Middle-preserving pancreatectomy for synchronous ampullary carcinoma and solid-pseudopapillary tumor of distal pancreas

Abstract

Introduction

Total pancreatectomy is the treatment of choice for multicentric diseases involving the pancreas. Middle-preserving pancreatectomy is a recently reported alternative procedure when the pancreatic body is spared from disease.

Presentation of case

We report a 63-year old lady who underwent a combined Whipple's operation and distal splenopancreatectomy for her synchronous ampullary carcinoma and solid-pseudopapillary tumor of the distal pancreas.

Discussion

For multiple tumors of the pancreas, the choice of surgery should be based on the nature of pathology and follow the principle of oncological resection.

Conclusion

Middle-preserving pancreatectomy is a safe and feasible option for patient with multicentric or synchronous pancreatic pathologies.

1. Introduction

Total pancreatectomy is the treatment of choice for multicentric diseases involving the pancreas, especially for pathologies with frank malignancy. In recent years, there has been an increased use of pancreatic resection for benign or low-grade malignant lesions, especially in young patients with long life-expectancy. For patients with multiple pancreatic lesions, parenchyma-sparing resection decreases the risk of exocrine/endocrine insufficiency. Middle-preserving pancreatectomy is a recently reported alternative procedure when the pancreatic body is spared from disease,^1,2 with good long-term functional and oncological results.

We report the successful use of middle pancreatectomy for a patient with synchronous ampullary carcinoma and solid-pseudopapillary tumor of the distal pancreas.

2. Case report

In January 2011, a 63-years old female patient presented with progressive painless jaundice for 10 days. Physical examination showed jaundice and a palpable 5-cm vague mass in the left upper quadrant of the abdomen. Preoperative hepatic function showed obstructive jaundice with a total bilirubin of 229.5 μmol/L. Carbohydrate antigen 19-9 (CA19-9) was elevated to 210.8 IU/mL. Carcinoembryonic antigen (CEA) was normal (5.7 μg/L). Her fasting glucose was 5.85 mmo/L. Ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) showed dilated intrahepatic and extrahepatic ducts with a 1.8 cm × 1.7 cm tumor in the ampullary region, and a 5 cm × 4.1 cm tumor in the pancreatic tail region. Endoscopic retrograde cholangiopancreatography (ERCP) and ampullary tumor biopsy confirmed ampullary carcinoma.

A combined Whipple's operation and distal splenopancreatectomy was carried out. The operating time was 450 min. The intraoperative blood loss was 400 mL. She had no procedure-related complications and was discharged from hospital on postoperative day 12. The operative photo is shown in Fig. 1.

Fig. 1.

Operative photograph showing pancreas after Whipple's operation. Tumor at distal part of pancreas indicated by tip of forceps.

Postoperative pathology reported T3N1 (AJCC TNM staging 7th edition) moderate differentiated adenocarcinoma of ampulla and solid-pseudopapillary tumor of the tail of pancreas. All resection margins were clear.

At six month follow-up after surgery, the patient was well. She had no diabetes mellitus and no tumor recurrence.

3. Discussion

The involvement of two or more pancreatic regions by malignant lesions generally warrants a total pancreatectomy. While a total pancreatectomy is advisable for multicentric pancreatic malignancies as there may be premalignant changes in the whole pancreatic duct, it is an overtreatment for multiple benign lesions or lesions with borderline malignancies, especially in young and otherwise healthy patients. Total pancreatectomy results in a total loss of normal pancreatic parenchyma and causes impairment of exocrine and endocrine functions.^1–3 The appropriate surgical treatment for a pancreatic multifocal disease which spares the body of the pancreas remains unclear.

Our patient suffered from a frankly malignant ampullary tumor and a pancreatic tail tumor with low malignant potential.⁴ Radical pancreaticoduodenectomy is the conventional treatment for ampullary carcinoma with relatively good prognosis. Solid pseudopapillary tumors account for 5.5–12% of pancreatic cystic neoplasms. They typically occur in young women. Morphologically, solid pseudopapillary tumors are typically large and encapsulated lesions, with solid and cystic areas and pseudopapillary patterns on histology. They often present as a large, multilobular mass of homogeneous, fleshy tissue separated by areas of hemorrhagic and necrotic cystic degeneration. They are generally surrounded by a fibrous capsule and are well-demarcated from the rest of the pancreas, although infiltration into surrounding tissues is not uncommon. We chose a combined Whipple's operation and distal pancreatectomy rather than a total pancreatectomy and the patient recovered well without diabetes mellitus.

Technical feasibility, short- and long-term outcomes of middle-preserving pancreatectomy for multiple pathologies in the pancreas have rarely been reported. Partelli et al. reported 5 patients who underwent middle-preserving pancreatectomies for multicentric pancreatic benign or slowly growing malignant pancreatic lesions.⁵ The median operative time was 365 min (range 330–440 min). Postoperative mortality was nil and postoperative morbidity was 1 (20%). At a median follow-up of 20 months (range 14–118 months) all patients were alive and disease-free. Two patients developed insulin-dependent diabetes mellitus, and exocrine insufficiency. One patient developed exocrine insufficiency only. Ohzato et al. reported on a 67-year old lady who underwent a middle-preserving pancreatectomy for metastatic tumors in the pancreas. On computed tomography there were five well-demarcated, strongly enhancing nodules in the pancreas: 5.5 cm in the head, 2.0 and 1.8 cm in the body, and 1.2 and 1.0 cm in the tail.⁶ Sperti et al. reported a 59-year old man who underwent a middle-preserving pancreatectomy for multicentric intraductal papillary mucinous neoplasia (IPMN).⁷ Ikematsu et al. reported a 59-year old man who underwent sequential distal pancreatectomy and pancreaticoduodenectomy for metachronous multiple adenocarcinomas of the pancreas.⁸

For multiple tumors of the pancreas, the choice of surgery should be based on the nature of pathology and follow the principle of oncological resection. If possible, pancreatic parencyma should be preserved to reduce long-term complications and improve quality of life of the patients. A middle-preserving pancreatectomy can be performed safely for multiple pathologies which involve the head and the tail of the pancreas. It prevents the problems associated with total pancreatectomy.

Conflict of interest statement

None.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of IJS Case Reports on request.

Contributors

Chen HW and Wang FJ are the attending surgeons who did the acquisition of data, provided technical and material support and wrote the first draft of the case report. Lai ECH and Lau WY did the critical revision and final proof of the article.