Video: Performing a Middle Pancreatectomy

When it comes to surgically removing tumors on the pancreas, there are two main procedures that are often regarded as the standards of care: a distal pancreatectomy, which involves the removal of the tail and/or body of the pancreas including the spleen, and a Whipple procedure, which involves the removal of the head of the pancreas, the duodenum, sometimes part of the stomach, the bile duct and the gallbladder.

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But what can be done for patients with pre-cancerous, benign or low-grade malignant pancreatic tumors to circumvent extensive removal of the pancreas and the associated postoperative risks?

In 1998, Andrew Warshaw, MD, director of the Andrew L. Warshaw Institute for Pancreatic Cancer Research at the Massachusetts General Hospital Cancer Center, surgeon-in-chief-emeritus and former program director of the Department of Surgery's Pancreas and Biliary Surgery Program, and colleagues applied a novel technique for the first time in the United States to treat these types of tumors—a middle pancreatectomy, also known as a central pancreatectomy, which involves a limited removal of the mid-portion of the pancreas (published on JAMA Surgery). Through this procedure, surgeons remove approximately 10% of the pancreas as opposed to the standard 60%.

Throughout the years, this technique has proven effective in salvaging healthy pancreatic tissue, reducing the risk of exocrine and endocrine insufficiency and, ultimately, diabetes.

Watch the video of a middle pancreatectomy »

In this video, Carlos Fernandez-del Castillo, MD, director of the Pancreas and Biliary Surgery Program at Mass General and clinical co-director of the Center for Gastrointestinal Cancers at the Mass General Cancer Center, performs a middle pancreatectomy. Below, he answers questions about this procedure.

Q. What should be considered when evaluating a patient for this procedure?

It's an uncommon procedure that requires careful selection of the patients. Considerations for whether or not a patient qualifies for the procedure include the tumor's location on the pancreas and if it's a benign or low-grade malignant tumor.

At Mass General, we perform about six middle pancreatectomies a year for patients who we feel would benefit from it rather than having a more extensive resection. Over the years, we've done this procedure quite a few times and have become advocates for it.

Q. What are the challenges with performing this procedure?

The dissection is more extensive than that of a distal pancreatectomy because you have to dissect around the vessels while also mobilizing the pancreas for a certain distance. As such, both the surgery and the recovery often take longer.

We approach these procedures as a united team, discussing the specifications of the case and its implications thoroughly and in advance of the operation.

Q. What benefits are associated with a middle pancreatectomy?

First and foremost, the primary benefit is that the patient is less likely to develop diabetes following surgery. For a frame of reference, the risk of developing diabetes as a result of a distal pancreatectomy is 32%, as opposed to a middle pancreatectomy, which is 4%.

Secondly, a middle pancreatectomy does not require the removal of the spleen, which is advantageous for the patient. For example, the spleen helps to fight certain types of infections. There is also data coming to light that shows that removal of the spleen increases your risk of coronary artery disease and overall risk of developing cancer. The mechanisms for why this is are not yet clear, but there is data showing these connections.

Lastly, the more pancreas you have, the fewer enzymes you need to help digest your food. By preserving more of the pancreas, we can help ensure the digestive system's function.

Q. Are there any disadvantages with middle pancreatectomy?

A middle pancreatectomy allows for the removal of fewer lymph nodes. When surgically treating cancer, we typically want to remove lymph nodes. This is why a middle pancreatectomy should only be done for tumors that are completely benign or have a low risk of being malignant.

When considering a middle pancreatectomy for a patient, it's important to note that the risk of leakage from the pancreas increases from one to two places. So, the leak rate often doubles. Sometimes, this increased complication rate is enough for some surgeons to opt for more conservative methods.

At Mass General, we will perform the middle pancreatectomy for patients who qualify in order to protect the patient from developing lifelong diabetes.

Learn more about the Pancreas & Biliary Surgery Program

Refer a patient to the Division of Gastrointestinal & Oncologic Surgery