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Purpose: While standard resections such as pancreaticoduodenectomy and distal pancreatectomy are necessary for malignant disease, low grade tumors and benign lesions of the pancreas and duodenum present a unique surgical dilemma. Select patients may benefit from non-standard resections (NSR) which preserve parenchyma and function, and thus may avoid the potential complications inherently related to more traditional resections. Here, we describe our experience with NSR of various pancreatic and duodenal lesions.
Methods: A retrospective review of a prospectively collected database of 777 patients who underwent resections of pancreatic and duodenal lesions between 1999 and 2012 was conducted. Of these, 45 patients underwent NSR, defined as pancreatic or duodenal resections excluding standard pancreaticoduodenectomy or distal pancreatectomy. Clinicopathologic features and outcomes were assessed.
Results: In sum, 26 males and 19 females were evaluated; median age 64 years (range 30-87) and median follow-up 4.4 years (range 0.3-13.3 years). Preoperatively, 32 patients underwent EGD, 33 EUS, and 39 CT scans. The median lesion size was 2.3 cm (range 0.7-9 cm). The various types of NSR included: 16 pancreas-sparing duodenectomies, 9 central pancreatectomies, 9 enucleations, 6 ampullectomies, 4 transduodenal polypectomies, and 1 endoscopic polypectomy. The final pathologic diagnoses included: 12 villous adenomas, 7 neuroendocrine tumors, 5 mucinous cystadenomas, 5 stromal tumors, 4 duodenal carcinomas, 3 serous cystadenomas, 3 tubular adenomas, 2 lymphoepithelial cysts, 2 IPMNs, and 2 other pathologies. EUS was 100% accurate in predicting depth of mucosal invasion, while EGD and CT were 100% accurate in identifying the lesion location. Furthermore, the overall accuracy of pre-operative imaging in selecting appropriate patients amenable to NSR was 100%. Overall, five patients developed post-procedure complications (10.9%). Of the central pancreatectomies (n=9), three developed pancreatic fistulas (33%), although no patients developed diabetes or steatorrhea. One patient had a subsequent episode of pancreatitis following ampullectomy, and one developed a pancreatic pseudocyst requiring endoscopic drainage following enucleation. There were no peri-operative mortalities. Of the four patients with duodenal carcinomas, all underwent pancreas-sparing duodenectomy, and the overall survival was 50% at the time of analysis (deaths occurred at 1.7 and 4 years; follow-up for two survivors was 4.1 and 11.7 years).
Conclusion: Based on our findings, EGD, CT, and EUS were 100% accurate in selecting appropriate patients for NSR. Therefore, proper selection of patients using certain imaging modalities may allow some patients to achieve adequate resection, while avoiding more complicated and morbid procedures, such as pancreaticoduodenectomy or distal pancreatectomy.