Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor

Abstract

BackgroundEither enucleation or more extended resection is performed to treat patients with pancreatic neuroendocrine tumor (pNET). Aim was to analyze the postoperative complications for each operation separately. Furthermore, independent risk factors for complications and incidence of pancreatic insufficiency were analyzed.MethodsRetrospective all resected patients from two academic hospitals in The Netherlands between 1992 and 2013 were included. Postoperative complications were scored by both ISGPS and Clavien–Dindo criteria. Based on tumor location, operations were compared. Independent risk factors for overall complications were identified. During long-term follow-up, pancreatic insufficiency and recurrent disease were analyzed.ResultsTumor enucleation was performed in 60/205 patients (29 %), pancreatoduodenectomy in 65/205 (31 %), distal pancreatectomy in 72/205 (35 %) and central pancreatectomy in 8/205 (4 %) patients. Overall complications after tumor enucleation of the pancreatic head and pancreatoduodenectomy were comparable, 24/35 (69 %) versus 52/65 (80 %). The same was found after tumor enucleation and resection of the pancreatic tail (36 vs.58 %). Number of re-interventions and readmissions were comparable between all operations. After pancreatoduodenectomy, 33/65 patients had lymph node metastasis and in patients with tumor size ≤2 cm, 55 % had lymph node metastasis. Tumor in the head and BMI ≥25 kg/m2 were independent risk factors for complications after enucleation. During follow-up, incidence of exocrine and endocrine insufficiency was significant higher after pancreatoduodenectomy (resp. 55 and 19 %) compared to the tumor enucleation and distal pancreatectomy(resp. 5 and 7 % vs.8 and 13 %). After tumor enucleation 19 % developed recurrent disease.ConclusionSince the complication rate, need for re-interventions and readmissions were comparable for all resections, tumor enucleation may be regarded as high risk. Appropriate operation should be based on tumor size, location, and functional status of the pNET.

Successful EUS-guided ethanol ablation of insulinoma, four-year follow-up. Case report and literature review

“…The less invasive method of treatment is tumour enucleation, which is not always possible to perform. However, mortality, overall complication rates, and need of re-interventions are comparable between standard resections and enucleation, while the rate of fistula is even higher in the enucleation group [13,14]. In contrast, the incidence of exocrine and endocrine insufficiency are significantly higher after Whipple's procedure [13].…”

“…Surgical treatment is associated with significant risk of complications, which limits its use, especially in older individuals with comorbidities [13]. The less invasive method of treatment is tumour enucleation, which is not always possible to perform.…”

Laparoscopic surgery for pancreatic insulinomas: an update

“…51,60,62,69 Concerns giving rise to debate still persist in the management of solitary lesions located in the head of the pancreas due to complications (up to 64% may develop a fistula) after enucleation. 76,77 A review of the literature indicates that laparoscopic enucleation when employed in selected patients is a technically feasible procedure with comparable complication rates. 51,57,63,71 The most common surgical complication is pancreatic fistula (7.2% in all types of laparoscopic procedures) with the majority occurring in laparoscopic enucleations.…”

Unmet Needs in Functional and Nonfunctional Pancreatic Neuroendocrine Neoplasms

“…This is particularly important in patients postresection of PanNENs, because if reliable predictors of recurrence/growth/aggressive behavior were available, the postoperative follow-up time/investigations could be adjusted and appropriate neoadjuvant treatments considered [32]. The recurrence rate postresection in patients with PanNENs varies markedly in different series and, as outlined in a previous paragraph, it is affected by the type of PanNEN included (insulinomas, the most frequent F-PanNEN, have a very low recurrence rate) [61], the tumor grade, the tumor stage, and the pathologic features other than grade/differentiation of the tumors, such as degree of invasion [20, 21, 24-31, 33-36]. In addition, other molecular features of PanNENs have been shown to correlate with tumor aggressiveness/recurrence, including ATRX/DAXX/telomere changes and changes in other chromatin remodeling genes [62], miRNA/mRNA transcriptome profiles [63], methylation status [64], and a number of other alterations [65] (Table 2).…”

“…This also relates to identifying the group of higher risk patients who might benefit by adjuvant treatments [32]. The recurrence rate after resection in patients with NF-PanNENs varies from 9 to 40% at 3 years and is affected by whether patients with hereditable PanNENs are included, the percentage of patients with higher grade tumors (G2, G3) included, the percentage of patients with tumors with invasion (vascular, neural, lymphatic), disease stage, and percentage of patients with larger tumors (> 2–3 cm) [20, 21, 25, 33-36]. This will be discussed in more detail below.…”