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Combined resection of pancreatic head tumor with superior mesenteric vein and right hepatic artery
540
Journal of Gastrointestinal Surgery
Abstracts
to the bed of the pancreas. This corresponded to a small 12 × 9 mm retroperitoneal mass identifiable on CT scan that demonstrated marked enhancement in the arterial phase. Preoperative planning was facilitated by CT scan-generated three-dimensional imaging of the lesion and the surrounding vascular structures. The patient received 4.6 µCi of radiolabeled octreotide preoperatively. He was explored laparoscopically, and the suspected gastrinoma was localized using a laparoscopic scintigraphy probe. On histologic examination, the nodule contained a small glandular tumor embedded within lymphatic tissue. It consisted of tightly clustered, small, regular glands of tumor cells with an appearance characteristic of islet cell tumors. Immunohistochemically the tissue stained positive for synaptophysin, a marker for neuroendocrine differentiation. Postoperatively, the patient was discharged to home the following day. A serum gastrin level obtained at four weeks was found to be 36 pg/ml. He remained comfortable and asymptomatic without any further dyspepsia or diarrhea.
47 CENTRAL PANCREATECTOMY. A CONSERVATIVE TECHNIQUE PRESERVING FUNCTIONAL PANCREATIC PARENCHYMA Calogero Iacono, MD, Luca Bortolasi, MD, Marco Frisini, MD, Giovanni Serio, MD, University of Verona, Verona, Italy Central pancreatectomy (CP) is an operation that allows to resect benign or low malignant tumor located in the pancreatic isthmus that are not suitable for enucleation. The main advantage of this operation compared with major resections as pancreaticoduodenectomy and distal pancreatectomy is that it permits to spare normal pancreatic parenchyma and therefore the exocrine and endocrine functions are preserved. The video shows the technique: the operation is carried out by exposition of the pancreatic neck involved by the lesion and incision of the peritoneum along the superior and inferior margin of the part of the gland to be resected. Thereafter the gland is dissected from the splenic artery and portomesenteric axis and divided with a 1-cm clear margin on either sides of the lesion. The cephalic stump is sutured and the distal stump is anastomosed end-to-end with a Roux-en-Y jejunal loop. We treated 20 patients with this technique. Three patients were male and 17 female, mean age was 50 years. The indications for CP were serous cystadenoma in 7, mucinous in 3, solid cystic papillary tumor in 1, metastasis from renal cancer in 1, and endocrine tumor in 8 patients. Mean operative time was 235 min (range 180–300). Mean size of the lesions was 2.9 cm (range 1.2–5). Mortality rate was 0% and morbidity rate was 35%, pancreatic fistula occurred in 25% of the cases and was treated conservatively in all the cases. Mean postoperative hospital stay was 18 days (range 9–38). Postoperative endocrine and exocrine functional tests were normal in all controlled patients. All the patients are alive without clinical and imaging evidence of disease. We can conclude that CP is a safe technique for benign or low malignant tumor of the pancreatic neck that allows a cure of the tumor with evident functional results without increasing the risk for the patient.
treatment when accessible. The surgical technique of resection of a solitary uncinate mass is demonstrated on this video.
49 COMBINED RESECTION OF PANCREATIC HEAD TUMOR WITH SUPERIOR MESENTERIC VEIN AND RIGHT HEPATIC ARTERY Emilio Vicente, MD, Yolanda Quijano, MD, Carlos Monroy, MD, Carmelo Loinaz, MD, Isabel Prieto, MD, Rafael Beni, MD, Francisca Garcı´a-Moreno, MD, Jacobo Caban˜as, MD, Gonzalo Bueno, MD, Javier Rodriguez, MD, Hospital Madrid MontePrı´ncipe, Boadilla Del Monte. Madrid, Spain; Hospital Ramon y Cajal, Madrid, Spain Solid cystic tumors of the pancreas are a relatively rare type of cystic disease. These tumors usually present as a large asymptomatic mass of about 15 cm in diameter involving regional vascular structures. Recent advances in surgical techniques have contributed to an increased respectability rate in hepatobiliary and pancreatic benign and malignant tumors with vascular involvement. An acceptable early and late morbidity and mortality has been obtained. A huge pancreatic head tumor of more of 15 cm of diameter occurred on a 51-year-old woman. The complete resection was possible by a pancreatoduodenectomy associated to mesenteric vein and right hepatic artery resection. Vascular reconstruction was performed with an end-to-end anastomosis of the superior mesenteric vein and right hepatic artery, respectively. Microsurgery technique was performed in the arterial reconstruction. The video demonstrates the preoperative diagnostic procedures to evaluate the extent of tumor growth and the vascular invasion or compression as well as the surgical procedure.
50 LAPAROSCOPIC ROUX-EN-Y CYST-JEJUNOSTOMY FOR DRAINAGE OF PANCREATIC PSUEDOCYST S. Scott Davis, Jr., MD, Matthew I. Goldblatt, MD, W. Scott Melvin, MD, The Ohio State University, Columbus, OH The video depicts the operative management of a pancreatic pseudocyst using minimally invasive techniques to establish enteric drainage. The patient is a 25-year-old woman who suffered an attack of severe, necrotizing gallstone pancreatitis during the third trimester of pregnancy. She underwent laparoscopic cholecystectomy and subsequently delivered her baby. In the ensuing months, she developed an enlarging pseudocyst involving the tail of her pancreas. She experienced intermittent left upper quadrant abdominal pain associated with the development of the cyst. It was situated inferior to the stomach and contained heterogeneous enhancement on CT scan consistent with residual necrosis. A laparoscopic, transmesocolic approach allowed debridement of the cyst cavity and enteric drainage using a RouxEn-Y limb. She was discharged home without drains in the early postoperative period without any complications. This case demonstrates the feasibility of using laparoscopic techniques, as an alternative to open or endoscopic techniques, in the drainage of dependent pancreatic pseudocysts.
48 ISOLATED UNCINATE RESECTION FOR PANCREATIC CYSTIC NEOPLASM Richard Matthew Walsh, MD, Cleveland Clinic Foundation, Cleveland, OH Lesions in the uncinate process of the pancreas typically require pancreaticoduodenectomy. This is to ensure a curative resection for the difficult to expose area. Local resection of some pancreatic neoplasms, such as cystic neoplasms and neuroendocrine lesions is the preferred
51 LAPAROSCOPIC MAJOR HEPATIC RESECTION: ANALYSIS OF LOBECTOMY AND TRISEGMENTECTOMY Alan J. Koffron, Joseph Buell, MD, Michael Abecassis, MD, Northwestern University Medical School, Chicago, IL; University of Cincinnati, Cincinnati, OH; Northwestern University Medical School, Chicago, IL
Journal of Gastrointestinal Surgery
Abstracts
to the bed of the pancreas. This corresponded to a small 12 × 9 mm retroperitoneal mass identifiable on CT scan that demonstrated marked enhancement in the arterial phase. Preoperative planning was facilitated by CT scan-generated three-dimensional imaging of the lesion and the surrounding vascular structures. The patient received 4.6 µCi of radiolabeled octreotide preoperatively. He was explored laparoscopically, and the suspected gastrinoma was localized using a laparoscopic scintigraphy probe. On histologic examination, the nodule contained a small glandular tumor embedded within lymphatic tissue. It consisted of tightly clustered, small, regular glands of tumor cells with an appearance characteristic of islet cell tumors. Immunohistochemically the tissue stained positive for synaptophysin, a marker for neuroendocrine differentiation. Postoperatively, the patient was discharged to home the following day. A serum gastrin level obtained at four weeks was found to be 36 pg/ml. He remained comfortable and asymptomatic without any further dyspepsia or diarrhea.
47 CENTRAL PANCREATECTOMY. A CONSERVATIVE TECHNIQUE PRESERVING FUNCTIONAL PANCREATIC PARENCHYMA Calogero Iacono, MD, Luca Bortolasi, MD, Marco Frisini, MD, Giovanni Serio, MD, University of Verona, Verona, Italy Central pancreatectomy (CP) is an operation that allows to resect benign or low malignant tumor located in the pancreatic isthmus that are not suitable for enucleation. The main advantage of this operation compared with major resections as pancreaticoduodenectomy and distal pancreatectomy is that it permits to spare normal pancreatic parenchyma and therefore the exocrine and endocrine functions are preserved. The video shows the technique: the operation is carried out by exposition of the pancreatic neck involved by the lesion and incision of the peritoneum along the superior and inferior margin of the part of the gland to be resected. Thereafter the gland is dissected from the splenic artery and portomesenteric axis and divided with a 1-cm clear margin on either sides of the lesion. The cephalic stump is sutured and the distal stump is anastomosed end-to-end with a Roux-en-Y jejunal loop. We treated 20 patients with this technique. Three patients were male and 17 female, mean age was 50 years. The indications for CP were serous cystadenoma in 7, mucinous in 3, solid cystic papillary tumor in 1, metastasis from renal cancer in 1, and endocrine tumor in 8 patients. Mean operative time was 235 min (range 180–300). Mean size of the lesions was 2.9 cm (range 1.2–5). Mortality rate was 0% and morbidity rate was 35%, pancreatic fistula occurred in 25% of the cases and was treated conservatively in all the cases. Mean postoperative hospital stay was 18 days (range 9–38). Postoperative endocrine and exocrine functional tests were normal in all controlled patients. All the patients are alive without clinical and imaging evidence of disease. We can conclude that CP is a safe technique for benign or low malignant tumor of the pancreatic neck that allows a cure of the tumor with evident functional results without increasing the risk for the patient.
treatment when accessible. The surgical technique of resection of a solitary uncinate mass is demonstrated on this video.
49 COMBINED RESECTION OF PANCREATIC HEAD TUMOR WITH SUPERIOR MESENTERIC VEIN AND RIGHT HEPATIC ARTERY Emilio Vicente, MD, Yolanda Quijano, MD, Carlos Monroy, MD, Carmelo Loinaz, MD, Isabel Prieto, MD, Rafael Beni, MD, Francisca Garcı´a-Moreno, MD, Jacobo Caban˜as, MD, Gonzalo Bueno, MD, Javier Rodriguez, MD, Hospital Madrid MontePrı´ncipe, Boadilla Del Monte. Madrid, Spain; Hospital Ramon y Cajal, Madrid, Spain Solid cystic tumors of the pancreas are a relatively rare type of cystic disease. These tumors usually present as a large asymptomatic mass of about 15 cm in diameter involving regional vascular structures. Recent advances in surgical techniques have contributed to an increased respectability rate in hepatobiliary and pancreatic benign and malignant tumors with vascular involvement. An acceptable early and late morbidity and mortality has been obtained. A huge pancreatic head tumor of more of 15 cm of diameter occurred on a 51-year-old woman. The complete resection was possible by a pancreatoduodenectomy associated to mesenteric vein and right hepatic artery resection. Vascular reconstruction was performed with an end-to-end anastomosis of the superior mesenteric vein and right hepatic artery, respectively. Microsurgery technique was performed in the arterial reconstruction. The video demonstrates the preoperative diagnostic procedures to evaluate the extent of tumor growth and the vascular invasion or compression as well as the surgical procedure.
50 LAPAROSCOPIC ROUX-EN-Y CYST-JEJUNOSTOMY FOR DRAINAGE OF PANCREATIC PSUEDOCYST S. Scott Davis, Jr., MD, Matthew I. Goldblatt, MD, W. Scott Melvin, MD, The Ohio State University, Columbus, OH The video depicts the operative management of a pancreatic pseudocyst using minimally invasive techniques to establish enteric drainage. The patient is a 25-year-old woman who suffered an attack of severe, necrotizing gallstone pancreatitis during the third trimester of pregnancy. She underwent laparoscopic cholecystectomy and subsequently delivered her baby. In the ensuing months, she developed an enlarging pseudocyst involving the tail of her pancreas. She experienced intermittent left upper quadrant abdominal pain associated with the development of the cyst. It was situated inferior to the stomach and contained heterogeneous enhancement on CT scan consistent with residual necrosis. A laparoscopic, transmesocolic approach allowed debridement of the cyst cavity and enteric drainage using a RouxEn-Y limb. She was discharged home without drains in the early postoperative period without any complications. This case demonstrates the feasibility of using laparoscopic techniques, as an alternative to open or endoscopic techniques, in the drainage of dependent pancreatic pseudocysts.
48 ISOLATED UNCINATE RESECTION FOR PANCREATIC CYSTIC NEOPLASM Richard Matthew Walsh, MD, Cleveland Clinic Foundation, Cleveland, OH Lesions in the uncinate process of the pancreas typically require pancreaticoduodenectomy. This is to ensure a curative resection for the difficult to expose area. Local resection of some pancreatic neoplasms, such as cystic neoplasms and neuroendocrine lesions is the preferred
51 LAPAROSCOPIC MAJOR HEPATIC RESECTION: ANALYSIS OF LOBECTOMY AND TRISEGMENTECTOMY Alan J. Koffron, Joseph Buell, MD, Michael Abecassis, MD, Northwestern University Medical School, Chicago, IL; University of Cincinnati, Cincinnati, OH; Northwestern University Medical School, Chicago, IL