Total Subtotal Pancreatectomy

The first total pancreatectomy was performed in the 1940s although a near total pancreatectomy is attributed to Billroth in 1884. It was advocated in the 1950s because of the belief that pancreatic cancer is a multicentric disease, and a curative resection requires a total pancreatectomy. It also includes a more extensive lymphadenectomy which theorectically decreases the risk of local recurrence. In addition, problems with the pancreaticojejunal anastomosis are eliminated, but with the added cost of significant metabolic disorders, exocrine insufficiency, and diabetes in 100% of cases.

A total pancreatectomy involves removal of the entire gland, the duodenum, distal stomach, distal bile duct, spleen, and the greater omentum (Fig. 3). This procedure was largely abandoned after a high mortality rate was observed both early and late. The metabolic changes that ensue are also challenging to control. As many as 50% of all of the late deaths that occur after total pancreatectomy are a result of "iatrogenic hypoglycemia." Moreover, a survival benefit over the Whipple procedure has not been demonstrated for similar stage tumors of the proximal pancreas. Hence, the indication for a total pancreatectomy currently is the finding of carcinoma in the margin of a proximal pan-createctomy in a patient who can tolerate the metabolic demands of a complete resection.

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