Middle-segment preserving pancreatectomy for multifocal neuroendocrine pancreatic tumors.

Background: Multifocal neuroendocrine tumors (NET) usually occur in the context of a multiple neuroendocrine neoplasia type 1 (MEN1). When the proximal part of the pancreatic body is spared by NET, Miura et al. have proposed a "middle-segment preserving" pancreatectomy (MSP) as alternative to total pancreatectomy [1-3].
Video: A 28-year-old woman with MEN1 was referred for surgical resection of a multifocal pancreatic tumor with single metastasis located and a single liver metastasis in close contact with the left hepatic duct. The preoperative work-up by DOTATOC-PETSCAN revealed multifocal tumors sparing only the proximal part of the pancreatic body. Hormonal dosages were normal but Chromogranine A was elevated at 700 μg/l. At surgery pancreatic intraoperative ultrasonography confirmed the absence of tumor at the proximal part of the pancreas. A pancreaticoduodenectomy was performed first followed by a left pancreatectomy with partial splenectomy. A 3 × 5 cm remnant of the pancreatic body vascularized by a dorsal pancreatic artery was preserved (Fig. 1). A left hepatectomy was then performed (Fig. 2). Digestive reconstruction is performed by a pancreatojejunostomy with an externalized pancreatic stent (Fig. 3), hepaticojejunostomy and a gastrojejunal anastomosis.
Results: Surgery lasted 660 minutes. Postoperative course was uneventful but a late readmission was necessary because of pyelonephritis due to nephrolithiasis treated by ureteral stent insertion. At 11 months postoperative follow-up the patient was disease-free with no endocrine dysfunction under oral pancreatic enzyme supplementation. Total weight loss since surgery was 8 Kilograms.
Conclusions: A middle-segment-preserving pancreatectomy could be a valid surgical alternative to total pancreatectomy for multifocal pancreatic tumors sparing the proximal pancreatic body. This operation can achieve acceptable functional outcomes but large series with long-term follow up are needed to evaluate the advantages and results of MSP.
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