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Serous cyst adenoma of the pancreas: appraisal of active surgical strategy before it causes problems.

Hwang HK, Kim H, Kang CM, Lee WJ - Surg Endosc (2011)

Bottom Line: Seventeen patients (44.7%) were symptomatic, and the rest (21, 55.3%) were incidentally found to have SCA.Combined resection of the right colon was performed in two patients (5.3%) due to severe adhesion associated with large tumors.No mortality was found.

View Article: PubMed Central - PubMed

Affiliation: Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Ludlow Faculty Research Building #204, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.

ABSTRACT

Background: Patients who are diagnosed with symptomatic or ambiguous serous cyst adenoma (SCA) need surgery. The purpose of this study is to suggest a potential management plan based on analysis of surgically treated SCAs.

Methods: Between August 1995 and December 2010, 38 patients with SCA were surgically treated. Data were analyzed retrospectively.

Results: Among 38 patients, 28 were female and ten were male. Mean age was 49.6 ± 14.1 years, and five patients (13.2%) were older than 65 years. Among the five patients, two were more than 70 years old. Seventeen patients (44.7%) were symptomatic, and the rest (21, 55.3%) were incidentally found to have SCA. Twenty-seven patients underwent open pancreatectomy, and 11 patients received laparoscopic distal pancreatectomy. Mean tumor size was 4.4 ± 2.8 cm. Most asymptomatic patients of SCA had a left-sided pancreatic tumor and distal pancreatectomy with or without splenectomy were frequently performed with short operative time and less blood transfusion (P < 0.05). Minimally invasive surgery was mostly applied to left-sided tumors less than 5 cm in size (11/19 vs. 0/6, P = 0.029). Combined resection of the right colon was performed in two patients (5.3%) due to severe adhesion associated with large tumors. Significant association was noted between age and tumor size in asymptomatic patients (correlation coefficient = 0.541, R (2) = 0.293, P = 0.014). Postoperative pancreatic fistula was observed in five patients (13.2%, grade B) but could be managed conservatively. No mortality was found.

Conclusion: Before SCA causes symptoms or grows larger than 5 cm, an active surgical approach, such as minimally invasive surgery, needs to be considered.

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Related in: MedlinePlus

Suggested surgical approach for serous cyst adenoma. CT computed tomography; MRI magnetic resonance imaging; EUS endoscopic ultrasound. *A minimally invasive approach can be considered according to the surgeon’s experience, technique, and preference
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Fig2: Suggested surgical approach for serous cyst adenoma. CT computed tomography; MRI magnetic resonance imaging; EUS endoscopic ultrasound. *A minimally invasive approach can be considered according to the surgeon’s experience, technique, and preference

Mentions: In the past, it was thought that pancreatectomy should be avoided as much as possible due to its significant morbidity and potential mortality following pancreatectomy. However, operative morbidity and mortality have been reduced to generally acceptable ranges due to recent advances in surgical techniques and perioperative management, including interventional radiology, as well as increased surgical experience [12, 13]. It is reported that high-volume centers can now perform pancreatectomy very safely [6–8, 14]. Our study also showed no mortality, and about 20% of the complications (including 13.2% of grade B postoperative pancreatic fistula) were successfully treated by conservative management. This suggests that pancreatectomy for managing SCA is a safe and reliable procedure. In addition, minimally invasive (laparoscopic and robotic) distal pancreatectomy with or without splenectomy is now regarded as a safe and effective surgical modality in managing benign and borderline malignant pancreatic tumors [15, 16]. Even laparoscopic pancreatoduodenectomy is also thought to be safe in expert hands [17]. At our institute, application of minimally invasive distal pancreatectomy to left-sided SCAs has been increasing since 2005. On comparative analysis, left-sided pancreatic tumor was more frequently found in asymptomatic patients, and left-sided pancreatectomy was performed without increased perioperative risk in asymptomatic patients (Table 2). Minimally invasive approach is increasingly considered for asymptomatic left-sided SCA. SCN tends to become a large symptomatic tumor in the end and can create difficult clinical situations, such as open pancreatectomy, age-related comorbidity, and combined organ resection in spite of its benign characteristics. Thus, timely surgical intervention with either conventional open surgery or minimally invasive surgery is a reasonable strategy in current clinical practice. Based on the biologic properties of SCA and our experience, we suggest a potential strategy for managing SCA of the pancreas (Fig. 2). When a tumor is directly related to presenting clinical symptoms, pancreatectomy should be considered regardless of tumor size. In contrast, it may be better to serially follow an asymptomatic small SCA tumor less than 3 cm. However, in case of a tumor between 3 and 5 cm, minimally invasive pancreatectomy needs to be actively considered for well-selected left-sided SCA as it may grow indolently and then create difficult clinical problems. Although laparoscopic or robotic distal pancreatectomy with or without splenectomy is frequently and safely performed, application of this procedure should be cautiously considered by an expert at a high-volume center. If the tumor continues to grow or new clinical symptoms develop, surgery should be considered during the serial follow-up with the patient’s full consent and knowledge of the potential risk of progression and clinical problems.Fig. 2


Serous cyst adenoma of the pancreas: appraisal of active surgical strategy before it causes problems.

Hwang HK, Kim H, Kang CM, Lee WJ - Surg Endosc (2011)

Suggested surgical approach for serous cyst adenoma. CT computed tomography; MRI magnetic resonance imaging; EUS endoscopic ultrasound. *A minimally invasive approach can be considered according to the surgeon’s experience, technique, and preference
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3351602&req=5

Fig2: Suggested surgical approach for serous cyst adenoma. CT computed tomography; MRI magnetic resonance imaging; EUS endoscopic ultrasound. *A minimally invasive approach can be considered according to the surgeon’s experience, technique, and preference
Mentions: In the past, it was thought that pancreatectomy should be avoided as much as possible due to its significant morbidity and potential mortality following pancreatectomy. However, operative morbidity and mortality have been reduced to generally acceptable ranges due to recent advances in surgical techniques and perioperative management, including interventional radiology, as well as increased surgical experience [12, 13]. It is reported that high-volume centers can now perform pancreatectomy very safely [6–8, 14]. Our study also showed no mortality, and about 20% of the complications (including 13.2% of grade B postoperative pancreatic fistula) were successfully treated by conservative management. This suggests that pancreatectomy for managing SCA is a safe and reliable procedure. In addition, minimally invasive (laparoscopic and robotic) distal pancreatectomy with or without splenectomy is now regarded as a safe and effective surgical modality in managing benign and borderline malignant pancreatic tumors [15, 16]. Even laparoscopic pancreatoduodenectomy is also thought to be safe in expert hands [17]. At our institute, application of minimally invasive distal pancreatectomy to left-sided SCAs has been increasing since 2005. On comparative analysis, left-sided pancreatic tumor was more frequently found in asymptomatic patients, and left-sided pancreatectomy was performed without increased perioperative risk in asymptomatic patients (Table 2). Minimally invasive approach is increasingly considered for asymptomatic left-sided SCA. SCN tends to become a large symptomatic tumor in the end and can create difficult clinical situations, such as open pancreatectomy, age-related comorbidity, and combined organ resection in spite of its benign characteristics. Thus, timely surgical intervention with either conventional open surgery or minimally invasive surgery is a reasonable strategy in current clinical practice. Based on the biologic properties of SCA and our experience, we suggest a potential strategy for managing SCA of the pancreas (Fig. 2). When a tumor is directly related to presenting clinical symptoms, pancreatectomy should be considered regardless of tumor size. In contrast, it may be better to serially follow an asymptomatic small SCA tumor less than 3 cm. However, in case of a tumor between 3 and 5 cm, minimally invasive pancreatectomy needs to be actively considered for well-selected left-sided SCA as it may grow indolently and then create difficult clinical problems. Although laparoscopic or robotic distal pancreatectomy with or without splenectomy is frequently and safely performed, application of this procedure should be cautiously considered by an expert at a high-volume center. If the tumor continues to grow or new clinical symptoms develop, surgery should be considered during the serial follow-up with the patient’s full consent and knowledge of the potential risk of progression and clinical problems.Fig. 2

Bottom Line: Seventeen patients (44.7%) were symptomatic, and the rest (21, 55.3%) were incidentally found to have SCA.Combined resection of the right colon was performed in two patients (5.3%) due to severe adhesion associated with large tumors.No mortality was found.

View Article: PubMed Central - PubMed

Affiliation: Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Ludlow Faculty Research Building #204, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.

ABSTRACT

Background: Patients who are diagnosed with symptomatic or ambiguous serous cyst adenoma (SCA) need surgery. The purpose of this study is to suggest a potential management plan based on analysis of surgically treated SCAs.

Methods: Between August 1995 and December 2010, 38 patients with SCA were surgically treated. Data were analyzed retrospectively.

Results: Among 38 patients, 28 were female and ten were male. Mean age was 49.6 ± 14.1 years, and five patients (13.2%) were older than 65 years. Among the five patients, two were more than 70 years old. Seventeen patients (44.7%) were symptomatic, and the rest (21, 55.3%) were incidentally found to have SCA. Twenty-seven patients underwent open pancreatectomy, and 11 patients received laparoscopic distal pancreatectomy. Mean tumor size was 4.4 ± 2.8 cm. Most asymptomatic patients of SCA had a left-sided pancreatic tumor and distal pancreatectomy with or without splenectomy were frequently performed with short operative time and less blood transfusion (P < 0.05). Minimally invasive surgery was mostly applied to left-sided tumors less than 5 cm in size (11/19 vs. 0/6, P = 0.029). Combined resection of the right colon was performed in two patients (5.3%) due to severe adhesion associated with large tumors. Significant association was noted between age and tumor size in asymptomatic patients (correlation coefficient = 0.541, R (2) = 0.293, P = 0.014). Postoperative pancreatic fistula was observed in five patients (13.2%, grade B) but could be managed conservatively. No mortality was found.

Conclusion: Before SCA causes symptoms or grows larger than 5 cm, an active surgical approach, such as minimally invasive surgery, needs to be considered.

Show MeSH
Related in: MedlinePlus