- Michael D Kluger, MD, MPH
Michael D Kluger, MD, MPH
- Assistant Professor of Surgery
- College of Physicians and Surgeons
- New York-Presbyterian Hospital/CUMC
- James Lee, MD
James Lee, MD
- Edwin C. and Anne K. Weiskopf Associate Professor of Surgical Oncology (in Surgery and in the Herbert Irving Comprehensive Cancer Center)
- Columbia University Medical Center
- John Chabot, MD
John Chabot, MD
- David V. Habif Professor of Surgery
- Columbia University Medical Center
- Section Editors
- Sally E Carty, MD, FACS
Sally E Carty, MD, FACS
- Section Editor — Endocrine Surgery
- Professor, Chief, Division of Endocrine Surgery
- University of Pittsburgh School of Medicine
- Stanley W Ashley, MD
Stanley W Ashley, MD
- Section Editor — Pancreatic and Hepatobiliary Surgery
- Chief Medical Officer and Senior Vice President for Clinical Affairs
- Brigham and Women’s Hospital
- Frank Sawyer Professor of Surgery
- Harvard Medical School
The pancreas has exocrine and endocrine functions that are essential to life. A loss of such functions can result from either disease (eg, chronic pancreatitis, cystic fibrosis) or surgery (total pancreatectomy). The development of long-acting insulin and effective digestive enzymes have made it possible for patients to sustain a reasonable quality of life after a total pancreatectomy.
Total pancreatectomy has been performed since the 1970s, and its frequency has increased over the last two decades. The anatomy of the pancreas makes it difficult to remove. Along its length, the pancreas contacts almost all structures of the upper abdomen, and the head of the pancreas is densely adherent to the duodenum and envelops the distal common bile duct. As a result, a total pancreatectomy most often requires a concomitant duodenectomy, and subsequent gastric and biliary anastomoses to the jejunum to preserve gastrointestinal continuity.
The indications for and techniques of total pancreatectomy are discussed in this topic. Techniques of partial pancreatic resection are discussed in other topics. (See "Surgical resection of lesions of the head of the pancreas" and "Surgical resection of lesions of the body and tail of the pancreas".)
INDICATIONS FOR TOTAL PANCREATECTOMY
Total pancreatectomy is a major operation with potential for mortality and severe morbidity. It is reserved for patients who have failed medical management and are not candidates for less extensive surgery. The indications for total pancreatectomy:
●Severe benign or intractable conditions that cannot be effectively treated medically or with less extensive resection:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Almond M, Roberts KJ, Hodson J, et al. Changing indications for a total pancreatectomy: perspectives over a quarter of a century. HPB (Oxford) 2015; 17:416.
- Müller MW, Friess H, Kleeff J, et al. Is there still a role for total pancreatectomy? Ann Surg 2007; 246:966.
- Wilson GC, Sutton JM, Smith MT, et al. Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis. Surgery 2015; 158:872.
- Lowenfels AB, Maisonneuve P, Cavallini G, et al. Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med 1993; 328:1433.
- Raimondi S, Lowenfels AB, Morselli-Labate AM, et al. Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Best Pract Res Clin Gastroenterol 2010; 24:349.
- Stauffer JA, Nguyen JH, Heckman MG, et al. Patient outcomes after total pancreatectomy: a single centre contemporary experience. HPB (Oxford) 2009; 11:483.
- Bellin MD, Gelrud A, Arreaza-Rubin G, et al. Total pancreatectomy with islet autotransplantation: summary of an NIDDK workshop. Ann Surg 2015; 261:21.
- Lowenfels AB, Maisonneuve P, DiMagno EP, et al. Hereditary pancreatitis and the risk of pancreatic cancer. International Hereditary Pancreatitis Study Group. J Natl Cancer Inst 1997; 89:442.
- Howes N, Lerch MM, Greenhalf W, et al. Clinical and genetic characteristics of hereditary pancreatitis in Europe. Clin Gastroenterol Hepatol 2004; 2:252.
- Yamaguchi K, Konomi H, Kobayashi K, et al. Total pancreatectomy for intraductal papillary-mucinous tumor of the pancreas: reappraisal of total pancreatectomy. Hepatogastroenterology 2005; 52:1585.
- Roch AM, Ceppa EP, DeWitt JM, et al. International Consensus Guidelines parameters for the prediction of malignancy in intraductal papillary mucinous neoplasm are not properly weighted and are not cumulative. HPB (Oxford) 2014; 16:929.
- Shimizu Y, Yamaue H, Maguchi H, et al. Validation of a nomogram for predicting the probability of carcinoma in patients with intraductal papillary mucinous neoplasm in 180 pancreatic resection patients at 3 high-volume centers. Pancreas 2015; 44:459.
- Tanaka M, Fernández-del Castillo C, Adsay V, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12:183.
- Vege SS, Ziring B, Jain R, et al. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:819.
- Schmidt CM, Glant J, Winter JM, et al. Total pancreatectomy (R0 resection) improves survival over subtotal pancreatectomy in isolated neck margin positive pancreatic adenocarcinoma. Surgery 2007; 142:572.
- Karpoff HM, Klimstra DS, Brennan MF, Conlon KC. Results of total pancreatectomy for adenocarcinoma of the pancreas. Arch Surg 2001; 136:44.
- Satoi S, Murakami Y, Motoi F, et al. Reappraisal of Total Pancreatectomy in 45 Patients With Pancreatic Ductal Adenocarcinoma in the Modern Era Using Matched-Pairs Analysis: Multicenter Study Group of Pancreatobiliary Surgery in Japan. Pancreas 2016; 45:1003.
- Reddy S, Wolfgang CL, Cameron JL, et al. Total pancreatectomy for pancreatic adenocarcinoma: evaluation of morbidity and long-term survival. Ann Surg 2009; 250:282.
- Büchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003; 138:1310.
- Nathan H, Wolfgang CL, Edil BH, et al. Peri-operative mortality and long-term survival after total pancreatectomy for pancreatic adenocarcinoma: a population-based perspective. J Surg Oncol 2009; 99:87.
- Johnston WC, Hoen HM, Cassera MA, et al. Total pancreatectomy for pancreatic ductal adenocarcinoma: review of the National Cancer Data Base. HPB (Oxford) 2016; 18:21.
- Casadei R, Monari F, Buscemi S, et al. Total pancreatectomy: indications, operative technique, and results: a single centre experience and review of literature. Updates Surg 2010; 62:41.
- Norton JA, Kivlen M, Li M, et al. Morbidity and mortality of aggressive resection in patients with advanced neuroendocrine tumors. Arch Surg 2003; 138:859.
- Hill JS, McPhee JT, McDade TP, et al. Pancreatic neuroendocrine tumors: the impact of surgical resection on survival. Cancer 2009; 115:741.
- Patti ME, McMahon G, Mun EC, et al. Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Diabetologia 2005; 48:2236.
- Clancy TE, Moore FD Jr, Zinner MJ. Post-gastric bypass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia. J Gastrointest Surg 2006; 10:1116.
- Law CH, Wei AC, Hanna SS, et al. Pancreatic resection for metastatic renal cell carcinoma: presentation, treatment, and outcome. Ann Surg Oncol 2003; 10:922.
- Yuasa T, Inoshita N, Saiura A, et al. Clinical outcome of patients with pancreatic metastases from renal cell cancer. BMC Cancer 2015; 15:46.
- Kulu Y, Schmied BM, Werner J, et al. Total pancreatectomy for pancreatic cancer: indications and operative technique. HPB (Oxford) 2009; 11:469.
- Nentwich MF, El Gammal AT, Lemcke T, et al. Salvage Completion Pancreatectomies as Damage Control for Post-pancreatic Surgery Complications: A Single-Center Retrospective Analysis. World J Surg 2015; 39:1550.
- Smith CD, Sarr MG, vanHeerden JA. Completion pancreatectomy following pancreaticoduodenectomy: clinical experience. World J Surg 1992; 16:521.
- Gueroult S, Parc Y, Duron F, et al. Completion pancreatectomy for postoperative peritonitis after pancreaticoduodenectomy: early and late outcome. Arch Surg 2004; 139:16.
- Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8.
- Haddad LB, Scatton O, Randone B, et al. Pancreatic fistula after pancreaticoduodenectomy: the conservative treatment of choice. HPB (Oxford) 2009; 11:203.
- US Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases. Recommended adult immunization schedule—United States – 2015 www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf (Accessed on January 10, 2016).
- Heidt DG, Burant C, Simeone DM. Total pancreatectomy: indications, operative technique, and postoperative sequelae. J Gastrointest Surg 2007; 11:209.
- Sutherland DE, Radosevich DM, Bellin MD, et al. Total pancreatectomy and islet autotransplantation for chronic pancreatitis. J Am Coll Surg 2012; 214:409.
- Chinnakotla S, Radosevich DM, Dunn TB, et al. Long-term outcomes of total pancreatectomy and islet auto transplantation for hereditary/genetic pancreatitis. J Am Coll Surg 2014; 218:530.
- Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg 1988; 123:550.
- Alexakis N, Ghaneh P, Connor S, et al. Duodenum- and spleen-preserving total pancreatectomy for end-stage chronic pancreatitis. Br J Surg 2003; 90:1401.
- Dallemagne B, de Oliveira AT, Lacerda CF, et al. Full laparoscopic total pancreatectomy with and without spleen and pylorus preservation: a feasibility report. J Hepatobiliary Pancreat Sci 2013; 20:647.
- Sa Cunha A, Rault A, Beau C, et al. A single-institution prospective study of laparoscopic pancreatic resection. Arch Surg 2008; 143:289.
- Choi SH, Hwang HK, Kang CM, et al. Pylorus- and spleen-preserving total pancreatoduodenectomy with resection of both whole splenic vessels: feasibility and laparoscopic application to intraductal papillary mucin-producing tumors of the pancreas. Surg Endosc 2012; 26:2072.
- Casadei R, Marchegiani G, Laterza M, et al. Total pancreatectomy: doing it with a mini-invasive approach. JOP 2009; 10:328.
- Dokmak S, Aussilhou B, Sauvanet A, et al. Hand-assisted laparoscopic total pancreatectomy: a report of two cases. J Laparoendosc Adv Surg Tech A 2013; 23:539.
- Giulianotti PC, Addeo P, Buchs NC, et al. Early experience with robotic total pancreatectomy. Pancreas 2011; 40:311.
- Chinnakotla S, Beilman GJ, Dunn TB, et al. Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases. Ann Surg 2015; 262:610.
- Wilson GC, Sutton JM, Abbott DE, et al. Long-term outcomes after total pancreatectomy and islet cell autotransplantation: is it a durable operation? Ann Surg 2014; 260:659.
- Webb MA, Illouz SC, Pollard CA, et al. Islet auto transplantation following total pancreatectomy: a long-term assessment of graft function. Pancreas 2008; 37:282.
- US Food and Drug Administration. Updated questions and answers for healthcare professionals and the public: use an approved pancreatic enzyme product (PEP). May 7, 2012. www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm204745.htm (Accessed on January 10, 2016).
- Giuliano CA, Dehoorne-Smith ML, Kale-Pradhan PB. Pancreatic enzyme products: digesting the changes. Ann Pharmacother 2011; 45:658.
- Kuhn RJ, Eyting S, Henniges F, Potthoff A. In Vitro Comparison of Physical Parameters, Enzyme Activity, Acid Resistance, and pH Dissolution Characteristics of Enteric-Coated Pancreatic Enzyme Preparations: Implications for Clinical Variability and Pharmacy Substitution. J Pediatr Pharmacol Ther 2007; 12:115.
- Gubergrits N, Malecka-Panas E, Lehman GA, et al. A 6-month, open-label clinical trial of pancrelipase delayed-release capsules (Creon) in patients with exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatic surgery. Aliment Pharmacol Ther 2011; 33:1152.
- Whitcomb DC, Lehman GA, Vasileva G, et al. Pancrelipase delayed-release capsules (CREON) for exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatic surgery: A double-blind randomized trial. Am J Gastroenterol 2010; 105:2276.
- Seiler CM, Izbicki J, Varga-Szabó L, et al. Randomised clinical trial: a 1-week, double-blind, placebo-controlled study of pancreatin 25 000 Ph. Eur. minimicrospheres (Creon 25000 MMS) for pancreatic exocrine insufficiency after pancreatic surgery, with a 1-year open-label extension. Aliment Pharmacol Ther 2013; 37:691.
- Kneuertz PJ, Pitt HA, Bilimoria KY, et al. Risk of morbidity and mortality following hepato-pancreato-biliary surgery. J Gastrointest Surg 2012; 16:1727.
- Pedrazzoli S, Liessi G, Pasquali C, et al. Postoperative pancreatic fistulas: preventing severe complications and reducing reoperation and mortality rate. Ann Surg 2009; 249:97.
- Hackert T, Hinz U, Pausch T, et al. Postoperative pancreatic fistula: We need to redefine grades B and C. Surgery 2016; 159:872.
- Moran A, Brunzell C, Cohen RC, et al. Clinical care guidelines for cystic fibrosis-related diabetes: a position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society. Diabetes Care 2010; 33:2697.
- van den Berg JM, Morton AM, Kok SW, et al. Microvascular complications in patients with cystic fibrosis-related diabetes (CFRD). J Cyst Fibros 2008; 7:515.
- Schwarzenberg SJ, Thomas W, Olsen TW, et al. Microvascular complications in cystic fibrosis-related diabetes. Diabetes Care 2007; 30:1056.
- Sinaasappel M, Stern M, Littlewood J, et al. Nutrition in patients with cystic fibrosis: a European Consensus. J Cyst Fibros 2002; 1:51.
- Kosińska M, Szwed A, Cieślik J, et al. Assessment of the biological condition and nutritional status of adult patients with cystic fibrosis. Anthropol Rev 2005; 68:53.
- Sharma R, Florea VG, Bolger AP, et al. Wasting as an independent predictor of mortality in patients with cystic fibrosis. Thorax 2001; 56:746.
- Haeusler G, Frisch H, Waldhör T, Götz M. Perspectives of longitudinal growth in cystic fibrosis from birth to adult age. Eur J Pediatr 1994; 153:158.
- American Diabetes Association. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2016; 39 Suppl 1:S60.
- Roberts KJ, Blanco G, Webber J, et al. How severe is diabetes after total pancreatectomy? A case-matched analysis. HPB (Oxford) 2014; 16:814.
- Jethwa P, Sodergren M, Lala A, et al. Diabetic control after total pancreatectomy. Dig Liver Dis 2006; 38:415.
- Barbier L, Jamal W, Dokmak S, et al. Impact of total pancreatectomy: short- and long-term assessment. HPB (Oxford) 2013; 15:882.
- Casadei R, Ricci C, Taffurelli G, et al. Is total pancreatectomy as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy? A single center, prospective, observational study. J Gastrointest Surg 2016; 20:1595.
- Epelboym I, Winner M, DiNorcia J, et al. Quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection. J Surg Res 2014; 187:189.
- Billings BJ, Christein JD, Harmsen WS, et al. Quality-of-life after total pancreatectomy: is it really that bad on long-term follow-up? J Gastrointest Surg 2005; 9:1059.
- INDICATIONS FOR TOTAL PANCREATECTOMY
- Planned total pancreatectomy
- - Chronic pancreatitis
- - Hereditary pancreatitis
- - Intraductal papillary mucinous neoplasm
- - Pancreatic cancer
- - Pancreatic neuroendocrine tumor
- - Pancreatic metastasis of renal cell cancer
- Conversion total pancreatectomy
- Completion (rescue) pancreatectomy
- PREOPERATIVE PREPARATION
- Patient screening
- Imaging studies
- INTRAOPERATIVE MANAGEMENT AND TECHNIQUES
- Standard technique
- - Incision
- - Pancreatectomy
- - Reconstruction
- - Islet cell transplantation
- Other techniques
- POSTOPERATIVE MANAGEMENT
- Endocrine replacement
- - After islet autotransplantation
- Exocrine replacement
- MORBIDITY AND MORTALITY
- - Complications of diabetes
- - Malnutrition
- - Quality of life
- SUMMARY AND RECOMMENDATIONS