Laparoscopic pancreatic enucleation with pancreatic stenting (LPE + PS) was adopted in 2016 at our institution. Between January 2016 and December 2019, patients underwent either LPE + PS or LPE alone were reviewed. The patients were divided into two groups as LPE + PS and LPE. The data considered for clinical comparison were patient demographics, intraoperative variables (operative time, estimated blood loss (EBL), blood transfusion requirement), complications, duration of hospital stay, and final pathology. This study was approved by the Ethics Committee for Clinical Research of our institution and met the guidelines of the Declaration of Helsinki.
Endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the MPD ERCP was performed under deep sedation in the prone position by gastroenterologist within 3 hours before LPE. We performed peroral endoscopic duodenoscopy to the descending duodenum, identified the duodenal papilla, adjusted the scope to the center of the field of view (Fig. 1a). Guide-wired deep cannulation of the MPD was achieved using a hydrophilic wire (Fig. 1b). Small quantity of contrast was injected to confirm the correct position of the guide-wire inside the duct. Pancreatic sphincterotomy was performed over the wire, an appropriate plastic pancreatic duct stent (Model: CHN; 5–7 Fr/4–9 cm; Micro-Tech Co., Ltd., Nanjing, China) according to the diameter of the residual pancreatic duct was deployed (Fig. 1c). The length of the stent was chosen to place its intra-pancreatic end over the lesion. Figure 1d shows the pancreatic stent placement.
Laparoscopic pancreatic enucleation (LPE)
With the patient in a supine position with legs abducted, and after inducing general anesthesia with tracheal intubation, we routinely placed sterile drapes. A small curved incision was made under the umbilicus, and pneumoperitoneum was established by Veress needle puncture with a pneumoperitoneum pressure of 12–15 mmHg (1 mmHg = 0.133 kPa). We then performed a 10-mm cannula puncture, and inserted a 30° laparoscope. A 5-mm cannula was placed 2 cm below the costal margin of the left and right anterior axillary lines as traction ports, during laparoscopy. We set a 12-mm cannula as the main operating port, 2 cm above the umbilicus on the outer edge of right rectus abdominis muscle, horizontally, and set another 10-mm cannula as a traction port at the corresponding position on the left side. The five punctures were V-shaped.
The abdominal cavity was explored to exclude tumor peritoneal metastasis, and we used an ultrasonic scalpel (Harmonic Ace; Ethicon Endo-Surgery, Cincinnati, OH, USA) to incise the gastrocolic ligament and enter the lesser omental bursa. Once the pancreatic parenchyma was exposed, intraoperative ultrasound allowed to identify the lesion and the MPD containing the stent (Fig. 2b). The mass was dissected free using a 1–2-mm side opening in the pancreatic capsule to guarantee complete enucleation of the tumor, using the electrosurgical and ultrasonic scalpels (Fig. 2c). No sealants or patches were used to the resection wound. After bagging the specimen, we extended the incision below the umbilicus longitudinally and inferiorly to remove the specimen. The specimen and its margins were then sent for intraoperative frozen section histopathological examination. After the abdominal cavity was flushed, and no active bleeding was found. One closed-suction drainage tube was placed close to the site of enucleation (1 case showed in Fig. 2).
POPF was assessed according to the International Study Group on Pancreatic Fistula recommendations, and Postoperative morbidity was graded using the Clavien–Dindo classification. Grades I and II were grouped as minor, and grades III–V were considered as major complications.
We removed the stent approximately 1 month postoperatively (Fig. 2e). In patients with POPF, we removed the pancreatic stent 3 months after recovery and discharge from the hospital. Recurrence was diagnosed by CT (Fig. 2f). Pancreatic endocrine insufficiency was defined as new-onset diabetes and worsening diabetes. Patients with diarrhea and steatorrhea, weight loss, and taking of pancreatic enzyme supplementation were considered to have pancreatic exocrine insufficiency. Patients were followed up via phone call or out-patient examination. The final follow-up was taken in April 2020.
Demographic, pathologic, and perioperative details were extracted from this database. Continuous clinicopathological data were expressed as mean ± standard deviation or median (range) as appropriate. Categorical variables were reported as number and percentage. Continuous clinicopathological data were analyzed with Student’s t test (or Mann–Whitney U test). Categorical variables were analyzed with the Fisher’s exact test (or likelihood ratio). We performed all statistical analyses with SPSS v22.0 (IBM Corp., Armonk, NY, USA). P < 0.05 was considered statistically significant.