Pancreatic Endocrine Tumors Less Than 4 cm in Diameter Resect or Enucleate? A Single-Center Experience

Dipartimento di Scienze Chirurgiche e Anestesiologiche, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Bologna, Italy.
Pancreas (Impact Factor: 3.01). 08/2010; 39(6):825-8. DOI: 10.1097/MPA.0b013e3181cf155c
Source: PubMed

ABSTRACT Pancreatic endocrine tumors (PETs) are usually small, benign or low-grade malignant, and surgery should preserve the pancreatic parenchyma as much as possible. The aim of the study was to evaluate the postoperative and long-term survival of patients undergoing enucleation in small PETs.
Of 82 patients having PETs, 46 with tumor less than 4 cm in diameter, without distant metastases and with R0 resection by final pathologic examination, were included in this study. Enucleation was performed when the tumor did not involve the main pancreatic duct and in the absence of peripancreatic lymphadenopathy (group A); a typical resection was carried out in all other cases (group B). The 2 groups were compared regarding postoperative mortality and morbidity, pancreatic fistula, postoperative hospital stay, reoperation, World Health Organization classification, TNM stage, recurrence, and long-term survival.
There were 15 patients (32.6%) in group A and 31 (67.4%) in group B. Postoperative and long-term results were similar in the 2 groups, whereas World Health Organization classification was significantly different; enucleation was performed more frequently than typical R0 resection in benign tumors (P = 0.009).
Enucleation should be reserved for patients having benign PETs less than 4 cm in diameter and far from the main pancreatic duct.


Available from: Ricci Claudio, Jun 03, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: Only small, potentially benign pancreatic tumors located ≥3 mm distant from the main pancreatic duct (MPD) are considered good candidates for enucleation. This study evaluates the outcome of enucleations with regard to their distance to the MPD. Clinical characteristics, complications, and outcomes of prospectively documented patients with small (≤30 mm), potentially benign pancreatic tumors, who underwent enucleation, were retrospectively analyzed. Patients were divided in two groups, either deep enucleation (DE, distance ≤3 mm) or standard enucleation (SE, distance >3 mm), as determined by intraoperative ultrasonography (IOUS). Sixty patients underwent DE (n = 30) or SE (n = 30) with IOUS. Both groups did not differ regarding age, tumor size, pathology, and operating time. Complications occurred in 24/30 (80 %) patients of the DE group compared to 15/30 (50 %) patients after SE (P = 0.029). Mortality was nil. The most frequent complication was pancreatic fistula (POPF) occurring in 22/30 (73.3 %) patients after DE and 9/30 (30 %) patients undergoing SE (P = 0.002). Especially, the rate of clinically significant POPF types B and C was higher after DE (21 of 30 patients) compared to SE (7 of 30 patients, P = 0.0006). Univariate and multivariate analyses revealed DE as the only significant factor that negatively influenced the occurrence of POPF. Postoperative hospital stay tended to be longer after DE (15 vs. 11.5 days, P = 0.050). All but two patients with metastatic gastrinoma and two patients, who died of unrelated causes, showed no evidence of disease after a median follow-up of 24 (3-235) months. Deep enucleation of small, potentially benign pancreatic tumors should be considered with caution given the high rate of clinically relevant POPF.
    Langenbeck s Archives of Surgery 02/2014; 399(3). DOI:10.1007/s00423-014-1171-0 · 2.16 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard. To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate. Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2 -3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20 % of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11 %, pancreatic fistula in 33 %. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33 % pancreatic fistula and severe post-operative complications of 18 % is related to management of proximal pancreatic stump. DPPHRt/s is used in 70 % for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10 % for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy. The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.
    International Journal of Surgery (London, England) 04/2014; DOI:10.1016/j.ijsu.2014.03.020 · 1.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Pancreatic neuroendocrine tumors (pNETs) are relatively rare tumors comprising 1-2% of all pancreas neoplasms. In the last 10 years our understanding of this disease has increased dramatically allowing for advancements in the treatment of pNETs. Surgical excision remains the primary therapy for localized tumors and only potential for cure. New surgical techniques using laparoscopic approaches to complex pancreatic resections are a major advancement in surgical therapy and increasingly possible. With early detection being less common, most patients present with metastatic disease. Management of these patients requires multidisciplinary care combining the best of surgery, chemotherapy and other targeted therapies. In addition to surgical advances, recently, there have been significant advances in systemic therapy and targeted molecular therapy.