Are There Indications for Total Pancreatectomy in 2016?

Abstract

An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pancreatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers.

Total pancreatectomy for pancreatic malignancy with preservation of the spleen

“…Its indications include PDAC, multicentric or diffuse IPMN, multiple pancreatic neuroendocrine tumors, and multifocal pancreatic metastases from renal cell carcinoma. 3,30 To achieve an When cancer is the indication for distal pancreatectomy, splenectomy offers the theoretical oncologic advantage of removing the lymph nodes along the splenic vessels and in the splenic hilum.…”

Systematic review of functional outcome and quality of life after total pancreatectomy

“…Total pancreatectomy for IPMN requires extensive counselling, as this is prophylactic surgery. Other indications for total pancreatectomy could be multifocal pancreatic disease (such as neuroendocrine tumours and renal cell cancer metastases) and technical difficulties, or patients with a very high risk of having a pancreatic anastomosis (for instance in arterial reconstruction).…”

Pancreaticojejunostomy—a review of modern techniques

“…The removal of the pancreatic stump is performed rarely, only when the resection margins are cancer positive or when the cancer is multifocal. This procedure is also acceptable in extremely high-risk patients, in whom according to an experienced surgeon, the risk of a POPF is very high (soft pancreatic tissue, MPD < 3 mm) [5][6][7]. In some centers, in order to prevent the difficult to manage postoperative diabetes, an auto-transplantation of pancreatic islets is additionally proposed [8].…”