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Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas – Case report
Pancreatology 14 (2014) 550e552
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Case report
Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas e Case report P. Senthilnathan*, Nikunj Patel, V.P. Nalankilli, C. Palanivelu, R. Parthasarthi, P. Praveenraj GEM Hospital and Research Centre, Coimbatore, India
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 2 July 2014
Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumour commonly seen in young women without significant clinical features. SPN is usually a lowgrade malignant neoplasm which warrants resection. Recurrence and metastasis is seen rarely after complete resection. Pancreaticoduodenectomy is indicated for SPN situated in head of the pancreas which is generally performed by open approach. Laparoscopic pancreaticoduodenectomy (LPD) is difficult to perform for this condition because of smaller size of pancreatic and hepatic ducts more so in paediatric population. We report a case of 12 years old girl having SPN arising from head of the pancreas. She underwent laparoscopic pylorus preserving pancreaticoduodenectomy. Post-operative period was uneventful. Histological examination of resected specimen confirmed diagnosis of SPN. At 6 months follow up, she was doing well without any recurrence. To best of our knowledge, no case of LPD in paediatric patients is reported in literature available to us. Copyright © 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Keywords: Laparoscopic pancreaticoduodenectomy Solid pseudopapillary neoplasm of the pancreas Children Benign tumours of pancreas Pancreatic tumour in children Laparoscopic surgery in pediatric age
1. Introduction Solid pseudopapillary neoplasm (SPN) is one of the rare primary tumours of the pancreas, first described by Frantz [1] in 1959. It mainly affects young females in the second and third decades. It has a low malignant potential with very low risk of recurrence or metastasis after complete resection. Recommended definitive treatment of pancreatic SPN is complete resection, with the surgical approach depending on both tumour location and size. The first surgical resection of a pancreatic SPN was performed by Grosfeld and described by Hamoudi in 1970 [2]. Carricaburu [3] reported the first case of laparoscopic SPN resection (distal pancreatectomy) in a child. Since then only few case reports and small case series of open pancreaticoduodenectomy for SPN in children have been published. Laparoscopic resection of the pancreas was first reported in the literature in the early 1990s. The first laparoscopic pancreaticoduodenectomy (LPD) was performed in 1994 [4]. It was followed by few reports from centres with experience in
* Corresponding author. Department of HPB Surgery, GEM Hospital and Research Centre, Coimbatore 641045, India. Tel.: þ91 9842210173. E-mail address: [email protected] (P. Senthilnathan).
performing this procedure and the initial reported clinical outcomes of LPD had been unsatisfactory [5,6]. We started LPD after gaining sufficient experience in other major laparoscopic procedures and reported our outcomes which were comparable to open approach [7]. LPD, with known advantages of laparoscopic surgery over open pancreaticoduodenectomy, may be acceptable as an alternative to open procedure if technical feasibility and safety can be ensured with acceptable morbidity and mortality for the treatment of benign or low-grade malignant lesions like SPN. To best of our knowledge, no case report of LPD in children has been published so far.
2. Case report A 12 years girl without any significant medical or surgical history presented to her family physician for pain in upper abdomen with vomiting for 2 weeks. Ultrasound (US) abdomen revealed a mass lesion in head of the pancreas. So she was referred to us for further management. General and per abdomen examinations were unremarkable. Blood investigations including tumour markers CEA and CA 19-9 were within normal limits. MDCT abdomen with triple phase showed large well defined relatively hypodense lesion (61 53 mm) in head of the pancreas with rim of peripheral
http://dx.doi.org/10.1016/j.pan.2014.06.005 1424-3903/Copyright © 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
P. Senthilnathan et al. / Pancreatology 14 (2014) 550e552
calcifications and mild heterogenous enhancement and irregular septal enhancement (Fig. 1). The findings were consistent with solid papillary epithelial neoplasm. EUS (endoscopic ultrasound) guided FNA (fine-needle aspiration) showed necrotic tumour tissue composed of sheets of necrotic small round cells intervened by fibrovascular tissue with scattered small clusters of small round cells with dense nucleus and scanty cytoplasm with the possibility of solid pseudopapillary tumour. After detailed discussion with relatives regarding pros and cons of management, written consent was obtained and patient underwent laparoscopic pylorus preserving pancreaticoduodenectomy (Fig. 2). Our operative technique has been standardised and published in detail [7]. We made minor modifications in our technique as it is performed in paediatric patient. (1) Throughout the procedure, we maintained pneumo-peritoneum at pressure of 10 mmHg. (2) Instead of umbilical port for camera, we placed camera port slightly below umbilicus. (3) We used 3 mm epigastric port and blunt instrument for liver retraction. (4) Patient position, rest of port placement and resection technique remained same as we used in adults. (5) Because of smaller size of pancreatic duct, we performed end-to-side modified dunking pancreaticojejunostomy (PJ) using 5-0 PDS. (6) Similarly, due to smaller size of common hepatic duct (CHD), anterior slit was made to widen the CHD and end-to-side hepaticojejunostomy (HJ) was performed in a single layer interrupted sutures with 4-0 PDS. End-to-side duodenojejunostomy was performed in the infracolic region. Total blood loss was 100 ml with no blood transfusion required in intra-operative or post-operative period. Total operating time was 435 min. Post operatively patient kept on elective ventilator support for 12 h. Patient kept in intensive care unit for 2 days. Nasogastric tube was removed on 2nd post-operative day (POD) and oral feeding commenced on 4th POD after return of bowel activity. Drain fluid amylase was done on 3rd and 7th post-operative days which showed no PJ leak. 1st drain removed on 6th POD and 2nd on 7th POD. Patient discharged on 8th post-operative day without any complication. Histological examination (Fig. 3) confirmed diagnosis of SPN with all resected margins free and 11 resected lymph nodes were negative for tumour involvement. At 6 months of follow up at the time of writing this article, patient was doing well without any morbidity/recurrence.
Fig. 1. Contrast enhanced CT showing large well defined relatively hypodense lesion (61 53 mm) in head of pancreas with rim of peripheral calcifications and mild heterogenous enhancement and irregular septal enhancement.
551
Fig. 2. Intra-operative image following resection phase. HA e hepatic artery, PV e portal vein, SMV e superior mesenteric vein, SV e splenic vein, CHD e common hepatic duct, PAN e cut surface of pancreas with feeding tube in main pancreatic duct.
3. Discussion Laparoscopic surgical techniques have grown rapidly in last decade due to development in laparoscopic instruments, energy sources to control bleeding and growing laparoscopic experience. Laparoscopic pancreatic surgery is still not universally practiced though laparoscopic distal pancreatic resections are now proven to be safe and readily feasible [8,9]. LPD is a complex procedure with technical difficulties during dissection because of nearby large vessels and complex reconstruction. Many surgeons have questioned the safety and advantages of LPD over its open counterpart and this has appropriately resulted in slow adoption of the technique. Magnified view, better exposure, delicate handling of tissues and decreased blood loss are still advantages of the laparoscopic approach. The learning curve is steep, operative times are generally longer and hospital stay and recovery are not shortened as much as for other laparoscopic procedures. Technically also, LPD is difficult for benign or low-grade malignant pancreatic head lesions like SPN particularly reconstruction part due to the soft pancreas and the small size of pancreatic and bile ducts. However, many surgeons in recent years have acquired the necessary surgical skills to perform a safe procedure with acceptable results and as such laparoscopic pancreaticoduodenectomy is becoming a more frequently performed operation for benign as well as malignant lesions of the
Fig. 3. Histological examination shows papillary structures surrounded by medium sized polyhedral cells with extensive degenerative changes (H&E 100).
552
P. Senthilnathan et al. / Pancreatology 14 (2014) 550e552
head of the pancreas. This operation requires high level of laparoscopic skills and should be performed in high volume dedicated centres by expert laparoscopic surgeons if optimum results are to be obtained. We have performed more than 140 LPD till now. Solid pseudopapillary tumour/neoplasm (SPT/SPN) of the pancreas is a rare neoplasm accounting for 0.17%e2.7% of all pancreatic tumours [11]. Frantz [1] first described this tumour in 1959 as a papillary tumour of the pancreas. In 1996, the World Health Organization renamed it as SPT [10]. The tumour has low malignant potential with recurrence or metastasis rare after complete resection. It is usually seen in young women in the second or third decade of life. [11] Most of the patients present with nonspecific clinical features as in our case including abdominal pain, abdominal discomfort, poor appetite and nausea which may be related to compression of the adjacent organs by tumour. Majority of these tumours are diagnosed during complementary imaging investigations such as CT or US of the abdomen. CT/MRI scans typically show a large wellcircumscribed, heterogeneous mass with varying solid and cystic components, generally demarcated by a peripheral capsule and occasional calcification. MRI is superior to CT in distinguishing certain tissue characteristics such as haemorrhage, cystic degeneration or the presence of a capsule and may suggest correct diagnosis [12].The diagnosis can be confirmed by fine-needle aspiration (FNA) under endoscopic ultrasound (EUS) [13]guidance or percutaneously under ultrasound/CT-guidance. Currently, complete aggressive surgical resection is the treatment of choice for SPN of the pancreas. The overall 5 year survival was estimated to be 95% in a review of 718 patients reported in the English literature [11]. Surgical approach depends on both tumour location and size. Laparoscopic distal pancreatectomy is now well established procedure for SPN of distal body and tail. Open pancreaticoduodenectomy is recommended for SPN of head of the pancreas. To best of our knowledge, there are few reports of LPD for SPT in adults but no case is reported in literature of LPD for SPN in children. Because of experience and acquisition of adequate laparoscopic skills, we are able to perform this complex operation in 12 years old patient safely with acceptable oncological outcome.
4. Conclusion Solid pseudopapillary neoplasm is a rare tumour of the pancreas. Pancreaticodudenectomy is recommended treatment for this tumour located in head of the pancreas. Laparoscopic approach can be an alternative if expertise is available even in paediatric patients.
References [1] Frantz VK. Tumours of the pancreas. In: Blumberg CW, editor. Atlas of tumour pathology. Washington, DC: US Armed Forces Institute of Pathology; 1959. pp. 32e3. [2] Hamoudi AB, Misugi K, Grosfeld JL, Reiner CB. Papillary epithelial neoplasm of pancreas in a child. Report of a case with electron microscopy. Cancer 1970;26:1126e34. [3] Carricaburu E, Enezian G, Bonnard A, Berrebi D, Belarbi N, Huot O, et al. Laparoscopic distal pancreatectomy for Frantz's tumour in a child. Surg Endosc 2003;17(12):2028e31. [4] Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 1994;8:408e10. [5] Gagner M, Pomp A. Laparoscopic pancreatic resection: is it worthwhile? J Gastrointest Surg 1997;1:20e6. [6] Cuschieri A. Laparoscopic surgery of the pancreas. J R Coll Surg Edinb 1994;39: 178e84. [7] Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, et al. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. J Hepatobiliary Pancreat Surg 2009;16:731e40. [8] Teh SH, Tseng D, Sheppard BC. Laparoscopic and open distal pancreatic resection for benign pancreatic disease. J Gastrointest Surg 2007;11:1120e5. [9] Kim SC, Park KT, Hwang JW, Shin HC, Lee SS, Seo DW, et al. Comparative analysis of clinical outcomes of laparoscopic distal pancreatic resection and open distal pancreatic resection in a single institution. Surg Endosc 2008;22:2261e8. €ppel G, Solcia E, Longnecker DS, Capella C, Sobin LH. Histological typing of [10] Klo tumours of the exocrine pancreas. World Health Organization International Histological Classification of Tumours. 2nd ed. New York: Springer; 1996. pp. 120e8. [11] Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg 2005;200:965e72. [12] Cantisani V, Mortele KJ, Levy A, Glickman JN, Ricci P, Passariello R, et al. MR imaging features of solid pseudopapillary tumour of the pancreas in adult and paediatric patients. Am J Roentgenol 2003;181:395e401. [13] Jani N, Dewitt J, Eloubeidi M, Varadarajulu S, Appalaneni V, Hoffman B, et al. Endoscopic ultrasoundguided fine-needle aspiration for the diagnosis of solidpseudopapillary tumours of the pancreas: a multicenter experience. Endoscopy 2008;40:200e3.
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Case report
Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas e Case report P. Senthilnathan*, Nikunj Patel, V.P. Nalankilli, C. Palanivelu, R. Parthasarthi, P. Praveenraj GEM Hospital and Research Centre, Coimbatore, India
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 2 July 2014
Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumour commonly seen in young women without significant clinical features. SPN is usually a lowgrade malignant neoplasm which warrants resection. Recurrence and metastasis is seen rarely after complete resection. Pancreaticoduodenectomy is indicated for SPN situated in head of the pancreas which is generally performed by open approach. Laparoscopic pancreaticoduodenectomy (LPD) is difficult to perform for this condition because of smaller size of pancreatic and hepatic ducts more so in paediatric population. We report a case of 12 years old girl having SPN arising from head of the pancreas. She underwent laparoscopic pylorus preserving pancreaticoduodenectomy. Post-operative period was uneventful. Histological examination of resected specimen confirmed diagnosis of SPN. At 6 months follow up, she was doing well without any recurrence. To best of our knowledge, no case of LPD in paediatric patients is reported in literature available to us. Copyright © 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Keywords: Laparoscopic pancreaticoduodenectomy Solid pseudopapillary neoplasm of the pancreas Children Benign tumours of pancreas Pancreatic tumour in children Laparoscopic surgery in pediatric age
1. Introduction Solid pseudopapillary neoplasm (SPN) is one of the rare primary tumours of the pancreas, first described by Frantz [1] in 1959. It mainly affects young females in the second and third decades. It has a low malignant potential with very low risk of recurrence or metastasis after complete resection. Recommended definitive treatment of pancreatic SPN is complete resection, with the surgical approach depending on both tumour location and size. The first surgical resection of a pancreatic SPN was performed by Grosfeld and described by Hamoudi in 1970 [2]. Carricaburu [3] reported the first case of laparoscopic SPN resection (distal pancreatectomy) in a child. Since then only few case reports and small case series of open pancreaticoduodenectomy for SPN in children have been published. Laparoscopic resection of the pancreas was first reported in the literature in the early 1990s. The first laparoscopic pancreaticoduodenectomy (LPD) was performed in 1994 [4]. It was followed by few reports from centres with experience in
* Corresponding author. Department of HPB Surgery, GEM Hospital and Research Centre, Coimbatore 641045, India. Tel.: þ91 9842210173. E-mail address: [email protected] (P. Senthilnathan).
performing this procedure and the initial reported clinical outcomes of LPD had been unsatisfactory [5,6]. We started LPD after gaining sufficient experience in other major laparoscopic procedures and reported our outcomes which were comparable to open approach [7]. LPD, with known advantages of laparoscopic surgery over open pancreaticoduodenectomy, may be acceptable as an alternative to open procedure if technical feasibility and safety can be ensured with acceptable morbidity and mortality for the treatment of benign or low-grade malignant lesions like SPN. To best of our knowledge, no case report of LPD in children has been published so far.
2. Case report A 12 years girl without any significant medical or surgical history presented to her family physician for pain in upper abdomen with vomiting for 2 weeks. Ultrasound (US) abdomen revealed a mass lesion in head of the pancreas. So she was referred to us for further management. General and per abdomen examinations were unremarkable. Blood investigations including tumour markers CEA and CA 19-9 were within normal limits. MDCT abdomen with triple phase showed large well defined relatively hypodense lesion (61 53 mm) in head of the pancreas with rim of peripheral
http://dx.doi.org/10.1016/j.pan.2014.06.005 1424-3903/Copyright © 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
P. Senthilnathan et al. / Pancreatology 14 (2014) 550e552
calcifications and mild heterogenous enhancement and irregular septal enhancement (Fig. 1). The findings were consistent with solid papillary epithelial neoplasm. EUS (endoscopic ultrasound) guided FNA (fine-needle aspiration) showed necrotic tumour tissue composed of sheets of necrotic small round cells intervened by fibrovascular tissue with scattered small clusters of small round cells with dense nucleus and scanty cytoplasm with the possibility of solid pseudopapillary tumour. After detailed discussion with relatives regarding pros and cons of management, written consent was obtained and patient underwent laparoscopic pylorus preserving pancreaticoduodenectomy (Fig. 2). Our operative technique has been standardised and published in detail [7]. We made minor modifications in our technique as it is performed in paediatric patient. (1) Throughout the procedure, we maintained pneumo-peritoneum at pressure of 10 mmHg. (2) Instead of umbilical port for camera, we placed camera port slightly below umbilicus. (3) We used 3 mm epigastric port and blunt instrument for liver retraction. (4) Patient position, rest of port placement and resection technique remained same as we used in adults. (5) Because of smaller size of pancreatic duct, we performed end-to-side modified dunking pancreaticojejunostomy (PJ) using 5-0 PDS. (6) Similarly, due to smaller size of common hepatic duct (CHD), anterior slit was made to widen the CHD and end-to-side hepaticojejunostomy (HJ) was performed in a single layer interrupted sutures with 4-0 PDS. End-to-side duodenojejunostomy was performed in the infracolic region. Total blood loss was 100 ml with no blood transfusion required in intra-operative or post-operative period. Total operating time was 435 min. Post operatively patient kept on elective ventilator support for 12 h. Patient kept in intensive care unit for 2 days. Nasogastric tube was removed on 2nd post-operative day (POD) and oral feeding commenced on 4th POD after return of bowel activity. Drain fluid amylase was done on 3rd and 7th post-operative days which showed no PJ leak. 1st drain removed on 6th POD and 2nd on 7th POD. Patient discharged on 8th post-operative day without any complication. Histological examination (Fig. 3) confirmed diagnosis of SPN with all resected margins free and 11 resected lymph nodes were negative for tumour involvement. At 6 months of follow up at the time of writing this article, patient was doing well without any morbidity/recurrence.
Fig. 1. Contrast enhanced CT showing large well defined relatively hypodense lesion (61 53 mm) in head of pancreas with rim of peripheral calcifications and mild heterogenous enhancement and irregular septal enhancement.
551
Fig. 2. Intra-operative image following resection phase. HA e hepatic artery, PV e portal vein, SMV e superior mesenteric vein, SV e splenic vein, CHD e common hepatic duct, PAN e cut surface of pancreas with feeding tube in main pancreatic duct.
3. Discussion Laparoscopic surgical techniques have grown rapidly in last decade due to development in laparoscopic instruments, energy sources to control bleeding and growing laparoscopic experience. Laparoscopic pancreatic surgery is still not universally practiced though laparoscopic distal pancreatic resections are now proven to be safe and readily feasible [8,9]. LPD is a complex procedure with technical difficulties during dissection because of nearby large vessels and complex reconstruction. Many surgeons have questioned the safety and advantages of LPD over its open counterpart and this has appropriately resulted in slow adoption of the technique. Magnified view, better exposure, delicate handling of tissues and decreased blood loss are still advantages of the laparoscopic approach. The learning curve is steep, operative times are generally longer and hospital stay and recovery are not shortened as much as for other laparoscopic procedures. Technically also, LPD is difficult for benign or low-grade malignant pancreatic head lesions like SPN particularly reconstruction part due to the soft pancreas and the small size of pancreatic and bile ducts. However, many surgeons in recent years have acquired the necessary surgical skills to perform a safe procedure with acceptable results and as such laparoscopic pancreaticoduodenectomy is becoming a more frequently performed operation for benign as well as malignant lesions of the
Fig. 3. Histological examination shows papillary structures surrounded by medium sized polyhedral cells with extensive degenerative changes (H&E 100).
552
P. Senthilnathan et al. / Pancreatology 14 (2014) 550e552
head of the pancreas. This operation requires high level of laparoscopic skills and should be performed in high volume dedicated centres by expert laparoscopic surgeons if optimum results are to be obtained. We have performed more than 140 LPD till now. Solid pseudopapillary tumour/neoplasm (SPT/SPN) of the pancreas is a rare neoplasm accounting for 0.17%e2.7% of all pancreatic tumours [11]. Frantz [1] first described this tumour in 1959 as a papillary tumour of the pancreas. In 1996, the World Health Organization renamed it as SPT [10]. The tumour has low malignant potential with recurrence or metastasis rare after complete resection. It is usually seen in young women in the second or third decade of life. [11] Most of the patients present with nonspecific clinical features as in our case including abdominal pain, abdominal discomfort, poor appetite and nausea which may be related to compression of the adjacent organs by tumour. Majority of these tumours are diagnosed during complementary imaging investigations such as CT or US of the abdomen. CT/MRI scans typically show a large wellcircumscribed, heterogeneous mass with varying solid and cystic components, generally demarcated by a peripheral capsule and occasional calcification. MRI is superior to CT in distinguishing certain tissue characteristics such as haemorrhage, cystic degeneration or the presence of a capsule and may suggest correct diagnosis [12].The diagnosis can be confirmed by fine-needle aspiration (FNA) under endoscopic ultrasound (EUS) [13]guidance or percutaneously under ultrasound/CT-guidance. Currently, complete aggressive surgical resection is the treatment of choice for SPN of the pancreas. The overall 5 year survival was estimated to be 95% in a review of 718 patients reported in the English literature [11]. Surgical approach depends on both tumour location and size. Laparoscopic distal pancreatectomy is now well established procedure for SPN of distal body and tail. Open pancreaticoduodenectomy is recommended for SPN of head of the pancreas. To best of our knowledge, there are few reports of LPD for SPT in adults but no case is reported in literature of LPD for SPN in children. Because of experience and acquisition of adequate laparoscopic skills, we are able to perform this complex operation in 12 years old patient safely with acceptable oncological outcome.
4. Conclusion Solid pseudopapillary neoplasm is a rare tumour of the pancreas. Pancreaticodudenectomy is recommended treatment for this tumour located in head of the pancreas. Laparoscopic approach can be an alternative if expertise is available even in paediatric patients.
References [1] Frantz VK. Tumours of the pancreas. In: Blumberg CW, editor. Atlas of tumour pathology. Washington, DC: US Armed Forces Institute of Pathology; 1959. pp. 32e3. [2] Hamoudi AB, Misugi K, Grosfeld JL, Reiner CB. Papillary epithelial neoplasm of pancreas in a child. Report of a case with electron microscopy. Cancer 1970;26:1126e34. [3] Carricaburu E, Enezian G, Bonnard A, Berrebi D, Belarbi N, Huot O, et al. Laparoscopic distal pancreatectomy for Frantz's tumour in a child. Surg Endosc 2003;17(12):2028e31. [4] Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 1994;8:408e10. [5] Gagner M, Pomp A. Laparoscopic pancreatic resection: is it worthwhile? J Gastrointest Surg 1997;1:20e6. [6] Cuschieri A. Laparoscopic surgery of the pancreas. J R Coll Surg Edinb 1994;39: 178e84. [7] Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, et al. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. J Hepatobiliary Pancreat Surg 2009;16:731e40. [8] Teh SH, Tseng D, Sheppard BC. Laparoscopic and open distal pancreatic resection for benign pancreatic disease. J Gastrointest Surg 2007;11:1120e5. [9] Kim SC, Park KT, Hwang JW, Shin HC, Lee SS, Seo DW, et al. Comparative analysis of clinical outcomes of laparoscopic distal pancreatic resection and open distal pancreatic resection in a single institution. Surg Endosc 2008;22:2261e8. €ppel G, Solcia E, Longnecker DS, Capella C, Sobin LH. Histological typing of [10] Klo tumours of the exocrine pancreas. World Health Organization International Histological Classification of Tumours. 2nd ed. New York: Springer; 1996. pp. 120e8. [11] Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg 2005;200:965e72. [12] Cantisani V, Mortele KJ, Levy A, Glickman JN, Ricci P, Passariello R, et al. MR imaging features of solid pseudopapillary tumour of the pancreas in adult and paediatric patients. Am J Roentgenol 2003;181:395e401. [13] Jani N, Dewitt J, Eloubeidi M, Varadarajulu S, Appalaneni V, Hoffman B, et al. Endoscopic ultrasoundguided fine-needle aspiration for the diagnosis of solidpseudopapillary tumours of the pancreas: a multicenter experience. Endoscopy 2008;40:200e3.