Ileal duplication in adults: A rare case.

INTRODUCTION AND IMPORTANCE: Intestinal duplication is an uncommon congenital malformation affecting the alimentary tract. This article presents a case of enteric duplication cyst (EDC) in an adult, accompanied by a review of the available literature. CASE PRESENTATION: A 34-year-old woman with polymyositis underwent a routine CT scan as part of her medical assessment revealing an 8 cm mass near the caecum and terminal ileum. Diagnostic procedures confirmed a cystic spherical mass. The patient underwent ileo-cecal resection, with primary anastomosis and an uneventful recovery. CLINICAL DISCUSSION: Studies indicate that the frequency of polymyositis coexisting with a neoplasm range from 6 % to 40 %. Therefore, a body CT scan is recommended for patients with myopathy as in our patient. Intestinal duplications are predominantly found in children but can also occur in adults, often discovered incidentally or due to complications. Diagnostic imaging techniques, such as ultrasonography and CT scan, are crucial in identifying duplication location and characteristics. In this case, colonoscopy indicated ileocecal valve compression, and histological examination confirmed an enteric duplication cyst with ectopic gastric mucosa. CONCLUSION: Enteric duplication cysts are rare, and the existing literature on the topic somewhat limited. Early diagnosis and surgical intervention are essential to stave off potential complications and reduce morbidity. Clinician awareness of enteric duplication cysts enables timely management, enhancing patient outcomes. Further research is needed to improve understanding and optimize patient care.

Outcome and survival were similar with laparoscopic and open pancreatectomy in 102 solid pseudopapillary neoplasms.

BACKGROUND: Solid pseudopapillary neoplasms of the pancreas (SPNP) are rare tumors predominantly in young women. We report the largest single-center cohort study comparing resection of SPNP by laparoscopic approach (LA) and the open approach (OA). METHOD: Between 2001 and 2021, 102 patients (84% women, median age: 30) underwent pancreatectomy for SPNP and were retrospectively studied. Demographic, perioperative, pathological, early and the long-term results were evaluated between patients operated by LA and those by OA. RESULTS: Population included 40 LA and 62 OA. There were no significant differences in demographics data between the groups. A preoperative biopsy by endoscopic ultrasound was performed in 45 patients (44%) with no difference between the groups. Pancreatoduodenectomy (PD) was less frequently performed by LA (25 vs 53%, p = 0.004) and distal pancreatectomy (DP) was more frequently performed by LA (40 vs 16%, p = 0.003). In the subgroup analysis by surgical procedure, LA-PD was associated with one mortality, less median blood loss (180 vs 200 ml, p = 0.034) and fewer harvested lymph nodes (11 vs 15, p = 0.02). LA-DP was associated with smaller median tumor size on imaging (40 vs 80mm, p = 0.048), shorter surgery (135 vs 190 min, p = 0.028), and fewer complications according to the median comprehensive complication index score (0 vs 8.7, p = 0.048). LA-Central pancreatectomy was associated with shorter surgery (160 vs 240, p = 0.037), less median blood loss (60 vs 200, p = 0.043), and less harvested lymph nodes (5 vs 2, p = 0.025). After a median follow-up of 60 months, two recurrences (2%) were observed and were unrelated to the approach. CONCLUSIONS: The LA for SPNP appears to be safe, should be applied cautiously in case of PD for large lesion, and was not associated with recurrence.

Jejunogastric intussusception associated with jejunojejunal intussusception (double telescoping) occurring 20 years after gastrojejunostomy.

INTRODUCTION: Jejunogastric intussusception (JGI) is a rare but potentially lethal complication following gastrectomy or gastrojejunostomy surgeries. Diagnosis of this condition can be challenging due to its rarity and non-specific symptoms. This article presents a case report of a 60-year-old male with a history of trans mesocolic gastrojejunostomy who developed acute symptoms of JGI. CASE REPORT: The patient presented with acute epigastric pain, vomiting, and hematemesis. Physical examination and laboratory tests indicated dehydration, tachycardia, and leukocytosis. Computed tomography (CT) revealed intussuscepted loops within the stomach. Emergency laparotomy was performed, and the intussusception was manually reduced without the need for resection. The patient recovered well and was discharged five days post-surgery. DISCUSSION: Retrograde jejunogastric intussusception is a rare complication, often occurring years after gastric surgery. It can be classified into acute and chronic forms, with the former presenting with intense pain and potential hematemesis. The condition can arise in different surgical contexts and even spontaneously. The cause of JGI remains unclear, but factors such as hyperacidity, abnormal motility, and increased intra-abdominal pressure have been implicated. Diagnosis can be made through endoscopy or alternative imaging modalities such as CT. Surgical intervention is the treatment of choice, with various options available based on intraoperative findings. CONCLUSION: Retrograde jejunogastric intussusception is challenging to diagnose and treat due to its rarity and lack of understanding of its causes. Imaging techniques and endoscopy play important roles in diagnosis, while surgery remains the primary treatment option. Vigilance is necessary among medical professionals to consider JGI in cases of acute abdominal pain and vomiting following gastric surgery, allowing for prompt diagnosis and intervention to prevent bowel necrosis. Further research is needed to establish optimal surgical strategies and evaluate recurrence rates.

Long-term quality of life is better after laparoscopic compared to open pancreatoduodenectomy.

BACKGROUND: Three randomized controlled trials have reported improved functional recovery after Laparoscopic pancreatoduodenectomy (LPD), as compared to open pancreatoduodenectomy (OPD). Long-term results regarding quality of life (QoL) are lacking. The aim of this study was to compare long-term QoL of LPD versus OPD. METHODS AND PATIENTS: A monocentric retrospective cross-sectional study was performed among patients < 75 years old who underwent LPD or OPD for a benign or premalignant pathology in a high-volume center (2011-2021). An electronic three-part questionnaire was sent to eligible patients, including two diseases specific QoL questionnaires (the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire for cancer (QLQ-C30) and a pancreatic cancer module (PAN26) and a body image questionnaire. Patient demographics and postoperative data were collected and compared between LPD and OPD. RESULTS: Among 948 patients who underwent PD (137 LPD, 811 OPD), 170 were eligible and 111 responded (58 LPD and 53 OPD). LPD versus OPD showed no difference in mean age (51 vs. 55 years, p = 0.199) and female gender (40% vs. 45%, p = 0.631), but LPD showed lower BMI (24 vs 26; p = 0.028) and higher preoperative pancreatitis (29% vs 13%; p = 0.041). The postoperative outcome showed similar Clavien-Dindo ≥ III morbidity (19% vs. 23%; p = 0.343) and length of stay (24 vs. 21 days, p = 0.963). After a similar median follow-up (3 vs. 3 years; p = 0.122), LPD vs OPD patients reported higher QoL (QLQ-C30: 49.6 vs 56.3; p = 0.07), better pancreas specific health status score (PAN20: 50.5 vs 55.5; p = 0.002), physical functioning (p = 0.002), and activities limitations (p = 0.02). Scar scores were better after LPD regarding esthetics (p = 0.001), satisfaction (p = 0.04), chronic pain at rest (p = 0.036), moving (p = 0.011) or in daily activities (p = 0.02). There was no difference in digestive symptoms (p = 0.995). CONCLUSION: This monocentric study found improved long-term QoL in patients undergoing LPD, as compared to OPD, for benign and premalignant diseases. These results could be considered when choosing the surgical approach in these patients.

Short-term Outcomes After Spleen-preserving Minimally Invasive Distal Pancreatectomy With or Without Preservation of Splenic Vessels: A Pan-European Retrospective Study in High-volume Centers.

OBJECTIVE: To compare short-term clinical outcomes after Kimura and Warshaw MIDP. BACKGROUND: Spleen preservation during distal pancreatectomy can be achieved by either preservation (Kimura) or resection (Warshaw) of the splenic vessels. Multicenter studies reporting outcomes of Kimura and Warshaw spleen-preserving MIDP are scarce. METHODS: Multicenter retrospective study including consecutive MIDP procedures intended to be spleen-preserving from 29 high-volume centers (≥15 distal pancreatectomies annually) in 8 European countries. Primary outcomes were secondary splenectomy for ischemia and major (Clavien-Dindo grade ≥III) complications. Sensitivity analysis assessed the impact of excluding ("rescue") Warshaw procedures which were performed in centers that typically (>75%) performed Kimura MIDP. RESULTS: Overall, 1095 patients after MIDP were included with successful splenic preservation in 878 patients (80%), including 634 Kimura and 244 Warshaw procedures. Rates of clinically relevant splenic ischemia (0.6% vs 1.6%, P = 0.127) and major complications (11.5% vs 14.4%, P = 0.308) did not differ significantly between Kimura and Warshaw MIDP, respectively. Mortality rates were higher after Warshaw MIDP (0.0% vs 1.2%, P = 0.023), and decreased in the sensitivity analysis (0.0% vs 0.6%, P = 0.052). Kimura MIDP was associated with longer operative time (202 vs 184 minutes, P = 0.033) and less blood loss (100 vs 150 mL, P < 0.001) as compared to Warshaw MIDP. Unplanned splenectomy was associated with a higher conversion rate (20.7% vs 5.0%, P < 0.001). CONCLUSIONS: Kimura and Warshaw spleen-preserving MIDP provide equivalent short-term outcomes with low rates of secondary splenectomy and postoperative morbidity. Further analyses of long-term outcomes are needed.

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula.

BACKGROUND: Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN. METHODS AND PATIENTS: All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF. RESULTS: From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51 years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20 mm (9-110); 30 mm (20-110) for mucinous cystadenoma and 18 mm (8-33) for NET. The median operative time was 90 mn (30-330), median blood loss was 20 ml (0-800) ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7 days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24 months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3 mm. CONCLUSION: In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.

Benchmarking of robotic and laparoscopic spleen-preserving distal pancreatectomy by using two different methods.

BACKGROUND: Benchmarking is an important tool for quality comparison and improvement. However, no benchmark values are available for minimally invasive spleen-preserving distal pancreatectomy, either laparoscopically or robotically assisted. The aim of this study was to establish benchmarks for these techniques using two different methods. METHODS: Data from patients undergoing laparoscopically or robotically assisted spleen-preserving distal pancreatectomy were extracted from a multicentre database (2006-2019). Benchmarks for 10 outcomes were calculated using the Achievable Benchmark of Care (ABC) and best-patient-in-best-centre methods. RESULTS: Overall, 951 laparoscopically assisted (77.3 per cent) and 279 robotically assisted (22.7 per cent) procedures were included. Using the ABC method, the benchmarks for laparoscopically assisted and robotically assisted spleen-preserving distal pancreatectomy respectively were: 150 and 207 min for duration of operation, 55 and 100 ml for blood loss, 3.5 and 1.7 per cent for conversion, 0 and 1.7 per cent for failure to preserve the spleen, 27.3 and 34.0 per cent for overall morbidity, 5.1 and 3.3 per cent for major morbidity, 3.6 and 7.1 per cent for pancreatic fistula grade B/C, 5 and 6 days for duration of hospital stay, 2.9 and 5.4 per cent for readmissions, and 0 and 0 per cent for 90-day mortality. Best-patient-in-best-centre methodology revealed milder benchmark cut-offs for laparoscopically and robotically assisted procedures, with operating times of 254 and 262.5 min, blood loss of 150 and 195 ml, conversion rates of 5.8 and 8.2 per cent, rates of failure to salvage spleen of 29.9 and 27.3 per cent, overall morbidity rates of 62.7 and 55.7 per cent, major morbidity rates of 20.4 and 14 per cent, POPF B/C rates of 23.8 and 24.2 per cent, duration of hospital stay of 8 and 8 days, readmission rates of 20 and 15.1 per cent, and 90-day mortality rates of 0 and 0 per cent respectively. CONCLUSION: Two benchmark methods for minimally invasive distal pancreatectomy produced different values, and should be interpreted and applied differently.

Resection of the splenic vessels during laparoscopic central pancreatectomy is safe and does not compromise preservation of the distal pancreas.

BACKGROUND: The diagnosis of low potential malignant diseases is increasingly frequent, and laparoscopic central pancreatectomy can be indicated in these patients. Laparoscopic central pancreatectomy that usually preserves the splenic vessels results in a low risk of new-onset diabetes but high morbidity, mainly due to postoperative pancreatic fistula and postpancreatectomy hemorrhage. In this study, we evaluated the short and long-term complications after laparoscopic central pancreatectomy with splenic vessel resection. METHODS: This retrospective single-center cohort study included 650 laparoscopic pancreatic resections from 2008 to 2020 with 84 laparoscopic central pancreatectomy; 15 laparoscopic central pancreatectomy with splenic vessel resection; and 69 laparoscopic central pancreatectomy with preservation of the splenic vessels. Pancreaticogastrostomy was routinely performed, and the patients were discharged after complications had been treated. The 15 laparoscopic central pancreatectomy with splenic vessel resection were matched for age, sex, body mass index, and tumor characteristics [1:2] and compared with 30 laparoscopic central pancreatectomy with the preservation of the splenic vessels. RESULTS: In the laparoscopic central pancreatectomy with splenic vessel resection group, resection of splenic vessels was performed due to tumoral or inflammatory adhesions (n = 11) or accidental vascular injury (n = 4). The demographic characteristics of the groups were similar. Tumors were larger in the laparoscopic central pancreatectomy with splenic vessel resection group (40 vs 21 mm; P = .008), and right transection on the body of the pancreas (53% vs 13%; P = .01) was more frequent. There were no differences in the characteristics of the pancreas (Wirsung duct size or consistency). The median operative time (minutes) was longer in the laparoscopic central pancreatectomy with splenic vessel resection group than in the laparoscopic central pancreatectomy with preservation of the splenic vessels group (210 vs 180, respectively; P = .15) with more blood loss (100 mL vs 50 mL, respectively; P = .012). The lengths (mm) of the resected pancreas and remnant distal pancreas in the 2 groups were 65 vs 50 (P = .053) and 40 vs 65 (P = .006), respectively. There were no differences in postoperative mortality (0% vs 3%; P = .47), grade B-C postoperative pancreatic fistula (27% vs 27%; P = 1), reintervention (7% vs 13%; P = .50), grade B-C postpancreatectomy hemorrhage (0% vs 13%; P = .13), length of hospital stay (20 days vs 22 days; P = .15), or new-onset diabetes (7% vs 10%; P = .67) between the 2 groups. CONCLUSION: Laparoscopic central pancreatectomy with splenic vessel resection is a safe technical modification of central pancreatectomy that does not prevent preservation of the distal pancreas and does not influence postoperative pancreatic fistula or endocrine insufficiency. Furthermore, it could reduce the risk of postpancreatectomy hemorrhage.

Benchmarking of minimally invasive distal pancreatectomy with splenectomy: European multicentre study.

BACKGROUND: Benchmarking is the process to used assess the best achievable results and compare outcomes with that standard. This study aimed to assess best achievable outcomes in minimally invasive distal pancreatectomy with splenectomy (MIDPS). METHODS: This retrospective study included consecutive patients undergoing MIDPS for any indication, between 2003 and 2019, in 31 European centres. Benchmarks of the main clinical outcomes were calculated according to the Achievable Benchmark of Care (ABC™) method. After identifying independent risk factors for severe morbidity and conversion, risk-adjusted ABCs were calculated for each subgroup of patients at risk. RESULTS: A total of 1595 patients were included. The ABC was 2.5 per cent for conversion and 8.4 per cent for severe morbidity. ABC values were 160 min for duration of operation time, 8.3 per cent for POPF, 1.8 per cent for reoperation, and 0 per cent for mortality. Multivariable analysis showed that conversion was associated with male sex (OR 1.48), BMI exceeding 30 kg/m2 (OR 2.42), multivisceral resection (OR 3.04), and laparoscopy (OR 2.24). Increased risk of severe morbidity was associated with ASA fitness grade above II (OR 1.60), multivisceral resection (OR 1.88), and robotic approach (OR 1.87). CONCLUSION: The benchmark values obtained using the ABC method represent optimal outcomes from best achievable care, including low complication rates and zero mortality. These benchmarks should be used to set standards to improve patient outcomes.

The outcome of laparoscopic pancreatoduodenectomy is improved with patient selection and the learning curve.

BACKGROUND: In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results. METHOD: Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44). RESULTS: In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III-IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m2, and patients operated in the third period. CONCLUSION: This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.

The long-term outcomes of laparoscopic versus open pancreatoduodenectomy for ampullary carcinoma showed similar survival: a case-matched comparative study.

BACKGROUND: Few studies have compared the oncological benefit of laparoscopic (LPD) and open pancreatoduodenectomy (OPD) for ampullary carcinoma. The aim of this study was to compare the oncological results of these two approaches. METHODS: Between 2011 and 2020, 103 patients who underwent PD for ampullary carcinoma, including 31 LPD and 72 OPD, were retrospectively analyzed. Patients were matched on a 1:2 basis for age, sex, body mass index, American Society of Anaesthesiologists score, and preoperative biliary drainage. Short- and long-term outcomes of LPD and OPD were compared. RESULTS: The 31 LPD were matched (1:2) to 62 OPD. LPD was associated with a shorter operative time (298 vs. 341 min, p = 0.02) than OPD and similar blood loss (361 vs. 341 mL, p = 0.747), but with more intra- and post-operative transfusions (29 vs. 8%, p = 0.008). There was no significant difference in postoperative mortality (6 vs. 2%), grades B/C postoperative pancreatic fistula (22 vs. 21%), delayed gastric emptying (23 vs. 35%), bleeding (22 vs. 11%), Clavien ≥ III morbidity (22 vs. 19%), or the length of hospital stay (26 vs. 21 days) between LPD and OPD, respectively, but there were more reinterventions (22 vs. 5%, p = 0.009). Pathological characteristics were similar for tumor size (21 vs. 22 mm), well differentiated tumors (41 vs. 38%), the number of harvested (23 vs. 26) or invaded lymph nodes (48 vs. 52%), R0 resection (84 vs. 90%), and other subtypes (T1/2, T3/4, phenotype). With a comparable mean follow-up (41 vs. 37 months, p = 0.59), there was no difference in 1-, 3-, and 5-year overall (p = 0.725) or recurrence-free survival (p = 0.155) which were (93, 74, 67% vs. 97, 79, 76%) and (85, 58, 58% vs. 90, 73, 73%), respectively. CONCLUSION: This study showed a similar long-term oncological results between LPD and OPD for ampullary carcinoma. However, the higher morbidity observed with LPD compared to OPD, restricting its use to experienced centers.

Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications.

PURPOSE: The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center. METHODS: Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied. RESULTS: The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO. CONCLUSIONS: Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.

Extended Laparoscopic Central Pancreatectomy with Clamping of the Mesentericoportal Vein and Resection of the Splenic Vessels for a Large Solid Pseudopapillary Tumor.

BACKGROUND: Solid pseudopapillary tumors (SPPTs) are low malignant potential entities found mainly in young females.1,2 Pancreatectomy without tumor rupture is the treatment of choice, and the laparoscopic approach is indicated.3,4 Limited pancreatectomy is possible due to the low risk of malignancy (< 10%) based on the low risk of lymph node invasion or true vascular invasion.1,2 Centrally located large SPPTs can be treated by extended central pancreatectomy with or without vascular resection to avoid pancreatoduodenectomy or distal pancreatectomy. METHODS: A 24-year-old woman was admitted with abdominal pain. A 6-cm SPPT was discovered at the neck-body junction in close contact with the anterior aspect of the mesentericoportal vein (MPV) and the splenic vessels, with signs of segmental portal hypertension. To avoid an extended pancreatectomy for this young patient, an extended central pancreatectomy was performed, with resection of the splenic vessels, and the MPV was freed from the tumor under clamping for 10 min, with no need for vascular reconstruction. The duration of the surgery was 260 min, with 200 ml of blood loss and no transfusion. RESULTS: The woman's postoperative course was uneventful, with a hospital stay of 16 days. Histology confirmed the diagnosis of a 6-cm SPPT tumor (R0 and N0). The patient was asymptomatic 1 year later, with no tumor recurrence and no pancreatic insufficiency. Between 2011 and 2018 the authors performed 72 laparoscopic central pancreatectomies, with SPPT performed for 13 patients (18%). Laparoscopic central pancreatectomy was extended (n = 5) or standard (n = 8) with no conversion, no recurrence, and no pancreatic insufficiency. CONCLUSION: An SPPT tumor is a good indication for the laparoscopic approach because this entity is found in young patients with a low risk of malignancy. Large centrally located tumors can be treated by extended central pancreatectomy to avoid a large pancreatectomy with greater early and long-term disadvantages.

Pancreatic fistula following laparoscopic distal pancreatectomy is probably unrelated to the stapler size but to the drainage modality and significantly decreased with a small suction drain.

INTRODUCTION: Risk factors of postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (LDP) are not well known and were studied, including the stapler cartridge size and drainage modality. METHODS: Between January 2008 and December 2016, 181 LDP were performed and the pancreas was sectioned by stapler in 130 patients (72%). Patients received white (2.5 mm), blue (3.5 mm), or green (4.1 mm) staplers and the size was not based on any pre or peroperative randomization. As primary analysis of the first 84 patients (28 in each group) showed no effect of stapler size on POPF, we decided to use the white (total = 47) or blue and finally the blue (total = 55) of medium size for standardization. Drainage was obtained by multi-tubular drain (first, 79) and a small suction drain (last, 102). Risk factors of POPF were studied and grades B and C were compared to grade A or no POPF. RESULTS: POPF (n = 66; 36%) was of grade A (n = 25, 14%), grade B (n = 32, 18%), and grade C (n = 9, 5%). The comparison of the three groups of staplers showed that the blue stapler was used more with a small suction drain (85 vs 23%, p < 0.0001), had lower rate of grade B POPF (p = 0.028), and a shorter hospital stay (p = 0.004). On multivariate analysis, only the use of a small suction drain was associated with significant decrease in grades B and C POPF (6 vs 44%, odds ratio 7.385 (1.919-28.418); p = 0.004). CONCLUSION: The occurrence of POPF following LDP is influenced by the type of drainage alone and is significantly decreased with a small suction drain.

Double Gastric Hanging for Gastric Exposure in Laparoscopic Distal Pancreatectomy.

BACKGROUND: Gastric traction is essential in laparoscopic distal pancreatic resections. We already described the single gastric hanging providing good exposure on the left pancreas and we herein introduce a modification named the double gastric hanging. METHODS: The double gastric hanging in which 2 surgical tapes encircle the body and antrum of the stomach is indicated in patients who requiring pancreatic neck resection, dissection along the celiac trunk collaterals and lymph nodes, the duodenal wall, and the gastroduodenal artery. We describe our surgical technique, we compare our results between the double and single gastric hanging and we illustrate by 2 shorts videos for distal pancreatectomy and central pancreatectomy. RESULTS: Between September 2016 and December 2017, this technique was performed in 36 patients who underwent central pancreatectomy (n = 18), distal pancreatectomy (n = 14), and enucleation (n = 4). There was no conversion, no transfusion, no mortalities, and no gastric related complications or reinterventions. Although not significant, the double gastric hanging and compared to single gastric hanging showed more favorable operative results with shorter operative time, less blood loss, and higher number of harvested lymph nodes. In patients operated for pancreatic adenocarcinoma, the mean number of harvested lymph nodes was higher with the double gastric hanging (23 vs. 14, p = 0.027). CONCLUSION: The double gastric hanging provides excellent exposure of the pancreatic neck, celiac trunk collaterals, and lymph nodes for better technical and oncological resections with no related complications.

Laparoscopic pancreaticoduodenectomy with reconstruction of the mesentericoportal vein with the parietal peritoneum and the falciform ligament.

BACKGROUND: With the improvement of the surgical technique of Laparoscopic pancreaticoduodenectomy (LPD), indications will be extended to patients with vascular invasion. With LPD, vascular grafts for reconstruction are more frequently needed because adequate mobilization is not always done and vascular grafts can safely facilitate reconstruction. We describe our experience of reconstruction with the falciform ligament. METHODS: Venous reconstruction is performed after removal of the specimen. The falciform ligament is rapidly harvested within the same surgical field and for any size and used for lateral reconstruction of the mesentericoportal vein. Therapeutic anticoagulation is not needed and venous patency was assessed by postoperative CT scan. Since April 2011 and among the 93 patients who underwent LPD, four patients had this procedure. RESULTS: The mean age was 73 years old (69-77) and 3 were women. Indications for resection were pancreatic adenocarcinoma (n = 3) and IPMN in severe dysplasia (n = 1) and the mean patch size of 13 mm (10-30). The mean operative time was 397 min (330-480); vascular clamping lasted 54 min (45-60), and mean blood loss was 437 ml (150-1000) and one was transfused. Resection was R0 in patients with adenocarcinoma (n = 3). The postoperative course was uneventful in 3 patients and one patient was re-operated for bile leak and partial venous thrombosis and redo venous reconstruction was done. Complete venous patency was demonstrated in patients (n = 2) who still alive 1 year after resection. CONCLUSION: Venous resection will be more frequently done with LPD and vascular grafts more frequently needed. Compared to other available vascular grafts (autogenous, synthetic, cadaveric and bovine pericardium, etc), the parietal peritoneum had the advantages of being rapidly available, easy to harvest by the laparoscopic approach, not expensive, no need for anticoagulation and at lower risk of infection.