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PubMed2002

Segmental pancreatectomy for benign tumor of the pancreas.

BACKGROUND: Enucleation of pancreatic tumor has the potential risk for damage of the main pancreatic duct. Benign tumors located in the neck or body of the pancreas are usually removed by left (spleno-) pancreatectomy or pancreatoduodenectomy. Standard pancreatic resection may result in serious loss of normal pancreatic parenchyme and impairment of pancreatic function. The aim of this study is to evaluate the results of segmental pancreatectomy, a limited resection of the midportion of the pancreas, in patients with benign tumor of the pancreas. METHODS: Four patients with benign tumor over pancreatic neck or body were treated with segmental pancreatectomy after pathological confirmation by frozen section. The proximal stump was closed and distal stump was anastomosed with a Roux-en-Y pancreaticojejunostomy. Clinical evaluation, routine blood sugar, stool fat examination and abdominal ultrasonography were performed for their follow up. RESULTS: Segmental pancreatectomy was satisfactory in these four patients. The pathologic examinations revealed serous cystadenoma. No mortality was noted. Minor pancreatic fistula was found in three of them and was treated conservatively. No obvious exocrine insufficiency was noticed. One patient had diabetes mellitus before operation, which was persisted postoperatively. CONCLUSIONS: Segmental pancreatectomy is a safe and effective alternative to major pancreatic resection in selected patients with benign tumor of the pancreas. This procedure has a surgical risk similar to that of the standard operation, but preserves more pancreatic tissues, which may prevent pancreatic function impairment.

Adult↗
PubMedDate not supplied

Spleen-preserving distal pancreatectomy with preservation of the splenic artery and vein for intraductal papillary-mucinous tumor (IPMT): three interesting cases.

Preservation of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first trial and success with spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis, this procedure has been performed more frequently. Three patients with intraductal papillary-mucinous tumor underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. In this procedure, the splenic vein is identified behind the pancreas and the connective tissue membrane is cut longitudinally above the splenic vein. An important point is to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen. In one patient with intraductal papillary-mucinous tumor in the body of the pancreas who had undergone distal gastrectomy for duodenal ulcer 32 years previously, residual proximal gastrectomy could be avoided with this procedure. In this case, the histological diagnosis was a pseudocyst, and epithelial dysplasia was found in other pancreatic ductuli. In another case, epithelia were borderline between hyperplasia and adenoma. In both of these cases, the histological diagnosis was different from the preoperative diagnosis. Even with advances in imaging techniques, diagnosis of a cystic lesion of the pancreas is still very difficult. Ordinary distal pancreatectomy with splenectomy would have been oversurgery in these two cases, which could be avoided using our procedure. Severe complications were not found in any of the three cases and the postoperative course was uneventful. The patients have been followed as outpatients without any recurrence. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is easy and safe, and should be performed for some patients with intraductal papillary mucinous tumor of the pancreas.

Adenocarcinoma, Mucinous↗
PubMedDate not supplied

How necessary is vagotomy after pancreaticoduodenectomy and total pancreatectomy.

BACKGROUND/AIMS: Gastrectomy with gastrojejunostomy is a fundamental step used for the restoration of the alimentary tract after pancreaticoduodenectomy or total pancreatectomy. Anastomotic ulcers occurring after pancreaticoduodenectomy, is a well known problem. The aim of our study is to investigate the incidence of anastomotic ulcer after pancreaticoduodenectomy or total pancreatectomy and to elucidate whether vagotomy is necessary. METHODOLOGY: In this study we reviewed the medical records of 94 patients who underwent pancreaticoduodenectomy or total pancreatectomy without vagotomy and we report the results after systemic follow-up 3-14 years, emphasizing the cases in which anastomotic ulcer is jeopardized. RESULTS: A total of 78 Whipple procedures and 16 total pancreatectomies without vagotomy were performed. The overall incidence of anastomotic ulceration following pancreatectomy was 11.7%. In our series the symptoms and complications associated with anastomotic ulceration were pain in 6 patients, bleeding in 4 patients and free perforation in one patient. Six patients needed a reoperation, the 4 patients with bleeding that underwent truncal vagotomy, the patient with free perforation in which oversew and bilateral vagotomy was performed and a patient with refractory pain who underwent a bilateral vagotomy. Among the 11 patients with anastomotic ulcer, the overall postoperative mortality rate was 27.3%. CONCLUSIONS: It seems reasonable to perform bilateral truncal vagotomy only in patients with a history of peptic ulceration and for patients with favorable prognosis and potential for long survival.

Adult↗
PubMed1983

Subtotal pancreatectomy in the chicken: evidence of a diabetic state and effect on the somatostatin cells of the digestive tract.

The effect of subtotal pancreatectomy on the regulation of plasma glucose was studied in the chicken. The eventual appearance of an extra-pancreatic source of insulin and the effect of pancreatectomy on somatostatin containing cells of the intestine were also investigated. Over a period of 3-5 weeks, pancreatectomy decreased body weight gain, greatly impaired glucose tolerance and hindered the regulation of plasma glucose levels after a meal. A large deficit in the insulin release induced by a meal was noticed after pancreatectomy. Therefore, in the fed chicken, pancreatectomy results in the typical signs of diabetes. No extrapancreatic source of insulin could be found either by radioimmunoassay of extracts of proventriculus, gizzard, gizzard-duodenum junction and duodenum from controls or depancreatized chickens, or by immunohistological studies in the same organs plus pancreatic ducts. No glucagon producing cells could be found by immunohistological studies in the gastrointestinal tract. The size of the somatostatin cells from the gizzard-duodenum junction was negatively related to the magnitude of the glucose-induced insulin release, which suggests an increase in somatostatin cell activity in true insulin-deficient depancreatized chickens as observed in insulin deficient diabetic mammals.

Animals↗
PubMed1984

[Regional pancreatectomy in the treatment of pancreatic adenocarcinoma. Apropos of 41 cases].

Out of 88 carcinomas of the pancreas observed from 1973 through 1981, 41 regional total (19 patients) or subtotal (22 patients) pancreatectomies were performed. Routine histological examination of 12 lymph nodes areas and pancreatic peritoneal involvement were used to determine three stages: 1) stage I without metastatic lymph nodes involvement (18 patients), 2) stage II with peripancreatic metastatic lymph node involvement (14 patients), 3) stage III with pedicular and/or retroperitoneal metastatic lymph node and/or peritoneal involvement. Six patients died in the postoperative period (14.6 p. 100). Complications were infections (11 patients), pancreatic anastomotic leakage after subtotal pancreatectomy (11 patients), digestive bleeding (8 patients). No patients need insulin two months after subtotal pancreatectomy. After total pancreatectomy diabetes mellitus was controlled by 0.30 UI/kg/day of insulin (mean). The three years survival was 38 p. 100 (Kaplan-Meier). In the author's experience, regional pancreatectomy seems to be the best surgical procedure in patients with carcinoma of the pancreas except in patients with poor general condition, age over 75, and stage III.

Adenocarcinoma↗
PubMed1978

Absence of true pancreatic glucagon but persistence of circulating pancreatic glucagon-like immunoreactivity after pancreatectomy in pigs.

The possible existence of circulating pancreatic type glucagon (immunoreactive glucagon as measured with a highly specific antibody) of extrapancreatic origin was investigated in 20-25 kg pigs after pancreatectomy. In intact conscious animals intravenous arginine infusions stimulated glucagon as well as insulin secretion, while blood glucose remained unaffected. Two weeks after pancreatectomy, and 48 hours after insulin withdrawal, basal glucagon and glucose concentrations were elevated (from 22 +/- 3.7 to 55 +/- 9.5 pmol/1 and 5.8 +/- 0.4 to 16.2 +/- 2.0 mmol/l, respectively), (mean +/- SEM), while insulin concentrations were either undetectable or very low. After pancreatectomy, however, glucagon concentrations no longer increased during arginine infusion. Gut type glucagon levels were not affected by pancreatectomy, and did not change during arginine infusion. When examined by gel filtration, plasma from unoperated pigs contained two components of pancreatic type glucagon, one coeluting with the glucagon marker, the other eluting earlier, probably reflecting larger molecular size. After pancreatectomy only this larger component was found in the plasma. The role of this component in the control of blood glucose is unknown.

Animals↗
PubMed1996

Completion pancreatectomy for surgical complications after pancreaticoduodenectomy.

Significant complications continue to occur in a minority of patients undergoing pancreaticoduodenectomy; these frequently have fatal consequences. Analysis of 458 patients undergoing the Whipple procedure in this institution from 1972 to 1994 revealed that 16 patients with malignant periampullary tumours (ampullary, eight; pancreatic, seven; bile duct, one), and one patient with chronic pancreatitis subsequently required completion pancreatectomy. Postoperative difficulties after pancreaticoduodenectomy and indications for re-exploration were multifactorial: leakage (n = 8), pancreatitis (n = 7), bleeding (n = 1), and a delayed report of cancer at the margin of the pancreatic transection (n = 1). Completion pancreatectomy was often difficult (mean operating time 2.7 h, mean estimated blood loss 1897 ml). There was considerable significant postoperative morbidity (41 per cent) and mortality (24 per cent) after completion pancreatectomy. Patients who survived completion pancreatectomy lived a mean of nearly 4 years (range 4 months to 9.7 years, median 2.6 years). Tumour recurrence led to death in ten of 13 patients. Three patients remain alive and free of recurrence each more than 8 years after resection. Re-exploration and subsequent completion pancreatectomy after pancreaticoduodenectomy is rarely necessary, but if clinical manifestations occur secondary to failure of the pancreaticojejunostomy, early surgical intervention may maximize survival.

Adenocarcinoma↗
PubMed2003

Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy.

HYPOTHESIS: Advances in specialized centers for pancreatic diseases have improved surgical morbidity and outcome. In the past, postoperative local complications (pancreatic fistulae) were causing most of the mortality. Now, more patients experience postoperative complications related to their comorbidity. DESIGN: To report a prospective audit of a single center's experience with pancreatic resection during an 8-year period. SETTING: Tertiary referral center focused on pancreatic diseases. PATIENTS AND INTERVENTIONS: Six hundred seventeen consecutive patients underwent pancreatectomy between November 1, 1993, and August 31, 2001. The series included 468 pancreatic head resections (76%), 25 total pancreatectomies (4%), 88 left-sided resections (14%), and 36 others (6%). MAIN OUTCOME MEASURES: Morbidity after pancreatic resection. RESULTS: Postoperative in-hospital mortality was 1.6%, and the additional operation rate was 4.1%. Four patients died of surgical complications and 6 of systemic complications. Systemic morbidity was 18% and consisted primarily of cardiopulmonary complications (13%). The most frequent postoperative complication was delayed gastric emptying (14%), which caused significant prolongation of the hospital stay. No patients died of a postoperative pancreatic fistula, which occurred in 3.2%, and no completion pancreatectomies were necessary. CONCLUSIONS: Pancreatic resections can be performed with considerable safety and a low rate of pancreatic complications. More patients die of systemic complications than in the past, which increases the demand for precise preoperative patient selection. Completion pancreatectomy should no longer be considered in patients with a pancreatic fistula.

Adolescent↗
PubMed1989

Radical pancreatectomy for ductal cell carcinoma of the head of the pancreas.

Seventy-four patients were treated with a radical or a nonradical pancreatectomy for ductal cell carcinoma of the head of the pancreas. Their survival rates and the selection of the operative procedure were evaluated. In 32 patients, a radical pancreatectomy was attempted where there was sufficient clearance of regional or juxta-regional lymph nodes beyond the group of suspected metastatic nodes, as well as a resection of a greater margin of soft tissue around the pancreas. These patients' cumulative 5-year survival rate was 33.4%. In 14 Stage I or Stage II patients, the cumulative 5-year survival rate was 46.4%. In 18 Stage III or Stage IV patients, the cumulative 5-year survival rate was 20.7%. For 42 patients treated with a nonradical pancreatectomy with the dissection of lymph nodes adjacent to the pancreas or of regional lymph nodes but with insufficient clearance of the soft tissue around the pancreas, the cumulative 2-year and 3-year survival rates were 5.4% and 0%, respectively. In seven patients with Stage II carcinoma, the survival rate was 16.7% after 2 years and 0% after three years. In 35 Stage III or Stage IV patients, the survival rate was 3.2% after 2 years and 0% after 3 years. Thus, the survival rates were significantly higher in patients treated with radical operation than in patients who had nonradical operation. These results indicate that a radical pancreatectomy with sufficient lymph node clearance with the surrounding connective tissue around the pancreas is indispensable to cure patients with ductal cell carcinoma of the pancreas.

Adult↗
PubMed1991

Distal pancreatectomy with and without splenectomy.

Splenectomy is performed routinely during distal pancreatectomy, yet the spleen has an important role in host defence and can often be preserved. A personal series of 100 distal pancreatectomies undertaken for pancreatic disease between 1978 and 1990 included 23 patients undergoing total pancreatic resection. The remaining 77 patients, who form the basis of the present report, underwent primary distal pancreatectomy and comprised 34 women and 43 men with a median age of 41 years (range 17-78 years). Conventional distal pancreatectomy including splenectomy was performed in 42 patients (55 per cent) for chronic pancreatitis (34 patients), pancreatic neoplasia (six patients), suspected pancreatitis (one patient) or pancreatitic trauma (one patient). Conservative resection with splenic preservation was performed in 35 patients (45 per cent) for chronic pancreatitis (12 patients), suspected pancreatitis (13 patients, including eight patients with pancreas divisum), pancreatic neoplasia (six patients), recurrent acute pancreatitis (two patients) and pancreatic trauma (two patients). There were no postoperative deaths in either group. Early complications followed conventional resection in 10 patients (24 per cent) and conservative resection in seven patients (20 per cent). In five patients the splenic vessels were ligated away from the splenic hilum and the spleen was left in situ, but subsequent isotope scans and haematological indices showed no hyposplenism. The spleen can safely be preserved in many distal pancreatic resections, including those for inflammatory disease, and we now prefer a retrograde technique for dissecting the pancreas off the splenic vessels.

Adolescent↗
PubMed2003

Duodenum- and spleen-preserving total pancreatectomy for end-stage chronic pancreatitis.

BACKGROUND: Total pancreatectomy may be warranted in patients with advanced chronic pancreatitis in whom partial resection has failed and in those with end-stage pancreatic function. A new operation, duodenum- and spleen-preserving total pancreatectomy, is described. METHODS: Nineteen consecutive patients with chronic pancreatitis who had duodenum- and spleen-preserving total pancreatectomy were studied. RESULTS: There were 15 men and four women with a median age of 40 (range 29-64) years. The aetiology was alcohol misuse in nine, hereditary pancreatitis in five and idiopathic in five patients. All patients had chronic intractable abdominal pain. Six had undergone pancreatic surgery previously and one had had multiple coeliac plexus blocks. There were ten postoperative complications in five patients, and one hospital death. The median hospital stay was 25 (range 10-84) days. There was a reduction in pain (P < 0.001) and analgesic use (P < 0.001) after surgery, and weight gain was noted at 12 and 24 months (P < 0.001). Nine patients required readmission to hospital, four because of surgical complications: adhesional obstruction in one, biliary stricture in two and duodenal obstruction in one. In the other five patients (four of whom had long-standing pre-existing diabetes mellitus) readmission was for better control of pain (three patients), diabetes mellitus (two), and diabetes-associated diarrhoea (two) or gastropathy (one). CONCLUSION: Duodenum- and spleen-preserving total pancreatectomy has a role in selected patients with medically intractable pain from chronic pancreatitis.

Abdominal Pain↗
PubMed1985

Hyperalaninaemia is an early feature of diabetes secondary to total pancreatectomy.

High levels of gluconeogenic precursors have been reported in patients with long-term diabetes secondary to total pancreatectomy. In the present study, blood concentrations of alanine, lactate and pyruvate were measured in six patients undergoing total pancreatectomy and in nine control subjects undergoing major abdominal surgery. To exclude the simple effect of lack of insulin and hyperglycaemia in the development of hyperalaninaemia following total pancreatectomy, three pancreatectomized patients and five control subjects underwent surgical operation while connected to an artificial pancreas. Blood concentration of alanine was constant in the control subjects during surgery (182 +/- 20 and 243 +/- 31 mumol/l with and without the artificial pancreas, respectively). In pancreatectomized patients basal blood alanine levels were similar to those in control subjects. Blood alanine level rose quickly after removal of the pancreas from 182 +/- 24 to 285 +/- 15 mumol/1 (p less than 0.05) in the patients connected to the artificial pancreas, and from 198 +/- 17 to 395 +/- 47 mumol/1 (p less than 0.05) in patients undergoing total pancreatectomy without artificial pancreas. These values were higher than those observed in the control subjects at the end of the operation (192 +/- 22 and 230 +/- 45 mumol/l with and without artificial pancreas, respectively.) Basal and intraoperative blood concentrations of lactate and pyruvate were similar in pancreatectomized patients and control subjects.

Adenocarcinoma↗
PubMedDate not supplied

Total pancreatectomy for ductal adenocarcinoma of the pancreas with special reference to resection of the portal vein and multicentric cancer.

Between March 1, 1968 and March 1, 1986, 323 patients underwent surgery for cancer of the pancreas or the periampullary region. Extirpative procedures were performed in 91 patients, of whom 51 had ductal carcinoma of the pancreas. Forty-seven patients had total pancreatectomy, 9 associated with resection of the portal vein and 1 with total gastrectomy. Operative mortality was 15% but fell to zero for the 19 total pancreatectomies performed after 1981. With the introduction of total pancreatectomy, the resectability rate increased from 15% to 32%. Overall mean survival was 14.4 months. Actuarial survival was 42.4% at 1 year, 25.6% at 2 years, 11.9% at 3 years, and 8% at 5 years. Six patients are alive 7, 11, 14, 30, 30, and 73 months, respectively, after operation. Survival was calculated according to the classifications of Hermreck, Tryka and Brooks, and the TNM system. Ductal carcinoma was multifocal in 32% of patients, and 25% had epithelial dysplasia of the pancreatic duct. When portal vein resection was necessary, mean survival was 6.1 months, compared with 18.25 months when it was not performed. We conclude that total pancreatectomy has increased our resectability rate, mainly in patients with tumor spread beyond the usual margins of division for Whipple's procedure. However, the procedure does not appear worthwhile when portal vein resection is necessary or when multicentric cancer or neoplastic emboli are observed in the operative specimen.

Adult↗
PubMed1988

Laser pancreatectomy. A comparison between dog and pig.

Total pancreatectomy was performed in dogs (n = 5) and pigs (n = 6) using a contact Nd:YAG laser with a wave length of 1060 nm. The fiber was connected to a laser scalpel, and a 1.0-mm-diameter sapphire tip was used. The power was set at 10-12 W with a pulse time of 9.9 s. The animals were followed postoperatively (p.o.) for 1 week, and no mortality, infection, or any other complication were observed. Total pancreatectomy was significantly faster to perform in pigs than in dogs (P less than 0.001). The number of ligatures (P less than 0.05) and the amount of bleeding (P less than 0.05) were significantly less in pigs than in dogs. The present paper describes the anatomy of the pancreas in dogs and pigs, and also the technical procedure of total pancreatectomy in both species is presented. In conclusion, total pancreatectomy is easier to perform in pigs than in dogs. Furthermore, the anatomy of the pancreas in the pig resembles much that in man.

Animals↗
PubMed1994

Laparoscopic distal pancreatectomy in the porcine model.

Our aim was to assess the feasibility and safety of laparoscopic distal pancreatectomy in an animate model. After developing the technique in acute animal experiments, laparoscopic distal pancreatectomy was performed in five young domestic pigs. Five trocars were used (2-10 mm, 2-12 mm, 1-11 mm) for video laparoscopic access to the peritoneal cavity. The operations were performed without complication in 62-95 min (mean +/- SEM, 77 +/- 7 min). Each animal tolerated oral feedings on the first postoperative day and subsequently gained 6-11 kg (10 +/- 2 kg) in the 4-7-week interval prior to sacrifice. Although there was a significant increase in serum amylase on the first postoperative day, this was associated with a comparable increase in hematocrit, possibly representing hemoconcentration. The weight of the laparoscopically resected pancreatic segment ranged from 16 to 36 g (19 +/- 2 g) while that of the pancreatic head at sacrifice was 13-29 g (21 +/- 3 g). At the time of sacrifice, there were few intraabdominal adhesions and no evidence of fluid collection or pancreatitis. The staple line across the body of the pancreas was grossly intact in all animals. We conclude that laparoscopic distal pancreatectomy in the porcine model is feasible and safe. It may therefore be possible to perform laparoscopic distal pancreatectomy in humans.

Animals↗
PubMed2003

Laparoscopic distal pancreatectomy for Frantz's tumor in a child.

Solid pseudopapillary tumor of the pancreas is a rare pathologic entity. Although the role of laparoscopy in surgery of the pancreas is still controversial, laparoscopic distal pancreatectomy has been reported with good results in adults. We report a laparoscopic spleen-preserving distal pancreatectomy in a 9-year-old boy who presented with a low-grade malignant tumor. Needle biopsy was impossible. A laparoscopic spleen-preserving distal pancreatectomy was performed. We used four trocars, and the operative time was 240 min. Conversion to open surgery was not necessary. The boy's postoperative recovery was uneventful, and he was discharged on the 6th day. CT-scan control at 6 months was normal. This case shows that even in advanced surgical cases, such as spleen-preserving distal pancreatectomy, laparoscopic procedures can be done safely, within a reasonable operative time, in children.

Abdominal Pain↗
PubMed2004

Laparoscopic distal pancreatectomy.

BACKGROUND: Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. Laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this study was to review our preliminary experience with laparoscopic distal pancreatectomy for benign and malignant pancreatic pathologies. METHODS: A retrospective chart review of consecutive patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in a university-affiliated department of surgery between 1997 and 2003 was performed. Data relative to demographic and clinical characteristics, indications for surgery, surgical procedure, and postoperative course were recorded. RESULTS: Laparoscopic distal pancreatectomy was attempted for 12 patients with benign (n = 8) and malignant (n = 4) pancreatic tumors and successfully completed laparoscopically in 75%, of these cases. Six early postoperative complications (two abscesses, two instances of diabetes mellitus, two pancreatic leaks) developed in three patients. The spleen was successfully preserved in 58% of the cases. CONCLUSIONS: This preliminary experience suggests that laparoscopic distal pancreatectomy is a feasible and safe procedure with a morbidity rate comparable with that for the conventional open procedure. However, laparoscopic surgery for malignant pancreatic tumors remains controversial. Larger series with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the treatment of pancreatic pathologies.

Adult↗
PubMed2006

The lasso technique for laparoscopic distal pancreatectomy.

BACKGROUND: Laparoscopic distal pancreatectomy with or without splenectomy is becoming an acceptable alternative to open resection for selected pancreatic lesions. One of the difficulties with this approach is manipulating the pancreas with laparoscopic instruments to avoid unnecessary injury to the pancreas, and yet obtain adequate margins. The described technique accomplishes these goals. METHODS: Data from all patients who underwent laparoscopic distal pancreatectomy (always with splenectomy) were reviewed for age, gender, laparoscopic completion of the resection, postoperative complications, length of hospital stay, and pathology. The essential component of the technique is use of a Penrose drain around the neck or proximal body of the pancreas as a "lasso" for atraumatic manipulation. This technique is described in detail. RESULTS: A total of 11 patients have undergone laparoscopic distal pancreatectomy with splenectomy using the lasso technique. Two patients (18%) underwent conversion to an open laparotomy: the because of bleeding from the pancreatic parenchyma and the other due to local invasion of a pancreatic adenocarcinoma. The average operating time was 162 +/- 39 min, and the median length of hospital stay was 3 days. There were two (18%) pancreatic leaks, both of which were treated conservatively with resolution. Pathologic examination, found six cystic neoplasms, two neuroendocrine tumors, two masses of chronic pancreatitis, and one adenocarcinoma. CONCLUSIONS: The lasso technique simplifies intraoperative manipulation of the pancreas during laparoscopic distal pancreatectomy. It allows for safe manipulation of the pancreas and may expand the indications for the laparoscopic approach to pancreatic resection.

Aged↗