Background : For patients suffering from pancreatic tumors separately in the pancreatic head and body-tail is uncommon. Whether total pancreatectomy or partial pancreatectomy is still controversial and there is not much research on this issue. To preserve pancreas function, in order to avoid delayed onset insufficiency of insulin, we performed simultaneous pancreaticoduodenectomy and distal pancreatectomy by robotic approach in a case of simultaneous pancreatic neuroendocrine tumor over head and body-tail separately. The prognosis including fasting blood sugar, HbA1c and C-peptide after operation were followed.

Methods : The patient was a 68 years-old female presenting two asymptomatic tumors separately in pancreatic head and body-tail by routine health check with sonography in 2018. The lab data including CEA, CA-199, amylase, lipase, fasting blood sugar, HbA1c, C-peptide were not remarkable. Both CT scan and MRI showed hypervascular lesions , one about 3.6cm in size at uncinate process, and another about 3.4 cm tumor at pancreatic body-tail. Tentative diagnosis was pancreatic neuroendocrine tumors. To avoid total pancreatectomy, simultaneous robotic pancreaticoduodenectomy and distal pancreatectomy with preservation of 3.8 cm central pancreas was successfully performed in August 2018, with minimal blood loss.

Results : The final pathological examination revealed a 3.8 x 3 cm grade 1 NET at pancreatic uncinate process, another 3.2 x 2.5 cm grade 2 NET at pancreatic body-tail, and there was no lymph node involved. Post-operative C-peptide was 1.45 ng/mL on postoperative day (POD) 1 and 1.11 ng/mL on POD 7. Patient recovered well and was discharged on POD 10. After that, the patient kept regular follow-up at Endocrine out-patient department under oral medication, Glucophage and Januvia, for blood sugar control. The 1-year follow-up fasting blood sugar, HbA1c and C-peptide were within normal limits, 111 mg/dL, 5.6% and 1.11 ng/mL respectively. Oral hypoglycemic agent (OHA) titrated up dose and adjusted Januvia to Canagliflozin 2 years after, the best HbA1c was 7.0%, still insulin free after operation.

Conclusions : For the patient suffering from neuroendocrine tumor separately in the pancreatic head and body-tail is uncommon. To preserve the more parenchyma would be considered as a good strategy. We would like to propose this unique technique by robotic simultaneous pancreaticoduodenectomy and distal pancreatectomy (RSPDDP) with preserving the central pancreas as an alternative to total pancreatectomy in order to try to preserve patient’s endocrine and exocrine functions.