Intraductal papillary mucinous neoplasm of the pancreas; resection and cancer prevention

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

BACKGROUND

Parenchyma-sparing local extirpation of benign tumors of the pancreatic head provides the potential benefits of preservation of functional tissue and low postoperative morbidity.

METHODS

Medline/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).

RESULTS

Three 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).

CONCLUSION

Parenchyma-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.

Limited surgery for benign tumours of the pancreas: a systematic review

BACKGROUND

Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections.

METHODS

Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively.

RESULTS

The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2%, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5% of patients; pancreatic fistula in 36.7, 35.2 and 20.1%; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72%; and after DPPHRt/p 0.49%. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001).

CONCLUSION

EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.

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

BACKGROUND

Potential 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.

METHODS

Medline/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 ANALYSIS

Of 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-ANALYSIS

DPPHRt/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.

CONCLUSION

DPPHRt/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.

Benign cystic neoplasm and endocrine tumours of the pancreas--when and how to operate--an overview

BACKGROUND

The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard.

OBJECTIVES

To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate.

RESULTS

Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2-3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20% of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11%, pancreatic fistula in 33%. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33% pancreatic fistula and severe post-operative complications of 18% is related to management of proximal pancreatic stump. DPPHRt/s is used in 70% for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10% for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy.

CONCLUSION

The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.

[Duodenum-preserving total pancreatic head resection : an organ-sparing operation technique for cystic neoplasms and non-invasive malignant tumors]

Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions

BACKGROUND

Cystic neoplasms of the pancreas are diagnosed frequently due to early use of abdominal imaging techniques. Intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and serous pseudopapillary neoplasia are considered pre-cancerous lesions because of frequent transformation to cancer. Complete surgical resection of the benign lesion is a pancreatic cancer preventive treatment.

OBJECTIVES

The application for a limited surgical resection for the benign lesions is increasingly used to reduce the surgical trauma with a short- and long-term benefit compared to major surgical procedures. Duodenum-preserving total pancreatic head resection introduced for inflammatory tumors in the pancreatic head transfers to the patient with a benign cystic lesion located in the pancreatic head, the advantages of a minimalized surgical treatment.

PATIENTS

Based on the experience of 17 patients treated for cystic neoplastic lesions with duodenum-preserving total pancreatic head resection, the surgical technique of total pancreatic head resection for adenoma, borderline tumors, and carcinoma in situ of cystic neoplasm is presented. A segmental resection of the peripapillary duodenum is recommended in case of suspected tissue ischemia of the peripapillary duodenum. In 305 patients, collected from the literature by PubMed search, in about 40% of the patients a segmental resection of the duodenum and 60% a duodenum and common bile duct-preserving total pancreatic head resection has been performed.

RESULTS

Hospital mortality of the 17 patients was 0%. In 305 patients collected, the hospital mortality was 0.65%, 13.2% experienced a delay of gastric emptying and a pancreatic fistula in 18.2%. Recurrence of the disease was 1.5%. Thirty-two of 175 patients had carcinoma in situ.

CONCLUSION

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions is a safe surgical procedure with low post-operative morbidity and mortality.

Risk factors associated with the postoperative recurrence of intraductal papillary mucinous neoplasms of the pancreas

OBJECTIVES

The risk factors correlated with the post-operative recurrence of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are not well established. The aim was to determine the risk factors of recurrence.

METHODS

We reviewed retrospectively the differences of clinicopathologic features between the recurrence and nonrecurrence groups of patients with IPMN who underwent surgical resection and analyzed the recurrence-related factors.

RESULTS

A total of 103 patients were confirmed to have IPMNs. The mean postoperative follow-up was 3.2 years, and the recurrence rate was 12.6%. Recurrent cases (n=13) had the following pathologic grades: adenoma, 1; and invasive carcinoma, 12. The mean postoperative survival was 17.0 months in the recurrence group and 41.4 months in the nonrecurrence group (P<0.001). The independent risk factors of recurrence were invasive carcinoma (P=0.017, hazard ratio=71.79; 95% confidence interval (CI)=2.13-2417.05), elevated carbohydrate antigen 19-9 (P=0.007, hazard ratio=37.97, 95% CI=2.66-542.32), and main location in the pancreatic head (P=0.038, hazard ratio=0.16, 95% CI=0.03-0.90).

CONCLUSIONS

The risk factors associated with recurrence of IPMNs were invasive pathology, elevated carbohydrate antigen 19-9, and main location in the pancreatic head. A more careful follow-up is needed for such patients.

Role of frozen section assessment for intraductal papillary and mucinous tumor of the pancreas

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas include a spectrum of dysplasia ranging from minimal mucinous hyperplasia to invasive carcinoma and are extensive tumors that often spread along the ductal tree. Several studies have demonstrated that preoperative imaging is not accurate enough to adapt the extent of pancreatectomy and have suggested routinely using frozen sectioning (FS) to evaluate the completeness of resection and also to check if ductal dilatation is active or passive, in order to avoid an excessive pancreatic resection. Separate main duct and branch duct analysis is needed due to the difference in the natural history of the disease. FS accuracy averages 95%. Eroded epithelium on the main duct, severe ductal inflammation mimicking dysplasia and reactive epithelial changes secondary to obstruction can lead to inappropriate FS results. FS results change the planned extent of resection in up to 30% of cases. The optimal cut-off leading to extend pancreatectomy is not consensual and our standard option is to extend pancreatectomy if FS reveals: (1) at least IPMN adenoma on the main duct; or (2) at least borderline IPMN on branch ducts; or (3) invasive carcinoma. However, the decision to extend resection must be taken after a multidisciplinary discussion since it does not exclusively depend on the FS result but also on age, general condition and expected prognosis after resection. The main limitation of using FS is the existence of discontinuous (“skip”) lesions which account for approximately 10% of IPMN in surgical series and can lead to reoperation in up to 8% of cases.

Intraductal papillary mucinous neoplasms of the pancreas: diagnosis and management

Intraductal papillary mucinous neoplasms (IPMNs), characterized by intraductal papillary growth and thick mucin secretion, have increasingly been recognized. Despite modern preoperative evaluation, major difficulties still remain in distinguishing malignant invasive types from benign IPMNs. Following a PubMed database search, all relevant abstracts and articles on IPMN published in English and Chinese were reviewed. Main-duct and the mixed type IPMNs carry a higher risk of malignancy as compared with branch-duct type IPMNs. Treatment of branch-duct type IPMNs remains controversial. Once operation is indicated, intraoperative frozen section of margins plays an important role in the decision concerning the extent and type of surgery. Pancreatectomy, partly preserving both endocrine and exocrine pancreatic function, is advocated for most patients with IPMN, though total pancreatectomy may be necessary in some. Both for patients subjected to surgery and those only observed, IPMN patients need regular close follow-up to identify recurrence or progressive disease.

Intraductal papillary mucinous neoplasms of the pancreas: indication, extent, and results of surgery

In intraductal and papillary mucinous neoplasm (IPMN) of the pancreas, the aims of surgery differ according to the presence of malignancy. For malignant IPMN and especially for invasive malignancy, radical resection is essential, but entails a substantial operative risk and long-term pancreatic insufficiency. For benign IPMN, in theory, the operative risk and the loss of pancreatic function should be minimal. Thus, surgery for malignant and benign IPMN differs in patient selection, surgical technique, and accepted risk of long-term functional disorders. This article details the indications, surgical techniques, and results of surgery in IPMN.