Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors
Summary
The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.
Abstract
Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient’s history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient’s pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient’s pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.
Introduction
From a clinical perspective, it is important to note that not all tumors that develop in the pancreas are classified as pancreatic cancers. Pancreatic tumors can be broadly categorized into two main groups: benign tumors of the pancreas and pancreatic malignancies. Benign neoplasms of the pancreas encompass cystadenoma, intraductal papillary mucinous neoplasm, pancreatic hemangioma, and others1. The detection rate of benign pancreatic tumors has been consistently increasing over the years, and surgery remains the most effective treatment option2. However, traditional surgical procedures such as pancreatoduodenectomy or body and tail resection of the pancreas, while ensuring complete tumor removal, often result in the removal of excessive normal pancreatic tissue. This can significantly impact the long-term quality of life for patients, particularly leading to a higher incidence of endocrine and exocrine dysfunction3,4.
In recent years, the field of laparoscopic pancreatic surgery has seen significant advancements due to the rapid development of minimally invasive techniques like laparoscopic surgery and robotic surgery5. This has led to an increase in the number of hospitals performing laparoscopic pancreatic surgery, which has yielded positive outcomes. Among the various surgical methods, laparoscopic mid-pancreatectomy is considered to be the most suitable approach for treating benign or low-grade malignant tumors located in the neck or proximal part of the pancreas6.
The first mid-pancreatectomy was performed in 2003 by the Baca team on a patient with pancreatic cystadenoma7, and since then, this procedure has been adopted worldwide. Compared to other techniques like local enucleation of pancreatic tumor, laparoscopic caudal pancreatectomy, and laparoscopic pancreaticoduodenectomy, mid-pancreatectomy offers the advantage of preserving normal pancreatic parenchyma and reducing the risk of insufficient internal and external pancreatic secretion4,6,8. However, a challenge arises after resecting the middle part of the pancreas, as traditionally, the broken ends of the pancreas were believed to be unable to be anastomosed. To reconstruct the digestive tract, two main methods are employed. The first method involves a single anastomosis, where the distal end of the pancreas is anastomosed with the stomach or jejunum after closing the proximal end. The second method is a double anastomosis, where both the proximal and distal ends of the pancreas are anastomosed with the jejunum in the shape of a Ω. However, these reconstruction techniques pose the risk of pancreatic stump fistula and pancreatic-enterostomy fistula for patients, which can lead to abdominal infection and abdominal bleeding. Overcoming these challenges remains a significant concern for pancreatic surgeons8,9.
This paper proposes a novel treatment method called laparoscopic mid-pancreatectomy combined with end-to-end anastomosis. The method involves removing the tumor in the middle part of the pancreas and placing stent tubes into the pancreatic duct at both ends of the pancreas. The pancreatic tissue is then continuously sutured to reconstruct the pancreas. The primary objective of this method is to preserve the substance and function of the pancreas while removing the tumor, thereby reducing the risk of postoperative pancreatic fistula, secondary infection, and bleeding10,11. Additionally, it aims to improve surgical safety.
The patient, a 57-year-old male, was admitted to the hospital due to the discovery of a pancreatic mass during a CT scan. The mass was a round cystic structure with low density, measuring approximately 28 mm x 40 mm, and had an unclear boundary. The patient had a history of type II diabetes for 3 years and hepatitis B virus infection for over 10 years. Before the operation, the levels of alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were measured to be 30.53 ng/mL and 5.8 ng/mL, respectively. Laparoscopic mid-pancreatectomy combined with end-to-end anastomosis was performed on June 15, 2022. The postoperative pathology report indicated the presence of a solid cystic mass in the pancreatic tissue, measuring 3.8 cm x 2.5 cm x 2 cm. The mass appeared gray and white, and the cyst contained transparent fluid with a clear boundary (see Figure 1). Postoperative pathology confirmed pancreatic hemangioma. Tumor markers and drainage tube amylase levels showed a decreasing trend after the surgery, and the patient had a successful recovery.
Protocol
Representative Results
Discussion
The pancreas, an important digestive organ in the human body, has several important secretory functions. Therefore, in pancreatic surgery, attention needs to be paid to the preservation of pancreatic parenchyma and its function. With the rising detection rate of benign pancreatic tumors and low-grade malignancies, various procedures have been developed to preserve function, including local enucleation of the pancreas, mid-pancreatectomy, and pancreatic head resection with preservation of the duodenum12<…
Declarações
The authors have nothing to disclose.
Acknowledgements
This work was supported by grants from the Project of Guangdong clinical medical research center of digestive diseases (2020B1111170004), National Key Clinical Discipline and the program of Guangdong Provincial Clinical Research Center for Digestive Diseases.
Materials
| abdominal instrument button | Johnson & Johnson | ||
| abdominal instrument cap | Johnson & Johnson | ||
| abdominal instrument collar | Johnson & Johnson | ||
| abdominal instrument connector | Johnson & Johnson | ||
| Absorbable ligature clip | Sichuan Guona Technology Co., LTD | 230716 | |
| barbs | Johnson & Johnson | ||
| blade | Johnson & Johnson | ||
| blood pad | Johnson & Johnson | ||
| Cloth towel forceps | Johnson & Johnson | ||
| disposable drainage tube | Johnson & Johnson | 412280 | 6 cm x 2 mm |
| Electric knife head | Johnson & Johnson | ||
| forceps | Johnson & Johnson | ||
| hilt | Johnson & Johnson | ||
| holding flask | Johnson & Johnson | ||
| intestinal forceps | Johnson & Johnson | ||
| laparoscope | Johnson & Johnson | ||
| laparoscopic instruments | Johnson & Johnson | ||
| Ligating clip | Teleflex Medical | 73H2300118 | |
| long curved forceps | Johnson & Johnson | ||
| medium curved forceps | Johnson & Johnson | ||
| Nail clamp | Ethicon,USA | 584C82 | |
| needle holders | Johnson & Johnson | ||
| ovoid forceps | Johnson & Johnson | ||
| Paraffin oil | Johnson & Johnson | ||
| purse string forceps | Johnson & Johnson | ||
| right angled forceps | Johnson & Johnson | ||
| right angled forceps | Johnson & Johnson | ||
| scissors | Johnson & Johnson | ||
| Siphonhead | Johnson & Johnson | ||
| Small cup | Johnson & Johnson | ||
| small curved forceps | Johnson & Johnson | ||
| Sonotome keyhole | Johnson & Johnson | ||
| steel ruler | Johnson & Johnson | ||
| Straight forceps | Johnson & Johnson | ||
| Suction needle plate | Johnson & Johnson | ||
| Suture needle | Johnson & Johnson | Vcp397H | |
| Syringe | Johnson & Johnson | ||
| syringe needle | Johnson & Johnson | ||
| tissue forceps | Johnson & Johnson | ||
| trocar(XCEL) | Ethicon Endo-Surgery | 695C71 | |
| Ultrasonic knife spacers | Johnson & Johnson | ||
| ultrasound knife | Johnson & Johnson | ||
| yarn ball | Johnson & Johnson |
Referências
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