Better preservation of endocrine function after central versus distal pancreatectomy for mid-gland lesions

doi:10.1016/j.surg.2010.09.003

Surgery

Volume 148, Issue 6, December 2010, Pages 1247-1256

https://doi.org/10.1016/j.surg.2010.09.003 Get rights and content

Background

Traditional resections for benign and low-grade malignant neoplasms of the mid pancreas result in loss of normal parenchyma that can cause pancreatic endocrine and exocrine insufficiency. Central pancreatectomy (CP) is a parenchyma-sparing option for such lesions. This study evaluates a single institution’s experience with CP and compares outcomes with distal pancreatectomy (DP).

Methods

We retrospectively collected data on CP patients from 1997 through 2009 and evaluated outcomes. In a subset of 50 patients, we performed a matched-pairs analysis to directly compare the short- and long-term outcomes of CP and DP.

Results

Seventy-three patients underwent CP with a median operating room time of 254 minutes. Overall morbidity was 41.1% with pancreatic fistula in 20.5%. Mortality was 0%. There were no differences in fistula, morbidity, and mortality rates between the CP and DP groups. The CP group had resected for smaller lesions. CP patients had a lower rate of new-onset and worsening diabetes than DP patients (14% vs 46%; P = .003). Of new-onset and worsening diabetics, only 1 CP patient required insulin compared with 14 DP patients (P = .002).

Conclusion

CP is safe and effective for select neoplasms of the mid pancreas. Patients undergoing CP have markedly decreased insulin requirements compared with DP patients.

Section snippets

Methods

We performed a retrospective review of a prospectively maintained database of patients with pancreatic disease. The database is maintained by The Pancreas Center of Columbia University Medical Center and includes the patients of 4 surgeons (JA, JC, JL, BS). After approval from the institutional review board and in compliance with Health Insurance Portability and Accountability Act regulations, we queried our database to identify all patients who underwent CP or DP at Columbia University Medical

Results

A total of 77 patients were brought to the OR for CP between July 29, 1997, and December 31, 2009. The operation was performed successfully in 73 (94.8%) and aborted in 4 (5.2%). All 4 aborted CP patients had pancreatic adenocarcinoma on intraoperative biopsy, and reasons for aborting included the presence of metastatic disease in 2 patients, adherence to the celiac axis in 1, and diffuse disease throughout the gland in 1. Of the completed CP patients, 20 (27.4%) were men and 53 (72.6%) women

Discussion

The recent trend in pancreatic surgery favors conservative over radical resection for pancreatic lesions when oncologically appropriate. In this context, there has been renewed interest in CP, with reports in the literature supporting its safety and feasibility for benign and low-grade malignant lesions that cannot be enucleated.3, 5, 6, 14, 15 When compared with pancreaticoduodenectomy or DP, CP spares pancreatic parenchyma, preserves the spleen, and maintains the integrity of the upper

References (20)

K.M. Brown et al.
Central pancreatectomy for benign pancreatic lesions
HPB
(2006)
S. Hirono et al.
A central pancreatectomy for benign or low-grade malignant neoplasms
J Gastrointest Surg
(2009)
T. Shikano et al.
Middle pancreatectomy: safety and long-term results
Surgery
(2010)
M.J. Goldstein et al.
Pancreaticogastrostomy: a novel application after central pancreatectomy
J Am Coll Surg
(2004)
C. Bassi et al.
Postoperative pancreatic fistula: an international study group (ISGPF) definition
Surgery
(2005)
H. Lavu et al.
Middle segment pancreatectomy can be safely incorporated into a pancreatic surgeon’s clinical practice
HPB
(2008)
K.K. Roggin et al.
Central pancreatectomy revisited
J Gastrointest Surg
(2006)
A. Sauvanet et al.
Medial pancreatectomy: a multi-institutional retrospective study of 53 patients by the French Pancreas Club
Surgery
(2002)
J. King et al.
Distal pancreatectomy: incidence of postoperative diabetes
J Gastrointest Surg
(2008)
C. Iacono et al.
The Degradi-Serio-Iacono Operation Central Pancreatectomy
J Gastrointest Surg
(2007)

There are more references available in the full text version of this article.

Cited by (94)

Short and long-term outcomes of minimally invasive central pancreatectomy: Comparison with minimally invasive spleen-preserving subtotal distal pancreatectomy
2023, Asian Journal of Surgery
Central pancreatectomy(CP) is more complex surgery and higher complication rate than distal pancreatectomy(DP). However, with the development of minimally invasive surgery, CP has become a safer surgery technique. In this study, we compare minimally invasive CP(MI-CP) and Minimally invasive spleen-preserving subtotal DP(MI-SpSTDP) to figure out the short-term and long-term outcomes of MI-CP.
From March 2007 to June 2020, 36 cases of MI-SpSTDP and 23 cases of MI-CP were performed for benign and borderline malignant pancreatic tumors in Severance hospital. The occurrence of postoperative pancreatic fistula(POPF) and Clavian-Dindo classification grade 3 or more in the two group was investigated, and the Controlling nutritional status scores(CONUT score) before and 1-year after surgery were compared to determine the long-term outcomes of exocrine function.
There was no difference in postoperative complications including POPF between the two groups(17.4% vs 5.1%, p = 0.294). And there were no statistical differences in either the MI-CP group (0.74 ± 0.75 vs. 0.78 ± 0.99, p = 0.803) or the MI-SpSTDP group (0.86 ± 0.83 to 0.61 ± 0.59, p = 0.071).
MI-CP had longer operation time and hospital stay and is safe and effective in preserving endocrine and exocrine functions in treatment of benign or borderline tumors located at the neck or proximal body of the pancreas.
Minimally invasive versus open central pancreatectomy: Systematic review and meta-analysis
2022, Surgery (United States)
This systematic review and meta-analysis aimed to give an overview on the postoperative outcome after a minimally invasive (ie, laparoscopic and robot-assisted) central pancreatectomy and open central pancreatectomy with a specific emphasis on the postoperative pancreatic fistula. For benign and low-grade malignant lesions in the pancreatic neck and body, central pancreatectomy may be an alternative to distal pancreatectomy. Exocrine and endocrine insufficiency occur less often after central pancreatectomy, but the rate of postoperative pancreatic fistula is higher.
An electronic search was performed for studies on elective minimally invasive central pancreatectomy and open central pancreatectomy, which reported on major morbidity and postoperative pancreatic fistula in PubMed, Cochrane Register, Embase, and Google Scholar until June 1, 2021. A review protocol was developed a priori and registered in PROSPERO as CRD42021259738. A meta-regression was performed by using a random effects model.
Overall, 41 studies were included involving 1,004 patients, consisting of 158 laparoscopic minimally invasive central pancreatectomies, 80 robot-assisted minimally invasive central pancreatectomies, and 766 open central pancreatectomies. The overall rate of postoperative pancreatic fistula was 14%, major morbidity 14%, and 30-day mortality 1%. The rates of postoperative pancreatic fistula (17% vs 24%, P = .194), major morbidity (17% vs 14%, P = .672), and new-onset diabetes (3% vs 6%, P = .353) did not differ significantly between minimally invasive central pancreatectomy and open central pancreatectomy, respectively. Minimally invasive central pancreatectomy was associated with significantly fewer blood transfusions, less exocrine pancreatic insufficiency, and fewer readmissions compared with open central pancreatectomy. A meta-regression was performed with a random effects model between minimally invasive central pancreatectomy and open central pancreatectomy and showed no significant difference for postoperative pancreatic fistula (random effects model 0.16 [0.10; 0.24] with P = .789), major morbidity (random effects model 0.20 [0.15; 0.25] with P = .410), and new-onset diabetes mellitus (random effects model 0.04 [0.02; 0.07] with P = .651).
In selected patients and in experienced hands, minimally invasive central pancreatectomy is a safe alternative to open central pancreatectomy for benign and low-grade malignant lesions of the neck and body. Ideally, further research should confirm this with the main focus on postoperative pancreatic fistula and endocrine and exocrine insufficiency.
Resection of the splenic vessels during laparoscopic central pancreatectomy is safe and does not compromise preservation of the distal pancreas
2022, Surgery (United States)
The diagnosis of low potential malignant diseases is increasingly frequent, and laparoscopic central pancreatectomy can be indicated in these patients. Laparoscopic central pancreatectomy that usually preserves the splenic vessels results in a low risk of new-onset diabetes but high morbidity, mainly due to postoperative pancreatic fistula and postpancreatectomy hemorrhage. In this study, we evaluated the short and long-term complications after laparoscopic central pancreatectomy with splenic vessel resection.
This retrospective single-center cohort study included 650 laparoscopic pancreatic resections from 2008 to 2020 with 84 laparoscopic central pancreatectomy; 15 laparoscopic central pancreatectomy with splenic vessel resection; and 69 laparoscopic central pancreatectomy with preservation of the splenic vessels. Pancreaticogastrostomy was routinely performed, and the patients were discharged after complications had been treated. The 15 laparoscopic central pancreatectomy with splenic vessel resection were matched for age, sex, body mass index, and tumor characteristics [1:2] and compared with 30 laparoscopic central pancreatectomy with the preservation of the splenic vessels.
In the laparoscopic central pancreatectomy with splenic vessel resection group, resection of splenic vessels was performed due to tumoral or inflammatory adhesions (n = 11) or accidental vascular injury (n = 4). The demographic characteristics of the groups were similar. Tumors were larger in the laparoscopic central pancreatectomy with splenic vessel resection group (40 vs 21 mm; P = .008), and right transection on the body of the pancreas (53% vs 13%; P = .01) was more frequent. There were no differences in the characteristics of the pancreas (Wirsung duct size or consistency). The median operative time (minutes) was longer in the laparoscopic central pancreatectomy with splenic vessel resection group than in the laparoscopic central pancreatectomy with preservation of the splenic vessels group (210 vs 180, respectively; P = .15) with more blood loss (100 mL vs 50 mL, respectively; P = .012). The lengths (mm) of the resected pancreas and remnant distal pancreas in the 2 groups were 65 vs 50 (P = .053) and 40 vs 65 (P = .006), respectively. There were no differences in postoperative mortality (0% vs 3%; P = .47), grade B–C postoperative pancreatic fistula (27% vs 27%; P = 1), reintervention (7% vs 13%; P = .50), grade B–C postpancreatectomy hemorrhage (0% vs 13%; P = .13), length of hospital stay (20 days vs 22 days; P = .15), or new-onset diabetes (7% vs 10%; P = .67) between the 2 groups.
Laparoscopic central pancreatectomy with splenic vessel resection is a safe technical modification of central pancreatectomy that does not prevent preservation of the distal pancreas and does not influence postoperative pancreatic fistula or endocrine insufficiency. Furthermore, it could reduce the risk of postpancreatectomy hemorrhage.
Robotic central pancreatectomy: a systematic review and meta-analysis
2022, HPB
Central pancreatectomy is usually performed to excise lesions of the neck or proximal body of the pancreas. In the last decade, thanks to the advent of novel technologies, surgeons have started to perform this procedure robotically. This review aims to appraise the results and outcomes of robotic central pancreatectomies (RCP) through a systematic review and meta-analysis.
A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of RCP. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modelling.
Thirteen series involving 265 patients were included. In all cases but one, RCP was performed to excise benign or low-grade tumours. Clinically relevant post-operative pancreatic fistula (POPF) occurred in 42.3% of patients. While overall complications were reported in 57.5% of patients, only 9.4% had a Clavien-Dindo score ≥ III. Re-operation was necessary in 0.7% of the patients. New-onset diabetes occurred postoperatively in 0.3% of patients and negligible mortality and open conversion rates were observed.
RCP is safe and associated with low perioperative mortality and well preserved postoperative pancreatic function, although burdened by high overall morbidity and POPF rates.
Long-term health after pancreatic surgery: the view from 9.5 years
2021, HPB
Discussing the impact of pancreatic surgery on long-term health is poorly understood, but necessary for informed consent. Given the increased number of pancreatic operations being performed annually, further investigation is necessary.
Patients surviving longer than 5 years after pancreatic surgery were surveyed for postoperative hospitalizations, operations, pain, nutrition and diabetes. Variables were analyzed according to patient and peri-operative variables, and validated using medical records.
Eighty individuals completed the survey; median follow-up was 9.5 years (IQR:6.43,12.73). 47.5% underwent a pancreatoduodenectomy, and 25.0% a distal pancreatectomy; 40.0% had adenocarcinoma. 57.1% reported long-term weight loss, of which 65.9% was unintentional. While 1.3% took pancreatic enzymes before surgery, 38.8% utilized after. 12.5% had diabetes before, and 28.6% after surgery; 22 of 30 patients required insulin replacement therapy (73.3%). 41.3% reported hospitalizations, 17.5% required endoscopies and 28.8% additional operations after full recovery. Need for additional interventions were not related to pathology or post-operative complications, but were more common among patients undergoing a Whipple.
More than half of patients will have a long-term medical complication attributable to pancreatectomy. In comparison to the literature, it may be inferred that consequences occur within the first few years after surgery, and do not compound over time.
Outcomes of limited resection for patients with intraductal papillary mucinous neoplasm of the pancreas: A single-center experience
2020, Pancreatology
/ObjectivesThe aim of this study was to clarify the oncological outcomes of patients with intraductal papillary mucinous neoplasm (IPMN) who underwent limited resection (LR).
This retrospective study analyzed the data of 110 patients with IPMN. Patients with IPMN without a history of pancreatitis who had neither tumor infiltration nor regional lymph node swelling on imaging findings underwent LR. We assessed the oncological outcomes of LR for patients with IPMN by comparing the surgical outcomes of LR and standard resection.
LR was performed in 50 patients (45.5%), including duodenum-preserving pancreatic head resection (n = 31), middle-pancreatectomy (n = 12), spleen-preserving distal pancreatectomy (n = 3), total parenchymal pancreatectomy (n = 3), and partial resection (n = 1). In the LR group, 18 patients had postoperative complications of Clavien-Dindo classification ≥ IIIa. After histopathological examination, the presence of high-grade dysplasia (HGD) and invasive carcinoma (IC) were observed in nine and three patients, respectively, in the LR group, and eight and 22 patients, respectively, in the standard resection group. There was a significant difference in the histopathological diagnosis of IC between the two groups (p < 0.001). Finally, in the LR group, postoperative recurrences occurred in three patients, and the 5-, 10-, and 15-year disease-specific survival rates were all 97.0%.
For patients with IPMN judged to have no infiltrating lesions based on the detailed imaging examination, LR is acceptable and may be considered as an alternative to standard resection.

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: Supported by the Ruth L. Kirschstein National Research Service Award (T32 HL-007854-14), Doris Duke Charitable Foundation, I.W. Foundation.

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American Association of Endocrine SurgeonBetter preservation of endocrine function after central versus distal pancreatectomy for mid-gland lesions

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

HPB

J Gastrointest Surg

Surgery

J Am Coll Surg

Surgery

HPB

J Gastrointest Surg

Surgery

J Gastrointest Surg

J Gastrointest Surg

American Association of Endocrine Surgeon
Better preservation of endocrine function after central versus distal pancreatectomy for mid-gland lesions