An aggressive resectional approach to cystic neoplasms of the pancreas

Background: Prognosis is good after curative resection for serous and mucinous cystic neoplasms of the pancreas. There has been a recent trend to resect all cystic neoplasms, without attempts to preoperatively determine the exact histologic subtype. Our purpose is to report on the results of such an aggressive surgical approach to all cystic neoplasms of the pancreas. Methods: This is a retrospective cohort analysis of 25 patients with cystic neoplasms of the pancreas treated between July 1991 and July 1998. Data include patient demographics, presenting symptom, operative procedure, pathologic diagnosis, periop morbidity and mortality, survival, and symptomatic follow-up data. Results: Twenty-one patients were women, with a mean age of 60 for the entire cohort. Mean follow-up was 24 months (range 6 months to 4.3 years) with complete follow-up possible in 92%. Twenty-three patients had curative resections and 2 had palliative resections. One patient with an uncinate mass had a partial pancreatectomy; 4 patients underwent distal pancreatectomy and 9 had distal pancreatectomy with splenectomy; 11 patients required a pancreatoduodenectomy, and of these, 4 had tumors involving the portal vein, necessitating a portal vein resection. Pathologic analysis revealed 12 serous cystadenomas, 4 mucinous cystadenomas, 3 mucinous cystadenocarcinomas, 5 intraductal papillary cystic neoplasms, and 1 serous cystadenocarcinoma. The overall perioperative complication rate was 40% with 5 major and 5 minor complications. In the 11 pancreatoduodenectomy patients alone, there were 1 major and 4 minor complications. There were no pancreatic fistulas or portal vein thromboses and no operative mortalities. Two patients, both with mucinous cystadenocarcinomas, died of their disease at 6 and 16 months postoperatively. All 11 pancreatoduodenectomy patients have only mild pancreatic insufficiency relieved by daily enzyme replacement. Conclusions: The good outcomes in this study support an aggressive surgical approach to all patients diagnosed with a cystic neoplasm of the pancreas, if medically fit to tolerate surgery. This approach is justified for the following reasons: (1) preoperative differentiation of a benign versus malignant tumor is unreliable and routine testing for this purpose is of questionable utility; (2) potential adverse consequences of nonresectional therapy are significant; (3) perioperative morbidity and mortality of pancreatic surgery is low; and (4) prognosis with c