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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic total remnant pancreatectomy after laparoscopic pancreaticoduodenectomy Hiroki Sunagawa, Yasuaki Mayama, Tomofumi Orokawa & Naoto Oshiro Department of Surgery, Nakagami Hospital, Okinawa, Japan
Keywords Laparoscopic pancreaticoduodenectomy; laparoscopic total remnant pancreatectomy; remnant pancreatic cancer Correspondence Hiroki Sunagawa, Department of Surgery, Nakagami Hospital, 6-25-5 Chibana, Okinawa-shi, Okinawa 904-2195, Japan. Tel: +81 98 939 1300 Fax: +81 98 937 8699 Email: [email protected] Received: 8 July 2013; revised 3 September 2013; accepted 4 September 2013 DOI:10.1111/ases.12064
Abstract Total remnant pancreatectomy after pancreaticoduodenectomy (PD) is a difficult procedure. Recently, distal pancreatectomy and PD have been performed laparoscopically. Herein, we present the first case report of a laparoscopic total remnant pancreatectomy. A 72-year-old woman underwent a totally laparoscopic pylorus-preserving PD for inferior bile duct cancer. The tumor was composed of moderately differentiated tubular adenocarcinoma and was diagnosed as pStage III according to the UICC-TNM classification. Eighteen months later, CT showed a low-density mass in the remnant pancreas. We conducted a total resection of the remnant pancreas laparoscopically. Histologically, it was diagnosed as a primary pancreatic cancer. The patient’s postoperative course was uneventful. She was discharged on postoperative day 14. When an initial PD is performed laparoscopically, laparoscopic total remnant pancreatectomy is technically feasible and safe in selected patients.
Introduction Total pancreatic resection for remnant pancreatic cancer offers the best chance for curability (1,2). Recently, distal pancreatectomy and pancreaticoduodenectomy (PD) have been performed laparoscopically (3). However, total remnant pancreatectomy for remnant pancreatic cancer after PD is difficult; the organ reconstruction created at the time of the initial surgery leaves severe adhesions, resulting in poor visualization. Additionally, laparoscopic pancreatic resection of pancreatic cancer is still uncommon as an alternative approach to open surgery because of the oncological perspective. Based on advances in laparoscopic technology and instruments, several surgeons have reported favorable results of laparoscopic resection of pancreatic cancer (4,5). There have been no reports of repeated laparoscopic pancreatectomy for a remnant pancreatic cancer after a laparoscopic PD. Herein, we report the first case report of laparoscopic total remnant pancreatectomy after PD.
Case Presentation A 72-year-old woman underwent a totally laparoscopic pylorus-preserving PD, with a modified Child’s recon-
struction, for inferior bile duct cancer at Nakagami Hospital (Okinawa, Japan) on 13 May 2011. A histological examination revealed that the tumor was a moderately differentiated tubular adenocarcinoma, and the presence of lymph node metastasis (1/20) was indicated. The surgical margins of the resected specimen were free from cancer cells. The histopathological diagnosis was pStage III (T3, N1) according to the UICC-TNM classification (6). In November 2012, CT indicated a mass lesion about 1.7 cm in diameter in the remnant pancreatic body (Figure 1). This tumor was observed to have fluorodeoxyglucose accumulation (maximum standard uptake volume = 6.1) on PET, but it was not possible to make a definitive diagnosis of pancreatic cancer. However, based on the comprehensive evaluation, a remnant pancreatic cancer was considered to be likely. The pancreatic tumor was small (1.7 cm in diameter) and there was no metastasis. Therefore, we considered a repeat pancreatectomy to be possible. We explained the risks and benefits of the laparoscopic total remnant pancreatectomy relative to the open procedure to the patient and obtained the approval of the ethics committee. The patient chose the laparoscopic total remnant pancreatectomy and provided written informed consent.
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
71
Laparoscopic remnant pancreatectomy
H Sunagawa et al.
Figure 2 The jejunal limb between the pancreaticojejunostomy and the choledocojejunostomy were divided. Site of the pancreatojejunostomy (arrows).
Figure 1 An abdominal CT detected a 1.7-cm tumor in the remnant pancreatic body (arrows).
A totally laparoscopic approach with five ports was used for the procedure. Using laparoscopic ultrasonography, we confirmed that there was no hepatic metastasis and that the tumor was inside the pancreas. The anastomosis sites (choledocojejunostomy and pancreatojejunostomy) of the initial surgery had adhesions, but the other side of these sites had limited adhesion. Using a linear stapler, we cut the jejunum between the site of the pancreaticojejunostomy and the choleocojejunostomy (Figure 2). The stomach was surrounded by tape and lifted to the ventral side. We entered and opened the retro-pancreatic space from the left side of the superior mesenteric artery. We cut the Gerota’s fascia and proceeded to the lower pole of the spleen. The retro-pancreatic approach is more advantageous for the laparoscopic approach than for the open surgery (Figure 3). When the remnant pancreas was free from the dorsal side, the splenocolonic ligament and gastrosplenic ligament were resected. Subsequently, the spleno-pancreas was pulled on the right side through the back of the stomach, and the left gastroepiploic vessels and short gastric vessels were resected with laparoscopic coagulating shears (HARMONIC Scalpel, Ethicon Endo-Surgery, Cincinnati, USA; LigaSure; Tyco Healthcare, Mansfield, USA). The spleen and the pancreatic tail were completely free and passed under the stomach (Figure 4). The remnant pancreas had dense adhesions to the hepatic artery, supra mesenteric vein and supra mesenteric artery, which we identified by
72
Figure 3 The retro-pancreatic space was opened.
laparoscopic ultrasonography. The splenic artery and vein were clipped and divided. Finally, we resected between the hepatic artery and pancreas. The specimen was then removed. The length of the operation was 462 min, and blood loss was 1200 mL. The number of retrieved lymph nodes was nine, and R0 resection was obtained. An immunohistochemical examination revealed primary tubular adenocarcinoma with moderate differentiation originating from the pancreas. The patient was diagnosed with pStage III (T3, N0). The patient started oral intake on postoperative day 3. Her recovery was uneventful, and she was discharged on postoperative day 14, after establishing the injection of insulin.
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic remnant pancreatectomy
H Sunagawa et al.
limited adhesions as a result of the laparoscopic procedure at the initial PD. The remnant pancreas in the present case had dense adhesions to the hepatic artery, supra mesenteric vein and supra mesenteric artery. It is important to confirm the anatomy of these vessels with laparoscopic ultrasonography. In conclusion, it remains controversial whether a repeated laparoscopic pancreatectomy for pancreatic cancer in the remnant pancreas contributes to a patient’s prognosis, as this is the first case that has been reported. We suggest that laparoscopic total remnant pancreatectomy is feasible and safe for selected patients. Nevertheless, we advocate a long-term follow-up after total remnant pancreatectomy, and the accumulation of further similar cases will be needed to confirm our findings.
Figure 4 The remnant pancreas was pulled out to the ventral side on the stomach. HA, hepatic artery; SMA, supra mesenteric artery; SMV, supra mesenteric vein.
Discussion By combining the advances in both surgical procedures and postoperative management, several surgeons have reported favorable results of laparoscopic pancreatectomy (4,5). However, laparoscopic PD remains technically difficult to perform, although it has increased in popularity and good results have been reported (4,7,8). Invasive ductal carcinoma of the pancreas is one of the cancers with the poorest prognosis. Unless it is treated during the early stages, most pancreatic carcinomas eventually become intractable. A pancreas-confined tumor with an intact fascia layer between the pancreas and left kidney is thought to be a potential indication for minimally invasive treatment (9,10). Although resection of the remnant pancreas can be performed safely (1,2), there have been no previous reports of a laparoscopic total remnant pancreatectomy after laparoscopic PD. In the present case, we planned a laparoscopic total remnant pancreatectomy because CT indicated that the tumor was small (1.7 cm) and confined to the pancreas. Because the pancreas is behind the stomach, which is fixed and immovable by duodenojejunostomy after PD with a modified Child’s reconstruction, it is useful to start the resection from the dorsal side of the pancreas. When the remnant pancreas is free from the dorsal side, the splenocolonic and gastrosplenic ligaments can be divided easily as a result of the increased mobility of the pancreas. In addition, the other side of the anastomosis sites had
Acknowledgment The authors have no conflicts of interest to disclose.
References 1. Kleeff J, Reiser C, Hinz U et al. Surgery for recurrent pancreatic ductal adenocarcinoma. Ann Surg 2007; 245: 566– 572. 2. Kinoshita H, Yamade N, Nakai H et al. Successful resection of pancreatic carcinoma recurrence in the remnant pancreas after a pancreaticoduodenectomy. Hepatogastroenterology 2012; 58: 1406–1408. 3. Nakamura M & Nakashima H. Laparoscopic distal pancreatectomy and pancreatoduodenectomy: Is it worthwhile? A meta-analysis of laparoscopic pancreatectomy. J Hepatobiliary Pancreat Sci 2013; 20: 421–428. 4. Kim SC, Song KB, Jung YS et al. Short-term clinical outcomes for 100 consecutive cases of laparoscopic pyloruspreserving pancreatoduodenectomy: Improvement with surgical experience. Surg Endosc 2013; 27: 95–103. 5. Cho A, Yamamoto H, Nagata M et al. Laparoscopic major hepato-biliary-pancreatic surgery: Formidable challenge to standardization. J Hepatobiliary Pancreat Surg 2009; 16: 705– 710. 6. Sobin LH & Wittekind C. UICC TMN classification of malignant tumors, 5th edn. New York: Wiley-Liss, 1997. 7. Cho A, Yamamoto H, Nagata M et al. Comparison of laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy for periampullary disease. Am J Surg 2009; 198: 445–449. 8. Kendrick ML & Cusati D. Total laparoscopic pancreaticoduodenectomy: Feasibility and outcome in an early experience. Arch Surg 2010; 145: 19–23. 9. Choi SH, Kang CM, Lee WJ et al. Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
73
Laparoscopic remnant pancreatectomy
H Sunagawa et al.
cancer: Technical feasibility and interim results. Surg Endosc 2011; 25: 2360–2361. 10. Strasberg SM, Linehan DC, Hawkins WG. Radical antegrade modular pancreatosplenectomy procedure for adeno-
74
carcinoma of the body and tail of the pancreas: Ability to obtain negative tangential margins. J Am Coll Surg 2007; 204: 244–249.
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic total remnant pancreatectomy after laparoscopic pancreaticoduodenectomy Hiroki Sunagawa, Yasuaki Mayama, Tomofumi Orokawa & Naoto Oshiro Department of Surgery, Nakagami Hospital, Okinawa, Japan
Keywords Laparoscopic pancreaticoduodenectomy; laparoscopic total remnant pancreatectomy; remnant pancreatic cancer Correspondence Hiroki Sunagawa, Department of Surgery, Nakagami Hospital, 6-25-5 Chibana, Okinawa-shi, Okinawa 904-2195, Japan. Tel: +81 98 939 1300 Fax: +81 98 937 8699 Email: [email protected] Received: 8 July 2013; revised 3 September 2013; accepted 4 September 2013 DOI:10.1111/ases.12064
Abstract Total remnant pancreatectomy after pancreaticoduodenectomy (PD) is a difficult procedure. Recently, distal pancreatectomy and PD have been performed laparoscopically. Herein, we present the first case report of a laparoscopic total remnant pancreatectomy. A 72-year-old woman underwent a totally laparoscopic pylorus-preserving PD for inferior bile duct cancer. The tumor was composed of moderately differentiated tubular adenocarcinoma and was diagnosed as pStage III according to the UICC-TNM classification. Eighteen months later, CT showed a low-density mass in the remnant pancreas. We conducted a total resection of the remnant pancreas laparoscopically. Histologically, it was diagnosed as a primary pancreatic cancer. The patient’s postoperative course was uneventful. She was discharged on postoperative day 14. When an initial PD is performed laparoscopically, laparoscopic total remnant pancreatectomy is technically feasible and safe in selected patients.
Introduction Total pancreatic resection for remnant pancreatic cancer offers the best chance for curability (1,2). Recently, distal pancreatectomy and pancreaticoduodenectomy (PD) have been performed laparoscopically (3). However, total remnant pancreatectomy for remnant pancreatic cancer after PD is difficult; the organ reconstruction created at the time of the initial surgery leaves severe adhesions, resulting in poor visualization. Additionally, laparoscopic pancreatic resection of pancreatic cancer is still uncommon as an alternative approach to open surgery because of the oncological perspective. Based on advances in laparoscopic technology and instruments, several surgeons have reported favorable results of laparoscopic resection of pancreatic cancer (4,5). There have been no reports of repeated laparoscopic pancreatectomy for a remnant pancreatic cancer after a laparoscopic PD. Herein, we report the first case report of laparoscopic total remnant pancreatectomy after PD.
Case Presentation A 72-year-old woman underwent a totally laparoscopic pylorus-preserving PD, with a modified Child’s recon-
struction, for inferior bile duct cancer at Nakagami Hospital (Okinawa, Japan) on 13 May 2011. A histological examination revealed that the tumor was a moderately differentiated tubular adenocarcinoma, and the presence of lymph node metastasis (1/20) was indicated. The surgical margins of the resected specimen were free from cancer cells. The histopathological diagnosis was pStage III (T3, N1) according to the UICC-TNM classification (6). In November 2012, CT indicated a mass lesion about 1.7 cm in diameter in the remnant pancreatic body (Figure 1). This tumor was observed to have fluorodeoxyglucose accumulation (maximum standard uptake volume = 6.1) on PET, but it was not possible to make a definitive diagnosis of pancreatic cancer. However, based on the comprehensive evaluation, a remnant pancreatic cancer was considered to be likely. The pancreatic tumor was small (1.7 cm in diameter) and there was no metastasis. Therefore, we considered a repeat pancreatectomy to be possible. We explained the risks and benefits of the laparoscopic total remnant pancreatectomy relative to the open procedure to the patient and obtained the approval of the ethics committee. The patient chose the laparoscopic total remnant pancreatectomy and provided written informed consent.
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
71
Laparoscopic remnant pancreatectomy
H Sunagawa et al.
Figure 2 The jejunal limb between the pancreaticojejunostomy and the choledocojejunostomy were divided. Site of the pancreatojejunostomy (arrows).
Figure 1 An abdominal CT detected a 1.7-cm tumor in the remnant pancreatic body (arrows).
A totally laparoscopic approach with five ports was used for the procedure. Using laparoscopic ultrasonography, we confirmed that there was no hepatic metastasis and that the tumor was inside the pancreas. The anastomosis sites (choledocojejunostomy and pancreatojejunostomy) of the initial surgery had adhesions, but the other side of these sites had limited adhesion. Using a linear stapler, we cut the jejunum between the site of the pancreaticojejunostomy and the choleocojejunostomy (Figure 2). The stomach was surrounded by tape and lifted to the ventral side. We entered and opened the retro-pancreatic space from the left side of the superior mesenteric artery. We cut the Gerota’s fascia and proceeded to the lower pole of the spleen. The retro-pancreatic approach is more advantageous for the laparoscopic approach than for the open surgery (Figure 3). When the remnant pancreas was free from the dorsal side, the splenocolonic ligament and gastrosplenic ligament were resected. Subsequently, the spleno-pancreas was pulled on the right side through the back of the stomach, and the left gastroepiploic vessels and short gastric vessels were resected with laparoscopic coagulating shears (HARMONIC Scalpel, Ethicon Endo-Surgery, Cincinnati, USA; LigaSure; Tyco Healthcare, Mansfield, USA). The spleen and the pancreatic tail were completely free and passed under the stomach (Figure 4). The remnant pancreas had dense adhesions to the hepatic artery, supra mesenteric vein and supra mesenteric artery, which we identified by
72
Figure 3 The retro-pancreatic space was opened.
laparoscopic ultrasonography. The splenic artery and vein were clipped and divided. Finally, we resected between the hepatic artery and pancreas. The specimen was then removed. The length of the operation was 462 min, and blood loss was 1200 mL. The number of retrieved lymph nodes was nine, and R0 resection was obtained. An immunohistochemical examination revealed primary tubular adenocarcinoma with moderate differentiation originating from the pancreas. The patient was diagnosed with pStage III (T3, N0). The patient started oral intake on postoperative day 3. Her recovery was uneventful, and she was discharged on postoperative day 14, after establishing the injection of insulin.
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic remnant pancreatectomy
H Sunagawa et al.
limited adhesions as a result of the laparoscopic procedure at the initial PD. The remnant pancreas in the present case had dense adhesions to the hepatic artery, supra mesenteric vein and supra mesenteric artery. It is important to confirm the anatomy of these vessels with laparoscopic ultrasonography. In conclusion, it remains controversial whether a repeated laparoscopic pancreatectomy for pancreatic cancer in the remnant pancreas contributes to a patient’s prognosis, as this is the first case that has been reported. We suggest that laparoscopic total remnant pancreatectomy is feasible and safe for selected patients. Nevertheless, we advocate a long-term follow-up after total remnant pancreatectomy, and the accumulation of further similar cases will be needed to confirm our findings.
Figure 4 The remnant pancreas was pulled out to the ventral side on the stomach. HA, hepatic artery; SMA, supra mesenteric artery; SMV, supra mesenteric vein.
Discussion By combining the advances in both surgical procedures and postoperative management, several surgeons have reported favorable results of laparoscopic pancreatectomy (4,5). However, laparoscopic PD remains technically difficult to perform, although it has increased in popularity and good results have been reported (4,7,8). Invasive ductal carcinoma of the pancreas is one of the cancers with the poorest prognosis. Unless it is treated during the early stages, most pancreatic carcinomas eventually become intractable. A pancreas-confined tumor with an intact fascia layer between the pancreas and left kidney is thought to be a potential indication for minimally invasive treatment (9,10). Although resection of the remnant pancreas can be performed safely (1,2), there have been no previous reports of a laparoscopic total remnant pancreatectomy after laparoscopic PD. In the present case, we planned a laparoscopic total remnant pancreatectomy because CT indicated that the tumor was small (1.7 cm) and confined to the pancreas. Because the pancreas is behind the stomach, which is fixed and immovable by duodenojejunostomy after PD with a modified Child’s reconstruction, it is useful to start the resection from the dorsal side of the pancreas. When the remnant pancreas is free from the dorsal side, the splenocolonic and gastrosplenic ligaments can be divided easily as a result of the increased mobility of the pancreas. In addition, the other side of the anastomosis sites had
Acknowledgment The authors have no conflicts of interest to disclose.
References 1. Kleeff J, Reiser C, Hinz U et al. Surgery for recurrent pancreatic ductal adenocarcinoma. Ann Surg 2007; 245: 566– 572. 2. Kinoshita H, Yamade N, Nakai H et al. Successful resection of pancreatic carcinoma recurrence in the remnant pancreas after a pancreaticoduodenectomy. Hepatogastroenterology 2012; 58: 1406–1408. 3. Nakamura M & Nakashima H. Laparoscopic distal pancreatectomy and pancreatoduodenectomy: Is it worthwhile? A meta-analysis of laparoscopic pancreatectomy. J Hepatobiliary Pancreat Sci 2013; 20: 421–428. 4. Kim SC, Song KB, Jung YS et al. Short-term clinical outcomes for 100 consecutive cases of laparoscopic pyloruspreserving pancreatoduodenectomy: Improvement with surgical experience. Surg Endosc 2013; 27: 95–103. 5. Cho A, Yamamoto H, Nagata M et al. Laparoscopic major hepato-biliary-pancreatic surgery: Formidable challenge to standardization. J Hepatobiliary Pancreat Surg 2009; 16: 705– 710. 6. Sobin LH & Wittekind C. UICC TMN classification of malignant tumors, 5th edn. New York: Wiley-Liss, 1997. 7. Cho A, Yamamoto H, Nagata M et al. Comparison of laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy for periampullary disease. Am J Surg 2009; 198: 445–449. 8. Kendrick ML & Cusati D. Total laparoscopic pancreaticoduodenectomy: Feasibility and outcome in an early experience. Arch Surg 2010; 145: 19–23. 9. Choi SH, Kang CM, Lee WJ et al. Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
73
Laparoscopic remnant pancreatectomy
H Sunagawa et al.
cancer: Technical feasibility and interim results. Surg Endosc 2011; 25: 2360–2361. 10. Strasberg SM, Linehan DC, Hawkins WG. Radical antegrade modular pancreatosplenectomy procedure for adeno-
74
carcinoma of the body and tail of the pancreas: Ability to obtain negative tangential margins. J Am Coll Surg 2007; 204: 244–249.
Asian J Endosc Surg 7 (2014) 71–74 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
