ORIGINAL ARTICLE
Laparoscopic Distal Pancreatectomy for Solid-Pseudopapillary Tumor of the Pancreas Yunqiang Cai, MD, Bing Peng, MD, PhD, Gang Mai, MD, PhD, Nengwen Ke, MD, PhD, and Xubao Liu, MD, PhD
Purpose: Solid-pseudopapillary tumor (SPT) of pancreas is a rare entity with a low malignant potential. We aimed to identify the safety and the feasibility of laparoscopic distal pancreatectomy for SPT. Methods: From May 2008 to August 2011, we performed 4 cases of laparoscopic, spleen-preserving, distal pancreatectomies for patients with SPT. We retrospectively collected the demographic characteristics, operative and postoperative details, and follow-up outcomes of the patients. Results: Three female patients and 1 male patient with SPT underwent laparoscopic, spleen-preserving, distal pancreatectomy. The average operating time was 200 minutes. The average blood loss was 90 mL. The postoperative course of these patients was uneventful. All patients were followed-up and no local recurrence or metastasis was found. Conclusions: Laparoscopic distal pancreatectomy for patients with SPT is safe and feasible, with preferable operative outcomes, longterm tumor-free survival, and high spleen-preserving rate. Key Words: solid-pseudopapillary tumor, pancreatectomy, follow-up
(Surg Laparosc Endosc Percutan Tech 2015;25:e8–e10)
S
olid-pseudopapillary tumor (SPT) of pancreas is a rare entity with a distinct female preponderance and low malignant potential, accounting for 1% to 3% of all pancreatic neoplasms.1 Surgical resection of the tumor offers an excellent long-term survival. A 5-year survival rate of >95% after resection has been reported in several studies.2,3 The first laparoscopic distal pancreatectomy was reported in 1996.4 Compared with open surgeries, laparoscopic distal pancreatectomy offers many advantages in terms of earlier oral intake, fewer blood loss, shorter posthospital stays, and fewer surgery-related complications.5 Furthermore, the magnified sights of the operative field facilitates separation of splenic vein and artery from the pancreatic parenchyma; therefore, the spleen-preserving rate is higher.6 Because of the absence of anastomosis, distal pancreatectomy is well suited for laparoscopic approach. In this study, we report 4 cases of laparoscopic, spleenpreserving, distal pancreatectomies for SPT, emphasizing the safety, feasibility of this procedure and the good results Received for publication June 9, 2013; accepted October 22, 2013. From the Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China. The authors declare no conflicts of interest. Reprints: Xubao Liu, MD, PhD, Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
e8 | www.surgical-laparoscopy.com
obtained with regard to the quick recovery and long-term survival of the patients.
MATERIALS AND METHODS From May 2008 to August 2011, we performed 4 cases of laparoscopic, spleen-preserving, distal pancreatectomies for pancreatic body or tail lesions in the Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, China. All the lesions were confirmed to be SPT by histopathologic examination. We collected the demographic characteristics, operative details, postoperative courses, and follow-up outcomes of these patients. Written consents were obtained from the patients included in this study, and the study was approved by the Ethics Committee of Sichuan University.
Operation Procedures All the patients received general anesthesia and were placed in a supine position with the operating table slightly tilted to the reverse Trendelenburg position. Generally, 5 trocars were used. A 10 mm trocar was placed at the lower umbilicus for a 10 mm, 30-degree camera. Two 12 mm trocars were placed at the right and left flank, respectively. Another two 5 mm trocars were placed at the left axillary line and in the xiphoid area, respectively. The operation began with the dissection of greater omentum. We inserted a tube to raise the gastric body from the xiphoid trocar, enabling good exposure of the body and tail of the pancreas (Fig. 1A). The inferior border and the superior border of the pancreas was dissected, with the splenic artery and vein identified. The body of the pancreas was transected using an endoscopic linear stapler. We dissected the branches of the splenic vessels first from the pancreatic body and then toward the splenic hilum. The gland was then dissected from the retroperitoneum, with the splenic vessels preserved. The specimen was placed in a retrieval bag, morcellated with forceps, and retracted through the 12 mm incision (Fig. 1B). A closed suction drain was routinely placed near the pancreatic stump for the detection of pancreatic fistula.
RESULTS We successfully carried out laparoscopic, spleen-preserving, distal pancreatectomies for 4 patients in our series. Demographic characteristics and preoperative findings of the patients are shown in Table 1. The mean age of these patients was 34 years (range, 28 to 41 y). Three SPTs were located in the pancreatic tail and 1 in the pancreatic body. The blood chemistry was within normal limits. The serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen were normal. The operative and postoperative details are shown in Table 2. None of these patients required conversion to open surgery. The average operating
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015
Laparoscopic Distal Pancreatectomy for SPT
FIGURE 1. A, The stomach was raised and the tumor was revealed. B, The specimen was placed in a retrieval bag, morcellated with forceps, and retracted through the 12 mm incision. F indicates forceps; SPT, solid-pseudopapillary tumor.
time was 200 minutes (range, 155 to 255 min). The average blood loss was 90 mL (range, 50 to 150 mL). No metastasis or lymph node involvement was found in the 4 patients. It is worth noting that the splenic vein was infiltrated by tumor in 1 patient. We dissected the splenic vein along with the distal pancreas, preserving the splenic artery and spleen. The postoperative course of patients was uneventful. The average postoperative hospital stay was 6.5 days (range, 5 to 9 d). All patients were followed-up and no local recurrence or metastasis was found.
DISCUSSION SPT of pancreas was first described by Frantz in 1959.7 Since then, this tumor has been designated with various names, such as: papillary cystic tumor, solid and papillary tumor, solid-cystic tumor, and solid and papillary epithelial neoplasm. SPT was the final terminology adopted by the WHO in 1996.8 The preoperative accurate diagnosis of SPT is difficult.9 The clinical presentations of SPT are not specific. To date, with better understanding of the tumor, imaging studies and its strong preponderance in young women are the cardinal preoperative diagnosis strategies.10 The computed tomographic presentation of SPT is a wellencapsulated hypodense mass, with various solid and cystic components, without dilatation of the pancreatic duct and parenchymal atrophy.11 It is controversial to perform fineneedle aspiration for patients suspected with SPT. Some authors stated that the fine-needle aspiration could provide accurate histologic diagnosis,12 whereas some others claimed that this strategy may cause tumor cell dissemination.13,14 Overall, the diagnosis of SPT should be highly suspected for a young female patient, with typical radiologic appearance and normal level of carbohydrate antigen 19-9.
To date, complete surgical resection (R0) is the most effective therapy for SPT, even in patients with metastasis.15 Laparoscopic distal pancreatectomy has been accepted as a safe and feasible procedure for benign and borderline malignant tumors of the pancreas.16 Because SPT is a welldefined low-grade malignant tumor and it mainly affects the tail of the pancreas, and is mostly seen in young women, who have more cosmetic requirements, it is a preferable indication for laparoscopic distal pancreatectomy.5 Fais et al17 performed laparoscopic management for 3 patients with SPT, including biopsy and resection in 1 patient and biopsy only in the other 2 patients. They stated that laparoscopic procedure for SPT was not suitable due to high local recurrence after long-term follow-up. Levy et al18 also stated in their article that tumor cells dissemination might be induced by trauma, including tumor biopsies, which should never be performed. Kim et al19 advised that radiologic diagnosis is sufficient for patients with SPT, especially when planning surgery. However, in our series, no local recurrence or metastasis was found after long-term follow-up (range, 20 to 59 mo). Integral resection of the tumor (R0 resection) is the key point for preventing tumor cells dissemination. Spleen has important immunologic functions, and many complications are associated with splenectomy, such as overwhelming postsplenectomy sepsis, late malignancies, and venous thrombosis.20 Furthermore, patients who underwent distal pancreatectomy without splenectomy had lower rates of infectious and fewer complications as well as a shorter hospital stay compared with patients who underwent distal pancreatectomy with splenectomy.21 Traditionally, distal pancreatectomy with splenectomy is recommended to patients with pancreatic adenocarcinoma to assure that an adequate oncologic operation has been carried out.22 With increasing reorganization in the nature of SPT (low-grade malignancy), more and more surgeons
TABLE 1. Demographic Characteristics and Preoperative Findings
Patients Sex Age (y) Symptoms CA19-9 CEA Metastasis Vessels involvement
Patient 1
Patient 2
Patient 3
Patient 4
Female 28 Abdominal pain Normal Normal No No
Female 31 Asymptomatic Normal Normal No No
Female 36 Asymptomatic Normal Normal No Splenic vein involvement
Male 41 Abdominal pain Normal Normal No No
CA 19-9 indicates carbohydrate antigen 19-9; CEA, carcinoembryonic antigen.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
e9
Surg Laparosc Endosc Percutan Tech
Cai et al
Volume 25, Number 1, February 2015
TABLE 2. Operative and Postoperative Details
Patients Operating time (min) Blood loss (mL) Tumor location Tumor size (cm) Postoperative hospital stay (d) Complications Recurrence
Patient 1
Patient 2
Patient 3
Patient 4
200 70 Pancreatic tail 4 6 No No
155 50 Pancreatic tail 3 6 No No
255 200 Pancreatic body 4 9 No No
190 80 Pancreatic tail 5 5 No No
emphasize the importance of preserving the spleen in the setting of SPT. Spleen-preserving distal pancreatectomy was first reported by Mallet-Guy and Vachon in 1943. In the procedure, they preserved the splenic artery and vein while ligating the vessels connected to the body and tail of the pancreas. With the magnified sights of operative field, it is easier to separate the splenic vein and artery from the pancreatic parenchyma during the laparoscopic distal pancreatectomy, resulting in higher spleen-preserving rate. The specimens in our series were placed in a retrieval bag, morcellated with forceps, and retracted through the 12 mm incision. No additional incision was required to retrieve the specimen. The morcellated specimen did not interfere with the histologic examination. However, attention should be paid to keep the intactness of the retrieval bag. The limitations of this study are its retrospective cohort design and small number of patients, all from a single institution. This observational results may be influenced by selection bias or confounding factors. Furthermore, it is still a technical challenge to perform laparoscopic, spleen-preserving, distal pancreatectomy, especially for the novices and less experienced surgeons. Because of its rarity, it is difficult to carry out a prospective study with large number of patients from a single institution. A multicenter prospective study with more number of patients is required to establish a definite evidence of safety and feasibility of laparoscopic distal pancreatectomy for SPT. In conclusion, SPT is a low-grade malignant tumor, with a distinct female preponderance. Long-term survival is highly expected for patients after surgical resection. Laparoscopic distal pancreatectomy for patients with SPT is safe and feasible, with preferable operative outcomes, long-term tumor-free survival, and high spleen-preserving rate. Therefore, laparoscopic, spleen-preserving, distal pancreatectomy may be the first choice for well-selected patients with SPT of the distal pancreas. REFERENCES 1. Machado MC, Machado MA, Bacchella T, et al. Solid pseudopapillary neoplasm of the pancreas: distinct patterns of onset, diagnosis, and prognosis for male versus female patients. Surgery. 2008;143:29–34. 2. Potrc S, Kavalar R, Horvat M, et al. Urgent Whipple resection for solid pseudopapillary tumor of the pancreas. J Hepatobiliary Pancreat Surg. 2003;10:386–389. 3. Sperti C, Berselli M, Pasquali C, et al. Aggressive behaviour of solid-pseudopapillary tumor of the pancreas in adults: a case report and review of the literature. World J Gastroenterol. 2008;14:960–965. 4. Becmeur F, Hofmann-Zango I, Moog R, et al. Small bowel obstruction and laparoscopic treatment in children. J Chir. 1996;133:418–421.
e10 | www.surgical-laparoscopy.com
5. Kang CM, Choi SH, Hwang HK, et al. Minimally invasive (laparoscopic and robot-assisted) approach for solid pseudopapillary tumor of the distal pancreas: a single-center experience. J Hepatobiliary Pancreat Sci. 2011;18:87–93. 6. Melotti G, Cavallini A, Butturini G, et al. Laparoscopic distal pancreatectomy in children: case report and review of the literature. Ann Surg Oncol. 2007;14:1065–1069. 7. Frantz V. Tumors of the Pancreas. Atlas of Tumor Pathology,Section VII, Fascicles 27 and 28. Washington, DC: Armed Forces Institute of Pathology; 1959:32–33. 8. Klo¨ppel G, Solcia E, Longnecker DS, et al. Histological Typing of Tumors of the Exocrine Pancreas. New York: Springer; 1996. 9. Zhang H, Liang TB, Wang WL, et al. Diagnosis and treatment of solid-pseudopapillary tumor of the pancreas. Hepatobiliary Pancreat Dis Int. 2006;5:454–458. 10. Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg. 2005;200:965–972. 11. Miao F, Zhan Y, Wang XY, et al. CT manifestations and features of solid cystic tumors of the pancreas. Hepatobiliary Pancreat Dis Int. 2002;1:465–468. 12. Jani N, Dewitt J, Eloubeidi M, et al. Endoscopic ultrasoundguided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: a multicenter experience. Endoscopy. 2008;40:200–203. 13. Pettinato G, Di Vizio D, Manivel JC, et al. Solid-pseudopapillary tumor of the pancreas: a neoplasm with distinct and highly characteristic cytological features. Diagn Cytopathol. 2002;27: 325–334. 14. Levy P, Auber A, Ruszniewski P. Do not biopsy solid pseudopapillary tumors of the pancreas! Endoscopy. 2008;40:959, author reply 60. 15. Nagri S, Abdu A, Anand S, et al. Liver metastasis four years after Whipple’s resection for solid-pseudopapillary tumor of the pancreas. JOP. 2007;8:223–227. 16. Kim SC, Park KT, Hwang JW, et al. Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution. Surg Endosc. 2008;22:2261–2268. 17. Fais PO, Carricaburu E, Sarnacki S, et al. Is laparoscopic management suitable for solid pseudo-papillary tumors of the pancreas? Pediatr Surg Int. 2009;25:617–621. 18. Levy P, Bougaran J, Gayet B. Diffuse peritoneal carcinosis of pseudo-papillary and solid tumor of the pancreas. Role of abdominal injury. Gastroenterol Clin Biol. 1997;21:789–793. 19. Kim CW, Han DJ, Kim J, et al. Solid pseudopapillary tumor of the pancreas: can malignancy be predicted? Surgery. 2011;149:625–634. 20. Beane JD, Pitt HA, Nakeeb A, et al. Splenic preserving distal pancreatectomy: does vessel preservation matter? J Am Coll Surg. 2011;212:651–657; discussion 7-8. 21. Shoup M, Brennan MF, McWhite K, et al. The value of splenic preservation with distal pancreatectomy. Arch Surg. 2002;137: 164–168. 22. Strasberg SM, Linehan DC, Hawkins WG. Radical antegrade modular pancreatosplenectomy procedure for adenocarcinoma of the body and tail of the pancreas: ability to obtain negative tangential margins. J Am Coll Surg. 2007;204: 244–249.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Laparoscopic Distal Pancreatectomy for Solid-Pseudopapillary Tumor of the Pancreas Yunqiang Cai, MD, Bing Peng, MD, PhD, Gang Mai, MD, PhD, Nengwen Ke, MD, PhD, and Xubao Liu, MD, PhD
Purpose: Solid-pseudopapillary tumor (SPT) of pancreas is a rare entity with a low malignant potential. We aimed to identify the safety and the feasibility of laparoscopic distal pancreatectomy for SPT. Methods: From May 2008 to August 2011, we performed 4 cases of laparoscopic, spleen-preserving, distal pancreatectomies for patients with SPT. We retrospectively collected the demographic characteristics, operative and postoperative details, and follow-up outcomes of the patients. Results: Three female patients and 1 male patient with SPT underwent laparoscopic, spleen-preserving, distal pancreatectomy. The average operating time was 200 minutes. The average blood loss was 90 mL. The postoperative course of these patients was uneventful. All patients were followed-up and no local recurrence or metastasis was found. Conclusions: Laparoscopic distal pancreatectomy for patients with SPT is safe and feasible, with preferable operative outcomes, longterm tumor-free survival, and high spleen-preserving rate. Key Words: solid-pseudopapillary tumor, pancreatectomy, follow-up
(Surg Laparosc Endosc Percutan Tech 2015;25:e8–e10)
S
olid-pseudopapillary tumor (SPT) of pancreas is a rare entity with a distinct female preponderance and low malignant potential, accounting for 1% to 3% of all pancreatic neoplasms.1 Surgical resection of the tumor offers an excellent long-term survival. A 5-year survival rate of >95% after resection has been reported in several studies.2,3 The first laparoscopic distal pancreatectomy was reported in 1996.4 Compared with open surgeries, laparoscopic distal pancreatectomy offers many advantages in terms of earlier oral intake, fewer blood loss, shorter posthospital stays, and fewer surgery-related complications.5 Furthermore, the magnified sights of the operative field facilitates separation of splenic vein and artery from the pancreatic parenchyma; therefore, the spleen-preserving rate is higher.6 Because of the absence of anastomosis, distal pancreatectomy is well suited for laparoscopic approach. In this study, we report 4 cases of laparoscopic, spleenpreserving, distal pancreatectomies for SPT, emphasizing the safety, feasibility of this procedure and the good results Received for publication June 9, 2013; accepted October 22, 2013. From the Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China. The authors declare no conflicts of interest. Reprints: Xubao Liu, MD, PhD, Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
e8 | www.surgical-laparoscopy.com
obtained with regard to the quick recovery and long-term survival of the patients.
MATERIALS AND METHODS From May 2008 to August 2011, we performed 4 cases of laparoscopic, spleen-preserving, distal pancreatectomies for pancreatic body or tail lesions in the Department of Hepatopancreatobiliary Surgery, West China Hospital, Sichuan University, China. All the lesions were confirmed to be SPT by histopathologic examination. We collected the demographic characteristics, operative details, postoperative courses, and follow-up outcomes of these patients. Written consents were obtained from the patients included in this study, and the study was approved by the Ethics Committee of Sichuan University.
Operation Procedures All the patients received general anesthesia and were placed in a supine position with the operating table slightly tilted to the reverse Trendelenburg position. Generally, 5 trocars were used. A 10 mm trocar was placed at the lower umbilicus for a 10 mm, 30-degree camera. Two 12 mm trocars were placed at the right and left flank, respectively. Another two 5 mm trocars were placed at the left axillary line and in the xiphoid area, respectively. The operation began with the dissection of greater omentum. We inserted a tube to raise the gastric body from the xiphoid trocar, enabling good exposure of the body and tail of the pancreas (Fig. 1A). The inferior border and the superior border of the pancreas was dissected, with the splenic artery and vein identified. The body of the pancreas was transected using an endoscopic linear stapler. We dissected the branches of the splenic vessels first from the pancreatic body and then toward the splenic hilum. The gland was then dissected from the retroperitoneum, with the splenic vessels preserved. The specimen was placed in a retrieval bag, morcellated with forceps, and retracted through the 12 mm incision (Fig. 1B). A closed suction drain was routinely placed near the pancreatic stump for the detection of pancreatic fistula.
RESULTS We successfully carried out laparoscopic, spleen-preserving, distal pancreatectomies for 4 patients in our series. Demographic characteristics and preoperative findings of the patients are shown in Table 1. The mean age of these patients was 34 years (range, 28 to 41 y). Three SPTs were located in the pancreatic tail and 1 in the pancreatic body. The blood chemistry was within normal limits. The serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen were normal. The operative and postoperative details are shown in Table 2. None of these patients required conversion to open surgery. The average operating
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015
Laparoscopic Distal Pancreatectomy for SPT
FIGURE 1. A, The stomach was raised and the tumor was revealed. B, The specimen was placed in a retrieval bag, morcellated with forceps, and retracted through the 12 mm incision. F indicates forceps; SPT, solid-pseudopapillary tumor.
time was 200 minutes (range, 155 to 255 min). The average blood loss was 90 mL (range, 50 to 150 mL). No metastasis or lymph node involvement was found in the 4 patients. It is worth noting that the splenic vein was infiltrated by tumor in 1 patient. We dissected the splenic vein along with the distal pancreas, preserving the splenic artery and spleen. The postoperative course of patients was uneventful. The average postoperative hospital stay was 6.5 days (range, 5 to 9 d). All patients were followed-up and no local recurrence or metastasis was found.
DISCUSSION SPT of pancreas was first described by Frantz in 1959.7 Since then, this tumor has been designated with various names, such as: papillary cystic tumor, solid and papillary tumor, solid-cystic tumor, and solid and papillary epithelial neoplasm. SPT was the final terminology adopted by the WHO in 1996.8 The preoperative accurate diagnosis of SPT is difficult.9 The clinical presentations of SPT are not specific. To date, with better understanding of the tumor, imaging studies and its strong preponderance in young women are the cardinal preoperative diagnosis strategies.10 The computed tomographic presentation of SPT is a wellencapsulated hypodense mass, with various solid and cystic components, without dilatation of the pancreatic duct and parenchymal atrophy.11 It is controversial to perform fineneedle aspiration for patients suspected with SPT. Some authors stated that the fine-needle aspiration could provide accurate histologic diagnosis,12 whereas some others claimed that this strategy may cause tumor cell dissemination.13,14 Overall, the diagnosis of SPT should be highly suspected for a young female patient, with typical radiologic appearance and normal level of carbohydrate antigen 19-9.
To date, complete surgical resection (R0) is the most effective therapy for SPT, even in patients with metastasis.15 Laparoscopic distal pancreatectomy has been accepted as a safe and feasible procedure for benign and borderline malignant tumors of the pancreas.16 Because SPT is a welldefined low-grade malignant tumor and it mainly affects the tail of the pancreas, and is mostly seen in young women, who have more cosmetic requirements, it is a preferable indication for laparoscopic distal pancreatectomy.5 Fais et al17 performed laparoscopic management for 3 patients with SPT, including biopsy and resection in 1 patient and biopsy only in the other 2 patients. They stated that laparoscopic procedure for SPT was not suitable due to high local recurrence after long-term follow-up. Levy et al18 also stated in their article that tumor cells dissemination might be induced by trauma, including tumor biopsies, which should never be performed. Kim et al19 advised that radiologic diagnosis is sufficient for patients with SPT, especially when planning surgery. However, in our series, no local recurrence or metastasis was found after long-term follow-up (range, 20 to 59 mo). Integral resection of the tumor (R0 resection) is the key point for preventing tumor cells dissemination. Spleen has important immunologic functions, and many complications are associated with splenectomy, such as overwhelming postsplenectomy sepsis, late malignancies, and venous thrombosis.20 Furthermore, patients who underwent distal pancreatectomy without splenectomy had lower rates of infectious and fewer complications as well as a shorter hospital stay compared with patients who underwent distal pancreatectomy with splenectomy.21 Traditionally, distal pancreatectomy with splenectomy is recommended to patients with pancreatic adenocarcinoma to assure that an adequate oncologic operation has been carried out.22 With increasing reorganization in the nature of SPT (low-grade malignancy), more and more surgeons
TABLE 1. Demographic Characteristics and Preoperative Findings
Patients Sex Age (y) Symptoms CA19-9 CEA Metastasis Vessels involvement
Patient 1
Patient 2
Patient 3
Patient 4
Female 28 Abdominal pain Normal Normal No No
Female 31 Asymptomatic Normal Normal No No
Female 36 Asymptomatic Normal Normal No Splenic vein involvement
Male 41 Abdominal pain Normal Normal No No
CA 19-9 indicates carbohydrate antigen 19-9; CEA, carcinoembryonic antigen.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
e9
Surg Laparosc Endosc Percutan Tech
Cai et al
Volume 25, Number 1, February 2015
TABLE 2. Operative and Postoperative Details
Patients Operating time (min) Blood loss (mL) Tumor location Tumor size (cm) Postoperative hospital stay (d) Complications Recurrence
Patient 1
Patient 2
Patient 3
Patient 4
200 70 Pancreatic tail 4 6 No No
155 50 Pancreatic tail 3 6 No No
255 200 Pancreatic body 4 9 No No
190 80 Pancreatic tail 5 5 No No
emphasize the importance of preserving the spleen in the setting of SPT. Spleen-preserving distal pancreatectomy was first reported by Mallet-Guy and Vachon in 1943. In the procedure, they preserved the splenic artery and vein while ligating the vessels connected to the body and tail of the pancreas. With the magnified sights of operative field, it is easier to separate the splenic vein and artery from the pancreatic parenchyma during the laparoscopic distal pancreatectomy, resulting in higher spleen-preserving rate. The specimens in our series were placed in a retrieval bag, morcellated with forceps, and retracted through the 12 mm incision. No additional incision was required to retrieve the specimen. The morcellated specimen did not interfere with the histologic examination. However, attention should be paid to keep the intactness of the retrieval bag. The limitations of this study are its retrospective cohort design and small number of patients, all from a single institution. This observational results may be influenced by selection bias or confounding factors. Furthermore, it is still a technical challenge to perform laparoscopic, spleen-preserving, distal pancreatectomy, especially for the novices and less experienced surgeons. Because of its rarity, it is difficult to carry out a prospective study with large number of patients from a single institution. A multicenter prospective study with more number of patients is required to establish a definite evidence of safety and feasibility of laparoscopic distal pancreatectomy for SPT. In conclusion, SPT is a low-grade malignant tumor, with a distinct female preponderance. Long-term survival is highly expected for patients after surgical resection. Laparoscopic distal pancreatectomy for patients with SPT is safe and feasible, with preferable operative outcomes, long-term tumor-free survival, and high spleen-preserving rate. Therefore, laparoscopic, spleen-preserving, distal pancreatectomy may be the first choice for well-selected patients with SPT of the distal pancreas. REFERENCES 1. Machado MC, Machado MA, Bacchella T, et al. Solid pseudopapillary neoplasm of the pancreas: distinct patterns of onset, diagnosis, and prognosis for male versus female patients. Surgery. 2008;143:29–34. 2. Potrc S, Kavalar R, Horvat M, et al. Urgent Whipple resection for solid pseudopapillary tumor of the pancreas. J Hepatobiliary Pancreat Surg. 2003;10:386–389. 3. Sperti C, Berselli M, Pasquali C, et al. Aggressive behaviour of solid-pseudopapillary tumor of the pancreas in adults: a case report and review of the literature. World J Gastroenterol. 2008;14:960–965. 4. Becmeur F, Hofmann-Zango I, Moog R, et al. Small bowel obstruction and laparoscopic treatment in children. J Chir. 1996;133:418–421.
e10 | www.surgical-laparoscopy.com
5. Kang CM, Choi SH, Hwang HK, et al. Minimally invasive (laparoscopic and robot-assisted) approach for solid pseudopapillary tumor of the distal pancreas: a single-center experience. J Hepatobiliary Pancreat Sci. 2011;18:87–93. 6. Melotti G, Cavallini A, Butturini G, et al. Laparoscopic distal pancreatectomy in children: case report and review of the literature. Ann Surg Oncol. 2007;14:1065–1069. 7. Frantz V. Tumors of the Pancreas. Atlas of Tumor Pathology,Section VII, Fascicles 27 and 28. Washington, DC: Armed Forces Institute of Pathology; 1959:32–33. 8. Klo¨ppel G, Solcia E, Longnecker DS, et al. Histological Typing of Tumors of the Exocrine Pancreas. New York: Springer; 1996. 9. Zhang H, Liang TB, Wang WL, et al. Diagnosis and treatment of solid-pseudopapillary tumor of the pancreas. Hepatobiliary Pancreat Dis Int. 2006;5:454–458. 10. Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg. 2005;200:965–972. 11. Miao F, Zhan Y, Wang XY, et al. CT manifestations and features of solid cystic tumors of the pancreas. Hepatobiliary Pancreat Dis Int. 2002;1:465–468. 12. Jani N, Dewitt J, Eloubeidi M, et al. Endoscopic ultrasoundguided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: a multicenter experience. Endoscopy. 2008;40:200–203. 13. Pettinato G, Di Vizio D, Manivel JC, et al. Solid-pseudopapillary tumor of the pancreas: a neoplasm with distinct and highly characteristic cytological features. Diagn Cytopathol. 2002;27: 325–334. 14. Levy P, Auber A, Ruszniewski P. Do not biopsy solid pseudopapillary tumors of the pancreas! Endoscopy. 2008;40:959, author reply 60. 15. Nagri S, Abdu A, Anand S, et al. Liver metastasis four years after Whipple’s resection for solid-pseudopapillary tumor of the pancreas. JOP. 2007;8:223–227. 16. Kim SC, Park KT, Hwang JW, et al. Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution. Surg Endosc. 2008;22:2261–2268. 17. Fais PO, Carricaburu E, Sarnacki S, et al. Is laparoscopic management suitable for solid pseudo-papillary tumors of the pancreas? Pediatr Surg Int. 2009;25:617–621. 18. Levy P, Bougaran J, Gayet B. Diffuse peritoneal carcinosis of pseudo-papillary and solid tumor of the pancreas. Role of abdominal injury. Gastroenterol Clin Biol. 1997;21:789–793. 19. Kim CW, Han DJ, Kim J, et al. Solid pseudopapillary tumor of the pancreas: can malignancy be predicted? Surgery. 2011;149:625–634. 20. Beane JD, Pitt HA, Nakeeb A, et al. Splenic preserving distal pancreatectomy: does vessel preservation matter? J Am Coll Surg. 2011;212:651–657; discussion 7-8. 21. Shoup M, Brennan MF, McWhite K, et al. The value of splenic preservation with distal pancreatectomy. Arch Surg. 2002;137: 164–168. 22. Strasberg SM, Linehan DC, Hawkins WG. Radical antegrade modular pancreatosplenectomy procedure for adenocarcinoma of the body and tail of the pancreas: ability to obtain negative tangential margins. J Am Coll Surg. 2007;204: 244–249.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
