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Journal of Pediatric Surgery (2010) 45, 1525–1529

Case reports

Laparoscopic spleen-preserving distal pancreatectomy forsolid pseudopapillary tumor with conservation ofsplenic vessels in a childHiroo Uchidaa,⁎, Chikashi Gotoa, Hiroshi Kishimotob, Hiroshi Kawashimaa,Kaori Satoa, Mariko Yoshidaa, Syunnya Takazawaa

aDepartment of Pediatric Surgery, Saitama Children's Medical Center, Iwatsuki, Saitama, Saitama 339-8551, JapanbDepartment of Pathology, Saitama Children's Medical Center, Iwatsuki, Saitama, Saitama 339-8551, Japan

Received 4 January 2010; revised 9 March 2010; accepted 10 March 2010

0d

Key words:Laparoscopic distalpancreatectomy;

Splenic-preservation;Conservation of splenicvessels;

Children;Solid pseudopapillarytumor

Abstract Laparoscopic spleen-preserving distal pancreatectomy (LSDP) with conservation of the splenicvessels is gaining acceptance as a reliable treatment for selected patients with low-grade malignanttumors of the pancreas in adults. The operation requires advanced laparoscopic skills to safely divide thefine branches of the splenic vessels. Laparoscopic spleen-preserving distal pancreatectomy withconservation of splenic vessels is rarely reported in children. We describe a 12-year-old girl with solidpseudopapillary tumor in the body of the pancreas that was successfully treated with LSDP, preservingthe splenic vessels. The postoperative course was uneventful, and the functional and aesthetic resultswere satisfactory. Laparoscopic spleen-preserving distal pancreatectomy with conservation of splenicvessels may be a safe and feasible treatment option for children with pancreatic disease.© 2010 Elsevier Inc. All rights reserved.

Solid pseudopapillary tumor (SPT) of the pancreas is anuncommon but distinct pancreatic neoplasm with low-grademalignancy that accounts for 1% to 3% of primary pancreatictumors. More than 80% of patients are female, and 85% areless than 30 years old [1]. In contrast to other childhoodpancreatic malignancies, SPT is generally resectable, withcomplete surgical excision resulting in a favorable prognosisin more than 95% of cases.

Laparoscopic resection of benign and low-grade malig-nant tumor in the distal pancreas is an advanced minimallyinvasive procedure that is gaining wide acceptance in adults

⁎ Corresponding author. Tel.: +81 48 758 1811; fax: +81 48 758 1818.E-mail address: uchida.hiroo@pref.saitama.lg.jp (H. Uchida).

022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2010.03.013

[2]. It is a safe and reliable method, comparable with opensurgery. In children, few cases of laparoscopic distalpancreatectomy have been reported [3]. Here, we report thesuccessful use of laparoscopic spleen-preserving distalpancreatectomy (LSDP) with conservation of splenic vesselsin a 12-year-old girl with SPT.

1. Case report

A 12-year-old, previously healthy girl presented to anoutside hospital complaining of an epigastric mass. Trans-abdominal ultrasound examination revealed a hypoechoic,round mass with solid and cystic components in the body of

Fig. 1 Enhanced CT shows a well-encapsulated, solid, and fairlyhomogeneous mass with small cystic areas in the body of pancreas.There is no internal enhancement. The tumor compresses thesplenic vessels and the stomach.

ig. 2 (A) Mobilization of the pancreas is performed to visua-ze its posterior wall, with the splenic vein. A branch of the splenicein (black arrow) is divided using a vessel sealing system.) Distal pancreatectomy is performed using an endoscopic linear0-mm stapler.

1526 H. Uchida et al.

the pancreas. The patient was referred to our hospital forfurther treatment. She was reassessed and physical exami-nation revealed no further abnormalities.

Blood chemistry and tumor markers, such as carcinoem-bryonic antigen and carbohydrate antigen 19-9, were withinnormal ranges. Abdominal computed tomography (CT)and magnetic resonance imaging revealed a 40 × 38 ×36-mm well-circumscribed, solid, and fairly homogeneouslesion with a thick wall in the body of pancreas (Fig. 1).The rest of the pancreas was uninvolved. The tumorshowed no marked contrast enhancement. It compressed(but did not involve) the splenic vessels dorsally andcranially. Other organs were normal, and no lymphadenop-athy was observed. These findings are all typical features ofSPT of the pancreas.

Laparoscopic spleen-preserving distal pancreatectomysparing the splenic vessels was performed. Under generalanesthesia, the patient was placed supine in the reverse 30°Trendelenburg position with the legs apart. The surgeonstood between the patient's legs, and the monitor was placedover the patient's left shoulder. A 5-mm camera port wasinserted at the umbilicus, using an open technique. Afterestablishment of carbon dioxide pneumoperitoneum set at10 mm Hg, a 12-mm port was introduced at the left flank,whereas two 5-mm ports were inserted at the epigastriumand right flank under direct vision.

After port placement, the gastrocolic ligament wasdivided using an ultrasonic dissector (Harmonic scalpel;Ethicon, Cincinnati, Ohio) from the midline toward thespleen. With the stomach elevated, the dissection began atthe inferior margin of the body of the pancreas, andfurther dissection was performed in the avascular planeposterior to the pancreas until the splenic vein wasidentified. Once identified, the small pancreatic branchesbetween the pancreas and the main vessels were dividedon the surface of the gland using a vessel sealing system

(BiCOAG cutting forceps; Amuko, Tokyo, Japan) (Fig. 2A).This dissection was continued 2 cm beyond the margin ofthe tumor toward the pancreatic head. An adequatewindow was created, after which the pancreas wastransected using a 60-mm Endo-Cutter stapler (Ethicon)(Fig. 2B).

Dissection was carried out from the body of the pancreastoward the hilum of the spleen. Several small branchesarising from the splenic vessels were divided using thevessel sealing system. Because the pancreatic substance iswrapped around the splenic vein, further dissection was alaborious process. Using this technique, the distal tail of thepancreas and the tumor were freed from the splenic vesselsand retroperitoneum. The dissected part was retrieved usingan endoscopic bag through a 5-cm Pfannenstiel incision.The stapled closure of the proximal pancreatic stump was

Fliv(B6

Fig. 3 The distal tail of the pancreas and the tumor were dissectedfrom the splenic artery (white dashed arrow) and vein (whitearrow). The stapled closure of the proximal pancreatic stump wasreinforced using fibrin glue.

Fig. 5 (A) Resected specimen of the mass and distal pancreas.The tumor was a solid lobulated tumor with regular margins. (B)Microscopic appearance of the SPT. It had small and uniform tumorcells with round nuclei, with both solid and cystic growth patterns.

1527Laparoscopic spleen-preserving distal pancreatectomy

reinforced using fibrin glue (Fig. 3). A closed suction drainretained at the pancreatic stump was then drawn outthrough the 12-mm port site. Operative time was 340minutes, and there was little blood loss.

There was no evidence of postoperative pancreatitis witha normal serum amylase level noted on postoperative day(POD) 1. The patient resumed oral intake on POD 3. Shedeveloped a viral illness associated with diarrhea on POD 7that delayed her discharge until POD 15. A repeat CT scanwith contrast revealed sufficient blood flow in the mainsplenic vessels and substantial splenic volume at 3 months

Fig. 4 The aesthetic result 6 months after surgery is satisfactory.

after the procedure. Six months postoperatively, her exocrineand endocrine pancreatic functions were normal. Thefunctional and aesthetic results are satisfactory (Fig. 4).

Macroscopically, the mass was a solid lobulated tumorwith regular margins (Fig. 5A). It had small and uniformtumor cells with round nuclei, with both solid and cysticgrowth patterns (Fig. 5B). The tumor cells had a pseudopa-pillary pattern with fibrovascular stalks. Immunohistochemi-cally, the tumor cells were positive for neuron-specificenolase, β-catenin, and vimentin; they were negative forchromogranin A and cytokeratin AE1/AE3. These findingsprovided a definitive diagnosis of SPT of the pancreas.

2. Discussion

Solid pseudopapillary tumor is a rare neoplasm with low-grade malignancy, first described by Frantz [4] in 1959 as apapillary tumor of the pancreas. In 1996, the World HealthOrganization renamed this tumor as solid pseudopapillarytumor. This uncommon neoplasm is found mainly in womenaged 20 to 30 years, although rare cases have been reportedin children and men. Most SPTs exhibit benign behavior, butmalignant degeneration and lymph node metastasis rarelyoccur [5]. Unlike other childhood pancreatic neoplasms, theprognosis after complete surgical resection is quite favorable,

1528 H. Uchida et al.

and tumor recurrence is relatively rare [6]. Laparoscopicsurgery for a highly malignant tumor is consideredcontroversial; however, SPT of the pancreas is found mainlyin young women and has low-grade malignant potential.Function-preserving minimally invasive surgery is consid-ered the procedure of choice in cases of SPT in the body andtail of the pancreas. The first laparoscopic distal pancreatec-tomy (DP) was performed in 1996 [7]. Development ofendoscopic instruments and advances in technique havemade laparoscopic DP an effective option for the treatmentof pancreatic disease. Laparoscopic DP offers benefits to thepatient in postoperative recovery and cosmetic considera-tions, compared with the open approach, which requireswide access exposure to the pancreas [8,9]. The laparoscopicapproach has recently been proposed for the treatment ofbenign lesions or low-grade malignancy in the distalpancreas; however, LSDP with sparing of the splenic vesselsis an advanced and highly skilled laparoscopic procedure andis rarely performed, even in adults [8,9]. To the best of ourknowledge, few cases of LSDP with sparing the splenicvessels have been described in children [3,10-13].

Splenic preservation with DP is recognized as a usefulsurgical procedure. Postsplenectomy patients are known tobe at risk for fatal sepsis in rare instances, usually caused byencapsulated organisms including Streptococcus pneumo-niae [14]. The highest risk occurs in the youngest patients.Two main techniques of spleen preservation have beendescribed in DP. Warshaw [15] first described the techniqueof spleen conservation in DP, in which the splenic vessels areligated and the short gastric vessels are preserved. Theviability of the spleen is maintained by flow through theshort gastric vessels. With this technique, there exists thepossibility that blood supply to the spleen may be insufficientafter division of the splenic vessels, resulting in complica-tions such as splenic infarction and abscess [15,16]. Thisprocedure is easier to perform than that of preservation of thesplenic vessels; however, it is important to check carefullyfor these complications during follow-up observations.

In contrast, LSDP preserving the splenic vessels is bothtime-consuming and laborious. It results in a good bloodsupply to the spleen and thus, a reduced risk of splenicnecrosis and abscess. In LSDP, it is preferable to preserve themain splenic vessels rather than depend solely on the shortgastric vessels to perfuse the spleen. It requires advancedsurgical skills to dissect the splenic vessels from the pancreasduring laparoscopic surgery. The magnified view of theoperative field may facilitate separation of splenic vesselsfrom the pancreatic parenchyma; however, the conversionrate to an open procedure is reported to range from 0% to36% [9,17]. It is noted that treatment failure is commonlycaused by tumor encroaching on the splenic hilum and byrecent acute inflammation with encasement of the hilum withscar tissue [15]. In the present case, the pancreaticparenchyma was completely wrapped around the splenicvein without any adherence to the splenic hilum; therefore,we laboriously but uneventfully accomplished LSDP

preserving the splenic vessels. We divided the branches ofthe splenic vessels first from the pancreatic body and thentoward the splenic hilum to avoid hemorrhage at the splenichilum. We applied the vessel sealing system, which is widelyaccepted as a useful device during laparoscopic surgery, indissecting the branches. We used the most commonly usedtechnique for LSDP.

Management of the pancreatic stump remains a majorchallenge. The risks (5%-30%) of postoperative pancreaticfistula in the laparoscopic approach are reported to becomparable with those observed in distal open pancrea-tectomy [9,18]. It was reported that the best method todivide the pancreas is using the linear stapler [18]. Onthe other hand, pancreatic leakage occurred in 1 of the29 patients where the staple line was reinforced withabsorbable mesh and 4 leaks in 11 patients without mesh[19]. In the present case, postoperative fistula did not occurusing the linear stapler and fibrin glue; however, this isan observation in only one case, and further technicalimprovements are necessary to avoid development ofpancreatic fistula.

Laparoscopic spleen-preserving distal pancreatectomywith conservation of the splenic artery and vein requiresadvanced laparoscopic skill to divide the splenic vesselsfrom the pancreatic substance; however, the technique iswell established and reproducible. It provides a safe andfeasible treatment option that preserves splenic function forbenign or low-grade malignant tumors of the distalpancreas in children.

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