Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome.
OBJECTIVE
Currently, 3 guidelines are available for the management of pancreatic cysts. These guidelines vary in their indication for resection of high-risk cysts. We retrospectively compared the final pathologic outcome of surgically removed pancreatic cysts with the indications for resection according to 3 different guidelines.


METHODS
Patients who underwent pancreatic resection were extracted from our prospective pancreatic cyst database (2006-present). The final histopathologic diagnosis was compared with the initial indication for surgery stated by the guidelines of the International Association of Pancreatology (IAP), European Study Group on Cystic tumors of the Pancreas and American Gastroenterological Association (AGA). We considered surgery in retrospect justified for malignancy, high-grade dysplasia, solid pseudopapillary neoplasms, neuroendocrine tumors or symptom improvement. Furthermore, we evaluated the patients with suspected intraductal papillary mucinous neoplasm (IPMN) separately.


RESULTS
Overall, 115 patients underwent pancreatic resection. The preoperative diagnosis was correct in 83 of 115 patients (72%) and differentiation between benign and premalignant in 99 of 115 patients (86%). In retrospect, surgery was justified according to the aforementioned criteria in 52 of 115 patients (45%). For patients with suspected IPMN (n = 75) resection was justified in 36 of 67 (54%), 36 of 68 (53%), and 32 of 54 (59%) of patients who would have had surgery based on the IAP, European, or AGA guidelines, respectively. The AGA guideline would have avoided resection in 21 of 75 (28%) patients, versus 8 of 75 (11%) and 7 of 75 (9%) when the IAP or European guideline would have been applied strictly. Nevertheless, 4 of 33 patients (12%) with high-grade dysplasia or malignancy would have been missed with the AGA guidelines, compared with none with the IAP or European guidelines.


CONCLUSIONS
Although fewer patients undergo unnecessary surgery based on the AGA guidelines, the risk of missing malignancy or high-grade dysplasia with this guideline seems considerably high.
Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
Selma J
SJ
Lekkerkerker
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
Marc G
MG
Besselink
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
Olivier R
OR
Busch
Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands.
Joanne
J
Verheij
Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
Marc R
MR
Engelbrecht
Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
Erik A
EA
Rauws
Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
Paul
P
Fockens
Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
Jeanin E
JE
van Hooft
D000328:Adult; D000368:Aged; D021441:Carcinoma, Pancreatic Ductal / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018297:Neoplasms, Cystic, Mucinous, and Serous / Q000473:pathology / Q000601:surgery*; D018358:Neuroendocrine Tumors / Q000473:pathology / Q000601:surgery*; D010180:Pancreatectomy / Q000379:methods*; D010181:Pancreatic Cyst / Q000473:pathology / Q000601:surgery*; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D047368:Tumor Burden