Benign Tumors of the Pancreas - Limited Local Surgical Treatment for Cystic Neoplasms and Neuroendocrine Tumors - an Overview
Background. Benign tumors of the pancreas are intraductal papillary mucinous neoplasia, mucinous cystic neoplasia, serous cystic adenoma, solid pseudopapillary neoplasia and endocrine tumors, most frequently insulinomas. The evolution of limited local surgical procedures for benign pancreatic lesions like enucleation (EN), pancreatic middle segment resection (CP) and duodenum-preserving total or partial pancreatic head resection (DPPHRt/p) shifted options of surgical treatment to application of local techniques. Objectives. Surgical treatment of benign cystic neoplasms and neuroendocrine tumors using local surgical extirpation techniques are evaluated based on present knowledge about indication to surgery, early postoperative complications and late outcome perspectives. Results. Tumor enucleation is recommended for all symptomatic neuroendocrine adenomas of a size up to 3 cm and non-adherence to pancreatic main ducts. EN was applied predominantly for neuroendocrine tumors and less frequently for cystic neoplasms. About 20% of enucleations are performed as minimal invasive procedures. Surgery-related severe postoperative complications with the need of reintervention are observed in 11%, pancreatic fistula in 33%, but hospital mortality was below 1%. Major advantages of EN are low procedure-related early postoperative morbidity and a very low hospital mortality. CP is applied in two thirds for symptomatic cystic neoplasms and in one third for neuroendocrine tumors. The high level of pancreatic fistula and severe postoperative complications are associated with management of the proximal pancreatic stump. Hospital mortality of 0.8% is a benefit of this procedure. DPPHRt/p has been applied in about 50% as total pancreatic head resection with segment resection of the peripapillary duodenum and the intrapancreatic common bile duct. Two thirds of patients suffered symptomatic or asymptomatic cystic neoplasms and 10% neuroendocrine tumors. Major advantages of local pancreatic head resection compared to Whipple type pancreaticoduodenectomy are highly significant preservation of the exo- and endocrine functions and a low hospital mortality below 0.5%. The level of evidence for EN and CP is low, because of retrospective data evaluation and absence of results from controlled studies. For DPPHRt/p results of 9 prospective controlled studies, 3 case controlled studies and 2 retrospective controlled studies underline the advantages of DPPHRt/p compared to partial pancreaticoduodenectomy. Conclusion. The application of tumor enucleation, pancreatic middle segment resection and duodenum-preserving total or partial pancreatic head resection are associated with low level of surgery-related early postoperative complications and a very low hospital mortality. The major advantages of the limited procedures are preservation of exo- and endocrine pancreatic functions and maintenance of peripancreatic Gl-tract tissue.