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Доброкачественные опухоли поджелудочной железы - ограниченные хирургические операции при кистозных и нейроэндокринных новообразованиях - обзор хирургических вмешательств

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Введение. К доброкачественным опухолям поджелудочной железы (ПЖ) могут быть отнесены внутрипротоковые папиллярно-муцинозные опухоли, муцинозные кистозные опухоли, серозная цистаденома, солидно-псевдопапиллярная опухоль и нейроэндокринные опухоли (НЭО), чаще всего инсулиномы. Эволюция таких органосберегающих вмешательств, как энуклеация, центральная резекция (ЦР) ПЖ и дуоденумсохраняющая тотальная или частичная резекция головки ПЖ (ДСРГПЖ), демонстрирует их эффективность при доброкачественных опухолях ПЖ. Цель. Оценить возможности хирургического лечения доброкачественных опухолей ПЖ локальной резекцией, базируясь на существующих показаниях к оперативному лечению, анализе ранних послеоперационных осложнений и отдаленных результатов. Результаты. Энуклеация опухоли рекомендуется для всех манифестных нейроэндокринных новообразований размером до 3 см при отсутствии контакта с протоком поджелудочной железы. Этот метод применялся в основном при НЭО и реже при кистозных опухолях. Порядка 20% энуклеаций выполнены минимально инвазивным доступом. Тяжелые хирургические послеоперационные осложнения, потребовавшие повторных вмешательств, отмечены в 11% наблюдений, панкреатическая фистула - в 33% наблюдений, госпитальная летальность составила менее 1%. Основными преимуществами энуклеаций являются низкий уровень послеоперационных осложнений и очень низкая госпитальная летальность. Две трети ЦР выполнены пациентам с манифестными кистозными опухолями и 1/3 - при НЭО. Высокая частота панкреатических фистул и тяжелых послеоперационных осложнений связана с обработкой проксимальной культи ПЖ. Госпитальная летальность 0,8% является преимуществом этой операции. ДСРГПЖ в 50% наблюдений применена в виде тотальной резекции головки с сегментарной резекцией перипапиллярной зоны двенадцатиперстной кишки и интрапанкреатической части общего желчного протока. У 2/3 этих больных были манифестные или бессимптомные кистозные опухоли и у 10% - НЭО. Основным преимуществом этих операций по сравнению с панкреатодуоденальной резекцией (ПДР) является сохранение в большей степени экзо- и эндокринной функций и госпитальная летальность менее 0,5%. Уровень доказательности для энуклеаций и ЦР низкий в связи с ретроспективной оценкой данных и отсутствием результатов контрольных исследований. Преимущества ДСРГПЖ перед ПДР были показаны результатами 9 проспективных контролируемых исследований, 3 исследований “случай-контроль” и двумя ретроспективными контролируемыми исследованиями. Заключение. При использовании энуклеаций, ЦР, тотальных и частичных ДСРГПЖ отмечаются низкий уровень послеоперационных осложнений и очень низкая госпитальная летальность. Основным преимуществом ограниченных резекций является сохранение экзо- и эндокринной функций ПЖ и перипанкреатических тканей.

Ключевые слова:
поджелудочная железа, кистозная опухоль, нейроэндокринная опухоль, энуклеация, резекция, осложнения, летальность, pancreas, cystic neoplasia, neuroendocrine tumor, enucleation, resection, postoperative complication, hospital mortality

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Benign Tumors of the Pancreas - Limited Local Surgical Treatment for Cystic Neoplasms and Neuroendocrine Tumors - an Overview

Background. Benign tumors of the pancreas are intraductal papillary mucinous neoplasia, mucinous cystic neoplasia, serous cystic adenoma, solid pseudopapillary neoplasia and endocrine tumors, most frequently insulinomas. The evolution of limited local surgical procedures for benign pancreatic lesions like enucleation (EN), pancreatic middle segment resection (CP) and duodenum-preserving total or partial pancreatic head resection (DPPHRt/p) shifted options of surgical treatment to application of local techniques. Objectives. Surgical treatment of benign cystic neoplasms and neuroendocrine tumors using local surgical extirpation techniques are evaluated based on present knowledge about indication to surgery, early postoperative complications and late outcome perspectives. Results. Tumor enucleation is recommended for all symptomatic neuroendocrine adenomas of a size up to 3 cm and non-adherence to pancreatic main ducts. EN was applied predominantly for neuroendocrine tumors and less frequently for cystic neoplasms. About 20% of enucleations are performed as minimal invasive procedures. Surgery-related severe postoperative complications with the need of reintervention are observed in 11%, pancreatic fistula in 33%, but hospital mortality was below 1%. Major advantages of EN are low procedure-related early postoperative morbidity and a very low hospital mortality. CP is applied in two thirds for symptomatic cystic neoplasms and in one third for neuroendocrine tumors. The high level of pancreatic fistula and severe postoperative complications are associated with management of the proximal pancreatic stump. Hospital mortality of 0.8% is a benefit of this procedure. DPPHRt/p has been applied in about 50% as total pancreatic head resection with segment resection of the peripapillary duodenum and the intrapancreatic common bile duct. Two thirds of patients suffered symptomatic or asymptomatic cystic neoplasms and 10% neuroendocrine tumors. Major advantages of local pancreatic head resection compared to Whipple type pancreaticoduodenectomy are highly significant preservation of the exo- and endocrine functions and a low hospital mortality below 0.5%. The level of evidence for EN and CP is low, because of retrospective data evaluation and absence of results from controlled studies. For DPPHRt/p results of 9 prospective controlled studies, 3 case controlled studies and 2 retrospective controlled studies underline the advantages of DPPHRt/p compared to partial pancreaticoduodenectomy. Conclusion. The application of tumor enucleation, pancreatic middle segment resection and duodenum-preserving total or partial pancreatic head resection are associated with low level of surgery-related early postoperative complications and a very low hospital mortality. The major advantages of the limited procedures are preservation of exo- and endocrine pancreatic functions and maintenance of peripancreatic Gl-tract tissue.

Keywords:
поджелудочная железа, кистозная опухоль, нейроэндокринная опухоль, энуклеация, резекция, осложнения, летальность, pancreas, cystic neoplasia, neuroendocrine tumor, enucleation, resection, postoperative complication, hospital mortality