Single-Stage Endoscopic Retrograde Cholangiopancreatography Combined with Laparoscopic Enucleation of Pancreatic Cystic Neoplasms

Summary

We describe a novel minimally invasive procedure involving single-stage endoscopic retrograde cholangiopancreatography combined with laparoscopic enucleation of pancreatic cystic neoplasms. This procedure preserves pancreatic function while avoiding injury to the main pancreatic duct. It also offers advantages such as minimal invasiveness, reduced hospital length of stay, and fewer complications.

Abstract

Pancreatic cystic neoplasms (PCNs) represent a heterogeneous group of lesions, with some specific subtypes harboring malignant potential or exhibiting low-grade malignancy. Surgical resection remains the primary treatment modality. Traditional pancreatoduodenectomy is associated with severe trauma and slow recovery, while minimally invasive methods like laparoscopic central pancreatectomy (LCP) mitigate these issues; Laparoscopic enucleation (LE), a common procedure in function-preserving surgery, carries a risk of postoperative pancreatic fistula (POPF) for PCNs adjacent to the main pancreatic duct (MPD). While laparoscopic enucleation paired with two-staged endoscopic retrograde cholangiopancreatography (ERCP-LE) can mitigate POPF, this approach increases the length of hospital stay (LOS). Thus, we applied single-stage ERCP-LE for the treatment of PCNs, fully leveraging the advantages of both techniques. This approach enables the simultaneous performance of ERCP-guided pancreatic duct mapping, transpapillary stent placement, and laparoscopic enucleation of the target lesion during a single operative session. The technique boasts prominent advantages and pioneering value: it completes multi-step procedures in one stage, avoiding interval pancreatitis associated with staged operations while shortening treatment duration, reducing the risks of repeated anesthesia, stent migration, and additional costs; ERCP-guided stent placement minimizes injury to the MPD, facilitates immediate repair if injury occurs, and diverts pancreatic juice to significantly lower the incidence of POPF and pancreatitis. As an innovative therapeutic approach for high-risk PCNs adjacent to the MPD, single-stage ERCP-LE overcomes the limitations of traditional surgery and two-staged ERCP-LE. It is therefore expected to become the standard treatment for PCNs adjacent to the MPD, enabling more precise minimally invasive therapy while significantly preserving pancreatic function.

Introduction

The detection rate of Pancreatic cystic neoplasms (PCNs) has risen markedly with advances in imaging techniques. These lesions, which exhibit diverse pathological subtypes, primarily comprising serous cystic neoplasms, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary neoplasms, each demonstrate distinct biological behavior and clinical manifestations¹. Most PCNs are asymptomatic in the early stages. As the neoplasm enlarges, symptoms such as epigastric pain, abdominal fullness, nausea, and vomiting may develop. In severe cases, the neoplasm can compress adjacent tissues, leading to organ dysfunction....

Protocol

This study was approved by the Ethics Committee of the Fifth Affiliated Hospital, Southern Medical University. Written informed consent was obtained from the patient before the procedure.

1. Patient selection

1. Confirm indication for surgery by performing imaging studies and considering persistent clinical symptoms such as pain and neurological deficits.

2. Informed consent

1. Provide detailed counseling on the surgical procedure and its inherent risks, including POPF, hemorrhage, and infection, to the patient and the family. Discuss alternative treatmen....

Results

Studies indicate that LCP demonstrates the following outcomes: an operative time of 226.59 ± 158.73 min; intraoperative blood loss of 137.91 ± 195.69 mL; a major morbidity rate of 14.2% (18/127); a POPF B/C rate of 27.3% (73/267); and a length of hospital stay of 19.08 ± 12.03 days (Table 1 )⁹. In contrast, LE yields: operative time 137.34 ± 149.22 min, blood loss 59.06 ± 70.50 mL, major morbidity 17.8% (23/129), POPF B/C rate 21.2% (24/113), and length of.......

Discussion

Traditional open surgery long dominated the management of PCNs but was limited by significant trauma and prolonged recovery. Since Gagner et al.'s first report of laparoscopic pancreatic surgery in 1994¹², the laparoscopic approach has demonstrated superior safety and efficacy over open procedures, reducing intraoperative blood loss and shortening hospital stays¹³. This advancement has progressively expanded to diverse pancreatic resections. For PCNs at different locations .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Cannulating Sphincterotome	Boston Scientific	M00583100	Duodenal papillary sphincterotomy
Drainage catheter	Zhongkangshun	C-Fr18	Postoperative drainage
Esophagogastroduodenoscopy	Olympus Optical Co	TJF-260	ERCP treatment
Fibrin sealant	Glubran	G-NB-2 1ml	Microvascular hemostasis
Laparoscopic needle driver	Mindray	221-56426	Laparoscopic surgery
Laparoscopic suction/irrigation system	Kangji	102Y 202	Laparoscopic surgery
Nasobiliary catheter	Boston Scientific	M00540130 7.5 Fr, 16 cm	Post-ERCP temporary drainage
Suture material	Ethicon	W8557 4-0 polypropylene	Incision suturing
Trocar	Ethicon	5 mm, 10 mm, 12 mm	Puncturing the abdominal wall
Ultrasonic surgical scalpel	Innolcon	OSG35	Dissection and hemostasis
Wireguided	Boston Scientific	M00558610	Duodenal papilla dilatation