ABSTRACT
Total pancreatectomy with islet autotransplantation, (TPIAT) is a complex surgical procedure for recurrent acute pancreatitis (RAP) and chronic pancreatitis, which can eliminate the risk of pancreatitis for pancreatic cancer and reduce the threat of severe diabetes mellitus. An increa-sing number of centers, here in the United States and internationally, are performing TPIAT and studies emerging from multiple centers highlight the benefits and persistent challenges of TPIAT for RAP and chronic pancreatitis. However, clear guidance on indications, contraindications, evaluation, timing of treatment and follow-up is lacking. The author reviews the history of TPIAT, and discusses the current state of TPIAT including indications of treatment, preoperative evaluations, surgical method, islet isolation and portal vein infusion, and postoperative management and a single center′s experience in TPIAT. A multiple center study with large numbers of patients will be critical to optimizing the successful application of this procedure.
ABSTRACT
Chronic pancreatitis is a progressive chronic inflammatory disease of caused by gene and other environmental factors, and clinical manifestation includes recurrent abdominal pain and dysfunction of exocrine and endocrine. For the chronic pancreatitis therapy, surgical treatment mainly aims at the intractable pain which is unresponsive to medical and endoscopic treatment, as well as complications of chronic pancreatitis. Total pancreatectomy with islet autotransplantation (TPIAT) gradually becomes a major therapeutic option for chronic pancreatitis surgical treatment, because it relieves the abdominal pain, reduces the opioid dependent, improves the quality of life, and increases the opportunity of insulin independent. In the past few years, a range of researches have been focusing on islet isolation, surgical approach, curative effect and postoperative complication, improvement of islet function after operation. The purpose of this article is to summarize the progression of TPIAT related research in the recent years.
ABSTRACT
OBJECTIVE: To investigate the application and clinical value of total pancreatectomy that combined vascular reconstruction with en bloc resection through both left and right pathways in pancreatic neck tumor. METHODS: The clinical data concerned about 12 patients of pancreatic neck tumor accepted total pancreatectomy combined vascular reconstruction with en bloc resection through both left and right pathways in Changhai Hospital,Naval Military Medical University between March 2015 and March 2017 were analyzed retrospectively. The clinical data especially the data in general situation,operation,hospital stay,perioperative complications,postoperative pathology,condition of surgical margin,postoperative survival time and prognosis were analyzed. RESULTS: All of the 12 patients were diagnosed with pancreatic neck tumor infringing the peripancreatic arteriovenous vein and had accepted total pancreatectomy joint with intravenous resection and reconstruction. The median age of patients was 58 years,whose median BMI reached 23.41,and the number of males was up to 6,equal as females. The information about the operation was as follows:no intraoperative death case,median surgery time being 235 min,median intraoperative blood loss being 800 m L,median plasma-reduced blood transfusion volume being 600 mL,median resection length of vessel being 4.10 cm,median time of portal vein blocking being 15 min. After the operation,9 cases were conducted to large tissue biopsy examination with R0 resection rate of 91.7%. Besides,all the patients were managed with ERAS technique with the postoperative pain relief rate of 100%. Only one case suffered from gastric emptying disorder(Grade A)and two cases had infection. No patients died 30 days after operation,whose median postoperative hospital stay was 12 days and median survival time was 19.8 months. CONCLUSION: The total pancreatectomy combined vascular reconstruction with en bloc resection through both left and right pathways is safe and efficient to treat pancreatic neck tumor,improving operation security and living quality of patients. However,the surgery is so difficult that it could only be applied in certain pancreatic surgery centers with high levels.
ABSTRACT
Objective To investigate the clinical efficacy of total pancreatectomy (TP) tor pancreatic cancer.Methods The retrospective descriptive study was conducted.The clinicopathological data of 11 patients who underwent TP for pancreatic cancer in the First Affiliated Hospital of Harbin Medical University from March 2009 to January 2016 were collected.Patients received planned TP or unplanned TP and digestive tract reconstruction using biliojejunal end-to-side anastomosis and side-to-side gastrojejunostomy.Observation indicators included:(1) treatment situations;(2) follow-up situation.Follow-up using outpatient examination and telephone interview was performed to detect the level of fasting blood glucose,glycosylated hemoglobin,dosages of insulin and pancreatic enzymes,symptoms of emaciation and diarrhea and patients' prognosis up to November 2016.Measurement data were represented as (x)±s,average (range) and M (range).Results (1) Treatment situations:all the 11 patients underwent successful TP,including 4 undergoing planned TP due to pancreatic multiple spaceoccupying lesions by preoperative imaging examination and 7 undergoing unplanned TP.Two patients received partial resection of the superior mesenteric vein and artificial vascular replacement due to tumor invading superior mesenteric vein.Two patients without cholangiectasis received external drainage through intraoperative biliary stent placement,and drainage tube was removed at month 1 postoperatively.Operation time was 270-640 minutes,with an average of 450 minutes.Volume of intraoperative blood loss was 200-1 500 mL,with an average of 564 mL.Five patients had intraoperative blood transfusion,with volume of 400-1 600 mL.Results of postoperative pathological examination of 11 patients:R0 and R1 resection were respectively detected in 10 and 1 patients;4 and 7 patients were in stage Ⅱ A and Ⅱ B,showing pancreatic ductal adenocarcinoma.Number of lymph node dissected with an average of 17.2±2.3 per case.Seven patients were complicated with local lymph node metastases,with a number of 2.1 per case.Three of 11 patients received postoperative 6-cycle chemotherapy regimens of gemcitabine and cisplatin.Four patients with postoperative complications were improved by conservative treatment,including 2 with infection,1 with bile leakage and 1 with delayed gastric emptying,without death.Duration of hospital stay was 15-56 days,with an average of 24 days.(2) Follow-up situation:11 patients were followed up for 5-24 months.During follow-up,levels of fasting blood glucose and glycosylated hemoglobin were respectively 5.0-10.0 mmol/L and 5.4％-10.4％,with averages of 7.6 mmol/L and 7.5％.Dosages of insulin and pancreatic enzymes were respectively 18.0-28.0 U/d and 450-900 mg/d,with averages of 22.7 U/d and 640 mg/d.During follow-up,4,5 and 2 patients had respectively increased,normal and decreased appetites.Three,4 and 4 patients had respectively increased,unchanged and decreased body weights.Symptoms of diarrhea,fatty liver (outpatient reexamination) and hypoglycemia were occurred in 2,2 and 1 patients,respectively.Of 11 patients,2 had tumorfree survival,and 9 had survival with tumor,with a median survival time of 12 months (range,5-23 months),including 3 with abdominal metastases or recurrence,2 with liver metastases,2 with pulmonary metastases and 2 with retroperitoneal lymphatic metastasis.Conclusion TP is safe and feasible for pancreatic cancer,it can also provide better quality of life for patients under conditions of regulating blood glucose and supplying pancreatic enzyme.
ABSTRACT
Intraductal Papillary Mucinous Neoplasm (IPMN) of the pancreas in association with Autosomal Dominant Polycystic Kidney Disease (ADPKD) is extremely rare, even though 10% of ADPKD patients may develop simple pancreatic cyst. The first case report was published by Yasunori Sato from Japan in 2009. Since then less than 10 case reports are available worldwide to describe about this condition. We reported such a rare case of a 67-year-old man with ADPKD who was referred to our centre because of chronic abdominal pain and diagnosed as IPMN based on the serial imaging procedures. Despite of the high risk comorbidities, he successfully underwent pylorus preserving total pancreaticoduodenectomy with splenectomy.
ABSTRACT
Objective To investigate the clinical efficacy of total pancreatectomy (TP) tor pancreatic cancer.Methods The retrospective descriptive study was conducted.The clinicopathological data of 11 patients who underwent TP for pancreatic cancer in the First Affiliated Hospital of Harbin Medical University from March 2009 to January 2016 were collected.Patients received planned TP or unplanned TP and digestive tract reconstruction using biliojejunal end-to-side anastomosis and side-to-side gastrojejunostomy.Observation indicators included:(1) treatment situations;(2) follow-up situation.Follow-up using outpatient examination and telephone interview was performed to detect the level of fasting blood glucose,glycosylated hemoglobin,dosages of insulin and pancreatic enzymes,symptoms of emaciation and diarrhea and patients' prognosis up to November 2016.Measurement data were represented as (x)±s,average (range) and M (range).Results (1) Treatment situations:all the 11 patients underwent successful TP,including 4 undergoing planned TP due to pancreatic multiple spaceoccupying lesions by preoperative imaging examination and 7 undergoing unplanned TP.Two patients received partial resection of the superior mesenteric vein and artificial vascular replacement due to tumor invading superior mesenteric vein.Two patients without cholangiectasis received external drainage through intraoperative biliary stent placement,and drainage tube was removed at month 1 postoperatively.Operation time was 270-640 minutes,with an average of 450 minutes.Volume of intraoperative blood loss was 200-1 500 mL,with an average of 564 mL.Five patients had intraoperative blood transfusion,with volume of 400-1 600 mL.Results of postoperative pathological examination of 11 patients:R0 and R1 resection were respectively detected in 10 and 1 patients;4 and 7 patients were in stage Ⅱ A and Ⅱ B,showing pancreatic ductal adenocarcinoma.Number of lymph node dissected with an average of 17.2±2.3 per case.Seven patients were complicated with local lymph node metastases,with a number of 2.1 per case.Three of 11 patients received postoperative 6-cycle chemotherapy regimens of gemcitabine and cisplatin.Four patients with postoperative complications were improved by conservative treatment,including 2 with infection,1 with bile leakage and 1 with delayed gastric emptying,without death.Duration of hospital stay was 15-56 days,with an average of 24 days.(2) Follow-up situation:11 patients were followed up for 5-24 months.During follow-up,levels of fasting blood glucose and glycosylated hemoglobin were respectively 5.0-10.0 mmol/L and 5.4％-10.4％,with averages of 7.6 mmol/L and 7.5％.Dosages of insulin and pancreatic enzymes were respectively 18.0-28.0 U/d and 450-900 mg/d,with averages of 22.7 U/d and 640 mg/d.During follow-up,4,5 and 2 patients had respectively increased,normal and decreased appetites.Three,4 and 4 patients had respectively increased,unchanged and decreased body weights.Symptoms of diarrhea,fatty liver (outpatient reexamination) and hypoglycemia were occurred in 2,2 and 1 patients,respectively.Of 11 patients,2 had tumorfree survival,and 9 had survival with tumor,with a median survival time of 12 months (range,5-23 months),including 3 with abdominal metastases or recurrence,2 with liver metastases,2 with pulmonary metastases and 2 with retroperitoneal lymphatic metastasis.Conclusion TP is safe and feasible for pancreatic cancer,it can also provide better quality of life for patients under conditions of regulating blood glucose and supplying pancreatic enzyme.
ABSTRACT
Objective To evaluate the post-operative glucose level and insulin dose of patients undergoing total pancreatectomy.Methods From September 1980 to September 2014, 21 patients underwent total pancrea-tectomy in Peking Union Medical College Hospital, who were enrolled in our study.We reviewed the changes in their insulin dosage and glucose levels after operation, also summarized type and dose of insulin as well as glucose level in stable period.Results The required insulin dose reached peak within 4 days after surgery ( maximum dose 300 U/d).The average dose was (143.5 ±62.8) U/d and decreased gradually.During the perioperative period (needing parenteral nutrition), the blood glucose level fluctuated markedly (1.52-29.06 mmol/L) and the average level was (11.18 ±0.95) mmol/L.During the stable period ( without parenteral nutrition) , patients on average had (5.3 ±2.0) U of preprandial rapid-acting insulin and (8.1 ±2.9) U of long-acting insulin be-fore sleeping;the average fasting blood glucose was (6.69 ±1.48) mmol/L, 2 h postprandial blood glucose was (9.08 ±2.84) mmol/L, bedtime blood glucose was (9.66 ±2.49) mmol/L, and blood glucose level at night was (8.15 ±2.78) mmol/L.67%of the patients had 13 hypoglycemic episodes monthly on average.For those five followed-up patients, the average hemoglobin A1c was (6.15 ±1.20)%.Conclusions Patients undergoing total pancreatectomy may experience marked fluctuation of blood glucose level and short-term increase of insulin need which gradually decreases afterwards.After entering the stable period, the glucose level could be well-con-trolled but with frequent hypoglycemia.There is no diabetic ketoacidosis.
ABSTRACT
Cold perfusion of liver can significantly alleviate the ischemia-reperfusion injury caused by hepatic blood flow occlusion. We have modified the technique of cold perfusion of liver and applied it to total pancreatectomy for patients with pancreatic head carcinoma complicated with metastasis to the body and tail of pancreas and with portal invasion. After skeletonization of the hepatoduodenal ligament, the amputation of the portal vein and blockage of the superior mesentoric vein were performed before portal perfusion. Meanwhile, pancreatic head resection, duodenectomy, subtotal gastrectomy and partial resection of the superior mesenteric vein and portal vein were carried out. Superior mesenteric vein and portal vein bypass grafting was achieved with artificial vessels. The digestive tract was reconstructed after it was freed of the spleen and resection of the body and tail of pancreas to the left side of superior mesenteric vein, greater omentum and intestine from the end of the colon to splenic flexure of colon. The patient was followed up for 3 months, and the general condition was good, although diarrhea frequently occurred. No tumor metastasis occurred.
ABSTRACT
PURPOSE: The surgical strategy for patients with a pancreatic intraductal papillary mucinous tumor (IPMT) is still controversial. In this study the clinicopathologic findings in a series of patients were used to rationalize surgical choice and reassess the need for a total pancreatectomy. METHODS: Between Oct. 1994 and Nov. 2001, 25 patients with IPMT underwent surgery. We retrospectively examined the clinicopathologic features and surgical treatment. The factors evaluated included: symptoms, tumor site, operation type, histological findings, resection margin, follow-up and survival. RESULTS: Pancreaticoduodenectomy was the most frequent surgical treatment (10 patients: 40%) followed by distal pancreatectomy (6), pylorus-preserving-pancreatico-duodenectomy (5) and total pancreatectomy (4). Histological assessment revealed the tumors to be an adenoma in 11 patients (44%), a borderline tumor in 8 patients (32%) and a carcinoma in 6 patients (24%). There were no operative or hospital deaths. All of the cases with hyperplasia, adenoma and noninvasive carcinoma survived. Only two of the patients with invasive carcinoma died. Mild to moderate dysplasia was present at the resection margin in two patients (8%), and carcinoma in one. A total pancreatectomy was performed in four patients. Invasive carcinoma patient survival was significantly associated with the presence of peri- pancreatic lymph node involvement. CONCLUSION: Our study and review of the literature indicates that preoperative indicators of malignancy in IPMT are still lacking. These results suggest that resection should be the treatment for IPMT. Sometimes IPMT is best treated by a total pancreatectomy, although lesser subtotal resections should definitely be considered. When selecting a surgical procedure for treating these tumors, it is useful to confirm the tumors' extent by intra-operative imaging modalities. In the cases with invasion, a radical resection is required.
Subject(s)
Humans , Adenoma , Follow-Up Studies , Hyperplasia , Lymph Nodes , Mucins , Pancreas , Pancreatectomy , Pancreaticoduodenectomy , Retrospective StudiesABSTRACT
Nesidioblastosis, persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a disorder characterized by diffuse pancreatic islet cell hyperplasia arising from the ductal epithelium. Patients usually present during the neonatal or infantile period with apnea, hypotonia, poor feeding, lethargy, or seizure. Despite of greater awareness, one in three has some degree of mental retardation by the time the diagnosis is made. The diagnosis is established by demonstrating high plasma insulin concentration during an episode of hypoglycemia. This hypoglycemia is initially managed medically, but these medical treatment modalities are failed in more than half of nesidioblastosis. Patient who failed to respond to optimal medical treatment should be referred for surgery early, if permanent neurologic damage is to be avoided. The surgical procedure of choice is near total pancreatectomy (95~98% resection). We herein discuss the anesthetic management of a patient with nesidioblastosis who presented for near total pancreatectomy.