Abstract
Background
Enucleation has become an alternative treatment in benign or low-malignant cystic tumors, including intraductal papillary mucinous neoplasms (IPMN). For enucleation to be a safe alternative to the standard procedures, there must be good access to the resection area. In this report, we present such a route for dorsally situated IPMNs.
Methods
The head of the pancreas was exposed by an extended Kocher maneuver to the left lateral edge of the aorta. Stay sutures were placed along the second part of the duodenum to allow maximal rotation of the pancreatic head to the left, which exposed the posterior aspect of the pancreatic head. The cystic lesion was then enucleated followed by a protective pancreaticojejunostomy on the resection cavity.
Results
Two consecutive patients with IPMNs of the dorsal pancreatic head successfully underwent dorsal enucleation. The postoperative course was uneventful in the first patient, while the course of the second patient was complicated by a clinically relevant pancreatic fistula, delayed gastric emptying, and hospital discharge on day 35.
Conclusion
This study shows the feasibility of a dorsal approach to the pancreatic head for enucleation as well as reconstruction by means of posterior Roux-en-Y pancreaticojejunostomy. In very selected cases in specialized centers, cystic lesions in the posterior aspect of the pancreatic head will become amenable to enucleation with preservation of pancreatic functionality. However, more research is needed to clarify postoperative outcomes of this approach.
Similar content being viewed by others
References
Pinho DF, Rofsky NM, Pedrosa I (2014) Incidental pancreatic cysts: role of magnetic resonance imaging. Top Magn Reson Imaging TMRI 23:117–128. https://doi.org/10.1097/RMR.0000000000000018
Grutzmann R, Niedergethmann M, Pilarsky C, Kloppel G, Saeger HD (2010) Intraductal papillary mucinous tumors of the pancreas: biology, diagnosis, and treatment. The Oncologist 15:1294–1309. https://doi.org/10.1634/theoncologist.2010-0151
Tanaka M, Fernández-del Castillo C, Adsay V, Chari S, Falconi M, Jang J-Y, Kimura W, Levy P, Pitman MB, Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K, International Association of Pancreatology (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatol Off J Int Assoc Pancreatol IAP Al 12:183–197. https://doi.org/10.1016/j.pan.2012.04.004
Hackert T, Fritz S, Büchler MW (2015) Main- and branch-duct intraductal papillary mucinous neoplasms: extent of surgical resection. Viszeralmedizin 31:38–42. https://doi.org/10.1159/000375111
Miller JR, Meyer JE, Waters JA, Al-Haddad M, DeWitt J, Sherman S, Lillemoe KD, Schmidt CM (2011) Outcome of the pancreatic remnant following segmental pancreatectomy for non-invasive intraductal papillary mucinous neoplasm. HPB 13:759–766. https://doi.org/10.1111/j.1477-2574.2011.00354.x
Käppeli RM, Müller SA, Hummel B, Kruse C, Müller P, Fornaro J, Wilhelm A, Zadnikar M, Schmied BM, Tarantino I (2013) IPMN: surgical treatment. Langenbecks Arch Surg 398:1029–1037. https://doi.org/10.1007/s00423-013-1106-1
Tanaka M, Fernández-del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL (2017) Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. https://doi.org/10.1016/j.pan.2017.07.007
Hüttner FJ, Koessler-Ebs J, Hackert T, Ulrich A, Büchler MW, Diener MK (2015) Meta-analysis of surgical outcome after enucleation versus standard resection for pancreatic neoplasms. Br J Surg 102:1026–1036. https://doi.org/10.1002/bjs.9819
Song KB, Kim SC, Hwang DW, Lee JH, Lee DJ, Lee JW, Jun ES, Sin SH, Kim HE, Park K-M, Lee Y-J (2015) Enucleation for benign or low-grade malignant lesions of the pancreas: single-center experience with 65 consecutive patients. Surgery 158:1203–1210. https://doi.org/10.1016/j.surg.2014.10.008
Faitot F, Gaujoux S, Barbier L, Novaes M, Dokmak S, Aussilhou B, Couvelard A, Rebours V, Ruszniewski P, Belghiti J, Sauvanet A (2015) Reappraisal of pancreatic enucleations: a single-center experience of 126 procedures. Surgery 158:201–210. https://doi.org/10.1016/j.surg.2015.03.023
Hwang HK, Park JS, Kim JK, Park C-M, Cho SI, Yoon DS (2012) Comparison of efficacy of enucleation and pancreaticoduodenectomy for small (<3 cm) branch duct type intraductal papillary mucinous neoplasm located at the head of pancreas and the uncinate process. Yonsei Med J 53:106–110. https://doi.org/10.3349/ymj.2012.53.1.106
Sauvanet A, Gaujoux S, Blanc B, Couvelard A, Dokmak S, Vullierme M-P, Ruszniewski P, Belghiti J, Lévy P (2014) Parenchyma-sparing pancreatectomy for presumed noninvasive intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 260:364–371. https://doi.org/10.1097/SLA.0000000000000601
Heeger K, Falconi M, Partelli S, Waldmann J, Crippa S, Fendrich V, Bartsch DK (2014) Increased rate of clinically relevant pancreatic fistula after deep enucleation of small pancreatic tumors. Langenbecks Arch Surg 399:315–321. https://doi.org/10.1007/s00423-014-1171-0
Brient C, Regenet N, Sulpice L, Brunaud L, Mucci-Hennekine S, Carrère N, Milin J, Ayav A, Pradere B, Hamy A, Bresler L, Meunier B, Mirallié E (2012) Risk factors for postoperative pancreatic fistulization subsequent to enucleation. J Gastrointest Surg 16:1883–1887. https://doi.org/10.1007/s11605-012-1971-x
Xiao Z, Luo G, Liu Z, Jin K, Xu J, Liu C, Liu L, Ni Q, Long J, Yu X (2016) Roux-en-Y pancreaticojejunostomy reconstruction after deep enucleation of benign or borderline pancreatic lesions: a single-institution experience. HPB 18:145–152. https://doi.org/10.1016/j.hpb.2015.08.007
Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KCH, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CHC, ERAS® Society, European Society for Clinical Nutrition and Metabolism, International Association for Surgical Metabolism and Nutrition (2012) Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr Edinb Scotl 31:817–830. https://doi.org/10.1016/j.clnu.2012.08.011
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142:761–768. https://doi.org/10.1016/j.surg.2007.05.005
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic Surgery (ISGPS) (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584–591. https://doi.org/10.1016/j.surg.2016.11.014
Beger HG, Nakao A, Mayer B, Poch B (2015) Duodenum-preserving total and partial pancreatic head resection for benign tumors – systematic review and meta-analysis. Pancreatology 15:167–178. https://doi.org/10.1016/j.pan.2015.01.009
Soejima Y, Toshima T, Motomura T, Yokota T, Joko K, Oshiro Y, Takahashi I, Nishizaki T, Maehara Y (2017) Technical feasibility and oncological legitimacy of enucleation of intraductal papillary mucinous neoplasm located at the pancreatic head or uncinate process. Anticancer Res 37:321–326. https://doi.org/10.21873/anticanres.11324
Kaiser J, Fritz S, Klauss M, Bergmann F, Hinz U, Strobel O, Schneider L, Büchler MW, Hackert T (2017) Enucleation: a treatment alternative for branch duct intraductal papillary mucinous neoplasms. Surgery 161:602–610. https://doi.org/10.1016/j.surg.2016.09.026
Sahora K, Castillo CF, Dong F, Marchegiani G, Thayer SP, Ferrone CR, Sahani DV, Brugge WR, Warshaw AL, Lillemoe KD, Mino-Kenudson M (2014) Not all mixed-type intraductal papillary mucinous neoplasms behave like main-duct lesions: implications of minimal involvement of the main pancreatic duct. Surgery 156:611–621. https://doi.org/10.1016/j.surg.2014.04.023
European Study Group on Cystic Tumours of the Pancreas (2018) European evidence-based guidelines on pancreatic cystic neoplasms. Gut 67:789–804. https://doi.org/10.1136/gutjnl-2018-316027
Chua TC, Yang TX, Gill AJ, Samra JS (2016) Systematic review and meta-analysis of enucleation versus standardized resection for small pancreatic lesions. Ann Surg Oncol 23:592–599. https://doi.org/10.1245/s10434-015-4826-3
Strobel O, Cherrez A, Hinz U, Mayer P, Kaiser J, Fritz S, Schneider L, Klauss M, Büchler MW, Hackert T (2015) Risk of pancreatic fistula after enucleation of pancreatic tumours: Pancreatic fistula after enucleation of pancreatic tumours. Br J Surg 102:1258–1266. https://doi.org/10.1002/bjs.9843
Ohtsuka T, Mori Y, Fujimoto T, Miyasaka Y, Nakata K, Ohuchida K, Nagai E, Oda Y, Shimizu S, Nakamura M (2018) Feasibility of prophylactic pancreatojejunostomy in possible high-risk patients for prevention of pancreatic fistula during enucleation or limited pancreatic resection. Am Surg 84:149–153
Funding
The study was funded by institutional means.
Author information
Authors and Affiliations
Contributions
Study conception and design: Müller SA, Müller PC, and Z’graggen K. Acquisition of data: Z’graggen K, Müller SA, and Pärli MS, Razza C. Analysis and interpretation of data: Pärli MS, Müller PC, and Ruzza C. Drafting of manuscript: Pärli MS, Müller SA, and Müller PC. Critical revision: Ruzza C and Z’graggen K.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Video 1
(MP4 324056 kb)
Rights and permissions
About this article
Cite this article
Pärli, M.S., Müller, P.C., Müller, S.A. et al. Posterior enucleation of the pancreatic head: an alternative route of access for parenchyma-sparing pancreatic resection. Langenbecks Arch Surg 404, 1023–1028 (2019). https://doi.org/10.1007/s00423-019-01835-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00423-019-01835-5