Laparoscopic central pancreatectomy for solid pseudopapillary tumors of the pancreas: our experience with ten cases
© Chen et al.; licensee BioMed Central Ltd. 2014
Received: 16 April 2014
Accepted: 1 October 2014
Published: 13 October 2014
Solid pseudopapillary tumors (SPTs) of the pancreas are a rare neoplasm. There are few reports of laparoscopic central pancreatectomies (LCPs) for SPT of the pancreas. The objective of this study was to evaluate the feasibility, safety and long-term outcome of LCP based on a series of SPT patients.
This retrospective study included ten patients who underwent LCP between 2009 and 2013. Clinical characteristics and intra- and postoperative data were retrospectively analyzed. A follow-up of at least 3 months was available for all patients.
All procedures were successfully performed laparoscopically, and no patient required intraoperative blood transfusion. The median operative time was 271 min (range 250 to 310 min) and the median loss of blood was 104 ml (range 80 to 150 ml). The mean tumor size was 51 mm (range 38 to 62 mm). All patients underwent complete resection with negative surgical margin. An average of 5.8 lymph nodes were resected without metastases. The median first flatus time was 2 days, and the median starting time for diet was 3 days. The median postoperative hospital stay was 13 days (range 10 to 23 days). Morbidity was 20%. The median follow-up was 22.9 months (range 3 to 48 months), at which point all patients were alive with no recurrence. None of the patients developed exocrine or endocrine insufficiency. No hospital mortalities occurred in our patient group.
LCP is a safe and effective technique for resecting SPT of the neck and proximal body of the pancreas while preserving pancreatic endocrine and exocrine function, and the spleen.
Solid pseudopapillary tumors (SPTs) are a rare clinical entity, representing 1% to 2% of all primary exocrine tumors of the pancreas; more than 80% of patients are female . SPT is of unclear histopathogenesis, and low-grade malignancy, malignant degeneration and lymph node metastasis rarely occur . Surgical resection of this tumor can result in long-term survival. Laparoscopic resection of the pancreas was initially described in the medical literature in the early 1990s. The first laparoscopic pancreatoduodenectomy was performed in 1994, and the first distal pancreatectomy was performed in 1996 [3, 4]. However, patients who require central pancreatectomy are still being treated with the open approach or with laparoscopic distal pancreatectomy. Central pancreatectomy is an alternative technique for benign or low-grade malignant tumors of the neck of the pancreas. This pancreas-sparing technique was developed to avoid exocrine and/or endocrine insufficiency, which could be detrimental to the patient’s quality of life, especially for benign or low-grade malignant neoplasms.
Although laparoscopic central pancreatectomy (LCP) is thought to be a function-preserving and minimally invasive pancreatectomy, due to the difficulty of pancreaticoenteric reconstruction, LCP has been slow to gain popularity. In an attempt to define the role and the efficacy of minimally invasive surgery in the treatment of SPT of the pancreas better, we therefore describe a complete LCP.
We undertook a retrospective cohort study of patients treated for SPT in our institution between February 2009 and December 2013 (n =15). Of the patients, 66.6% (10/15) were treated using LCP, and the other five patients underwent a laparoscopic distal pancreatectomy. Descriptive data were collected. Preoperative variables include age, gender and indication for surgery. Pancreatic fistula, delayed gastric emptying and post-pancreatectomy hemorrhage were defined according to the International Study Group of Pancreatic Surgery definitions [5–7]. Data collected included patient characteristics, operative details, morbidity and mortality, postoperative hospital stay, pathological findings and follow-up results. Oncologic outcomes were analyzed for all patients, and the data includes tumor size (maximum dimension in centimeters), total number of lymph nodes, number of positive lymph nodes and margin status. The fasting blood glucose level (normal ≤110 mg/dL) was used to evaluate the pancreatic endocrine function. A clinical evaluation was used to assess the pancreatic exocrine function. Patients with diarrhea, weight loss and fatty stools were considered to have pancreatic exocrine insufficiency. Ethics committee of the third affiliated hospital of Soochow University approval and informed consent from the patients were obtained to perform LCP.
Surgery-related information and postoperative outcomes
Operative time (min)
Blood loss (ml)
Hospital stay (days)
Tumor size (mm)
Exocrine or endocrine insufficiency
Laparoscopic pancreatic surgery has undergone significant development in the last few years. The majority of procedures are left pancreatectomy and enucleations [8–10]. More complex pancreatic resections such as pancreatoduodenectomies, resections of the uncinate process of the pancreas and central pancreatectomies are performed routinely in very few centers [11, 12].
The first surgical resection of a pancreatic SPT was performed in 1970 and the first laparoscopic SPT resection was in 2003 [13, 14]. The first series of laparoscopic SPT resection (ten cases) was published by Cavallini et al.  in 2011. However, there have been few reports of LCP for SPT of the pancreas. Most of these articles are case reports and small series. The two largest series of LCP, with six and nine cases, respectively, reported morbidity rates of 33.3% and 33.3% with pancreatic fistula rates of 33.3% and 22.2%, respectively, with no mortality [16, 17]. A review of 512 patients from 21 series who underwent an open central pancreatectomy reported an overall morbidity rate of 41% (range 13% to 62%), a pancreatic fistula rate of 27% (range 0% to 62%) and a reoperation rate of 4% (range 0% to 21%) . Our series with ten cases had a morbidity rate of 20% (two cases of a pancreatic fistula), similar to what has been reported. In a comparative study, the outcomes after a central pancreatectomy were compared with a control group that underwent extended left pancreatectomy for neoplasms in the mid pancreas . After a median follow-up of 54 months, the incidences of endocrine and exocrine insufficiency after the central pancreatectomy were 4% and 5%, respectively, compared to 38% and 15.6% in patients who underwent an extended distal pancreatectomy. In this study, we have not observed any recurrence or pancreatic endocrine or exocrine insufficiency.
Laparoscopic resection of the neck of the pancreas or of any segment in the middle of the pancreas is not difficult. However, it entails reconstruction of the main pancreatic duct, which may be difficult and sometimes hazardous laparoscopically. The popularity of laparoscopic left pancreatectomy has certainly reduced the number of patients undergoing LCP. However, this is at the expense of the endocrine and exocrine deficiency that an extended left pancreatectomy may produce. For benign or low-grade neoplasms, a left pancreatectomy may remove too much of the functioning pancreatic parenchyma. Due to this, for cases with a tumor in the neck of the pancreas, our procedure of choice is a central pancreatectomy with Roux-en-Y pancreatojejunostomy. The management for a distal pancreas can be pancreatogastrostomy or Roux-en-Y pancreatojejunostomy. Pancreatogastrostomy is easier and faster, but it may delay oral feeding and it prolongs the length of stay. Pancreatojejunostomy is a more complex reconstruction, but has better long-term outcomes in terms of endocrine and exocrine function. As central pancreatectomy is indicated in patients with an expected long survival, some authors consider pancreatojejunostomy as the best management for the distal pancreas after central pancreatectomy. We also prefer reconstruction with Roux-en-Y pancreatojejunostomy.
Depending on whether the duct of Wirsung could be identified, we used two methods to accomplish the pancreaticojejunal reconstruction: end-to-side or duct-to-mucosa pancreaticojejunal. If the diameter of the duct of Wirsung is larger than 5 mm, duct-to-mucosa pancreaticojejunal is easier to execute. In our series, all patients had an undilated duct of Wirsung, which is difficult to identify. Therefore, end-to-side pancreaticojejunal seems to be easier and faster. A comparison between duct-to-mucosa and end-to-side pancreaticojejunal reconstruction after pancreaticoduodenectomy revealed no significant differences in the rate of complications . In our study, an end-to-side pancreaticojejunal was used to accomplish the pancreaticojejunal reconstruction and we had a pancreatic fistula rate of 20%. A recent comparative study has shown that division of the pancreatic parenchyma with vascular cartridges resulted in a significantly lower fistula rate compared with standard cartridges . It is still unclear if the use of staple-line reinforcement reduces the risk of a pancreatic fistula . The limitations of this study were its retrospective design and low number of patients. These problems can be overcome only by a large, prospective randomized trial, which would be difficult to accomplish owing to the infrequent diagnosis of patients with SPT of the pancreas.
In conclusion, LCP is a safe and effective technique for resecting SPT of the neck and proximal body of the pancreas while preserving pancreatic endocrine and exocrine function, and the spleen. A minimally invasive approach ensures adequate treatment despite requiring the expertise of highly skilled laparoscopic surgeons.
The authors thank Sheng yong Liu for language editing.
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