[Developments in Pancreatic Surgery During the Past Ten Years.]

Klinik für Allgemeine, Viszerale und Transplantationschirurgie, Universität Heidelberg, Deutschland.
Zentralblatt für Chirurgie (Impact Factor: 1.05). 07/2013; 139(3). DOI: 10.1055/s-0032-1328181
Source: PubMed


Pancreatic surgery has undergone significant progress during recent years. Specialised centres with interdisciplinary expertise have led to improved patient care with decreased morbidity and mortality. Regarding evidence-based medicine, consensus definitions on morbidity as well as high-quality studies, systematic reviews and meta-analyses on different topics of pancreatic surgery have been published. In acute pancreatitis paradigms have shifted towards conservative management, in chronic pancreatitis parenchyma-sparing resection techniques have widely become accepted. Management of cystic lesions - especially intraductal papillary mucinous neoplasms (IPMN) - has attracted great interest in surgical practice. In pancreatic cancer treatment not only surgical resection techniques have improved but also the central impact of adjuvant treatment has been demonstrated in large multicentre trials.

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    ABSTRACT: Surgical treatment of intraductal papillary mucinous neoplasms (IPMN) requires a differentiated approach regarding indications and extent of resection. The review summarizes the current literature on indication, timing, and surgical procedures in IPMN. The most important differentiation has to be made between main-duct and branch-duct IPMN as well as mixed-type lesions that biologically mimic main-duct types. In main-duct and mixed-type IPMN, the resection should be indicated by the time of the diagnosis - in accordance with the international consensus guidelines - and should follow oncological principles. Depending on IPMN localization, this implies partial pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy and includes the corresponding types of lymphadenectomy. Furthermore, branch-duct IPMN > 3 cm or bearing high-risk features (mural nodules in magnetic resonance imaging, computed tomography, or endoscopic ultrasound imaging; symptomatic lesions; elevated tumor markers) are similarly treated. As the risk for malignancy in smaller branch-duct IPMN is lower, the decision for surgical treatment is often individually made - despite the updated 2012 guidelines. In these lesions, limited surgical approaches, including enucleation and central pancreatectomy, are possible. Timely and radical resection of IPMN offers the unique opportunity to prevent pancreatic cancer, and even in malignant IPMN surgery can offer a curative approach with excellent long-term outcome in early stages. A structured imaging follow-up should be considered to recognize IPMN recurrence and metachronous pancreatic cancer as well as gastrointestinal neoplasias by endoscopic surveillance.
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    ABSTRACT: Hospital volume, surgeons' experience, and adequate management of complications are factors that contribute to a better outcome after pancreatic resections. The aim of our study was to analyze trends in indications, surgical techniques, and postoperative outcome in more than 1,100 pancreatic resections. One thousand one hundred twenty pancreatic resections were performed since 1994. The vast majority of operations were performed by three surgeons. Perioperative data were documented in a pancreatic database. For the purpose of our analysis, the study period was sub-classified into three periods (A 1994 to 2001/n = 363; B 2001 to 2006/n = 305; C since 2007 to 2012/n = 452). The median patient age increased from 51 (A) to 65 years (C; P < 0.001). Indications for surgery were pancreatic/periampullary cancer (49%), chronic pancreatitis (CP; 33%), and various other lesions (18%). About two thirds of the operations were pylorus-preserving pancreaticoduodenectomies. The frequency of mesenterico-portal vein resections increased from 8% (A) to 20% (C; P < 0.01). The overall mortality was 2.4% and comparable in all three periods (2.8%, 2.0%, 2.4%; P = 0.8). Overall complication rates increased from 42% (A) to 56% (C; P < 0.01). Mortality remained low despite a more aggressive surgical approach to pancreatic disease. An increased overall morbidity may be explained by more clinically relevant pancreatic fistulas and better documentation.
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