Duodenum-preserving total pancreatectomy for pancreatic neoplasms

Abstract

Background/Purpose: Total pancreatectomy (TP) is sometimes performed to treat low-grade malignant neoplasms that are spreading to the entire pancreas. However, TP impairs quality of life, due to the resulting loss of pancreatic exocrine and endocrine function, and an organ-preserving procedure should be chosen to minimize the impact of pancreatic dysfunction. Recently, we performed four duodenum-preserving TPs (DPTPs) on patients with low-grade malignant neoplasms of the entire pancreas and we introduce our operative technique and results herein. Methods: DPTP is performed with the objective of preserving the arterial arcade of the posterior pancreas so as to maintain good blood flow in the duodenum and common bile duct. Care must also be taken to preserve the splenic artery and vein to protect the spleen. When patients are also undergoing a bile duct resection, an end-to-side choledochoduodenostomy is also performed to reconstruct the biliary tract. Results: Patient 1: DPTP with preservation of the spleen, conserving splenic vessels, was performed on a patient with hereditary pancreatic carcinoma with pancreatic intraepithelial neoplasia-3 (PanIN-3). Patient 2: DPTP with splenectomy was performed on a patient with multiple metastases of the entire pancreas from renal cell carcinoma. Patient 3: DPTP with preservation of the common bile duct and the spleen, conserving splenic vessels, was performed on a patient with minimally invasive carcinoma derived from intraductal papillary mucinous neoplasm (IPMN). Patient 4: DPTP with preservation of the spleen, conserving splenic vessels, was performed on a patient with minimally invasive carcinoma derived from IPMN. No deaths or morbidity occurred. All patients were placed on pancreatic enzyme replacement therapy and given a daily dose of insulin of approximately 30 U. Complete professional rehabiliation was achieved in all patients. All patients except one gained weight, and the hemoglobin A1c (HbA1c) levels have been maintained at around 7%. Conclusions: DPTP is a useful organ-preserving procedure for low-grade malignant neoplasms spreading within the entire pancreas. This procedure minimizes the impact of pancreatic dysfunction and allows the patient to maintain good nutrition after surgery. © Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer 2009.