We thank Dr. Meng and colleagues for commenting on our multicenter study evaluating postoperative and long-term outcomes of parenchyma and lymph node sparing procedures (PSR) in small (<3 cm) nonfunctional pancreatic neuroendocrine tumors (pNET).1 The authors have raised important aspects about decision-making and patient selection for PSR and lymph node sparing procedures and their potential impact on surgical and oncological outcomes. Optimal patient selection for lymph node sparing procedures remains controversial. Although oncological resection may appear as the safest option for small nonfunctional pNET, lymph node dissection bears an additional risk of postoperative morbidity. The authors state that the rate of lymph node sampling in the PSR group (40.2%) is particularly high and discuss whether oncologic resection may have been safer in patients with intraoperatively suspicious or enlarged lymph nodes. The decision for PSR and lymph node sparing resection was based on a standardized 2-step decision-making process. A multidisciplinary expert panel reviewed the cases, and PSR was only considered if there were no suspicious lymph nodes in preoperative imaging. Potential lymph node involvement was again carefully evaluated intraoperatively by the surgical team. If lymph nodes appeared suspicious for involvement, sampling was performed. This was the case in 111 of 221 patients with PSR; in these patients, a mean number of 1.4 lymph nodes were removed; however, only 15 in 221 patients (6.7%) with PSR had actual lymph node metastasis. Comparing disease-free and overall survival of patients with PSR and oncological resection, both procedures were equivalent. We, therefore, conclude that careful consideration of lymph node sampling during PSR is oncologically safe. Exposing these patients to a higher risk of postoperative complications associated with systematic lymph node dissection does not seem justified. The authors further remark that the long time period from 2000 to 2021 may lead to heterogeneity in terms of surgical indications and technique. The 4 high-volume centers participating in this study have developed extensive experience in multidisciplinary treatment of pNET patients and follow standardized decision-making processes across centers. During the entire study period, decisions for PSR have been made by multidisciplinary boards as described earlier and lymph node involvement was re-evaluated intraoperatively. PSR have been performed since the beginning of the study period and surgical technique has not changed considerably over time. We, therefore, describe a large homogeneous patient cohort of small nonfunctional pNET with one of the longest follow-up periods available to date (median 208 months). Today, further diagnostic modalities such as endoscopic ultrasound guided fine-needle aspiration biopsy sampling can further guide risk stratification in small nonfunctional pNETs and DOTATAE PET scans can help to identify potential locoregional involvement.2,3 It may be assumed that these additional preoperative tools can lead to a higher rate of involved lymph nodes detected before surgery. The authors further state that indications for surgery have changed and the option of surveillance instead of surgery for nonfunctional pNET of up to 2 cm in size should lead to the exclusion of this low-risk subgroup from the analyses. The most recent North American Neuroendocrine Tumor Society Consensus Paper states that surveillance is an acceptable alternative option to surgery in nonfunctional pNET smaller than 1 cm.4 However, the evidence is derived from few retrospective studies. In this group of patients, surgery still remains a first-line treatment, and individual decisions should be made taking into account all patient-related factors. For small 1 to 2 cm nonfunctional pNET, the safety of surveillance is even more controversial and large studies with long follow-up periods are lacking. The Asymptomatic Small Pancreatic Endocrine Neoplasms (ASPEN) trial is still ongoing and it is hoped that the final results will shed light on the optimal treatment strategy in small 1 to 2 cm nonfunctional pNET.5 To date, surgery and PSR in particular are important first-line strategies in nonfunctional pNET smaller than 2 cm and we would not consider removing this patient group from the analysis. The authors also raised the point whether further subgroup analyses of surgical procedures or tumor characteristics would be crucial for the study. We have compared the subgroups of patients with tumor size of up to 2 cm versus 2 to 3 cm and found no difference in disease-free and overall survival for PSR and oncological resection for the respective subgroups. We further compared postoperative complications for enucleations and central pancreatectomies versus oncological resection. Central pancreatectomies in particular were associated with higher complication rates, while there was only a trend for enucleations. Disease-free (enucleations 193.2 months vs central pancreatectomies 196.3 months vs oncological resection 190.5 months) and overall survival (enucleations 195.3 months vs central pancreatectomies 198.5 months vs oncological resection 192.6 months) are equivalent for both PSR procedures and oncological resection. We did not compare oncological pancreatic head versus tail resections in terms of postoperative complications because the differences in blood loss, operative time, and postoperative complication rates are well-known and beyond the scope of this study evaluating the role of PSR. Further analyses regarding exact tumor location in the pancreatic head, body or tail, distance from the main pancreatic duct, and exocrine and endocrine pancreatic function were unfortunately not feasible, because these detailed information were not available from our database. In summary, the decision for PSR or lymph node sampling versus lymph node dissection and oncological resection has to be considered very carefully by a multidisciplinary team. New preoperative diagnostics such as endoscopic ultrasound-guided fine-needle aspiration and DOTATAE PET scans can help to improve the accuracy of preoperative lymph node assessment. With this standardized decision-making process, we deem PSR safe in small nonfunctional pNET. For nonfunctional pNET smaller than 2 cm, surgery is still an important option given the scarce evidence for surveillance. PSR procedures bear different risk profiles for postoperative morbidity and central pancreatectomy in particular is associated with a higher rate of postoperative complications as compared with oncological resection. Both PSR procedures enucleation and central pancreatectomy are associated with equivalent long-term outcomes as compared with oncological resection.