Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes

Abstract

Background: Total pancreatectomy (TP) is usually considered a therapeutic option for pancreatic cancer in which Whipple surgery and distal pancreatectomy are undesirable, but brittle diabetes and poor quality of life (QoL) remain major concerns. A subset of patients who underwent TP even died due to severe hypoglycemia. For pancreatic cancer involving the pancreatic head and proximal body but without invasion to the pancreatic tail, we performed partial pancreatic tail preserving subtotal pancreatectomy (PPTP-SP) in selected patients, in order to improve postoperative glycemic control and QoL without compromising oncological outcomes.

Aim: To evaluate the efficacy of PPTP-SP for patients with pancreatic cancer.

Methods: We retrospectively reviewed 56 patients with pancreatic ductal adenocarcinoma who underwent PPTP-SP (n = 18) or TP (n = 38) at our institution from May 2014 to January 2019. Clinical outcomes were compared between the two groups, with an emphasis on oncological outcomes, postoperative glycemic control, and QoL. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 and EORTC PAN26). All patients were followed until May 2019 or until death.

Results: A total of 56 consecutive patients were enrolled in this study. Perioperative outcomes, recurrence-free survival, and overall survival were comparable between the two groups. No patients in the PPTP-SP group developed cancer recurrence in the pancreatic tail stump or splenic hilum, or a clinical pancreatic fistula. Patients who underwent PPTP-SP had significantly better glycemic control, based on their higher rate of insulin-independence (P = 0.014), lower hemoglobin A1c (HbA1c) level (P = 0.046), lower daily insulin dosage (P < 0.001), and less frequent hypoglycemic episodes (P < 0.001). Global health was similar in the two groups, but patients who underwent PPTP-SP had better functional status (P = 0.036), milder symptoms (P = 0.013), less severe diet restriction (P = 0.011), and higher confidence regarding future life (P = 0.035).

Conclusion: For pancreatic cancer involving the pancreatic head and proximal body, PPTP-SP achieves perioperative and oncological outcomes comparable to TP in selected patients while significantly improving long-term glycemic control and QoL.

Keywords: Diabetes mellitus; Pancreatic cancer; Partial pancreatic tail preserving subtotal pancreatectomy; Quality of life; Total pancreatectomy; Treatment outcome.

Figure 1

Preoperative and postoperative computed tomography images of a 65-year-old male patient who underwent partial pancreatic tail preserving subtotal pancreatectomy for pancreatic ductal adenocarcinoma. The pancreatic cancer involved the pancreatic head and proximal body, which led to the dilatation of the distal pancreatic duct. The length of the preserved pancreatic stump was 31 mm, and the patient was still insulin-independent at the last follow-up. A and B: Preoperative; C: Postoperative. PV: Portal vein.

Figure 2

Diagrams and intraoperative image showing the surgical technique. A and B: Care was taken to ensure the integrity of the left gastroepiploic vessels, the short gastric vessels, and the network of collateral vessels near the splenic hilum. The left gastric vein was preserved as much as possible (B); C: A tunnel was created behind the pancreatic tail, and the pancreas could be transected along the bold dashed line. SA: Splenic artery; Pb: Pancreatic body; RP: Remnant pancreas.

Figure 3

Comparison of recurrence-free survival and overall survival between patients who underwent partial pancreatic tail preserving subtotal pancreatectomy or total pancreatectomy for pancreatic ductal adenocarcinoma. A: Recurrence-free survival; B: Overall survival. RFS: Recurrence-free survival; OS: Overall survival.

Figure 4

Change of hemoglobin A1c levels after partial pancreatic tail preserving subtotal pancreatectomy or total pancreatectomy. The asterisk indicates a statistical difference. HbA1c: Hemoglobin A1c; PPTP-SP: Partial pancreatic tail preserving subtotal pancreatectomy; TP: Total pancreatectomy.

Figure 5

Patients’ quality of life (QoL) after partial pancreatic tail preserving subtotal pancreatectomy or TP. A: Quality of life (QoL) evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30; B: Functional status; C: Pancreatic disease-specific symptoms. Patients who underwent partial pancreatic tail preserving subtotal pancreatectomy had better functional status, milder symptoms, less severe diet restriction, and stronger confidence regarding future life. The asterisk indicates a statistical difference. EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; PPTP-SP: Partial pancreatic tail preserving subtotal pancreatectomy; TP: Total pancreatectomy.