[Total pancreatectomy for pancreatic malignancy - from history to the present day]

Currently, total pancreatectomy (TP) is indicated in approximately one in ten surgical patients with pancreatic cancer. Key role in the decision falls in the competence of the multidisciplinary team, alternatively of the surgeon in the intraoperative period in some cases. Exceptionally, TP is approached in the so-called salvage surgery. Perioperative mortality of TP as an elective procedure does not exceed that of partial resections; however, mortality of up to 50% is associated with salvage surgery in acute postoperative pancreatitis. Postoperatively, patients are afflicted with the so-called brittle diabetes comparable with type 1 diabetes. The aim of our overview is to inform about the current position of TP in the treatment of malignant pancreatic diseases.Key words: pancreatic cancer - total pancreatectomy - multidisciplinary team.

[History of surgical intervention in severe acute pancreatitis treatment]

Severe acute pancreatitis (SAP) is hard to treat for the abrupt onset, critical condition and complicated pathophysiology. Historically, the treatment strategy of SAP hovered between surgical intervention and conservative treatment. At the turn of the 20(th) century, SAP was reported to be cured by surgical intervention in a series cases, which lead to the dominance of surgical intervention in SAP treatment. Subsequently, SAP was documented to respond to nonoperative therapy. A wave of conservatism emerged, and surgical intervention for SAP was rarely practiced for the next 3 decades. However, surgeons refined the indications and considered new approaches for surgical treatment in 1960s because of the poor outcomes of conservation, and surgical interventions was mainly performed at early stage of SAP. However, a series of prospective studies showed that conservative treatment of patients with sterile pancreatic necrosis is superior to surgical intervention, and that delayed intervention provide improved outcomes in 1990s, which changed the treatment concept of SAP again. The modern treatment concept formed during the progression: organ supportive care dominates in the early stage of the disease, and surgical intervention should be performed at late stage with proper indications. Despite the advances in treatment, the morbidity of SAP is still 5%-20%, which suggests the pancreatic surgeons' exploration in the future.

Central pancreatectomy: The Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure. The aims are to clarify the history and the development of CP and to give credits to those from whom it came. Ehrhardt, in 1908, described segmental neck resection (SNR) followed, in 1910, by Finney without reconstructive part. In 1950 Honjyo described two cases of SNR combined with gastrectomy for gastric cancer infiltrating the neck of the pancreas. Guillemin and Bessot (1957) and Letton and Wilson (1959) dealt only with the reconstructive aspect of CP. Dagradi and Serio, in 1982, performed the first CP including the resective and reconstructive aspects. Subsequently Iacono has validated it with functional endocrine and exocrine tests and popularized it worldwide. In 2003, Baca and Bokan performed laparoscopic CP and, In 2004, Giulianotti et al performed a robotic assisted CP. CP is performed worldwide either by open surgery or by using minimally-invasive or robotic approaches. This confirms that the operation does not belong to whom introduced it but to everyone who carries out it; however credit must be given to those from whom it came.

[Surgery of the pancreas]

Historically, pancreatic surgery has been considered a "major" procedure, usually consisting of pancreatectomy in old or other high-risk patients. Pancreatic surgery carries a risk of fatal complications, major morbidity, and long-term adverse effects. Recently, both the indications and techniques of pancreatic surgery have diversified, notably with the emergence of parenchyma-preserving resection for benign lesions at high risk of malignant transformation, which are often discovered incidentally. A multidisciplinary approach is needed for accurate decision-making, based on the presumed diagnosis, tumor location, surgical risk, and medical history.

Brunner's missing 'Aha experience' delayed progress in diabetes research by 200 years

In 1889, the pancreatectomy performed on a dog by Joseph von Mehring and Oskar Minkowski led to the discovery of the pancreatic origin of diabetes disease. Already 200 years before, Johann Conrad Brunner had successfully performed eight pancreatectomies on dogs and had precisely described the symptoms of polyphagia, polyuria, and polydipsia. He did not, however, recognize the association with the diabetes disease and thus missed an opportunity to accelerate the course of diabetes research by 200 years.

[One name, two physicians. About Whipple's procedure and Whipple's disease]

The biographical silhouettes of two contemporary, but unrelated American physicians using the same name: Allen Oldfather Whipple and Gorge Hoyt Whipple are presented. Both significantly influenced their medical specialties. A.O. Whipple was a pioneer in modern surgery of the pancreas. His name is used as an eponym for resection of the pancreas head (Whipple's procedure). G.H. Whipple, the pathologist and physiologists received the Nobel Prize for his input into scientific evidence for the treatment of anemia. His name serves as an eponym for extremely rare disease of the bowel (Whipple's disease).

[Evolution of the treatment of pancreatic cancer]

Cancer of the pancreas was not diagnosed until the nineteenth century, and the first surgical attempts were not carried out until the end of that century, and then only within the framework of local tumour removal. Already in 1898, however, Codivilla described the operative method that is today considered the standard operation and which, in the form of partial duodenopancreatectomy, is the most commonly performed procedure on the pancreas. Evolutionary change in this area represents nothing more than the gradual introduction of minor modifications which, however, had no impact on the " heart" of the surgical approach. The particular feature of surgical treatment of pancreatic cancer--since 1935 known as Whipple's procedure--is the considerable length of time of 80 years that it took before it finally found widespread acceptance. Further several decades passed until, by the end of the 20th century, recognizable successes were reported, for example, a resection rate of 30%, a hospital mortality rate of less than 5% in specialized centers, and a reported 5-year survival rate varying from 1% to 20%. Even after the last 100 years of slow evolution, surgeons have by no means conquered cancer of the pancreas, and the low 5-year survival rates, together with the recurrences and late metastases prompted Trede in the year 2002 to remark: "we have to conclude that surgery alone cannot cure pancreatic carcinoma".

[Surgery of the liver and pancreas in Japan--message to the special symposium commemorating Dr. Ichio Honjo]

About half a century ago, Ichio Honjo performed successful right hepatic lobectomy following ligation of the right hepatic artery and the right branch of the portal vein. That was the world's first successful case of right hepatic lobectomy with preliminary hilar ligation of the right branches of both the hepatic artery and portal vein. In the same year, Honjo carried out a total pancreatectomy for pancreatic cancer for the first time in Japan. Since then, marked progress in the surgical fields of the liver and pancreas has been made and appear to have nearly reached the pinnacle. Surgeons in the late half of the 20th century attempted to extend operative interventions and expand surgical fields while devoting themselves to treating incurable diseases. Therefore the period may be called the "challenging era." We are entering the era of evaluation and selection of the procedures most suitable to both the disease stage and each individual patient.

Historical survey of carcinoma of the pancreas

The ancient Egyptians probably recognized cancerous lesions on the surface of the body. Hippocrates described cancers of the skin, larynx, breast, inguinal region, uterus, and vagina. For centuries, the treatments were excision, cauterization, ointment application, and fomentation. The development of anesthesia, antisepsis, and disinfection, and the discoveries of X-rays and radium in the nineteenth century, have greatly promoted advances in surgery in the twentieth century. At the beginning of this century, it became possible for surgeons to extirpate tumors from previously inaccessible body interiors, and today surgeons are able to remove affected organ systems and even entire regions of the body with safety because of advances in physiology, anesthesia, transfusion, and anti-infective agents. The surgical results for most gastrointestinal cancers have improved markedly in recent years, only with pancreatic cancer showing no improvement in results. Drastic extensive surgery has not led to better results. A small carcinoma less than 1 cm in diameter may not always be an early carcinoma. Early cancer in duct cell carcinoma may be one localized in the mucous membrane of the pancreatic duct. There is now an expectation that early diagnosis will be possible by using magnetic resonance cholangiopancreatography and cytological diagnosis of the pancreatic juice.

Surgical therapy of pancreatic cancer

Surgical resection remains the only curative modality for pancreatic cancer. Improvements in surgical technique have greatly reduced the morbidity and mortality from pancreatic resection. These results clearly justify the use of pancreatic resection for localized and resectable pancreatic cancer. New surgical techniques such as laparoscopy can aid in the proper selection of candidates for curative resection. Integration of surgery with more effective treatments to prevent systemic relapse are needed to further improve survival.

Surgical treatment of idiopathic hyperinsulinemic hypoglycemia in children. First successful subtotal pancreatectomy with preservation of spleen reported by Evarts A. Graham (1934)

The first successful subtotal pancreatectomy for idiopathic hypoglycemia in a child was performed by Dr. Evarts Graham in 1934. He did an extended resection and preserved the spleen. Although both of these aspects of the operation are now identified as important principles, it is apparent from a review of the literature that their importance was not recognized for many years.