Transpapillary endopancreatic surgery: decompression of duct system and comparison of greenlight laser with monopolar electrosurgical device in ex vivo and in vivo animal models
Endopancreatic surgery (EPS) is an experimental minimally invasive technique for resection of pancreatic tissue from inside the pancreatic duct, accessed via the duodenum and papilla. It is proposed as an alternative to duodenum-preserving pancreatic head resection in benign diseases such as chronic pancreatitis (CP). This study evaluated the use of EPS for resection of pancreatic duct stenoses. Moreover, greenlight laser (GLL) and monopolar electrosurgical device (MES) were compared as resection tools for EPS.
The suitability of EPS for resection of stenoses was evaluated in ex vivo bovine pancreas (n = 8). Artificially created stenoses in the pancreatic head were accessed via the duodenal papilla and resected from inside the organ with MES through a rigid endoscope. Furthermore, standardized pancreatic resections were performed in an in vivo porcine model using either GLL (n = 18) or MES (n = 18) to compare blood loss, operating time, and complications. Thermal damage to the surrounding tissue was assessed using a standardized histological classification.
Stenosis resection by EPS was feasible in 8/8 bovine pancreases, with a procedure time of 17 (12–24) min. No perforation of the organ occurred. Resection by GLL was associated with reduced blood loss [median 1.7 (interquartile range 0.6–2.6) ml vs. 5.1 (3.8–13.2) ml; p < 0.01] and shorter operating time [109 (81–127) s vs. 390 (337–555) s; p < 0.01] compared with MES. The zone of thermal tissue damage was more extensive when using GLL than with MES [4.12 (3.48–4.89) mm vs. 1.33 (1.09–1.48) mm; p < 0.01].
Transduodenal-transpapillary EPS can be used to resect stenoses and decompress the pancreatic duct system. Both GLL and MES are feasible resection methods for EPS. However, GLL showed better hemostatic characteristics than MES in an in vivo porcine model. Safety measures such as temperature control and image-guided navigation should be employed to monitor the resection and tissue heating.
KeywordsPancreatic surgery Minimally invasive pancreatic surgery Chronic pancreatitis Pancreatoscopy Greenlight laser
Duodenum-preserving pancreatic head resection
Electrothermal bipolar vessel sealing systems
Monopolar electrosurgical device
Ultrasonic coagulation shears
The authors thank Felix Lasitschka of the Institute of Pathology. University Hospital Heidelberg for his advice and help on the experiments.
PCM: study design, performing the experiments, statistical analysis, writing the manuscript; DCS: study design, performing the experiments, writing the manuscript; LC: performing the experiments, statistical analysis, writing the manuscript; GH, FN: performing the experiments, critical revision of the manuscript; KZ and BPM: study design, interpretation of data, critical revision of the manuscript.
Philip C. Müller is supported by the Swiss Pancreas Foundation. All other authors have nothing to disclose. The work was supported by the Heidelberg Foundation of Surgery.
Compliance with ethical standards
Philip C. Müller, Daniel C. Steinemann, Lukas Chinczewski, Gencay Hatiboglu, Felix Nickel, Kaspar Z’graggen, and Beat P. Müller-Stich have no conflict of interest or financial ties to disclose.
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- 5.Diener MK, Rahbari NN, Fischer L, Antes G, Büchler MW, Seiler CM (2008) Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis. Ann Surg 247:950–961. https://doi.org/10.1097/SLA.0b013e3181724ee7 CrossRefPubMedGoogle Scholar
- 7.Müller PC, Steinemann DC, Nickel F, Chinczewski L, Müller-Stich BP, Linke GR, Z’graggen K (2017) Transduodenal-transpapillary endopancreatic surgery with a rigid resectoscope: experiments on ex vivo, in vivo animal models and human cadavers. Surg Endosc. https://doi.org/10.1007/s00464-017-5465-5 CrossRefPubMedGoogle Scholar
- 11.Müller PC, Senft JD, Gath P, Steinemann DC, Nickel F, Billeter AT, Müller-Stich BP, Linke GR (2017) Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study. Surg Endosc. https://doi.org/10.1007/s00464-017-5804-6 CrossRefPubMedGoogle Scholar
- 16.Bordeianou L, Sylla P, Kinnier CV, Rattner D (2015) Perineal sigmoidopexy utilizing transanal endoscopic microsurgery (TEM) to treat full thickness rectal prolapse: a feasibility trial in porcine and human cadaver models. Surg Endosc 29:686–691. https://doi.org/10.1007/s00464-014-3722-4 CrossRefPubMedGoogle Scholar
- 17.Zdichavsky M, Krautwald M, Meile T, Wichmann D, Lange J, Königsrainer A, Schurr MO (2015) Single-port live donor nephrectomy using a novel curved radius r2 surgical system in an in vivo model. Minim Invasive Ther Allied Technol 24:63–67. https://doi.org/10.3109/13645706.2014.975134 CrossRefPubMedGoogle Scholar
- 19.Al-Ansari A, Younes N, Sampige VP, Al-Rumaihi K, Ghafouri A, Gul T, Shokeir AA (2010) GreenLight HPS 120-W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a randomized clinical trial with midterm follow-up. Eur Urol 58:349–355. https://doi.org/10.1016/j.eururo.2010.05.026 CrossRefPubMedGoogle Scholar
- 20.Bruyère F, Huglo D, Challacombe B, Haillot O, Valat C, Brichart N (2011) Blood loss comparison during transurethral resection of prostate and high power GreenLight(™) laser therapy using isotopic measure of red blood cells volume. J Endourol 25:1655–1659. https://doi.org/10.1089/end.2011.0104 CrossRefPubMedGoogle Scholar
- 21.Rückert F, Brussig T, Kuhn M, Kersting S, Bunk A, Hunger M, Saeger H-D, Niedergethmann M, Post S, Grützmann R (2013) Malignancy in chronic pancreatitis: analysis of diagnostic procedures and proposal of a clinical algorithm. Pancreatology 13:243–249. https://doi.org/10.1016/j.pan.2013.03.014 CrossRefPubMedGoogle Scholar
- 24.Banz VM, Müller PC, Tinguely P, Inderbitzin D, Ribes D, Peterhans M, Candinas D, Weber S (2016) Intraoperative image-guided navigation system: development and applicability in 65 patients undergoing liver surgery. Langenbecks Arch Surg 401:495–502. https://doi.org/10.1007/s00423-016-1417-0 CrossRefPubMedGoogle Scholar