Pediatr Surg Int (2014) 30:259–266 DOI 10.1007/s00383-014-3471-4
ORIGINAL ARTICLE
Laparoscopic distal pancreatectomy to treat solid pseudopapillary tumors in children: transition from open to laparoscopic approaches in suitable cases Jung-Man Namgoong • Dae-Yeon Kim Seong-Chul Kim • Song-Cheol Kim • Ji-Hee Hwang • Ki-Byung Song
•
Accepted: 9 January 2014 / Published online: 29 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The aim of this study was to evaluate the outcomes of open and laparoscopic distal pancreatectomy (LDP) in the treatment of solid pseudopapillary tumors (SPT) in children. Methods This was a retrospective study of 22 patients under 18 years of age who underwent a distal pancreatectomy for SPT between January 1995 and December 2012. Results Fourteen patients and eight patients underwent LDP and open distal pancreatectomy (ODP), respectively, and 71.4 % of the LDP and 25.0 % of the ODP procedures were spleen-sparing operations. The median duration of surgery in the LDP group was shorter than that in the ODP group [175 (range 120–540) vs. 257 (range 200–305) min, p = 0.024]. There were no differences in postoperative complications. The LDP patients commenced oral intake earlier than the ODP patients [2.0 (range 1.0–7.0) vs. 4.0 (range 3.0–12.0) days, p = 0.010], and had an earlier discharge from hospital [7.0 (range 5.0–20.0) vs. 13.0 (range 7.0–22.0) days, p = 0.009]. Conclusion LDP treatment for SPT in children is associated with a shorter hospitalization and a shorter time to oral intake compared to ODP. LDP is a safe and feasible option for SPT in select pediatric patients.
J.-M. Namgoong D.-Y. Kim (&) S.-C. Kim J.-H. Hwang Division of Pediatric Surgery, Department of Surgery, Asan Medical Center, 88, East Building 10th Floor, Olympic-RO 43-GIL, Songpa-gu, Seoul 138-736, Korea e-mail: [email protected] S.-C. Kim K.-B. Song Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Asan Medical Center, 88, East Building 10th Floor, Olympic-RO 43-GIL, Songpa-gu, Seoul 138-736, Korea
Keywords Solid pseudopapillary tumor Laparoscopic distal pancreatectomy Spleen-sparing laparoscopic pancreatectomy Distal pancreatectomy
Introduction Solid pseudopapillary tumor (SPT) of the pancreas is a rare primary neoplasm of low-grade malignancy that accounts for 1–3 % of primary pancreatic tumors [1]. This tumor was first described as a new entity in 1959 as a Frantz tumor [2]. SPT is an epithelial tumor with solid and cystic macroscopic features; and solid, pseudopapillary, and cystic microscopic features. These are associated with immunohistochemical expression of epithelial, mesenchymal, and endocrine markers. The prognosis after surgical resection of an SPT is quite favorable with an overall survival rate reported to be higher than 90 % [3]. There has been a steady increase in the incidence of SPT over last two decades [4]. Pancreatic tumors are exceedingly rare in children and only a limited number of cases have been reported, which limits our understanding of their clinical course and outcome [5–7]. Surgical procedures to treat pancreatic tumors vary based on the location of the lesion. When these tumors are located in tail or body of the pancreas, a distal pancreatectomy (DP) is the treatment of choice. Recently, however, laparoscopic distal pancreatectomy (LDP) is being more widely used due to increasing evidence that it is a safe and efficient alternative to the open approach [8]. Although LDP has been accepted as the standard surgical procedure for solid tumors on the distal part of the pancreas in adult patients, there have been few studies of LDP in pediatric patients with pancreatic tumors. At our institution, we have experienced a change to the laparoscopic
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approach for various types of pediatric surgery including the pancreas, and the proportion of laparoscopic surgeries has been increasing. SPT is the most common pancreatic tumor in children and we here report our experiences with open distal pancreatectomy (ODP) and LDP surgeries to treat pediatric SPT cases.
Patients and methods A retrospective chart review was conducted for pediatric patients who had undergone distal pancreatectomy for pathologically confirmed SPT at our tertiary medical center, Seoul, Korea between January 1995 and December 2012. Only patients under the age of 18 years old were reviewed. We included data from four different surgeons in our analysis; two performed ODP and LDP and two performed only ODP. Clinical characteristics, surgical and pathologic data, and surgical outcomes were obtained from medical records. SPT had been diagnosed pathologically in our patients based on gross and microscopic appearances of each tumor. In addition, all specimens had been assessed by immunohistochemical staining to confirm the diagnosis, including staining with antibodies against beta-catenin, E-cadherin and synaptophysin. Our data variables included patient demographics such as age and sex, as well as clinical presentation, tumor size, tumor grade, presence of metastasis, tumor markers, type of surgery, complications, hospital stay, time to oral feeding, duration of follow-up, and status at the end of follow-up. After surgery, patients were periodically followed up until death unless they could not be contacted. Operative technique
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ODP All of our patients were operated on under general anesthesia in the supine position. An upper transverse or L-shape incision was made. The lesser sac was entered through the gastrocolic ligament, and the colonic splenic flexure was mobilized. The superior and inferior borders of the pancreas were defined, and the splenic vessels were identified and preserved or ligated depending on whether splenic preservation would be performed. The tail of the pancreas was mobilized and transected. We divided the pancreas parenchyma with staples or knife with suture ligation of the main pancreatic duct. A drainage tube was left in the pancreatic bed and subphrenic space, and the abdomen was closed. LDP For LDP procedures, patients under general anesthesia were placed in the supine position with their legs apart. A pneumoperitoneum at 12 mmHg by CO2 gas was first established in the umbilical region with a Veress needle, and a 10 mm trocar was placed in the upper umbilical region. The location of the trocars is outlined in Fig. 1. After confirming the intraperitoneal cavity by 30° laparoscopy, the main working trocar (10 mm) was inserted at the left side of the patient 5–7 cm away from the epigastric midline. An assisting trocar for the surgeon was inserted at the right upper abdomen for dissection of the upper margin of the pancreas and for adequate traction of pancreatic tissue. An assisting trocar for the assistant was inserted at the left flank of the patient. After accessing the lesser sac, we sutured and fixed the posterior wall of stomach to the anterior wall of the upper abdomen for suitable exposure of the tail of the pancreas (Fig. 2a). When the surgical field of
Transition of surgical approaches Because of the small number of patients in our cohort and the relatively long period of treatment, the selection of surgical approach was related to surgical technique transition. In pediatric patients at our institution, the first laparoscopic surgeries for SPT in June 2007 involved enucleation of the mass on the median pancreas and the first LDP for SPT was performed in July 2008. From the beginning of our use of LDP, we tried to treat all cases of SPT of the distal pancreas using this method. The current treatment policy of our institution for distal masses of the pancreas is to use laparoscopic surgery. Between 1996 and 2000, there were four pediatric cases that received ODP with concomitant splenectomy. Spleen-sparing distal pancreatectomy was first performed for children in November 2001 at our hospital and it is now our institutional policy to save spleen when performing a DP.
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Fig. 1 Location of trocars during LDP. The surgeon uses 12 and 5 mm trocars and the assistant uses left-sided 5 mm trocar for traction
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Fig. 2 Operative procedures of LDP. a Fixation of stomach to the abdominal wall. b Mobilization of lower pancreas and dissection of the splenic vein. c Hanging of pancreas with nylon tape. d Division of the pancreas with an endoscopic stapler
view was good enough and there was no further traction needed, we used only three trocars in the operation without a 5 mm trocar for the assistant. An intraoperative ultrasound was performed to assess the location of the lesion and pancreatic dissection was started using laparoscopic instruments or an ultrasonic shears (Harmonic scalpelTM; Ethicon EndoSurgery, Cincinnati, OH) by mobilizing the lower pancreatic margin and gaining access to the posterior pancreatic surface (Fig. 2b). A nylon tape was placed around the pancreas to lift it and expose the surgical planes (Fig. 2c). The pancreas was divided using an endoscopic stapler (Echelon 60; Ethicon EndoSurgery, Cincinnati, OH; Fig. 2d). The specimen was then retrieved within an endobag (Endocatch, Ethicon EndoSurgery) introduced through a 10 mm umbilical port. We extended the umbilical incision a little further for specimen retrieval to minimize damage to the specimen when pulling it through the tight cavity. Patient follow-up Patients were periodically followed up until death unless they became unavailable for contact. In all patients, computed tomography (CT) scans or sonographies of the abdomen, and serum amylase and lipase were checked in the outpatient clinic at 1 week, 1 month, and 6 months
post-operation, and annually thereafter. Amylase and lipase levels in the Jackson-Pratt (JP) drainage were also routinely examined at 3 and 7 days post-operation. Statistical analysis SPSS software version 18.0 for Windows from SPSS Inc. (Chicago, IL) was used for statistical analysis. The Mann– Whitney U test and Wilcoxon test were used to assess significance in the nonparametric data sets. The significance level was set at a p value of less than 0.05.
Results A total of 48 pediatric patients had received surgery for SPT during the study period at our hospital, 22 of whom underwent distal pancreatectomy. Fourteen (63.6 %) of these 22 patients underwent LDP and the remaining 8 (36.4 %) cases received an ODP for SPT. This patient group comprised 17 females and 5 males with ages ranging from 9–18 years, and a median age of 15 years (Table 1). There was no history of previous upper abdominal surgery in this cohort of 22 patients. The patient characteristics were comparable between the LDP and ODP groups. The most common symptom in the group was abdominal pain
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Table 1 Patient characteristics Total 22 (100)
LDP 14 (100)
ODP 8 (100)
p value
Age (years)
15 (9–18)
15 (9–18)
14 (10–18)
0.837
Sex (f:m)
3.4:1
6:1
1.7:1
0.222
Symptom
19 (86.4)
11 (78.6)
8 (100)
0.169
Abdominal pain
19 (86.4)
11 (78.6)
8 (100)
0.169
Vomiting
1 (4.5)
0 (0)
1 (12.5)
0.186
Diarrhea
1 (4.5)
1 (7.1)
0 (0)
0.450
Back pain
1 (4.5)
0 (0)
1 (12.5)
0.450
Duration of symptom (month)
1 (0–12)
1 (0–12)
4 (0–12)
0.228
Palpable mass
1 (4.5)
0 (0)
1 (12.5)
0.286
Diagnosis by chance
2 (9.1)
2 (14.2)
0 (0)
0.273
History of pancreatitis
1 (4.5)
0 (0)
1 (12.5)
0.186
CA19-9 (normal range 0–37 U/ml)
13.2 (1.7–24.5)
10.5 (1.7–15.6)
18.6 (12.4–24.5)
0.317
[number (n) = 19, 86.4 %]. Other common symptoms included vomiting (n = 1), diarrhea (n = 1) and back pain (n = 1). Three patients were asymptomatic. The two patient groups also had no statistically significant differences in distribution with regard to age, sex, symptoms, or history of pancreatitis (Table 1). The levels of CA19-9 in the LDP and ODP groups were also not significantly different (p = 0.317). The perioperative outcomes in our study subjects are summarized in Table 2. We performed spleen-sparing distal pancreatectomy for 12 (54.5 %) pediatric cases of SPT in our current study period. Among these patients, 10 cases (71.4 % of the LDP) were treated using spleensparing laparoscopic distal pancreatectomy (SSLDP) and 2 cases (25.0 % of the ODP) using spleen-sparing open distal pancreatectomy (SSODP). There was a significant difference in the rate of spleen conservation (p \ 0.001). Because the initial four SPT cases who underwent ODP received a splenectomy, this influenced the overall results for spleen preservation. In the SSLDP cases, we used the Warshow technique [9] in two patients and single-port SSLDP in one patient. There were no additional organ resections in our LDP group, but a single patient in the
Values are presented as the median (range) or number (%)
Table 2 Perioperative outcomes Total 22 (100)
LDP 14 (100)
ODP 8 (100)
p value
Splenic preservation
12 (54.5)
10 (71.4)
2 (25.0)
\0.001
Portal vein resection
1 (4.5)
0 (0)
1 (12.5)
0.186
Duration of surgery (min)
210 (120–540)
175 (120–540)
257 (200–305)
0.024
Intraoperative blood loss (ml)
165 (50–1,040)
140 (50–1,040)
240 (150–620)
0.013
Postoperative complication
13 (59.1)
8 (57.1)
5 (62.5)
0.810
Fluid collection
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Postoperative ileus
1 (4.5)
1 (7.1)
0 (0)
0.450
Splenic infarction
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Chylous drain
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Pancreatic fistulaa
6 (27.3)
4 (28.5)
2 (25.0)
0.860
Grade A
4 (18.2)
3 (21.4)
1 (12.5)
0.610
Grade B
2 (9.1)
1 (7.1)
1 (12.5)
0.681
0 (0)
0 (0)
0 (0)
–
Grade C Dindo–Clavien classification Grade I
10 (45.5)
6 (42.8)
4 (50)
0.757
Grade II
3 (13.6)
2 (14.3)
1 (12.5)
0.909
Grade IIIa/IIIb
0/0
0/0
0/0
–
Duration of hospitalization (day)
9.0 (5.0–22.0)
7.0 (5.0–20.0)
13.0 (7.0–22.0)
0.009
Time to oral intake (day)
2.5 (1.0–12.0)
2.0 (1.0–7.0)
4.0 (3.0–12.0)
0.010
Time to full feeding (day)
5.0 (3.0–15.0)
3.5 (3.0–9.0)
6.5 (5.0–15.0)
0.005
Values are presented as the median (range) or number (%) a
Defined using the international study group of pancreatic fistula (ISGPF) definition
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Table 3 Histopathological outcomes of SPT and prognosis
Tumor size on imaging (cm)
Total 22 (100)
LDP 14 (100)
ODP 8 (100)
p value
5.0 (2.0–15.5)
4.5 (2.0–9.0)
10.7 (2.0–15.5)
0.024
Tumor size on pathology (cm)
4.7 (1.8–15)
4.4 (2.0–7.4)
10.0 (1.8–15.0)
0.060
Distance to resection margin (cm)
1.5 (0.1–5.2)
1.0 (1.8–5.2)
1.9 (0.1–4.0)
0.780
Resection margin involvement
0 (0)
0 (0)
0 (0)
–
Radial margin involvement
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Malignancy
3 (13.6)
0 (0)
3 (37.5)
0.016
2 (9.1) 1 (4.5)
0 (0) 0 (0)
2 (25.0) 1 (12.5)
0.055 0.186
Capsular invasion Peripancreatic soft tissue invasion
1 (4.5)
0 (0)
1 (12.5)
0.186
Follow-up period (month)
Vessel involvement
48 (11–207)
20 (11–92)
128 (13–207)
0.007
Recurrence
1 (4.5)
0 (0)
1 (12.5)
0.186
Mortality
0 (0)
0 (0)
0 (0)
–
Values are presented as the median (range) or number (%)
ODP group underwent portal vein resection and anastomosis due to portal vein invasion. The median duration of the surgery in the LDP group was less than that in the ODP group [175 (range 120–540) vs. 257 (range 200–305) min, p = 0.024]. The durations of surgery in the two cases treated using SSLDP with the Warshow technique were 120 and 135 min, whereas the single-port SSLDP procedure took 420 min. The median intraoperative blood loss was less in the LDP group than in the ODP group [140 (range 50–1,040) vs. 240 (range 150–620) ml, p = 0.013]. There was no difference in postoperative complications, which included fluid collection, postoperative ileus, splenic infarction, chylous drainage, and pancreatic fistula (Table 2). We classified the pancreatic fistula patients according to the definition provided by the International Study Group of Pancreatic Fistula (ISGPF) [10]. The only difference found was that two patients in our ODP group
were discharged with a drainage tube because of chylous drainage and pancreatic fistula, whereas there were no such cases in the LDP group. The drainage tube was removed approximately 3 weeks after the operation and there were no wound complications in either group. There was a statistically significant difference found in the median duration of hospitalization: 7 (range 5–20) days in the LDP group and 13 (range 7–22) days in the ODP group (p = 0.009). With regard to oral intake, we investigated the time to oral intake and to full feeding. The LDP patients commenced oral intake earlier than the ODP patients [2.0 (range 1.0–7.0) vs. 4.0 (range 3.0–12.0) days, p = 0.010], and required a shorter period of time to reach full feeding [3.5 (range 3.0–9.0) vs. 6.5 (range 5.0–15.0) days, p = 0.005]. The median tumor size on pathology was 4.4 (range 2.0–8.4) cm in the LDP group and 10.0 (range 1.8–15.0) cm in the ODP group (p = 0.060) (Table 3). Our initial
Fig. 3 Distribution of tumor size combined with surgical approaches
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Table 4 Characteristics of SPC Patient number
Sex/age
Tumor size
Operation
1 2 3
Proportion of solid mass (%)
Invasion
F/17
13
M/13
12.5
LDP
50
SSLDP
50
M/10
11
SSLDP
20
Capsule
Disease free survival (month)
Follow-up period (month)
Peripancreatic tissue
Vessels
Not exist
Exist
Exist
Recurred
82
205
Exist
Not exist
Not exist
Not recurred
128
128
Exist
Not exist
Not exist
Not recurred
121
121
five ODP cases involved large tumors, therefore the tumor sizes in the ODP group were approximately 2-fold greater than those of the LDP group (Fig. 3). The median distance from the tumor capsule to the resection margin was longer than 1.0 cm in both groups, and there was no case in which the tumor involved the resection margin. The malignant potency of a tumor can result in a radial margin involvement by the tumor. Each of our groups had one such case of radial margin involvement (p = 0.681). These tumors varied from almost entirely cystic to entirely solid. Among the 22 patients in our study cohort, 16 cases had entirely cystic masses, and 6 cases (2:4 in LDP:ODP) had a solid portion of more than 30 %. Histopathologically, the SPT’s in our pediatric cohort showed a combination of solid components of pseudopapillae with fibrovascular stalks and cystic components with degeneration and hemorrhage. Solid pseudopapillary cancer (SPC) was diagnosed based on WHO histological criteria [11] in three of our patients who underwent ODP but there was no SPC among our LDP patients (Table 4). The sizes of the SPC lesions were larger than 11 cm, and two of these patients had a 50 % solid portion in their SPC mass. There was only one case of recurrence at 82 months after surgery. The recurred tumor in this patient was located on the retroperitoneal tissue abutting the portal vein. This patient survived after excision of the recurred mass with portal vein resection and anastomosis, and shows no evidence of recurrence to date. There was no perioperative or long-term mortality in current study.
Discussion SPT is the most common pancreatic tumor but is associated with an excellent surgical outcome. Compared to other pancreatic neoplasms in childhood, the prognosis of SPT patients after complete surgical resection is favorable and tumor recurrence is relatively rare. Rojas et al. [7] have reported a 5-year survival rate of 100 % for patients with SPT which accords with other previously reported 5-year survival rates of 90–97 % [3, 12]. Lam et al. [13] found that 15 % (66 of 452 patients) of reported SPT tumors were malignant, evidenced by the presence of metastases or
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Recurrence
invasion of adjacent structures. In 2011, Kim et al. [4] reported a 22.8 % (26 of 114 patients) rate of malignancy in an SPT series. In our current study, 3 (13.6 %) of our pediatric patients also developed SPC, which was a comparable rate to previously reported results. The recurrence of SPT was found to be possible at 7 years after surgery in our study cohort. We concluded from this that all such patients should be followed up for more than 10 years. Laparoscopic surgery for a highly malignant tumor is considered controversial. However, SPT of the pancreas is found mainly in young women (possibly due to a role of sex hormones [13, 14]) and has relatively lower malignant potential in children than in adults [15]. Recently, LDP has been considered superior to conventional ODP as it has been shown to result in a more rapid postoperative recovery and a lower incidence of postoperative adhesive ileus and intestinal obstruction, as well as a much better cosmetic outcome [8, 14, 16, 17]. Laparoscopic pancreatic surgery in children has developed slowly due to several issues. A principal cause of this is the limited number of such cases and thus the insufficient opportunities for pediatric surgeons to master the surgical procedures required. Almost all published reports on laparoscopic pancreatic resections are case reports, with a small number of well-designed studies on hyperinsulinemic hypoglycemia in infancy also now published [18–23]. Including the subject cases of our present study, we have performed 25 laparoscopic pancreatic surgeries in children to date for pancreatic lesions including benign and malignant tumors. As with any study of a small number of cases, our current study was limited by the small number of operations for each disorder. We believe, however that pediatric surgeons are not all on a steep learning curve when it comes to laparoscopic pancreatic surgery for the reasons mentioned above. The second cause of a delay in the advancement of laparoscopic pancreatic surgery techniques has been the development of instruments. The small patient size relative to the laparoscopic instruments being used has delayed progress. Adequately advanced laparoscopic instruments, such as vessel-sealing devices, have become obtainable only in the last decade, and are now available in sizes that are appropriate for use in children [20]. At the present time, pediatric surgeons can perform
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laparoscopic and thoracoscopic surgery even in neonates, thanks to the availability of 2 and 3 mm trocars and their matching laparoscopic instruments. We have performed 10 cases of SSLDP (71.4 % of the LDP cases in our current cohort). In various LDP series, the rate of spleen conservation has been reported to range 32–84 % [14, 20]. Since overwhelming postsplenectomy infections are more prevalent in children, many pediatric surgeons pay keen attention to the immunological role of the spleen and have favored an open approach to maximize splenic preservation whenever possible during pancreatectomies for benign to low-grade tumors [24]. The advantages of splenic conservation in distal pancreatic surgery have been demonstrated in several studies, which have reported positive findings such as decreased perioperative complications and a lower incidence of grade B and C pancreatic fistulas [25, 26]. We have successfully maximized vessel preservation in the 10 cases of SSLDP we have performed to date, which include the Warshow technique in 2 cases and a single-port SSLDP in 1 case. Mehta et al. [14] have previously reported an overall complication rate of 46.6 % (50 % in an LDP group and 43.3 % in an ODP group, p = 0.604). In our current study, the overall complication rate was 45.5 % (42.9 % in the LDP group and 50.0 % in ODP group), which is comparable to previous findings. The most common adverse event following LDP in adults is pancreatic fistula, with a reported incidence of 8–30 %, similar to the results from open pancreatectomy series [8, 14, 27]. However, no pediatric study of corresponding size has been reported for comparison. We found pancreatic fistula in six of our current study patients (four in LDP and two in ODP, p = 0.860), but no additional procedure was performed in any of these cases. Four of these patients recovered within 10 days of surgery. Two patients had to fast for 5 days, and their pancreatic fistulas resolved through the maintenance of drainage at 3 weeks after surgery. As expected, our LDP group required a shorter time to recommence oral intake and also a shorter hospital stay. Similar results have been reported in numerous studies [8, 14, 27, 28]. In our present study series, two patients in the ODP group remained in hospital for more than 3 weeks because of a pancreatic fistula and fluid collection. This influenced the longer duration of hospitalization in the ODP group. Nakamura et al. [28] have reported that LDP patients commenced oral intake in less than half the time that was required for ODP patients (2.4 ± 1.1 vs. 6.3 ± 5.0 days, p = 0.002). In our present study cohort, the LDP group had significantly shorter values than the ODP group for the median time to oral intake and to full feeding (Table 2). In our present analyses, the LDP group showed better outcomes than the ODP group in terms of blood loss, duration of surgery, duration of hospitalization, and time to
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oral intake (Table 2). However, direct comparisons between these two surgical approaches have several problems of note. The limitations of this study derived from the relatively small number of patients who were analyzed, the retrospective nature of our analysis, the difference in the period between the approaches and differences in the tumor sizes (Fig. 3). The tumor size in the era of ODP was incidentally bigger than it has been in the more recent laparoscopic era. Tumor size can influence surgery feasibility and perioperative outcomes such as duration of surgery, blood loss, splenic conservation rate, and possibly morbidity and malignant potential. Indeed, tumor size and the malignancy rate have most likely influenced the results of our study, as the main factors that more or less define the level of operative difficulty with a distal pancreatectomy are the underlying pathology and the size of lesion. If the SPT is larger than 10 cm, the LDP may have little benefit. A 12 cm subcostal incision was enough to perform ODP for over 11 cm lesions in our experience, however, the length of the retrieval site of LDP for a 12-cm-sized tumor comes close to 10-cm length. We think that the advantages of a laparoscopic wound are established for pancreatic tumors up to a maximal length of 10 cm. When we performed LDP for 9 cm SPT, we had to make a 7 cm incision to retrieve the tumor and distal pancreas. These were time-consuming operations because we were still on a learning curve for SSLDP. If the tumor is large but the surgeon is highly skilled in laparoscopy, we think that the selection of approach becomes the surgeon’s preference. In our present study, notwithstanding the biases that we have discussed, LDP for SPT in pediatric patients was found to be associated with a higher rate of successful splenic conservation, a shorter duration of hospitalization and a shorter time to oral intake compared to ODP for this tumor type. The postoperative complication rates were also comparable between laparoscopic and open approaches. We conclude from this that if the pancreatic tumor is suitable for LDP due to its size and vessel encasement, laparoscopic approach is a safe and feasible option for the distal pancreatectomy as a treatment of SPT in children. Further randomized studies will be required in the future to establish whether LDP could become the standard treatment option for distal pancreatic solid tumors in children. Conflict of interest The authors declare no competing interests in relation to this study.
References 1. Rebhandl W, Felberbauer FX, Puig S, Paya K, Hochschorner S, Barlan M, Horcher E (2001) Solid-pseudopapillary tumor of the pancreas (Frantz tumor) in children: report of four cases and review of the literature. J Surg Oncol 76:289–296
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Pediatr Surg Int (2014) 30:259–266 17. Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL (2012) Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg 255:1048–1059 18. Carricaburu E, Enezian G, Bonnard A, Berrebi D, Belarbi N, Huot O, Aigrain Y, de Lagausie P (2003) Laparoscopic distal pancreatectomy for Frantz’s tumor in a child. Surg Endosc 17:2028–2031 19. Melotti G, Cavallini A, Butturini G, Piccoli M, Delvecchio A, Salvi C, Pederzoli P (2007) Laparoscopic distal pancreatectomy in children: case report and review of the literature. Ann Surg Oncol 14:1065–1069 20. Mukherjee K, Morrow SE, Yang EY (2010) Laparoscopic distal pancreatectomy in children: four cases and review of the literature. J Laparoendosc Adv Surg Tech A 20:373–377 21. Sokolov YY, Stonogin SV, Donskoy DV, Povarnin OY, Vilesov AV (2009) Laparoscopic pancreatic resections for solid pseudopapillary tumor in children. Eur J Pediatr Surg 19:399–401 22. Yoder SM, Rothenberg S, Tsao K, Wulkan ML, Ponsky TA, St Peter SD, Ostlie DJ, Kane TD (2009) Laparoscopic treatment of pancreatic pseudocysts in children. J Laparoendosc Adv Surg Tech A 19(Suppl 1):S37–S40 23. Al-Shanafey S, Habib Z, AlNassar S (2009) Laparoscopic pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy. J Pediatr Surg 44:134–138. discussion 138 24. Butturini G, Inama M, Malleo G, Manfredi R, Melotti GL, Piccoli M, Perandini S, Pederzoli P, Bassi C (2012) Perioperative and long-term results of laparoscopic spleen-preserving distal pancreatectomy with or without splenic vessels conservation: a retrospective analysis. J Surg Oncol 105:387–392 25. Goh BK, Tan YM, Chung YF, Cheow PC, Ong HS, Chan WH, Chow PK, Soo KC, Wong WK, Ooi LL (2008) Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution. Arch Surg 143:956–965 26. Kleeff J, Diener MK, Z’graggen K, Hinz U, Wagner M, Bachmann J, Zehetner J, Muller MW, Friess H, Buchler MW (2007) Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 245:573–582 27. Fox AM, Pitzul K, Bhojani F, Kaplan M, Moulton CA, Wei AC, McGilvray I, Cleary S, Okrainec A (2012) Comparison of outcomes and costs between laparoscopic distal pancreatectomy and open resection at a single center. Surg Endosc 26:1220–1230 28. Nakamura Y, Uchida E, Aimoto T, Matsumoto S, Yoshida H, Tajiri T (2009) Clinical outcome of laparoscopic distal pancreatectomy. J Hepatobiliary Pancreat Surg 16:35–41
ORIGINAL ARTICLE
Laparoscopic distal pancreatectomy to treat solid pseudopapillary tumors in children: transition from open to laparoscopic approaches in suitable cases Jung-Man Namgoong • Dae-Yeon Kim Seong-Chul Kim • Song-Cheol Kim • Ji-Hee Hwang • Ki-Byung Song
•
Accepted: 9 January 2014 / Published online: 29 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The aim of this study was to evaluate the outcomes of open and laparoscopic distal pancreatectomy (LDP) in the treatment of solid pseudopapillary tumors (SPT) in children. Methods This was a retrospective study of 22 patients under 18 years of age who underwent a distal pancreatectomy for SPT between January 1995 and December 2012. Results Fourteen patients and eight patients underwent LDP and open distal pancreatectomy (ODP), respectively, and 71.4 % of the LDP and 25.0 % of the ODP procedures were spleen-sparing operations. The median duration of surgery in the LDP group was shorter than that in the ODP group [175 (range 120–540) vs. 257 (range 200–305) min, p = 0.024]. There were no differences in postoperative complications. The LDP patients commenced oral intake earlier than the ODP patients [2.0 (range 1.0–7.0) vs. 4.0 (range 3.0–12.0) days, p = 0.010], and had an earlier discharge from hospital [7.0 (range 5.0–20.0) vs. 13.0 (range 7.0–22.0) days, p = 0.009]. Conclusion LDP treatment for SPT in children is associated with a shorter hospitalization and a shorter time to oral intake compared to ODP. LDP is a safe and feasible option for SPT in select pediatric patients.
J.-M. Namgoong D.-Y. Kim (&) S.-C. Kim J.-H. Hwang Division of Pediatric Surgery, Department of Surgery, Asan Medical Center, 88, East Building 10th Floor, Olympic-RO 43-GIL, Songpa-gu, Seoul 138-736, Korea e-mail: [email protected] S.-C. Kim K.-B. Song Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Asan Medical Center, 88, East Building 10th Floor, Olympic-RO 43-GIL, Songpa-gu, Seoul 138-736, Korea
Keywords Solid pseudopapillary tumor Laparoscopic distal pancreatectomy Spleen-sparing laparoscopic pancreatectomy Distal pancreatectomy
Introduction Solid pseudopapillary tumor (SPT) of the pancreas is a rare primary neoplasm of low-grade malignancy that accounts for 1–3 % of primary pancreatic tumors [1]. This tumor was first described as a new entity in 1959 as a Frantz tumor [2]. SPT is an epithelial tumor with solid and cystic macroscopic features; and solid, pseudopapillary, and cystic microscopic features. These are associated with immunohistochemical expression of epithelial, mesenchymal, and endocrine markers. The prognosis after surgical resection of an SPT is quite favorable with an overall survival rate reported to be higher than 90 % [3]. There has been a steady increase in the incidence of SPT over last two decades [4]. Pancreatic tumors are exceedingly rare in children and only a limited number of cases have been reported, which limits our understanding of their clinical course and outcome [5–7]. Surgical procedures to treat pancreatic tumors vary based on the location of the lesion. When these tumors are located in tail or body of the pancreas, a distal pancreatectomy (DP) is the treatment of choice. Recently, however, laparoscopic distal pancreatectomy (LDP) is being more widely used due to increasing evidence that it is a safe and efficient alternative to the open approach [8]. Although LDP has been accepted as the standard surgical procedure for solid tumors on the distal part of the pancreas in adult patients, there have been few studies of LDP in pediatric patients with pancreatic tumors. At our institution, we have experienced a change to the laparoscopic
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approach for various types of pediatric surgery including the pancreas, and the proportion of laparoscopic surgeries has been increasing. SPT is the most common pancreatic tumor in children and we here report our experiences with open distal pancreatectomy (ODP) and LDP surgeries to treat pediatric SPT cases.
Patients and methods A retrospective chart review was conducted for pediatric patients who had undergone distal pancreatectomy for pathologically confirmed SPT at our tertiary medical center, Seoul, Korea between January 1995 and December 2012. Only patients under the age of 18 years old were reviewed. We included data from four different surgeons in our analysis; two performed ODP and LDP and two performed only ODP. Clinical characteristics, surgical and pathologic data, and surgical outcomes were obtained from medical records. SPT had been diagnosed pathologically in our patients based on gross and microscopic appearances of each tumor. In addition, all specimens had been assessed by immunohistochemical staining to confirm the diagnosis, including staining with antibodies against beta-catenin, E-cadherin and synaptophysin. Our data variables included patient demographics such as age and sex, as well as clinical presentation, tumor size, tumor grade, presence of metastasis, tumor markers, type of surgery, complications, hospital stay, time to oral feeding, duration of follow-up, and status at the end of follow-up. After surgery, patients were periodically followed up until death unless they could not be contacted. Operative technique
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ODP All of our patients were operated on under general anesthesia in the supine position. An upper transverse or L-shape incision was made. The lesser sac was entered through the gastrocolic ligament, and the colonic splenic flexure was mobilized. The superior and inferior borders of the pancreas were defined, and the splenic vessels were identified and preserved or ligated depending on whether splenic preservation would be performed. The tail of the pancreas was mobilized and transected. We divided the pancreas parenchyma with staples or knife with suture ligation of the main pancreatic duct. A drainage tube was left in the pancreatic bed and subphrenic space, and the abdomen was closed. LDP For LDP procedures, patients under general anesthesia were placed in the supine position with their legs apart. A pneumoperitoneum at 12 mmHg by CO2 gas was first established in the umbilical region with a Veress needle, and a 10 mm trocar was placed in the upper umbilical region. The location of the trocars is outlined in Fig. 1. After confirming the intraperitoneal cavity by 30° laparoscopy, the main working trocar (10 mm) was inserted at the left side of the patient 5–7 cm away from the epigastric midline. An assisting trocar for the surgeon was inserted at the right upper abdomen for dissection of the upper margin of the pancreas and for adequate traction of pancreatic tissue. An assisting trocar for the assistant was inserted at the left flank of the patient. After accessing the lesser sac, we sutured and fixed the posterior wall of stomach to the anterior wall of the upper abdomen for suitable exposure of the tail of the pancreas (Fig. 2a). When the surgical field of
Transition of surgical approaches Because of the small number of patients in our cohort and the relatively long period of treatment, the selection of surgical approach was related to surgical technique transition. In pediatric patients at our institution, the first laparoscopic surgeries for SPT in June 2007 involved enucleation of the mass on the median pancreas and the first LDP for SPT was performed in July 2008. From the beginning of our use of LDP, we tried to treat all cases of SPT of the distal pancreas using this method. The current treatment policy of our institution for distal masses of the pancreas is to use laparoscopic surgery. Between 1996 and 2000, there were four pediatric cases that received ODP with concomitant splenectomy. Spleen-sparing distal pancreatectomy was first performed for children in November 2001 at our hospital and it is now our institutional policy to save spleen when performing a DP.
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Fig. 1 Location of trocars during LDP. The surgeon uses 12 and 5 mm trocars and the assistant uses left-sided 5 mm trocar for traction
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Fig. 2 Operative procedures of LDP. a Fixation of stomach to the abdominal wall. b Mobilization of lower pancreas and dissection of the splenic vein. c Hanging of pancreas with nylon tape. d Division of the pancreas with an endoscopic stapler
view was good enough and there was no further traction needed, we used only three trocars in the operation without a 5 mm trocar for the assistant. An intraoperative ultrasound was performed to assess the location of the lesion and pancreatic dissection was started using laparoscopic instruments or an ultrasonic shears (Harmonic scalpelTM; Ethicon EndoSurgery, Cincinnati, OH) by mobilizing the lower pancreatic margin and gaining access to the posterior pancreatic surface (Fig. 2b). A nylon tape was placed around the pancreas to lift it and expose the surgical planes (Fig. 2c). The pancreas was divided using an endoscopic stapler (Echelon 60; Ethicon EndoSurgery, Cincinnati, OH; Fig. 2d). The specimen was then retrieved within an endobag (Endocatch, Ethicon EndoSurgery) introduced through a 10 mm umbilical port. We extended the umbilical incision a little further for specimen retrieval to minimize damage to the specimen when pulling it through the tight cavity. Patient follow-up Patients were periodically followed up until death unless they became unavailable for contact. In all patients, computed tomography (CT) scans or sonographies of the abdomen, and serum amylase and lipase were checked in the outpatient clinic at 1 week, 1 month, and 6 months
post-operation, and annually thereafter. Amylase and lipase levels in the Jackson-Pratt (JP) drainage were also routinely examined at 3 and 7 days post-operation. Statistical analysis SPSS software version 18.0 for Windows from SPSS Inc. (Chicago, IL) was used for statistical analysis. The Mann– Whitney U test and Wilcoxon test were used to assess significance in the nonparametric data sets. The significance level was set at a p value of less than 0.05.
Results A total of 48 pediatric patients had received surgery for SPT during the study period at our hospital, 22 of whom underwent distal pancreatectomy. Fourteen (63.6 %) of these 22 patients underwent LDP and the remaining 8 (36.4 %) cases received an ODP for SPT. This patient group comprised 17 females and 5 males with ages ranging from 9–18 years, and a median age of 15 years (Table 1). There was no history of previous upper abdominal surgery in this cohort of 22 patients. The patient characteristics were comparable between the LDP and ODP groups. The most common symptom in the group was abdominal pain
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Table 1 Patient characteristics Total 22 (100)
LDP 14 (100)
ODP 8 (100)
p value
Age (years)
15 (9–18)
15 (9–18)
14 (10–18)
0.837
Sex (f:m)
3.4:1
6:1
1.7:1
0.222
Symptom
19 (86.4)
11 (78.6)
8 (100)
0.169
Abdominal pain
19 (86.4)
11 (78.6)
8 (100)
0.169
Vomiting
1 (4.5)
0 (0)
1 (12.5)
0.186
Diarrhea
1 (4.5)
1 (7.1)
0 (0)
0.450
Back pain
1 (4.5)
0 (0)
1 (12.5)
0.450
Duration of symptom (month)
1 (0–12)
1 (0–12)
4 (0–12)
0.228
Palpable mass
1 (4.5)
0 (0)
1 (12.5)
0.286
Diagnosis by chance
2 (9.1)
2 (14.2)
0 (0)
0.273
History of pancreatitis
1 (4.5)
0 (0)
1 (12.5)
0.186
CA19-9 (normal range 0–37 U/ml)
13.2 (1.7–24.5)
10.5 (1.7–15.6)
18.6 (12.4–24.5)
0.317
[number (n) = 19, 86.4 %]. Other common symptoms included vomiting (n = 1), diarrhea (n = 1) and back pain (n = 1). Three patients were asymptomatic. The two patient groups also had no statistically significant differences in distribution with regard to age, sex, symptoms, or history of pancreatitis (Table 1). The levels of CA19-9 in the LDP and ODP groups were also not significantly different (p = 0.317). The perioperative outcomes in our study subjects are summarized in Table 2. We performed spleen-sparing distal pancreatectomy for 12 (54.5 %) pediatric cases of SPT in our current study period. Among these patients, 10 cases (71.4 % of the LDP) were treated using spleensparing laparoscopic distal pancreatectomy (SSLDP) and 2 cases (25.0 % of the ODP) using spleen-sparing open distal pancreatectomy (SSODP). There was a significant difference in the rate of spleen conservation (p \ 0.001). Because the initial four SPT cases who underwent ODP received a splenectomy, this influenced the overall results for spleen preservation. In the SSLDP cases, we used the Warshow technique [9] in two patients and single-port SSLDP in one patient. There were no additional organ resections in our LDP group, but a single patient in the
Values are presented as the median (range) or number (%)
Table 2 Perioperative outcomes Total 22 (100)
LDP 14 (100)
ODP 8 (100)
p value
Splenic preservation
12 (54.5)
10 (71.4)
2 (25.0)
\0.001
Portal vein resection
1 (4.5)
0 (0)
1 (12.5)
0.186
Duration of surgery (min)
210 (120–540)
175 (120–540)
257 (200–305)
0.024
Intraoperative blood loss (ml)
165 (50–1,040)
140 (50–1,040)
240 (150–620)
0.013
Postoperative complication
13 (59.1)
8 (57.1)
5 (62.5)
0.810
Fluid collection
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Postoperative ileus
1 (4.5)
1 (7.1)
0 (0)
0.450
Splenic infarction
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Chylous drain
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Pancreatic fistulaa
6 (27.3)
4 (28.5)
2 (25.0)
0.860
Grade A
4 (18.2)
3 (21.4)
1 (12.5)
0.610
Grade B
2 (9.1)
1 (7.1)
1 (12.5)
0.681
0 (0)
0 (0)
0 (0)
–
Grade C Dindo–Clavien classification Grade I
10 (45.5)
6 (42.8)
4 (50)
0.757
Grade II
3 (13.6)
2 (14.3)
1 (12.5)
0.909
Grade IIIa/IIIb
0/0
0/0
0/0
–
Duration of hospitalization (day)
9.0 (5.0–22.0)
7.0 (5.0–20.0)
13.0 (7.0–22.0)
0.009
Time to oral intake (day)
2.5 (1.0–12.0)
2.0 (1.0–7.0)
4.0 (3.0–12.0)
0.010
Time to full feeding (day)
5.0 (3.0–15.0)
3.5 (3.0–9.0)
6.5 (5.0–15.0)
0.005
Values are presented as the median (range) or number (%) a
Defined using the international study group of pancreatic fistula (ISGPF) definition
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Table 3 Histopathological outcomes of SPT and prognosis
Tumor size on imaging (cm)
Total 22 (100)
LDP 14 (100)
ODP 8 (100)
p value
5.0 (2.0–15.5)
4.5 (2.0–9.0)
10.7 (2.0–15.5)
0.024
Tumor size on pathology (cm)
4.7 (1.8–15)
4.4 (2.0–7.4)
10.0 (1.8–15.0)
0.060
Distance to resection margin (cm)
1.5 (0.1–5.2)
1.0 (1.8–5.2)
1.9 (0.1–4.0)
0.780
Resection margin involvement
0 (0)
0 (0)
0 (0)
–
Radial margin involvement
2 (9.1)
1 (7.1)
1 (12.5)
0.681
Malignancy
3 (13.6)
0 (0)
3 (37.5)
0.016
2 (9.1) 1 (4.5)
0 (0) 0 (0)
2 (25.0) 1 (12.5)
0.055 0.186
Capsular invasion Peripancreatic soft tissue invasion
1 (4.5)
0 (0)
1 (12.5)
0.186
Follow-up period (month)
Vessel involvement
48 (11–207)
20 (11–92)
128 (13–207)
0.007
Recurrence
1 (4.5)
0 (0)
1 (12.5)
0.186
Mortality
0 (0)
0 (0)
0 (0)
–
Values are presented as the median (range) or number (%)
ODP group underwent portal vein resection and anastomosis due to portal vein invasion. The median duration of the surgery in the LDP group was less than that in the ODP group [175 (range 120–540) vs. 257 (range 200–305) min, p = 0.024]. The durations of surgery in the two cases treated using SSLDP with the Warshow technique were 120 and 135 min, whereas the single-port SSLDP procedure took 420 min. The median intraoperative blood loss was less in the LDP group than in the ODP group [140 (range 50–1,040) vs. 240 (range 150–620) ml, p = 0.013]. There was no difference in postoperative complications, which included fluid collection, postoperative ileus, splenic infarction, chylous drainage, and pancreatic fistula (Table 2). We classified the pancreatic fistula patients according to the definition provided by the International Study Group of Pancreatic Fistula (ISGPF) [10]. The only difference found was that two patients in our ODP group
were discharged with a drainage tube because of chylous drainage and pancreatic fistula, whereas there were no such cases in the LDP group. The drainage tube was removed approximately 3 weeks after the operation and there were no wound complications in either group. There was a statistically significant difference found in the median duration of hospitalization: 7 (range 5–20) days in the LDP group and 13 (range 7–22) days in the ODP group (p = 0.009). With regard to oral intake, we investigated the time to oral intake and to full feeding. The LDP patients commenced oral intake earlier than the ODP patients [2.0 (range 1.0–7.0) vs. 4.0 (range 3.0–12.0) days, p = 0.010], and required a shorter period of time to reach full feeding [3.5 (range 3.0–9.0) vs. 6.5 (range 5.0–15.0) days, p = 0.005]. The median tumor size on pathology was 4.4 (range 2.0–8.4) cm in the LDP group and 10.0 (range 1.8–15.0) cm in the ODP group (p = 0.060) (Table 3). Our initial
Fig. 3 Distribution of tumor size combined with surgical approaches
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Table 4 Characteristics of SPC Patient number
Sex/age
Tumor size
Operation
1 2 3
Proportion of solid mass (%)
Invasion
F/17
13
M/13
12.5
LDP
50
SSLDP
50
M/10
11
SSLDP
20
Capsule
Disease free survival (month)
Follow-up period (month)
Peripancreatic tissue
Vessels
Not exist
Exist
Exist
Recurred
82
205
Exist
Not exist
Not exist
Not recurred
128
128
Exist
Not exist
Not exist
Not recurred
121
121
five ODP cases involved large tumors, therefore the tumor sizes in the ODP group were approximately 2-fold greater than those of the LDP group (Fig. 3). The median distance from the tumor capsule to the resection margin was longer than 1.0 cm in both groups, and there was no case in which the tumor involved the resection margin. The malignant potency of a tumor can result in a radial margin involvement by the tumor. Each of our groups had one such case of radial margin involvement (p = 0.681). These tumors varied from almost entirely cystic to entirely solid. Among the 22 patients in our study cohort, 16 cases had entirely cystic masses, and 6 cases (2:4 in LDP:ODP) had a solid portion of more than 30 %. Histopathologically, the SPT’s in our pediatric cohort showed a combination of solid components of pseudopapillae with fibrovascular stalks and cystic components with degeneration and hemorrhage. Solid pseudopapillary cancer (SPC) was diagnosed based on WHO histological criteria [11] in three of our patients who underwent ODP but there was no SPC among our LDP patients (Table 4). The sizes of the SPC lesions were larger than 11 cm, and two of these patients had a 50 % solid portion in their SPC mass. There was only one case of recurrence at 82 months after surgery. The recurred tumor in this patient was located on the retroperitoneal tissue abutting the portal vein. This patient survived after excision of the recurred mass with portal vein resection and anastomosis, and shows no evidence of recurrence to date. There was no perioperative or long-term mortality in current study.
Discussion SPT is the most common pancreatic tumor but is associated with an excellent surgical outcome. Compared to other pancreatic neoplasms in childhood, the prognosis of SPT patients after complete surgical resection is favorable and tumor recurrence is relatively rare. Rojas et al. [7] have reported a 5-year survival rate of 100 % for patients with SPT which accords with other previously reported 5-year survival rates of 90–97 % [3, 12]. Lam et al. [13] found that 15 % (66 of 452 patients) of reported SPT tumors were malignant, evidenced by the presence of metastases or
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Recurrence
invasion of adjacent structures. In 2011, Kim et al. [4] reported a 22.8 % (26 of 114 patients) rate of malignancy in an SPT series. In our current study, 3 (13.6 %) of our pediatric patients also developed SPC, which was a comparable rate to previously reported results. The recurrence of SPT was found to be possible at 7 years after surgery in our study cohort. We concluded from this that all such patients should be followed up for more than 10 years. Laparoscopic surgery for a highly malignant tumor is considered controversial. However, SPT of the pancreas is found mainly in young women (possibly due to a role of sex hormones [13, 14]) and has relatively lower malignant potential in children than in adults [15]. Recently, LDP has been considered superior to conventional ODP as it has been shown to result in a more rapid postoperative recovery and a lower incidence of postoperative adhesive ileus and intestinal obstruction, as well as a much better cosmetic outcome [8, 14, 16, 17]. Laparoscopic pancreatic surgery in children has developed slowly due to several issues. A principal cause of this is the limited number of such cases and thus the insufficient opportunities for pediatric surgeons to master the surgical procedures required. Almost all published reports on laparoscopic pancreatic resections are case reports, with a small number of well-designed studies on hyperinsulinemic hypoglycemia in infancy also now published [18–23]. Including the subject cases of our present study, we have performed 25 laparoscopic pancreatic surgeries in children to date for pancreatic lesions including benign and malignant tumors. As with any study of a small number of cases, our current study was limited by the small number of operations for each disorder. We believe, however that pediatric surgeons are not all on a steep learning curve when it comes to laparoscopic pancreatic surgery for the reasons mentioned above. The second cause of a delay in the advancement of laparoscopic pancreatic surgery techniques has been the development of instruments. The small patient size relative to the laparoscopic instruments being used has delayed progress. Adequately advanced laparoscopic instruments, such as vessel-sealing devices, have become obtainable only in the last decade, and are now available in sizes that are appropriate for use in children [20]. At the present time, pediatric surgeons can perform
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laparoscopic and thoracoscopic surgery even in neonates, thanks to the availability of 2 and 3 mm trocars and their matching laparoscopic instruments. We have performed 10 cases of SSLDP (71.4 % of the LDP cases in our current cohort). In various LDP series, the rate of spleen conservation has been reported to range 32–84 % [14, 20]. Since overwhelming postsplenectomy infections are more prevalent in children, many pediatric surgeons pay keen attention to the immunological role of the spleen and have favored an open approach to maximize splenic preservation whenever possible during pancreatectomies for benign to low-grade tumors [24]. The advantages of splenic conservation in distal pancreatic surgery have been demonstrated in several studies, which have reported positive findings such as decreased perioperative complications and a lower incidence of grade B and C pancreatic fistulas [25, 26]. We have successfully maximized vessel preservation in the 10 cases of SSLDP we have performed to date, which include the Warshow technique in 2 cases and a single-port SSLDP in 1 case. Mehta et al. [14] have previously reported an overall complication rate of 46.6 % (50 % in an LDP group and 43.3 % in an ODP group, p = 0.604). In our current study, the overall complication rate was 45.5 % (42.9 % in the LDP group and 50.0 % in ODP group), which is comparable to previous findings. The most common adverse event following LDP in adults is pancreatic fistula, with a reported incidence of 8–30 %, similar to the results from open pancreatectomy series [8, 14, 27]. However, no pediatric study of corresponding size has been reported for comparison. We found pancreatic fistula in six of our current study patients (four in LDP and two in ODP, p = 0.860), but no additional procedure was performed in any of these cases. Four of these patients recovered within 10 days of surgery. Two patients had to fast for 5 days, and their pancreatic fistulas resolved through the maintenance of drainage at 3 weeks after surgery. As expected, our LDP group required a shorter time to recommence oral intake and also a shorter hospital stay. Similar results have been reported in numerous studies [8, 14, 27, 28]. In our present study series, two patients in the ODP group remained in hospital for more than 3 weeks because of a pancreatic fistula and fluid collection. This influenced the longer duration of hospitalization in the ODP group. Nakamura et al. [28] have reported that LDP patients commenced oral intake in less than half the time that was required for ODP patients (2.4 ± 1.1 vs. 6.3 ± 5.0 days, p = 0.002). In our present study cohort, the LDP group had significantly shorter values than the ODP group for the median time to oral intake and to full feeding (Table 2). In our present analyses, the LDP group showed better outcomes than the ODP group in terms of blood loss, duration of surgery, duration of hospitalization, and time to
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oral intake (Table 2). However, direct comparisons between these two surgical approaches have several problems of note. The limitations of this study derived from the relatively small number of patients who were analyzed, the retrospective nature of our analysis, the difference in the period between the approaches and differences in the tumor sizes (Fig. 3). The tumor size in the era of ODP was incidentally bigger than it has been in the more recent laparoscopic era. Tumor size can influence surgery feasibility and perioperative outcomes such as duration of surgery, blood loss, splenic conservation rate, and possibly morbidity and malignant potential. Indeed, tumor size and the malignancy rate have most likely influenced the results of our study, as the main factors that more or less define the level of operative difficulty with a distal pancreatectomy are the underlying pathology and the size of lesion. If the SPT is larger than 10 cm, the LDP may have little benefit. A 12 cm subcostal incision was enough to perform ODP for over 11 cm lesions in our experience, however, the length of the retrieval site of LDP for a 12-cm-sized tumor comes close to 10-cm length. We think that the advantages of a laparoscopic wound are established for pancreatic tumors up to a maximal length of 10 cm. When we performed LDP for 9 cm SPT, we had to make a 7 cm incision to retrieve the tumor and distal pancreas. These were time-consuming operations because we were still on a learning curve for SSLDP. If the tumor is large but the surgeon is highly skilled in laparoscopy, we think that the selection of approach becomes the surgeon’s preference. In our present study, notwithstanding the biases that we have discussed, LDP for SPT in pediatric patients was found to be associated with a higher rate of successful splenic conservation, a shorter duration of hospitalization and a shorter time to oral intake compared to ODP for this tumor type. The postoperative complication rates were also comparable between laparoscopic and open approaches. We conclude from this that if the pancreatic tumor is suitable for LDP due to its size and vessel encasement, laparoscopic approach is a safe and feasible option for the distal pancreatectomy as a treatment of SPT in children. Further randomized studies will be required in the future to establish whether LDP could become the standard treatment option for distal pancreatic solid tumors in children. Conflict of interest The authors declare no competing interests in relation to this study.
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