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DECISION-MAKING FOR THE MANAGEMENT OF CYSTIC LESIONS OF THE PANCREAS: HOW SATISFIED ARE PATIENTS WITH SURGERY?
Priya M. Puri*1, Ammara A. Watkins2, Laura Maggino1, Tara S. Kent2, Charles Vollmer1
1Surgery, University of Pennsylvania, Philadelphia, PA; 2Surgery, Beth Israel Deaconess Medical Center, Boston, MA
Introduction Decision-making in the treatment of pancreatic cystic lesions (PCL) is challenging, as the potential morbidity and life-style changes induced by surgery must be weighed against the threat of malignancy and anxiety from surveillance. While treatment decisions are often based on clinical and radiologic facts, accurate preoperative diagnosis remains elusive and patients’ preferences should also be valued. This study aims to understand patients’ perspectives about choosing surgery for PCL, and to determine their satisfaction in light of the final pathological diagnosis and clinical outcome.
Methods A survey was administered to all living patients who had a pancreatic resection for a PCL by 12 surgeons at two pancreatic specialty centers (2004-2016). Sixty-two questions (including Y/N, 5-point Likert scale, multiple choice options) were administered either online, during clinic, or via telephone/mail. Patients’ final diagnoses and perioperative outcomes were retrieved from prospectively maintained databases and correlated to the survey’s results.
Results Among 483 patients who had undergone resection for a PCL, 405 (83.9%) were alive, and 113 of these (27.9%) completed the survey. Table 1 shows their clinical features. Despite 89.4% of respondents discussing their condition with more than one physician, and only 9.1% seeing the surgeon as the first doctor, 75.2% considered the surgeon their best source of information. Patients overwhelmingly (94.5%) felt they had the right amount of involvement in the decision-making process. Fear of cancer was quite or extremely important for 95.4% in their decision to proceed with surgery. Respondents were quite or fully satisfied with the outcomes of surgery (91.1%) and with the decision-making process (89.3%). Only 2.8% and 5.4% would have changed either the decision or the timing of surgery, respectively. Impaired lifestyle since surgery was reported by 30.4%; however, in retrospect, distress from anxiety about the cyst before surgery (58.6%) largely outweighed that from post-surgical lifestyle changes (14.4%). Even patients who suffered postoperative complications, recalled perceiving surgery to be the best decision in the post-recovery period (91.5%), and this persisted in the long-term (93.2%). Furthermore, 88.7% patients with non-malignant pathology were quite or fully satisfied with their decision to have surgery, and those with mucinous neoplasms reported high satisfaction rates independent of the grade of dysplasia or malignancy (p=0.650).
Conclusion These results suggest that patients with a resected PCL are highly satisfied with their decision to have surgery, regardless of the final diagnosis or clinical outcome. Fear of cancer is the main driver in the decision-making process, and the anxiety of harboring a cyst is more frequently a cause of distress than are post-operative lifestyle changes.
Table 1. Clinical features of the study population.
| Clinical Variable | Frequency | | Median Age (range) | 65 (22-83) years | Gender
Female
Male | 61.8%
38.2% | Symptomatic at Diagnosis
Yes
No | 43.9%
56.1% | Surgical Procedure
Pancreatoduodenectomy
Distal pancreatectomy
Total pancreatectomy
Central pancreatectomy | 48.2%
48.2%
2.7%
0.9% | Final Pathologic Diagnosis
Intraductal papillary mucinous neoplasm
Mucinous cystic neoplasm
Pancreatic ductal adenocarcinoma
Serous cystadenoma
Other lesion
Neuroendocrine tumor
Cholangiocarcinoma
Pseudocyst | 58.4%
14.2%
8.8%
7.1%
5.3%
4.4%
0.9%
0.9% | Differentiation of Mucinous Cysts
Low-grade Dysplasia
Moderate-grade Dysplasia
High-grade Dysplasia
Invasive cancer | 43.8%
29.7%
18.7%
7.8% | Final Pathology
Benign
Malignant* | 73.8%
26.2% | Postoperative Course
Median length of stay (range)
Complicated postoperative course**
Major complications (Accordion ≥3)
New-onset or progressive diabetes
Exocrine insufficiency | 7 (4-30) days
57.1%
10.2%
26.1%
27.0% |
*Malignant final pathology includes invasive carcinoma and high-grade dysplasia cystic neoplasms. **Complicated postoperative course is defined as having one or more complications.
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