[Show abstract][Hide abstract] ABSTRACT: Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections.
Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively.
The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2 %, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5 % of patients; pancreatic fistula in 36.7, 35.2 and 20.1 %; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72 %; and after DPPHRt/p 0.49 %. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001).
EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.
Full-text · Article · Feb 2015 · World Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Background
The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard.
To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate.
Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2 -3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20 % of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11 %, pancreatic fistula in 33 %. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33 % pancreatic fistula and severe post-operative complications of 18 % is related to management of proximal pancreatic stump. DPPHRt/s is used in 70 % for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10 % for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy.
The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.
[Show abstract][Hide abstract] ABSTRACT: Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called „Laparoscopic pancreatic surgery“ was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.
For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.
It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called "Laparoscopic pancreatic surgery" was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: After the routine use of ether narcosis and surgical antisepsis, the evolution of surgery experienced fascinating and genuinely surgical technique-related advancements. Surgeons from Germany contributed strongly to the upturn of operative treatment in the second half of the nineteenth century. DISCUSSION: B. von Langenbeck inaugurated in 1852 an osteosynthese device in a patient with pseudoarthrosis. He is credited to be the very first in introducing the principle of fixateur externe. Th. Billroth performed in 1873 the first extirpation of the larynx in a patient with a malignant tumor. Postoperatively, the patient was cared with an artificial larynx. The first successful resection of the distal stomach inaugurated by Th. Billroth in 1881 was later called the Billroth II procedure. Rydygier from Kulm and Billroth from Wien are the first who successfully performed resection of the lower part of the stomach with anastomosis to the duodenum (Billroth I type of resection). In 1883, Th. Kocher from Bern reported 101 cases of thyroidectomy, the largest single-surgeon experience. L. Rehn from Frankfurt did in 1887 the first successful suturing of a beating heart to repair a large stab wound. A. Braun, Königsberg presented in 1892 his techniques of side-to-side anastomosis of the intestine to avoid a circular intestinal anastomosis. F. Sauerbruch from Breslau published in 1904 his thoracotomy chamber with space for two surgeons opening routine access to intrathoracic tissues protecting pulmonary ventilation during surgery. W. Kausch from Berlin reported in 1912 about three successful pancreatic head resections for peripapillary cancer. The first successful pancreatic head resection was performed in 1909 in a patient with a cancer of the papilla. The patient survived for a long term.
No preview · Article · Mar 2010 · Langenbeck s Archives of Surgery
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: In February 1860, B. Langenbeck, Th. Billroth, and G. Gurlt certified in Berlin with the publisher A. Hirschwald the founding of Archiv für Klinische Chirurgie. The journal published extended reports about application of new and case-proven surgical procedures. Separate sections were dedicated to surgical casuistics and small surgical communications and report of surgical institutions from Germany, Austria, and Switzerland as well as annual statistical reports of hospitals. Beginning with the first issue, the Archive was an international journal with the focus on gastrointestinal, trauma, orthopedic, thyroid, and vascular surgery. A section Achievements and Progress in Surgery referred to published results in national and international medical and surgical journals. GERMAN SOCIETY OF SURGERY: Surgeons from Germany contributed strongly to the rise of operative treatment concepts in the second half of the nineteenth century by new surgical procedures, many of them published in the Archiv für Klinische Chirurgie. Since 1923, the German Society of Surgery took Archiv für Klinische Chirurgie as the official journal of the society. Beginning 1950, Langenbeck's published in a separate supplement the proceedings of the annual congress of the German Society of Surgery. A second supplement published since 1972 focused exclusively on reporting of research work presented in the section of Surgical Forum for Experimental and Clinical Surgery. AFTER THE WAR: After World War II, Langenbeck's Archiv für Chirurgie gained acceptance as the leading scientific surgical journal in Germany. Since 1998, the concept of Langenbeck's Archiv was completely changed to an English journal with the title Langenbeck's Archives of Surgery. In the last 12 years, Langenbeck's has turned to an international German-surgery-based electronic journal. Langenbeck's Archives of Surgery experienced an increasing international reputation; in 2001, only two non-American journals (British Journal of Surgery and Langenbeck's) belonged to the top ten journals in general and GI-tract surgery. The present impact factor (IF) of Langenbeck's Archives of Surgery is 1.829 (5-year IF). The decrease of subscriptions for the journal is compensated by an increase of electronic readers. The electronic supplementary material provided by the Springer Company is used to publish manuscripts in the section How-To-Do Surgery, combined with a video clip about surgical techniques. The focus of Langenbeck's is general, GI-tract, endocrine, and HBP surgery. CONCLUSION: Langenbeck's has continuously been published for 150 years and is considered to be the worldwide oldest scientific surgical journal. The English-language-based journal contributes increasingly to an international communication of surgical research and clinical surgeons from Germany.
No preview · Article · Mar 2010 · Langenbeck s Archives of Surgery
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: For treatment of inflammatory and benign neoplastic lesions of the pancreatic head, a subtotal or total pancreatic head resection is a limited surgical procedure with the impact of replacing the application of a Whipple procedure. The objective of this work is to describe the technical modifications of subtotal and total pancreatic head resection for inflammatory and neoplastic lesions of the pancreas. The advantages of this limited surgical procedure are the preservation of the stomach, the duodenum and the extrahepatic biliary ducts for treatment of benign lesions of the pancreatic head, papilla, and intrapancreatic segment of the common bile duct. For chronic pancreatitis with an inflammatory mass complicated by compression of the common bile duct or causing multiple pancreatic main duct stenoses and dilatations, a subtotal pancreatic head resection results in a long-lasting pain control. Performing, in addition, a biliary anastomosis or a Partington Rochelle type of pancreatic main duct drainage, respectively, is a logic and simple extension of the procedure. The rationale for the application of duodenum-preserving total pancreatic head resection for cystic neoplastic lesions are complete exstirpation of the tumor and, as a consequence, interruption of carcinogenesis of the neoplasia preventing development of pancreatic cancer. Duodenum-preserving total head resection necessitates additional biliary and duodenal anastomoses. For mono-centric IPMN, MCN, and SCA tumors, located in the pancreatic head, total duodenum-preserving pancreatic head resection can be performed without hospital mortality and resurgery for recurrency. Based on controlled clinical trials, duodenum-preserving pancreatic head resection is superior to the Whipple-type resection with regard to lower postoperative morbidity, almost no delay of gastric emptying, preservation of the endocrine function, lower frequency of rehospitalization, early professional rehabilitation, and establishment of a predisease level of quality of life. CONCLUSION: The limited surgical procedures of subtotal or total pancreatic head resection are simple, safe, ensures free tumour margins and replace in the authors institution the application of a Whipple-type head resection.
No preview · Article · Jul 2008 · Journal of Gastrointestinal Surgery
[Show abstract][Hide abstract] ABSTRACT: Duodenum-preserving pancreatic head resection (DPPHR) was introduced in clinical practice in 1972 after experimentation on dogs to elucidate the technique of a segmental resection of pancreatic tissue with regard to early and late histology of the two pancreaticojejunostomoses and maintenance of adequate vascularization of the pancreatic head rest along the duodenum.
[Show abstract][Hide abstract] ABSTRACT: Pancreatic pseudocysts are a frequent complication of acute pancreatitis and remain a challenging problem. The advent of advanced imaging techniques has improved considerably our knowledge about the natural course of pancreatic pseudocysts and driven the management away from surgery toward conservative approaches. More than 50% of postacute pseudocysts are asymptomatic and resolve spontaneously over time, whereas some form of drainage is required if symptoms or complications arise. To choose the most appropriate approach to drainage, a precise classification into acute- and acute-on-chronic-type pseudocysts with the assessment of pancreatic duct morphology is of central importance. A variety of operative, interventional, radiologic, and endoscopic techniques for cyst drainage are currently available, with a clear shift from open surgery to interventional approaches over the past decades. However, as a result of incorrect or vague terminology, interinstitutional comparison of data is often difficult and controversies in management and outcome are the consequence. A review of well-defined patient series since the 1990s reveals that open surgery of pancreatic pseudocysts carries a long-term recurrence rate of 8% and a hospital mortality of only 3%. The results of recent laparoscopic techniques to pseudocyst drainage in limited patient numbers compares well with the short- and long-term outcome of the open procedures. This chapter provides an overview of the current evidence regarding the natural course, diagnostic aspects, and operative management strategies of postacute pancreatic pseudocysts.
[Show abstract][Hide abstract] ABSTRACT: Pancreatic infection is one of the major complication of acute pancreatitis. Due to improvements in surgical and intensive care management, most patients survive the initial phase of severe acute pancreatitis, but their lives are still at risk as soon as septic complications occur. Today, pancreatic infection is regarded as the leading cause of late death in severe acute pancreatitis [1-3] (Table 22.1). Bacterial infection of necrosis occurs in 40-70% of all patients with necrotizing pancreatitis [1,4,5]. Pancreatic abscess develops in about 10% of all patients suffering from a necrotizing pancreatitis and in about 3% of all patients with acute pancreatitis (Table 22.2) [6-8]. The definition of a pancreatic abscess as a distinct clinical entity in the late course of acute pancreatitis, different from infected necrosis, was provided by Bittner et al. [1,9]. The terms pancreatic abscess, pancreatic sepsis, pancreatic phlegmon, and infected necrosis have often been used as a synonym in the past, which has contributed to a considerable confusion about adequate therapeutic approaches and their results .
[Show abstract][Hide abstract] ABSTRACT: In industrialized countries, two-thirds of patients suffer from chronic alcoholic pancreatitis, 20% from idiopathic chronic pancreatitis, and ≤10% from hereditary chronic pancreatitis. It is believed that chronic alcoholic pancreatitis is a consequence of recurrent attacks of acute pancreatitis causing small areas of pancreatic necrosis, which lead to tissue granulation and fibrosis . Chronic pancreatitis is a disease of the exocrine pancreatic tissue compartment, which, in the late course, extends to the endocrine tissue. In the majority of patients it develops after a preclinical period of 3-12 years, with upper abdominal pain being the first sign of disease. Continuous alcohol consumption and cigarette smoking enhances the progression of chronic pancreatitis. In the late stage, local complications are caused by a progressive inflammatory process. In addition to severe medically intractable upper abdominal pain, morbidity is characterized in about 30-50% by the development of an inflammatory mass in the head of the pancreas, by common bile duct stenosis in 30%, and by the development of large pseudocysts, severe stenosis of the duodenum, portal vein compression, portal vein and splenic vein occlusion/thrombosis, and most frequently by pancreatic main duct and side branch stenoses (Table 35.1) .
[Show abstract][Hide abstract] ABSTRACT: Chronic pancreatitis, which is usually caused by chronic alcohol abuse, is primarily a disease of the exocrine compartment of the pancreas. Several pathological concepts have been proposed to explain the morphological changes that occur during the disease. The most widely accepted concept is based on the observation that overconsumption of alcohol leads to increasing formation of protein plaques [1, 2]. Protein plaques cause obstruction of the pancreatic ducts, resulting in the induction and perpetuation of local chronic inflammatory processes in the pancreas in addition to the alcohol damage imposed directly on the acinar and ductal cells. In recent years, it has been hypothesized that chronic pancreatitis is the consequence of recurrent attacks of acute pancreatitis causing small areas of pancreatic necrosis, which lead to granulation tissue and fibrosis [3-5]. Periductal formation of fibrotic tissue after focal tissue necrosis and inflammatory areas lead to ductal obstruction, including the main pancreatic duct. However, none of these proposed concepts can conclusively explain the causal factors and the consequent local events leading to that disease. An additional factor that enhances chronic inflammatory pancreatitis is cigarette smoking, which has been shown in animal experiments to result in a specific type of chronic pancreatitis with tissue calcification .
[Show abstract][Hide abstract] ABSTRACT: Acute pancreatitis is characterized by an extreme variability in clinical presentation and outcome that has plagued the study and management of this disease ever since its first description by Reginald Fitz in 1889 . At that time the diagnosis of acute pancreatitis was restricted to the most severe cases by means of clinical symptoms - surgery was a desperate attempt to lower the excessively high mortality rates. Sir Berkeley Moynihan summed up the prevailing opinion at the turn of the century: "recovery from this disease, apart from operation, is so rare that no case should be left untreated" . The development of serum amylase assays in 1925 as a reliable means to diagnose acute pancreatitis substantially changed the general understanding of the natural course of this disease . It became evident that in the majority of patients a mild course with spontaneous recovery was the rule rather than the exception. As a consequence, the therapeutic approach was directed toward conservative management [4,5]. However, mortality rates among patients with severe disease continued to be high and physicians felt the need to reassess the role of surgery in this specific setting [6,7]. These efforts culminated in a variety of surgical approaches ranging from conservative simple peripancreatic drainage [8-10] to aggressive operative techniques such as total pancreatectomy [11-16]. In the subsequent years, clinical observations flanked by novel diagnostic imaging procedures helped us to gain further insights into the pathophysiological background of acute pancreatitis. It became evident that complications develop in about 20% of all patients, and these are closely related to the morphological features of intra- and extrapancreatic necrosis [17-20]. Several factors have been identified as the main determinants of outcome in this severely ill group of patients: (1) the extent of intra- and extrapancreatic necrosis [10,18-20], (2) infection of pancreatic necrosis [21,22], and, most recently (30) early onset [23-26] and persisting [27,28] multiorgan dysfunction syndrome. Considering the individuality and dynamics of the natural course of acute pancreatitis, physicians became aware that any single therapeutic concept would be unlikely to be successful for each of these patients during the different stages of the disease. Therefore, a multidisciplinary approach of improved intensive care management and the combination of widespread necrosectomy with some form of drainage of the peripancreatic space markedly decreased the mortality of necrotizing pancreatitis to about 20% in the past 20 years . Besides simple drainage, two major additional concepts were introduced in the 1980s and have gained widespread acceptance because they provide further evacuation of necrotic or infected pancreatic and peripancreatic tissue: the open approach by either controlled packing or repeated, planned reoperative debridement [30-35], and the closed approach with continuous lavage [36-42] or simple drainage [43-48]. Despite the benefits of these new surgical concepts, postoperative morbidity and procedure-related complications still remained a major point of concern. Bearing in mind the prognostic importance of infection, a completely conservative approach was attempted during the early 1990s in the subset of patients with sterile necrosis, for which the mortality rates were surprisingly favorable as long as infection was absent [49-51]. In this context, several new diagnostic and therapeutic protocols, such as guided fine-needle aspiration (FNA) of necrosis [52,53], early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis , prophylactic antibiotics , and early enteral feeding  helped to correctly diagnose or even to decrease the occurrence of subsequent complications, most importantly infections. Thus, the therapeutic pendulum once again swung away from operative toward conservative approaches [38,57-60]. Currently, the overall percentage of patients with necrotizing pancreatitis ultimately subjected to operative treatment has decreased to less than 20%.