title: Benign cystic neoplasm and endocrine tumours of the pancreas--when and how to operate--an overview.
abstract: BACKGROUND
  The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard.
  
  
  OBJECTIVE
  To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate.
  
  
  RESULTS
  Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2-3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20% of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11%, pancreatic fistula in 33%. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33% pancreatic fistula and severe post-operative complications of 18% is related to management of proximal pancreatic stump. DPPHRt/s is used in 70% for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10% for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy.
  
  
  CONCLUSIONS
  The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.
authors.affiliation: Department of General- and Visceral Surgery, c/o University of Ulm, Ulm, Germany. Electronic address: sekretariat@beger-ulm.de.
authors.forename: H G
authors.initials: HG
authors.lastname: Beger
authors.affiliation: Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donouklinikum Neu-Ulm, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Poch
authors.affiliation: Department of General Surgery and Liver Transplantation, Fundei Clinical Institute, Bucharest, Romania.
authors.forename: C
authors.initials: C
authors.lastname: Vasilescu
mesh_terms: D018278:Carcinoma, Neuroendocrine / Q000601:surgery*; D006801:Humans; D018297:Neoplasms, Cystic, Mucinous, and Serous / Q000601:surgery*; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000601:surgery*; D011446:Prospective Studies; D012189:Retrospective Studies
keywords: Cystic neoplasm; Duodenum preserving total pancreatic head resection; Endocrine tumours of the pancreas; Enucleation; Pancreatic middle segment resection