Parenchyma-sparing, local duodenum-preserving pancreatic head resection for cystic neoplasms, neuroendocrine adenoma and low-risk periampullary cancer

Surgical treatment of tumors of the pancreatic head -benign or malignant- are performed by applying pancreatoduodenectomy (PD). The short- and long-term outcome after PD is burdened with procedure-related risk of considerable early postoperative morbidity, substantial risk of mortality and long-term functional impairment of the endocrine and exocrine capacities. Duodenum-preserving total or partial pancreatic head resection (DPPHR-T) for benign tumors of the pancreatic head is a local resective procedure with low early and late postoperative morbidity. In 603 patients, DPPHR for inflammatory head tumor showed low postoperative procedure-related morbidity. Results of a systemic review of 503 patients after DPPHR-T for benign cystic neoplasms and endocrine tumors revealed: severe early postoperative morbidity (Clavien-Dindo above IIIa) in 13 %, pancreatic fistula B and C in 14 % and a 90-day-hospital mortality below 0.5 %. Despite surgery-related diminished pancreatic head tissue, DPPHR-T procedure maintains endocrine pancreatic functions as reflected by HbA1C levels, glucose tolerance test and frequency of postoperative new onset of diabetes mellitus. The exocrine pancreatic functional capacities after DPPHR, using BT-Paba test and fecal chymotrypsin measurements exhibited no change of the exocrine functional level, compared to the preoperative status.The most frequent indications for the application of duodenum-preserving total or partial pancreatic head resection are inflammatory tumors and cystic neoplasms (IPMN, SCA, SPN and rarely MCN). Histopathologically, 7 % of cystic neoplasms mostly IPMN tumors showed carcinoma in situ and 3 % a minimal invasive carcinoma. Of pancreatic neuroendocrine tumors, DPPHR-T was most frequently applied for insulinoma. Duodenum-preserving total pancreatic head resection with segment resection of the peripapillary duodenum and the intrapancreatic common bile duct is applied for low-risk periampullary cancers T1a N0M0 cancer of the papilla, distal common bile duct and duodenum. Lymph tissue dissection of the N1 lymph nodes around pancreatic head is additionally performed. Conclusion:The benefits of parenchyma-sparing duodenum-preserving pancreatic head resection are maintenance of functional tissue of the pancreas and duodenum, a low rate of severe surgery-related morbidity, low frequency of pancreatic fistula B+C and very low hospital mortality. The application of total pancreatic head resection with and without preservation of the peripapillary duodenum and the intrapancreatic common bile duct is associated with the conservation of duodenal functions and maintenance of the exocrine and endocrine pancreatic functional capacity.