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Objectives: There is a paucity of literature evaluating new-onset diabetes mellitus (NODM) after resection of pancreatic cystic lesions (PCLs). We sought to characterize the incidence and risk factors associated with NODM after partial pancreatectomy for PCLs., Methods: We utilized the IBM MarketScan Database (2012-2018) to identify all nondiabetic adults who underwent partial pancreatectomy for PCLs. Patients with any other pancreatic disease were excluded. We performed Kaplan-Meier analysis and multivariable Cox proportional hazards regression to define the incidence and risk factors of postoperative NODM., Results: Among 311 patients, the overall risk (95% confidence interval) of NODM was 9.1% (6.3-12.9%), 15.1% (11.3-20.2%), and 20.2% (15.3-26.4%) at 6, 12 and 24 months, respectively. Multivariable analysis (adjusted hazard ratio; 95% confidence interval) revealed that older age (1.97; 1.04-3.72; 55-64 vs 18-54 years), obesity (2.63; 1.35-5.12), hypertension (1.79; 1.01-3.17), and cardiovascular disease (2.54; 1.02-6.28) were independent predictors of NODM. Rates of NODM were similar after distal pancreatectomy versus pancreaticoduodenectomy., Conclusions: Within 2 years, 1 in 5 patients without any other pancreatic disease will develop NODM after partial pancreatectomy for PCLs. Those with advanced age, metabolic syndrome features, and/or cardiovascular disease may benefit from preoperative counseling and intensive postoperative monitoring, education, and treatment for diabetes mellitus., Competing Interests: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. No other potential conflicts of interest exist for any author in relationship to this publication., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Pancreatic surgery has undergone significant progress during recent years. Specialised centres with interdisciplinary expertise have led to improved patient care with decreased morbidity and mortality. Regarding evidence-based medicine, consensus definitions on morbidity as well as high-quality studies, systematic reviews and meta-analyses on different topics of pancreatic surgery have been published. In acute pancreatitis paradigms have shifted towards conservative management, in chronic pancreatitis parenchyma-sparing resection techniques have widely become accepted. Management of cystic lesions - especially intraductal papillary mucinous neoplasms (IPMN) - has attracted great interest in surgical practice. In pancreatic cancer treatment not only surgical resection techniques have improved but also the central impact of adjuvant treatment has been demonstrated in large multicentre trials., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Accessory spleen is a relatively common congenital defect with a 10% incidence in the population. Intrapancreatic accessory spleens are rare and cystic formation may mimic a hypervascular pancreatic tumour., Case Report: We present the case of a 27-year-old woman who underwent abdominal ultrasonography (USG) because of chronic abdominal discomfort. USG findings revealed a 20 mm cystic mass in the tail of the pancreas. Additional preoperative investigations showed a tumour in the tail of the pancreas suspected of being a non-active neuroendocrine tumour. The intraoperative finding was a hard mass in the tail of the pancreas and neither peritoneal dissemination nor metastasis was detected. Distal pancreatectomy was performed. Pathological examination described an epithelial cyst in an intrapancreatic accessory spleen., Discussion: Cyst formation in an intrapancreatic accessory spleen is extremely rare. Most patients with this condition have no clinical symptoms and it is often detected incidentally by imaging studies. It is difficult to differentiate an epithelial splenic cyst in the pancreas from a primary pancreatic neoplasm because it lacks particular characteristics on radiological examination; epithelial splenic cysts should be considered in the differential diagnosis of a cystic lesion in the tail of the pancreas. Key words: spleen - epithelial cyst - intrapancreatic accessory spleen.

Background: Arteriovenous malformations of the pancreas are very rare, most frequently congenital ones, but tending to increase frequency, predominantly due to the introduction and use of new diagnostic modalities. They usually present with gastrointestinal bleeding and abdominal pain., Case Report: The autors presented a 52-year-old woman in whom, during the investigation for the abdominal pain and gastrointestinal bleeding, an ultrasonography showed a hypoechogenic lesion within the head of the pancreas 3 cm in diameter. Endoscopic ultrasound showed an irregular hypoechogenic lesion. Computed tomography showed a low density area within the lesion (< 10HU). At endoscopic retrograde cholangiopancreatography, a cystic lesion within the head of the pancreas was filled with contrast from the normal pancreatic duct. Angiography showed an arteriovenous malformation within the head of the pancreas. The patient underwent pylorus preserving cephalic duodenopancreatectomy. The diagnosis of arteriovenous malformation, probably of congenital origin, was confirmed on histology., Conclusion: Arteriovenous malformations should be considered in patients with gastrointestinal bleeding of unknown etiology. In this case, the lesion was taken into account preoperatively, based on color Doppler ultrasonography and angiography. The best results of treatment can be achieved with resection, but it has to be performed before an eventual portal hypertension takes place.

Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.

Laparoscopic surgery of the pancreas has been used for diagnostic but also for therapeutic purposes in increasing number. Case reports and multicenter studies summarizing the European and world wide experience have been published recently. The results show that laparoscopic surgery can be used for tumor staging of pancreatic cancer but also for the treatment of acute necrotizing pancreatitis and treatment of chronic pancreatitis, benign cystic lesions and solid tumors. In particular left sided pancreatic resection (90 % of the cases) is the preferred approach delivering good results. Recent studies show that the conversion rate is 14 % and mortality can be as low as 0 %. The reoperation rate is 6.3 % and the fistula formation is 17 % which is comparable to the results of open pancreatic surgery. The postoperative hospital stay seems to be limited to a mean of 7 days as compared to pancreatic surgery in the open abdomen. The laparoscopic Whipple resection with less than 3 % of the cases in the literature remains the exception.

Objectives: To describe the frequency and range of pancreatic disorders in children requiring surgical intervention and to highlight the importance of multidisciplinary management., Methods: An audit of all children under 17 years of age referred with surgical disorders of the pancreas or pancreatitis to a regional pediatric gastroenterology unit in the United Kingdom during a 10-year period. A retrospective chart review of clinical features, pathology and outcome was undertaken., Results: Surgical intervention was required for the following pancreatic disorders: persistent hyperinsulinemic hypoglycemia of infancy (n = 4), pancreatic tumors (n = 5), pancreaticobiliary malunion (n = 12), pancreatic trauma (n = 6) and pancreatitis (n = 10). The indications for surgery in acute pancreatitis were a persistent pseudocyst (n = 1) and treatment of an underlying cause of pancreatitis (n = 4); in chronic pancreatitis, surgery was used to treat symptomatic pancreatic duct strictures (n = 4). One child died of a progressive lymphoma but all others who underwent surgery are alive and well. All 33 children with acute pancreatitis, including four with pancreatic necrosis, survived., Conclusions: Surgery for pancreatic disorders in children is rarely required but may be necessary a) for definitive management of primary pancreatic pathology, b) to treat sequelae of acute or chronic pancreatitis and c) to treat an underlying cause of pancreatitis. There is a broad spectrum of potential pathologies. These patients are best managed by a multidisciplinary team approach.

Background: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease., Methods: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors ( n=13), unspecified tumors ( n=11), cysts ( n=2), idiopathic thrombocytopenic purpura with ectopic spleen ( n=2), annular pancreas ( n=1), trauma ( n=1), aneurysm of the splenic artery ( n=1), and adenocarcinoma ( n=1)., Results: Enucleations ( n=7) and distal pancreatectomy with ( n=12) and without splenectomy ( n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2-22). Postoperatively, opioid medication was given for a median of 2 days (range, 0-13)., Conclusion: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Background: Although minimally invasive surgery has achieved worldwide acceptance in various fields, laparoscopic surgery for pancreatic diseases has been reported only rarely. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery., Methods: Fifteen patients, comprising eight men and seven women with an average age of 54 years, underwent laparoscopic pancreatic surgery. Distal pancreatectomy was indicated for solid tumors ( n = 4), cystic lesions ( n = 3), and chronic pancreatitis ( n = 2). Cystogastrostomy was performed for pseudocysts ( n = 4) and enucleation for insulinomas ( n = 2). The lesions varied in size from 1 to 9 cm (2.9 +/- 2.4 cm) and were located in the pancreatic head ( n = 2), body ( n = 3), or tail ( n = 10). For distal pancreatectomy, the splenic artery was divided and the parenchyma was transected with a linear stapler. Laparoscopic ultrasonography was used to determine the distance between the tumor and the main pancreatic duct for enucleation as well as to localize the lesion for distal pancreatectomy. Cystogastrostomy, 4.5 cm in length, was also performed with the linear stapler through the window of the lesser omentum., Results: Mean operation time was 249 +/- 70 min (293 +/- 58 min in distal pancreatectomy, 185 +/- 14 min in enucleation, 204 +/- 50 min in cystogastrostomy), and mean blood loss was 138 +/- 184 g (213 +/- 227 g, 75 +/- 35 g, 38 +/- 48 g, respectively). Two distal pancreatectomies (13%) were converted to open surgery due to severe peripancreatic inflammation. There was no related mortality, but there were two cases (15%) of pancreatic fistula, one in a distal pancreatectomy case and the other in an enucleation case, and both were treated conservatively., Conclusions: Laparoscopic pancreatic surgery is safe and feasible for patients with benign tumors and cystic lesions.

Background: Much attention has been focused on the competence to perform endoscopic procedures. The aim of this study was to determine the impact of procedure experience on patient outcomes after endoscopic pancreatic fluid collection drainage., Methods: Outcomes for consecutive patients with symptoms from pancreatic fluid collections who were referred for endoscopic transmural and/or transpapillary drainage were analyzed retrospectively. Collections were classified as acute pseudocyst, chronic pseudocyst, and pancreatic necrosis. To assess the impact of endoscopist experience, outcomes for patients who underwent the first 20 procedures were compared with those for patients who had subsequent procedures., Results: In total, 175 patients underwent pancreatic fluid collection drainage; 40 (23%) acute pseudocyst, 78 (44%) chronic pseudocyst, and 57 (33%) pancreatic necrosis. Procedure complication rates, collection recurrence rates, and patient outcomes after acute pseudocyst drainage were independent of endoscopist experience. There was a dramatic improvement in chronic pseudocyst resolution rates after the first 20 procedures versus subsequent procedures (45% vs. 93%; p = 0.0002) and a reduction in days to resolution (50 days, initial 20 procedures vs. 33.5 days, subsequent procedures; p = 0.05). In patients with pancreatic necrosis, there was a decrease in median hospital stay with greater experience (23 days to 15 days; p = 0.04)., Conclusions: Resolution of chronic pseudocyst after endoscopic drainage improves markedly with increasing endoscopist experience. Future prospective studies assessing skill acquisition are required to define the minimum number of collection drainage procedures at which competence can be achieved.

Twelve patients with von Hippel-Lindau disease were collected in our institute from 1981 to 1995. All had a family history of the disease. Eleven patients underwent abdominal computed tomography, sonography, or angiographic studies. Ten had pancreatic involvement that included cystic lesions in nine and a solid lesion in one. Seven patients were asymptomatic. Another three presented with obstructive jaundice or upper gastrointestinal (UGI) bleeding. Except for case 8, who died of a central nervous system complication soon after diagnosis of the pancreatic lesion, the other patients had been found to have pancreatic involvement for a variable period of time, ranging from 1 to 13 years (median 5 years). Serous cystadenoma was proved pathologically in two with cystic lesions, and pancreatic endocrine tumor was diagnosed in one with a solid mass. One patient (case 1) underwent biliary bypass due to obstructive jaundice and died of cholangitis and pneumonia 6 years later. One patient (case 3) had total pancreatectomy and lived well with good diabetic control for more than 5 years. The patient with a solid lesion was explored because of repeated UGI bleeding. Surgical resection was impossible owing to advanced tumor with vascular involvement, and a pancreatic endocrine tumor was diagnosed pathologically. He was followed for 1 year. The other seven patients remained asymptomatic during the successive follow-up period. From a literature review and our own experience, we suggest that conservative measures are adequate for the cystic lesions; however, aggressive resection is mandatory for a solid pancreatic lesion in von Hippel-Lindau disease.

Transcutaneous puncture of pancreatic cavities under ultrasonographic control was conducted in 68 patients. The cavity contents investigation using cytological, bacteriological and biochemical methods was conducted. The method permits to diagnose the cavity, its connection with ductal system of pancreas, to select the adequate antibacterial therapy, to conduct the cavity decompression before the operation. It may be applied for symptomatic treatment conduction. There were no complications observed as a consequence of the procedure.

The results of surgical treatment are analysed on the basis of experience in 131 operations on the pancreas in pancreonecrosis (81 resections of the pancreas, 28 operations for drainage of the cyst in the acute stage, 22 operations for necr- and sequestrectomy). The indications for various types of intervention according to the destruction of the pancreas and the stage of the process are determined. Twenty-one patients died after the operation.

Focal lesions of the pancreas or its surroundings comprise a variety of morphologic substrates that do not always require treatment. Cysts and neoplasms are the two important groups. Postpancreatic cysts are increasingly and successfully treated by endoscopy and interventions guided by ultrasound. They have to be distinguished from cystic neoplasms or intracavitary hemorrhage which have to be approached by primary surgery. Pancreatic malignancies do not necessarily invite to a fatalistic attitude. Only ductal pancreatic cancer carries a still poor prognosis although we have achieved a 20% 5 year survival rate if resection without residual tumor was possible. If lymph nodes were not involved 43% of patients survived for 5 years. Periampullary carcinoma and the other pancreatic neoplasms carry a much better prognosis. The search for focal pancreatic lesions must be particularly thorough in patients presenting with diabetes of sudden onset, persistent hyperamylasemia and in some cases with an acute, possibly severe pancreatitis without apparent cause and an age of over 40 years.

A case with pancreatic ascites is presented in which the site of leak from a pancreatic pseudocyst was identified by oral endoscopic pancreatography. It is suggested that this procedure be done early in the clinical course of most patients with pancreatic ascites, since the information obtained will facilitate medical and surgical management.

CT-x-ray examination of 98 patients yielded pathologic results in 42 patients; in 33 patients results of CT could be controlled by surgery or at autopsy. In 14 cases necrotizing pancreatitis or pancreatic pseudocysts were suspected and these cases were operated upon; only 1 case turned out to be a falsely positive diagnosis. In 15 cases pancreatic carcinoma were found at surgery; 13 of these cases had been diagnosed preoperatively by CT; the diameters of the 2 tumors not diagnosed were below 3-4 cm. Differentiation between cysts, pancreatitis and tumors was possible in 2/3 of all cases; in 1/3 of the cases differentiation was neither possible by applying morphological criteria nor by evaluating absorption spectra. It turned out to be advantageous to examine the parenchymatous organs surrounding the pancreas by CT as well; in about 12% of cases with pathological findings the processes were found to be localized extrapancreatically.

Twelve cases of pancreatic abscess, managed at two hospitals in the District of Columbia, are analyzed. Forty-two percent of cases followed acute pancreatitis and infected pancreatic pseudocysts without previous surgical intervention. In 58 percent of the patients, pancreatic abscess was a complication of internal drainage of pancreatic pseudocysts. A discussion of management problems is presented.

Spontaneous hemorrhage caused by erosion of major arteries by a pseudocyst of the pancreas is a rare condition. We have encountered three cases, one involving the abdominal aorta and two the superior pancreaticoduodenal artery. It is important to keep in mind that pseudocyst of the pancreas may cause massive gastrointestinal or intraabdominal bleeding. Operative treatment offers a better chance of survival than more conservative management.

The annular pancreas which is responsible for one third of the cases of duodenal obstruction plays a central role in pancreatic malformations. Therapy of choice is a duodeno-duodenostomy. Prognosis is deteriorated by frequent premature delivery, Down's syndrome and associated malformations. Among pancreatic tumors the congenital pancreatic cyst, the cysto-papillary adenoma and the insulinoma are particularly considered the latter in connection with the discussion of hyperinsulinism which also nesidioblastosis is associated. Pancreatic tumors to require surgical therapy and a subtotal excision of the pancreas is frequently necessary in nesidioblastosis. Besides pancreatitis which is diagnosed in Germany also pancreatic rupture with subsequent posttraumatic pancreatitis leading to pancreatic pseudocysts is discussed. There are no deaths after isolated pancreatic trauma or surgery of pancreatic pseudocysts.

Seventy-five operative procedures were done in 63 patients to correct one or more complications of chronic pancreatitis. Operations included resection, pancreaticojejunostomy, choledochoduodenostomy, draining and/or excision of pseudocysts, sphincteroplasty, and bypass surgery for relief of duodenal obstruction. All patients were followed up for up to 10 years, with 22 being followed up longer than five years. Recurrent pancreatitis occurred in three patients after resection and in two after drainage procedures, but attacks were milder with only an occasional occurrence. Operative procedures to relieve specific complications of chronic pancreatitis provided good results. However, because internal drainage of pseudocysts associated with chronic pancreatitis was frequently accompanied by recurrence of symptoms, excision offered better results. When the pancreatic duct was dilated, good results were obtained by pancreaticojejunostomy. In the absence of dilation, after strict preoperative slection of patients, and in the presence of diffuse parenchymal fibrosis, subtotal pancreatectomy is the procedure of choice.

In a patient with chronic ascites, an abnormally raised ascitic fluid amylase concentration and a protein content above 2.5 gm/100 ml is diagnostic of pancreatic ascites. Thirty-one episodes in 26 patients treated between 1958 and 1975 have been analyzed. Twenty patients (65%) experienced abdominal pain and ten (32%) had concomitant pleural effusions roentgenographically. Although a leaking pancreatic pseudocyst was the cause of ascites in at least 21 episodes (70%), an abdominal mass could only be palpated in two of 26 patients. Roentgenographic series of the upper part of the gastrointestinal tract failed to demonstrate pancreatic pseudocyst in 7 of 21 episodes (33%). Endoscopic retrograde pancreatography is invaluable in delineating the pancreatic ductal system and, in conjunction with intraoperative pancreatography, makes a vital contribution to rational surgical therapy. Medical treatment or external drainage during 18 episodes resulted in death in four (22%) and recurrences of ascites or pancreatic pseudocyst in nine (64%). Since routine pancreatography followed by pancreatic resection or internal drainage has been instituted, mortality and recurrence have been reduced to zero.

The authors analyze the surgical indications and procedures for cases of chronic pancreatites. There were but few cases and the procedures were chosen for minimal harm ; there were : 4 external marsupialisations, 1 resection of a true cyst, 5 cystoanastomoses, 2 biliary bypasses, 4 left pancreatectomies. Postoperative courses were normal in 12 patients; 2 had recurrent pancreatitis because of alcoholism. Our attitude towards chronic pancreatic lesions is thus as follows: 1. Cautions and reserved indications. 2. Ad minima procedures.

Radiographically guided therapeutic percutaneous catheter drainage was used to manage 25 patients with 27 pancreatic and peripancreatic fluid collections. Nine of 11 (82%) noninfected and 11 of 16 (69%) infected collections were successfully managed with percutaneous drainage. Overall, eight complications and four deaths occurred in this group of patients. The morbidity and mortality in this series is somewhat higher than that previously reported in the radiologic literature. A discussion of the guidelines for percutaneous drainage is presented.

Direct demonstration of intrapancreatic abscesses and pseudocysts can be made by means of duodenoscopic retrograde pancreatography. The most important findings are escape of contrast medium from the duct system into a cavity and its visualization, the tryptic perforation of one or more ducts and the concomitant deformity which may be general or limited to the vicinity of the lesion. The differential diagnosis of pancreatic abscess and carcinoma with penetration of contrast medium in the tumor tissue is supported by the fact that the contours of a necrotic cavity are rather well defined, whereas in carcinoma the extraductal opacification is diffuse. As a rule in a necrotic lesion the ductal system is distorted locally or the whole excretory duct system may be involved. In carcinoma the ductal system generally appears normal distally to the tumor. Accurate demonstration of the necrotic lesion, the assessment as to its localization and size are of decisive importance for indication and choice of the surgical procedure.

We have reviewed the literature relating to experience of haemorrhage associated with pancreatic pseudocysts and abscesses in an attempt to evaluate different types of management. A further case, where extensive pancreatic resection successfully halted bleeding which followed drainage of a pancreatic abscess, is described to illustrate some of the principles of management.

Case report on two patients with massive hemorrhage from the pancreatic duct as proven by duodenoscopy and retrograde pancreatography. In patients with blood pouring from the orifice of the papilla of Vater retrograde ductography should be performed to prove hemobilia or hemosuccus pancreaticus.