Organ- and Parenchyma-sparing Pancreatic Surgery

Abstract

AbstractConventional pancreatectomies, such as pancreaticoduodenectomy and distal and total pancreatectomy, result in an important loss of normal pancreatic parenchyma and the nearby organs (spleen, upper digestive tract, and common bile duct). In addition, these procedures involve significant mortality, high morbidity, and long-term disorders, including infections, thromboembolic complications, digestive disorders, pancreatic exocrine insufficiency, and diabetes. Although conventional pancreatectomies are mandatory for malignant tumor, they are an overtreatment for benign tumors as healthy functional pancreatic parenchyma is sacrificed, especially in young patients with long life expectancy. Unfortunately, enucleation is not always advisable in lesions of uncertain histology or those deeply located in the pancreatic gland owing to the risk of a positive surgical margin or injury to the main pancreatic duct, respectively. Since the 1980s, the prospects for pancreatic resection have widened with the development of organ- and parenchyma-sparing pancreatic surgery (OPSPS) for benign or low-grade malignant tumors involving isolated or multiple segments of the pancreas. New operations, such as spleen-preserving distal pancreatectomy, duodenum-sparing pancreas head resection, dorsal pancreatectomy, resection of the ventral or uncinate process of the pancreas, middle-preserving pancreatectomy, and central pancreatectomy (the Dagradi-Serio-Iacono operation), aim to preserve pancreatic exocrine and endocrine function, spare the nearby organs, ensure oncological radicality, and achieve better quality of life after surgery. In fact, according to vascular anatomy and embryological development, the pancreatic gland is divided in four segments and each of these can be resected independently. In experienced hands, OPSPS is technically feasible and can be performed with low mortality. Early morbidity is greater than that achieved using standard resection owing to the high rate of postoperative pancreatic fistula. However, most of these pancreatic leakages are managed conservatively. Furthermore, possible poor short-term outcomes are counterbalanced by the preservation of pancreatic endocrine and exocrine function and the low rate of reoperations for tumor recurrence. Currently, OPSPS can also be performed by laparoscopic or robotic approach achieving better results in term of blood loss, operative time, hospital stay, recovery and scarring. Careful case selection, accurate pre- and intraoperative evaluation of the lesion, and experience in pancreatic surgery are required for optimal results.