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Duodenum and Ventral Pancreas Preserving Submit a Manuscript: http://www.f6publishing.com World J Gastroenterol 2017 September 21; 23(35): 6457-6466 DOI: 10.3748/wjg.v23.i35.6457 ISSN 1007-9327 (print) ISSN 2219-2840 (online) ORIGINAL ARTICLE Retrospective Study Duodenum and ventral pancreas preserving subtotal pancreatectomy for low-grade malignant neoplasms of the pancreas: An alternative procedure to total pancreatectomy for low-grade pancreatic neoplasms Xing Wang, Chun-Lu Tan, Hai-Yu Song, Qiang Yao, Xu-Bao Liu Xing Wang, Chun-Lu Tan, Hai-Yu Song, Xu-Bao Liu, Fax: +86-28-85422474 Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China Received: June 13, 2017 Peer-review started: June 16, 2017 Qiang Yao, West China School of Public Health, Sichuan First decision: July 17, 2017 University, Chengdu 610041, Sichuan Province, China Revised: July 27, 2017 Accepted: August 15, 2017 ORCID number: Xing Wang (0000-0002-4959-1118); Article in press: August 15, 2017 Chun-Lu Tan (0000-0001-5259-3002); Hai-Yu Song Published online: September 21, 2017 (0000-0003-4772-2855); Qiang Yao (0000-0003-4686-961X); Xu-Bao Liu(0000-0002-1288-7089). Author contributions: Wang X and Liu XB designed the research; Wang X, Tan CL and Yao Q performed the research Abstract and analyzed the data; Wang X, Tan CL and Song HY wrote the AIM paper; Liu XB proofread and revised the manuscript; all authors To describe the indications, technique and outcomes approved the version to be published. of the novel surgical procedure of duodenum and ventral pancreas preserving subtotal pancreatectomy Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported. (DVPPSP). Data sharing statement: No additional data are available. METHODS Data collected retrospectively from 43 patients who Open-Access: This article is an open-access article which was underwent DVPPSP and TP between 2009 and 2015 in selected by an in-house editor and fully peer-reviewed by external our single centre were analysed. For enrolment, only reviewers. It is distributed in accordance with the Creative patients with low-grade pancreatic neoplasms, such as Commons Attribution Non Commercial (CC BY-NC 4.0) license, pancreatic neuroendocrine tumors, intraductal papillary which permits others to distribute, remix, adapt, build upon this mucinous neoplasms (IPMNs), and solid pseudo- work non-commercially, and license their derivative works on papillary tumors, were included. Ten DVPPSP (group different terms, provided the original work is properly cited and 1) and 13 TP (group 2) patients were selected in this the use is non-commercial. See: http://creativecommons.org/ study. licenses/by-nc/4.0/ Manuscript source: Unsolicited manuscript RESULTS There were no significant differences in age, gender, Correspondence to: Xu-Bao Liu, MD, PhD, Department of comorbidities, preoperative symptoms, American Society Pancreatic Surgery, West China Hospital, Sichuan University, No. of Anesthesiologists score or indications for surgery 37, Guo Xue Alley, Chengdu 610041, Sichuan Province, between the two groups. The most common indication China. [email protected] was IPMN for DVPPSP and TP (60% vs 85%, P = 0.411). Telephone: +86-28-85422477 Compared with the TP group, the DVPPSP group had WJG|www.wjgnet.com 6457 September 21, 2017|Volume 23|Issue 35| Wang X et al. DVPPSP are safe and effective comparable postoperative morbidities (P = 0.405) and diseases, the percentages of total pancreatectomy mortalities (both nil), but significantly shorter operative (TP) range from 5% to 28% because these diseases [5-7] time (232 ± 19.6 min vs 335 ± 32.3 min, P < 0.001). frequently involve the entire gland . The indications DVPPSP preserved better long-term pancreatic function for primary elective TP are typically these pancreatic with less supplementary therapy (P < 0.001) and better diseases. Although TP could be performed safely in quality of life (QoL) after surgery, including better many centres, the long-term metabolic complications scores in social (P = 0.042) and global health (P = that include brittle diabetes and unmanageable 0.047) on functional scales and less appetite loss (P = steatorrhea prevent its application. Additionally, 0.049) on the symptom scale. wide resection of the total pancreas and duodenum after TP could lead to a reduced quality of life (QoL), CONCLUSION which makes patients anguished. The conventional DVPPSP is a feasible and safe procedure that could be parenchyma-sparing procedures, such as enucleation an alternative to TP for low-grade neoplasms arising and central pancreatectomy, are unable to substitute from the body and tail region but across the neck TP for lesions involving the head, body and tail of the region of the pancreas; DVPPSP had better metabolic pancreas. function and QoL after surgery. [8] As a function preserving procedure, Thayer et al reported a complete dorsal pancreatectomy with Key words: Low-grade malignant neoplasm; Ventral preservation of the ventral pancreas (the proximal pancreas preserving; Subtotal pancreatectomy; Quality duodenum was resected for ischemia) in 2002. of life Duodenum-preserving pancreatic head resection was © The Author(s) 2017. Published by Baishideng Publishing introduced into surgical practice in 1972. This surgical [9] Group Inc. All rights reserved. method has been well developed by Doctor Beger et al in past decades. The rationale to apply a duodenum- Core tip: Although total pancreatectomy (TP) can be preserving pancreatic resection is to avoid resection performed safely, the long-term metabolic complications of the gastric antrum, to preserve the duodenum and prevent its application. Herein, we report our experience the extrahepatic biliary duct for low-grade lesions. This of duodenum and ventral pancreas preserving procedure has low short-term postoperative morbidity subtotal pancreatectomy (DVPPSP), which could be an and mortality, and maintenance of the endocrine and alternative procedure to TP for low-grade pancreatic exocrine functions in the long-term after surgery. A neoplasms, with a focus on the surgical indications, significant superiority of the duodenum-preserving techniques and outcomes. Our results indicate that procedure regarding overall improvement of QoL DVPPSP is a feasible and safe procedure that could be was reported[10]. Herein, we report our experience an alternative to TP for low-grade neoplasms arising of duodenum and ventral pancreas preserving from the body and tail region but across the neck subtotal pancreatectomy (DVPPSP), which could be region of the pancreas, with a better metabolic function an alternative procedure to TP for selected patients and quality of life after surgery. with low-grade pancreatic neoplasms. The aim of our present study was mainly to describe the indications, operative technique and outcomes of the novel surgical Wang X, Tan CL, Song HY, Yao Q, Liu XB. Duodenum and procedure compared with TP. ventral pancreas preserving subtotal pancreatectomy for low- grade malignant neoplasms of the pancreas: An alternative procedure to total pancreatectomy for low-grade pancreatic MATERIALS AND METHODS neoplasms. World J Gastroenterol 2017; 23(35): 6457-6466 From January 2009 to January 2015, patients who Available from: URL: http://www.wjgnet.com/1007-9327/full/ underwent DVPPSP for low-grade pancreatic neoplasms v23/i35/6457.htm DOI: http://dx.doi.org/10.3748/wjg.v23. (such as NETs, IPMNs and SPTs) were identified in i35.6457 our institution. To evaluate the outcomes of DVPPSP compared with TP, patients who underwent TP for low-grade pancreatic neoplasms were also identified during this period. Surgeries for pancreatic ductal INTRODUCTION adenocarcinoma and chronic pancreatitis determined Parenchyma-sparing procedures are increasingly on postoperative pathology were excluded. The performed for low-grade pancreatic neoplasms, such selected patients were divided into two groups as as intraductal papillary mucinous neoplasms (IPMNs), follows: DVPPSP group (group 1) and TP group neuroendocrine tumors (NETs), and pseudo-papillary (group 2). The groups were analysed regarding age, tumors (SPTs)[1,2]. These procedures preserve the gender, type of comorbidities, body mass index (BMI), pancreatic parenchyma and decrease the risk of long- American Society of Anesthesiologists score (ASA), term endocrine and exocrine dysfunction[3,4]. However, operative time, blood transfusion and postoperative according to different reports, in these low-grade data (histology of pancreatic disease, postoperative WJG|www.wjgnet.com 6458 September 21, 2017|Volume 23|Issue 35| Wang X et al. DVPPSP are safe and effective mortality and morbidity, postoperative length of hospital stay). The postoperative mortality rate included all deaths within 30 d after surgery. The morbidity rate included all complications following surgery until discharge. Major postoperative morbidities were defined and graded using the criteria recommended by the International Study Group of Pancreatic Surgery, including postoperative pancreatic fistula, delayed gastric emptying, and postpancreatectomy haemorrhage[11-13]. Biliary leak was defined as drainage of any volume of fluid from percutaneous drains or a wound consistent with bile, which was defined by a bilirubin concentration greater than the serum concentration. Enteric leaks were identified using Figure 1 Preoperative computed tomography view of a 26-year-old female radiographic contrast imaging. Fluid collection in the patient
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