Middle-preserving pancreatectomy: report of two cases and review of the literature

Abstract

Background: Middle-preserving pancreatectomy (MPP) is a parenchyma-sparing surgical procedure which has recently been sporadically reported for the treatment of multicentric periampullary-pancreatic lesions. However, a comprehensive recognition of this procedure has not been clearly elucidated.

Case presentation: We herein report two patients undergoing MPP due to synchronous multicentric pancreatic neoplasm. Patient one was a 24-year-old woman with a multicentric solid pseudopapillary neoplasm (SPN) and patient two was a 36-year-old woman with a multicentric serous cystic neoplasm (SCN). Simultaneous atypical pancreaticoduodenectomy and atypical left pancreatectomy were performed in patient one; simultaneous standard pancreaticoduodenectomy and atypical left pancreatectomy with spleen preservation were performed in patient two. Approximately 6 cm and 5 cm segments of the middle portion of the pancreas were preserved, respectively. At follow-up at 36 months and 6 months respectively, patient one had developed diabetes and malabsorption requiring dietary control, exercise and pancreatic enzyme supplement whereas patient two showed normal fasting blood glucose without diarrhea. Both patients were disease-free and in good nutritional condition. We reviewed twenty cases of MPP that were previously reported in the literature. Patient characteristics, surgical techniques and short- and long-term outcomes were analyzed.

Conclusion: MPP is mainly beneficial for multicentric noninvasive periampullary-pancreatic lesions. However, for multicentric periampullary-pancreatic lesions involving even primary invasive cancers, as long as the invasive cancers affect only one side of the pancreas (proximal or distal), MPP could serve as a rational choice in well-selected patients.

Figure 1

CT scans and intraoperative imaging of patient one. a) Plain CT revealed two well-defined heterogeneous lesions: calcification was shown in the pancreatic head tumor (white arrow) and a septum was shown in the tail tumor (black arrow). b) Enhanced CT showed peripheral enhancement and complex cystic components with areas of necrosis; calcification (white arrow) and septum (black arrow) were clearer (arrow). c) Enhanced CT scan in portal phase. d) After a simultaneous atypical PD and atypical LP, about 6 cm of the pancreatic body was preserved (Pan), proper hepatic artery (black arrow) and the stapled stump of the splenic vein (white arrow) can be seen. D, duodenum; G, gallbladder; Pan, Pancreas; T, tumor.

Figure 2

CT scans and intraoperative imaging of patient two. a) Plain CT revealed two well-defined cystic lesions (white arrow). b) Enhanced CT demonstrated polycystic appearance of the tumor with no enhancement in the arterial phase (white arrow). c) Enhanced CT demonstrated polycystic appearance of the tumor with no enhancement in portal phase (white arrow). d) After a simultaneous standard PD and spleen-preserving atypical LP, about 5 cm of the pancreatic body (Pan) and the splenic vein (arrow) were preserved. Pan, pancreas; PHA, proper hepatic artery; PV, portal vein.