clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Central Resection

Sergio Pedrazzoli, Claudio Pasquali, Cosimo Sperti

Introduction

In 1959, Letton and Wilson reported the first non-resective treatment of traumatic rupture of the neck of the pancreas. The right stump of the pancreatic head was oversewn, and a Roux-en-Y loop of jejunum was anastomosed to the left body/tail of the pancreas. In 1984, Dagradi and Serio reported the first central pancreatectomy for an insulinoma, and in 1988, Fagniez, Kracht, and Rotman reported two central pancreatectomies performed for an insulinoma and a serous cystadenoma. At least 150 central pancreatectomies have been reported so far without mortality. Central pancreatectomy involves anatomic removal of benign or borderline lesions of the neck and/or proximal body of the pancreas together with 1cm of normal tissue on both sides. The goal is to preserve at least 5cm of the normal pancreatic tissue of the body/tail of the pancreas that would otherwise be removed with a complete left pancreatectomy.

Indications and Contraindications

nance imaging, or endoscopic ultrasonography

– 111In-pentetreotide scintigraphy (OctreoScan): endocrine neoplasms

– Positron emission tomography (PET): differentiates between benign and malignant lesions

Preoperative preparation: – Somatostatin analogues: no specific study on central pancreatectomy

– Perioperative antibiotics: as for any clean-contaminated operation

The pancreas is exposed by detaching the greater omentum from the transverse colon and freeing the superior aspect of the middle colic vessels until the anterior aspect of the pancreas is exposed completely; stomach is retracted rostrally.

The superior mesenteric vein is identified, and its anterior surface cleared below the neck of the pancreas; care must be taken not to injure venous tributaries; occasionally a middle colic branch of the superior mesenteric vein requires division, especially if it joins in a V-shaped way with the right gastroepiploic vein. Gastroepiploic vessels are preserved, unless the lesion reaches the right border of the superior mesenteric-portal vein (A-1).

Evaluate the extent of the lesion by intraoperative ultrasonography (IOUS); this technique is particularly useful for small, deeply located lesions. Mark with electrocautery the exact extent of the planned central pancreatectomy including 1cm of normal pancreatic tissue on both sides (A-2).

Transection of pancreas: Stay sutures are placed on the superior and inferior pancreatic margins just to the right and left of the proximal and distal lines of division to occlude the superior and inferior pancreatic vessels running transversely in the parenchyma.

The pancreas is divided by scalpel using a V-shaped incision on the right side of the tumor to facilitate closure in a fish-mouth fashion; the pancreas is transected 1cm to the left of the tumor with suture ligation of the larger arterial bleeders in the cut edge (A-1). The pancreatic duct in the right side of the remnant gland is suture-ligated with 5-0 non-absorbable monofilament, and the pancreatic tissue closed in a fish-mouth fashion

with interrupted 3-0 synthetic absorbable sutures (A-2).

A very thin neck of pancreas can also be closed with a stapler and bleeding from small arteries controlled with absorbable synthetic stitches; the pancreatic duct is still identified and suture-ligated individually with 5-0 non-absorbable monofilament (A-3). The right-sided limit of a central pancreatectomy is the left side of the gastroduo-

denal artery; transecting the pancreas to the right of the gastroduodenal artery can injure the common bile duct.

The specimen is sent to the pathologist for frozen section examination and for checking the right and left resection margins. A stitch on one margin will orient the specimen for the pathologist.

Local Postoperative Complications

■Short term:

–Anastomotic disruption

–Pancreatic fistula

–Peripancreatic abscess

–Intra-abdominal bleeding

–Acute pancreatitis

–Subdiaphragmatic abscess

–Splenic-portal vein thrombosis

–Pleural effusion

■Long term:

–Pancreatic pseudocyst

–Pancreatic ascites

–Pancreatitis

–Diabetes

Tricks of the Senior Surgeon

■If the approach to the superior mesenteric portal trunk is difficult, Kocherization of the head of the pancreas is advisable; control of bleeding will be easier.

■If the superior mesenteric/portal trunk or one of its branches is injured, do not panic and use instruments blindly! Compress the venous trunk between the fingers inserted posteriorly (after the Kocher maneuver) behind the head of the pancreas and the thumb on the anterior aspect of the pancreas; suture the tear with 5-0 polypropylene.

■If the pancreas is too large for an invagination/dunking pancreatojejunostomy, choose either a duct-to-mucosal anastomosis or a pancreaticogastrostomy. Closure of the left pancreatic stump is followed by gland fibrosis that compromises endocrine secretion, nullifying the long term benefits of the central resection.