Parenchyma-Sparing Pancreatectomy for Presumed Noninvasive Intraductal Papillary Mucinous Neoplasms of the Pancreas

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Abstract
To assess the feasibility and outcomes of parenchyma-sparing pancreatectomy (PSP), including enucleation (EN), resection of uncinate process (RUP), and central pancreatectomy (CP), as an alternative to standard pancreatectomy for presumed noninvasive intraductal papillary and mucinous neoplasms (IPMNs). Pancreaticoduodenectomy and distal pancreatectomy are associated with significant perioperative morbidity, a substantial risk of pancreatic insufficiency, and may overtreat noninvasive IPMNs. From 1999 to 2011, PSP was attempted in 91 patients with presumed noninvasive IPMNs, after complete preoperative work-up including computed tomography, magnetic resonance imaging, and endoscopic ultrasonography. Intraoperative frozen section examination was routinely performed to assess surgical margins and rule out invasive malignancy. Follow-up included clinical, biochemical, and radiological assessments. Overall PSP was achieved with a feasibility rate of 89% (n = 81), including 44 ENs, 5 RUPs, and 32 CPs. Postoperative mortality rate was 1.3% (n = 1), and overall morbidity was noteworthy (61%; n = 47). Definitive pathological examination confirmed IPMN diagnosis in 95% of patients (n = 77), all except 2 (3%), without invasive component. After a median follow-up of 50 months, both pancreatic endocrine/exocrine functions were preserved in 92% of patients. Ten-year progression-free survival was 76%, and reoperation for recurrence was required in 4% of patients (n = 3). In selected patients, PSP for presumed noninvasive IPMN in experienced hands is highly feasible and avoids inappropriate standard resections for IPMN-mimicking lesions. Early morbidity is greater than that after standard resections but counterbalanced by preservation of pancreatic endocrine/exocrine functions and a low rate of reoperation for tumor recurrence.

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