Role of Medial Pancreatectomy in the Management of Intraductal Papillary Mucinous Neoplasms and Islet Cell Tumors of the Pancreatic Neck and Body

Abstract

Background/Aim: Medial pancreatectomy has been applied as a safe and effective alternative in benign diseases located in the pancreatic neck or body. However, the role of this procedure remains controversial. We investigate outcomes using this method in 14 patients. Methods: Fourteen consecutive patients underwent medial pancreatectomy. The surgical indications, postoperative outcomes, and pathologic characteristics were retrospectively analyzed. Results: Among 10 patients with intraductal papillary mucinous neoplasms, 3 patients had minimally invasive adenocarcinoma, and 3 had adenocarcinoma in situ. Four patients required an additional resection of the pancreatic remnant because of a positive surgical margin. A medial pancreatectomy was converted to a distal pancreatectomy in 1 patient with adenocarcinoma in situ. Three patients with islet cell tumor and 1 patient with solid pseudopapillary tumor had no malignant disease. Postoperative complications occurred in 6 patients (43%): 5 had pancreatic fistulas and 1 had a gastric ulcer. All of the patients are doing well without recurrence. Conclusions: A medial pancreatectomy is a safe and effective alternative for the treatment of intraductal papillary mucinous neoplasm, islet cell tumor, or solid pseudopapillary tumor located in the neck or body of the pancreas. However, a precise preoperative and intraoperative assessment including an examination of frozen sections is mandatory to select the appropriate surgical procedure.

Experiences in Central Pancreatectomy

“…Considering that the pancreas in patients who underwent CP is generally a soft pancreas with normal-caliber pancreatic duct, and surgeons need to manage 2 resectional margins of the pancreas at one time, if each resectional margin of the remnant pancreas has the same risk of pancreatic fistula it may not be surprising that pancreatic leak or fistula rate may exceed the commonly accepted range following distal pancratectomy or pancreaictoduodenectomy. The higher occurrence of pancreatic fistula following CP was also demonstrated in other large volume studies (range 25–50%) [12,14,20,21,22,23,24,25]. However, theoretically, pancreatic leaks after CP with pancreaticogastrostomy can be managed safely by conservative management alone, because pancreatic juices are not exposed to bile enzyme activation, as occurs after pancreaticoduodenectomy, which means pancreatic leak following central pancreatectomy may naturally possess a lower risk of auto-digestive activity [21].…”

Systematic review of central pancreatectomy and meta-analysis of centralversusdistal pancreatectomy

“…To minimize heterogeneity among studies, only the 21 studies (19 retrospective and 2 prospective) involving more than ten patients undergoing CP were included in the systematic review of overall outcome of CP, yielding 656 patients ( Table ). Most patients were women (435 of 656, 66·3 per cent).…”

Central pancreatectomy revisited

“…(6,8,49,50) However, good oncological outcomes were reported in several studies, for the branch type intraductal papillary mucinous neoplasms with minimally-invasive or in situ adenocarcinoma, when a margins negative resection could be accomplished. (17,51,52) Uncommon indications for a CP are chronic pancreatitis (17,29) and pancreatic trauma. (53) Large published series have shown that the main indications for a CP were represented by the neuroendocrine tumors (8%-36%), serous cystadenomas (20%-44%), mucinous cystadenomas (8%-35%), and branch type intraductal papillary mucinous neoplasms (12%-35%) (table 1).…”