Efficacy of pancreatic duct stenting prior to laparoscopic pancreatic tumor enucleation

Efficacy of pancreatic duct stenting prior to laparoscopic pancreatic tumor enucleation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of pancreatic duct stenting prior to laparoscopic pancreatic tumor enucleation Guixing Jiang, Xinyang Zhou, Meng Wang, Tianyu Lin, Jionghuang Chen, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1530046/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Laparoscopic pancreatic tumor enucleation (LPE) is a viable option for the removal of non-malignant pancreatic masses leading to maximally preservation of organ function. However, postoperative pancreatic fistula (POPF) is a concern, particularly when the mass is close to the main pancreatic duct (MPD). Pancreatic duct stents are used to treat refractory pancreatic leakage, Preoperative stenting of the MPD might prevent its injury when performing LPE. Aimas To explore the application value of pancreatic duct stents in laparoscopic pancreatic tumor enucleation. Methods We reviewed the clinical data of patients who underwent either Laparoscopic pancreatic enucleation with pancreatic stenting (LPE + PS) or LPE from January 2016 to December 2019. The patients were divided into two groups as LPE + PS and LPE. Results Twenty (9 LPE and 11 LPE + PS) were included in the final analysis. The 2 groups were equivalent in baseline characteristics and pathologic variables. LPE + PS group showed shorter hospital stay (p = 0.045), lower Grade B/C postoperative pancreatic fistula rates than the LPE group (p = 0.047). Intraoperative and postoperative outcomes, including operating time (p = 0.124), estimated blood loss (p = 0.258), were similar in the two groups. No local recurrence and no patients presented exocrine or endocrine insufficiency was detected in either group. Conclusion This procedure is associated with acceptable morbidity and it is safe. The preoperative stenting of the MPD may facilitates to identify the main pancreatic duct intraoperatively, might avoid the occurrence of Grade B/C POPF. Laparoscopic pancreatic enucleation Pancreatic duct stenting Postoperative pancreatic fistula Figures Figure 1 Figure 2 Introduction Traditionally, pancreaticoduodenectomy and distal pancreatectomy with splenectomy for benign or low malignant-potential pancreatic neoplasms have the risk of pancreatic function insufficiency [ 1 – 3 ] .By reporter, more than 30% of patients develop diabetes and from 16 to 49% develop exocrine insufficiency after standard pancreatic resections [ 1 , 4 , 5 ] . Therefore, Laparoscopic pancreatectomy, such as Laparoscopic pancreatic tumor enucleation (LPE) can preserve normal pancreatic tissue, characterized by excellent long-term outcomes due to preserves organ function [ 6 – 8 ] . So, LPE may represents a limited resection alternative to pancreaticoduodenectomy and distal pancreatectomy with splenectomy for the treatment of these neoplasms [ 9 ] . However, the defect of LPE is the high rate of surgical complications, associated with postoperative pancreatic fistula (POPF), whose rate is reported from 15 to 69% in the literature [ 10 , 11 ] .Particularly, when the neoplasm is deep or located near the main pancreatic duct (MPD), the MPD is easily injured, resulting in POPF [ 10 , 12 , 13 ] . To recognize the site of the MPD during surgery, the risk of pancreatic duct disruption would be diminished. Thus, in this study, we report a statistical analysis of multiple preoperative and perioperative variables related to 20 LPE, sought the clinical effect of pancreatic duct stenting in LPE. Patients And Methods Laparoscopic pancreatic enucleation with pancreatic stenting (LPE + PS) was adopted in 2016 at our institution. Between January 2016 and December 2019, patients underwent either LPE + PS or LPE alone were reviewed. The patients were divided into two groups as LPE + PS and LPE. The data considered for clinical comparison were patient demographics, intraoperative variables (operative time, estimated blood loss (EBL), blood transfusion requirement), complications, duration of hospital stay, and final pathology. This study was approved by the Ethics Committee for Clinical Research of our institution and met the guidelines of the Declaration of Helsinki. Endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the MPD ERCP was performed under deep sedation in the prone position by gastroenterologist within 3 hours before LPE. We performed peroral endoscopic duodenoscopy to the descending duodenum, identified the duodenal papilla, adjusted the scope to the center of the field of view (Fig. 1 a). Guide-wired deep cannulation of the MPD was achieved using a hydrophilic wire (Fig. 1 b). Small quantity of contrast was injected to confirm the correct position of the guide-wire inside the duct. Pancreatic sphincterotomy was performed over the wire, an appropriate plastic pancreatic duct stent (Model: CHN; 5–7 Fr/4–9 cm; Micro-Tech Co., Ltd., Nanjing, China) according to the diameter of the residual pancreatic duct was deployed (Fig. 1 c). The length of the stent was chosen to place its intra-pancreatic end over the lesion. Figure 1 d shows the pancreatic stent placement. Laparoscopic pancreatic enucleation (LPE) With the patient in a supine position with legs abducted, and after inducing general anesthesia with tracheal intubation, we routinely placed sterile drapes. A small curved incision was made under the umbilicus, and pneumoperitoneum was established by Veress needle puncture with a pneumoperitoneum pressure of 12–15 mmHg (1 mmHg = 0.133 kPa). We then performed a 10-mm cannula puncture, and inserted a 30° laparoscope. A 5-mm cannula was placed 2 cm below the costal margin of the left and right anterior axillary lines as traction ports, during laparoscopy. We set a 12-mm cannula as the main operating port, 2 cm above the umbilicus on the outer edge of right rectus abdominis muscle, horizontally, and set another 10-mm cannula as a traction port at the corresponding position on the left side. The five punctures were V-shaped. The abdominal cavity was explored to exclude tumor peritoneal metastasis, and we used an ultrasonic scalpel (Harmonic Ace; Ethicon Endo-Surgery, Cincinnati, OH, USA) to incise the gastrocolic ligament and enter the lesser omental bursa. Once the pancreatic parenchyma was exposed, intraoperative ultrasound allowed to identify the lesion and the MPD containing the stent (Fig. 2 b). The mass was dissected free using a 1–2-mm side opening in the pancreatic capsule to guarantee complete enucleation of the tumor, using the electrosurgical and ultrasonic scalpels (Fig. 2 c). No sealants or patches were used to the resection wound. After bagging the specimen, we extended the incision below the umbilicus longitudinally and inferiorly to remove the specimen. The specimen and its margins were then sent for intraoperative frozen section histopathological examination. After the abdominal cavity was flushed, and no active bleeding was found. One closed-suction drainage tube was placed close to the site of enucleation (1 case showed in Fig. 2 ). POPF was assessed according to the International Study Group on Pancreatic Fistula recommendations [ 14 ] , and Postoperative morbidity was graded using the Clavien–Dindo classification [ 15 ] . Grades I and II were grouped as minor, and grades III–V were considered as major complications [ 15 ] . Follow-up We removed the stent approximately 1 month postoperatively (Fig. 2 e). In patients with POPF, we removed the pancreatic stent 3 months after recovery and discharge from the hospital. Recurrence was diagnosed by CT (Fig. 2 f). Pancreatic endocrine insufficiency was defined as new-onset diabetes and worsening diabetes. Patients with diarrhea and steatorrhea, weight loss, and taking of pancreatic enzyme supplementation were considered to have pancreatic exocrine insufficiency. Patients were followed up via phone call or out-patient examination. The final follow-up was taken in April 2020. Statistical analysis Demographic, pathologic, and perioperative details were extracted from this database. Continuous clinicopathological data were expressed as mean ± standard deviation or median (range) as appropriate. Categorical variables were reported as number and percentage. Continuous clinicopathological data were analyzed with Student’s t test (or Mann–Whitney U test). Categorical variables were analyzed with the Fisher’s exact test (or likelihood ratio). We performed all statistical analyses with SPSS v22.0 (IBM Corp., Armonk, NY, USA). P < 0.05 was considered statistically significant. Results Baseline characteristics 20 patients were included in the final analysis, of which 9 patients (45.0%) underwent LPE + PS and 11 patients (55.0%) underwent LPE. Table 1 demonstrates that the baseline characteristics was equivalent between the 2 patient groups. The distribution of tumor size, tumor location and histopathologic diagnosis was also equal between the 2 groups (Table 1 ). Surgery outcomes in the LPE + PS and LPE groups Results of our statistical analysis of surgical outcomes are shown in Table 2 . This analysis revealed that the LPE + PS group had shorter hospital stay (8.7 ± 3.2 vs. 13.2 ± 5.6 days, p = 0.045) than the LPE group, lower Grade B/C postoperative pancreatic fistula rates than the LPE group (p = 0.047). Intraoperative outcomes, including operating time (p = 0.124), estimated blood loss (p = 0.258), were similar in the two groups. Postoperative complications occurred in 6 patients (66.7%) in the LPE + PS group and 6 patients (54.5%) in the LPE group (p = 0.670) (Table 3). The rate of minor and major complications did not differ between two groups (p = 0.685). The rates of bleeding, reoperation, delayed gastric emptying, and cardiopulmonary complication were similar in the two groups. No patients required post-operative intensive care management. There was one patient developed postoperative abdominal hemorrhage required reoperation, and no perioperative deaths in either group. Long-term outcomes A total of 20 patients (follow-up rate 94.6%) were followed up via phone call or out-patient examination. The median follow-up period was 27 months (range 10–39 months) and 29 months (range 14–39 months) for the LPE group and 25 months (range 10–32 months) for the LPE + PS group. No local recurrence and no patients presented exocrine or endocrine insufficiency was detected in either group. Discussion LPE was initially described by Gagner et al [ 16 ] in 1996. It represents a valid tool for radical treatment of small non-malignant masses and is technically straightforward and ensures normal functional outcomes. However, LPE is associated with substantial rates of POPF due to the high risk of damaging the pancreatic ductal system. Studies have revealed that POPF remains the most common complication after LPE (9 to 69%) [ 10 , 11 , 17 , 18 ] . Particularly when the location of the tumor is deep, or close to the MPD [ 10 , 12 , 13 ] . Protecting the main pancreatic duct during surgery to avoid POPF is the key to the safe implementation of LPE. To protect MPD from damage when performing LPE, There were several attempts to preoperatively stent the MPD. In 2007, seven cases of pancreatic enucleation (PE) with MPD stent were reported in Japan [ 19 ] . One group reported 10 patients with small pancreatic tumors who were assigned PE prior to preoperative endoscopic placement of the MPD stent and described the relationship between the tumor and MPD [ 20 ] .Another group reported 3 cases of preoperative MPD stenting, a total of 65 cases of PE, and stenting was performed in patients with a close distance between tumor and MPD [ 21 ] . Several other single case reports also have been published [ 22 – 24 ] . However, previous studies have not compared preoperative endoscopic pancreatic stenting with simple PE, and the potential benefit of the procedure was questionable. Our data show that, in 2 patient groups undergoing LPE, LPE + PS group had lower Grade B/C POPF rates than the LPE group (p = 0.047)and shorter postoperative hospital stay (8.7 ± 3.2 vs. 13.2 ± 5.6 days, p = 0.045).This result was probably achieved because of preoperative endoscopic pancreatic stenting has the following advantages: First, endoscopic pancreatic stent implantation is a minimally invasive well-proven procedure [ 19 ] . Second, intraoperatively, surgeons were able to recognize the site of the pancreatic duct during surgery and the presence of the stent facilitates detecting injury to the main pancreatic duct and permits timely treatment, if injury occurs. Third, the support of the stent effectively reduces the pancreatic secretion pressure and duodenal pressure difference and establishes effective internal drainage, which is conducive to pancreatic wound healing after enucleation [ 22 , 25 – 27 ] . For these reasons, we believe that the preoperative positioning of the stent reduces the occurrence of Grade B/C POPF and shortens the length of postoperative hospital stay. Studies show that Post-ERCP pancreatitis occurrence ranges from 5 to 25% [ 28 , 29 ] . We recommend LPE was scheduled within 3 hours after the ERCP with stenting of the MPD to reduce the risk of stent spontaneous migration, and anticipate the development of sequelae related to the Post-ERCP pancreatitis as well as to reduce the length of hospital stay [ 30 ] . In this study, 1 patient developed postoperative abdominal hemorrhage. Emergency surgical exploration revealed bleeding at the enucleation site from small blood vessels in the wound, prompting the caution that intraoperatively, it is important to carefully separate the tumor along the pancreatic capsule and identify whether the pancreatic duct or a vascular stump is incorporated into the wound. we recommend intraoperatively suturing the pancreatic wound with 4 − 0 non-absorbable suture to reduce the incidence of postoperative wound bleeding. As regards the stent removal, patients without POPF, we removed the stent approximately 1 month postoperatively. In patients with POPF, we removed the pancreatic stent 3 months after recovery and discharge from the hospital. Conclusion This procedure is associated with acceptable morbidity and it is safe. The preoperative stenting of the MPD may facilitates to identify the main pancreatic duct intraoperatively, might avoid the occurrence of Grade B/C POPF. The limitations of this study were its retrospective and nonrandomized design with relatively small number of cases. Nevertheless, this is a single-center pilot study, which might lay the foundation for future studies with larger samples. Abbreviations LPE Laparoscopic pancreatic tumor enucleation POPF postoperative pancreatic fistula MPD main pancreatic duct PS pancreatic stenting EBL estimated blood loss ERCP Endoscopic retrograde cholangiopancreatography. Declarations Acknowledgments The authors thank all colleagues of the department of general surgery in Sir Run Run Shaw Hospital of Zhejiang University. Authors ’ contributions GJ, MW and XZ were responsible for the conception and design of the study. All authors were responsible for acquisition and analysis of data, and GJ, XZ, and TL performed the statistical analyses. GJ and XZ drafted the manuscript; LC,GJ, and XZ revised and commented on the draft of the manuscript; and all authors read and approved the final version of the manuscript. Funding This work was supported by grants from the Zhejiang Provincial Medical and Health Science and Technology Program (Grant Number: 2018KY491). Availability of data and materials All the data can be obtained from the author by email ( [email protected] ). Ethics approval and consent to participate This study was approved by the ethics committee of Sir Run Run Shaw Hospital. Written informed consent was obtained from all participants. Consent for publication Written informed consent was obtained from all patients enrolled in the investigation. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and the guidelines of the regional ethical committees of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China. Competing interests The authors declare that they have no competing interests. References Falconi M, Mantovani W, Crippa S, Mascetta G, Salvia R, Pederzoli P. Pancreatic insufficiency after different resections for benign tumours. Br J Surg 2008;951:85–91. Nakamura H, Murakami Y, Uemura K, Hayashidani Y, Sudo T, Ohge H, et al. Predictive factors for exocrine pancreatic insufficiency after pancreatoduodenectomy with pancreaticogastrostomy. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2009;137:1321–7. Okano K, Murakami Y, Nakagawa N, Uemura K, Sudo T, Hashimoto Y, et al. Remnant pancreatic parenchymal volume predicts postoperative pancreatic exocrine insufficiency after pancreatectomy. Surgery 2016;1593:885–92. Beger HG, Poch B, Mayer B, Siech M. New Onset of Diabetes and Pancreatic Exocrine Insufficiency After Pancreaticoduodenectomy for Benign and Malignant Tumors: A Systematic Review and Meta-analysis of Long-term Results. Ann Surg 2018;2672:259–70. Beger HG, Mayer B. Early postoperative and late metabolic morbidity after pancreatic resections: An old and new challenge for surgeons - A review. American journal of surgery 2018;2161:131–4. Hackert T, Hinz U, Fritz S, Strobel O, Schneider L, Hartwig W, et al. Enucleation in pancreatic surgery: indications, technique, and outcome compared to standard pancreatic resections. Langenbeck's archives of surgery 2011;3968:1197–203. Crippa S, Bassi C, Salvia R, Falconi M, Butturini G, Pederzoli P. Enucleation of pancreatic neoplasms. The British journal of surgery 2007;9410:1254–9. Cauley CE, Pitt HA, Ziegler KM, Nakeeb A, Schmidt CM, Zyromski NJ, et al. Pancreatic Enucleation: Improved Outcomes Compared to Resection. J Gastrointest Surg 2012;167:1347–53. Crippa S, Boninsegna L, Partelli S, Falconi M. Parenchyma-sparing resections for pancreatic neoplasms. Journal of hepato-biliary-pancreatic sciences 2010;176:782–7. Heeger K, Falconi M, Partelli S, Waldmann J, Crippa S, Fendrich V, et al. Increased rate of clinically relevant pancreatic fistula after deep enucleation of small pancreatic tumors. Langenbeck's archives of surgery 2014;3993:315–21. Strobel O, Cherrez A, Hinz U, Mayer P, Kaiser J, Fritz S, et al. Risk of pancreatic fistula after enucleation of pancreatic tumours. The British journal of surgery 2015;10210:1258–66. Lu WJ, Xu B, Gao SL, Dong X, Zhang B, Wu YL. Enucleation of benign or borderline pancreatic head tumors adjacent to the common pancreatic duct. Pancreas 2012;412:336–7. Costi R, Randone B, Mal F, Basato S, Levard H, Gayet B. A critical appraisal of laparoscopic pancreatic enucleations: right-sided procedures (Pancreatic Head, Uncus) are not mini-invasive surgery. Surgical laparoscopy, endoscopy & percutaneous techniques 2013;236:524 – 31. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;1613:584–91. Dindo D, Demartines N, Clavien PA. Classification of surgical complications - A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;2402:205–13. Gagner M, Pomp A, Herrera MF. Early experience with laparoscopic resections of islet cell tumors. Surgery 1996;1206:1051–4. Crippa S, Zerbi A, Boninsegna L, Capitanio V, Partelli S, Balzano G, et al. Surgical management of insulinomas: short- and long-term outcomes after enucleations and pancreatic resections. Archives of surgery (Chicago, Ill: 1960) 2012;1473:261-6. Brient C, Regenet N, Sulpice L, Brunaud L, Mucci-Hennekine S, Carrere N, et al. Risk factors for postoperative pancreatic fistulization subsequent to enucleation. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2012;1610:1883–7. Shimura T, Suehiro T, Suzuki H, Mochida Y, Okada K, Araki K, et al. Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic duct disruption during extirpation of a pancreatic head tumor. American journal of surgery 2007;1944:553–5. Giuliani T, Marchegiani G, Girgis MD, Crino SF, Muthusamy VR, Bernardoni L, et al. Endoscopic placement of pancreatic stent for "Deep" pancreatic enucleations operative technique and preliminary experience at two high-volume centers. Surgical endoscopy 2020;346:2796–802. Song KB, Kim SC, Hwang DW, Lee JH, Lee DJ, Lee JW, et al. Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients. Surgery 2015;1585:1203–10. Misawa T, Imazu H, Fujiwara Y, Kitamura H, Tsutsui N, Ito R, et al. Efficacy of nasopancreatic stenting prior to laparoscopic enucleation of pancreatic neuroendocrine tumor. Asian journal of endoscopic surgery 2013;62:140–2. Tanaka K, Misawa T, Haruki K, Saito R, Gocho T, Akiba T. Enucleation of solid pseudopapillary tumor with a preoperative nasopancreatic drainage stent in a child. Asian journal of endoscopic surgery 2017;104:438–41. Ide S, Uchida K, Inoue M, Koike Y, Otake K, Matsushita K, et al. Tumor enucleation with preoperative endoscopic transpapillary stenting for pediatric insulinoma. Pediatric surgery international 2012;287:707–9. Hikita K, Chiba N, Takano K, Ozawa Y, Sano T, Tomita K, et al. Efficacy of Perioperative Endoscopic Naso-Pancreatic Drainage in Laparoscopic Enucleation of Pancreatic Nonfunctioning Neuroendocrine Tumor. The American surgeon 2019;852:e89-e92. Kim S, Kim JW, Jung PY, Kwon HY, Shim H, Jang JY, et al. Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: Single center experience for 34 years. International journal of surgery (London, England) 2017;42:152–7. Krige JEJ, Kotze UK, Navsaria PH, Nicol AJ. Endoscopic and operative treatment of delayed complications after pancreatic trauma: An analysis of 27 civilians treated in an academic Level 1 Trauma Centre. Pancreatology: official journal of the International Association of Pancreatology (IAP) [et al] 2015;155:563–9. Tryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: Pathophysiology, early identification and risk stratification. Advances in clinical and experimental medicine: official organ Wroclaw Medical University 2018;271:149–54. Elmunzer BJ. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis. Digestive endoscopy: official journal of the Japan Gastroenterological Endoscopy Society 2017;297:749–57. Chahal P, Baron TH, Petersen BT, Topazian MD, Gostout CJ, Levy MJ. Pancreatic stent prophylaxis of post endoscopic retrograde cholangiopancreatography pancreatitis: spontaneous migration rates and clinical outcomes. Minerva gastroenterologica e dietologica 2007;533:225–30. Tables Table 1 Baseline characteristics. Laparoscopic pancreatic enucleation + pancreatic stenting (n = 9) Laparoscopic pancreatic enucleation alone (n = 11) P Female/male 7/2 7/4 0.642 Age (year) 48.0 ± 9.1 47.8 ± 7.6 0.962 BMI (kg/m 2 ) 22.6 ± 1.9 23.8 ± 3.2 0.335 Symptoms 0.630 Yes 6 7 No 3 4 Previous laparotomy 0.604 Yes 2 3 No 7 8 Comorbidity 2 4 0.642 Cardiopulmonary disease 2 3 0.500 Diabetes mellitus 0 1 ASA classification 0.904 I 1 1 II 7 8 III 1 2 Tumor size on histopathology (cm) 2.5 ± 0.97 2.9 ± 0.86 0.431 Final Pathology 0.963 panNETs 3 4 SPN 4 4 SCAs 1 2 MCA 1 1 Location of tumor 0.962 Head 1 1 Neck 1 2 Body 3 4 Tail 4 4 Data are expressed as mean ± SD or n or unless otherwise specified BMI body mass index, ASA American Society of Anesthesiologists, panNETs pancreatic neuroendocrine tumors, MCA mucinous cystadenoma, SCA serous cystadenoma, SPN: solid pseudo-papillary neoplasms. Table 2 Surgical outcomes of 2 groups. Laparoscopic pancreatic enucleation + pancreatic stenting (n = 9) Laparoscopic pancreatic enucleation alone (n = 11) P Operative outcomes Operating time (min) 112.2 ± 11.8 124.6 ± 20.4 0.124 Estimated blood loss (mL) 83.1 ± 23.4 98.0 ± 31.7 0.258 Blood transfusion 0 0 - Hospital staying (days) 8.7 ± 3.2 13.2 ± 5.6 0.045 Postoperative pancreatic fistula 6 6 0.670 Biochemical leak (BL) 5 1 0.047 Grade B + C 1 5 Overall complications 6 6 0.670 Minor complications (grade I, II) 5 4 0.685 Major complications (grade III) 1 2 Bleeding 0.550 Yes 0 1 No 9 10 Reoperation Yes 0 1 0.550 No 9 10 Delayed gastric emptying 0.579 Yes 1 2 No 8 9 Cardiopulmonary complication 0 0 - Data are expressed as mean ± SD or n or unless otherwise specified Table 3 is not available with this version. Additional Declarations No competing interests reported. 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Cao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYHACxgMJDBIgRgLDBwY2EMOAoB64FsYZRGuBMZh5IDR+Lfzthw8ceLjDIk/e/8AzaZs/fIkN7M3bJBhq7uDUInEmLeFA4hmJYsMDB9Kkc3jYEht4jpVJMBx7hlOLAUOOwYHENonEjY0NQC0SQC0SOWYSjA2HcWvhfwPV0syQJm1hANQi/4aAFgmoLfPZgFoYEkC28ODXInHjGdgviRt4GJItew6wGbfxpBVbJBzDrYW/P/ngw5876hLn959JvPHjzzHZfvbDG298qMGtBQwYG4AuPMCTAGQeg0RmAn4NEC3yDewHgMwaQmpHwSgYBaNgBAIA05JWpaUtG1UAAAAASUVORK5CYII=","orcid":"","institution":"Zhejiang University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Liping","middleName":"","lastName":"Cao","suffix":""}],"badges":[],"createdAt":"2022-04-06 14:29:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1530046/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1530046/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":20564550,"identity":"1577b685-1249-4656-b844-8f859c22495c","added_by":"auto","created_at":"2022-04-20 16:47:05","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15975,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea:\u003c/strong\u003e Identified the duodenal papilla. \u003cstrong\u003eb\u003c/strong\u003e: Placed a guidewire in the end of the pancreatic duct along the needle-knife. \u003cstrong\u003ec\u003c/strong\u003e: Prior to LPE, we placed a pancreatic duct stent in the main pancreatic duct. \u003cstrong\u003ed:\u003c/strong\u003e Figure shows position of the pancreatic duct stent.\u003cstrong\u003e (\u003c/strong\u003eLPE: Laparoscopic pancreatic enucleation)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1530046/v1/d6f3597b804807f6b1441882.jpeg"},{"id":20564551,"identity":"3728afb6-f847-438b-b41e-1f3408b4d8cd","added_by":"auto","created_at":"2022-04-20 16:47:05","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":30209,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e: Preoperative CT. A tumor (arrow) in the pancreatic body is seen as a homogenous low-density mass. The tumor has a clear border with the surrounding tissue without metastasis or invasion. \u003cstrong\u003eb\u003c/strong\u003e: Intraoperative findings showing a well-defined cystic tumor in the pancreatic body. \u003cstrong\u003ec\u003c/strong\u003e: Enucleation. The pancreatic wound is visible following the enucleation, and the preoperatively-placed stent is located in the main pancreatic duct (white dotted line). \u003cstrong\u003ed:\u003c/strong\u003e After LPE, the tumor was completely removed. \u003cstrong\u003ee: \u003c/strong\u003eThe stent was removed. \u003cstrong\u003ef: \u003c/strong\u003ePostoperative CT showing no obvious abnormalities.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1530046/v1/9d03ef52c9029a65001c4537.jpeg"},{"id":20564555,"identity":"8c96dd1a-3858-4c77-a97b-1438e79bc4f6","added_by":"auto","created_at":"2022-04-20 16:47:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":423196,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1530046/v1/442d7841-c10d-4d46-b396-3001276cd92e.pdf"},{"id":20564553,"identity":"75beb287-608c-4238-8824-28eff53c5237","added_by":"auto","created_at":"2022-04-20 16:47:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":423196,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1530046/v1/e09e545f-88de-4bf3-a2ca-04dae2337f35.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of pancreatic duct stenting prior to laparoscopic pancreatic tumor enucleation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraditionally, pancreaticoduodenectomy and distal pancreatectomy with splenectomy for benign or low malignant-potential pancreatic neoplasms have the risk of pancreatic function insufficiency\u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.By reporter, more than 30% of patients develop diabetes and from 16 to 49% develop exocrine insufficiency after standard pancreatic resections\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, Laparoscopic pancreatectomy, such as Laparoscopic pancreatic tumor enucleation (LPE) can preserve normal pancreatic tissue, characterized by excellent long-term outcomes due to preserves organ function\u003csup\u003e[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. So, LPE may represents a limited resection alternative to pancreaticoduodenectomy and distal pancreatectomy with splenectomy for the treatment of these neoplasms\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, the defect of LPE is the high rate of surgical complications, associated with postoperative pancreatic fistula (POPF), whose rate is reported from 15 to 69% in the literature\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.Particularly, when the neoplasm is deep or located near the main pancreatic duct (MPD), the MPD is easily injured, resulting in POPF \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo recognize the site of the MPD during surgery, the risk of pancreatic duct disruption would be diminished. Thus, in this study, we report a statistical analysis of multiple preoperative and perioperative variables related to 20 LPE, sought the clinical effect of pancreatic duct stenting in LPE.\u003c/p\u003e"},{"header":"Patients And Methods","content":"\u003cp\u003eLaparoscopic pancreatic enucleation with pancreatic stenting (LPE\u0026thinsp;+\u0026thinsp;PS) was adopted in 2016 at our institution. Between January 2016 and December 2019, patients underwent either LPE\u0026thinsp;+\u0026thinsp;PS or LPE alone were reviewed. The patients were divided into two groups as LPE\u0026thinsp;+\u0026thinsp;PS and LPE. The data considered for clinical comparison were patient demographics, intraoperative variables (operative time, estimated blood loss (EBL), blood transfusion requirement), complications, duration of hospital stay, and final pathology. This study was approved by the Ethics Committee for Clinical Research of our institution and met the guidelines of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) with stenting of the MPD ERCP was performed under deep sedation in the prone position by gastroenterologist within 3 hours before LPE. We performed peroral endoscopic duodenoscopy to the descending duodenum, identified the duodenal papilla, adjusted the scope to the center of the field of view (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Guide-wired deep cannulation of the MPD was achieved using a hydrophilic wire (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Small quantity of contrast was injected to confirm the correct position of the guide-wire inside the duct. Pancreatic sphincterotomy was performed over the wire, an appropriate plastic pancreatic duct stent (Model: CHN; 5\u0026ndash;7 Fr/4\u0026ndash;9 cm; Micro-Tech Co., Ltd., Nanjing, China) according to the diameter of the residual pancreatic duct was deployed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec). The length of the stent was chosen to place its intra-pancreatic end over the lesion. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed shows the pancreatic stent placement.\u003c/p\u003e\u003cp\u003eLaparoscopic pancreatic enucleation (LPE)\u003c/p\u003e \u003cp\u003eWith the patient in a supine position with legs abducted, and after inducing general anesthesia with tracheal intubation, we routinely placed sterile drapes. A small curved incision was made under the umbilicus, and pneumoperitoneum was established by Veress needle puncture with a pneumoperitoneum pressure of 12\u0026ndash;15 mmHg (1 mmHg\u0026thinsp;=\u0026thinsp;0.133 kPa). We then performed a 10-mm cannula puncture, and inserted a 30\u0026deg; laparoscope. A 5-mm cannula was placed 2 cm below the costal margin of the left and right anterior axillary lines as traction ports, during laparoscopy. We set a 12-mm cannula as the main operating port, 2 cm above the umbilicus on the outer edge of right rectus abdominis muscle, horizontally, and set another 10-mm cannula as a traction port at the corresponding position on the left side. The five punctures were V-shaped.\u003c/p\u003e \u003cp\u003e The abdominal cavity was explored to exclude tumor peritoneal metastasis, and we used an ultrasonic scalpel (Harmonic Ace; Ethicon Endo-Surgery, Cincinnati, OH, USA) to incise the gastrocolic ligament and enter the lesser omental bursa. Once the pancreatic parenchyma was exposed, intraoperative ultrasound allowed to identify the lesion and the MPD containing the stent (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). The mass was dissected free using a 1\u0026ndash;2-mm side opening in the pancreatic capsule to guarantee complete enucleation of the tumor, using the electrosurgical and ultrasonic scalpels (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). No sealants or patches were used to the resection wound. After bagging the specimen, we extended the incision below the umbilicus longitudinally and inferiorly to remove the specimen. The specimen and its margins were then sent for intraoperative frozen section histopathological examination. After the abdominal cavity was flushed, and no active bleeding was found. One closed-suction drainage tube was placed close to the site of enucleation (1 case showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePOPF was assessed according to the International Study Group on Pancreatic Fistula recommendations\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, and Postoperative morbidity was graded using the Clavien\u0026ndash;Dindo classification\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Grades I and II were grouped as minor, and grades III\u0026ndash;V were considered as major complications\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003eWe removed the stent approximately 1 month postoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee). In patients with POPF, we removed the pancreatic stent 3 months after recovery and discharge from the hospital. Recurrence was diagnosed by CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef). Pancreatic endocrine insufficiency was defined as new-onset diabetes and worsening diabetes. Patients with diarrhea and steatorrhea, weight loss, and taking of pancreatic enzyme supplementation were considered to have pancreatic exocrine insufficiency. Patients were followed up via phone call or out-patient examination. The final follow-up was taken in April 2020.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDemographic, pathologic, and perioperative details were extracted from this database. Continuous clinicopathological data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (range) as appropriate. Categorical variables were reported as number and percentage. Continuous clinicopathological data were analyzed with Student\u0026rsquo;s t test (or Mann\u0026ndash;Whitney U test). Categorical variables were analyzed with the Fisher\u0026rsquo;s exact test (or likelihood ratio). We performed all statistical analyses with SPSS v22.0 (IBM Corp., Armonk, NY, USA). P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline characteristics\u003c/p\u003e\n\u003cp\u003e20 patients were included in the final analysis, of which 9 patients (45.0%) underwent LPE\u0026thinsp;+\u0026thinsp;PS and 11 patients (55.0%) underwent LPE. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates that the baseline characteristics was equivalent between the 2 patient groups. The distribution of tumor size, tumor location and histopathologic diagnosis was also equal between the 2 groups (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSurgery outcomes in the LPE\u0026thinsp;+\u0026thinsp;PS and LPE groups\u003c/p\u003e\n\u003cp\u003eResults of our statistical analysis of surgical outcomes are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. This analysis revealed that the LPE\u0026thinsp;+\u0026thinsp;PS group had shorter hospital stay (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 vs. 13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 days, p\u0026thinsp;=\u0026thinsp;0.045) than the LPE group, lower Grade B/C postoperative pancreatic fistula rates than the LPE group (p\u0026thinsp;=\u0026thinsp;0.047). Intraoperative outcomes, including operating time (p\u0026thinsp;=\u0026thinsp;0.124), estimated blood loss (p\u0026thinsp;=\u0026thinsp;0.258), were similar in the two groups. Postoperative complications occurred in 6 patients (66.7%) in the LPE\u0026thinsp;+\u0026thinsp;PS group and 6 patients (54.5%) in the LPE group (p\u0026thinsp;=\u0026thinsp;0.670) (Table\u0026nbsp;3). The rate of minor and major complications did not differ between two groups (p\u0026thinsp;=\u0026thinsp;0.685). The rates of bleeding, reoperation, delayed gastric emptying, and cardiopulmonary complication were similar in the two groups. No patients required post-operative intensive care management. There was one patient developed postoperative abdominal hemorrhage required reoperation, and no perioperative deaths in either group.\u003c/p\u003e\n\u003cp\u003eLong-term outcomes\u003c/p\u003e\n\u003cp\u003eA total of 20 patients (follow-up rate 94.6%) were followed up via phone call or out-patient examination. The median follow-up period was 27 months (range 10\u0026ndash;39 months) and 29 months (range 14\u0026ndash;39 months) for the LPE group and 25 months (range 10\u0026ndash;32 months) for the LPE\u0026thinsp;+\u0026thinsp;PS group. No local recurrence and no patients presented exocrine or endocrine insufficiency was detected in either group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLPE was initially described by Gagner et al\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e in 1996. It represents a valid tool for radical treatment of small non-malignant masses and is technically straightforward and ensures normal functional outcomes. However, LPE is associated with substantial rates of POPF due to the high risk of damaging the pancreatic ductal system. Studies have revealed that POPF remains the most common complication after LPE (9 to 69%)\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Particularly when the location of the tumor is deep, or close to the MPD\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Protecting the main pancreatic duct during surgery to avoid POPF is the key to the safe implementation of LPE.\u003c/p\u003e \u003cp\u003eTo protect MPD from damage when performing LPE, There were several attempts to preoperatively stent the MPD. In 2007, seven cases of pancreatic enucleation (PE) with MPD stent were reported in Japan\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. One group reported 10 patients with small pancreatic tumors who were assigned PE prior to preoperative endoscopic placement of the MPD stent and described the relationship between the tumor and MPD\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.Another group reported 3 cases of preoperative MPD stenting, a total of 65 cases of PE, and stenting was performed in patients with a close distance between tumor and MPD\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Several other single case reports also have been published\u003csup\u003e[\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. However, previous studies have not compared preoperative endoscopic pancreatic stenting with simple PE, and the potential benefit of the procedure was questionable.\u003c/p\u003e \u003cp\u003eOur data show that, in 2 patient groups undergoing LPE, LPE\u0026thinsp;+\u0026thinsp;PS group had lower Grade B/C POPF rates than the LPE group (p\u0026thinsp;=\u0026thinsp;0.047)and shorter postoperative hospital stay (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 vs. 13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 days, p\u0026thinsp;=\u0026thinsp;0.045).This result was probably achieved because of preoperative endoscopic pancreatic stenting has the following advantages: First, endoscopic pancreatic stent implantation is a minimally invasive well-proven procedure\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Second, intraoperatively, surgeons were able to recognize the site of the pancreatic duct during surgery and the presence of the stent facilitates detecting injury to the main pancreatic duct and permits timely treatment, if injury occurs. Third, the support of the stent effectively reduces the pancreatic secretion pressure and duodenal pressure difference and establishes effective internal drainage, which is conducive to pancreatic wound healing after enucleation\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. For these reasons, we believe that the preoperative positioning of the stent reduces the occurrence of Grade B/C POPF and shortens the length of postoperative hospital stay.\u003c/p\u003e \u003cp\u003eStudies show that Post-ERCP pancreatitis occurrence ranges from 5 to 25%\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. We recommend LPE was scheduled within 3 hours after the ERCP with stenting of the MPD to reduce the risk of stent spontaneous migration, and anticipate the development of sequelae related to the Post-ERCP pancreatitis as well as to reduce the length of hospital stay\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. In this study, 1 patient developed postoperative abdominal hemorrhage. Emergency surgical exploration revealed bleeding at the enucleation site from small blood vessels in the wound, prompting the caution that intraoperatively, it is important to carefully separate the tumor along the pancreatic capsule and identify whether the pancreatic duct or a vascular stump is incorporated into the wound. we recommend intraoperatively suturing the pancreatic wound with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 non-absorbable suture to reduce the incidence of postoperative wound bleeding. As regards the stent removal, patients without POPF, we removed the stent approximately 1 month postoperatively. In patients with POPF, we removed the pancreatic stent 3 months after recovery and discharge from the hospital.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis procedure is associated with acceptable morbidity and it is safe. The preoperative stenting of the MPD may facilitates to identify the main pancreatic duct intraoperatively, might avoid the occurrence of Grade B/C POPF. The limitations of this study were its retrospective and nonrandomized design with relatively small number of cases. Nevertheless, this is a single-center pilot study, which might lay the foundation for future studies with larger samples.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLPE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLaparoscopic pancreatic tumor enucleation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOPF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epostoperative pancreatic fistula\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emain pancreatic duct\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epancreatic stenting\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eestimated blood loss\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEndoscopic retrograde cholangiopancreatography.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all colleagues of the department of general surgery in Sir\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRun Run Shaw Hospital of Zhejiang University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e’ contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGJ, MW and XZ were responsible for the conception and design of the study. All authors were responsible for acquisition and analysis of data, and GJ, XZ, and TL performed the statistical analyses. GJ and XZ drafted the manuscript; LC,GJ, and XZ revised and commented on the draft of the manuscript; and all authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work\u0026nbsp;was supported by grants from the Zhejiang Provincial Medical and Health Science and Technology Program (Grant Number: 2018KY491).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data can be obtained from the author by email ( [email protected]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of Sir Run Run Shaw Hospital. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all patients enrolled in the investigation. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and the guidelines of the regional ethical committees of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFalconi M, Mantovani W, Crippa S, Mascetta G, Salvia R, Pederzoli P. Pancreatic insufficiency after different resections for benign tumours. Br J Surg 2008;951:85\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura H, Murakami Y, Uemura K, Hayashidani Y, Sudo T, Ohge H, et al. Predictive factors for exocrine pancreatic insufficiency after pancreatoduodenectomy with pancreaticogastrostomy. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2009;137:1321\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkano K, Murakami Y, Nakagawa N, Uemura K, Sudo T, Hashimoto Y, et al. Remnant pancreatic parenchymal volume predicts postoperative pancreatic exocrine insufficiency after pancreatectomy. Surgery 2016;1593:885\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeger HG, Poch B, Mayer B, Siech M. New Onset of Diabetes and Pancreatic Exocrine Insufficiency After Pancreaticoduodenectomy for Benign and Malignant Tumors: A Systematic Review and Meta-analysis of Long-term Results. Ann Surg 2018;2672:259\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeger HG, Mayer B. Early postoperative and late metabolic morbidity after pancreatic resections: An old and new challenge for surgeons - A review. American journal of surgery 2018;2161:131\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHackert T, Hinz U, Fritz S, Strobel O, Schneider L, Hartwig W, et al. Enucleation in pancreatic surgery: indications, technique, and outcome compared to standard pancreatic resections. Langenbeck's archives of surgery 2011;3968:1197\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrippa S, Bassi C, Salvia R, Falconi M, Butturini G, Pederzoli P. Enucleation of pancreatic neoplasms. The British journal of surgery 2007;9410:1254\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCauley CE, Pitt HA, Ziegler KM, Nakeeb A, Schmidt CM, Zyromski NJ, et al. Pancreatic Enucleation: Improved Outcomes Compared to Resection. J Gastrointest Surg 2012;167:1347\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrippa S, Boninsegna L, Partelli S, Falconi M. Parenchyma-sparing resections for pancreatic neoplasms. Journal of hepato-biliary-pancreatic sciences 2010;176:782\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeeger K, Falconi M, Partelli S, Waldmann J, Crippa S, Fendrich V, et al. Increased rate of clinically relevant pancreatic fistula after deep enucleation of small pancreatic tumors. Langenbeck's archives of surgery 2014;3993:315\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrobel O, Cherrez A, Hinz U, Mayer P, Kaiser J, Fritz S, et al. Risk of pancreatic fistula after enucleation of pancreatic tumours. The British journal of surgery 2015;10210:1258\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu WJ, Xu B, Gao SL, Dong X, Zhang B, Wu YL. Enucleation of benign or borderline pancreatic head tumors adjacent to the common pancreatic duct. Pancreas 2012;412:336\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosti R, Randone B, Mal F, Basato S, Levard H, Gayet B. A critical appraisal of laparoscopic pancreatic enucleations: right-sided procedures (Pancreatic Head, Uncus) are not mini-invasive surgery. Surgical laparoscopy, endoscopy \u0026amp; percutaneous techniques 2013;236:524 \u0026ndash; 31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;1613:584\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications - A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;2402:205\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagner M, Pomp A, Herrera MF. Early experience with laparoscopic resections of islet cell tumors. Surgery 1996;1206:1051\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrippa S, Zerbi A, Boninsegna L, Capitanio V, Partelli S, Balzano G, et al. Surgical management of insulinomas: short- and long-term outcomes after enucleations and pancreatic resections. Archives of surgery (Chicago, Ill: 1960) 2012;1473:261-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrient C, Regenet N, Sulpice L, Brunaud L, Mucci-Hennekine S, Carrere N, et al. Risk factors for postoperative pancreatic fistulization subsequent to enucleation. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2012;1610:1883\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimura T, Suehiro T, Suzuki H, Mochida Y, Okada K, Araki K, et al. Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic duct disruption during extirpation of a pancreatic head tumor. American journal of surgery 2007;1944:553\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiuliani T, Marchegiani G, Girgis MD, Crino SF, Muthusamy VR, Bernardoni L, et al. Endoscopic placement of pancreatic stent for \"Deep\" pancreatic enucleations operative technique and preliminary experience at two high-volume centers. Surgical endoscopy 2020;346:2796\u0026ndash;802.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong KB, Kim SC, Hwang DW, Lee JH, Lee DJ, Lee JW, et al. Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients. Surgery 2015;1585:1203\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisawa T, Imazu H, Fujiwara Y, Kitamura H, Tsutsui N, Ito R, et al. Efficacy of nasopancreatic stenting prior to laparoscopic enucleation of pancreatic neuroendocrine tumor. Asian journal of endoscopic surgery 2013;62:140\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanaka K, Misawa T, Haruki K, Saito R, Gocho T, Akiba T. Enucleation of solid pseudopapillary tumor with a preoperative nasopancreatic drainage stent in a child. Asian journal of endoscopic surgery 2017;104:438\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIde S, Uchida K, Inoue M, Koike Y, Otake K, Matsushita K, et al. Tumor enucleation with preoperative endoscopic transpapillary stenting for pediatric insulinoma. Pediatric surgery international 2012;287:707\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHikita K, Chiba N, Takano K, Ozawa Y, Sano T, Tomita K, et al. Efficacy of Perioperative Endoscopic Naso-Pancreatic Drainage in Laparoscopic Enucleation of Pancreatic Nonfunctioning Neuroendocrine Tumor. The American surgeon 2019;852:e89-e92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim S, Kim JW, Jung PY, Kwon HY, Shim H, Jang JY, et al. Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: Single center experience for 34 years. International journal of surgery (London, England) 2017;42:152\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrige JEJ, Kotze UK, Navsaria PH, Nicol AJ. Endoscopic and operative treatment of delayed complications after pancreatic trauma: An analysis of 27 civilians treated in an academic Level 1 Trauma Centre. Pancreatology: official journal of the International Association of Pancreatology (IAP) [et al] 2015;155:563\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: Pathophysiology, early identification and risk stratification. Advances in clinical and experimental medicine: official organ Wroclaw Medical University 2018;271:149\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElmunzer BJ. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis. Digestive endoscopy: official journal of the Japan Gastroenterological Endoscopy Society 2017;297:749\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChahal P, Baron TH, Petersen BT, Topazian MD, Gostout CJ, Levy MJ. Pancreatic stent prophylaxis of post endoscopic retrograde cholangiopancreatography pancreatitis: spontaneous migration rates and clinical outcomes. Minerva gastroenterologica e dietologica 2007;533:225\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic pancreatic enucleation\u0026thinsp;+\u0026thinsp;pancreatic stenting\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic pancreatic enucleation alone\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale/male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.335\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.630\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious laparotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiopulmonary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eASA classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.904\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTumor size on histopathology (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal Pathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.963\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epanNETs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSPN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSCAs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocation of tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHead\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n or unless otherwise specified\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eBMI body mass index, ASA American Society of Anesthesiologists, panNETs pancreatic neuroendocrine tumors, MCA mucinous cystadenoma, SCA serous cystadenoma, SPN: solid pseudo-papillary neoplasms.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSurgical outcomes of 2 groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic pancreatic enucleation\u003c/p\u003e\n \u003cp\u003e+ pancreatic stenting\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic pancreatic enucleation alone\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperative outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperating time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124.6\u0026thinsp;\u0026plusmn;\u0026thinsp;20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.1\u0026thinsp;\u0026plusmn;\u0026thinsp;23.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98.0\u0026thinsp;\u0026plusmn;\u0026thinsp;31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital staying (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative pancreatic fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBiochemical leak (BL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade B\u0026thinsp;+\u0026thinsp;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverall complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMinor complications (grade I, II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.685\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajor complications (grade III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelayed gastric emptying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiopulmonary complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n or unless otherwise specified\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\u003c/br\u003e\n\u003cp\u003eTable 3 is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic pancreatic enucleation, Pancreatic duct stenting, Postoperative pancreatic fistula","lastPublishedDoi":"10.21203/rs.3.rs-1530046/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1530046/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLaparoscopic pancreatic tumor enucleation (LPE) is a viable option for the removal of non-malignant pancreatic masses leading to maximally preservation of organ function. However, postoperative pancreatic fistula (POPF) is a concern, particularly when the mass is close to the main pancreatic duct (MPD). Pancreatic duct stents are used to treat refractory pancreatic leakage, Preoperative stenting of the MPD might prevent its injury when performing LPE.\u003c/p\u003e\u003ch2\u003eAimas\u003c/h2\u003e \u003cp\u003eTo explore the application value of pancreatic duct stents in laparoscopic pancreatic tumor enucleation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe reviewed the clinical data of patients who underwent either Laparoscopic pancreatic enucleation with pancreatic stenting (LPE\u0026thinsp;+\u0026thinsp;PS) or LPE from January 2016 to December 2019. The patients were divided into two groups as LPE\u0026thinsp;+\u0026thinsp;PS and LPE.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty (9 LPE and 11 LPE\u0026thinsp;+\u0026thinsp;PS) were included in the final analysis. The 2 groups were equivalent in baseline characteristics and pathologic variables. LPE\u0026thinsp;+\u0026thinsp;PS group showed shorter hospital stay (p\u0026thinsp;=\u0026thinsp;0.045), lower Grade B/C postoperative pancreatic fistula rates than the LPE group (p\u0026thinsp;=\u0026thinsp;0.047). Intraoperative and postoperative outcomes, including operating time (p\u0026thinsp;=\u0026thinsp;0.124), estimated blood loss (p\u0026thinsp;=\u0026thinsp;0.258), were similar in the two groups. No local recurrence and no patients presented exocrine or endocrine insufficiency was detected in either group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis procedure is associated with acceptable morbidity and it is safe. The preoperative stenting of the MPD may facilitates to identify the main pancreatic duct intraoperatively, might avoid the occurrence of Grade B/C POPF.\u003c/p\u003e","manuscriptTitle":"Efficacy of pancreatic duct stenting prior to laparoscopic pancreatic tumor enucleation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-04-20 16:47:04","doi":"10.21203/rs.3.rs-1530046/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0dbd81c0-8996-4dbb-b872-57daecbac881","owner":[],"postedDate":"April 20th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-04-20T16:47:05+00:00","versionOfRecord":[],"versionCreatedAt":"2022-04-20 16:47:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1530046","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1530046","identity":"rs-1530046","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}