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Enucleation in pancreatic surgery: indications, technique, and outcome compared to standard pancreatic resections

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Abstract

Purpose

Pancreatic surgery is a technically challenging intervention with high demands for preoperative diagnostics and perioperative management. A perioperative mortality rate below 5% is achieved in high-volume centers due to the high level of standardization in surgical procedures and perioperative care. Besides standard resections, certain indications may require individualized surgical concepts such as tumor enucleations. The aim of the study was to evaluate the indications, technique, and outcome of this limited local approach compared to major resections.

Materials and methods

Data from patients undergoing pancreatic surgery were prospectively recorded. All patients with tumor enucleations were compared with classical resections (pancreaticoduodenectomy or left resection) in a matched-pair analysis (1:2). Tumor type, localization, operative parameters, complications, and outcome were evaluated.

Results

Fifty-three patients underwent pancreatic tumor enucleation between October 2001 and December 2009. Indications included cystic lesions, IPMNs, and neuroendocrine pancreatic tumors. Enucleations were associated with shorter operation time, less blood loss as well as shorter ICU and hospital stay compared to pancreaticoduodenectomy and left resections. The overall surgical morbidity of enucleations was 28.3% without major complications. Leading clinical problems were ISGPF type A fistulas (20.8%) requiring prolonged primary drainage. No surgical revisions were necessary, and no deaths occurred.

Conclusions

Pancreatic tumor enucleations can be carried out with good results and no mortality. Decisions regarding enucleations are highly individual compared to standard resections, underlining the importance of treatment in experienced high-volume institutions. Enucleations should be carried out whenever possible and oncologically feasible to prevent the typical complications of major pancreatic resection.

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References

  1. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128–1137

    Article  PubMed  Google Scholar 

  2. van Heek NT, Kuhlmann KF, Scholten RJ, de Castro SM, Busch OR, van Gulik TM, Obertop H, Gouma DJ (2005) Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg 242:781–788

    Article  PubMed  Google Scholar 

  3. Buchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’graggen K (2003) Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 138:1310–1314

    Article  PubMed  Google Scholar 

  4. McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF (2007) Perioperative mortality for pancreatectomy: a national perspective. Ann Surg 246:246–253

    Article  PubMed  Google Scholar 

  5. Talamini MA, Moesinger R, Yeo CJ, Poulose B, Hruban RH, Cameron JL, Pitt HA (1998) Cystadenomas of the pancreas: is enucleation an adequate operation? Ann Surg 227:896–903

    Article  PubMed  CAS  Google Scholar 

  6. Pitt SC, Pitt HA, Baker MS, Christians K, Touzios JG, Kiely JM, Weber SM, Wilson SD, Howard TJ, Talamonti MS, Rikkers LF (2009) Small pancreatic and periampullary neuroendocrine tumors: resect or enucleate? J Gastrointest Surg 13:1692–1698

    Article  PubMed  Google Scholar 

  7. Kiely JM, Nakeeb A, Komorowski RA, Wilson SD, Pitt HA (2003) Cystic pancreatic neoplasms: enucleate or resect? J Gastrointest Surg 7:890–897

    Article  PubMed  Google Scholar 

  8. Fang WL, Su CH, Shyr YM, Chen TH, Lee RC, Tai LC, Wu CW, Lui WY (2007) Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy. Pancreas 35:361–365

    Article  PubMed  Google Scholar 

  9. Othman M, Basturk O, Groisman G, Krasinskas A, Adsay NV (2007) Squamoid cyst of pancreatic ducts: a distinct type of cystic lesion in the pancreas. Am J Surg Pathol 31:291–297

    Article  PubMed  Google Scholar 

  10. Crippa S, Bassi C, Salvia R, Falconi M, Butturini G, Pederzoli P (2007) Enucleation of pancreatic neoplasms. Br J Surg 94:1254–1259

    Article  PubMed  CAS  Google Scholar 

  11. Andersson R, Vagianos C, Williamson R (2004) Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma. HPB (Oxf) 6:5–12

    CAS  Google Scholar 

  12. Schima W, Ba-Ssalamah A, Goetzinger P, Scharitzer M, Koelblinger C (2007) State-of-the-art magnetic resonance imaging of pancreatic cancer. Top Magn Reson Imaging 18:421–429, Review

    Article  PubMed  Google Scholar 

  13. Rha SE, Jung SE, Lee KH, Ku YM, Byun JY, Lee JM (2007) CT and MR imaging findings of endocrine tumor of the pancreas according to WHO classification. Eur J Radiol 62:371–377, Review

    Article  PubMed  Google Scholar 

  14. Chung JC, Choi SH, Jo SH, Heo JS, Choi DW, Kim YI (2006) Localization and surgical treatment of the pancreatic insulinomas. ANZ J Surg 76:1051–1055

    Article  PubMed  Google Scholar 

  15. Ritzel RA, Isermann B, Schilling T, Knaebel HP, Büchler MW, Nawroth PP (2004) Diagnosis and localization of insulinoma after negative laparotomy by hyperinsulinemic, hypoglycaemic clamp and intra-arterial calcium stimulation. Rev Diabet Stud 1:42–46

    Article  PubMed  Google Scholar 

  16. Kisker O, Bastian D, Bartsch D, Nies C, Rothmund M (1998) Localization, malignant potential, and surgical management of gastrinomas. World J Surg 22:651–657

    Article  PubMed  CAS  Google Scholar 

  17. Schmitz-Winnenthal FH, Z’graggen K, Volk C, Schmied BM, Büchler MW (2003) Intraductal papillary mucinous tumors of the pancreas. Curr Gastroenterol Rep 5:133–140

    Article  PubMed  Google Scholar 

  18. Lee CJ, Scheiman J, Anderson MA, Hines OJ, Reber HA, Farrell J, Kochman ML, Foley PJ, Drebin J, Oh YS, Ginsberg G, Ahmad N, Merchant NB, Isbell J, Parikh AA, Stokes JB, Bauer T, Adams RB, Simeone DM (2008) Risk of malignancy in resected cystic tumors of the pancreas < or = 3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report. J Gastrointest Surg 12:234–242

    Article  PubMed  CAS  Google Scholar 

  19. Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, Yamaguchi K, Yamao K, Matsuno S (2006) International Association of Pancreatology. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32, Review

    Article  PubMed  Google Scholar 

  20. Casadei R, Ricci C, Rega D, D’Ambra M, Pezzilli R, Tomassetti P, Campana D, Nori F, Minni F (2010) Pancreatic endocrine tumors less than 4 cm in diameter: resect or enucleate? a single-center experience. Pancreas 39:825–828

    Article  PubMed  Google Scholar 

  21. Schmidt CM, White PB, Waters JA, Yiannoutsos CT, Cummings OW, Baker M, Howard TJ, Zyromski NJ, Nakeeb A, DeWitt JM, Akisik FM, Sherman S, Pitt HA, Lillemoe KD (2007) Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg 246:644–651

    Article  PubMed  Google Scholar 

  22. Jang JY, Kim SW, Lee SE, Yang SH, Lee KU, Lee YJ, Kim SC, Han DJ, Choi DW, Choi SH, Heo JS, Cho BH, Yu HC, Yoon DS, Lee WJ, Lee HE, Kang GH, Lee JM (2008) Treatment guidelines for branch duct type intraductal papillary mucinous neoplasms of the pancreas: when can we operate or observe? Ann Surg Oncol 15:199–205

    Article  PubMed  Google Scholar 

  23. Falconi M, Zerbi A, Crippa S, Balzano G, Boninsegna L, Capitanio V, Bassi C, Di Carlo V, Pederzoli P (2010) Parenchyma-preserving resections for small nonfunctioning pancreatic endocrine tumors. Ann Surg Oncol 17:1621–1627

    Article  PubMed  Google Scholar 

  24. Nikfarjam M, Warshaw AL, Axelrod L, Deshpande V, Thayer SP, Ferrone CR, Fernández-del Castillo C (2008) Improved contemporary surgical management of insulinomas: a 25-year experience at the Massachusetts General Hospital. Ann Surg 247:165–172

    Article  PubMed  Google Scholar 

  25. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M (2005) International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13, Review

    Article  PubMed  Google Scholar 

  26. Müller MW, Friess H, Kleeff J, Hinz U, Wente MN, Paramythiotis D, Berberat PO, Ceyhan GO, Büchler MW (2006) Middle segmental pancreatic resection: An option to treat benign pancreatic body lesions. Ann Surg 244:909–918

    Article  PubMed  Google Scholar 

  27. Bassi C (2007) Middle segment pancreatectomy: a useful tool in the management of pancreatic neoplasms. J Gastrointest Surg 11:726–729

    Article  PubMed  Google Scholar 

  28. Christein JD, Smoot RL, Farnell MB (2006) Central pancreatectomy: a technique for the resection of pancreatic neck lesions. Arch Surg 141:293–299

    Article  PubMed  Google Scholar 

  29. Roggin KK, Rudloff U, Blumgart LH, Brennan MF (2006) Central pancreatectomy revisited. J Gastrointest Surg 10:804–812

    Article  PubMed  Google Scholar 

  30. Hamilton L, Rohan Jeyarajah D (2007) Hemoglobin A1c can be helpful in predicting progression to diabetes after Whipple procedure. HPB (Oxf) 9:26–28

    Google Scholar 

  31. Jimenez RE, Fernandez-del Castillo C, Rattner DW, Chang Y, Warshaw AL (2000) Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis. Ann Surg 231:293–300

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany

    Thilo Hackert, Ulf Hinz, Stefan Fritz, Oliver Strobel, Lutz Schneider, Werner Hartwig, Markus W. Büchler & Jens Werner

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  1. Thilo Hackert
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  2. Ulf Hinz
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  3. Stefan Fritz
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  4. Oliver Strobel
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  5. Lutz Schneider
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Correspondence to Thilo Hackert.

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Hackert, T., Hinz, U., Fritz, S. et al. Enucleation in pancreatic surgery: indications, technique, and outcome compared to standard pancreatic resections. Langenbecks Arch Surg 396, 1197–1203 (2011). https://doi.org/10.1007/s00423-011-0801-z

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  • DOI: https://doi.org/10.1007/s00423-011-0801-z

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