Outcome After Curative Resection of Large (≥10 cm) Gastric Gastrointestinal Stromal Tumors: How Frequent is Adjacent Organ Involvement and is Concomitant Distal Pancreatectomy Necessary?
Introduction Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltra...
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| Veröffentlicht in: | Journal of gastrointestinal surgery 2010-04, Vol.14 (4), p.607-613 |
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| creator | Goh, Brian K. P. Chow, Pierce K. H. Kesavan, Sittampalam M. Yap, Wai-Ming Chung, Yaw-Fui A. Wong, Wai-Keong |
| description | Introduction
Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltration is not infrequently performed during resection of large gastric GISTs. This study aims to determine the true frequency of adjacent organ involvement by large gastric GISTs with particular attention to the pancreas and compares the outcome after curative resection with and without a concomitant DP in order to determine if DP is truly necessary.
Methods
A retrospective review of 37 patients who underwent curative resection of large (≥10 cm) gastric GISTs was conducted.
Results
Wedge resections were performed in 22, partial gastectomies in nine, and total gastrectomies in six patients. The median operative time was 180 min (range, 60–330 min), and the patients had a median postoperative stay of 8 days (range, 4–29 days). Overall, there were eight (22%) morbidities including two (5%) mortalities. Nineteen (51%) had concomitant adjacent organ resection, and these included 15 (41%) DPs with splenectomies. Direct organ invasion was demonstrated in 5/19 patients (26%) and 7/30 organs (23%) resected. Only 1/15 (6.7%) DP specimens demonstrated tumor infiltration. Comparison between the patients with and without a concomitant DP demonstrated that performance of a DP was associated with a longer operation time [225 min (range, 105–305 min) vs 158 min (60–330 min),
P
= .002)], increased postoperative stay [9 days (range, 7–29 days) vs 7.5 days (4–19 days),
P
= .042], and increased postoperative morbidity [6 (40%) vs 2 (9%),
P
= .025]. The DP cohort also had a statistically significant poorer 5-year recurrence free survival (22% vs 60%,
P
= .017).
Conclusion
Although adjacent organ involvement is not uncommon with large gastric GISTs, concomitant DP is usually unnecessary as direct pancreatic invasion is rare. Furthermore, concomitant DP with splenectomy is associated with an increase in postoperative morbidity. |
| doi_str_mv | 10.1007/s11605-009-1083-4 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_733255352</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2790403371</sourcerecordid><originalsourceid>FETCH-LOGICAL-c371t-9a2b324585dea8ffd79f2233f7cdc3e9ca6c971780c39d4c060345ee32da41ca3</originalsourceid><addsrcrecordid>eNp1UUuO1DAQjRCI-cAB2CBLLIBFoGwncTIb1OphPlKLRjBI7CyPU2m5ldiD7fRojjC3YMMx2HAUToKjDAghsarn8qtXn5dlTyi8ogDidaC0gjIHaHIKNc-Le9k-rUUCFavuJwwNzVlZft7LDkLYAlABtH6Y7TGAqioF7Gff12PUbkCy6CJ6shy9imaH5AMG1NE4S1xHVspvkLz4efuNwo-venhJTlWI3ug5OmMjhmis6snH9BxSvBgH58MROXPX5MTjlxFtJCaQRbtVesJrv1GWnNud63c4TBll24mxdDYNZKJKqWMTYhJ7r6z2qGKayA035B1qDEH5mzePsged6gM-vouH2aeTtxfLs3y1Pj1fLla55oLGvFHskrOirMsWVd11rWg6xjjvhG41x0arSjeCiho0b9pCQwW8KBE5a1VBteKH2fNZ98q7tEqIcjBBY98ri24MUnCezsxLlpjP_mFu3ejTZYKklDJepTZNYtGZpb0LwWMnr7wZ0kaSgpyslbO1MlkrJ2tlkWqe3imPlwO2fyp-e5kIbCaE9GU36P9q_V_VX2GWsxM</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1112367179</pqid></control><display><type>article</type><title>Outcome After Curative Resection of Large (≥10 cm) Gastric Gastrointestinal Stromal Tumors: How Frequent is Adjacent Organ Involvement and is Concomitant Distal Pancreatectomy Necessary?</title><source>MEDLINE</source><source>SpringerLink Journals - AutoHoldings</source><creator>Goh, Brian K. P. ; Chow, Pierce K. H. ; Kesavan, Sittampalam M. ; Yap, Wai-Ming ; Chung, Yaw-Fui A. ; Wong, Wai-Keong</creator><creatorcontrib>Goh, Brian K. P. ; Chow, Pierce K. H. ; Kesavan, Sittampalam M. ; Yap, Wai-Ming ; Chung, Yaw-Fui A. ; Wong, Wai-Keong</creatorcontrib><description>Introduction
Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltration is not infrequently performed during resection of large gastric GISTs. This study aims to determine the true frequency of adjacent organ involvement by large gastric GISTs with particular attention to the pancreas and compares the outcome after curative resection with and without a concomitant DP in order to determine if DP is truly necessary.
Methods
A retrospective review of 37 patients who underwent curative resection of large (≥10 cm) gastric GISTs was conducted.
Results
Wedge resections were performed in 22, partial gastectomies in nine, and total gastrectomies in six patients. The median operative time was 180 min (range, 60–330 min), and the patients had a median postoperative stay of 8 days (range, 4–29 days). Overall, there were eight (22%) morbidities including two (5%) mortalities. Nineteen (51%) had concomitant adjacent organ resection, and these included 15 (41%) DPs with splenectomies. Direct organ invasion was demonstrated in 5/19 patients (26%) and 7/30 organs (23%) resected. Only 1/15 (6.7%) DP specimens demonstrated tumor infiltration. Comparison between the patients with and without a concomitant DP demonstrated that performance of a DP was associated with a longer operation time [225 min (range, 105–305 min) vs 158 min (60–330 min),
P
= .002)], increased postoperative stay [9 days (range, 7–29 days) vs 7.5 days (4–19 days),
P
= .042], and increased postoperative morbidity [6 (40%) vs 2 (9%),
P
= .025]. The DP cohort also had a statistically significant poorer 5-year recurrence free survival (22% vs 60%,
P
= .017).
Conclusion
Although adjacent organ involvement is not uncommon with large gastric GISTs, concomitant DP is usually unnecessary as direct pancreatic invasion is rare. Furthermore, concomitant DP with splenectomy is associated with an increase in postoperative morbidity.</description><identifier>ISSN: 1091-255X</identifier><identifier>EISSN: 1873-4626</identifier><identifier>DOI: 10.1007/s11605-009-1083-4</identifier><identifier>PMID: 20066570</identifier><language>eng</language><publisher>New York: Springer-Verlag</publisher><subject>Adult ; Aged ; Aged, 80 and over ; Cancer ; Chi-Square Distribution ; Female ; Gastrectomy - methods ; Gastroenterology ; Gastrointestinal Stromal Tumors - pathology ; Gastrointestinal Stromal Tumors - surgery ; Humans ; Immunohistochemistry ; Lymphatic Metastasis ; Male ; Medical research ; Medicine ; Medicine & Public Health ; Middle Aged ; Neoplasm Invasiveness ; Original Article ; Pancreatectomy ; Pancreatic Diseases - etiology ; Pancreatic Diseases - surgery ; Postoperative Complications - etiology ; Postoperative Complications - surgery ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Statistics, Nonparametric ; Surgery ; Survival Rate ; Treatment Outcome ; Tumors</subject><ispartof>Journal of gastrointestinal surgery, 2010-04, Vol.14 (4), p.607-613</ispartof><rights>The Society for Surgery of the Alimentary Tract 2010</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c371t-9a2b324585dea8ffd79f2233f7cdc3e9ca6c971780c39d4c060345ee32da41ca3</citedby><cites>FETCH-LOGICAL-c371t-9a2b324585dea8ffd79f2233f7cdc3e9ca6c971780c39d4c060345ee32da41ca3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s11605-009-1083-4$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s11605-009-1083-4$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,780,784,27924,27925,41488,42557,51319</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/20066570$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Goh, Brian K. P.</creatorcontrib><creatorcontrib>Chow, Pierce K. H.</creatorcontrib><creatorcontrib>Kesavan, Sittampalam M.</creatorcontrib><creatorcontrib>Yap, Wai-Ming</creatorcontrib><creatorcontrib>Chung, Yaw-Fui A.</creatorcontrib><creatorcontrib>Wong, Wai-Keong</creatorcontrib><title>Outcome After Curative Resection of Large (≥10 cm) Gastric Gastrointestinal Stromal Tumors: How Frequent is Adjacent Organ Involvement and is Concomitant Distal Pancreatectomy Necessary?</title><title>Journal of gastrointestinal surgery</title><addtitle>J Gastrointest Surg</addtitle><addtitle>J Gastrointest Surg</addtitle><description>Introduction
Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltration is not infrequently performed during resection of large gastric GISTs. This study aims to determine the true frequency of adjacent organ involvement by large gastric GISTs with particular attention to the pancreas and compares the outcome after curative resection with and without a concomitant DP in order to determine if DP is truly necessary.
Methods
A retrospective review of 37 patients who underwent curative resection of large (≥10 cm) gastric GISTs was conducted.
Results
Wedge resections were performed in 22, partial gastectomies in nine, and total gastrectomies in six patients. The median operative time was 180 min (range, 60–330 min), and the patients had a median postoperative stay of 8 days (range, 4–29 days). Overall, there were eight (22%) morbidities including two (5%) mortalities. Nineteen (51%) had concomitant adjacent organ resection, and these included 15 (41%) DPs with splenectomies. Direct organ invasion was demonstrated in 5/19 patients (26%) and 7/30 organs (23%) resected. Only 1/15 (6.7%) DP specimens demonstrated tumor infiltration. Comparison between the patients with and without a concomitant DP demonstrated that performance of a DP was associated with a longer operation time [225 min (range, 105–305 min) vs 158 min (60–330 min),
P
= .002)], increased postoperative stay [9 days (range, 7–29 days) vs 7.5 days (4–19 days),
P
= .042], and increased postoperative morbidity [6 (40%) vs 2 (9%),
P
= .025]. The DP cohort also had a statistically significant poorer 5-year recurrence free survival (22% vs 60%,
P
= .017).
Conclusion
Although adjacent organ involvement is not uncommon with large gastric GISTs, concomitant DP is usually unnecessary as direct pancreatic invasion is rare. Furthermore, concomitant DP with splenectomy is associated with an increase in postoperative morbidity.</description><subject>Adult</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Cancer</subject><subject>Chi-Square Distribution</subject><subject>Female</subject><subject>Gastrectomy - methods</subject><subject>Gastroenterology</subject><subject>Gastrointestinal Stromal Tumors - pathology</subject><subject>Gastrointestinal Stromal Tumors - surgery</subject><subject>Humans</subject><subject>Immunohistochemistry</subject><subject>Lymphatic Metastasis</subject><subject>Male</subject><subject>Medical research</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Middle Aged</subject><subject>Neoplasm Invasiveness</subject><subject>Original Article</subject><subject>Pancreatectomy</subject><subject>Pancreatic Diseases - etiology</subject><subject>Pancreatic Diseases - surgery</subject><subject>Postoperative Complications - etiology</subject><subject>Postoperative Complications - surgery</subject><subject>Prognosis</subject><subject>Proportional Hazards Models</subject><subject>Retrospective Studies</subject><subject>Statistics, Nonparametric</subject><subject>Surgery</subject><subject>Survival Rate</subject><subject>Treatment Outcome</subject><subject>Tumors</subject><issn>1091-255X</issn><issn>1873-4626</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2010</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><recordid>eNp1UUuO1DAQjRCI-cAB2CBLLIBFoGwncTIb1OphPlKLRjBI7CyPU2m5ldiD7fRojjC3YMMx2HAUToKjDAghsarn8qtXn5dlTyi8ogDidaC0gjIHaHIKNc-Le9k-rUUCFavuJwwNzVlZft7LDkLYAlABtH6Y7TGAqioF7Gff12PUbkCy6CJ6shy9imaH5AMG1NE4S1xHVspvkLz4efuNwo-venhJTlWI3ug5OmMjhmis6snH9BxSvBgH58MROXPX5MTjlxFtJCaQRbtVesJrv1GWnNud63c4TBll24mxdDYNZKJKqWMTYhJ7r6z2qGKayA035B1qDEH5mzePsged6gM-vouH2aeTtxfLs3y1Pj1fLla55oLGvFHskrOirMsWVd11rWg6xjjvhG41x0arSjeCiho0b9pCQwW8KBE5a1VBteKH2fNZ98q7tEqIcjBBY98ri24MUnCezsxLlpjP_mFu3ejTZYKklDJepTZNYtGZpb0LwWMnr7wZ0kaSgpyslbO1MlkrJ2tlkWqe3imPlwO2fyp-e5kIbCaE9GU36P9q_V_VX2GWsxM</recordid><startdate>20100401</startdate><enddate>20100401</enddate><creator>Goh, Brian K. P.</creator><creator>Chow, Pierce K. H.</creator><creator>Kesavan, Sittampalam M.</creator><creator>Yap, Wai-Ming</creator><creator>Chung, Yaw-Fui A.</creator><creator>Wong, Wai-Keong</creator><general>Springer-Verlag</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope></search><sort><creationdate>20100401</creationdate><title>Outcome After Curative Resection of Large (≥10 cm) Gastric Gastrointestinal Stromal Tumors: How Frequent is Adjacent Organ Involvement and is Concomitant Distal Pancreatectomy Necessary?</title><author>Goh, Brian K. P. ; Chow, Pierce K. H. ; Kesavan, Sittampalam M. ; Yap, Wai-Ming ; Chung, Yaw-Fui A. ; Wong, Wai-Keong</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c371t-9a2b324585dea8ffd79f2233f7cdc3e9ca6c971780c39d4c060345ee32da41ca3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2010</creationdate><topic>Adult</topic><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Cancer</topic><topic>Chi-Square Distribution</topic><topic>Female</topic><topic>Gastrectomy - methods</topic><topic>Gastroenterology</topic><topic>Gastrointestinal Stromal Tumors - pathology</topic><topic>Gastrointestinal Stromal Tumors - surgery</topic><topic>Humans</topic><topic>Immunohistochemistry</topic><topic>Lymphatic Metastasis</topic><topic>Male</topic><topic>Medical research</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Middle Aged</topic><topic>Neoplasm Invasiveness</topic><topic>Original Article</topic><topic>Pancreatectomy</topic><topic>Pancreatic Diseases - etiology</topic><topic>Pancreatic Diseases - surgery</topic><topic>Postoperative Complications - etiology</topic><topic>Postoperative Complications - surgery</topic><topic>Prognosis</topic><topic>Proportional Hazards Models</topic><topic>Retrospective Studies</topic><topic>Statistics, Nonparametric</topic><topic>Surgery</topic><topic>Survival Rate</topic><topic>Treatment Outcome</topic><topic>Tumors</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Goh, Brian K. P.</creatorcontrib><creatorcontrib>Chow, Pierce K. H.</creatorcontrib><creatorcontrib>Kesavan, Sittampalam M.</creatorcontrib><creatorcontrib>Yap, Wai-Ming</creatorcontrib><creatorcontrib>Chung, Yaw-Fui A.</creatorcontrib><creatorcontrib>Wong, Wai-Keong</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Proquest Nursing & Allied Health Source</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of gastrointestinal surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Goh, Brian K. P.</au><au>Chow, Pierce K. H.</au><au>Kesavan, Sittampalam M.</au><au>Yap, Wai-Ming</au><au>Chung, Yaw-Fui A.</au><au>Wong, Wai-Keong</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Outcome After Curative Resection of Large (≥10 cm) Gastric Gastrointestinal Stromal Tumors: How Frequent is Adjacent Organ Involvement and is Concomitant Distal Pancreatectomy Necessary?</atitle><jtitle>Journal of gastrointestinal surgery</jtitle><stitle>J Gastrointest Surg</stitle><addtitle>J Gastrointest Surg</addtitle><date>2010-04-01</date><risdate>2010</risdate><volume>14</volume><issue>4</issue><spage>607</spage><epage>613</epage><pages>607-613</pages><issn>1091-255X</issn><eissn>1873-4626</eissn><abstract>Introduction
Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltration is not infrequently performed during resection of large gastric GISTs. This study aims to determine the true frequency of adjacent organ involvement by large gastric GISTs with particular attention to the pancreas and compares the outcome after curative resection with and without a concomitant DP in order to determine if DP is truly necessary.
Methods
A retrospective review of 37 patients who underwent curative resection of large (≥10 cm) gastric GISTs was conducted.
Results
Wedge resections were performed in 22, partial gastectomies in nine, and total gastrectomies in six patients. The median operative time was 180 min (range, 60–330 min), and the patients had a median postoperative stay of 8 days (range, 4–29 days). Overall, there were eight (22%) morbidities including two (5%) mortalities. Nineteen (51%) had concomitant adjacent organ resection, and these included 15 (41%) DPs with splenectomies. Direct organ invasion was demonstrated in 5/19 patients (26%) and 7/30 organs (23%) resected. Only 1/15 (6.7%) DP specimens demonstrated tumor infiltration. Comparison between the patients with and without a concomitant DP demonstrated that performance of a DP was associated with a longer operation time [225 min (range, 105–305 min) vs 158 min (60–330 min),
P
= .002)], increased postoperative stay [9 days (range, 7–29 days) vs 7.5 days (4–19 days),
P
= .042], and increased postoperative morbidity [6 (40%) vs 2 (9%),
P
= .025]. The DP cohort also had a statistically significant poorer 5-year recurrence free survival (22% vs 60%,
P
= .017).
Conclusion
Although adjacent organ involvement is not uncommon with large gastric GISTs, concomitant DP is usually unnecessary as direct pancreatic invasion is rare. Furthermore, concomitant DP with splenectomy is associated with an increase in postoperative morbidity.</abstract><cop>New York</cop><pub>Springer-Verlag</pub><pmid>20066570</pmid><doi>10.1007/s11605-009-1083-4</doi><tpages>7</tpages></addata></record> |
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| ispartof | Journal of gastrointestinal surgery, 2010-04, Vol.14 (4), p.607-613 |
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| subjects | Adult Aged Aged, 80 and over Cancer Chi-Square Distribution Female Gastrectomy - methods Gastroenterology Gastrointestinal Stromal Tumors - pathology Gastrointestinal Stromal Tumors - surgery Humans Immunohistochemistry Lymphatic Metastasis Male Medical research Medicine Medicine & Public Health Middle Aged Neoplasm Invasiveness Original Article Pancreatectomy Pancreatic Diseases - etiology Pancreatic Diseases - surgery Postoperative Complications - etiology Postoperative Complications - surgery Prognosis Proportional Hazards Models Retrospective Studies Statistics, Nonparametric Surgery Survival Rate Treatment Outcome Tumors |
| title | Outcome After Curative Resection of Large (≥10 cm) Gastric Gastrointestinal Stromal Tumors: How Frequent is Adjacent Organ Involvement and is Concomitant Distal Pancreatectomy Necessary? |
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