Central Pancreatectomy for Low-Grade Neoplasms Results in 'Excellent' Pancreatic Function but Substantial Morbidity
The availability of cross-sectional imaging has resulted in increased diagnosis of low-grade pancreatic neoplasms and use of central pancreatectomy as an alternative to standard resection for such lesions. In a French single-center experience reported in JAMA Surgery, Goudard et al found that central pancreatectomy for benign and low-grade pancreatic neoplasms produced excellent long-term pancreatic function but was associated with substantial morbidity and higher-than-expected mortality.
Study Details
The retrospective case series included 100 consecutive patients undergoing central pancreatectomy with pancreaticogastrostomy between January 2000 and March 2012 at a single tertiary referral center. Central pancreatectomy was considered for patients with symptomatic benign lesions, including serous cystadenomas, or low-grade neoplasms, including pancreatic neuroendocrine tumors, branch and segmental main duct intraductal papillary mucinous neoplasms, and mucinous cystadenomas.
Central pancreatectomy was not considered for patient with lesions suspected to be malignant, including pancreatic neuroendocrine tumors associated with enlarged lymph nodes or distant metastasis, intraductal papillary mucinous neoplasms, and mucinous cystadenomas with solid components or mural nodules > 5 mm, or for those with symptoms suggestive of malignancy, such as weight loss, recent diabetes mellitus, continuous abdominal pain, and mass syndrome.
Complications
The most common indications for central pancreatectomy were pancreatic neuroendocrine tumors (35%), intraductal papillary mucinous neoplasms (33%), solid pseudopapillary neoplasms (12%), and mucinous cystadenomas (6%).
The postoperative mortality rate was 3%, with death occurring in two patients due to pulmonary embolism and in one due to hemorrhage after pancreatic fistula. The overall morbidity rate was 72%, including severe complications (Clavien-Dindo classification III, IV, or V) in 18%. Postoperative pancreatic fistula, the most common complication, occurred in 63% of patients and was clinically significant (grade B or C) in 44%. Severe complications led to radiologic drainage procedures in 10% of patients, endoscopic procedures in 7%, and repeat surgery in 6%.
Long-Term Outcome
After median follow-up of 36 months, new-onset exocrine insufficiency had occurred in 6% of patients and new-onset endocrine insufficiency had occurred in 2%. Lesions in 7% of patients were considered undertreated, including node-negative R0 microinvasive intraductal papillary mucinous neoplasms in 3% and node-positive neuroendocrine tumors in 4%. Among 25 patients with a doubtful preoperative diagnosis, 9 (36%) were considered to be overtreated, since they underwent surgery for benign nonevolving asymptomatic lesions.
Tumors recurred in 3% of patients. Rates of disease-free survival at 1, 2, 3, and 5 years were 100%, 100%, 100%, and 90%.
The investigators concluded, “Central pancreatectomy is associated with an excellent pancreatic function at the expense of a significant morbidity and a non-nil mortality rate, underestimated by the published literature. The procedure is best indicated for benign or low-grade lesions in young and fit patients who can sustain a significant postoperative morbidity and could benefit from the excellent long-term results.”
Alain Sauvanet, MD, of Assistance Publique-Hôpitaux de Paris, is the corresponding author for the JAMA Surgery article.
The study authors reported no potential conflicts of interest.
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