Search Results (18)

Parenchyma-sparing pancreatic surgery (PSPS) is a patient-centered alternative to traditional radical resections for benign and low-grade pancreatic lesions. Unlike pancreaticoduodenectomy and distal pancreatectomy, which tend to cause long-term exocrine and endocrine deficiency, PSPS aims to preserve functional tissue with a guarantee of oncologic safety. Techniques such as enucleation, central pancreatectomy, duodenum-preserving head resection, and uncinectomy are illustrative of this equipoise, with less risk of new-onset diabetes and malabsorption but more short-term morbidity in the form of postoperative pancreatic fistula. Advances in imaging technology, minimally invasive procedures, and robotics technology have extended PSPS indications beyond conventional candidates to thoughtfully selected neuroendocrine tumors, cystic neoplasms, and solid pseudopapillary neoplasms. Results are strongly dependent on patient selection, surgeon experience, and institutional volume, highlighting the importance of centralization and subspecialist training. While oncologic proficiency remains essential in aggressive tumors, evidence is in favor of PSPS being a curative and function-preserving option for properly screened patients with low-grade or benign conditions. Priorities for the future include multicenter prospective trials, optimization of perioperative techniques, and inclusion of patient-reported outcomes. PSPS represents a paradigm shift in pancreatic surgery, where technical innovation is balanced with quality of life in the long term and evolving principles of modern, individualized surgical practice. Full article

Background/Objectives: Acute pancreatitis in pregnancy and the early postpartum period (APIP) is an uncommon but potentially life-threatening condition associated with significant maternal morbidity. Physiological adaptations of pregnancy, recent obstetric surgery, and overlapping postoperative symptoms frequently obscure early diagnosis and complicate perioperative and critical care management. This review provides a clinically oriented, anaesthesiology-focused overview of APIP, integrating current evidence with perioperative decision-making, pain management strategies, and intensive care considerations relevant to obstetric practice. Methods: A narrative, clinically structured review of the literature was performed focusing on epidemiology, aetiology, diagnosis, severity stratification, and management of APIP. Anaesthesiology- and ICU-specific aspects are synthesised into a pragmatic management framework. Results: Gallstone disease and hypertriglyceridaemia remain the predominant causes of APIP, with most cases occurring in the third trimester or early postpartum period. Diagnosis relies on pancreatic enzyme elevation and pregnancy-adapted imaging strategies. Early goal-directed fluid resuscitation, effective multimodal analgesia, and timely initiation of enteral nutrition are key determinants of outcome. Therapeutic ERCP and laparoscopic cholecystectomy can be safely performed during pregnancy when clinically indicated and may reduce recurrence in biliary pancreatitis. Neuraxial analgesia provides effective, opioid-sparing pain control and may improve respiratory mechanics and haemodynamic stability. Persistent organ failure remains the strongest predictor of adverse outcome and should prompt early intensive care admission. Conclusions: APIP requires early recognition and severity-adapted, multidisciplinary management. Anaesthesiology-led strategies play a central role in optimising analgesia, haemodynamic stability, and timely escalation of care. Framing APIP within a perioperative and critical care context may improve maternal outcomes in this vulnerable patient population. Full article

Background/Objectives: Insulinomas are rare insulin-secreting pancreatic neuroendocrine tumours (pNETs). Preoperative tumour localisation can usually be achieved by computed tomography (CT), magnetic resonance imaging, or positron emission tomography (PET)-CT. However, cross-sectional imaging can be negative, defining an insulinoma as occult and thus hampering surgical resection. Methods: All patients who underwent minimally invasive (MI) surgery for an insulinoma at the University Medical Center Hamburg-Eppendorf since 2017 were analysed. Clinicopathological parameters and diagnostic and operative approaches were assessed. A literature search of the MI resection of occult insulinomas was conducted. Results: Of eight patients with MI-resected insulinomas, two (25%) had negative preoperative imaging. Mean tumour size was 17.2 ± 13.3 mm. Patients underwent distal pancreatectomy (DP), enucleation, and pancreatic head resection (PHR) in 62.5% (5/8), 25.0% (2/8), and 12.5% (1/8) of cases, respectively. One patient had a major postoperative complication (Clavien–Dindo ≥ 3a). Twenty-four studies reporting on 140 occult insulinomas were identified. Occult insulinomas were more frequent in females, often located in the distal pancreas and G1-differentiated. Glucagon-Like Peptide-1 Receptor/PET-CT most frequently localised the conventionally non-visible insulinomas (positive in 67/76, 88.2%). Enucleation, DP, PHR and other resections were conducted in 47/94 (50.0%), 40/94 (42.6%), 4/94 (4.3%), and 3 (3.2%) of the reported cases. MI resection was reported in 10 of 19 (52.6%) specified resections. Conclusions: Insulinomas can be undetectable in cross-sectional and functional imaging. Surgical exploration with intraoperative ultrasound should be considered when clinical presentation and biochemical findings are highly suggestive for insulinoma. Minimally invasive and parenchyma sparing resection is feasible even for occult insulinomas and should always be considered. Full article

Background/Objectives: Patients with pancreatic neuroendocrine tumors (PanNETs) often have a good prognosis with long overall survival. We evaluated quality of life (QoL) after surgery for PanNETs, using the new EORTC-specific questionnaires. Methods: PanNET patients operated on in our unit (1990–2023) received three EORTC questionnaires (QLQ-C30 and the new P.NET15 and P.NET19). We evaluated the following: (1) QLQ-C30 outcomes; (2) mixed domains from QLQ-C30, P.NET15, and P.NET19; and (3) domains from P.NET19 and P.NET15 only. Functional and symptom scales were investigated in relationship with clinical variables. Gamma regression and multivariable analyses were performed with R software. Results: The 100 patients enrolled (median time 133 months after surgery) showed a good QoL (median 83.3/100). Old age was related to worse QoL and physical functioning (p = 0.007 and p < 0.001, respectively). Diabetes negatively influenced QoL (p < 0.001), physical functioning (p = 0.005), and fatigue (p = 0.03). Patients undergoing parenchyma-sparing surgery showed less fatigue (p = 0.046), while non-insulinoma PanNET diagnosis was related to worse QoL (p = 0.039). Multiple comorbidities were negatively associated with physical functioning (p = 0.010), fatigue (p = 0.001), and pain (p = 0.021). According to the new questionnaires, the most affected outcome was muscle energy, depending on age (p = 0.042), diabetes (p = 0.014), type of surgery (p = 0.018), and non-insulinoma diagnosis (p = 0.007). Conclusions: A good QoL evaluated with EORTC questionnaires is reported in PanNET patients after surgery. Elderly and diabetic patients who underwent standard resection for gastrinoma/non-functioning PanNETs showed worse QoL outcomes. Full article

Background/Objectives: Traditional thermal ablation for pancreatic cancer is limited by collateral injury, often leading to complications such as pancreatitis. Irreversible electroporation (IRE) is a non-thermal alternative. We investigated tissue responses in a porcine pancreas model, focusing on cell death, thermal effects, and fibrosis. Methods: Seven pigs underwent pancreatic IRE via open surgery. Local tissue temperature was monitored near the electrode. Histological evaluation included H&E, TUNEL (apoptosis), Ki-67 (proliferation), vimentin (fibroblast activation), and insulin staining. Tissue remodeling was assessed at multiple time points up to 14 days. Results: IRE induced marked apoptosis within the ablated region, peaking at day 2. The maximum measured temperature was 78.4 °C. Over two weeks, fibrosis progressed with increased collagen and fibroblast activity. Regeneration was partial, with Ki-67-positive cell proliferation and gradual loss of insulin expression, while unablated tissue showed minimal damage. Conclusions: IRE enables localized pancreatic ablation while sparing surrounding tissue. However, fibrosis limits full recovery. Limitations include small sample size, short follow-up, and species differences. Further studies are needed to refine IRE parameters and assess long-term functional outcomes. Full article

Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used (“NET”, “pancreatic”, “surgery”, “laparoscopic”, “minimally invasive”, “robotic”, “enucleation”, “parenchyma sparing”) and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body–tail, while laparoscopic enucleation is better for head pNETs. Full article

Complete surgical resection in the context of a multimodal approach has been associated with excellent long-term survival in children diagnosed with pancreatoblastoma (PB). Traditionally, curative intent surgery for PB implies standard pancreatic resections such as pancreaticoduodenectomies and distal pancreatectomies with splenectomies, surgical procedures that may lead to significant long-term pancreatic functional deficiencies. Postoperative pancreatic functional deficiencies are particularly interesting to children because they may interfere with their development, considering their long life expectancy and the significant role of pancreatic functions in their nutritional status and growth. Thus, organ-sparing pancreatectomies, such as spleen-preserving distal pancreatectomies and central pancreatectomies, are emerging in specific tumoral pathologies in children. However, data about organ-sparing pancreatectomies’ potential role in curative-intent PB surgery in children are scarce. Based on the literature data, the current review aims to present the early and late outcomes of pancreatectomies in children (including long-term deficiencies and their potential impact on the development and quality of life), particularly for PB, and further explore the potential role of organ-sparing pancreatectomies for PB. Organ-sparing pancreatectomies are associated with better long-term pancreatic functional outcomes, particularly central pancreatectomies, and have a reduced impact on children’s development and quality of life without jeopardizing their oncological safety. The long-term preservation of pancreatic functions should not be disregarded when performing pancreatectomies for PB in children. A subset of patients with PB might benefit from organ-sparing pancreatectomies, particularly from central pancreatectomies, with the same oncological results as standard pancreatectomies but with significantly less impact on long-term functional outcomes. Full article

Background: Patient selection for lymphadenectomy remains a controversial aspect in the treatment of pancreatic neuroendocrine tumors (pNETs), given the growing importance of parenchyma-sparing resections and minimally invasive procedures. Methods: This population-based analysis was derived from the German Cancer Registry Group during the period from 2000 to 2021. Patients with upfront resected non-functional non-metastatic pNETs were included. Results: Out of 5520 patients with pNET, 1006 patients met the inclusion criteria. Fifty-three percent of the patients were male. The median age was 64 ± 17 years. G1, G2, and G3 pNETs were found in 57%, 37%, and 7% of the patients, respectively. Lymph node metastasis (LNM) was present in 253 (24%) of all patients. LNM was an independent prognostic factor (HR 1.79, CI 95% 1.21–2.64, p = 0.001) for disease-free survival (DFS). The 3-, 5-, and 10-year disease-free survival in nodal negative tumors compared to nodal positive was 82% vs. 53%, 75% vs. 38%, and 48% vs. 16%. LNM was present in 5% of T1 tumors, 25% of T2 tumors, and 49% of T3–T4 tumors. In T1 tumors, G1 was the most predominant tumor grade (80%). However, in T2 tumors, G2 and G3 represented 44% and 5% of all tumors. LNM was associated with tumors located in the pancreatic head (p < 0.001), positive resection margin (p < 0.001), tumors larger than 2 cm (p < 0.001), and higher tumor grade (p < 0.001). The multivariable analysis showed that tumor size, tumor grade, and location were independent prognostic factors associated with LNM that could potentially be used to predict LNM preoperatively. Conclusion: LNM is an independent negative prognostic factor for DFS in pNETs. Due to the low incidence of LNM in T1 tumors (5%), parenchyma-sparing surgery seems oncologically adequate in small G1 pNETs, while regional lymphadenectomy should be recommended in T2 or G2/G3 pNETs. Full article

(1) Background: Patients with pancreatic Neuroendocrine Neoplasms (PanNENs) often have a long overall survival. We evaluated determinants of quality of life (QoL) after surgery for PanNENs. (2) Methods: Patients operated on for a PanNEN in our center (1990–2021) received three EORTC QoL questionnaires (QLQ-C30, QLQ-GI.NET21, QLQ-PAN26). Six domains were selected as outcome variables (global QoL, physical function -PF, social function -SF, disease-related worries -DRWs, pain, upper-gastrointestinal (GI) symptoms) and evaluated in relation to the clinical variables. Statistical analysis was performed using R software v 4.2.2. (3) Results: One hundred and four patients enrolled showed a good global QoL (median 83.3). Old age was a determinant of worse global QoL (p 0.006) and worse PF (p 0.003). Multiple comorbidities (p 0.002) and old age (p 0.034) were associated with pain, while male gender was related to better PF (p 0.007) and less pain (p 0.012). Patients who had undergone parenchyma-sparing surgery demonstrated better PF (p 0.037), better SF (p 0.012), and less upper-GI symptoms (p 0.047). At multivariable analysis, age (p 0.005) and type of surgery (p 0.028) were confirmed as determinants of global QoL. (4) Conclusions: In patients operated on for a PanNEN, a good HRQoL is generally reported; notably, younger age and parenchyma-sparing surgery seem to positively affect HRQoL. Full article

Frantz tumors or solid pseudopapillary pancreatic neoplasm (SPN) are rare exocrine neoplasms that carry a favorable prognosis; they represent up to 3% of all tumors located in the region of the pancreas and have specific age and gender predispositions. In recent years, the rising curve of diagnosis is entitled to the evolution and access of diagnostic imaging. In this paper, we have retrospectively reviewed and described the clinical course of 40 patients with SPN from three institutions in Brazil, who had their diagnosis between 2005 and 2020, and analyzed the clinicopathological, genetic, and surgical aspects of these individuals. In accordance with the literature, most patients were women, 60% with unspecified symptoms at diagnosis, with tumors mainly located in the body and tail of the pancreas, of whom 70% underwent a distal pancreatectomy with sparing splenectomy as a standard procedure, and none of the cases have experienced recurrence to date. Surgery still remains the mainstay of treatment given the low metastatic potential, but more conservative approaches as observed in this cohort are evolving to become the standard of care. Herein, we present an in-depth analysis of cases focusing on the latest literature and report some of the smallest tumor cases in the literature. To our knowledge, this is the first report evaluating germline genetic testing and presenting a case of detected Li-Fraumeni syndrome. Full article

Background: Endosonography-guided fine needle aspiration biopsy (EUS-FNA)-associated metachronous gastric seeding metastases (GSM) of pancreatic ductal adenocarcinoma (PDAC) represent a serious condition with insufficient evidence. Methods: Retrospective analysis of PDAC resections with a curative-intent, proven pathological diagnosis of PDAC, preoperative EUS-FNA and post-resection follow-up of at least 60 months. The systematic literature search of published data was used for the GSM growth evaluation using Pearson correlation and the linear regression analyses. Results: The inclusion criteria met 59/134 cases, 16 (27%) had retained needle tract (15 following distal pancreatectomy, 1 following pylorus-sparing head resection). In total, 3/16 cases (19%) developed identical solitary GSM (10–26th month following primary surgery) and were radically resected. A total of 30 published cases of PDAC GSM following EUS-FNA were identified. Lesion was resected in 20 distal pancreatectomy cases with complete information in 14 cases. A correlation between the metastasis size and time (r = 0.612) was proven. The regression coefficient b = 0.72 expresses the growth of 0.72 mm per month. Conclusions: The GSM represent a preventable and curable condition. A remarkably high number of GSM following EUS-FNA was identified, leading to follow-up recommendation of EUS-FNA sampled patients. Multimodal management (gastric resection, adjuvant chemotherapy) may prolong survival. Full article

Pancreatic neuroendocrine tumors (p-NETs) are rare tumors with a recent growing incidence. In the 2017 WHO classification, p-NETs are classified into well-differentiated (i.e., p-NETs grade 1 to 3) and poorly differentiated neuroendocrine carcinomas (i.e., p-NECs). P-NETs G1 and G2 are often non-functioning tumors, of which the prognosis depends on the metastatic status. In the localized setting, p-NETs should be surgically managed, as no benefit for adjuvant chemotherapy has been demonstrated. Parenchymal sparing resection, including both duodenum and pancreas, are safe procedures in selected patients with reduced endocrine and exocrine long-term dysfunction. When the p-NET is benign or borderline malignant, this surgical option is associated with low rates of severe postoperative morbidity and in-hospital mortality. This narrative review offers comments, tips, and tricks from reviewing the available literature on these different options in order to clarify their indications. We also sum up the overall current data on p-NETs G1 and G2 management. Full article

Pancreatic neuroendocrine tumours (pNETs) represent 1 to 2% of all pancreatic neoplasm with an increasing incidence. They have a varied clinical, biological and radiological presentation, depending on whether they are sporadic or genetic in origin, whether they are functional or non-functional, and whether there is a single or multiple lesions. These pNETs are often diagnosed at an advanced stage with locoregional lymph nodes invasion or distant metastases. In most cases, the gold standard curative treatment is surgical resection of the pancreatic tumour, but the postoperative complications and functional consequences are not negligible. Thus, these patients should be managed in specialised high-volume centres with multidisciplinary discussion involving surgeons, oncologists, radiologists and pathologists. Innovative managements such as “watch and wait” strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge. The aim of this work is to update the surgical management of pNETs and to highlight key elements in view of the recent literature. Full article

Pancreatic neuroendocrine neoplasms (PanNENs) are relatively rare, but their incidence has increased significantly in the last decades. Precise diagnosis and prognostic stratification are crucial for proper patient management. Endoscopic ultrasound (EUS) is the modality of choice for diagnosis of solid pancreatic tumors, showing a higher tumor detection rate than other imaging modalities, especially for small size lesions. EUS also serves as a guide for preoperative sampling and other interventions. EUS-tissue acquisition is a safe and highly accurate technique for cyto/histological diagnosis of PanNENs with a well-demonstrated correlation between Ki-67 proliferation index values and tumor grading on EUS and surgical specimens according to the WHO 2017 classification. Furthermore, the possibility of a preoperative EUS-guided fine needle tattooing or fiducial markers placement may help the surgeon to locate small and deep tumors, thus avoiding formal pancreatic resections in favor of parenchymal-sparing surgery. Finally, locoregional ablative treatments using either ethanol injection or radiofrequency ablation have been proposed in recent studies with promising results in order to control symptoms or reduce tumor burden in selected patients unfit for surgery with functioning or non-functioning PanNENs. This article review highlights the current role of EUS in PanNENs management, focusing on the present and future applications of EUS-guided interventions. Full article

Parenchymal sparing duodenal and pancreatic resection are safe procedures in selected patients with the aim to reduce endocrine and exocrine long-term dysfunction. When the tumor is benign or borderline malignant, this appears to be a good option for the surgeon, associated with low rates of severe surgery-related early postoperative complications and low in-hospital mortality. This mini review offers comments, tips and tricks, and a review of literature concerning those different options with specific illustrations in order to clarify their indication. Full article