Pancreaticoduodenectomy for suspected periampullary cancers: the mimes of malignancy.

BACKGROUND: Pancreaticoduodenectomies are often undertaken with suspicion of malignancy. We undertook this study to determine if and how unnecessary pancreaticoduodenectomies can be avoided.
METHODS: Data from patients undergoing pancreaticoduodenectomy were prospectively collected. Operative indications, including presenting symptoms and results with imaging, with or without biopsy, were reviewed.
RESULTS: From 1996 through to 2007, 551 patients underwent pancreaticoduodenectomy at our institution. Chronic pancreatitis was the operative indication in 3% of patients; premalignant/malignant lesions were present in 86% of patients. Eleven per cent of patients underwent 'unnecessary' pancreaticoduodenectomies with presumptive diagnoses of cancer but were without premalignant/malignant disease on final report by Pathology [pancreatitis in 63%, serous cystadenomas (<4 cm) in 14%]. Of the unnecessary resections, 20% had histories and imaging sufficient to diagnose pancreatitis, 18% had inaccurate preoperative brushings/biopsies 'documenting' cancer, 11% had clear misinterpretations of their imaging studies and 7% had inadequate preoperative evaluations. However, 45% had signs/symptoms of cancer with a pancreatic head mass/biliary stricture.
CONCLUSION: Only a small minority of patients undergoing pancreaticoduodenectomy for suspicion of periampullary cancer do so unnecessarily. Preoperative review of biopsies, better considerations of pancreatitis and careful evaluation of imaging, particularly for cystic masses, will decrease unnecessary pancreaticoduodenectomies.