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Medial pancreatectomy is indicated for resection of benign or low-malignant tumors located in the middle part of the pancreas and not treatable by enucleation. This unfrequent procedure, the alternative of which is mainly left pancreatectomy, aims to preserve at the most pancreatic function.
Nesidioblastosis is a rare condition that requires near-total pancreatectomy in a minority of cases. Splenic vein thrombosis resulting in gastric variceal hemorrhage has not been a previously reported complication from 95% pancreatectomy for this indication. A case is presented and the management of this unusual complication discussed.
The infrequent occurrence of benign epithelial cysts of the pancreas is the reason why little is known regarding their clinical relevance and surgical management. We report the case of a 38-year-old woman with a benign epithelial cyst that was resected by the rarely performed central pancreatectomy. The presentation, evaluation, and differences between this and other cystic lesions of the pancreas are discussed. The benefits of central pancreatectomy for this benign lesion are reviewed.
Recently, simultaneous hepatectomy and pancreatoduodenectomy has been performed for the treatment of some biliary tract cancers in Japan. Postoperative hepatic failure is a common and potentially fatal complication. The aim of this study was to examine the reduction in the rate of liver regeneration after 70% hepatectomy (Hx) alone or in combination with 70% pancreatectomy (HPx). Male Sprague-Dawley rats underwent hepatectomy or simultaneous hepatectomy and pancreatectomy. The ratio of liver weight to body weight, the labeling index of hepatocytes in vivo, and DNA synthesis of the hepatocytes and/or Kupffer cells in primary culture were analyzed. The ratio of liver weight to body weight and the labeling index in HPx rat were found to be significantly lower than those values in Hx rats. There were no significant differences in plasma alanine aminotransferase levels between the two groups. The inhibitory effect on DNA synthesis was observed with coculture of hepatocytes and Kupffer cells when the portal plasma obtained 1 hour after operation was added. We further observed that the conditioned medium of Kupffer cells stimulated by the addition of the portal plasma that was obtained 1 hour after HPx inhibited DNA synthesis of hepatocytes. This effect was abolished after incubation at 56 degrees C for 30 minutes. These results strongly suggest the existence of a growth inhibitory factor in portal plasma after HPx. This heat-labile growth inhibitory factor was released from Kupffer cells and would appear to act on hepatocytes in a paracrine manner.
The Otsuka Long-Evans Tokushima Fatty (OLETF) rat is an animal model for obese-type non-insulin-dependent diabetes mellitus (NIDDM) in humans. The OLETF rat exhibits sustained hyperglycaemia after partial pancreatectomy, while the normal control rat does not. This difference is thought to be genetically determined and to be caused by impairment of beta-cell regrowth, a possible event involved in the pathogenesis of NIDDM. Our investigation was designed to identify quantitative trait loci (QTL) responsible for post-pancreatectomy hyperglycaemia by performing a genome-wide scan in an F2 intercross obtained by mating the OLETF and Fischer-344 (F344) rats. We have identified three possible QTL on rat chromosomes (Chrs) 3, 14 and 19 that account for a total of approximately 75% of the genetic variance in the F2. For the QTL on Chr 14, the OLETF allele corresponds with increased glucose levels, as expected. Surprisingly, for the QTL on Chr 19, the F344 allele corresponds with increased glucose levels. The Chr 3 QTL exhibits heterosis, heterozygotes showing significantly higher glucose levels than OLETF or F344 homozygotes. We also found evidence for interaction (epistasis) between the QTL on Chrs 14 and 19.
BACKGROUND: Resection of the non-fibrotic pancreas is prone to postoperative pancreatic fistula because of well preserved exocrine secretions and easily crushed soft parenchyma. The purpose of this study was to evaluate ultrasonic dissection for division of the non-fibrotic pancreas in distal pancreatectomy. METHODS: All pancreata included in this study were soft on direct palpation and their main ducts had no dilatation, at least proximally from the transection line. Fifty-eight patients with gastric cancer or pancreatic disease were randomly assigned to the two groups. In the ultrasonic dissection (UD) group (n = 27), all pancreatic ducts were identified and ligated securely. The stump was left open without parenchymal suturing. In the conventional (CV) group (n = 31), the pancreas was cut with a knife and the stump was oversewn in mattress fashion. The main pancreatic duct was ligated in all patients in both groups. Pancreatic fistula was defined as a pancreatic fluid discharge for more than 7 days after operation diagnosed according to amylase concentration in the drainage fluid. RESULTS: In the UD group, approximately 20-30 tubes including a mean(s.d.) 5.2(0.8) (range 4-6) pancreatic ducts were skeletonized and ligated per patient. There were nine pancreatic fistulas (16 per cent); one in the UD group and eight in the CV group (P = 0.020). CONCLUSION: In distal pancreatectomy for the non-fibrotic pancreas, ultrasonic dissection without suture closure of the stump reduced the incidence of pancreatic fistula compared with conventional division and suture, in this randomized trial.
Hyperinsulinism is a rare cause of severe persistent hypoglycaemia in the neonatal period. It is associated with a high incidence of brain damage and mental retardation as a consequence of repeated episodes of hypoglycaemia. Subtotal to near total pancreatectomy is indicated as a matter of urgency to decrease the amount of circulating insulin. The perioperative management of a 45-day-old, 5 kg male infant with hyperinsulinaemia (nesidioblastosis) is described. He had a history of generalized tonic clonic seizures 4 h after birth. The blood sugar at that time was 0.66 mmol x l(-1) (12 mg x dl(-1)) and serum calcium was 2.4 mmol x l(-1) (9.82 mg x dl(-1)). The insulin : glucose ratio was 1.6 (normal < 0.4). Occasional episodes of hypoglycaemia persisted in spite of medical line of management with intravenous dextrose 12%, 2 h gastric tube feeds, hydrocortisone (5 mg x kg(-1) x day(-1) i.v.) and oral diazoxide 10 mg x kg(-1), 8 h for 3 weeks. A CT scan and USG did not reveal any abnormality of the pancreas. However, the EEG varied from one of abnormally low amplitude to an isoelectric record. Renal, liver function tests and coagulation profile were normal. The patient was scheduled for elective subtotal pancreatectomy. The anaesthetic management with emphasis on glucose homeostasis and fluid balance is discussed.
Insulinoma is a rare, almost always benign endocrine tumor of the pancreas, clinically characterized by hyperinsulinemic, hypoglycemic episodes. Surgical excision is the therapy of choice, which may lead to postpancreatectomy diabetes mellitus in the case of extensive pancreatic resection. We present the cases and the metabolic follow up of two patients, 81 and 73 years old, with insulinoma localized close to the main duct in the pancreatic neck. Both patients underwent an 80% left pancreatectomy, avoiding a pancreatico-enteric anastomosis. In order to prevent postpancreatectomy diabetes, the islets from the tumor-free part of the resected pancreas were isolated and injected via a right colic vein into the portal system. After a follow up of 6 and 3 years respectively, both patients remained insulin-independent without any dietary restrictions. Fasting and glucagon-stimulated C-peptide-levels and glycosylated hemoglobin remained within normal range. There were no signs of recurrent insulinoma. Liver biopsy performed in one patient at 1 year after autotransplantation, showed intact, insulin-producing islets within the portal spaces. In conclusion, autologous islet transplantation can preserve the insulin secretory reserve after extended left pancreatectomy for the treatment of benign tumors in the pancreatic neck.
Four children are presented with Class II pancreas injury as a result of a motor vehicle accident. The first child was taken to the operating room promptly due to concomitant perforation of the hollow viscus (gastric rupture) and underwent successful spleen-sparing distal pancreatectomy with preservation of the splenic artery and vein. The next three cases with isolated abdominal symptoms of pancreatic injury generally experienced a delay of one day before the onset of abdominal symptoms and positive diagnostic investigation results and were managed non-operatively (NOM) on admission; they were then treated surgically due to developing peritonitis after 24, 36, and 38 hours, respectively. The same type of operation, even though delayed and technically much more demanding, was performed, but this was not an obstacle to our efforts to preserve the spleen and its full circulation, in order to provide full immunological and haematological support during the expected prolonged postoperative course. We did not lose any of the children. A reintervention was needed in two children due to the retention of necrotic tissue and intraabdominal abscess. The serum amylase level in all cases remained above normal. We believe that a spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed, even in delayed operations, and should be indicated for the surgical management.
A 37-year-old woman with a history of syncope was hospitalized with a diagnosis of hypoglycemia due to insulinoma. Computed tomography (CT) and magnetic resonance imaging revealed an enhanced solid mass, 1.5 cm in diameter, at the tail of the pancreas. Angiography via the splenic artery revealed a hypervascular mass. Because the tumor was located deep in the pancreatic parenchyma, laparoscopic distal pancreatectomy was performed. The pancreas was exposed by dissecting the greater omentum, and the tumor was located by intraoperative ultrasonography. After division of the splenic artery, the pancreas, main pancreatic duct, and splenic vein were transected with an endoscopic linear stapler. The pancreatic pedicle was divided at the splenic hilum to preserve the spleen. The postoperative course was uneventful except for the appearance of splenic infarction on a CT scan 2 weeks after surgery but without any overt symptoms. Spleen-preserving laparoscopic distal pancreatectomy by division of splenic vessels is a feasible treatment option for benign pancreatic disease.
Eighteen patients are reported who have had a regional pancreatectomy. The pancreatic segment of portal vein was excised with en bloc total pancreatectomy and regional lymph node dissection in all 18. Venous repair was by end-to-end anastomosis without a graft. Five of the 18 also had various arterial resections and reconstructions. Sixteen of the 18 had been explored and deemed nonresectable elsewhere. This operation has doubled the resectability rate in this institution. The 30-day operative mortality rate was 16.6%. Acurarial survival is 62% at one year compared with 36% one year survival rate for patients undergoing pancreaticoduodenectomy for less advanced cancer in previous years. A more valid comparison would be between those who had a palliative procedure since most patients in the present series were initially considered unresectable. One year survival for these patients was 22%. The quality of life was good for most patients.
Sixty-five patients operated with total pancreatectomy were reviewed with respect to factors influencing operative mortality and morbidity, long-term survival, and metabolic sequelae. The diagnoses were pancreatic cancer in 58 patients, periampullary cancer in three, cancer of the bile duct in two and leiomyosarcoma of the duodenum and cystadenocarcinoma of the pancreas in one patient, respectively. In nine of the 58 cases with cancer of the caput, the histological examination revealed multicentricity of the tumor. In 44%, there were signs of degeneration and fibrosis in the distal part of the gland. Hospital mortality was 23% for the entire series. After 1970 the hospital mortality was 17%, and among patients operated by senior surgeons especially trained in pancreatic surgery, the hospital mortality was 12% during the whole period. The peroperative bilirubin levels seemed to influence survival time. Among 24 patients operated before 1975 in whom the operating surgeon judged the operation as radical, a five year survival of 21% was recorded. In patients without detectable lymph node metastases, the mean survival time was 25 months. The postoperative exocrine insufficiency and diabetes were possible to control. A blood sugar level above 10 micromol/l was found to significantly decrease the frequency of hypoglycemic attacks. Total pancreatectomy appears to be the surgical procedure preferred when radical treatment is selected.
The metabolic consequences and the clinical results of total pancreatectomy for end-stage chronic pancreatitis are detailed. This experience, accumulated between the years 1952 and 1976, adds 26 cases to the world's literature, which now contains 53 cases reported singly or in small series. The patients were selected on the basis of far-advanced, incapacitating disease in three patients and the failure of 62 previous related operations in 23 patients. Total pancreatectomy was performed with a zero hospital mortality but with serious inhospital morbidity. After discharge, 24 patients required 55 hospital readmissions and 18 related surgical operations; 12 patients have died, five of unrelated causes. Of 14 living patients, five consider themselves to be in good to excellent condition, six in fair condition, and three in poor condition. Twelve thought they were improved over their preoperative state. Our estimate of the result in living patients was similar. In those 12 who died, only four had satisfactory results. The results are also evaluated relative to level of activity, presence of abdominal pain, use of narcotics, weight, alcohol consumption, and the efficiency of endocrine and exocrine replacement. In general, the procedure is effective for relief or amelioration of pain, but the patients' personalities preclude complete adaptation to the apancreatic state rehabilitation. A failure to thrive is the common denominator.
The increasing awareness among surgeons of overwhelming postsplenectomy sepsis has led to new and innovative procedures to save the spleen. In pancreatic transection injuries (Type II)26 the classical treatment has been distal pancreatectomy and splenectomy. The opportunity to treat several patients with pancreatic transections sustained during blunt abdominal trauma lead to the review of the literature on the subject. Particular attention was paid to treatment of these injuries during distal pancreatectomy with splenic salvage, appropriate drainage, and hyperalimentation. Associated complications were likewise investigated and reviewed.
Regional pancreatectomy refers to an en bloc removal of a tumor in or adjacent to the pancreas with an adequate soft tissue margin and with its regional lymphatic drainage. The pancreatic segment of portal vein is part of the en bloc resection with venous reconstruction by end-to-end anastomosis without a graft. This operation, called a Type I regional pancreatectomy, may utilize either a total or subtotal removal of the pancreas. Localized arterial involvement by a neoplasm necessitates adding a segmental resection of the artery with vascular reconstruction, a Type II procedure. Sixty-one patients have had this procedure from 1972 through 1982. They are a subset of the 270 patients with cancer of the pancreas, ampullary and periampullary regions, duodenum, or terminal portion of the common bile duct who were treated by the author during this period. The 61 consist of 35 patients who had an infiltrating duct adenocarcinoma of the pancreas and 21 who had other kinds of malignant tumors. In addition, four were classified as having pancreatitis and a fifth patient had a pseudolymphoma. The resectability rate is about 30%. The present operative mortality rate is 8%. Approximately one-third of the patients are alive; 43% of the 21 patients with malignant tumors other than infiltrating duct adenocarcinoma of the pancreas are alive with a median survival time of 40 months (3-92 months). Forty-three per cent were Stage I but more than half were T3 or T4 lesions. Twenty-five per cent of patients with Stages II or III are alive. Twenty per cent of patients with infiltrating duct carcinoma of the pancreas are presently alive, 28% died of recurrent disease, and 26% died of other causes; more than 90% of these patients had advanced stage disease (Stage II or III).
Surgical resection provides the only potential cure for pancreatic cancer, yet resection in patients 70 years of age and older remains controversial because of presumed increased morbidity and mortality. Our aim was to determine the operative results in patients 70 years of age or older undergoing potentially curative radical pancreatic resection for pancreatic cancer from 1982 through 1987. Of 206 consecutive patients explored for potential resection, 42 patients (mean age, 75 years) had potentially curative procedures, including radical pancreaticoduodenectomy in 23 patients, total pancreatectomy in 8 patients, and distal pancreatectomy in 11 patients. Ductal adenocarcinoma was the most frequently encountered neoplasm (69%), but cystadenocarcinoma and islet cell carcinoma accounted for 12% and 7%, respectively. The overall operative mortality rate was 9%, while surgical morbidity was 28%, and medical morbidity was 12%. Overall median survival was 19 months, and 5-year survival was 4%. Despite the low overall incidence of resectability and postoperative cure rate for pancreatic carcinoma, exploration for potential curative resection should not necessarily be withheld for healthy, selected patients who are older than 70 years. Morbidity and mortality rates, although slightly greater than for patients who are older than 70 years, are acceptable.
A case of distal pancreatectomy with splenic preservation is presented. In ten cadaver dissections of distal pancreas, an average of 22.1 tributaries of the splenic vein and 7.6 branches of the splenic artery were demonstrated. Anatomic considerations for splenic salvage during distal pancreatectomy are reviewed. Knowledge of the smaller pancreatic branches of the splenic vasculature is important in this surgical repair.
The regenerative potential of the adult rat pancreas following a 50% pancreatectomy was investigated. Blood glucose values and body weight were unchanged by the procedure. The mitotic index (MI) of alpha, beta, and exocrine cells was examined in formalin-fixed sections of the pancreas stained for hormones and 5-bromo-2'-deoxyuridine (BrDU) after treating the animals with 2.5 mg/kg colchicine and/or 50 mg/kg BrDU prior to sacrifice. The MI was unchanged within the control group. For pancreatectomized versus control animals, in beta cells after 5 days the MI was 0.84% versus 0.41% (p less than 0.05), while 7 days postoperatively it was 1.04% versus 0.57% (p less than 0.01); in alpha cells, the MI was 0.32% versus 0.17% (p less than 0.05) at 5 days and 0.47% versus 0.24% (p less than 0.05) at 7 days. The MI of exocrine cells rose transiently on day 3 postoperatively to 0.74% in the pancreatectomized group but remained low at 0.15% (p less than 0.01) in the control group. The mean ratio of BrDU + ve beta cells was 1.19% in the pancreatectomy group and 0.45% in the control group on day 5 postoperatively (p = 0.01). A highly significant (r = 0.97; p less than 0.001) correlation existed between BrDU + ve and mitotic cells. There was no difference between the two groups in the area occupied by insulin-positive cells in pancreatic sections, nor in the number of beta cells per islet.(ABSTRACT TRUNCATED AT 250 WORDS)