Clinical outcomes of organ-preserving pancreatectomy for benign or low-grade malignant pancreatic tumors: A multicenter nationwide survey in Japan

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

BACKGROUND

Pancreatoduodenectomy (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 METHODS

Pubmed, 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.

RESULTS

Concordance 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].

CONCLUSIONS

DPPHR 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.

Laparoscopic spleen-preserving total pancreatectomy for the treatment of low-grade malignant pancreatic tumors: Two case reports and review of literature

BACKGROUND

Function-preserving pancreatectomy can improve the long-term quality of life of patients with benign or low-grade malignant tumors, such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms. However, there is limited literature on laparoscopic spleen-preserving total pancreatectomy (L-SpTP) due to technical difficulties.

CASE SUMMARY

Patient 1 was a 51-year-old male diagnosed with IPMN based on preoperative imaging, showing solid nodules in the pancreatic head and diffuse dilation of the main pancreatic duct with atrophy of the distal pancreas. We performed L-SpTP with preservation of the splenic vessels, and the postoperative pathology report revealed IPMN with invasive carcinoma. Patient 2 was a 60-year-old male with multiple cystic lesions in the pancreatic head and body. L-SpTP was performed, and intraoperatively, the splenic vein was injured and required ligation. Postoperative pathology revealed a mucinous cystic tumor of the pancreas with low-grade dysplasia. Both patients were discharged on postoperative day 7, and there were no major complications during the perioperative period.

CONCLUSION

We believe that L-SpTP is a safe and feasible treatment for low-grade malignant pancreatic tumors, but more case studies are needed to evaluate its safety, efficacy, and long-term outcomes.

Clinical course of pancreas cancer diagnosed after spleen-preserving distal pancreatectomy with borderline lesion: two case reports

Distal pancreatectomy with splenectomy is considered the standard operation for pancreas tail and body cancer. However, splenectomy may be option for benign or low-grade malignant tumors including mucinous cystadenoma and intraductal papillary mucinous neoplasm. If spleen-preserving distal pancreatectomy (SPDP) with borderline lesion is performed and pancreas cancer is diagnosed on postoperative pathologic finding, if it is R0 resection, the necessity of additional splenectomy remains questionable. The authors would like report two clinical cases diagnosed as pancreatic cancer on postoperative pathology after SPDP and under observation without additional splenectomy.

Recent trends in organ-preserving pancreatectomy: Its problems and clinical advantages compared with other standard pancreatectomies

In this review article, we focus on recent papers on organ-preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new-onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade-off between increased short-term morbidity and long-term preservation of endocrine function. When the outcomes of two types of spleen-preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post-splenectomy infection is seen. The advantages of duodenum-preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ-preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long-term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected.

Minimally invasive radical antegrade modular pancreatosplenectomy: routine vs. modified

Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced in 2003 by Strasberg to improve survival outcomes in left-sided pancreatic ductal adenocarcinoma. Many investigators have shown the feasibility and safety of minimally invasive RAMPS (MI-RAMPS). However, the survival benefit of RAMPS is inconclusive, and possible risks following the procedure, such as exocrine and endocrine insufficiencies, cannot be ignored. Therefore, several modifications of RAMPS were designed. Modified RAMPS is not a specific technique but rather a reduced form of RAMPS that is undertaken without compromising oncologic principles. In this literature review, the surgical technique and strategies of MI-RAMPS were examined.

Prevalence of dysglycemia and associated risk factors in patients with pancreatic benign and low-grade malignant tumors before pancreatic surgery: A prospective observational study

BACKGROUND

Pancreatic benign and low-grade malignant tumors (PBLMT) have experienced a rapid increase in incidence rates worldwide. Few studies have focused on the glucose metabolism status of patients with PBLMT before pancreatic surgery.

METHODS

From August 2017 to June 2018, 70 patients with PBLMT were prospectively screened for abnormalities in glucose metabolism by an oral glucose tolerance test (OGTT) before pancreatic surgery. Patients were classified as having normal glucose tolerance (NGT), prediabetes mellitus (pre-DM), or new-onset DM (NOD) according to the American Diabetes Association (ADA) criteria. Glucose metabolism indices were calculated based on the OGTT parameters. Tumor volume and remnant pancreatic volume (RPV) were measured by computed tomography.

RESULTS

Forty-nine of 70 patients with PBLMT developed dysglycemia (pre-DM and NOD). RPV was smaller in the pre-DM (57.44 ± 18.20 cm³ vs. 70.48 ± 14.08 cm³, P = 0.001) and NOD groups (37.38 ± 20.40 cm³ vs. 70.48 ± 14.08 cm³, P < 0.001) than in the NGT group. The homeostasis model assessment of β-cell function (HOMA2-β), insulinogenic index (IGI), and insulin secretion/insulin resistance index (ISSI-2) were worse in the pre-DM and NOD groups compared with NGT group (all P < 0.05). After univariate and multivariate analyses, age over 60 years (P = 0.049, OR = 5.76, 95% CI: 1.01-32.92) and RPV less than 49.36 cm³ (P = 0.024, OR = 8.59, 95% CI: 1.34-55.22) were recognized as independent risk factors for dysglycemia. The analysis of all patients revealed inverse correlations between RPV and both in age (r = -0.28, P = 0.019) and tumor volume (r = -0.28, P = 0.032). Positive correlations were found between RPV and both IGI (r = 0.29, P = 0.019) and ISSI-2 (r = 0.39, P = 0.0011).

CONCLUSION

In patients with PBLMT, 70% had dysglycemia before surgery. Old age and a reduction in RPV were independent risk factors for developing dysglycemia before pancreatic surgery. The decisions to treat PBLMT with resection should hinge more on the risk of dysglycemia as well as potential malignancy.