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Nonstandard pancreatic resections for unusual lesions

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Abstract

Background

Pancreatic resections including pancreaticoduodenectomy and distal pancreatectomy are the standard of care for patients with malignant tumors of the pancreas. Patients with benign disease or unusual tumors may benefit from other nonstandard resections.

Methods

A review of the literature and the author’s experiences were undertaken.

Results

Parenchymal-sparing surgeries including pancreatic enucleation, central pancreatectomy, splenic-preserving distal pancreatectomy, and duodenal-preserving pancreatic head resection are described. The utility of each procedure is reviewed. Outcome results from published series are included.

Conclusions

Nonstandard pancreatic resections should be considered in select patients with unusual lesions. Such procedures are safe and effective and may be associated with a reduced incidence of exocrine insufficiency.

Section snippets

Pancreatic enucleation

Benign or low-malignant potential tumors of the pancreas have traditionally been treated with standard resection. Such procedures, although oncologically sound, involve resection of a notable amount of normal parenchyma in patients with benign disease. Enucleation of these tumors has the advantage of preserving pancreatic parenchyma as well as the spleen, without the morbidity, mortality, or late sequelae of extensive resection [1], [2], [3], [4], [5], [6], [7], [8], [9], [10].

Lesions that may

Central pancreatectomy

Enucleation of benign or low-grade malignant tumor types is not always possible because of pancreatic duct involvement or because of a pancreatic neck or body location. These patients have traditionally been treated with a distal subtotal pancreatectomy or extended pancreaticoduodenectomy. Recently, central pancreatectomy has gained much attention [17], [18], [19], [20], [21], [22], [23], [24], [25]. Central or median pancreatectomy involves a limited resection of the midportion of the

Splenic-preserving distal pancreatectomy

Distal pancreatectomy for distal tumors has traditionally included splenectomy. Over the past decade, the addition of splenectomy to other major upper abdominal organ resection has been associated with increased postoperative morbidity, especially infectious complications, and therefore, when possible, splenic preservation is considered the standard of care in patients undergoing gastric or colon resection [27], [28], [29]. Splenectomy in conjunction with distal pancreatectomy is clearly

Duodenal-preserving resection of the head of the pancreas

Patients with chronic pancreatitis and severe pain pose a therapeutic challenge [39]. In up to one third of patients with chronic pancreatitis, an inflammatory mass develops in the head of the pancreas, often resulting in common bile duct and duodenal stenosis [40]. This group of patients usually has abdominal pain that is refractory to analgesic treatment, with local complications [41], [42]. For these patients, pancreatectomy or lateral pancreaticojejunostomy have been the standard procedures

Conclusion

Pancreaticoduodenectomy and distal pancreatectomy with splenectomy are the standard operations recommended for patients with pancreatic carcinoma. Nonstandard resections for unusual pancreatic tumors should be considered in select patients. The procedures described have thus far been found to be safe and effective, with appropriate preservation of endocrine and exocrine function.

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