Pancreatic Neuroendocrine Tumors: What Is the Best Surgical Option?

Abstract

Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used ("NET", "pancreatic", "surgery", "laparoscopic", "minimally invasive", "robotic", "enucleation", "parenchyma sparing") and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body-tail, while laparoscopic enucleation is better for head pNETs.

Keywords: enucleation; neuroendocrine tumors; pNET; pancreas tumor; pancreatectomy; pancreatic cancer.

Figure 1

PRISMA flowchart. Diagram of the systematic review of the literature, performed in 4 databases from May 2007 to March 2022. Search terms included “NET”, “pancreatic”, “surgery”, “laparoscopic”, “minimally invasive”, “robotic”, “enucleation” “parenchyma-sparing”. Inclusion criteria are shown in the central box. Major reasons for exclusion were the presence of a clinical diagnosis, localization, and grading of pNET (n= 475) and the intraoperative, perioperative, and postoperative outcomes of pNET surgery (open or minimally invasive) (n = 1836). Further reasons for exclusion were non-comparative studies and those reporting inadequate or partial clinical data. This led to the final selection of 13 studies that fulfilled the inclusion criteria.