A Selective Approach to the Resection of Cystic Lesions of the Pancreas: Results From 539 Consecutive Patients

Abstract

The appropriate management of patients with cystic lesions of the pancreas is controversial. The identification of small asymptomatic pancreatic cysts is increasing, and the natural history of these lesions is unknown.1,2 Mucinous lesions, either intraductal papillary mucinous neoplasms (IPMN) or mucinous cystadenomas, are considered premalignant lesions; however, the time course of progression from benign to malignant has not been determined. Although serous cystadenomas are considered to be benign, local growth can result in symptoms. The growth rate of these lesions, and the size at which they become symptomatic is unknown. The present ability to determine the specific histopathology of a radiographically identified pancreatic cyst remains limited. Current laboratory, radiographic, and endoscopic studies are often able to distinguish mucinous from serous lesions, but their ability to identify malignancy within the mucinous subgroup is limited.3,4 Finally, although the mortality after pancreatectomy has decreased to less than 2% in high-volume centers, reported morbidity rates remain at approximately 40%, and reported mortality continues to be as high as 15% at lower volume hospitals.5,6 Because of the unknown natural history, and diagnostic uncertainty, some authors have recommended routine resection of all pancreatic cysts.7–9 These authors argue that because preoperative differentiation between benign and malignant is unreliable, and because the potential adverse consequences of nonresectional therapy are significant, all medically fit patients should undergo resection. Although this approach provides a guarantee to patients that no premalignant or malignant lesions will be observed, it exposes patients with benign lesions to the risks of operation with unclear benefit. Several recent reports, including a previous study from the authors’ institution, have recommended a more selective approach to resection.10–12 This approach argues that improved radiographic imaging techniques and an improved understanding of the various histologic entities allow the identification of a group of patients with an extremely low risk of malignancy. Most studies reporting selective management have recommended nonoperative management (radiographic follow-up) for patients with small, incidentally discovered cysts of the pancreas.10–12 This approach avoids the risks of operation in patients with benign lesions, but with current limitations in nonresectional diagnosis, cannot guarantee that a malignancy is not mistakenly being observed. This study was performed to further describe and review our selective approach to resection for patients with cystic lesions of the pancreas. The authors previously reported on a series of 209 patients.12 In that study, we identified the presence of a solid component, the cyst diameter, the presence of septations, and the presence of symptoms as factors associated with the decision to perform operative resection. The current data allow further assessment of these factors, and the ability to investigate the factors involved in the decision making process.