Re: Comparative Analysis of Duodenum-Preserving Head Resection and Pancreaticoduodenectomy
The comparative analysis of duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD) is a critical topic in the field of pancreatic surgery, particularly for the treatment of benign or borderline pancreatic diseases. This discussion is based on a recent study by Sun et al., which compared the perioperative and long-term outcomes of these two surgical techniques. The study highlighted several advantages of DPPHR, but also raised questions about the specifics of the surgical modifications used and the associated complications and mortality rates.
DPPHR is a surgical technique that aims to preserve the duodenum while resecting the pancreatic head. This method has several modifications, including the Beger, Frey, and Gloor procedures. The Beger procedure involves transecting the pancreas above the superior mesenteric portal vein and excavating the pancreatic head, preserving a small rim of pancreatic tissue along with the duodenum. The Frey modification includes a limited resection of the pancreatic head with extended drainage of the main pancreatic duct by longitudinal pancreatectomy of the body and tail of the pancreas. The Gloor modification is a variation of the Beger and Frey procedures, focusing on local excision of the tumor without dividing the pancreas over the portal vein.
In the study by Sun et al., 29 patients underwent DPPHR, with 10 patients receiving the Berne modification, 11 the Frey modification, and 8 the Beger procedure. The Berne modification involves local excision of the tumor in the head of the pancreas without division and cutting of the pancreas over the portal vein, with reconstruction accomplished by a single side-to-side pancreaticojejunostomy. The Frey modification includes limited resection of the pancreatic head with extended drainage of the main pancreatic duct by longitudinal pancreatectomy of the body and tail of the pancreas, with reconstruction performed with a Roux-en-Y loop with side-to-side pancreaticojejunostomy. The Beger modification involves transecting the pancreas above the superior mesenteric portal vein, excavating the pancreatic head, and preserving a small rim of pancreatic tissue along with the duodenum, with reconstruction accomplished by pancreaticojejunostomy.
Despite the advantages of DPPHR, the study did not specify which modification was applied to each patient, which is crucial for understanding the outcomes and potential complications associated with each technique. Additionally, the study did not report postoperative complications and mortality rates, which are essential for a comprehensive comparison of the two surgical methods.
In a separate study by Pedrazzoli et al., 27 DPPHR and 37 PD procedures were performed for benign or borderline diseases between 1991 and 2008. The study classified three types of DPPHR based on the size and site of the pancreatic head remnant: Type 1, where a small rim of pancreatic head tissue is preserved along all the inner duodenal surface; Type 2, where the rim of pancreatic tissue is preserved only superiorly to the major duodenal Vater’s Papilla; and Type 3, where pancreatic head tissue is completely removed, and the common bile duct (CBD) is skeletonized. The study found that DPPHR had a higher complication rate (81.5% vs. 40.5%) and pancreatic fistula rate (40.1% vs. 18.9%) compared to PD. However, the hospital mortality rate was 0% for DPPHR and 2.7% for PD.
Beger et al. also classified three types of DPPHR: DPPHR-S, which involves duodenum-preserving total pancreatic head resection and resection of the periampullary segment of the duodenum and intrapancreatic segment of CBD; DPPHR-T, which is equivalent to Type 3 DPPHR; and DPPHR-P, which involves partial pancreatic head resection, local tumor extirpation, and resection of the uncinate process. A systematic review by Beger et al. of 523 DPPHRs for premalignant and low-malignant neoplasms found an overall morbidity rate of 31.5% for DPPHR-T and 46.6% for DPPHR-S, with no significant difference in the incidence of severe complications and A-C postoperative pancreatic fistula. The mortality rate was 0.6%.
The study by Sun et al. reported the results of postoperative long-term follow-up but did not specify the mean and median follow-up periods. Significantly fewer DPPHR patients experienced exocrine pancreatic insufficiency or long-term cumulative complications compared to PD patients. Additionally, DPPHR patients had less weight loss and better overall health. However, the incidence of new-onset diabetes was higher among DPPHR patients (17.2%) than PD patients (7.0%). This higher incidence of new-onset diabetes among DPPHR patients may be due to the higher percentage of chronic pancreatitis patients in the DPPHR group (58.6%) compared to the PD group (31.6%).
In the study by Pedrazzoli et al., all DPPHR and PD patients were followed for a mean of 100 months and 135 months, respectively. DPPHR showed a lower incidence of benign cholangitis, insulin-dependent diabetes mellitus, and pancreatic insufficiency compared to PD. The study concluded that DPPHR has several advantages over PD, including better long-term outcomes and quality of life for patients.
In summary, the comparative analysis of DPPHR and PD highlights the advantages and disadvantages of each surgical technique. DPPHR offers several benefits, including better long-term outcomes and quality of life, but also has a higher complication rate and incidence of new-onset diabetes. The specific modifications of DPPHR used in each case are crucial for understanding the outcomes and potential complications associated with the procedure. Further studies with larger sample sizes and longer follow-up periods are needed to provide more comprehensive data on the perioperative complications and mortality rates of DPPHR and PD.
doi.org/10.1097/CM9.0000000000001995
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