As it was first reported by Guillemin and Bessot,1 central pancreatectomy (CP) has increasingly been applied for some lesions, including chronic pancreatitis, traumatic injury, and benign and borderline lesions localized at the neck and body of the pancreas. Pancreatic trauma occurs in 0.2% of patients with blunt trauma and 1% to 12% of patients with penetrating trauma. Reported outcomes after CP are conflicting.2–4
CP surgery in cases of pancreatic trauma has minor specifications with regard to limits of tissue resection. From this point the author started to try optimizing pancreatic tissue reserved distally that might not need gastrointestinal drainage and in the same time preserves the patient’s euo-insulinimic state; modified CP (MCP) is proposed.
The pancreatic tail is surgically far more reachable than the rest of the pancreas. The pancreatic tail is connected to the posterior wall of the stomach. It is held between the 2 layers of the lienorenal ligament together with the splenic vessels. This is a crucial landmark for the tail where it is contained in the lienorenal ligament where its vascular tree is relatively secured. This landmark is the basis to defining the distal pancreatic stump level of the MCP in this study. The tail as the distal pancreatic stump is approached from the left side, following the lienorenal ligament from its free end, separating the tail from the splenic hilum and elevating the pancreatic bed beyond the left kidney until the reflection of the lienorenal ligament on the renal surface where the pouch is closed and this limit defines the proximal end of the tail for surgical transection.5 A complete view of the pancreatic body can be obtained by opening the gastrocolic ligament. In case of traumatic pancreatic transection; reflection of the proximal pancreatic stump free end along the superior mesenteric vein (SMV) axis will define the free end of the proximal pancreatic stump. The remaining pancreatic tissue in between the free ends of the proximal and distal pancreatic stumps is the body of the pancreas that is to be excised in our procedure.
The extent of pancreatic resection is empiric; division at the neck equals 60% to 70% resection. Division at the proximal body to the left of the portal vein above and to the SMV below equals 50% to 60%. Because of almost symmetrical distribution of the exocrine cells through parts of the pancreas; with 80% pancreteactomy there is still good exocrine and endocrine activity. Resection of greater than 90% affects the endocrinal activity.6 In this study the applied technique is proposing resection of the pancreatic body that accounts preservation of >50% to 60% of the pancreatic tissue. This preserved amount of pancreatic tissue is more than enough for normal pancreatic function.
The diameter of the main pancreatic duct at the proximal body ranges between 3.5 and 2 mm and at proximal tail between 2.4 and 0.9 mm.7,8 Minimizing the duct of the tail to a diameter of <1.8 mm assures minimal exocrine glandular tissue and easy suppression by closure of the stump saving the higher content of the (A) cells in the tail.
Sections of pancreas from human fetuses, 6 to 20 weeks gestation, were stained with immune-peroxidase for insulin (B) cells, glucagon (A) cells, pancreatic polypeptide or somatostatin (D) cells. Morphometric analyses were performed on sections from head and tail regions of each fetus. No stained cells were found at 7 weeks. (A), (B), pancreatic polypeptide, and (D) cells were found at 9 weeks in primitive islets or as isolated cells adjacent to duct cells. There was no relationship between the density of each endocrine cell type and fetal age, but there was a significant increase in the relative density percentage total endocrine cells of (D) cells from 10 to 20 weeks.9 Another leading study states that the tail contains significantly higher fraction (A) cells and less pancreatic polypeptide cells than the head but similar densities of (B and D) cells. Lobules containing a high density of pancreatic polypeptide cells and few (A) cells were found in the posterior part of the head in 6 fetuses, aged 10 to 20 weeks.10 A third more recent study provides data indicating that insulin-secreting islet fraction is similar in all regions of the pancreas.11
Pancreatic injuries comprise to ~12% of victims of abdominal trauma, two-thirds of these injuries are penetrating in nature. Blunt pancreatic injuries, although less common often present diagnostic challenges. It appears that an important factor contributing to morbidity is failure of proper recognition of a main pancreatic duct. This factor dictates early and appropriate operative management. The methods used to definitely determine ductal injury remain controversial.12
PANCREATIC INJURY SCORING SCALE12
Pancreatic injury scoring scales’ grades were as follows:
Grade I: minor contusion or laceration without ductal injury.
Grade II: major contusion or laceration without ductal injury.
Grade III: distal transection or parenchymal injury with ductal injury.
Grade IV: proximal contusion or transection or injury involving ampulla.
Grade V: massive disruption of pancreatic head and combined pancreatico-duodenal injuries.
Abdominal-computerized tomographic (ACT) helical scanning with both intravenous and gastrointestinal contrast findings include: fluid in the lesser sac, extraperitoneal fluid, pancreatic edema or hematoma, thickening of the anterior renal fascia or fluid in the anterior pararenal space, and fluid between the splenic vein and the pancreatic parenchyma.13
In stable patients with suspected pancreatic injuries preoperative endoscopic retrograde cholangiopancreaticography for evaluation of the pancreatic duct is helpful in defining method of therapeutic management.7,14
Complete pancreatic transection or major pancreatic duct injury caused by blunt abdominal trauma all mandate CP for the macerated part, closure of the proximal pancreatic segment, and either drainage of the distal pancreas into Roux and Y or distal pancrearectomy and splenectomy. Pancreatic transection usually occurs in the line of superior pancreatic vessels at the neck of the gland or less commonly through the body or tail.15–18
Distal pancreatectomy to the left of SMVs is associated with loss of significant amount of normal pancreatic parenchyma, thereby increasing the risk of pancreatic insufficiency.19,20 Splenectomy is associated with a lifelong risk of infectious and hematologic morbidity.20,21 Endocrine and exocrine pancreatic insufficiency, and infectious and hematological complications following distal pancreatectomy and splenectomy have prompted the pancreas and spleen preserving strategies for the management of this uncommon injury.21
Endocrine impairment after standard left pancreatic resection is reported with wide variation in 17% to 85% of patients.22,23 Preservation of the spleen may not be always technically feasible as it is more time consuming and associated with increased blood loss.24
MATERIALS AND METHODS
After obtaining Institutional review board approval, consented patient recruitment according to selection criteria was achieved.
Type of study: the study describes a case series where the modified technique in the field of pancreatic surgery is applied on trauma patients through both laparoscopic and open approaches according to patients’ hemodynamic stability.
Patients criteria included the following:
- Patients having blunt abdominal trauma resulting in traumatic pancreatic transection with or without duodenal transection (pancreatic injury scoring scale III).
- Patients who did not need splenectomy procedure.
Between March 2010 and January 2015, a total number of 41 cases have the target diagnosis by ACT and operated by the author performing MCP technique with or without duodenoplasty as needed. Clinical assessment of both regional topography and pancreatic function has been achieved and documented for each patient.
Follow-up criteria: follow-up was based on clinical, radiologic, and laboratory assessments. Specific aims of long-term follow-up were to evaluate endocrine and exocrine functions. For this latter purpose, patients underwent clinical evaluation every 3 to 6 months.
According to the World Health Organization (WHO) recommendations, fasting glucose blood level was used as the reference test for the diagnosis of new-onset diabetes and oral glucose tolerance test was performed in doubtful cases. Endocrinal functions were glycemia and Hb A (1C) levels monitoring. No specific exocrine function tests were performed. New onset of exocrine insufficiency was defined as steatorrhea and weight loss requiring pancreatic enzymes supplementation.25
Design of the Surgical Procedures
The proposed MCP technique has been designed and fixed. The same technique has been applied in both open MCP (OMCP) and laparoscopic MCP (LMCP) procedures. The proximal pancreatic stump stapling or suture line has been defined to be along the SMV axis. The reserved tail of pancreas has been anatomically defined being the pancreatic tissue mass enclosed in the posteriorly free part of the lienorenal ligament. The blood supply of the distal pancreatic segment is enclosed within the lienorenal peritoneal fold being secure of any manipulative injury and so pancreatic tail tissue viability is assured. The lesser sac is kept widely open communicating to the greater sac to prevent postoperative collection and gastric distension.
After making an upper midline incision between from the xiphoid till just below the umbilicus to the right side, the gastrocolic ligament is divided to open the lesser sac and expose the pancreas. Early emphasis is paid towards hemostasis control of the transected pancreatic margins and duodenum in case of duodenal transection as well. The posterior peritoneum along the inferior and superior margins of the gland was dissected and the SMV was identified under the neck of the pancreas. Early emphasis is placed on establishing a dissection plane between the anterior surface of the mesentericoportal vein and the posterior surface of the neck of the pancreas along the pancreatic traumatic dissection line.
Wherever the pancreatic transection site; at neck or proximal body resection of pancreas is unified by vascular landmarks. The surgical resection landmarks are defined as follows; the cephalic pancreatic resection landmark is along the SMV axis. The caudal pancreatic landmark is where the pancreatic tissue becomes free posteriorly being enclosed in the avascular lienorenal ligament announcing the start of the tail segment. The caudal stump is cut with scissors and always inspected for the main duct to assure the pancreatic duct not >1.8 mm in diameter as calibrated by an umbilical catheter size 5 Fr (1.7 mm). The transection line is planned in between 2 of the vertical vascular arcades. Hemostasis of the cephalic stump of pancreas is performed with interrupted 4-0 nonabsorbable stitches. The cephalic pancreatic cut surface is sutured using nonabsorbable 3-0 polypropylene suture in a running manner continuous suture through the pancreatic capsule and tied loosely. The caudal stump is closed by GIA 60 mm stapler. The technique of stapling is the by prolonged perifiring compression (PPFC) with linear stapler for 30 seconds before firing to compress the parenchymal tissue and avoid destruction of the pancreatic capsule and parenchyma, especially in the absence of meshed stapler. No caudal stump drainage procedure was ever performed in any of the cases. Two closed system drainage tubes were placed in dependent position to the closed cephalic and caudal stumps.
Port locations were as follows:
- Umbilical (5 mm)—camera.
- Subxiphoid (5 mm)—stomach retracting port.
- Left lumbar (5 mm)—colon retracting port.
- Left midclavicular (11 mm)—right hand working port.
- Right midclavicular (11 mm)—left hand working port.
After general inspection of the peritoneal cavity, hemostasis of bleeding points, the lesser sac is entered by dividing the gastrocolic omentum from distal antrum up to the fundus of stomach including the short gastric vessels, so as to expose the tail of pancreas. Elevation of the right lobe of the liver and the stomach dissection of the inferior border of the pancreas mobilizing its posterior surface by retracting the transverse colon downwards and dividing the anterior layer of the transverse mesocolon. This exposes the areolar tissue at the back of the pancreas. Dissection is continued until the splenic vein is identified. The junction of the splenic vein and the SMV is identified by opening the fascial layer. Caution is paid to preserve the splenic vessels at the upper border of the pancreas. The splenic artery is dissected away from the pancreatic parenchyma and it is secured. The cephalic pancreatic stump is freed along the SMV from line of traumatic transection to the right side and secured by Endo GIA 60 mm stapler along the superior pancreatic vein axis. The technique of stapling is the by PPFC as mentioned before. Mobilization of the body of the pancreas is achieved beyond the portal vein till reaching the lienorenal ligament enclosing the free pancreatic tail. Pancreatic branches supplying the mobilized pancreas are secured and divided. Caudally the pancreas is divided by endoscissors at the level of distal body to proximal tail. The caudal stump is inspected for the pancreatic duct not to be >1.8 mm as mentioned before via calibration with an umbilical catheter size 5 Fr (1.7 mm) cannulation. The caudal stump is then secured by applying PPFC technique using an Endo GIA 60 mm stapler. No caudal pancreatic stump drainage procedure was ever performed in any of the patients. Two closed system drainage tubes were placed in dependent position to the closed cephalic and caudal stumps.
Perioperative outcomes included operative time, intraoperative hemorrhage, transfusion, pancreatic fistula, intra-abdominal abscess/infection, postoperative bleeding, reoperation, mortality, and postoperative hospital time.
- “Pancreatic fistula” new 2016 definition and grading of the International Study Group on Pancreatic Surgery (ISGPS).26
- “Perioperative mortality” is defined as in-hospital or 30-day death, and postoperative complications were evaluated.26
Preoperative and postoperative nutritional status (total protein, albumin, and hemoglobin) was evaluated using the formula: (discharge numerical value—preoperative numerical value)/preoperative numerical value×100 (%). Nutritional parameters were measured on the day of admission and the seventh postoperative day.
The abdominal drains were not removed until the drainage fluid volume was ≤10 mL/d and the amylase value was <125 IU/L (same as serum amylase level).
Postoperative Glycemic Control Protocol
Postoperative glycemic control protocol is as follows:
- Insulin is added to the glucose infusion (1 U insulin/5 g glucose).
- Blood glucose is monitored every 6 hours and additional insulin is given if blood glucose exceeded 10 mmol/L.
- Long-acting insulin is given when blood sugar is not well controlled using the above method. Glycemic control is determined as the mean daily fasting blood glucose.
All patients were evaluated for a follow-up period of at least 3 years. Aim is to evaluate the long-term pancreatic mass, changes in endocrine and exocrine functions and body weight change based on radiological, clinical and laboratory assessments. New-onset diabetes mellitus is diagnosed according to the criteria of the World Health Organization.25 Pancreatic exocrine insufficiency is defined as diarrhea and steatorrhea, and would be treated by daily enzyme administration.
The study sample total number is 41 patients. In total, 28 patients accounting for 2 thirds of the total number were hemodynamically unstable and categorized for open surgical procedure. The predominant mechanism of trauma was deceleration in 30 patients (73.2%), fall down from height or ejection from vehicle in 3 patients (7.3%) and direct blow to the abdomen in 8 patients (19.5%). All patients had ACT preoperatively that was diagnostic with 100% accuracy with regard to abdominal visceral injuries. Pancreatic transection was along the SMV axis in 37 patients (90.2%) and transecting the proximal body in 4 patients (9.8%). Seven patients (17.1%) had duodenal transection that was always accompanied by retroperitoneal hematoma and hemodynamic instability.
Detailed epidemiology and preoperative evaluation data are all tabulated in Table 1.
The operative time is comparable between the OMCP and LMCP groups in relation to the extrapancreatic operative effort in the former one. Intraoperative data including operative time, operative main and additional procedures, and amount of blood loss and transfusion are all documented in Table 2.
Early and late follow-up measures for all patients recruited in the study has followed the following measures:
- Radiologic measures were as follows:
- ACT on fifth day, before hospital discharge.
- Magnetic resonance cholangiopancreaticogram (MRCP) on day 60.
- Ultrasound abdomen (USA)/pancreas monthly after the second month.
- One to 2-year ACT follow-up documenting the dimensions and condition of the pancreatic stumps.
- Biochemical measures were as follows:
- Haemo gluco test: 6 hourly for the first week, once a day for 12 weeks, once weekly for the rest of follow-up duration.
- Hb A1 C: every other week for 30 weeks.
All patients had parenteral nutrition for the first 5 days to be discontinued and started on balanced diet of the needed caloric energy per patient.
As regards the radiologic follow-up observing intraperitoneal collection as an early alarm for peripancreatic collection, pancreatic necrosis or pancreatic fistula. There were minimal small collections around the distal pancreatic stump in 13 patients. The fluid collection foci ranged between 2 and 5 in number with size ranging between 7 and 20 mL clear serous fluid. Biochemical assay for the peripancreatic fluid for amylase levels were below indicators for pancreatic biochemical leak. None of these collection foci needed radiologic-guided aspiration and resolved completely in a time range of 6 to 11 days. Among 13 patients 9 patients showed either mild basal pleural effusion or mild atelectasis.
None of patients showed signs of diabetes mellitus, indigestion, or steatorrhea.
Around the day 60 all patients had MRCP to outline the new topography and exclude any pathology. As regards delayed follow-up MRCP imaging there were 7 cases (17.1%) of insignificant dimensional changes in both or either pancreatic segments that had no significant nor related functional pancreatic changes.
The median follow-up durations for LMCP and OMCP groups were 46 and 53 months, respectively.
Detailed postoperative follow-up data are all tabulated in Tables 3 and 4.
Figures 1–3 show radiologic progression for the same case with traumatic transection of both duodenum and pancreas.
The collected patients’ sample in this study has been unified with regard to the type of trauma, the integrity of the spleen and the level of pancreatic transection. The surgical procedure whether open or laparoscopic has similar landmarks with regard to the pancreatic tissue excised and the pancreatic stump control rules. On the basis of the literature review the following concepts have been identified:
- The amount of islets of Langerhans through all segments of the pancreas is similar or even more concentrated in the tail segment.
- The amount of exocrine glandular tissue is proportional to the duct system diameter. Applying this on the distal pancreatic stump; defining a duct diameter (<1.8 mm) as the level of preservation without creating an enteric drainage, seems theoretically acceptable.
- The diameter of the main pancreatic duct at the proximal body ranges between 3.5 and 2 mm that drains a big mass of exocrine cells and mandates drainage.
- Pancreatic body resection equals to 40% to 50% pancreatectomy and with up to 80% pancreatectomy there is still excellent exocrine and endocrine pancreatic function.
- Control of the pancreatic duct on the distal stump secured inside the lien-renal ligament with its intact blood supply after MCP would suppress the scanty exocrine cells within the tail of pancreas without fear of pancreatic fistula or exocrine function insufficiency.
- Preserving the pancreatic tail would assure preservation of the spleen as a function.
Interpreting the Above Points
Interpreting the above points would declare the following facts:
- The pancreatic tissue of the body is dispensable and so its drainage procedure into the gastrointestinal tract.
- Preservation of the tail of pancreas without a drainage procedure is theoretically applicable.
- Upon reserving the tail of pancreas the spleen would be reserved resulting in remarkable reduction of the operative time and procedure morbidity as well.
The Strict Patients’ Selective Criteria
The strict patients’ selective criteria in this study aims at the following targets:
- Verifying the distal pancreatic stump nondrainage procedure.
- Titrating the reserved pancreatic tissue mass in relation to both exocrine and endocrine functions.
Patients recruited in this study have shown enhanced postoperative recovery pathway evidently due to the minimal surgical physiologic interruption, reduced duration of anesthesia and directing own patients’ tissue reserves in an optimistic manner.
The postoperative monitoring for pancreatic fistula definition has adopted the ISGPS latest review in 2016,26 taking in the consideration the biochemical, extended biochemical, and the clinical assessments for all patients.
The described surgical procedure has made use of all the basic knowledge available in literature to conform the basic concept that could be served by a unique surgical technique. The traditional postpancreatectomy distal pancreatic gastroenteric drainage as a default procedure proved completely unnecessary conditioned by minimizing the amount of distal pancreatic stump. Reserving great amount of the distal stump tissue in not needed for a normal pancreatic function.
Furthermore the pancreatic drainage procedure is not a barrier against pancreatic fistula formation that has proved still high incidence of fistula formation with the accompanying high morbidity and mortality rates.27
It is for sure that case reported in literature to get pancreatic insufficiency after MCP surgery has no pancreatic tissue perfusion assessment to exclude an ischemic etiology. This issue is crucial to determine whether the reason behind is related to number of cells preserved primarily to function or this related to secondary necrosis due to an unconscious technique applied. That is why in the current study anatomic pancreatic evaluation is achieved as part of the follow-up parameters.
The first CP with 2 pancreaticoenteric anastomoses was described by Guillemin and Bessot in 19571 for chronic pancreatitis. Many case reports and small series have been reported since then, but the validity of CP has been still ambiguous. Most of the CP series are heterogenous, describe a high incidence of postoperative complications and lack information related to functional long-term results.28,29
In literature, studies comparing CP to left extended pancreatectomy techniques, have reported considerable less pancreatic fistula in the later (17% vs. 13%, respectively).27 This proves that the less distal pancreatic tissue we preserve the less exocrine output drainage and dependently a less prone pancreatic fistula.
The author in this study has designed the MCP procedure described on solid anatomic and histologic basis in addition to technical one. The procedure has spared the excess pancreatic body tissue that mandates an enteric drainage procedure due to the high output secretions. Having quite enough pancreatic tissue in the pancreatic head and tail accounting for not <60% of the total pancreatic tissue mass saves a strong rational behind the MCP procedure.
Having such a precise MCP, time saving procedure in trauma cases, that abolishes the serious complications of pancreatic fistula. In cases of traumatic pancreatic transection the proposed MCP technique is less demanding to a skillfull pancreatic surgeon and could be achieved by the general trauma surgeon after short training on the procedure. Moreover, the resected viable pancreatic body in cases of trauma would supply a precious pancreatic tissue reserve for transplantation banks upon patient’s consent.
The study by applying such a prototype surgery, opens widely a complete field of trials in cases of wondering or diseased pancreas with regard to the amount needed to preserve for normal pancreatic function on both endocrine and exocrine aspects. Critic is invited.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
central pancreatectomy; modified central pancreatectomy; distal pancreatic stump duct diameter; pancreatic fistula; prolonged perifiring compression