Benign tumours and low-grade malignant tumours on the tail or body of the pancreas are usually treated surgically with a distal pancreatectomy (with or without splenectomy). Since its description by DRAGUI [1], central pancreatectomy (CP) has become a surgical alternative in some situations to distal pancreatectomy.

Although central pancreatectomy offers benefits in terms of preserving pancreatic function, it is also associated with an increased risk of complications, including pancreatic fistulas [2-4]. Thus, the choice between CP and other surgical approaches should be based on a careful assessment of the characteristics of the patient, the tumor, and the risks specific to each case. CP should be reserved for selected patients who require preservation of postoperative pancreatic function [5].

In our practice, distal pancreatectomy with or without spleen preservation is the treatment of choice for tumors of the tail and body of the pancreas. However, we used the central pancreatectomy technique in two patients (<2% of pancreatectomies performed during the same period). The results were encouraging with an absence of early postoperative complications, a good quality of life of patients, including the absence or non-worsening of diabetes and pancreatic insufficiency, as well as the absence of long-term recurrence. These results encourage us to consider this surgical procedure and to adopt it in the treatment of benign pathologies with low malignancy potential of the pancreas medium.

The first patient was a 50-year-old man, hypertensive under well-controlled dual therapy and a smoker, who presented with epigastric pain that had been evolving for more than a year.

The CT scan revealed two pancreatic cystic formations suggesting a bifocal IPTMP, measuring 12x11 mm and 23x14 mm.   MRI also showed two bifocal intrapancreatic cystic formations, one body and one isthmic, in contact with the Wirsung duct, with intra-cystic micronodule (Figure 1a).

Endoscopic exploration revealed gastritis. Ultrasound showed cystic images in the isthmus of the pancreas. Echo-endoscopy confirmed the presence of a mixed intraductal papillary mucinous tumor (IPMN) located in the isthmus and main body of the pancreas, with signs of degeneration on echo-endoscopy (Figure 1).

Figure 1: Imaging and echo-endoscopy were suggestive of a mixed intraductal papillary mucinous tumor involving the isthmus and main body of the pancreas with endoscopic signs of degeneration.

Figure 1: Imaging and echo-endoscopy were suggestive of a mixed intraductal papillary mucinous tumor involving the isthmus and main body of the pancreas with endoscopic signs of degeneration.

Figure 2: Intraoperative findings.

A central pancreatectomy was performed after releasing posterior adhesions, while ensuring a sufficient margin of healthy pancreatic tissue on both the distal and proximal stumps. The cephalic pancreas stump was closed using a linear stapler (vascular TA 30) reinforced with a 5/0 prolene overjet. The remaining distal stump was anastomosed to the posterior surface of the stomach after a short anterior gastrostomy, and the Wirsung canal was catheterized through a small drain. The anterior gastrostomy was closed with a suture line. The immediate aftermath was uneventful, with no occurrence of a pancreatic fistula, and the Wirsung catheter was removed during a follow-up endoscopy.

The surgical specimen measured 6.5 /4/2 cm, and at the opening, there was a cyst of 2.5x2.5 cm in contact with the Wirsung. Histology confirmed the presence of a 2.5 cm gastric intraductal tumor (IPTMP) without signs of dysplasia or malignancy. The patient resumed his physical and professional activities with a very good quality of life without diabetes or signs of pancreatic insufficiency, and with a follow-up of more than 7 years. Imaging performed as part of regular follow-up, including MRI and endoscopic ultrasound, did not find abnormalities in the two pancreatic stumps (Figure 3).

Figure 3a: Pancreatic echo-endoscopy: incus and head of the areolar pancreas, Wirsung at 3.9mm in diameter, dilation of the caudal Wirsung upstream of a stenosis of the wirungo-fundic anastomosis.

  Figure 3b and 3c: MRI: no recurrences.

  Figure 3d: Pancreas-stomach Anastomosis.

The second patient was a 57-year-old woman with a history of diabetes and high blood pressure who was diagnosed with a left pancreatic nodule following an abdominal ultrasound. She complained of abdominal pain radiating to her back. The patient was in good physical condition, with a body mass index (BMI) of 26.22, stable blood pressure and well-balanced blood glucose under treatment.

MRI revealed bifocal dilation of the Wirsung canal. The first dilatation is in the body of the pancreas, measuring 10 mm in diameter and extending over 29 mm, accompanied by an intrapancreatic nodular lesion measuring 13x17 mm, with isointense intensity on T1-weighted images and hypointense on T2-weighted images. This lesion increases after administration of the contrast medium. An 8 mm mesenteric lymph node was also present. The second dilation was located in the caudal region (Figure 4).

Figure 4: Imagery (CT scan and MRI).

The CT scan showed the tumor process of the pancreatic isthmus in contact with the splenomesenteric trunk and gastroduodenal artery, which is coated by the tumor, covering about a quarter of its circumference, with small satellite lymph nodes (Figure 4).

Tumour markers were negative. After being informed of the treatment options and the different surgical approaches available, the patient underwent surgery.

A tumor mass was identified at the junction between the isthmus and the body of the pancreas, in contact with the venous pedicle and the peptic artery, but without obvious infiltration (Figure 5).

Figure 5: Intraoperative.

A central pancreatectomy was performed with R0 resection, retropancreatic release of the mesenteric and portal axis, and lymphadena and monobloc tomography with the pancreas, including retropancreatic lymph nodes along the vascular venous axis, and celiac trunk (5/3/2.5 cm operating room). The postoperative period was not complicated, and the patient was discharged on day 9.

Histological examination of the operating room confirmed well-differentiated ductal adenocarcinoma of the pancreas grade G2, with perineural invasion, but without vascular embolus. The surgical resection margins of the tail and head of the pancreas were free of infiltration (Figure 6).

Figure 6: a). Infiltration of the pancreatic parenchyma by tumor cells,   b). perineural invasion,  c). Limit of surgical excision.

The patient was referred to oncologists for adjuvant therapy.

During regular follow-up at three months postoperativelxxy, an endoscopy revealed a nodule in the gastric mucosa next to the mouth of the pancreas (Figure 7). The biopsy and pathological study showed no signs of recurrence. MRI and endoscopic ultrasound did not detect abnormalities on the two pancreatic stumps. No local or metastatic recurrence was observed after more than 5 years of follow-up (Figures 7, 8, and 9), and there was no worsening of diabetes.

Figure 7: EES three months postoperative pancreatic reaction and distal pseudo cyst Pancreas-stomach anastomosis (EES performed by Doctor DR BOUCHEMEL).

Figure 8: Endoscopic echo 12 months postoperative.

Figure 9: MRI 48 months postoperative.

Distal pancreatectomy (PD) is the standard procedure for primary malignancies in the neck or body of the pancreas. However, PD removes a significant amount of normal pancreatic parenchyma and can lead to endocrine and exocrine insufficiency [3-5]. The principle of parenchymal sparing is currently accepted and applied in pancreatic surgery, the main objective of which is to preserve the endocrine and exocrine function of the pancreas. This concept is applicable to benign tumors and tumors with low malignancy potential, which are not invasive at the time of their discovery. However, controversy persists over the choice between the two types of resection (distal pancreatectomy or central pancreatectomy).

Central pancreatectomy consists of resection of the central segment of the pancreas, limited on the right by the gastroduodenal artery and on the left, leaving at least 5 cm of normal pancreatic parenchyma. The Wirsung canal of the cephalic stump is selectively sutured with a non-absorbable stitch. Distal stump reconstruction can be performed using an anastomosis between the stump and a jejunal loop or using the stomach [1, 2].

In both cases, we closed the cephalic stump using a linear vascular stapler, while the distal stump was buried in the stomach. The resected pancreatic specimen was sent to the pathologist for confirmation of the diagnosis and to verify that the margins of resection are adequate.

The main advantage of central pancreatectomy (CP) is the preservation of endocrine and exocrine functions, as it spares more pancreatic parenchyma compared to distal pancreatectomy (PD). Thus, CP can be considered as an alternative for the treatment of small pancreatic ductal carcinomas (maximum tumor diameter ≤ 2 cm) confined to the pancreatic parenchyma in the neck of the pancreas [3-8]. However, it is important to note that central pancreatectomy may be associated with greater morbidity than distal pancreatectomy, particularly due to the incidence of pancreatic fistulas and postoperative hemorrhages.

Central pancreatectomy involves two stumps and requires two shunts (anastomoses) with the digestive tract, which increases the risk of these complications. In addition, the procedure is complex and is less frequently performed for benign or low-grades of malignancy tumors, often in a soft pancreas with a small duct [9-11].

Some studies reported a higher rate of clinically significant fistulas for CP compared to DP, while others found no significant difference.

Several meta-analyses involving a large number of patients who had undergone pancreatic resection compared the results according to the type of resection performed: central pancreatectomy or distal pancreatectomy. The conclusions of these different studies were in favour of distal pancreatectomy regarding duration of intervention, blood loss, morbidity and especially pancreatic fistulas (stages B and C). However, there was no significant difference in mortality, serious complications, and recurrence. In contrast, functional outcomes support central pancreatectomy with less exocrine and endocrine pancreatic insufficiency, as well as a reduced risk of de novo diabetes or worsening of pre-existing diabetes [3, 6, 8-13].

Lv A et al. found significant morbidity in patients who underwent central pancreatectomy (CP), particularly grade B/C postoperative pancreatic fistulas, compared to those who underwent distal pancreatectomy (DP) [10]. According to Regimi et al, CP should be reserved for carefully selected patients who require preservation of postoperative pancreatic function [5]. Indications for CP should be limited to situations where distal pancreatic volume can be significantly preserved, and DP can be avoided [8]. For patients with poor general condition, the safety of left pancreatectomy (LCP) should be taken seriously. In this regard, left distal splenopancreatectomy (LDSPP) can be considered safer, more physiological, and easier to perform for tumors located in the cervix of the pancreas [7, 14].

Gao H [15] found no significant difference between the CP and DP groups in terms of overall morbidity rate, pancreatic fistula, reinterventions, readmissions and survival. Another study conducted by Crippa [16] found no difference in overall morbidity, abdominal complications, overall pancreatic fistula rate, or grade B/C pancreatic fistula rate between CP and DP. However, the mean length of hospital stay was longer for DP patients (P = 0.005). In addition, the incidence of endocrine and exocrine insufficiency was significantly higher in the DP group compared to the CP group. Other authors find no differences in the incidence of pancreatic fistulas after central pancreatectomy compared to spleen-sparing pancreatectomy [17].

CP is a safe and effective procedure when performed as directed. Therefore, the indication for central pancreatectomy should be carefully chosen [6, 10-12, 17-19]. CP remains an acceptable and feasible procedure, especially when considering its ability to preserve postoperative pancreatic function [12, 13]. The incidence of de novo or worsening diabetes after central pancreatectomy is very low, and most comparative studies highlight the superiority of CP in preserving pancreatic endocrine function. In contrast, the incidence of postoperative diabetes is higher after distal pancreatectomy, and diabetes appears to require more aggressive treatment than that seen after central pancreatectomy [11, 18, 19]. The results of Crippa et al. [16] show that the incidence of de novo endocrine and exocrine insufficiency was higher in the group of patients with extensive distal pancreatectomy. Thus, it appears that central pancreatectomy (CP) offers an advantage in terms of postoperative endocrine and exocrine dysfunction over standard resections. Due to the good preservation of endocrine and exocrine functions of the pancreas, CP could be considered as an alternative for the treatment of a single small pancreatic ductal adenocarcinoma located at the cervix [15].

In summary, central pancreatectomy is a complex procedure that has benefits in terms of preserving pancreatic function, but it is also associated with a higher risk of complications, especially pancreatic fistulas. The choice between CP and other surgical approaches should be based on a careful assessment of the characteristics of the patient, the tumor and the risks specific to each case.

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