Posterior enucleation of the pancreatic head: an alternative route of access for parenchyma-sparing pancreatic resection
- 17 Downloads
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.
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.
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.
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.
KeywordsPancreatic resection Enucleation Cystic pancreatic lesion IPMN Surgical technique
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.
The study was funded by institutional means.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
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 was obtained from all individual participants included in the study.
- 3.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 CrossRefGoogle Scholar
- 5.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 CrossRefPubMedPubMedCentralGoogle Scholar
- 7.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 CrossRefGoogle Scholar
- 9.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 CrossRefPubMedGoogle Scholar
- 10.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 CrossRefPubMedGoogle Scholar
- 11.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 CrossRefPubMedGoogle Scholar
- 12.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 CrossRefPubMedGoogle Scholar
- 14.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 CrossRefPubMedGoogle Scholar
- 15.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 CrossRefPubMedGoogle Scholar
- 16.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 CrossRefGoogle Scholar
- 17.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 CrossRefPubMedGoogle Scholar
- 18.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 CrossRefPubMedGoogle Scholar
- 20.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 CrossRefPubMedGoogle Scholar
- 22.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 CrossRefPubMedPubMedCentralGoogle Scholar
- 25.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 CrossRefPubMedGoogle Scholar
- 26.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 84:149–153PubMedGoogle Scholar