Total Pancreatectomy for Cancer of the Pancreas: Is It Appropriate?

Abstract

During the late 1960s total pancreatectomy was advocated on theoretic grounds as an operation superior to subtotal (Whipple) resection in patients with pancreatic cancer. There are, however, no prospective randomized studies and only few institutional comparisons between the two operations. The aim of the present paper was to report the clinical outcome of total and subtotal pancreatectomy, respectively, in a consecutive series of patients with exocrine pancreatic cancer. The short- and long-term results of 89 consecutive patients who underwent total pancreatectomy (1959-1984) for pancreatic cancer were retrospectively compared with a similar group of 36 patients who had a subtotal pancreatectomy (1985-1992) for the same diagnosis. The clinical characteristics were on the whole similar in the two groups. Postoperative mortality and morbidity, the amount of intraoperative bleeding, operation time, reoperation rate, postoperative days in the intensive care unit, and duration of hospital stay were statistically significantly increased after total pancreatectomy. The 5-year survival rate was lower after total pancreatectomy when hospital deaths were included in the analysis. At multivariate analysis total pancreatectomy adversely influenced long-term survival compared to subtotal resection, as did positive lymph nodes and poor histologic differentiation. Better early and long-term results were found after subtotal than after total pancreatectomy in patients with exocrine pancreatic cancer. Although the two operations were done during different time periods, we believe the results suggest that total pancreatectomy cannot be recommended as a routine treatment for this patient group.

Incidence, Risk Factors, and Treatment of Pancreatic Leakage After Pancreaticoduodenectomy: Drainage versus Resection of the Pancreatic Remnant

“…This apancreatic diabetes can lead to severe episodes of hypoglycemia that can be very difficult to manage and can even lead to death. 12,46 In our series, none of the patients died from postresection diabetes during follow-up. In seven of the eight patients, diabetes was controlled with insulin treatment.…”

“…This is a procedure that might be considered because it can improve glucose tolerance after resection, and it might prevent the postoperative diabetes seen after total pancreatectomy. 46,47 Patients with severe and persistent pancreatic leakage can receive completion pancreatectomy without additional morbidity and mortality. Completion pancreatectomy for leakage is a very aggressive treatment and is not the first step in treatment of pancreatic leakage.…”

Extended Resection for Pancreatic Adenocarcinoma

“…Most of these series consist of procedures performed in an older era with higher mortality and morbidity after pancreatic resections compared with today. Both Karpoff et al [21] and Ihse et al [22] reported worse survival after TP than after a more limited pancreatectomy, whereas Sarr et al [20] did not note any survival differences. Only Ihse et al [22] accounted for differences in stage and lymph node status between groups of patients that underwent TP and subtotal pancreatectomy.…”

“…Both Karpoff et al [21] and Ihse et al [22] reported worse survival after TP than after a more limited pancreatectomy, whereas Sarr et al [20] did not note any survival differences. Only Ihse et al [22] accounted for differences in stage and lymph node status between groups of patients that underwent TP and subtotal pancreatectomy. They demonstrated an independent survival benefit for subtotal pancreatectomy versus TP (relative risk, 0.63; 95% confidence interval, 0.40 -0.99) with less postoperative mortality (3% versus 27%).…”

Extended pancreatectomy for pancreatic cancers

“…Radical resection is not indicated if extrapancreatic nerve plexus around the superior mesenteric or celiac artery is invaded since dissection around these mesenteric vessels to harvest distant lymph nodes disrupts the plexuses resulting in severe diarrhoea postoperatively [9,10]. Also, most studies reveal no survival benefi t and increased morbidity and mortality with total pancreatectomy over pancreaticoduodenectomy and distal pancreatectomy [11,12]. However, in rare situations including a soft pancreas with risk of a leak from pancreatoenterostomy, or if positive margins on sequential frozen sections are obtained while resection is carried out into the pancreatic tail, or if there are papillomatous changes or dysplasia throughout the pancreatic duct, or if a family history of multicentric disease exists total pancreatectomy should be considered [13].…”