Laparoscopic distal pancreatectomy and splenectomy for malignant tumors.
ABSTRACT Laparoscopic distal pancreatectomy has become the gold standard for benign tumors. As more surgeons have expertise in open and laparoscopic pancreatic surgery, increasing numbers of benign-appearing tumors are being removed via minimally invasive techniques and found to have malignancy on final pathology. Because of our growing experience in laparoscopic distal pancreatectomy, we have begun removing preoperatively suspected malignancies in the distal pancreas with minimally invasive techniques.
All cases were collected prospectively in a database and analyzed retrospectively. All cases begun laparoscopically with the intention of performing the resection with minimally invasive techniques were considered even if the operation was ultimately converted to an open procedure.
A total of 12 cases have been attempted of which four required hand assistance and one required conversion to an open approach due to delayed bleeding from a calcified splenic artery that had been transected with laparoscopic GIA stapler device. In total, eight (67%) patients had malignant disease and four (33%) were found to have benign tumors. The median lymph node retrieval is 8 (range 3-16) with no positive margins. The morbidity rate is 17% with one reoperation (8%) and one mortality (8%) at 30 and 90 days.
The laparoscopic approach to malignant pancreatic tumors is feasible with similar morbidity and mortality rates to benign series. When tumors are next to the confluence of the splenic portal vein, a hand-assisted approach may be adviseable. Calcified splenic arteries should be sought on preoperative imaging and either transected in non-calcified segments or controlled via open techniques via the hand port.
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ABSTRACT: We present an unusual case of primary malignant mesothelioma of the penis in an adult male. The clinical features and microscopic, immunohistochemical, and ultrastructural characteristics that help to identify this entity are described. A discussion of the behavior of malignant mesothelioma follows, as well as a possible explanation for its origin in the penis. To date, no cases of primary malignant mesothelioma of the penis have been reported.Urology 10/2003; 62(3):551. · 2.42 Impact Factor
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ABSTRACT: The reported experience with laparoscopic pancreatic resections (LPR) remains limited to case reports or small series of patients. A retrospective multicenter study was conducted in 25 European surgical centers concerning their experience with LPR. Detailed questionnaires were used, focusing on patients, tumors, operative data, and late outcome. During the study period, 127 patients with presumed pancreatic neoplasms were enrolled in this series. Final diagnoses included benign pancreatic diseases in 111 patients (87%; insulinoma: 22, neuroendocrine neoplasm: 20, mucinous cystadenoma: 26, serous cystadenoma: 21, chronic pancreatitis: 11, others: 11), and 16 patients (13%) had malignant pancreatic diseases (insulinoma: 3, neuroendocrine neoplasm: 5, ductal adenocarcinoma: 4, cystadenocarcinoma: 2, renal metastases: 2). Five patients with presumed benign pancreatic disease had malignancy at final pathology. The median tumor size was 30 mm (range, 5-120 mm); 89% of tumors were located in the left pancreas. Laparoscopically successful procedures included 21 enucleations, 24 distal splenopancreatectomies, 58 distal pancreatectomies with splenic preservation, and 3 pancreatoduodenal resections. The overall conversion rate was 14%. There were no postoperative deaths. The rate of overall postoperative pancreatic-related complications was 31%, including a 17% rate of clinical pancreatic fistula. The surgical reoperation rate was 6.3%. In laparoscopically successful operations, the median postoperative hospital stay was 7 days (range, 3-67 days), decreased compared with patients requiring conversion to open pancreatectomy. During a median follow-up of 15 months (range, 3-47 months), 23% of the patients with pancreatic malignancies had tumor recurrence. Late outcome was satisfactory in all patients with benign diseases. LPR is feasible and safe in selected patients with presumed benign and distal pancreatic tumors. The management of the pancreatic stump remains a challenge. The role of LPR for pancreatic malignancies remains controversial.Surgery 07/2005; 137(6):597-605. · 3.37 Impact Factor
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ABSTRACT: Pancreatic fistula is a major cause of morbidity after distal pancreatic resection. When resections are performed with linear stapling devices, the use of bioabsorbable staple line reinforcement has been suggested to decrease the rate of pancreatic fistula. Our objective was to investigate the incidence of pancreatic fistula when using the Gore Seamguard staple line reinforcement in stapled distal pancreatic resections. A retrospective review of 30 consecutive patients with stapled distal pancreatectomy was conducted. A broad definition of pancreatic fistula was used. Clinicopathologic factors and outcomes were compared between groups. Pancreatic fistula was diagnosed in 11 of 15 patients (73%) and three of 15 patients (20%) in the Seamguard and non-Seamguard groups, respectively (P = 0.002). Pancreatic parenchymal transection at the neck of the gland was associated with pancreatic fistula, whereas laparoscopic procedures, splenic preservation, or additional organ resection were not. On multivariate analysis, the association between Seamguard use and pancreatic fistula was significant (P = 0.005). In conclusion, after introduction of the Gore Seamguard bioabsorbable staple line reinforcement, we experienced a significant increase in the rate of pancreatic fistula. This experience raises concern about the efficacy of this device in limiting pancreatic fistula after stapled distal pancreatic resection.The American surgeon 10/2009; 75(10):954-7. · 0.92 Impact Factor