Der Chirurg

, Volume 84, Issue 5, pp 412–420 | Cite as

Duodenumerhaltende totale Pankreaskopfresektion

Ein organsparendes Verfahren bei zystischen Neoplasien und nichtinvasiven malignen Tumoren
Übersichten

Zusammenfassung

Zystische Neoplasien der Bauchspeicheldrüse werden zunehmend häufiger diagnostiziert und operiert. Intraduktale papilläre muzinöse Tumoren (IPMN) und muzinöse zystische Neoplasien (MCN) sind primär gutartige Tumoren, die eine maligne Transformation zum zystischen Adenokarzinom mit unterschiedlicher Häufigkeit durchlaufen. Die duodenumerhaltende totale Pankreaskopfresektion ist ein bei entzündlichen Pankreaskopftumoren zunehmend häufig angewandtes Operationsverfahren, das auch bei zystischen Neoplasien und nichtinvasiven Malignomen ein adäquates Therapieverfahren darstellt. Die totale Entfernung des Pankreaskopfes kann als eine das Duodenum vollständig erhaltende Operation oder mit zusätzlicher Segmentresektion des peripapillären Duodenums und des intrapankreatischen Ductus choledochus angewandt werden.

Eine Literaturrecherche ergab IPMN, MCN und SCA (seröse Zystadenome) -Tumoren als häufigste Operationsindikation; 9% der Patienten hatten ein In-situ-Karzinom; bei 74 (19%) Patienten erfolgte die Operation wegen eines T1N0-periampulären Karzinoms oder einer endokrinen Neoplasie oder wegen isolierter Pankreaskopfmetastase. 63% hatten eine duodenumerhaltende totale Pankreaskopfresektion (DPPHRt), bei 37% wurde auch das peripapilläre Segment des Duodenums reseziert. Früh-postoperative Komplikationen traten am Choledochus (10%), und am Duodenum (5,3%) auf; die Pankreasfistelhäufigkeit betrug 16,5%; die Reoperationshäufigkeit (1,8%) und Krankenhausletalität (0,52%) waren niedrig. Im Vergleich zur Whipple-Typ-Resektion vermindert die DPPHRt nicht die exokrinen und endokrinen Funktionen der Bauchspeicheldrüse.

Schlüsselwörter

Zystische Neoplasien Papilläre muzinöse Tumoren  Malignen Tumoren  Pankreaskopfresektion Organsparende Operation 

Duodenum-preserving total pancreatic head resection

An organ-sparing operation technique for cystic neoplasms and non-invasive malignant tumors

Abstract

Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.

Keywords

Cystic neoplasm Papillary mucinous tumor Malignant tumor Pancreatic head resection Organ-sparing operation 

Literatur

  1. 1.
    Adsay NV (2002) Intraductal papillary mucinous neoplasms of the pancreas: pathology and molecular genetics. J Gastrointest Surg 6:656–659PubMedCrossRefGoogle Scholar
  2. 2.
    Ahn YJ, Kim SW, Park YC et al (2003) Duodenal-preserving resection of the head of the pancreas and pancreatic head resection with second-portion duodenectomy for benign lesions, low-grade malignancies, and early carcinoma involving the periampullary region. Arch Surg 138:162–168PubMedCrossRefGoogle Scholar
  3. 3.
    Akiyama H, Ono K, Takano M et al (2002) Solid-pseudopapillary tumor of the pancreatic head causing marked distal atrophy: a tumor originated posterior to the main pancreatic duct. Int J Gastrointest Cancer 32:47–52PubMedCrossRefGoogle Scholar
  4. 4.
    Bassi C, Sarr MG, Lillemoe KD, Reber HA (2008) Natural history of intraductal papillary mucinous neoplasms (IPMN): current evidence and implications for management. J Gastrointest Surg 12:645–650PubMedCrossRefGoogle Scholar
  5. 5.
    Beger HG, Bittner R (1987) Die duodenumerhaltende Pankreaskopfresektion. Chirurg 58:7–13PubMedGoogle Scholar
  6. 6.
    Beger HG, Gloekler S, Gansauge F et al (2012) In: Fuchsberger PR, Ashburn HJ (Hrsg) ACS multimedia atlas of surgery, pancreas surgery. Ciné-Med, Inc. American College of Surgeons, Chicago, S 103–118Google Scholar
  7. 7.
    Beger HG, Schwarz M, Poch B (2012) How i do it: duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions. J Gastrointest Surg (in press)Google Scholar
  8. 8.
    Brambs HJ, Juchems M (2012) Radiologische Diagnostik der intraduktalen papillär muzinösen Neoplasie. Chirurg 83:116–122PubMedCrossRefGoogle Scholar
  9. 9.
    Brat DJ, Lillemoe KD, Yeo CJ et al (1998) Progression of pancreatic intraductal neoplasias to infiltrating adenocarcinoma of the pancreas. Am J Surg Pathol 22:163–169PubMedCrossRefGoogle Scholar
  10. 10.
    Busquets J, Fabregat J, Borobia FG et al (2010) Organ-preserving surgery for benign lesions and low-grade malignancies of the pancreatic head: a matched case-control study. Surg Today 40:125–131PubMedCrossRefGoogle Scholar
  11. 11.
    Cauley CE, Pitt HA, Ziegler KM et al (2012) Pancreatic enucleation: improved outcomes compared to resection. J Gastrointest Surg 16:1347–1353PubMedCrossRefGoogle Scholar
  12. 12.
    Ceppa EP, De la Fuente SG, Reddy SK et al (2010) Defining criteria for selective operative management of pancreatic cystic lesions: does size really matter? J Gastrointest Surg 14:236–244PubMedCrossRefGoogle Scholar
  13. 13.
    Chari ST, Yadav D, Smyrk TC et al (2002) Study of recurrence after surgical resection of intraductal papillary mucinous neoplasm of the pancreas. Gastroenterology 123:1500–1507PubMedCrossRefGoogle Scholar
  14. 14.
    Diener MK, Rahbari NN, Fischer L et al (2008) Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis. Ann Surg 247:950–961PubMedCrossRefGoogle Scholar
  15. 15.
    Fernández-Cruz L, Olvera C, López-Boado MA et al (2006) Organ-preserving resection of the pancreaticoduodenal region in the treatment of intraductal papillary mucinous tumors. Cir Esp 80:295–300PubMedCrossRefGoogle Scholar
  16. 16.
    Frossard JL, Amouyal P, Amouyal G et al (2003) Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions. Am J Gastroenterol 98:1516–1524PubMedCrossRefGoogle Scholar
  17. 17.
    Gong DJ, Zhang JM, Mao GJ et al (2012) Duodenum-preserving pancreatic head resection vs. pancreatoduodenectomy for benign lesions and low-grade malignancies of the pancreatic head. Hepatogastroenterology 60(121) doi:10.5754/hge12407. [Epub ahead of print]Google Scholar
  18. 18.
    Hirano S, Kondo S, Ambo Y et al (2004) Outcome of duodenum-preserving resection of the head of the pancreas for intraductal papillary-mucinous neoplasm. Dig Surg 21:242–245PubMedCrossRefGoogle Scholar
  19. 19.
    Horiguchi A, Miyakawa S, Ishihara S et al (2010) Surgical design and outcome of duodenum-preserving pancreatic head resection for benign or low-grade malignant tumors. J Hepatobiliary Pancreat Sci 17:792–797PubMedCrossRefGoogle Scholar
  20. 20.
    Hutchins GF, Draganov PV (2009) Cystic neoplasms of the pancreas: a diagnostic challenge. World J Gastroenterol 15:48–54PubMedCrossRefGoogle Scholar
  21. 21.
    Hwang DW, Jang JY, Lee SE et al (2012) Clinicopathologic analysis of surgically proven intraductal papillary mucinous neoplasms of the pancreas in SNUH: a 15-year experience at a single academic institution. Langenbecks Arch Surg 397:93–102PubMedCrossRefGoogle Scholar
  22. 22.
    Imaizumi T, Hatori T, Harada N et al (2007) Intraductal papillary mucinous neoplasm of the pancreas; resection and cancer prevention. Am J Surg 194:95–99CrossRefGoogle Scholar
  23. 23.
    Isaji S, Kawarada Y (2001) Pancreatic head resection with second-portion duodenectomy for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head region. Am J Surg 181:172–176PubMedCrossRefGoogle Scholar
  24. 24.
    Ito K (2005) Duodenum preservation in pancreatic head resection to maintain pancreatic exocrine function (determined by pancreatic function diagnostant test and cholecystokinin secretion). Hepatobiliary Pancreat Surg 12:123–128CrossRefGoogle Scholar
  25. 25.
    Kanazumi N, Nakao A, Kaneko T et al (2001) Surgical treatment of intraductal papillary-mucinous tumors of the pancreas. Hepatogastroenterology 48:967–971PubMedGoogle Scholar
  26. 26.
    Kimura W, Makuuchi M, Kuroda A (1998) Characteristics and treatment of mucin-producing tumor of the pancreas. Hepatogastroenterology 45:2001–2008PubMedGoogle Scholar
  27. 27.
    Kimura W, Nagai H (1995) Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas. Ann Surg 221:359–363PubMedCrossRefGoogle Scholar
  28. 28.
    Lee CJ, Scheiman J, Anderson MA et al (2008) Risk of malignancy in resected cystic tumors of the pancreas < or = 3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report. J Gastrointest Surg 12:234–242PubMedCrossRefGoogle Scholar
  29. 29.
    Lee SE, Jang JY, Hwang DW et al (2010) Clinical efficacy of organ-preserving pancreatectomy for benign or low-grade malignant potential lesion. J Korean Med Sci 25:97–103PubMedCrossRefGoogle Scholar
  30. 30.
    Lévy P, Jouannaud V, O’Toole D et al (2006) Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy. Clin Gastroenterol Hepatol 4:460–468PubMedCrossRefGoogle Scholar
  31. 31.
    Matthaei H, Norris AL, Tsiatis AC et al (2012) Clinicopathological characteristics and molecular analyses of multifocal intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 255:326–333PubMedCrossRefGoogle Scholar
  32. 32.
    Matthaei H, Schulick RD, Hruban RH, Maitra A (2011) Cystic precursors to invasive pancreatic cancer. Nat Rev Gastroenterol Hepatol 8:141–150PubMedCrossRefGoogle Scholar
  33. 33.
    Miller JR, Meyer JE, Waters JA et al (2011) Outcome of the pancreatic remnant following segmental pancreatectomy for non-invasive intraductal papillary mucinous neoplasm. HPB (Oxford) 13:759–766Google Scholar
  34. 34.
    Miyakawa S, Horiguchi A, Mizuno K et al (2003) Preservation of arterial arcades during duodenum-preserving total pancreatic head resection for intraductal papillary tumor. Hepatogastroenterology 50:993–997PubMedGoogle Scholar
  35. 35.
    Murakami Y, Uemura K, Yokoyama Y et al (2004) Pancreatic head resection with segmental duodenectomy for intraductal papillary mucinous tumors of the pancreas. J Gastrointest Surg 8:713–719PubMedCrossRefGoogle Scholar
  36. 36.
    Nakagohri T, Kinoshita T, Konishi M et al (2007) Surgical outcome of intraductal papillary mucinous neoplasms of the pancreas. Ann Surg Oncol 14:3174–3180PubMedCrossRefGoogle Scholar
  37. 37.
    Nakao A, Takeda S, Nomoto S et al (2010) Pancreatic head resection with segmental duodenectomy for pancreatic neoplasms. J Hepatobiliary Pancreat Sci 17:788–791PubMedCrossRefGoogle Scholar
  38. 38.
    Pedrazzoli S, Canton SA, Sperti C (2011) Duodenum-preserving versus pylorus-preserving pancreatic head resection for benign and premalignant lesions. J Hepatobiliary Pancreat Sci 18:94–102PubMedCrossRefGoogle Scholar
  39. 39.
    Rodriguez JR, Salvia R, Crippa S et al (2007) Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection. Gastroenterology 133:72–79; quiz 309–310PubMedCrossRefGoogle Scholar
  40. 40.
    Schoenberg MH, Hepp G, Beger HG (1998) Die duodenumerhaltende Pankreaskopfresektion zur Behandlung von benignen Pankreaskopftumoren. Chirurg 69:633–638PubMedCrossRefGoogle Scholar
  41. 41.
    Schwarz A, Beger HG (1996) Modifikation der duodenumerhaltenden Pankreaskopfresektion mit Segmentresektion des Duodenum – Erfahrung mit 4 Patienten (Vortrag). Jahrestagung der Mittelrheinischen Chirurgen, Ulm (September)Google Scholar
  42. 42.
    Siech M, Mattfeldt T, Schlosser W, Beger HG (2000) Duodenum-preserving pancreatic head resection in patients with benign and borderline tumors of the pancreatic head. Langenbecks Arch Surg 385:229–233PubMedCrossRefGoogle Scholar
  43. 43.
    Siech M, Tripp K, Schmidt-Rohlfing B et al (1999) Intraductal papillary cystic tumors of the pancreas. Am J Surg 177:117–120PubMedCrossRefGoogle Scholar
  44. 44.
    Takada T, Yasuda H, Amano H, Yoshida M (2004) A duodenum-preserving and bile duct-preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis. J Gastrointest Surg 8:220–224PubMedCrossRefGoogle Scholar
  45. 45.
    Tanaka M, Chari S, Adsay V et al (2006) International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32PubMedCrossRefGoogle Scholar
  46. 46.
    Tanaka M, Fernández-del Castillo C, Adsay V et al (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 12:183–197PubMedGoogle Scholar
  47. 47.
    Tseng JF, Warshaw AL, Sahani DV et al (2005) Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg 242:413–419; discussion 419–421PubMedGoogle Scholar
  48. 48.
    Xiong JX, Wang CY, Tao J, Zhang SH (2007) Indication and choice of operation technique for duodenum-preserving resection of pancreatic head: 22 cases reports. Zhonghua Wai Ke Za Zhi 45:24–26PubMedGoogle Scholar
  49. 49.
    Yamaguchi H, Wakiguchi S, Murakami G et al (2001) Blood supply to the duodenal papilla and the communicating artery between the anterior and posterior pancreaticoduodenal arterial arcades. J Hepatobiliary Pancreat Surg 8:238–244PubMedCrossRefGoogle Scholar
  50. 50.
    Yamaguchi K, Yokohata K, Nakano K et al (2001) Which is a less invasive pancreatic head resection: PD, PPPD, or DPPHR? Dig Dis Sci 46:282–288PubMedCrossRefGoogle Scholar
  51. 51.
    Yamao K, Yanagisawa A, Takahashi K et al (2011) Clinicopathological features and prognosis of mucinous cystic neoplasm with ovarian-type stroma: a multi-institutional study of the Japan pancreas society. Pancreas 40:67–71PubMedCrossRefGoogle Scholar
  52. 52.
    Yasuda H, Takada T, Toyota N et al (2000) Limited pancreatectomy: significance of postoperative maintenance of pancreatic exocrine function. J Hepatobiliary Pancreat Surg 7:466–472PubMedCrossRefGoogle Scholar
  53. 53.
    Imaizumi T, Hanyu F, Suzuki M et al (1995) Clinical experience with duodenum-preserving total resection of the head of the pancreas with pancreatocholedochoduodenostomie. J Hep Bil Pancr Surg 2:38-44CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Zentrum für onkologische, endokrinologische und minimalinvasive ChirurgieDonauklinikum Neu-UlmUlmDeutschland
  2. 2.Chirurgische Klinik IOstalb-KlinikumAalenDeutschland
  3. 3.c/o Universitätsklinikum UlmUlmDeutschland

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