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The Changing Spectrum of Surgically Treated Cystic Neoplasms of the Pancreas
Jennifer K. Plichta*, Jacqueline a. Brosius, Sam Pappas, Gerard Abood, Gerard V. Aranha
Department of Surgery, Loyola University Medical Center, Maywood, IL
Introduction: Pancreatic cystic lesions are divided into four main types: serous, mucinous, solid pseudopapillary, and intraductal papillary mucinous neoplasm (IPMN). While the incidence of pancreatic cystic lesions has steadily increased, we sought to evaluate the changes in their surgical management.
Methods: Patients with pancreatic cystic lesions who underwent surgical resection from 2003 to 2013 were identified (modern cohort), and clinicopathologic factors were analyzed and compared to a similar cohort of patients from 1992 to 2002.
Results: There were 134 patients, median age 66 years (range 18-88), with pancreatic cystic lesions who underwent surgical resection from 2003 to 2013, compared to 73 patients from 1992 to 2002. Patients were predominately female in both populations (67% vs. 67%, p=0.99). Pathology included: 18 serous, 47 mucinous, 11 pseudopapillary and 58 IPMN. There were significantly fewer serous lesions (13% vs. 36%, p<0.001) and more IPMN (43% vs. 25%, p=0.008). Malignancy was noted in 17% of the mucinous lesions and 38% of the IPMNs. While abdominal pain was the most common presenting symptom in both populations, it was less common in the modern cohort (48% vs. 64%, p=0.01). 62 lesions were noted incidentally. The most common preoperative imaging was a CT scan (98%), although 66% underwent EUS and 63% biopsy. Surgical resection included: 62 pancreaticoduodenectomies, 64 distal pancreatectomies, 4 central pancreatectomies, 1 total pancreatectomy, and 3 other procedures. In comparison, pancreaticoduodenectomy was significantly more common in the modern cohort (46% vs. 27%, p=0.008), while distal pancreatectomy decreased in frequency (48% vs. 59%, p=0.13). Post-operative complication rates were similar (32% vs. 27%, p=0.42), and peri-operative mortality rates were comparable (3% vs. 4%, p=0.67). Pancreatic fistula rates were slightly less common in the modern cohort (4% vs. 10%, p=0.085). Other complications included: 7 intra-abdominal abscesses, 3 GI bleeds, 5 with delayed gastric emptying, 6 urinary tract infections, 2 pneumonias, and 7 wound infections.
Conclusion: There has been a dramatic change in surgically treated pancreatic cystic tumors at our institution over the past two decades. Whereas in the first decade serous lesions were most common, the second saw IPMN's being most common while mucinous and solid pseudopapillary lesions remained constant. Our data suggests that the incorporation of new imaging and diagnostic tests has led to greater detection of cystic tumors and a decreased rate of resection of those that do not need surgical intervention. Therefore, all patients with cystic pancreatic lesions should undergo a focused CT-pancreas and EUS-FNA to select those that would benefit from surgical resection.
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