Surgery for Ipmn of the Pancreas: Preoperative Factors Tipping the Scale of the Decision Making. A Bicentric Analysis

Abstract

Purpose: In patients with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas the decision making depends on scaling the risk of malignancy with that of the surgical burden of a pancreatectomy. The aim of this study was to build a preoperative, disease-specific tool to predict surgical morbidity in surgery for IPMNs. Method: All resected IPMN at two Italian high-volume Institutions from 2012 to 2018 were eligible. Based on preoperative variables, logistic regression and classification tree analysis were applied to derive a predictive model identifying the risk of major morbidity (Clavien-Dindo >=3). Results: Among 524 included patients, 289 (55.2%) underwent pancreaticoduodenectomy (PD), 144 (27.5%) distal pancreatectomy (DP) and 91 (17.4%) total pancreatectomies (TP) with a diagnosis of main-duct (19%), branch-duct (12%) or mixed type (69%) IPMN. Postoperative pancreatic fistula rate and mortality were 11.8% and 3.5%, respectively. Ninety-eight (18.7%) patients developed major morbidity. Multivariate analysis revealed age, BMI and type of surgery to be independent predictors of major morbidity (all P< 0.05). The classification tree (AUC 0.70; CI 95% 0.63-0.77) segregated patients according to the type of surgery. Among DP, presence of preoperative diabetes identified two risk classes (5% and 25% of risk) for developing major morbidity, while among PD/TP, three different classes (15%, 20% and 36% of risk) were identified according to age and BMI. Conclusion: In presumed IPMNs, the disease-specific risk of major morbidity can be determined in the preoperative setting and used to personalize the possible surgical indication. The presence of diabetes and overweight tip the scale towards a less aggressive clinical management.