Neoplasms

Digestive System Diseases

Gland and Hormone Related Diseases

All Conditions

Behaviors and Mental Disorders

Rare Diseases

Pancreatic Neoplasms

Neuroendocrine Tumors

Neuroectodermal Tumors

Neuroectodermal Tumors, Primitive

Neoplasms, Germ Cell and Embryonal

Neoplasms by Histologic Type

Neoplasms, Nerve Tissue

Gastrointestinal Neoplasms

Digestive System Neoplasms

Endocrine Gland Neoplasms

Gastrointestinal Diseases

Pancreatic Diseases

Endocrine System Diseases

Quality of Life

Pancreatic Cancer

Neuroendocrine Tumor

Pancreatic Neuroendocrine Tumor

Neuroepithelioma

Coagulants

All Drugs and Chemicals

Hemostatics

In laparoscopic or robotic pancreatic tumor enucleation, it is inevitable that the main pancreatic duct (MPD) may be damaged due to its proximity or encasement by the tumor. After tumor resection, MPD repair or reconstruction can be performed. If there is no associated MPD dilation, a MPD stent can be inserted and secured with interrupted sutures. When placing the stent, it is important to ensure that the distal end of the stent passes through the duodenal papilla to sufficiently reduce the pressure inside the MPD. Vascular remnants or branch pancreatic duct remnants on the pancreatic resection surface should be sutured. After hemostasis, efforts should be made to restore the serosalization of the pancreatic resection surface. The surface can also be left exposed or covered with ligamentum teres hepatis. Fish-mouth-shaped incisions can be closed, but care should be taken to avoid creating dead spaces that may lead to fluid accumulation and hinder drainage.

During laparoscopic or robotic pancreatic tumor enucleation, if the main pancreatic duct (MPD) is damaged due to its proximity or encasement by the tumor, MPD repair or reconstruction is performed.

MPD Repair or Reconstruction

Xianjun Yu, MD, PhD

Zheng Li, MD

Xiaowu Xu, MD

The aim of this study is to evaluate the impact of concomitant main pancreatic duct repair or reconstruction during minimally invasive pancreatic tumor enucleation on long-term patient prognosis and quality of life.

Standard surgical procedures for benign or low-grade malignant pancreatic tumors is associated with increased risks of postoperative complications and long-term pancreatic functional impairment, while parenchyma-sparing pancreatectomy such as enucleation can reduce the incidence of complications and preserve healthy parenchyma, thereby preserve both endocrine and exocrine pancreatic function. It has been reported that pancreatic tumor enucleation is a safe and feasible approach in preserving normal physiological function in patients undergoing pancreatic surgery.

With the growing emphasis on routine screenings and the application of high-quality thin-slice imaging techniques, the detection rates of pancreatic tumors have witnessed a steady increase. Additionally, there is a notable trend towards younger patients being diagnosed with pancreatic tumors. Consequently, in conjunction with ensuring safe and thorough tumor resection while maximizing preservation of pancreatic function, there is a current clinical demand to further reduce surgical trauma.

Literature reviews and meta-analyses have demonstrated that minimally invasive enucleation procedures offer well-known advantages associated with minimally invasive approaches, such as shorter postoperative hospital stays and lower overall complication rates. While the occurrence rate of severe complications, such as postoperative hemorrhage, remains relatively low, the development of postoperative pancreatic fistula (POPF) continues to pose a challenging issue.

The distance between the tumor and the main pancreatic duct (MPD) is considered a crucial factor influencing the occurrence of POPF after enucleation. However, these data have been rarely described in previous studies, making it challenging to accurately assess their actual impact on the rate of POPF occurrence. Heeger et al. suggested that the risk of POPF increases with closer proximity of the tumor to the MPD. The incidence of POPF was higher in deep-seated tumors after pancreatic enucleation (distance to MPD \<3 mm) compared to superficial tumors (\>3 mm) (73.3% vs. 30.0%, P=0.002). Other studies have even limited this critical distance to 2mm. Some research has indicated that if the tumor invades or encases the MPD, enucleation surgery should be contraindicated, and standard resection should be preferred to avoid the risk of POPF postoperatively. However, a retrospective analysis by Strobel et al. on 166 cases of pancreatic tumor enucleation demonstrated that even tumors in close proximity to the MPD can be safely resected, although their study did not include cases with tumor encasement of the MPD. In 2021, Professor Liu Rong and colleagues introduced the concept of pancreatic duct surgery and outlined four main surgical approaches: MPD repair, pancreatic end-to-end anastomosis, local excision of branch-duct intraductal papillary mucinous neoplasms, and MPD replacement. However, detailed research data in this field are still lacking.

The safety and feasibility of minimally invasive pancreatic tumor enucleation procedures involving MPD repair or reconstruction, the control of POPF, and the long-term prognosis and quality of life of patients after MPD repair or reconstruction remain unclear. Therefore, this study aims to conduct a prospective, multicenter, single-arm clinical trial. The results of this study will serve as a valuable reference for clinical practice and promote the development and application of minimally invasive pancreatic tumor enucleation procedures.

Minimally Invasive Pancreatic Enucleation With Main Pancreatic Duct Repair or Reconstruction

Long-term Prognosis and Quality of Life in Minimally Invasive Pancreatic Enucleation With Main Pancreatic Duct Repair or Reconstruction: A Multicenter Prospective Single-Arm Clinical Trial

Clinically Relevant Pancreatic Fistula including Grade B fistulas, which require treatment beyond simple drainage, as well as Grade C fistulas.

Adverse events that occur during or after the surgery, reported according to the Clavien-Dindo classification.

Postoperative pancreatic hemorrhage (PPH) rate within 90 days after surgery, reported according to the ISGPS definition.

Delayed gastric emptying (DGE) rate within 90 days after surgery, reported according to the ISGPS definition.

Reoperation rate within 90 days after surgery.

Postoperative pancreatic enzyme-dependent malabsorption rate.

The patient's health-related quality of life after surgical intervention. It includes physical, emotional, and social aspects of a patient's well-being. This study evaluated quality of life using a telephone survey and the EORTC C30 scales.

R0 margin rate on postoperative pathological assessment.

The time of surgery to the time of tumor recurrence or death.

The Third Affiliated Hospital of Soochow University

Tongji Hospital

Qilu Hospital of Shandong University

Chinese PLA General Hospital

The Affiliated Hospital of Xuzhou Medical University

Fudan University

President of Fudan University Shanghai Cancer Center

Gastrointestinal Agents

Pancrelipase

Pancreatin

Laparoscopic spleen-preserving distal pancreatectomy using the Kimura technique.

Laparoscopic spleen-preserving distal pancreatectomy using the Warshaw technique.

The laparoscopic spleen-preserving distal pancreatectomy using the Kimura technique is defined as a surgical procedure that aims to remove the distal part of the pancreas while preserving the spleen by maintaining the splenic artery and vein (Hepatogastroenterology. 2003;50:2242).

Laparoscopic spleen-preserving distal pancreatectomy using the Kimura technique

Warshaw technique laparoscopic spleen-preserving distal pancreatectomy is defined as a surgical procedure that aims to preserve the spleen while removing the distal part of the pancreas. It involves ligating the splenic artery and vein, while preserving the left gastroepiploic artery and short gastric vessels (Arch Surg. 1988;123:550).

Laparoscopic spleen-preserving distal pancreatectomy using the Warshaw technique

This study aims to compare the surgical outcomes of laparoscopic spleen-preserving distal pancreatectomy using the Kimura technique versus the Warshaw technique. The primary focus is on the rates of unplanned splenectomy, occurrence of severe complications, as well as intraoperative and perioperative outcomes of both techniques.

For benign and low-grade malignant tumors of the pancreatic body and tail, laparoscopic distal pancreatosplenectomy (LDP) is commonly recommended due to its shorter hospital stay, lower intraoperative blood loss, and comparable complication rates. The DIPLOMA international multicenter clinical trial further established the non-inferiority of minimally invasive techniques in terms of curative resection for resectable pancreatic body and tail cancers.

As the spleen plays a crucial role in immune defense, splenectomy is associated with increased postoperative infection risk, significant increase in platelet count, and thrombosis. Therefore, for benign and low-grade malignant tumors of the pancreatic body and tail, minimally invasive spleen-preserving distal pancreatectomy should be the preferred approach.

The Kimura technique is the most commonly used and favored spleen-preserving distal pancreatectomy technique. It involves the complete preservation of splenic vessels, resulting in fewer postoperative complications. However, it is time-consuming and challenging due to the identification and ligation of numerous small and short vessels entering the pancreatic body and tail to preserve the fragile splenic artery and vein. On the other hand, the Warshaw technique involves segmental resection of splenic vessels and relies on the left gastroepiploic artery and short gastric vessels for splenic perfusion. It is a simpler procedure with less intraoperative blood loss and shorter operative time. However, it carries an increased risk of postoperative splenic infarction, gastric varices, and secondary bleeding.

Although a higher incidence of splenic infarction has been observed with the Warshaw technique, its clinical relevance remains controversial. Reports indicate that approximately 25% of patients undergoing Warshaw procedure show radiological evidence of asymptomatic gastric varices, but during a follow-up period of up to 21 years, no clinically relevant consequences of gastric varices were observed. Most cases of postoperative splenic infarction are transient and do not require specific treatment. Data from a large pan-European retrospective study showed no significant differences in the clinical incidence of splenic infarction (0.6% vs. 1.6%, P = 0.127) and major complication rates (11.5% vs. 14.4%, P = 0.308) between minimally invasive Kimura and Warshaw techniques.

While Kimura and Warshaw techniques demonstrate comparability in most postoperative outcomes, the former appears to have an advantage in reducing the risk of splenic infarction and gastric varices. Some experts propose a "Kimura-first" strategy. However, there is currently no prospective study comparing these two techniques. Therefore, this study has designed a multicenter randomized controlled clinical trial, focusing on the rates of unplanned splenectomy, severe complication occurrence, and intraoperative and perioperative outcomes of laparoscopic spleen-preserving distal pancreatectomy using the Kimura versus the Warshaw technique. Long-term follow-up will assess clinically relevant outcomes such as splenic ischemia, splenic hyperfunction, gastric varices, and postoperative quality of life. This study aims to provide higher-level evidence in the selection of laparoscopic spleen-preserving distal pancreatectomy techniques.

Comparison of Kimura Versus Warshaw Technique for Laparoscopic Spleen-Preserving Distal Pancreatectomy

Comparison of Kimura Versus Warshaw Technique for Laparoscopic Spleen-Preserving Distal Pancreatectomy: A Multicenter Randomized Controlled Clinical Trial

The unplanned splenectomy rate in both groups will be calculated, and detailed records of the specific reasons will be documented, such as adhesions, bleeding, intraoperative splenic infarction.

The rate of severe complications will be assessed by evaluating the severity of postoperative complications using the Clavien-Dindo classification system. In this classification system, complications graded as III and above are considered severe complications.

The spleen vessel preservation rate refers to the rate at which the spleen vessels are successfully preserved during surgery. In cases where the Kimura technique is unable to preserve the spleen vessels, salvage Warshaw procedure or splenectomy may be performed. This can include modified Warshaw procedures that involve the simple removal of the splenic artery or splenic vein.

CRSI is defined as the occurrence of spleen ischemia requiring splenectomy during either the initial hospitalization or subsequent readmissions. The reasons for the second splenectomy will be recorded.

The evaluation will be conducted using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30).

The EORTC QLQ-C30 is a widely used questionnaire to assess the quality of life. It consists of multiple scales and items that cover various aspects of physical functioning, role functioning, emotional functioning, cognitive functioning, social functioning, global health status, and symptom scales.

Each item in the questionnaire is rated on a four-point Likert scale, ranging from 1 (not at all) to 4 (very much). Some items are reverse-scored, meaning that a higher score indicates a worse outcome. The scores for each scale are then transformed to a 0-100 scale, where a higher score represents a better outcome for functioning scales and a worse outcome for symptom scales.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Minimally Invasive Pancreatic Enucleation With Main Pancreatic Duct Repair or Reconstruction	NCT06024343	Pancreatic Tumo... Pancreatic Neur... Solid Pseudopap...	MPD Repair or R...	18 Years - 70 Years	Fudan University
Minimally Invasive Pancreatic Enucleation With Main Pancreatic Duct Repair or Reconstruction	NCT06024343	Pancreatic Tumo... Pancreatic Neur... Solid Pseudopap...	MPD Repair or R...	18 Years - 70 Years	Fudan University
Comparison of Kimura Versus Warshaw Technique for Laparoscopic Spleen-Preserving Distal Pancreatectomy	NCT06167421	Pancreatic Tumo... Pancreatic Neur... Solid Pseudopap...	Laparoscopic sp... Laparoscopic sp...	18 Years - 70 Years	Fudan University

Spots Global Cancer Trial Database for pancreatic tumor, benign