Pancreatic resections for presumed malignancy: avoidable pitfalls?

Context: Despite the progress of Imaging unexpected benign diseases occur in 5-10% of Pancreaticoduodenectomies (PD) for presumed malignancy, most of them in the periampullary area. Accessory spleen is detected in almost 2% of Distal Pancreatectomies (DP) for presumed NET. We analyzed the rate of benign pathology in resections for presumed malignancy or pNETs and discussed pitfalls in the diagnostic workup. Methods: All patients resected for presumed malignancy from January 2009 to February 2017 are included. Clinical presentation, imaging, pathology and outcome are reported. Results: We enrolled 865 patients, 14 (1,6%) of them for unforeseen benign disease: 8 PD, 5 DP, 1 middle pancreatectomy. Complications occurred in 13 pts (93%). POPF rate was 28% (n=4). Mortality rate was 14% (n = 2). Symptoms were jaundice (n = 5), abdominal pain (n = 6), weight loss (n = 2) and acute pancreatitis (n = 1). Long lasting symptoms were reported in 4 pts. Five were asymptomatic. Ca 19.9 was abnormal in 4 pts (28%). Preoperative biopsy was performed in 10 pts (71,4%): 1 malignancy, 9 benign. Imaging showed biliary stricture in 7 pts (87%), 5 of them with associated Wirsung dilatation. Gallium 68 PET/CT scan was positive in 2 of 4 pts with suspected pNET of the tail. Conclusions: Periampullary area is challenging to investigate. Accurate imaging is mandatory especially in case of long lasting symptoms or no evidence of masses. Pathology could obfuscate the diagnosis but must be taken under consideration in case of uncommon clinic presentation. Short follow-up could represent an alternative to up-front resections in all unclear findings.