Duodenum-Preserving Pancreatic Head Resection

Abstract

Duodenum-preserving pancreatic head resection (DPPHR) was first described in the 1970s by Beger in Germany to treat patients with chronic pancreatitis [1, 2]. In 1988, Takada performed the first duodenum-preserving total pancreatic head resection (DPPHRt) to treat benign or low-grade malignant tumors of the pancreatic head by preserving the duodenum with its intact blood supply from the pancreatic duodenal arterial arcade [3, 4]. The increasing use of high resolution CT/MR and endoscopic ultrasonography has increased the diagnostic and accuracy rates of cystic tumors of the pancreatic head in recent years. Most tumors are benign but with a risk of potential malignant transformation, or are low-grade malignant tumors [5]. Some of these patients need to be treated by surgery because of symptoms like abdominal pain, distension, and jaundice, or because of the possibility of malignant transformation [6, 7]. DPPHR was initially designed for chronic pancreatitis. Although many surgeons believe that DPPHR results in improvements in intermediate and long-term outcomes which include the length of hospital stay, quality of life, postoperative rehabilitation, and preservation of exocrine function compared to PD and pylorus-preserving pancreaticoduodenectomy (PPPD) [1, 2]. Although a multi-center, randomized, controlled, double-blind ChroPac trial published in 2017 showed DPPHR to result in no difference in quality of life compared with partial pancreatoduodenectomy for chronic pancreatitis [8], DPPHR has recently been used to treat benign or low-grade malignant tumors in patients who are completely different to those with chronic pancreatitis. These patients are predominantly young females with normal pancreatic functions. A significant proportion of these patients wish to undergo minimally invasive treatment, not only because of small incisions, but also because of organ-preservation. When compared with pancreaticoduodenectomy (PD), the standard operation for pancreatic head tumors, DPPHRt maintained the integrity of the duodenum and biliary system, with non-inferiority in the short- and long-term outcomes for benign or low-grade malignant tumors [9–11]. The rapid advancements in minimally invasive technology in the past two decades have led to the increasing use of laparoscopic pancreatic surgery. Laparoscopic PD and distal pancreatectomy (DP) are now technically feasible [8], although the long-term oncological outcomes remain unclear [12, 13]. Peng et al. [14] in 2012 and Mouet [15] in 2016 reported the minimally invasive DPPHR. Cao et al. [16] in 2018 reported laparoscopic DPPHRt as a novel minimally invasive surgery for benign or low-grade malignant tumors of the pancreatic head. A systematic review showed DPPHR significantly preserved the levels of exocrine and endocrine pancreatic functions, with no significant differences in the rates of pancreatic fistula, delayed gastric emptying, and hospital mortality when compared to PD, the standard treatment for tumors of the pancreatic head [17, 18]. DPPHR, by preserving the integrity of the duodenum and biliary system with conservation of the peripancreatic tissues, should better maintain the exocrine and endocrine pancreatic functions in the short and long terms. In addition, the operation avoids the complications following a biliary anastomosis.