whereas neoplastic lesion located in the pancreatic head or body - tail are usually resected by pancreaticoduodenectomy or distal pancreatectomy , tumors in the neck represent a real challenge for a surgeon . in these cases , standard or extended pancreatectomies performed for
benign or borderline cases can determine the loss of a great amount of glandular tissue , significantly increasing the risk of diabetes , impaired exocrine function , and splenic loss.16 enucleation would be an adequate alternative for small , benign , and low - grade malignant tumors , such as endocrine and cystic neoplasms of the pancreas .
unfortunately this conservative procedure can not be always applicable . when the neoplastic lesion measures up to 2  cm or more , or it is encased within the pancreatic gland , enucleation is associated with a high risk of wirsung s duct damage ; moreover in the case of tumors with uncertain biological behavior this approach should be avoided because of the risk of tumor recurrence15 .
letton and wilson7 reported for the first time in the english literature in 1959 two cases of traumatic midpancreatic transection followed by a reconstruction with a roux - en - y jejunal loop anastomized to the distal part of the gland .
dagradi and serio,8 from our own department of surgery , were the first in 1984 to propose middle pancreatectomy with an 
subsequently , other authors reported cases of resection of the middle pancreas , of varying extent , using various terms such as  central pancreatectomy ,   middle segment pancreatectomy ,   segmental pancreatectomy ,  and  intermediate pancreatectomy.913 the underlying indications for surgery ranged from chronic pancreatitis to benign , uncertain behavior , or low - grade malignant exocrine and endocrine neoplasms119 .
different techniques were adopted for gastrointestinal reconstruction , including jejunal anastomosis of both the proximal and distal stump , or of only the distal stump , with pancreaticoduodenal or pancreaticogastric anastomosis.121
the gastrocolic ligament is opened , preserving the gastroepiploic vessels , and the pancreatic gland is exposed .
the superior mesenteric vein and the portal vein must be identified and their surfaces cleared below the gland .
the splenic artery and vein are dissected free and separated from the gland . some venous tributaries to the portomesenteric axis and some minor collaterals of the splenic artery can be ligated .
then , the posterior surface of the pancreatic neck is isolated from the portomesenteric axis and a ribbon is passed behind the gland to elevate it .
sutures are placed along the superior and inferior margins to indicate where the proximal and distal transection should be performed and to ligate those vessels running along the margins .
the segment of the pancreas with the tumor is subsequently transected through a knife or a stapler to the left and to the right of the lesion .
the cephalic stump is sutured with interrupted stitches after elective ligation of the wirsung s duct or by means of a stapler .
a small stent is placed in the main pancreatic duct while performing pancreojejunostomy or pancreogastrostomy ; the stent can be left in place , even if in our experience we have never done it .
two closed - system suction drains are used to drain the cephalic stump of the gland and the pancreaticojejunostomy / pancreaticogastrostomy .
it has been shown that standard pancreatic resections are nowadays associated with low mortality and morbidity if performed in high - volume centers by experienced surgeons.2224 it is remarkable that this type of surgery can lead to long - term complications , such as diabetes , exocrine insufficiency , and late postsplenectomy infection25,26 .
the incidence of postoperative exocrine and endocrine impairment is not predictable in patients with apparently  normal pancreas .  factors such as fibrosis of the remnant , wirsung s duct obstruction , preexisting chronic pancreatitis , benign or malignant disease , and subclinical diabetes may play a role as 
risk factors.13 after standard left - sided resection there is an increased incidence of endocrine impairment and onset of diabetes reported from 17 to 85% of patients ; it is reasonable that the extent of the resection is strictly related to the incidence of endocrine  exocrine long - term insufficiency2731 .
for all these reasons , more conservative surgical techniques have been advocated for small , benign , or low - grade malignant tumors located in the neck of the gland , aimed for sparing , as much as possible , pancreatic parenchyma .
whenever neoplastic lesions are not small and superficial enough to be simply enucleated , middle segment pancreatectomy should be considerated.16 middle segment pancreatectomy accounts for only 3% of the pancreatic resections performed at our institution and about 100 cases have been reported in the english literature121,3234 : this means careful selection of patients .
in fact , the small number of patients who underwent this type of operation is related to different factors : specific localizations of the neoplasm , well - selected indications ( benign or low - grade malignant tumors ) , and a distal pancreatic stump of at least 5  cm in length .
some authors1,3 have reported that this operation can be performed only in the case of small tumors ( < 5  cm in diameter ) ; in our experience , although the mean diameter of the resected lesions was 27.4  mm , we have safely performed middle segment resection for tumor measuring more than 5  cm , harboring from the anterior face of the pancreas .
middle segment pancreatectomy was also occasionally used for malignant disease : two islet cell carcinomas , one vipoma who subsequently developed hepatic metastases , one cystadenocarcinoma , and one carcinoma in situ2,3,1012 . in the past
we have also performed this operation for malignant tumor but we had pancreatic recurrence of the tumor in two patients ( one affected by metastasis and one by intraductal papillary mucinous neoplasms [ ipmn ] with in situ carcinoma ) ; moreover , two patients with adenoma and borderline main duct ipmn had a tumor recurrence in the pancreatic gland .
thus , we believe that in patients affected by primary or metastatic malignant tumor , a standard resection would be more appropriate
. moreover , middle pancreatectomy in our experience should also be avoided in patients affected by ipmn , especially main duct type because of their potential malignity and the possibility to have different degrees of dysplasia along the wirsung s duct in the same patients .
the surgeon must be sure to achieve tumor - free proximal and distal resection margins after performing middle segment pancreatectomy and , for this reason , frozen section examination is mandatory .
there is the possibility of leaks from both the closed cut edge of the head and the pancreaticojejunostomy , considering that in most patients we are dealing with a normal soft pancreatic texture with a small wirsung s duct .
thus , not only great care must be taken in selecting the patients who will benefit from this operation , but also an experienced pancreatic surgeon working in a high - volume center is required for performing the procedure.14,6,32,33 median pancreatectomy is reported to be associated with no mortality but with a high postoperative morbidity , above all consisting of pancreatic fistula.6 in our experience the  clinical  pancreatic fistula rates after pancreaticoduodenectomy and left pancreatectomy are 10 and 20% , respectively.23,3537 between january 1990 and december 2005 61 patients underwent middle segment pancreatectomy at our institution . the incidence of pancreatic fistula  according to the international study group on pancreatic fistula definition22was 51% .
it is remarkable that most patients complained of grade a fistula , which is a  biochemical  fistula without any clinical impact , whereas 13 patients ( 21% ) developed a grade b or c fistula , which required prolonged in - hospital stay . in almost all patients
the conservative management was successful ; no one underwent reoperation and in four cases intraabdominal collections were treated with ultrasound - guided drainage .
the risk of developing a pancreatic fistula must be taken into account in the preoperative decision making ; we believe that this risk is acceptable when the procedure is performed in a high - volume center and for patients with a long - life expectancy , such as young or middle - aged people affected by benign or low - grade tumors .
the most important advantage of middle segment pancreatectomy is the good endocrine and exocrine long - term function.16,10 iacono et al.1 in a series of 13 patients demonstrated that postoperative oral glucose tolerance , pancreaticolauryl and fecal fat excretion were normal in all cases and they studied six patients pre- and postoperatively with oral glucose tolerance test showing no significant differences before and after surgery .
moreover , sperti et al.3 showed , in a review of the literature , no case of impaired endocrine function in 59 evaluable patients whereas exocrine function was reported to be normal in 56 out of 59 .
another advantage of this procedure is the possibility to preserve the spleen , preventing the risk of postsplenectomy sepsis and hematologic disorders , which is low but exists in an adult.38,39 in conclusion , middle segment pancreatectomy is a safe and technically feasible surgical approach for removing pancreatic neck tumors in well - selected patients ; in experienced hands it is associated with no mortality but with high morbidity .
most of the complications do no require reoperation or prolonged in - hospital stay and can be successfully managed conservatively .
moreover , it allows the surgeon to preserve pancreatic parenchyma and consequently long - term endocrine and exocrine pancreatic function .
 small , benign , or low - grade malignant tumors located in the neck of the pancreas are usually treated with enucleation . however , if enucleation is too risky because of possible damage of the main pancreatic duct , standard pancreatic resections are performed . 
 such operations can lead to impaired long - term exocrine  endocrine function . 
 middle segment pancreatectomy consists of a limited resection of the midportion of the pancreas and can be performed in selected patients affected by tumors of the pancreatic neck . 
 middle segment pancreatectomy is a safe and feasible procedure for treating tumors of the pancreatic neck ; in experienced hands it is associated with no mortality but with high morbidity , even if the rate of  clinical  pancreatic fistula is about 20% . 
 moreover , it allows a surgeon to preserve pancreatic parenchyma and consequently long - term endocrine and exocrine pancreatic function . 
Introduction
Surgical Technique
Discussion