M. Katz

Total Laparoscopic Central Pancreatectomy with Pancreaticogastrostomy for High-Risk Cystic Neoplasm

BackgroundOrgan-sparing pancreatic resection is important in prophylactic surgery for cystic neoplasms. There is controversy regarding the optimal surgical approach for pancreatic lesions in the neck or proximal body of the pancreas. Central compared with distal pancreatectomy is technically more challenging, but preserves more functional pancreatic tissue. Because of the prophylactic nature of the surgery and long survival of patients with benign and borderline malignant lesions, surgeons need to stratify greater importance to surgical morbidity and sparing pancreatic parenchyma.PatientThe patient is a 59-year-old active woman with a symptomatic cystic neoplasm of the pancreas exhibiting high-risk imaging features. The cyst of 2.2xa0×xa01.8xa0cm in the body of the pancreas was impinging on the portal venous confluence.TechniqueThe patient was positioned in the French Position, the lesser sac was opened, and the pancreatic body exposed. A retropancreatic tunnel was created with staple division of the neck. The body was mobilized off the portal vein and splenic vessels transected. A retrogastric pancreaticogastrostomy was sewn through an anterior gastrotomy. The stent was delivered past the pylorus to decrease pancreatic enzymatic activation. Pathology demonstrated a mixed predominantly branch duct IPMN with multifocal high grade dysplasia and PanIN3.ConclusionsLaparoscopic ultrasound helps in defining cyst borders, and minimal blood loss optimizes visualization during the dissection. A minimally invasive pancreaticogastrostomy created through an anterior gastrotomy is technically feasible and safe. This approach can minimize the morbidity of prophylactic pancreatic surgery for patients with cystic neoplasms. Nevertheless, it should not compromise safety, oncologic completeness, or an organ-sparing approach.

Utility of (18) F-FDG PET/CT and CECT in conjunction with serum CA 19-9 for detecting recurrent pancreatic adenocarcinoma

PurposeThe roles of different cross-sectional imaging in evaluating the recurrence of pancreatic adenocarcinoma are not well established. We evaluated the utility of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced computed tomography (CECT) in the diagnosis of recurrent pancreatic adenocarcinoma in conjunction with the tumor marker CA 19-9.MethodsWe retrospectively reviewed the records of patients who underwent CECT and FDG PET/CT along with serum CA 19-9 measurement as a follow-up or on a clinical suspicion of recurrent disease after initial surgery for pancreatic adenocarcinoma. Two observers blinded to the other imaging modality results retrospectively reviewed and interpreted the images in consensus using a three-point scale (negative, equivocal, or positive). Pathologic analysis by biopsy or further clinical and radiologic follow-up determined the true status of the suspected recurrences. The imaging results were compared with CA 19-9 levels and true disease status.ResultsThirty-nine patients were included in the study. Thirty-three patients (85%) had proven recurrent cancer and six patients (15%) had no evidence of disease. Twenty-four patients had elevated CA 19-9 and 15 patients had normal CA 19-9. Sensitivity, specificity, and accuracy for recurrence were 90.9%, 100.0%, and 92.3% for PET/CT and 72.2%, 66.6%, and 71.7% for CECT, respectively. Sensitivity for locoregional recurrence was 94.4% for PET/CT but only 61.1% for CECT. PET/CT detected recurrence in 12 patients who had normal levels of CA 19-9. PET/CT showed lesions not visible on CECT in five (15%) patients. Although the sensitivity and specificity of PET/CT were higher than those of CECT, they were not statistically significant (pxa0=xa00.489 and pxa0=xa00.1489, respectively).ConclusionFDG PET/CT has a high sensitivity for pancreatic cancer recurrence. Normal CA 19-9 does not necessarily exclude these recurrences. FDG PET/CT is useful when CECT is equivocal and can detect recurrence in patients with normal CA 19-9.

Imaging findings of recurrent pancreatic cancer following resection

Pancreatic cancer is a challenging malignancy to treat, largely due to aggressive regional involvement, early systemic dissemination, high recurrence rate, and subsequent low patient survival. Generally, 15–20% of newly diagnosed pancreatic cancers are candidates for possible curative resection. Eighty percent of these patients, however, will experience locoregional or distant recurrence in first 2xa0years. Although there is no strong evidence-based guideline for optimal surveillance after pancreatic cancer resection, careful comparison of surveillance follow-up multi-detector CT (MDCT) studies with a postoperative baseline MDCT examination aids detection of early recurrent pancreatic cancer. In this review article, we describe imaging findings suggestive of recurrent pancreatic cancer and review routine and alternative imaging options.

Laparoscopic Partial Splenectomy for Unknown Primary Cancer: A Stepwise Approach

BackgroundLaparoscopic partial splenectomy (LPS) for focal splenic lesions is technically demanding and carries risk of hemorrhage. Nevertheless, it can be a valuable option, particularly for children and adults in whom attempt at preservation of splenic immunologic function outweighs risk associated with organ preservation.PatientA 58-year-old man was diagnosed with a focal splenic lesion at the upper splenic pole on surveillance imaging following axillary lymph node metastasis for cancer of unknown primary origin (CUP). After an interval of 8 months, repeat FDG-PET showed increase in size and PET-avidity without any evidence of new lesions. Due to isolated site and history of CUP, the patient was considered for a LPS.TechniqueWith the patient in reversed modified French position, the upper pole splenic vessels were controlled and a well-defined area of ischemia encompassing the lesion identified. Under intermittent inflow occlusion and ultrasonography guidance, the parenchymal transection was performed. Total operative time was 180xa0min, estimated blood loss was 175xa0cc, the patient was discharged on postoperative day 2, and final pathology confirmed an Epstein-Barr virus associated inflammatory pseudotumor.1,2ConclusionSafe LPS requires systematic pre-operative assessment of hilar vascular anatomy and a stepwise approach to controlling the vessels intra-operatively. Anatomic parenchymal transection and intermitted vascular isolation for lesions close to the demarcation zone minimizes blood loss. Risk/benefit stratification of LPS may be beneficial in select patients only. Whether in patients with CUP LPS may aid in preserving innate and adaptive immunity with potential clinical, including oncologic, benefits will require further investigations.3–5

Comparing Postoperative Complications and Inflammatory Markers Using Total Intravenous Anesthesia Versus Volatile Gas Anesthesia for Pancreatic Cancer Surgery

Objectives The objective of this study is to evaluate postoperative complications and inflammatory profiles when using a total intravenous anesthesia (TIVA) or volatile gas-opioid (VO) based anesthesia in patients undergoing pancreatic cancer surgery. Methods Design, retrospective propensity score matched cohort; Setting, major academic cancer hospital; Patients, all patients who had pancreatic surgery between November 2011 and August 2014 were retrospectively reviewed. Propensity score matched patient pairs were formed. A total of 134 patients were included for analysis with 67 matched pairs; Interventions, Patients were categorized according to type of anesthetic used (TIVA or VO). Patients in the TIVA group received preoperative celecoxib, tramadol, and pregabalin in addition to intraoperative TIVA with propofol, lidocaine, ketamine, and dexmedetomidine. The VO-group received a volatile-opioid based anesthetic; Measurements, demographic, perioperative clinical data, platelet lymphocyte ratios, and neutrophil lymphocyte ratios were collected. Complications were graded and collected prospectively and later reviewed retrospectively. Results Patients receiving TIVA were more likely to have no complication or a lower grade complication than the VO-group (P = 0.014). There were no differences in LOS or postoperative inflammatory profiles noted between the TIVA and VO groups. Conclusions In this retrospective matched analysis of patients undergoing pancreatic cancer surgery, TIVA was associated with lower grade postoperative complications. Length of hospital stay (LOS) and postoperative inflammatory profiles were not significantly different.