Total Pancreatic Head Resection Research Articles

Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis

BackgroundPancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications.Materials and MethodsPubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD.ResultsConcordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15–1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28–0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178–5.34); p = 0.96].ConclusionsDPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms.

Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?

Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is amultiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure anew onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, amortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.

Clinical outcomes of minimally invasive duodenum-preserving pancreatic head resection

BackgroundThe procedure of total duodenum-preserving pancreatic head resection (DPPHRt) has been reported frequently, but rare in minimally invasive procedure, especially robotic-assisted operation. Here we share our experience and analyze the clinical outcomes of minimally invasive DPPHRt in the treatment of benign lesions or low-grade malignant tumors of the pancreatic head in this study.Materials and methodsFrom October 2016 to January 2022, three patients received robot-assisted DPPHRt(RA-DPPHRt), and seventeen patients received laparoscopic DPPHRt(LDPPHRt). Data were retrospectively collected in terms of demographic characteristics (age, gender, body mass index, and pathological diagnosis), intraoperative variables (operative time, estimated blood loss), and post-operative variables (post-operative hospital stay, and complications).ResultsAll 20 patients received minimally invasive total duodenum-preserving pancreatic head resection successfully without conversion, including 8 males and 12 females. Pathological diagnosis suggested 1 case of serous cystadenoma (SCA), 4 cases of intraductal papillary mucinous neoplasm (IPMN) ,5 cases of mucinous cystic neoplasm (MCN), 4 cases of pancreatic neuroendocrine neoplasm (PNET), 2 cases of chronic pancreatitis (CP),4 case of solid pseudopapillary tumor (SPT). The average operation time was (285.35 ± 95.13 min), ranging from 95 to 420 min. The average estimate blood loss was (196.50 ± 174.45ml) ,ranging from 10 to 600ml.The average post-operative hospital stay was(20.90 ± 14.44days),ranging from 8 to 54 days. Postoperative complications occurred in 10 patients (50%). A total of 5 patients (20%) suffered grade B or C pancreatic fistula. Two patients (10%) suffered from biliary fistula. Two patients (10%) suffered from delayed gastric emptying. One patient (5%) suffered from abdominal bleeding. The 90-day mortality was 0. No patient was observed tumor recurrence and new-onset diabetes but one developed diarrhea.ConclusionRA-DPPHRt or LDPPHRt provided a minimally invasive approach with good organ-preservation for patients with benign and low-grade malignant pancreatic head tumor. It is only recommended to be performed in high-volume pancreatic centers by experienced pancreatic surgeons.

How to implement minimally invasive duodenum-preserving total pancreatic head resection for patients with pancreatic head lesions: A retrospective study.

Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has been widely reported. However, due to the challenges involved in performing total pancreatic head resection during operation, there are few studies reporting it. Between November 2016 and October 2022, we performed laparoscopic duodenum-preserving total pancreatic head resection (LDPPHRt) on 64 patients in the Department of Hepatobiliary Surgery, the Second Hospital of Hebei Medical University. Perioperative data of the patients such as age, gender, body mass index, operation time, blood loss, and postoperative hospital stay were collected and analyzed. This study included 40 women and 24 men aged 41.4 ± 15.7 years. All patients completed the surgery, and none of the patients underwent laparotomy. The average operation time was 275 (255, 310) min. The average postoperative hospital stay was 12 (10, 16) days. The rate of occurrence of pancreatic fistula was 10.9% (7/64), and that of the biliary fistula was 9.4% (6/64). One of the patients underwent cholangiojejunostomy 3 months after the operation due to painless jaundice and bile duct dilatation. By dissecting the space between the pancreatic head and duodenum, the posterior pancreatic duodenal arterial arch and the surface vascular network of the common bile duct (CBD) can be preserved. This ensures the success of LDPPHRt and avoids postoperative complications in the absence of intraoperative image guidance.

Risk factors for achieving textbook outcome after laparoscopic duodenum-preserving total pancreatic head resection: a retrospective cohort study.

The risk factors for achieving textbook outcome (TO) after laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) are unknown, and no relevant articles have been reported so far. The aim of this study was to identify the risk factors for achieving TO after LDPPHR-t. The risk factors for achieving TO after LDPPHR-t were retrospectively evaluated by logistic regression analysis in 31 consecutive patients from May 2020 to December 2021. All LDPPHR-t procedures were successfully performed without conversion. There was no death within 90 days after surgery and no readmission within 30 days after discharge. The percentage of achieving TO after LDPPHR-t was 61.3% (19/31). Among the six TO items, the postoperative complication of grade B/C postoperative pancreatic fistula (POPF) occurred most frequently with 22.6%, followed by grade B/C bile leakage with 19.4%, Clavien-Dindo≥III complications with 19.4%, and grade B/C postpancreatectomy hemorrhage with 16.1%. POPF was the major obstacle to achieve TO after LDPPHR-t. Placing an endoscopic nasobiliary drainage (ENBD) catheter and prolonged operation time (>311min) were significantly associated with the decreased probability of achieving TO after LDPPHR-t (odd ratio (OR), 25.775; P =0.012 and OR, 16.378; P =0.020, respectively). Placing an ENBD catheter was the only significant independent risk factor for POPF after LDPPHR-t (OR, 19.580; P =0.017). Bile leakage was the independent risk factor for postpancreatectomy hemorrhage after LDPPHR-t (OR, 15.754; P =0.040). The prolonged operation time was significantly correlated with Clavien-Dindo grade≥III complications after LDPPHR-t (OR, 19.126; P =0.024). Placing the ENBD catheter was the independent risk factor for POPF and achieving TO after LDPPHR-t. In order to reduce POPF and increase the probability of achieving TO, placing an ENBD catheter should be avoided prior to LDPPHR-t.

Laparoscopic duodenum-preserving total pancreatic-head resection versus standard pancreaticoduodenectomy for pancreatic-head intraductal papillary mucinous neoplasm

BackgroundCurrently, no literature specifically addresses the curative efficacy of laparoscopic duodenum-preserving total pancreatic head resection (LDPPHRt) in the treatment of pancreatic-head intraductal papillary mucinous neoplasm (IPMN). This study aimed to compare the short-term and long-term outcomes between LDPPHRt and laparoscopic pancreaticoduodenectomy (LPD) for pancreatic-head IPMN. MethodsWe retrospectively reviewed patients undergoing LDPPHRt or LPD for pancreatic-head IPMN in our institution between September 2014 and October 2020. We collected, analyzed and compared preoperative, intraoperative, and perioperative data, including quality of life as assessed using EORTC QLQ-C30 and QLQ-PAN26 questionnaires. ResultsIn total, 50 patients were incorporated into this study, which included 12 LDPPHRt patients and 38 LPD patients. Preoperative data was comparable in the two groups, and neither was there any significant difference in postoperative data. The incidence of exocrine and endocrine insufficiency was similar between the LDPPHRt and LPD groups (50% vs. 28.9%, p = 0.321; 8.3% vs. 7.9%, p = 1.000), but some differences between the two surgical procedures were apparent when evaluating postoperative quality of life. Specifically, patients in the LDPPHRt group reported higher physical functional and body image scores than the LPD group (96.1 ± 6.0 vs. 88.2 ± 13.9, p = 0.008; 65.3 ± 32.9 vs. 43.0 ± 31.4, p = 0.039), and LDPPHRt was also associated with lower digestive symptom scores (5.5 ± 12.9 vs. 28.9 ± 25.9, p = 0.004). ConclusionPerioperative outcomes for LDPPHRt were comparable to those for LPD, but the quality of life after operation was better in the LDPPHRt group.

Intracapsular approach used in laparoscopic duodenum-preserving total pancreatic head resection for pancreatic headbenign orlow-grade malignanttumors.

Laparoscopic duodenum-preserving total pancreatic head resection (LDPPHRt) is used for treating benign orlow-grade malignanttumors of the pancreatic head. However, preservation of the duodenum and biliary tract integrity remains challenging. We present a new approach for LDPPHRt and evaluate its feasibility and safety. From April 2020 to December 2020, 30 patients successfully underwent LDPPHRt using the intracapsular approach in our center. Their medical records were reviewed for relevant clinical characteristics, pathologic findings, postoperative complications, and survival. The median diameter of the lesions was 3.6cm (range, 2.0-5.5cm). The median operative time was 234.7min (range, 195-310min). The median blood loss was 66.7ml (range, 20-250ml). The morbidity rate was 26.7%, including POPF, hemorrhage, lymphatic leakage, wound infection, pulmonary infection, and delayed gastric emptying. Five patients developed pancreatic fistula type A, and two patients had type B, classified according to the International Study Group on Pancreatic Fistula. No biliary tract injury or duodenal leakage was observed. The median postoperative hospital stay was 11.5days (range, 6-25), and the operative mortality rate was 0%. The intracapsular approach is a feasible and safe surgical procedure in LDPPHRt for patients with benign orlow-grade malignanttumors, especially those without severe pancreatic head fibrosis or peripancreatic adhesions.

Duodenum-preserving total pancreatic head resection. Early postoperative outcomes

Aim. To study the early postoperative outcomes of duodenum-preserving total pancreatic head resections in benign, premalignant tumors of the pancreatic head and chronic pancreatitis complicated by duodenal dystrophy in comparison with the results of pylorus-preserving pancreaticoduodenectomy. Materials and methods. From 2006 to 2019, 54 patients underwent duodenum-preserving total pancreatic head resection for chronic pancreatitis complicated by duodenal dystrophy, benign or premalignant tumors of the pancreatic head. At the same time, in 25 cases, the operation was performed in an isolated version, in 29 – with a resection of the duodenum. As a comparison group, we used data from 89 patients who underwent pyloruspreserving pancreaticoduodenectomy during the same period. Results. Compared to pancreaticoduodenectomy, duodenum-preserving total pancreatic head resection exhibits significantly longer times for surgery (420 and 310 minutes, respectively). There was no statistically significant difference in the volume of intraoperative blood loss. There are no differences between groups in hospital morbidity (the frequency of pancreatic fistulas, delayed gastric emptying, bile leakage and post-resection bleeding). The frequency of postoperative complications for Clavien-Dindo III and higher did not differ significantly in the groups. There is no hospital mortality after duodenum-preserving total pancreatic head resection; three patients died after pancreatoduodenectomy. Conclusion. Early postoperative outcomes following duodenum-preserving total pancreatic head resection and pylorus-preserving pancreaticoduodenectomy are comparable. However, to develop a full-fledged concept of surgical treatment of pancreatic head benign, premalignant neoplasms and chronic pancreatitis with duodenal dystrophy, it is necessary to analyze the long-term outcomes of treatment.

How to Perform Total Laparoscopic Duodenum-Preserving Pancreatic Head Resection Safely and Efficiently with Innovative Techniques.

Although rapid progress has been achieved in laparoscopic pancreaticoduodenectomy (PD) over the last decade, laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) remains a challenging surgery that has been rarely reported due to not only requiring complicated pancreaticojejunostomy (PJ) but also ensuring sufficient blood supplies to duodenum and common bile duct (CBD). We completed LDPPHR for 22 patients safely and efficiently with innovative techniques. Clinical outcomes, including rate of conversion to laparotomy, time of residual pancreatic duct reconstruction, incidence of postoperative complications, and time of hospital stay, were collected for 22 consecutive patients who underwent LDPPHR with innovative techniques as follows: application of indocyanine green (ICG) to visualize and preserve CBD and the vessels supplying the duodenum and CBD, Hong's PJ, and pancreatic duct end-to-end anastomosis (ETEA) for the residual pancreas. All surgeries were performed successfully under laparoscopy except for one case. The duration of ETEA was significantly shorter than PJ (18.2 ± 5.1min versus 27.5 ± 8.3min, p < 0.05). There was no significant difference in incidence of postoperative complications between the Hong's PJ and ETEA group. The overall incidence of postoperative pancreatic fistula (POPF) in the Hong's PJ and ETEA group was 23.5% and 20%, respectively, without grade C fistula. All complications were resolved after conservative treatment. By utilizing intraoperative ICG navigation, LDPPHR is a minimally invasive, safe, and efficient approach for chronic pancreatitis with pancreatic head stones by using pancreatic duct ETEA and benign or low-grade malignant tumors of the pancreatic head by using Hong's PJ.

Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.

It is technical challenging to perform laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Only a few case reports and case series of LDPPHR are available in the literature. From February 2019 to November 2019, 24 cases of LDPPHR were carried out in the Department of Pancreas Surgery, West China Hospital, Sichuan University. Data were prospectively collected in terms of demographic characteristics (age, gender, BMI, and pathological diagnosis), intraoperative variables (operative time, estimated blood loss, transfusion, pancreatic texture, and diameter of main pancreatic duct), and post-operative variables (time for oral intake, post-operative hospital stay, and complications). Nine male patients and fifteen female patients were included in this study. The median age of these patients was 43years. All patients underwent duodenum-preserving total pancreatic head resection laparoscopically. The median operative time was 255min. The median estimated blood loss was 200ml. One patient required blood transfusion. The median post-operative hospital stay was 10days. Three patients suffered from biliary fistula. Eleven patients (45.8%) suffered from pancreatic fistula; however, only one patient (4.2%) suffered from grade B pancreatic fistula. No patient suffered from grade C pancreatic fistula. One patient with chronic pancreatitis required re-operation for jejunal anastomotic bleeding on the first post-operative day. No patient suffered from gastroparesis, duodenal necrosis, or abdominal bleeding. The 30-day mortality was 0. LDPPHR is safe and feasible. Real-time indocyanine green fluorescence imaging may help prevent bile duct injury and bile leakage.

Duodenum-preserving subtotal or total pancreatic head resection and total pancreatic head resection with segmental duodenectomy in tumors and chronic pancreatitis

Objectives: To estimate Results of the duodenum-preserving pancreatic head resections as alternatives to pancreaticoduodenectomy. Material & Methods: 135 pts duodenum-preserving subtotal pancreatic head resection (DPSPHR), duodenum-preserving total pancreatic head resection (DPTPHR) and total pancreatic head resection combined with segmental duodenectomy (TPHRSD). DPSPHR (Beger’s or Kimura’s method) was performed in 83 pts with a preoperative diagnosis of chronic pancreatitis in case of suspected cancer. Alimentary tract reconstruction after DPSPHR was performed by pancreatojejunostomy (Roux-en-Y) with the distal and proximal stump of the pancreas (Beger’s procedure) (n=67) or with the distal stump of the pancreas only (Kimura’s procedure) (n=16). DPTPHR (n=25) was performed pts with a preoperative diagnosis of serous (n=7) and mucinous (n=6) cystadenomas, IPMN-BD (n=7), neuroendocrine adenoma (n=4) and metastatic renal cell carcinoma (n=1). Alimentary tract reconstruction after DPTPHR was performed by pancreatojejunostomy (Roux-en-Y) (n=22) and pancreatogastrostomy (n=3). Laparoscopic approach was chosen in 7 cases from all DPTPHR. TPHRSD (n=27) was performed in chronic pancreatitis complicated by duodenal dystrophy (n=23), large serous cystadenoma (n=3), neuroendocrine adenoma (n=1). Alimentary tract reconstruction was performed by duodenoduodenostomy combined with pancreaticojejunostomy and choledochojejunostomy (n=8); pancreatogastrostomy and choledochoduodenostomy (n=15); pancreaticooduodenostomy duct-to-mucosa and choledochoduodenostomy (n=4). Results: Surgical parameters, postoperative complications, endocrine function, exocrine function, and long-term outcomes were evaluated. No differences were noted in the mean operation time and estimated blood loss between this procedures and pylorus-preserving pancreaticoduodenectomy. Ischemia of duodenum didn’t note in one case of DPSPHR or DPTPHR. Postoperative complication constituted the following: bile duct stricture (n=4), postoperative bleeding (n=7), delayed gastric emptying (n=2). Newly developed diabetes mellitus occurred in 12 pts. Exocrine pancreatic insufficiency was observed in 2 pts. There was no hospital or long-term mortality. Conclusions: Periampullary lesions could be treated with DPSPHR, DPTPHR and TPHRSD, which could substitute for pylorus-preserving pancreaticoduodenectomy.

Experience in the laparoscopic duodenum preserving pancreatic head resection: a report of 4 patients

Objective To summarized the experience in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Methods The clinical data of four patients who underwent LDPPHR from February 2017 to June 2018 in Hunan Provincial People’s Hospital were retrospectively analyzed. The Clinical characteristics, operation time, intraoperative blood loss, biliary fistula rate, pancreatic fistula rate and follow-up data were analyzed. Results The four patients included one patient with a solid pseudopapillary tumor and three patients with a serous cystadenoma. Two patients underwent duodenum-preserving total pancreatic head resection, and two patients underwent duodenum-preserving subtotal pancreatic head resection. The operation time of the four patients was (525.8±121.8) minutes, and the blood loss (250.0±191.5) ml. Biliary duct drainage was carried out in 2 patients: one patient developed biochemical bile leakage, while another had no postoperative complication. The two patients without biliary drainage developed grade B pancreatic leakage, delayed bile leakage, abdominal bleeding and infection. All the three patients who developed postoperative complications were treated conservatively and they recovered well. Conclusions LDPPHR was designed to better preserve the integrity and function of digestive tract. However, the perioperative complications were high. This operation should only be carried out in large pancreatic centers. Routine biliary drainage is recommended to surgeons with little experience in this operation. Key words: Laparoscopes; Pancreatic leakage; Bile leakage; Duodenum preserving pancreatic head resection

Limited Parenchyma-Sparing Pancreatic Head Resection for Benign Neuroendocrine Tumors and Cystic Neoplasms—the Use of Duodenum-Preserving Head Resection

Treating benign tumors of the pancreatic head by using duodenum-preserving total or subtotal pancreatic head resection (DPPHRt/s) has proven to reduce mortality and morbidity with a positive postoperative outcome, when compared with the standard approach which is represented by pancreaticoduodenectomy (PD). We present three cases of DPPHRs for benign tumors, in which pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) were used. The long-term outcome of these patients was favorable; with a single case that presents a rapid onset of an acute pancreatitis, with postoperative pancreatic fistula that necessitate reoperation. The best results on early postoperative outcome were recorded in the case of pancreaticogastrostomy, with rapid onset of digestive tolerance and short period of hospital stay. These cases come in aiding modern surgery by ensuring an alternative to reintegrate the pancreatic remnant into the digestive tract after limited pancreatic head resection, with lower rates of postoperative complications.

Laparoscopic duodenum-preserving total pancreatic head resection: a novel surgical approach for benign or low-grade malignant tumors

Duodenum-preserving total pancreatic head resection (DPPHRt) is an accepted alternative surgical procedure for 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. This study describes our experience in laparoscopic DPPHRt (LDPPHRt). To our knowledge, this is the first description of this novel minimally invasive operation. From August 2016 to May 2017, all consecutive patients who underwent LDPPHRt for pancreatic head lesions at the HPB Surgery Department, Sun Yat-Sen Memorial Hospital in Guangzhou, China were enrolled into this retrospective study. There were ten women and two men. The average age was 37.3years (range 8-61years). The average diameter of the pancreatic head lesions on pre-operative CT/MR was 3.7cm (range 2-4.8cm). All the LDPPHRt procedures were performed successfully. There was no peri-operative death. The average operative time was 272.5min (range 210-320min). The average blood loss was 215ml (range 50-450ml). Post-operative complications included pancreatic fistula grade B (two patients, or 16.7%) and biliary fistula (two patients, or 16.7%). All the complications responded well to conservative treatment. The mean post-operative hospital stay was 11.5days (range 6-25days). LDPPHRt provided a minimally invasive approach with good organ-preservation for benign or low-grade malignant tumors of the pancreatic head. The long-term oncological outcomes, and the exocrine and endocrine pancreatic functions after this operation require further studies.

Duodenum-preserving total pancreatic head resection and total pancreatic head resection with segmental duodenectomy in tumors and chronic pancreatitis

Duodenum-preserving total pancreatic head resection and total pancreatic head resection with segmental duodenectomy in tumors and chronic pancreatitis

Benign Tumors of the Pancreas – Limited Local Surgical Treatment for Cystic Neoplasms and Neuroendocrine Tumors – an Overview

Background. Benign tumors of the pancreas are intraductal papillary mucinous neoplasia, mucinous cystic neoplasia, serous cystic adenoma, solid pseudopapillary neoplasia and endocrine tumors, most frequently insulinomas. The evolution of limited local surgical procedures for benign pancreatic lesions like enucleation (EN), pancreatic middle segment resection (CP) and duodenum-preserving total or partial pancreatic head resection (DPPHRt/p) shifted options of surgical treatment to application of local techniques. Objectives. Surgical treatment of benign cystic neoplasms and neuroendocrine tumors using local surgical extirpation techniques are evaluated based on present knowledge about indication to surgery, early postoperative complications and late outcome perspectives. Results. Tumor enucleation is recommended for all symptomatic neuroendocrine adenomas of a size up to 3 cm and non-adherence to pancreatic main ducts. EN was applied predominantly for neuroendocrine tumors and less frequently for cystic neoplasms. About 20% of enucleations are performed as minimal invasive procedures. Surgery-related severe postoperative complications with the need of reintervention are observed in 11%, pancreatic fistula in 33%, but hospital mortality was below 1%. Major advantages of EN are low procedure-related early postoperative morbidity and a very low hospital mortality. CP is applied in two thirds for symptomatic cystic neoplasms and in one third for neuroendocrine tumors. The high level of pancreatic fistula and severe postoperative complications are associated with management of the proximal pancreatic stump. Hospital mortality of 0.8% is a benefit of this procedure. DPPHRt/p has been applied in about 50% as total pancreatic head resection with segment resection of the peripapillary duodenum and the intrapancreatic common bile duct. Two thirds of patients suffered symptomatic or asymptomatic cystic neoplasms and 10% neuroendocrine tumors. Major advantages of local pancreatic head resection compared to Whipple type pancreatico duodenectomy are highly significant preservation of the exo- and endocrine functions and a low hospital mortality below 0.5%. The level of evidence for EN and CP is low, because of retrospective data evaluation and absence of results from controlled studies. For DPPHRt/p results of 9 prospective controlled studies, 3 case controlled studies and 2 retrospective controlled studies underline the advantages of DPPHRt/p compared to partial pancreaticoduoden ectomy. Conclusion. The application of tumor enucleation, pancreatic middle segment resection and duodenum-preserving total or partial pancreatic head resection are associated with low level of surgery-related early postoperative complications and a very low hospital mortality. The major advantages of the limited procedures are preservation of exo- and endocrine pancreatic functions and maintenance of peripancreatic GI-tract tissue

Total pancreatic head resection with duodenum and bile duct preserving: a report of 31 patients

Objective To investigates the role of duodenum and bile duct preserving pancreatic head resection (DBPPHR) in treatment of benign or low-grade malignant diseases located in the head of pancreas. Methods The clinical data of 31 patients who underwent DBPPHR between April 2012 to May 2016 in Zhejiang Provincial People's Hospital and Zhangzhou Municipal Hospital of Fujian Province were analyzed retrospectively. Results Of the 31 patients, 4 patients underwent laparoscopic DBPPHR. One patient in the open group was converted to pancreaticoduodenectomy. For the open group, the mean operation time was (165.3±63.6) min; the mean estimated blood loss was (258.1±156.9) ml; and the mean postoperative stay was (11.7±6.3) days. The postoperative complications included 1 reoperation due to postoperative bleeding, 1 bile leakage and 13 patients developed grade A pancreatic fistula (48.2%). For the laparosco-pic group, the mean operation time was 350.0 (280.0~450.0) min; the mean estimated blood loss was 425.0 (250.0~600.0) ml; and the mean postoperative stay was 14 days. Three patients developed post-operative pancreatic fistula (grade A). The pathological diagnosis were: 12 patients with pancreatolithiasis, 8 patients with serous cystadenoma, 4 patients with branched intraductal papillary mucinous neoplasm, 5 patients with neuroendocrine tumor and 2 patients with mucinous cystadenoma. The follow-up period was 1~48 month, and there was no patient with diabetes or diarrhea. Conclusions DBPPHR was safe and efficacious. It is less invasive to treat benign or low-grade malignant diseases located in the head of pancreas. Key words: Pancreatic duct stone; Cystic-solid lesion, pancreas; Chronic pancreatitis; Duodenum preserving pancreatic head resection; Laparoscopic surgery

Surgical treatment of pancreatic cystic neoplasms: follow-up or surgical intervention

Pancreatic cystic neoplasm(PCN) are common and increasingly detected in recent years including serous cystic neoplasms, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary neoplasms and cystic pancreatic neuroendocrine tumors.Some of PCN have a low risk of malignancy while others have a high risk and need interventions, even in the same type of cystic neoplasms. The management of PCN requires risk stratification for malignant potential, and clinicians should have a systematic approach for establishing a diagnosis and determining which patients require surgical treatment. Under the guidance of minimally invasive surgery, some organ preserving procedures including tumor enucleation, segmental pancreatic resection, duodenum-preserving total or subtotal pancreatic head resection, and spleen-preserving pancreatic body and tail resection are recommended for treatment of PCN. The indications for follow-up or surgical intervention for treatment of PCN patients should be mastered strictly to avoid either insufficient- or over-treatment.

Parenchyma-Sparing, Limited Pancreatic Head Resection for Benign Tumors and Low-Risk Periampullary Cancer—a Systematic Review

BackgroundParenchyma-sparing local extirpation of benign tumors of the pancreatic head provides the potential benefits of preservation of functional tissue and low postoperative morbidity. MethodsMedline/PubMed, Embase, and Cochrane library databases were surveyed for studies performing limited resection of the pancreatic head and resection of a segment of the duodenum and common bile duct or preservation of the duodenum and common bile duct (CBD). The systematic analysis included 27 cohort studies that reported on limited pancreatic head resections for benign tumors. In a subgroup analysis, 12 of the cohort studies were additionally evaluated to compare the postoperative morbidity after total head resection including duodenal segment resection (DPPHR-S) and total head resection conserving duodenum and CBD (DPPHR-T). ResultsThree hundred thirty-nine of a total of 503 patients (67.4 %) underwent total head resections. One hundred forty-seven patients (29.2 %) of them underwent segmental resection of the duodenum and CBD (DPPHR-S) and 192 patients (38.2 %) underwent preservation of duodenum and CBD. One hundred sixty-four patients experienced partial head resection (32.6 %). The final histological diagnosis revealed in 338 of 503 patients (67.2 %) cystic neoplasms, 53 patients (10.3 %) neuroendocrine tumors, and 20 patients (4.0 %) low-risk periampullary carcinomas. Severe postoperative complications occurred in 62 of 490 patients (12.7 %), pancreatic fistula B + C in 40 of 295 patients (13.6 %), resurgery was experienced in 2.7 %, and delayed gastric emptying in 12.3 %. The 90-day mortality was 0.4 %. The subgroup analysis comparing 143 DPPHR-S patients with 95 DPPHR-T patients showed that the respective rates of procedure-related biliary complications were 0.7 % (1 of 143 patients) versus 8.4 % (8 of 95 patients) (p ≤ 0.0032), and rates of duodenal complications were 0 versus 6.3 % (6 of 95 patients) (p ≤ 0.0037). DPPHR-S was associated with a higher rate of delay of gastric emptying compared to DPPHR-T (18.9 vs. 2.1 %, p ≤ 0.0001). ConclusionParenchyma-sparing, limited head resection for benign tumors preserves functional pancreatic and duodenal tissue and carries in terms of fistula B + C rate, resurgery, rehospitalization, and 90-day mortality a low risk of postoperative complications. A subgroup analysis exhibited after total pancreatic head resection that preserves the duodenum and CBD an association with a significant increase in procedure-related biliary and duodenal complications compared to total head resection combined with resection of the periampullary segment of the duodenum and resection of the intrapancreatic CBD.

Duodenum-preserving total and partial pancreatic head resection for benign tumors – Systematic review and meta-analysis

BackgroundPotential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and maintenance of pancreatic functions. MethodsMedline/PubMed, Embase and Cochrane Library databases were searched to identify studies applying duodenum-preserving total or partial pancreatic-head resection (DPPHRt/p) and reporting short- and long-term outcomes. Twenty-four studies, including 416 patients who underwent DPPHRt/p, were identified for systematic analysis. The meta-analysis was based on 10 prospective controlled and 4 retrospective controlled cohort studies, comparing 293 DPPHRt/p resections with 372 pancreato-duodenectomies (PD). Results, systematic analysisOf 416 patients, 75.7% underwent total and 24.3% partial head resection, while 47.1% included segmentectomy of duodenum and CBD. The most common pathology was cystic neoplasm (65.8%) and endocrine tumors (13.4%). The frequencies of severe postoperative complications of 8.8%, pancreatic fistula of 19.2%, re-operation of 1.7% and hospital mortality of 0.48%, indicate a low level of early post-operative complications. Meta-analysisDPPHRt/p significantly preserved the level of exocrine (IV = −0.67, 95% CI −0.98 to −0.35, p = 0.0001) and endocrine (IV = 18.20, fixed, 95% CI −0.92 to 25.48, p = 0.0001) pancreatic functions compared to PD when the pre- and postoperative functional status in both groups are analyzed.There were no significant differences between DPPHRt/p and PD in frequency of pancreatic fistula, delayed gastric emptying or hospital mortality. ConclusionDPPHRt/p for benign neoplasms and neuro-endocrine tumors of the pancreatic head is associated with a low level of early-postoperative complications and a better conservation of exocrine and endocrine functions.