This work was supported by grants from the Project of Guangdong clinical medical research center of digestive diseases (2020B1111170004), National Key Clinical Discipline and the program of Guangdong Provincial Clinical Research Center for Digestive Diseases.

The operation is routine and has received ethics approval. This study was permitted by the Ethics Committee of the Six Affiliated Hospital of Sun Yat-sen University. Meanwhile, the informed written consent was obtained from the patient. Its research contents and methods meet the medical ethics norms and requirements.
1. Patient selection
<ol>
	<li>Use the following inclusion criteria: benign pancreatic tumors, including hemangioma, benign neuroendocrine tumor, serous or mucinous cystadenoma, solid pseudopapilloma, and non-invasive intraductal myxoma.</li>
	<li>Use the following exclusion criteria: pancreatic malignant tumors, atrophy of the tail of the pancreatic body, diffuse inflammation of the pancreas, and vascular variation.</li>
</ol>
2. Preoperative preparation, operative position, and anesthesia
<ol>
	<li>Ask the patient to consume a low in fat, salt, and sugar diet 1 day before the surgical operation and then abstain from eating food and drinking water at least 8 h prior to the surgery.</li>
	<li>Place the patient in a supine position with the head elevated and slightly tilted to the left. The surgery was performed using a dual primary knife mode. 
	NOTE: In the dual primary knife mode, two skilled and experienced surgeons alternate between the roles of surgeon and assistant as needed, aiming to improve efficiency and quality.</li>
	<li>Perform endotracheal intubation and give general anesthesia. Judge the anesthetic effect according to the patient&#39;s post-anesthesia and intraoperative conditions, such as complete anesthesia block, no additional drugs during operation, and stable vital signs.</li>
</ol>
3. Surgical technique
<ol>
	<li>Make a vertical incision 2 cm above the right side of the navel and establish pneumoperitoneum with a Veress needle. Insert a 12 mm trocar and introduce the laparoscope after establishing pneumoperitoneum.</li>
	<li>Place five trocars in the following positions: a 12 mm trocar in the supraumbilical region for observation, a 5 mm trocar in the right anterior axillary line, a 12 mm trocar under the costal margin of the right midclavicular line, a 5 mm trocar horizontally 2 cm below the xiphoid process, and a 12 mm trocar horizontally 2 cm at the supraumbilical level (see Figure 2).</li>
	<li>Explorate carefully the intraperitoneal organs and peritoneal surface to reveal a mass above the pancreas, protruding from the surface of the pancreas and measuring approximately 3cm x 3 cm.</li>
	<li>Use an ultrasonic knife to separate abdominal adhesions and excise a portion of omental tissue.</li>
	<li>Use an ultrasonic knife to free the greater curvature side tissues of the gastroepiploic artery, suspend the greater curvature of the stomach using clamps (see Table of Materials), and expose the pancreas.</li>
	<li>Following intraoperative B-ultrasound localization, use an ultrasonic scalpel to cut off 1 cm of normal pancreatic tissue from the edge of the pancreatic mass near the neck of the pancreas.</li>
	<li>Use an ultrasonic knife to free the splenic artery and vein at the upper posterior of the pancreas. Then, free the connective tissue between the tail and body of the pancreas and the splenic vessels (see Figure 3).</li>
	<li>Resect completely the pancreatic mass using an ultrasonic scalpel and remove the normal pancreatic tissue 1 cm proximal to the margin of the pancreatic mass.</li>
	<li>Place the stent tubes into the proximal and distal sides of the pancreas within the pancreatic ducts (see Figure 4). 
	NOTE: The diameter and length of the stent tubes in the pancreatic duct were 2 mm and 6 cm, respectively. (see Table of Materials).</li>
	<li>Suture the pancreatic tissue continuously using 4-0 priline (see Figure 5; see Table of Materials) and make an extended incision 2 cm below the navel to remove the pancreatic mass.</li>
	<li>Rinse the abdominal cavity with saline to check for any bleeding points and place a drain above and below the pancreatic anastomosis, respectively. Finally, suture the incision (see Figure 2), and the operation is concluded.</li>
</ol>
4. Postoperative nursing and monitoring
<ol>
	<li>Perform ECG monitoring and low-flow oxygen after the operation.</li>
	<li>Give the patient a semi-liquid diet and instruct the patient to turn over and exercise in bed on the 1st day after the operation.</li>
	<li>Provide hepatoprotective, anti-inflammatory, hemostatic, analgesic, albumin, and acid suppression treatment.</li>
	<li>Monitor amylase changes in the drainage tube at the 1st, 3rd, 4th, and 5th day after operation.</li>
</ol>

<ol>
	<li>Yoon, J. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cystic+neoplasms:+A+review+of+current+recommendations+for+surveillance+and+management.">Pancreatic cystic neoplasms: A review of current recommendations for surveillance and management.</a> Abdominal Radiol. 46 (8), 3946-3962 (2021).</li><li>Kromrey, M. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+study+on+the+incidence,+prevalence+and+5-year+pancreatic-related+mortality+of+pancreatic+cysts+in+a+population-based+study.">Prospective study on the incidence, prevalence and 5-year pancreatic-related mortality of pancreatic cysts in a population-based study.</a> Gut. 67 (1), 138-145 (2018).</li><li>Falconi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+insufficiency+after+different+resections+for+benign+tumours.">Pancreatic insufficiency after different resections for benign tumours.</a> The British J Surg. 95 (1), 85-91 (2008).</li><li>Fujii, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+pancreatic+head+resection+with+segmental+duodenectomy+and+pylorus-preserving+pancreatoduodenectomy+for+benign+and+low-grade+malignant+neoplasms+of+the+pancreatic+head.">Comparison of pancreatic head resection with segmental duodenectomy and pylorus-preserving pancreatoduodenectomy for benign and low-grade malignant neoplasms of the pancreatic head.</a> Pancreas. 40 (8), 1258-1263 (2011).</li><li>Wang, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Practice+patterns+and+perioperative+outcomes+of+laparoscopic+pancreaticoduodenectomy+in+China.">Practice patterns and perioperative outcomes of laparoscopic pancreaticoduodenectomy in China.</a> Ann Surg. 273 (1), 145-153 (2021).</li><li>M&#252;ller, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Middle+segmental+pancreatic+resection:+An+option+to+treat+benign+pancreatic+body+lesions.">Middle segmental pancreatic resection: An option to treat benign pancreatic body lesions.</a> Ann Surg. 244 (6), 918-920 (2006).</li><li>Baca, I., Bokan, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+segmental+pancreas+resection+and+pancreatic+cystadenoma.">Laparoscopic segmental pancreas resection and pancreatic cystadenoma.</a> Chirurg. 74 (10), 961-965 (2003).</li><li>Addeo, P., Julliard, O., Imperiale, A., Goichot, B., Bachellier, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Middle-segment+preserving+pancreatectomy+for+multifocal+neuroendocrine+pancreatic+tumors.">Middle-segment preserving pancreatectomy for multifocal neuroendocrine pancreatic tumors.</a> Surg Oncol. 35, 466-467 (2020).</li><li>Wakabayashi, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+central+pancreatectomy+for+well-differentiated+neuroendocrine+tumor:+Parenchymal-sparing+procedure.">Robotic central pancreatectomy for well-differentiated neuroendocrine tumor: Parenchymal-sparing procedure.</a> Ann Surg Oncol. 26 (7), 2121 (2019).</li><li>Liu, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Case+report:+Treatment+of+intraductal+papillary+mucinous+neoplasms+located+in+middle-segment+pancreas+with+end-to-end+anastomosis+reconstruction+after+laparoscopic+central+pancreatectomy+surgery+through+a+pigtail-tube-stent+placement+of+the+pancreatic+duct.">Case report: Treatment of intraductal papillary mucinous neoplasms located in middle-segment pancreas with end-to-end anastomosis reconstruction after laparoscopic central pancreatectomy surgery through a pigtail-tube-stent placement of the pancreatic duct.</a> Front Surg. 9, 937682 (2022).</li><li>Yang, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+pancreatectomy+with+external+drainage+of+monolayer+pancreaticojejunostomy+for+prevention+of+postoperative+pancreatic+fistula:+A+retrospective+cohort+study.">Central pancreatectomy with external drainage of monolayer pancreaticojejunostomy for prevention of postoperative pancreatic fistula: A retrospective cohort study.</a> Int J Surg. 51, 104-108 (2018).</li><li>Wang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Enucleation+of+pancreatic+solid+pseudopapillary+neoplasm:+Short-term+and+long-term+outcomes+from+a+7-year+large+single-center+experience.">Enucleation of pancreatic solid pseudopapillary neoplasm: Short-term and long-term outcomes from a 7-year large single-center experience.</a> Eur J Surg Oncol. 44 (5), 644-650 (2018).</li><li>Siech, M., Mattfeldt, T., Schlosser, W., Beger, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duodenum-preserving+pancreatic+head+resection+in+patients+with+benign+and+borderline+tumors+of+the+pancreatic+head.">Duodenum-preserving pancreatic head resection in patients with benign and borderline tumors of the pancreatic head.</a> Langenbeck's Arch Surg. 385 (3), 229-233 (2000).</li><li>Iacono, C., Ruzzenente, A., Bortolasi, L., Guglielmi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+pancreatectomy:+The+dagradi+serio+iacono+operation.+Evolution+of+a+surgical+technique+from+the+pioneers+to+the+robotic+approach.">Central pancreatectomy: The dagradi serio iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach.</a> World J Gastroenterol. 20 (42), 15674-15681 (2014).</li><li>Wang, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosis+and+treatment+of+solid-pseudopapillary+tumors+of+the+pancreas:+A+single+institution+experience+with+97+cases.">Diagnosis and treatment of solid-pseudopapillary tumors of the pancreas: A single institution experience with 97 cases.</a> Pancreatology. 18 (4), 415-419 (2018).</li><li>Sun, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticojejunal+bridge+stent+internal+drainage+as+a+safe+reconstruction+technique+after+middle+segmental+pancreatic+resection.">Pancreaticojejunal bridge stent internal drainage as a safe reconstruction technique after middle segmental pancreatic resection.</a> Chinese ed J. 131 (11), 1367-1368 (2018).</li></ol>

The authors have no conflicts of interest or financial ties to disclose.

The pancreas, an important digestive organ in the human body, has several important secretory functions. Therefore, in pancreatic surgery, attention needs to be paid to the preservation of pancreatic parenchyma and its function. With the rising detection rate of benign pancreatic tumors and low-grade malignancies, various procedures have been developed to preserve function, including local enucleation of the pancreas, mid-pancreatectomy, and pancreatic head resection with preservation of the duodenum12<...

From a clinical perspective, it is important to note that not all tumors that develop in the pancreas are classified as pancreatic cancers. Pancreatic tumors can be broadly categorized into two main groups: benign tumors of the pancreas and pancreatic malignancies. Benign neoplasms of the pancreas encompass cystadenoma, intraductal papillary mucinous neoplasm, pancreatic hemangioma, and others1. The detection rate of benign pancreatic tumors has been consistently increasing over the years, and surgery remains the most effective treatment option2. However, traditional surgical procedures such as pancreatoduodenectomy or body and tail resection of the pancreas, while ensuring complete tumor removal, often result in the removal of excessive normal pancreatic tissue. This can significantly impact the long-term quality of life for patients, particularly leading to a higher incidence of endocrine and exocrine dysfunction3,4.
In recent years, the field of laparoscopic pancreatic surgery has seen significant advancements due to the rapid development of minimally invasive techniques like laparoscopic surgery and robotic surgery5. This has led to an increase in the number of hospitals performing laparoscopic pancreatic surgery, which has yielded positive outcomes. Among the various surgical methods, laparoscopic mid-pancreatectomy is considered to be the most suitable approach for treating benign or low-grade malignant tumors located in the neck or proximal part of the pancreas6.
The first mid-pancreatectomy was performed in 2003 by the Baca team on a patient with pancreatic cystadenoma7, and since then, this procedure has been adopted worldwide. Compared to other techniques like local enucleation of pancreatic tumor, laparoscopic caudal pancreatectomy, and laparoscopic pancreaticoduodenectomy, mid-pancreatectomy offers the advantage of preserving normal pancreatic parenchyma and reducing the risk of insufficient internal and external pancreatic secretion4,6,8. However, a challenge arises after resecting the middle part of the pancreas, as traditionally, the broken ends of the pancreas were believed to be unable to be anastomosed. To reconstruct the digestive tract, two main methods are employed. The first method involves a single anastomosis, where the distal end of the pancreas is anastomosed with the stomach or jejunum after closing the proximal end. The second method is a double anastomosis, where both the proximal and distal ends of the pancreas are anastomosed with the jejunum in the shape of a &#937;. However, these reconstruction techniques pose the risk of pancreatic stump fistula and pancreatic-enterostomy fistula for patients, which can lead to abdominal infection and abdominal bleeding. Overcoming these challenges remains a significant concern for pancreatic surgeons8,9.
This paper proposes a novel treatment method called laparoscopic mid-pancreatectomy combined with end-to-end anastomosis. The method involves removing the tumor in the middle part of the pancreas and placing stent tubes into the pancreatic duct at both ends of the pancreas. The pancreatic tissue is then continuously sutured to reconstruct the pancreas. The primary objective of this method is to preserve the substance and function of the pancreas while removing the tumor, thereby reducing the risk of postoperative pancreatic fistula, secondary infection, and bleeding10,11. Additionally, it aims to improve surgical safety.
The patient, a 57-year-old male, was admitted to the hospital due to the discovery of a pancreatic mass during a CT scan. The mass was a round cystic structure with low density, measuring approximately 28 mm x 40 mm, and had an unclear boundary. The patient had a history of type II diabetes for 3 years and hepatitis B virus infection for over 10 years. Before the operation, the levels of alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were measured to be 30.53 ng/mL and 5.8 ng/mL, respectively. Laparoscopic mid-pancreatectomy combined with end-to-end anastomosis was performed on June 15, 2022. The postoperative pathology report indicated the presence of a solid cystic mass in the pancreatic tissue, measuring 3.8 cm x 2.5 cm x 2 cm. The mass appeared gray and white, and the cyst contained transparent fluid with a clear boundary (see Figure 1). Postoperative pathology confirmed pancreatic hemangioma. Tumor markers and drainage tube amylase levels showed a decreasing trend after the surgery, and the patient had a successful recovery.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>abdominal instrument button</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>abdominal instrument cap</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>abdominal instrument collar</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>abdominal instrument connector</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Absorbable ligature clip</td>
			<td>Sichuan Guona Technology Co., LTD</td>
			<td>230716</td>
			<td></td>
		</tr>
		<tr>
			<td>barbs</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>blade</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>blood pad</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cloth towel forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>disposable drainage tube</td>
			<td>Johnson &#38; Johnson</td>
			<td>412280</td>
			<td>6 cm x 2 mm</td>
		</tr>
		<tr>
			<td>Electric knife head</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>hilt</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>holding flask</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>intestinal forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>laparoscope</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>laparoscopic instruments</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ligating clip</td>
			<td>Teleflex Medical</td>
			<td>73H2300118</td>
			<td></td>
		</tr>
		<tr>
			<td>long curved forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>medium curved forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Nail clamp</td>
			<td>Ethicon,USA&#160;</td>
			<td>584C82</td>
			<td></td>
		</tr>
		<tr>
			<td>needle holders</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>ovoid forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Paraffin oil</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>purse string forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>right angled forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>right angled forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>scissors</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Siphonhead</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Small cup</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>small curved forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sonotome keyhole</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>steel ruler</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Straight forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Suction needle plate</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Suture needle</td>
			<td>Johnson &#38; Johnson</td>
			<td>Vcp397H</td>
			<td></td>
		</tr>
		<tr>
			<td>Syringe</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>syringe needle</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>tissue forceps</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>trocar(XCEL)</td>
			<td>Ethicon Endo-Surgery</td>
			<td>695C71</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic knife spacers</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>ultrasound knife</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>yarn ball</td>
			<td>Johnson &#38; Johnson</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

application of mid-pancreatectomy with end-to-end anastomosis in pancreatic benign tumors

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

The operation was completed within 1.5 h, and there was a minimal intraoperative bleeding volume of 50 mL, without the need for a blood transfusion. The dissociation of splenic arteriovenous during the surgery was sufficient to provide effective protection for preserving the pancreatic tail and spleen. The gap left after central pancreatectomy is 1.7 mm. There were no short-term complications, and the patient&#39;s postoperative recovery was successful. The duration of the hospital stay was 20 days, and the postoperative...

Read this Scientific Article Protocol about Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors at JoVE.com

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

The present protocol describes the application of mid-pancreatectomy combined with end-to-end anastomosis in the surgical treatment of pancreatic benign tumors, which presents a feasible solution for managing such tumors while concurrently preserving pancreatic function.

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor ...

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JoVE Journal

Medicine

259 Views.  Sun Yat-sen University. Dopo aver praticato un'incisione verticale sul paziente anestetizzato, esplorare attentamente gli organi intraperitoneali e la superficie peritoneale per rivelare una massa sopra il pancreas che misura circa tre centimetri per tre centimetri. Utilizzando un coltello a ultrasuoni, separare le aderenze addominali e asportare una parte del tessuto omentale. Libera i tessuti laterali a maggiore curvatura dell'arteria gastroepiploica con l'aiuto di un coltello ad ultrasuoni.Sospendi la magg...

Video: Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as studies on graft preservation and ischemia-reperfusion injury 1,2, immunological responses 3,4, hemodynamics 5,6, and small-for-size syndrome 7. The rat OLT is among the most difficult animal models in experimental surgery and demands advanced microsurgical skills that take a long time to learn. Consequently, the use of this model has been limited. Since the reliability and reproducibility of results are key components of the experiments in which such complex animal models are used, it is essential for surgeons who are involved in rat OLT to be trained in well-standardized and sophisticated procedures for this model.
While various techniques and modifications of OLT in rats have been reported 8 since the first model was described by Lee et al. 9 in 1973, the elimination of the hepatic arterial reconstruction 10 and the introduction of the cuff anastomosis technique by Kamada et al. 11 were a major advancement in this model, because they simplified the reconstruction procedures to a great degree. In the model by Kamada et al., the hepatic rearterialization was also eliminated. Since rats could survive without hepatic arterial flow after liver transplantation, there was considerable controversy over the value of hepatic arterialization. However, the physiological superiority of the arterialized model has been increasingly acknowledged, especially in terms of preserving the bile duct system 8,12 and the liver integrity 8,13,14.
In this article, we present detailed surgical procedures for a rat model of OLT with hepatic arterial reconstruction using a 50% partial graft after ex vivo liver resection. The reconstruction procedures for each vessel and the bile duct are performed by the following methods: a 7-0 polypropylene continuous suture for the supra- and infrahepatic vena cava; a cuff technique for the portal vein; and a stent technique for the hepatic artery and the bile duct.

Orthotopic liver transplantation in rats is an indispensable experimental model for biomedical research. Here we present our surgical procedures for orthotopic rat liver transplantation with hepatic arterial reconstruction using a 50% partial graft.

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

A Protocol for Genetic Induction and Visualization of Benign and Invasive Tumors in Cephalic Complexes of Drosophila melanogaster

Drosophila has illuminated our understanding of the genetic basis of normal development and disease for the past several decades and today it continues to contribute immensely to our understanding of complex diseases 1-7. Progression of tumors from a benign to a metastatic state is a complex event 8 and has been modeled in Drosophila to help us better understand the genetic basis of this disease 9. Here I present a simple protocol to genetically induce, observe and then analyze the progression of tumors in Drosophila larvae. The tumor induction technique is based on the MARCM system 10 and exploits the cooperation between an activated oncogene, RasV12 and loss of cell polarity genes (scribbled, discs large and lethal giant larvae) to generate invasive tumors 9. I demonstrate how these tumors can be visualized in the intact larvae and then how these can be dissected out for further analysis. The simplified protocol presented here should make it possible for this technique to be utilized by investigators interested in understanding the role of a gene in tumor invasion.

A Protocol for Genetic Induction and Visualization of Benign and Invasive Tumors in Cephalic Complexes of Drosophila melanogaster

Cooperation between an activated oncogene like RASV12 and mutations in cell polarity genes like scribbled, result in tumor growth in Drosophila where tumor cells also display invasive behaviors. Here a simple protocol for the induction and observation of the benign and invasive tumors is presented.

Drosophila has illuminated our  understanding of the genetic basis of normal development and disease for the  past several decades and today it continues ...

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

Studying Pancreatic Cancer Stem Cell Characteristics for Developing New Treatment Strategies

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor initiation, metastasis and resistance to radio- and chemotherapy. Here we describe a specific methodology for culturing primary human pancreatic CSCs as tumor spheres in anchorage-independent conditions. Cells are grown in serum-free, non-adherent conditions in order to enrich for CSCs while their more differentiated progenies do not survive and proliferate during the initial phase following seeding of single cells. This assay can be used to estimate the percentage of CSCs present in a population of tumor cells. Both size (which can range from 35 to 250 micrometers) and number of tumor spheres formed represents CSC activity harbored in either bulk populations of cultured cancer cells or freshly harvested and digested tumors 1,2. Using this assay, we recently found that metformin selectively ablates pancreatic CSCs; a finding that was subsequently further corroborated by demonstrating diminished expression of pluripotency-associated genes/surface markers and reduced in vivo tumorigenicity of metformin-treated cells. As the final step for preclinical development we treated mice bearing established tumors with metformin and found significantly prolonged survival. Clinical studies testing the use of metformin in patients with PDAC are currently underway (e.g., NCT01210911, NCT01167738, and NCT01488552). Mechanistically, we found that metformin induces a fatal energy crisis in CSCs by enhancing reactive oxygen species (ROS) production and reducing mitochondrial transmembrane potential. In contrast, non-CSCs were not eliminated by metformin treatment, but rather underwent reversible cell cycle arrest. Therefore, our study serves as a successful example for the potential of in vitro sphere formation as a screening tool to identify compounds that potentially target CSCs, but this technique will require further in vitro and in vivo validation to eliminate false discoveries.

Pancreatic cancer stem cells (CSCs) can be expanded in vitro using the anchorage-independent sphere culture technique, which represents a powerful tool to study CSC biology and can serve as the first step to develop novel CSC-targeting therapies. Here the methodology for expanding, analyzing and targeting of pancreatic CSCs is provided.

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Creation of Colonic Anastomosis in Mice

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of colonic surgeries and can occur in up to 26% of surgical anastomoses, with mortality being up to 39% for patients with such a leak. Currently, there remains a paucity of data detailing the cellular mechanisms of anastomotic healing. Devising preventative strategies and treatment modalities for anastomotic leak could be greatly potentiated by a better understanding of appropriate anastomotic healing.
A murine model is ideal as previous studies have shown that the murine anastomosis is the most clinically similar to the human case as compared with other animal models. We offer an easily reproducible murine model of colonic anastomosis in mice that will allow for further illustration of anastomotic healing.

Anastomotic leak or breakdown after surgery is a major cause of postoperative morbidity and mortality. Our surgery for creating a colonic anastomosis is a reliable and reproducible method for studying the healing mechanisms of anastomoses.

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of ...

One-anastomosis Gastric Bypass (OAGB) in Rats

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical model, longitudinal studies can be carried out to provide an improved understanding of the mechanisms underlying the outcomes seen after bariatric surgery in humans. For this purpose, rats are operated on through a laparotomy under general anesthesia with isoflurane. First, the surgeon creates a long and tubular gastric pouch: after greater curve and hiatal dissection, the nonglandular stomach is stapled and removed. Then, the remaining stomach is also stapled in order to create a gastric tube and exclude the antrum of the stomach. After that, the surgeon performs a single end-to-side gastrojejunostomy 35 cm from the duodenojejunal angle. This limb length has been chosen in order to reproduce the same ratio between the biliopancreatic limb (BPL) and common limb (CL) length as in human bariatric surgery. The operation ends by aponeurotic and cutaneous closure. The early postoperative management consists of subcutaneous hydration, an intramuscular prophylactic antibiotic injection, a parietal injection of xylocaine, the administration of painkillers, and a progressive reintroduction of diet.

One-anastomosis Gastric Bypass OAGB in Rats

This protocol is for the performance of one-anastomosis gastric bypass (OAGB) on rat. The operator performs a long and tubular-stapled gastric pouch followed by hand-sewn anastomosis. For this model, the operator reproduces the same ratio between biliopancreatic and common limb in humans; therefore, the biliopancreatic limb measures 35 cm.

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical ...

A Rat Carotid Artery Pressure-Controlled Segmental Balloon Injury with Periadventitial Therapeutic Application

Cardiovascular disease remains the leading cause of death and disability worldwide, in part due to atherosclerosis. Atherosclerotic plaque narrows the luminal surface area in arteries thereby reducing adequate blood flow to organs and distal tissues. Clinically, revascularization procedures such as balloon angioplasty with or without stent placement aim to restore blood flow. Although these procedures reestablish blood flow by reducing plaque burden, they damage the vessel wall, which initiates the arterial healing response. The prolonged healing response causes arterial restenosis, or re-narrowing, ultimately limiting the long-term success of these revascularization procedures. Therefore, preclinical animal models are integral for analyzing the pathophysiological mechanisms driving restenosis, and provide the opportunity to test novel therapeutic strategies. Murine models are cheaper and easier to operate on than large animal models. Balloon or wire injury are the two commonly accepted injury modalities used in murine models. Balloon injury models in particular mimic the clinical angioplasty procedure and cause adequate damage to the artery for the development of restenosis. Herein we describe the surgical details for performing and histologically analyzing the modified, pressure-controlled rat carotid artery balloon injury model. Additionally, this protocol highlights how local periadventitial application of therapeutics can be used to inhibit neointimal hyperplasia. Lastly, we present light sheet fluorescence microscopy as a novel approach for imaging and visualizing the arterial injury in three-dimensions.

The rat carotid artery balloon injury mimics the clinical angioplasty procedure performed to restore blood flow in atherosclerotic vessels. This model induces the arterial injury response by distending the arterial wall, and denuding the intimal layer of endothelial cells, ultimately causing remodeling and an intimal hyperplastic response.

Cardiovascular disease remains the leading cause of death and disability worldwide, in part due to atherosclerosis. Atherosclerotic plaque narrows the ...

On-Site Sampling and Extraction of Brain Tumors for Metabolomics and Lipidomics Analysis

Despite the variety of tools available for cancer diagnosis and classification, methods that enable fast and simple characterization of tumors are still in need. In recent years, mass spectrometry has become a method of choice for untargeted profiling of discriminatory compound as potential biomarkers of a disease. Biofluids are generally considered as preferable matrices given their accessibility and easier sample processing while direct tissue profiling provides more selective information about a given cancer. Preparation of tissues for the analysis via traditional methods is much more complex and time-consuming, and, therefore, not suitable for fast on-site analysis. The current work presents a protocol combining sample preparation and extraction of small molecules on-site, immediately after tumor resection. The sampling device, which is of the size of an acupuncture needle, can be inserted directly into the tissue and then transported to the nearby laboratory for instrumental analysis. The results of metabolomics and lipidomics analyses demonstrate the capability of the approach for the establishment of phenotypes of tumors related to the histological origin of the tumor, malignancy, and genetic mutations, as well as for the selection of discriminating compounds or potential biomarkers. The non-destructive nature of the technique permits subsequent performance of routinely used tests e.g., histological tests, on the same samples used for SPME analysis, thus enabling attainment of more comprehensive information to support personalized diagnostics.

The manuscript presents on-site sampling of human brain tumors with solid phase microextraction followed by their biochemical profiling towards the discovery of biomarkers.

Despite the variety of tools available for cancer diagnosis and classification, methods that enable fast and simple characterization of tumors are still ...

Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Model in Mice

Obesity is a major health issue worldwide. As a response, bariatric surgeries have emerged to treat obesity and its related comorbidities (e.g., diabetes mellitus, dyslipidemia, non-alcoholic steatohepatitis, cardiovascular events, and cancers) through restrictive and malabsorptive mechanisms. Understanding the mechanisms by which these procedures allow such improvements often require their transposition into animals, especially in mice, because of the ease of generating genetically modified animals. Recently, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has emerged as a procedure that uses both restrictive and malabsorptive effects, which is being used as an alternative to gastric bypass in case of major obesity. Thus far, this procedure has been associated with strong metabolic improvements, which has led to a marked increase in its use in daily clinical practice. However, the mechanisms underlying these metabolic effects have been poorly studied as a result of a lack of animal models. In this article, we present a reliable and reproducible model of SADI-S in mice, with a special focus on perioperative management. The description and use of this new rodent model will be helpful for the scientific community to better understand the molecular, metabolic, and structural changes induced by the SADI-S and to better define the surgical indications for clinical practice.

Single-anastomosis duodeno-ileal bypass (SADI-S) is an emerging bariatric procedure with important metabolic effects. In this article, we present a reliable and reproducible model of SADI-S in mice.

Obesity is a major health issue worldwide. As a response, bariatric surgeries have emerged to treat obesity and its related comorbidities (e.g., diabetes ...