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ABCD, arq. bras. cir. dig. vol.25 no.3 São Paulo July/Sept. 2012
José Francisco de Mattos FarahI, II; Renato Micelli LupinacciI, III; Franz R Apodaca-TorresII
de Cirurgia Geral e Oncológica, Hospital do Servidor Público Estadual
de São Paulo, SP, Brasil
IIDepartamento de Cirurgia do Aparelho Digestivo, Universidade Federal de São Paulo, SP, Brasil
IIIService de Chirurgie Général, Digestive et Endocrinienne, Hôpital de la Pitié-Salpetrière - APHP, Paris - France
Laparoscopic pancreatic resections have become increasingly frequent with
good results reported by several centers. However, few studies have focused
on laparoscopic treatment of pancreatic cystic lesions.
AIM: To analyze the results of minimally invasive treatment of pancreatic cystic lesions.
METHODS: Were included all laparoscopic pancreatic resections performed at three centers. Surgical procedures included resection of the pancreas and left enucleations (with or without splenectomy). The post-operative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if the amylase dosage of the drainage liquid in the third postoperative day was more than three times the amount of serum amylase.
RESULTS: Were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma and 13 had this diagnosis confirmed. There were 12 women (92%), and the average age of patients was 50 years. Six patients had minor postoperative complications. There were five (38%) pancreatic fistulas, neither considered as severe (C), and only one patient required hospital readmission and radiological drainage. In this series, there were no conversions, reoperations, or mortality.
CONCLUSIONS: The laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.
Headings: Rats. Wound healing. Insufflation. Traction.
Cystic neoplasms of the pancreas comprise 15-20% of pancreatic cystic lesions and approximately 10% of all pancreatic cancers1,2. Although infrequent, and with no specific symptoms, it has been observed an increase in diagnosis of the so called "incidental lesions", mostly because of technological improvement of diagnostic imaging methods. Belongs to this large group of neoplasms, a number of heterogeneous tumors which present very similar clinical and laboratory characteristics, however, with totally different prognosis23,24.
Cystic lesions of the pancreas may be divided into three groups according to their epithelial lining: 1) no epithelial lining (pseudocysts), 2) presence of epithelial lining (serous cystadenomas and mucinous cystadenomas), 3) presence of degeneration of the epithelial lining or solid lesions (solid-cystic papillary tumors, ductal adenocarcinomas, and neuroendocrine tumors).
Pancreatic cystadenomas, which surgical treatment constitutes the focus of this article, are classified according to their histopathological characteristics1,5,15: 1) serous cystic neoplasms (serous cystadenoma and serous cistoadenocarcinoma); 2) mucinous cystic neoplasm (mucinous cystadenoma, and mucinous cystadenoma with moderate dysplasia); 3) mucinous cistoadenocarcinoma, which can be divided into non-infiltrating and infiltrating.
Laparoscopic pancreatic resections have become increasingly frequent, with excellent results reported by several centers7,10,19,26. However, few studies have focused on laparoscopic treatment of pancreatic cystic lesions.
The aim of this study is to analyze the results of a minimally invasive approach to cystic pancreatic lesions.
This study is a retrospective analysis of a prospective collected database started in 2006. Were included all laparoscopic pancreatic resections performed in three centers (Service of General and Oncologic Surgery, Hospital do Servidor Público Estadual de São Paulo; Department of Digestive Surgery, Universidade Federal de São Paulo; Service of Oncologic Surgery of Cuiabá, MT, Brazil). The procedures performed included enucleations and distal pancreatectomies (with or without splenectomy). Preoperatively patients were given anti-pneumococcal vaccination (two weeks before surgery) and antibiotic prophylaxis (at general anesthesia induction and two additional doses at POD 1). Liquid diet was started in the first or second POD. The most common surgery performed was distal pancreatectomy with splenectomy.
Patient was placed in supine position with the surgeon standing between the patient's legs. The first assistant stands on the patient's right side (camera and forceps traction), and the second on the left of the patient. Five portals were used: 1) a 10 mm supra-umbilical (optical); 2) a 12 mm in the left hypochondrium (for dissection and stapler firing); 3) a 5 mm in the right hypochondrium (dissection); 4) a 5 mm in epigastrium (presentation); and 5) 5 mm on the left flank, if needed for presentation. The operation began with the opening of gastrocolic ligament beneath the gastroepiploic vessels for pancreas visualization and identification of the lesion. Omental complete section was performed from medial to lateral including the splenocolic ligament, also divided. Thus, was perform the dissection of the splenic artery in its middle third (in some cases was chosen just to tie with no division of the artery at this point). Dissection continued at the lower edge of the pancreas, with section of the root of the mid-colon. The inferior mesenteric vein and the splenic vein were visualized, freed, and the splenic vein was then ligated and divided. A retropancreatic tunnel was dissected and the pancreas divided with staplers (Wirsung´s duct, if identified, was sutured separately with 3-0 prolene). The splenic artery was then ligated and divided (which is extremely facilitated once the pancreas has been sectioned). The surgery ended with the complete mobilization of the splenopancreatic block. Was usually leaved a closed-suction drain in the sub-diaphragmatic space. Removal of the surgical specimen was usually done through a Pfannestiel incision.
Postoperative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if a drain output of any measurable volume of fluid on or after postoperative day 3 showed amylase content greater than three times the serum amylase activity, and were classified by the ISGPF statement2.
Between June/2006 and March/2012 were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma, and 13 had this diagnosis confirmed and two patients were classified as pancreatic pseudocysts. There were 12 women (92%), and the median age of patients was 50 years (33-74). The types of resections, the postoperative complications and the size of lesions are shown in Table 1.
There were no conversions, re-operations or mortality in this series. Six patients had minor postoperative complications (Dindo and Clavien classification categories I or II)6. One of the two patients who presented pancreatic fistulas classified as type B of Bassi et al. classification2, required re-hospitalization and a percutaneous image-guided drainage. Of the 13 patients confirmed to have cystadenomas at final pathological examination, there were seven (54%) mucinous cystadenomas, one macrocystic serous cystadenoma (one man), and three microcystic serous cystadenomas (Figure 1).
Diagnosis of pancreatic cystadenomas is a true dilemma12. The lesions are very often completely asymptomatic or have nonspecific symptoms. The use of data such as age, sex, personal antecedents, general health status, among others, can help in formulating a diagnosis. (Figure 2)
The criteria for the diagnosis of pancreatic cystic neoplasms are obtained from imaging methods (morphology), aspirated fluid analysis (cytology and tumor markers), and the histological analysis of the surgical specimen4,5,8. Figure 3 summarizes the expected results of the cyst´s fluid analysis
The highest frequency of lesions in female patients (92%), the mean age (50 years) and the distribution of the lesions (54% of mucinous lesions) in this study are similar to the literature1,4,5.
Serous cystadenoma is considered a benign disease by histopathological characteristics and outcome, with a chance of malignant transformation of less than 1%. A recent review of the literature reports only 27 cases of serous cystadenocarcinoma3. Although there is no consensus, especially in asymptomatic cases, regarding the therapeutic approach there is a trend in specialized centers to indicate the resection of all cystic lesions larger than 4 cm1,3,5,9,11,12,13.
Contrary to serous tumors, mucinous lesions are considered high-risk lesions of malignant transformation. Different studies have shown the presence of carcinoma in situ or invasive carcinoma in 34-48% of operated mucinous cystadenomas. Mucinous neoplasms are most commonly find in females between the 4th and 5th decades of life (over 80% of cases). Although most of these lesions are asymptomatic, some symptoms, in particular loss of weight and / or severe pain, if presented, should rise the suspicion of an associated malignant transformation. Once diagnosed, surgical resection is considered the treatment of choice for mucinous cystic neoplasms1,3,5,9,11,12,13.
Pancreatic fistula is the most frequent complication of distal pancreatectomy regardless of the approach14,17,19,21,26. The frequency of pancreatic fistula in this study (38%) is similar to the literature10,16,17. Several techniques and pitfalls have been proposed to reduce this complication, such as suture reinforcement20, individual ligation of Wirsung´s duct20, different types mechanical staples loads22, coating of suture lines with absorbable material25, and very slow closure of the stapler18. Taken together, these results are controversial and do not, so far, indicates a particular technique.
There are no sufficient studies in the literature to recommend the laparoscopic approach in confirmed cases of malignancy; so, a complete preoperative investigation should be performed and if relevant diagnostic doubt persists, the indication of the laparoscopic approach should be discussed individually.
Laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.
Sincere thanks to our colleagues who have collaborated and actively participated in the surgeries and therapeutic decisions: Tarcísio Triviño, Alberto Goldenberg, Edson José Lobo, Jose Carlos Del Grande, Renato Arioni Lupinacci, Miguel Ângelo Pedroso, Alceu Beani Jr, Adriano Corona, Pedro Oksman e Gilmar Ferreira do Espírito Santo.
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Correspondence: Received for publication:
José Francisco de Mattos Farah,
Accepted for publication: 26/05/2012
Financial source: none
Conflicts of interest: none
Received for publication: