Mucinous Ductal Ectasia Research Articles

Pancreatic Cystic Neoplasms: Management and Unanswered Questions

Approximately 10% of persons 70 years old or older are now diagnosed with pancreatic cysts, but it is not clear which ones require additional analysis, interventions, or follow-up. Primary care doctors rely on gastroenterologists for direction because no one wants to miss a diagnosis of pancreatic cancer, but meanwhile there is pressure to limit use of diagnostic tests and limit costs. We review the different cystic neoplasms of the pancreas and diagnostic strategies based on clinical features and imaging data. We discuss surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines. Intraductal papillary mucinous neoplasm (particularly the branch duct variant) is the lesion most frequently identified incidentally. We report what is known about its pathology, its risk of developing into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk. We also review surgical treatment and strategies for surveillance of pancreatic cysts.

MRCP Imaging of Intraductal Papillary-Mucinous Neoplasm of the Pancreas.

A 79-year-old man was admitted to the hospital with complaints of abdominal discomfort, jaundice and weight loss. His physical examination was unremarkable, but laboratory examinations revealed significant findings indicating steatorrhea and cholestasis. An ultrasound (US) study revealed marked dilatation of the main bile duct and bile duct as well as the associated branches, with no mass in the pancreatic head. A distended gallbladder was also observed on US. A magnetic resonance cholangiopancreatography (MRCP) revealed dilatation of the main pancreatic duct and side branches with irregular mural thickening and several filling defects (Figure A). These trends were also observed in 3-D volume rendering images (Figure B). Secondary to these findings, the gallbladder was distended, and the bile ducts were dilated. No mass was identified in the pancreas. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), and histopathological examination of the biopsy revealed intraductal papillary-mucinous neoplasm (IPMN). Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is characterized by the presence of a mucin-producing tumor and cystic dilatation of the branches of the pancreatic duct in the uncinate process (branch duct type), diffuse or segmental dilatation of the main pancreatic duct (main duct type) or dilatation of the main ducts and branch ducts (combined type). The dilated ducts often contain profuse mucin. This tumor is also known as a mucin-producing pancreatic tumor, mucinous ductal ectasia, intraductal mucin-hypersecreting tumor or ductectatic mucinous cystic tumor [1–2]. Dilatation of the main pancreatic duct and side branches led to diagnosis of combined-type IPMN. MRCP is especially helpful for staging and as a road map to surgical and percutaneous intervention. Because the increased spatial and contrast resolution increase the sensitivity to fluid and mucin on MRCP, the internal architecture of IPMNs and wall thickening of the main pancreatic duct and branches are better defined through the use of MRCP. The clinical and radiological presentation of IPMN and chronic pancreatitis are often indistinguishable. Talamini et al. [3–5] prospectively followed 473 patients with chronic pancreatitis, including 45 cases of IPMN, and found that approximately 12% of patients with IPMN have a history leading to a diagnosis of chronic pancreatitis, and roughly 2% of all chronic pancreatitis diagnoses are associated with IPMN. The misdiagnosis of IPMN as chronic pancreatitis can lead to serious delays in appropriate management. Curative surgery is only possible if the condition is detected early. Distinguishing a diagnosis of IPMN from chronic pancreatitis can only be achieved through histopathology [6]. Consequently, we considered chronic pancreatitis in the differential diagnosis of IPMN. The diagnosis is made through imaging studies that demonstrate characteristic dilatation of the branches or main duct of the pancreas and endoscopic studies that reveal thick mucin protruding through the bulging patulous duodenal papilla. The treatment decision with regard to IPMN is often based on the patient’s age at presentation, the presence or absence of symptoms, the location of the lesion in the pancreas, the extent of ductal involvement, and the presence or absence of malignant features [7, 8].

Cystic lesion of the pancreas

Cystic lesion of the pancreas

Ductal adenocarcinomas of the pancreas presenting as cystic tumors

Although all cystic neoplasms of the pancreas have relatively similar characteristics on modern imaging modalities, the cells of origin and their biologic aggressiveness are quite different and mandate a selective management approach. This spectrum of cystic disorders encompasses biologically diverse and questionably related diseases, which include the following four broad categories: 1Serous cystadenomas are composed of grapelike collections of predominantly small (< 2 cm), thin-walled, translucent cysts lined by a single layer of uniformly benign-appearing, glycogen-rich, serous cells.13 This category used to be referred to as microcystic neoplasm; however, this term is inappropriate and should be deleted from the current nomenclature.2Mucinous cystic neoplasms (formerly known inappropriately as macrocystic neoplasms) represent a continuum ranging from (a) clinically and pathologically benign mucinous cystadenomas; (b) histologically dysplastic, aggressive-appearing, yet non-invasive proliferative mucinous cystic neoplasms that, if fully resected, do not recur;14, 20and, (c) rare malignant (tissue invasion) mucinous cystadenocarcinomas, which approach the biologic aggressiveness of typical ductal cancer of the pancreas. These mucinous cystic neoplasms are composed of mucin-containing cells that may express varying degrees of atypia, dysplasia, carcinoma in situ, and tissue invasion within the same tumor.3Intraductal papillary mucinous tumor (IPMT) represents a newly recognized entity that also has been referred to most commonly as mucinous ductal ectasia. IPMT represents a spectrum of neoplastic processes composed of mucinous cells lining the main pancreatic duct or secondary pancreatic ducts.10 Significant controversy exists over whether IPMT represents a novel neoplasm arising from a different epithelium or a variant of mucinous cystic neoplasm involving the main pancreatic duct(s). Nevertheless, all agree that IPMT is a premalignant disorder that is recognized with increasing frequency. No reports of this disease existed before 1980. Whether IPMT truly represents a new entity (induced by environmental factors or a new mutation) or was previously overlooked and miscategorized as a ductal adenocarcinoma of the pancreas with mucinous differentiation is unclear; however, many of the clinical and imaging characteristics are so unique that it is hard to believe that it was merely overlooked in the past.4Unusual cystic neoplasms include the extremely rare cystic islet cell tumors (functional and nonfunctional), acinar cell cystadenocarcinomas, cystic choriocarcinomas, cystic teratomas, and cystic lymphangiomatous neoplasms.21 These are all so unusual that they are not mentioned further in this article.

A case of intraductal papillary mucinous tumor accompanied by obstructive jaundice due to generated mucus through pancreatico-cholangio-fistula

A 67-year-old man came to our hospital with a chief complaint of jaundice and itching. Abdominal ultrasonography and computed tomography showed cystic tumor of the pancreas head and dilatation of the bile and pancreatic ducts. After we diagnosed obstructive jaundice, we performed percutanous transhepatic cholangio-drainage. Magnetic resonance cholangiopancreatography and percutanous transhepatic cholangiography showed fistulous communication with pancreatic duct and common bile duct. We performed percutanous transhepatic cholangioscope, in result we found mucinous ductal ectasia into the through pancreatico-cholangio-fistula. Under the diagnosis of intraductal papillary mucinous tumor (adenoma) , the patient was treated by pancreatico-duodenectomy. Histological examination of the specimen showed invasive carcinoma drived from IPMT, accompanied by invasion into CBD. We reported the case of IPMT with obstructive jaundice due to mucus through pancreatico-cholangio-fistula.

EUS in cystic lesions of the pancreas

The differential diagnosis for cystic lesions of the pancreas is broad and the role of EUS is becoming more clearly defined. Pancreatic cysts may be inflammatory, such as pseudocysts, in which the cyst wall lacks an epithelium. Inflammatory cells line the fluid collection, which may often be located adjacent to an area of acute or chronic pancreatitis. Other types of pancreatic cysts may be broadly classified as benign or malignant. Benign cysts include serous cystadenomas (microcystic cystadenoma), lymphangioma, cystic teratoma, hemangioma, or paraganglioma. Malignant cysts include mucinous cystic neoplasms (mucinous cystadenoma or cystadenocarcinoma). These are lined by mucinous epithelium. Cystadenocarcinomas are believed to arise from cystadenomas. The latter are therefore considered premalignant. Other mucinous cystic lesions include mucinous ductal ectasia (MDE), now more correctly referred to as intraductal papillary mucinous tumor (IPMT). A rare form of islet cell tumor may include a cystic component, that is, cystic islet cell tumor. Occasionally, other neoplasms may be of mixed origin and are called solid cystic tumors.1 One possible etiology for mixed tumors is ossification of a cystic tumor.

Natural history of mucinous ductal ectasia of the pancreas: a case report and review of the literature

Mucinous ductal ectasia (MDE) remains a less known disease entity of the pancreas. In an attempt to further characterize its natural history, we report the case of a 68-yr-old man with MDE initially unrecognized in an abdominal CT obtained 5 yr before diagnosis and resection. Furthermore, we have reviewed available case reports in the English literature to clarify the differences between MDE and mucinous cystic neoplasm, two entities that have been frequently confused for one another. MDE is an uncommon disorder of the pancreas characterized by dilated primary and secondary ducts filled with thick mucus that appear as a mass or cyst by ultrasound or CT. ERCP demonstrates a patulous duodenal papilla with extruding mucin from the orifice. Histological changes within the ducts reveal hyperplasia, adenoma, or adenocarcinoma. The recognition of MDE is essential because early detection allows for curative surgical resection of these usually latent and indolent pancreatic neoplasms. Further characterization of MDE and additional longitudinal studies are necessary to elucidate its natural history and define its optimal management.

MUCINOUS DUCTAL ECTASIA OF THE BILIARY TREE SECONDARY TO MUCOUS METAPLASIA. A case report

Mucinous ductal ectasia is an uncommon disorder, characterized by ductal dilatation and filling with thick, viscid mucus, described in the pancreas. We report a case of mucinous ductal ectasia of the biliary tree. The cause of the mucus production was mucous metaplasia in the biliary epithelium. The patient was followed for 16 years, treated with serial saline flushings of the biliary tree whenever he became symptomatic.

Mucinous tumors of the exocrine pancreas.

Mucin-producing cystic neoplasms of the pancreas account for 1% of all malignant tumors of the pancreas. They include mucinous cystic neoplasms (MCNs) and mucinous ductal ectasia (MDE), also known as intraductal mucin-hypersecreting neoplasms. This review focuses on the clinical presentation, the role of diagnostic imaging modalities, and cyst fluid analysis preoperatively in the differentiation between these tumors and other nonneoplastic cysts of the pancreas. MCNs and MDE evolve from pancreatic duct epithelium, produce an abundance of mucin, and are considered premalignant or malignant. While MCNs affect primarily middle-aged women with lesions occurring predominantly in the body and tail of the pancreas, MDE affects primarily men in the sixth or seventh decade with lesions more often located in the head of the pancreas. All mucin-producing cystic tumors of both types require surgical resection because they are frankly malignant or premalignant. Survival rates of both tumors are better than those reported for ductal cell carcinomas. Future studies are needed to improve the accuracy of diagnosing these tumors preoperatively.

7125 How best to diagnose ipmt.

The purpose of the study was to review a single institutional experience of intraductal papillary mucinous tumors (IPMT) and compare different diagnostic modalities. Background: IPMT or mucinous ductal ectasia is a rare neoplasm of the pancreas. It is characterized by extensive intraductal growth with slow invasion and metastasis having a much better prognosis. Diagnosis is usually made by ERCP showing dilated main and side branches with multiple filling defects that represent mucus and often mucus extruding from the papilla. The value of brush cytology and biopsy is unknown. Methods: The medical records, endoscopic findings, brushing results, surgical findings and surgical pathology of 22 patients over a 6 year period were reviewed. Results: The mean age at presentation was 63.1 years. There were 15 females and 7 males. The prevalence of abdominal pain was 86%, h/o pancreatitis 64%, wt loss 23%, diabetes 18%, cholangitis 9%, steatorrhea 5%. CT scan was done in 11 (50 %) and showed cystic dilation in 1, cystic mass in 5, solid mass in 3, and was negative in 2. Three (14%) were found to have pancreas divisum with mucus in the dilated dorsal duct. Nineteen (86%) had tumor involvement in the head of the pancreas and 3 (14%) in the tail. Brushing of the pancreatic duct was performed in 17, biopsy in 8 with only 2 positive for mucinous neoplasm in each (using strict criteria). Pancreatoscopy was performed in 2 patients and revealed the intraductal papillary growth and white gelatinous mucus in both patients. Endoscopic ultrasound was performed on one patient and showed hyperechogenic collection in the dilated pancreatic duct. Eight patients underwent surgery; 4 pancreaticoduodenectomy, 2 pylorus preserving pancreaticoduodenectomy, 1 distal pancreatectomy and 1 total pancreatectomy. Invasive carcinoma was present in 2 (25%). Conclusion: IPMT which has malignant potential, presents with nonspecific symptoms. Non-invasive imaging may be misleading. ERCP is the procedure of choice in making the diagnosis. Brushings or biopsies of the pancreatic duct are insensitive. Pancreatoscopy is useful in determining the extent of the lesion to help guide surgical resection.

3491 Preliminary experiences of three-dimensional endoscopic ultrasonography in the united states.

INTRODUCTION: The advent of low cost computer power has greatly impacted body imaging resulting in a proliferation of technologies incorporating 3-D reconstruction. AIM: To image a variety of UGI lesions with a prototype 3-D EUS catheter probe to determine its potential clinical applications. METHOD: The 3D-EUS imaging system (Olympus Optical, Tokyo) consists of a 12 and 20 MHz ultrasonic probe (UM-3D2R, UM-3D3R), a motor unit, an ultrasound processor (EU-M30), and a computer for image processing (EU-IP2). Scanning and storing time is 4 to 13 sec. The ultrasound probe is housed in a clear sheath filled with water. The motor moves the probe radially (360°) and linearly (4cm). Images are stored and processed later. In all cases, the radial and linear images were reviewed and judgment was rendered as to whether combined imaging provided clinical benefit. Esophageal cases were performed using a condom placed over the end of a two channel endoscope. RESULT: Between 5/99 and 11/99, 13 3-D EUS cases were performed (2 esophageal cancer, 3 Barrett's esophagus, 4 esophageal SMT, 1 gastric SMT, 1 mucinous ductal ectasia, 1 common bile duct stricture). The simultaneous display of linear and radial images made imaging and interpretation of images of SMT easier but did not provide unique and significant advantages. Imaging and evaluation of Barrett's esophagus and biliary strictures was significantly better with the 3-D system because of the volume of area that can be scannedfrom a single position. CONCLUSION:We suggest that the simultaneous linear and radial images produced by this instrument may improve diagnosis in some circumstances. Prospective trials based on this data are ongoing. Volume rendering will be possible in the near future which may further expand the application of 3-D EUS.

Presentation and management of cystic neoplasms of the pancreas

Pancreatic cystic neoplasms are uncommon, but it is important to differentiate them from pseudocysts and ductal adenocarcinoma. A retrospective review was performed to determine distinguishing characteristics and optimal treatment. In 51 patients operated on between 1981 and 1994 at a referral center, the following cystic neoplasms were found: 20 serous cystadenomas, 10 mucinous cystadenomas, 11 mucinous cystadenocarcinomas, five cases of mucinous ductal ectasia, and five papillary cystic neoplasms. Both mucinous ductal ectasia and papillary cystic neoplasms had distinguishing features when compared to other cystic neoplasms. Mucinous ductal ectasia was seen only in men, presented with typical symptoms, and had distinctive features on endoscopic retrograde cholangiopancreatography. Papillary cystic neoplasms occurred in young women (mean age 31 years) and were larger (mean 10.3 cm). Mucinous tumors were always symptomatic, whereas 55% of serous tumors were asymptomatic ( P <0.001). The overall rate of resectability was 80%, and there was one operative death (2%). Intraoperative biopsy was diagnostic in 18 (78%) of 23 cases. An actuarial 5-year survival of 52% was found for resected mucinous cystadenocarcinomas. In conclusion, papillary cystic neoplasms and mucinous ductal ectasia have distinct characteristics that differentiate them from other types of pancreatic cystic tumors. Serous cystadenoma should be considered in asymptomatic patients and these patients should be closely observed. Symptomatic neoplasms should be resected with long-term survival expected for malignant forms.

Magnetic resonance cholangiopancreatography: Objectives and future

Magnetic resonance cholangiopancreatography (MRCP) is a rapidly developing non-invasive imaging method that can depict the biliopancreatic ducts. Compared to direct methods such as endoscopic retrograde cholangiopancreatography (ERCP), MRCP is not painful, does not require contrast media, and its success does not depend, to any great extent, on the operator's skill. It uses three-dimensional data sets for projection images, as well as arbitrary cross-sectional iamges. Faster data acquisition techniques are expanding its indications as a diagnostic tool. MRCP is undoubtedly the method of choice when ERCP is contraindicated or fails. Imaging after the injection of secretin improves pancreatic duct delineation, and may also add functional information to MRCP. Adequate diagnostic evaluation of acute pancreatitis, pancreatic trauma, and mucinous ductal ectasia may also be feasible. Further development and optimization of MRCP will substantially limit the indications for diagnostic endoscopic pancreatography.

Mucinous ductal ectasia of the pancreas.

Pancreatic mucinous ductal ectasia (MDE) is a recently described and poorly understood disorder, with few cases reported in the imaging literature. We undertook this study to describe the spectrum of CT and pancreatographic findings of MDE and to investigate the incidence of associated pancreatic malignancy. The medical records, CT scans, and pancreatograms of 12 consecutive patients with pathologically proven MDE were retrospectively reviewed. There were nine men and three women, ranging in age from 37 to 72 years (mean 59 years). Focal lesions involved primarily the uncinate (two patients) and head (eight patients) by CT imaging. The entire gland was involved in two patients. CT findings were variable and included focal pancreatic enlargement, a low attenuation or cystic mass, low attenuation of the entire gland, or marked ductal dilatation. Pancreatographic findings were more consistent, showing ductal dilatation with or without intraluminal filling defects, obstruction, or displacement. In all cases, findings at endoscopy were felt to be characteristic, with ductal dilatation, filling defects, or abundant mucus seen upon cannulation of the pancreatic duct. Carcinoma-in-situ was present in six cases, cellular atypia without malignancy in two, and in three cases the lesions were histologically benign. One case demonstrated invasive adenocarcinoma. No finding or group of findings on CT or pancreatography permitted differentiation between benign and malignant lesions. MDE can present with a variety of appearances on CT, none of which is diagnostic. Pancreatography can be diagnostic if dilatation and intraluminal filling defects are seen. Carcinoma-in-situ, invasive adenocarcinoma, or cellular atypia is present in approximately 75%, but cannot be accurately diagnosed prospectively.

The usefulness of pancreatoscopic examination in patients with mucinous ductal ectasia

Mucinous ductal ectas ia는 다량의 점액이 쉐관내에 존재하여 춰l관이 확장되고 점액이 유두 개 구부로 유출되는 특징적인 십이지장경 소견 및 례관 조영 소견을 보이는 비교적 드문 질환이다 저자등은 최근 경구 혜관경 검사를 시행하여 특징적인 춰l관경 검사 소견을 관찰할 수 있었던 mucinous ductal ectasia 3예를 쉐관경 검사의 유용성에 대한 고찰과 함께 보고하는 바이다 십이 지장경 소견상 3예 모두 개대된 유두 개구부와 점액 유출이 보였고 쉐관경 검사상 백색조의 점 액 배경내에 유두상 또는 융모상의 점막 증식이 관찰되었다 Mucinous ductal ectasia 환자에서 춰l 관경 검사는 방사선학적 검사상 진단이 확실치 않은 쉐장 낭성 종양의 감별 진단, 춰l관 조영상 에서 음영결손의 감별 진단에 유용할 뿐만 아니라 특히 수숨을 시행하는 환자에서 병변 부위의 범위 판정과 절제 범위 결정에 도움이 될 수 있다고 사료된다.

MR Pancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a diagnostic method that uses three-dimensional data sets for projection images, as well as arbitrary cross-sectional images, of the pancreatic ducts. The method is simple, not uncomfortable, and requires no contrast media. Magnetic resonance cholangiopancreatography (MRCP) was initially developed as a substitute for ERCP for diagnosis of pancreatic disorders such as neoplasm and chronic pancreatitis, but the method offers advantages other than safety and flexibility. MRCP may be the diagnostic method of choice when ERCP is contraindicated or fails. Imaging after injection of secretin may add functional information to MRCP that may reflect one aspect of pancreatic exocrine physiology. Adequate diagnostic evaluation of acute pancreatitis, pancreatic trauma, and mucinous ductal ectasia may also be feasible. Innovations such as fast sequences with breath-holding, receiver multicoils, high-power gradient systems, and postprocessing will further refine the technique. Optimized MRCP could limit indications for diagnostic endoscopic pancreatography substantially.

Pancreatoscopy and diagnosis of mucinous neoplasms of the pancreas

The existence of mucinous cystadenoma or cystadenocarcinoma of the pancreas has long been recognized. In addition to the classic mucinous cystadenoma, some authors have described two new types of tumors with mucin production and similar microscopic features, but with an intraductal growth pattern and different clinicopathologic findings. This group of lesions encompasses not only tumors that have been collectively termed intraductal papillary neoplasms1 but also neoplasms that have been described as mucin-producing tumors,2 ductectatic-type mucinous cystadenoma and cystadenocarcinoma (DMC),3,4 mucin-hypersecreting neoplasms or carcinomas,5,6 and mucinous ductal ectasia of the pancreas.

Diagnosis and management of mucinous ductal ectasia of the pancreas

Diagnosis and management of mucinous ductal ectasia of the pancreas

Intraductal Papillary Mucinous Neoplasms of the Pancreas Associated with So-called “Mucinous Ductal Ectasia” Histochemical and Immunohistochemical Analysis of 29 Cases

Twenty-nine patients (20 men, nine women; mean age, 65.9 years; range, 49-77 years) with intraductal papillary mucinous neoplasms associated with so-called "mucinous ductal ectasia" of the pancreas were studied both histochemically and immunohistochemically. These cases included six cases of hyperplasia, 13 adenomas, and 10 adenocarcinomas. The mean sizes of the hyperplasia, adenomas, and adenocarcinomas were 2.0 cm, 3.0 cm, and 4.8 cm in diameter, respectively. Tumor size correlated with the degree of cellular atypia. The proliferative rates were significantly higher in the carcinomatous epithelium with those in the hyperplastic and adenomatous epithelia. The polarity of distribution of carcinoembryonic antigen and carbohydrate antigen 19-9 were better preserved in the hyperplastic epithelia than in the carcinomatous epithelia. On the other hand, the papillary and nonpapillary hyperplastic epithelium contained mainly a neutral periodate-reactive glycoprotein with only trace amounts of sialomucins and sulphomucins. In addition, the adenomatous epithelium contained mostly sialomucins with a small amount of sulphomucins. The carcinomatous epithelium contained predominantly sulphomucin. The results of both the histological and immunohistochemical studies suggested the possibility of a sequential change from nonpapillary and papillary hyperplasia, via adenoma, to carcinoma in intraductal papillary-mucinous neoplasms associated with mucinous ductal ectasia. Moreover, these results, in combination with the histochemical findings, are considered helpful in making an appropriate preoperative diagnosis with endoscopic pancreatic ductal biopsy specimens, thus enabling the surgeon to select the most appropriate surgical procedure.

Standards for Pancreatic Resection in the 1990s

To describe the current indications and operative outcomes of pancreatic resection. Retrospective case series. Referral practice in a university hospital. Two hundred thirty-one consecutive patients undergoing pancreatoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy (TP) over a 44-month period. Their ages ranged from 16 to 85 years, with a mean of 54 years; 20% of the patients were 70 years old or older. Mortality, complications, and length of hospital stay. Operative mortality was 0.4% (one death following DP); there were no deaths in 142 PDs or in 18 TPs. The most common complication following PD was delayed gastric emptying. Pancreatic fistula occurred in 6.3% of PD and in 9.8% of DP patients. Overall, 58% of PD, 80% of DP, and 78% of TP patients had no complications. The mean +/- SD length of hospital stay was 15 +/- 7, 10 +/- 5, and 15 +/- 6 days for PD, DP, and TP, respectively. Reoperation for any cause was necessary in only 1.2% (3/231). The most frequent indication for PD was pancreatic cancer (36%) followed by chronic pancreatitis (26%); for DP it was chronic pancreatitis (28%) and cystic neoplasms (27%); and for TP, chronic pancreatitis (55%). Newer indications for pancreatic resection included mucinous ductal ectasia and intraductal papillary tumors (eight cases, 4%) and metastatic tumors (eight cases, 4%). Current indications for pancreatic resection have expanded. These procedures are associated with a low risk for death and postoperative complications when performed in a high-volume setting.