Laparoscopic management of cystic neoplasm of the pancreas: A Case Report

Hector F Sanchez-Maldonado, MD, Enrique J Cedillo-Aleman, MD, Marco A Juarez-Parra, MD, Ulises Caballero-de la Pena, MD, Ernesto Miranda-Cervantes, MD. Hospital Christus Muguerza Alta Especialidad / UDEM

Introduction: Cystic neoplasms represent only 10% of cystic lesions of the pancreas and 1% of all tumors. Their incidence has been reported to be rapidly increasing with the routine use of cross-sectional imaging.

Although majority of cystic lesions are inflammatory pseudo-cysts, the diagnosis is unlikely without the history of pancreatitis, trauma or associated risk factors. Serous cystadenoma is a benign lesion that requires non-surgical management if asymptomatic. Mucinous neoplasms are considered premalignant lesions and demand pancreatic resection. Despite improved radiographic imaging techniques, definitive diagnosis is only made after studying the resection sample.

Between 40-75% of the patients are asymptomic or diagnosed incidentally. When symptoms are present they tend to be nonspecific, including mass effect and abdominal pain. Although conservative management has been advocated in small lesions; those greater than 4 cm or symptomatic, tend to harbor malignant or premalignant lesions and operative intervention is a reasonable option.

We present the case of a distal pancreatic cystic tumor successfully treated by laparoscopy.

Case report: A 38 y.o. female with previous history of carcinoma of the cervix successfully treated with radical hysterectomy and adjuvant chemo-radiation. She presented with a 12 month history of diffuse intermittent lumbar pain, physical exam was unremarkable. An abdominal CT-scan demonstrated a spongy, well-circumscribed 8 cm lesion that contained multiples cysts separated by septa located in the tail of the pancreas. She was managed expectantly for 6 months.

Upon surgical consultation, an elective laparoscopic distal pancreatectomy was planned due to the increased size of the tumor and persistence of her symptoms. The tumor was found in closed relation with the spleen hilum and splenectomy was required. Vascular control was achieved with bipolar energy and transection of the pancreas performed with vascular stapler. The specimen was removed thought a pfannestiel incision and a drain was placed. She had an uneventful postoperative recovery. Pathology reported a microcystic serous cystadenoma.

Conclusion: The management of pancreatic cystic lesions remains controversial. Nevertheless, experts recommended surgical resection for all symptomatic pancreatic cysts not only for the relief of symptoms but because of the higher malignant potential in this subset of patients.

In the case of tumor in the tail, distal pancreatectomy can be performed laparoscopically with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than the open approach and can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated.

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