorption requires 90,000 USP U of lipase with meals. Relief of pain from organ directed treatment of chronic pancreatitis may depend upon timing of interventions and whether pain is visceral or nonvisceral.
Topics: Antioxidants; Celiac Disease; Diagnosis, Differential; Drug Administration Schedule; Exocrine Pancreatic Insufficiency; Humans; Pain Management; Pancreatectomy; Pancreatic Neoplasms; Pancreatin; Pancreatitis, Chronic; Sphincter of Oddi Dysfunction
PubMed: 23852141
DOI: 10.1097/MOG.0b013e3283639370 -
Surgical Endoscopy Aug 2018Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving.
BACKGROUND
Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving.
METHODS
In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intraductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014.
RESULTS
The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnostic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen; (7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12) Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73 patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and reduced mortality at 30 and 90 days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients who underwent TP was similar between robotic, laparoscopic, and open approaches.
CONCLUSION
Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and equivalent oncologic outcomes compared to open TP.
Topics: Female; Humans; Middle Aged; Pancreatectomy; Pancreatic Intraductal Neoplasms; Robotic Surgical Procedures; Splenectomy
PubMed: 29273875
DOI: 10.1007/s00464-017-6003-1 -
Medicine Jan 2017Laparoscopic total pancreatectomy is a complicated surgical procedure and rarely been reported. This study was conducted to investigate the safety and feasibility of... (Review)
Review
RATIONALE
Laparoscopic total pancreatectomy is a complicated surgical procedure and rarely been reported. This study was conducted to investigate the safety and feasibility of laparoscopic total pancreatectomy.
PATIENTS AND METHODS
Three patients underwent laparoscopic total pancreatectomy between May 2014 and August 2015. We reviewed their general demographic data, perioperative details, and short-term outcomes. General morbidity was assessed using Clavien-Dindo classification and delayed gastric emptying (DGE) was evaluated by International Study Group of Pancreatic Surgery (ISGPS) definition.
DIAGNOSIS AND OUTCOMES
The indications for laparoscopic total pancreatectomy were intraductal papillary mucinous neoplasm (IPMN) (n = 2) and pancreatic neuroendocrine tumor (PNET) (n = 1). All patients underwent laparoscopic pylorus and spleen-preserving total pancreatectomy, the mean operative time was 490 minutes (range 450-540 minutes), the mean estimated blood loss was 266 mL (range 100-400 minutes); 2 patients suffered from postoperative complication. All the patients recovered uneventfully with conservative treatment and discharged with a mean hospital stay 18 days (range 8-24 days). The short-term (from 108 to 600 days) follow up demonstrated 3 patients had normal and consistent glycated hemoglobin (HbA1c) level with acceptable quality of life.
LESSONS
Laparoscopic total pancreatectomy is feasible and safe in selected patients and pylorus and spleen preserving technique should be considered. Further prospective randomized studies are needed to obtain a comprehensive understanding the role of laparoscopic technique in total pancreatectomy.
Topics: Aged; Female; Humans; Laparoscopy; Male; Middle Aged; Pancreatectomy
PubMed: 28099344
DOI: 10.1097/MD.0000000000005869 -
Surgery Aug 2021Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of...
BACKGROUND
Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of total pancreatectomy among 4 Western countries.
METHODS
Patients who underwent one-stage total pancreatectomy were included from registries in the United States, Germany, the Netherlands, and Sweden (2014-2018). Use of total pancreatectomy was assessed by calculating the ratio total pancreatectomy to pancreatoduodenectomy. Primary outcomes were major morbidity (Clavien Dindo ≥3) and in-hospital mortality. Predictors for the primary outcomes were assessed in multivariable logistic regression analyses. Sensitivity analysis assessed the impact of volume (low-volume <40 or high-volume ≥40 pancreatoduodenectomies annually; data available for the Netherlands and Germany).
RESULTS
In total, 1,579 patients underwent one-stage total pancreatectomy. The relative use of total pancreatectomy to pancreatoduodenectomy varied up to fivefold (United States 0.03, Germany 0.15, the Netherlands 0.03, and Sweden 0.15; P < .001). Both the indication and several baseline characteristics differed significantly among countries. Major morbidity occurred in 423 patients (26.8%) and differed (22.3%, 34.9%, 38.3%, and 15.9%, respectively; P < .001). In-hospital mortality occurred in 85 patients (5.4%) and also differed (1.8%, 10.2%, 10.8%, 1.9%, respectively; P < .001). Country, age ≥75, and vascular resection were predictors for in-hospital mortality. In-hospital mortality was lower in high-volume centers in the Netherlands (4.9% vs 23.1%; P = .002), but not in Germany (9.8% vs 10.6%; P = .733).
CONCLUSION
Considerable differences in the use of total pancreatectomy, patient characteristics, and postoperative outcome were noted among 4 Western countries with better outcomes in the United States and Sweden. These large, yet unexplained, differences require further research to ultimately improve patient outcome.
Topics: Adult; Aged; Female; Germany; Humans; Male; Middle Aged; Netherlands; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Procedures and Techniques Utilization; Registries; Retrospective Studies; Sweden; United States
PubMed: 33741182
DOI: 10.1016/j.surg.2021.02.001