Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes

Table 1 Indications for partial pancreatic tail preserving subtotal pancreatectomy

Criteria	PPTP-SP	TP
Inclusive criteria (all must be fulfilled)
Tumor involving both Ph and left pancreas	Necessary	Necessary
No LGA involvement	Necessary	Unnecessary
Tumor’s lateral margin more than 6 cm away from Sh	Necessary	Unnecessary
No high metabolic regions in Pt or Sh on PET-CT	Necessary	Unnecessary
Pt margin is negative	Necessary	Unnecessary
Exclusive criteria (if any)
Multifocal cancer
Concomitant with IPMN	Unrecommended	Recommended
Multifocal PDAC	Unrecommended	Recommended
Enlarged LNs in Pt and/or Sh	Unrecommended	Recommended

Ph: Pancreatic head; LGA: Left gastric artery; Pt: Pancreatic tail; Sh: Splenic hilum; IPMN: Intraductal papillary mucinous neoplasms; PDAC: Pancreatic ductal adenocarcinoma.

Table 2 Demographic and baseline characteristics

Parameter	PPTP-SP (n = 18)	TP (n = 38)	P value
Male, n (%)	10 (55.6)	22 (57.9)	0.869
Age (yr), mean ± SD	63.9 ± 7.8	62.5 ± 8.9	0.565
BMI (kg/m2), mean ± SD	23.7 ± 3.2	22.3 ± 3.5	0.350
Symptomatic, n (%); Incident, n (%)	12 (66.7); 6 (33.3)	29 (76.3); 9 (23.7)	0.446
Comorbidities, n (%)
Hypertension	4 (22.2)	12 (31.6)	0.469
Preoperative DM	3 (16.7)	11 (28.9)	0.322
Heart diseases	3 (16.7)	4 (10.5)	0.525
COPD	1 (5.6)	1 (2.6)	0.582
Tumor location, n (%)			0.173
Pancreatic head	6 (33.3)	9 (23.7)
Pancreatic body and tail	0 (0.0)	4 (10.5)
Whole pancreas	12 (67.7)	25 (69.4)
Tobacco use, n (%)	6 (33.3)	11 (28.9)	0.739
Alcohol use, n (%)	7 (38.9)	17 (44.7)	0.680
CA19-9 ≥ 37 U/mL, n (%)	15 (83.3)	31 (81.6)	0.872
CA125 ≥ 35 U/mL, n (%)	4 (22.2)	9 (23.6)	0.904
CEA ≥ 10 μg/L, n (%)	2 (11.1)	7 (18.4)	0.475
Preoperative biliary drainage, n (%)	3 (16.7)	8 (21.1)	0.700
Neoadjuvant therapy, n (%)	5 (27.8)	9 (23.7)	0.741
ASA score (II-III), n (%)	10 (55.6)	26 (68.4)	0.348
Preoperative ALB (g/L), median (IQR)	42.0 (39.5-45.5)	40.5 (39.0-43.5)	0.201
Preoperative fasting C-peptide (μg/L), mean ± SD	1.39 ± 0.55	1.14 ± 0.97	0.265
Preoperative fasting insulin (mU/L), mean ± SD	8.80 ± 3.75	7.13 ± 3.58	0.422
Preoperative fasting blood sugar (mg/dL), median (IQR)	5.9 (4.9-6.7)	6.3 (4.2-7.1)	0.207

In the partial pancreatic tail preserving-subtotal pancreatectomy (PPTP-SP) group, ‘location in whole pancreas’ means that the tumor is locating in both the pancreatic head and proximal body. PPTP-SP: Partial pancreatic tail preserving-subtotal pancreatectomy; TP: Total pancreatectomy; BMI: Body mass index; DM: Diabetes mellitus; COPD: Chronic obstructive pulmonary disease; ASA: American Society of Anesthesiologists; ALB: Albumin; SD: Standard deviation; IQR: Interquartile range.

Table 3 Perioperative and pathological outcomes

Parameter	PPTP-SP (n = 18)	TP (n = 38)	P value
Perioperative outcomes
Operative time (h), median (IQR)	6.7 (6.6-8.2)	7.3 (6.8-8.6)	0.076
Estimated blood loss (mL), median (IQR)	550 (400-800)	600 (500-1200)	0.386
Red cells transfusion (mL), median (IQR)	200 (200-600)	400 (200-1000)	0.249
Resection of PV/SMV, n (%)	11 (61.1)	21 (55.3)	0.680
Overall morbidity, n (%)	7 (38.9)	13 (34.2)	0.733
Major complications, n (%)	1 (5.6)	3 (7.9)	0.751
Delayed gastric emptying, n (%)	2 (11.1)	4 (10.5)	0.947
Pulmonary disease, n (%)	3 (16.7)	4 (10.5)	0.516
Chyle leakage, n (%)	1 (5.6)	3 (7.9)	0.751
Postpancreatectomy hemorrhage, n (%)	1 (5.6)	2 (5.3)	0.964
Abdominal collection, n (%)	1 (5.6)	1 (2.6)	0.582
Arrhythmia, n (%)	2 (11.1)	3 (7.9)	0.693
Biliary leakage, n (%)	0 (0.0)	0 (0.0)	-
Biochemical leak, n (%)	2 (11.1)	0 (0.0)	0.099
Grade B or C pancreatic fistula, n (%)	0 (0.0)	0 (0.0)	-
Reoperation, n (%)	0 (0.0)	0 (0.0)	-
Morality, n (%)	0 (0.0)	0 (0.0)	-
Readmission, n (%)	1 (5.6)	3 (7.9)	0.751
Postoperative staying (d), median (IQR)	9.5 (7-16)	11.5 (9-17.5)	0.286
Pathological outcomes
Histology, n (%)			0.153
PDAC without IPMN	18 (100.0)	34 (89.5)
PDAC concomitant with IPMN	0 (0.0)	4 (10.5)
Differentiation, n (%)			0.829
High	1 (5.6) 1 (5.6)	3 (7.9)
Moderate	11 (61.1)	20 (52.6)
Poor	6 (33.3)	15 (39.5)
Harvested lymph nodes (n), median (IQR)	12.5 (9-16)	14.5 (10-20)	0.521
Lymph node metastasis, n (%)	9 (50.0)	25 (65.8)	0.259
Paraaortic lymph node metastasis (#16), n (%)	1 (5.6)	7 (18.4)	0.199
Resection Margin, n (%)			0.487
R0	18 (100.0)	37 (97.4)
R1	0 (0.0)	1 (2.6)
Vascular invasion (SMV/PV), n (%)	9 (50.0)	17 (44.7)	0.712
Perineural invasion, n (%)	13 (72.2)	20 (52.6)	0.164
Colonic invasion, n (%)	0 (0.0)	1 (2.6)	0.487
Tumor size (cm), median (IQR)	4.3 (3.0-5.1)	4.4 (3.4-6.6)	0.408
T stage			0.445
T1	0 (0.0)	2 (5.3)
T2	8 (44.4)	13 (34.2)
T3	10 (55.6)	22 (57.9)
T4	0 (0.0)	1 (2.6)
N stage			0.502
N0	9 (50.0)	13 (34.2)
N1	7 (38.9)	18 (47.4)
N2	2 (11.1)	7 (18.4)
AJCC 8th stage			0.657
IA-IB	4 (22.2)	7 (18.4)
IIA-IIB	12 (66.7)	23 (60.5)
III	2 (11.1)	8 (21.1)
IV	0 (0.0)	0 (0.0)

PPTP-SP: Partial pancreatic tail preserving-subtotal pancreatectomy; TP: Total pancreatectomy; PV/SMV: Portal vein and/or superior mesenteric vein; PDAC: Pancreatic ductal adenocarcinoma; IPMN: Intraductal papillary mucinous neoplasm; AJCC: American Joint Committee on Cancer; IQR: Interquartile range.

Table 4 Postoperative glycemic control

Parameter	PPTP-SP (n = 18)	TP (n = 38)	P value
Insulin-dependent DM, n (%)	14 (72.2)	38 (100)	0.014
Frequency of hypoglycemia (n/per week), median (IQR)	0.0 (0.0-0.25)	1.0 (1.0-2.0)	< 0.001
Total daily insulin dosage (U), median (IQR)	10 (6-14)	32 (28-39)	< 0.001
Fasting C-peptide (μg/L), mean ± SD	0.61 ± 0.15	< 0.14	-
Fasting insulin (mU/L), mean ± SD	6.3 ± 2.4	6.0 ± 3.9	0.418
Frequency of glucose monitoring (n/per day), median (IQR)	1.5 (1-2)	4 (2-4)	< 0.001

PPTP-SP: Partial pancreatic tail preserving-subtotal pancreatectomy; TP: Total pancreatectomy; DM: Diabetes mellitus; IQR: Interquartile range; SD: Standard deviation.