Pancreaticoduodenectomy (Whipple resections) in patients without malignancy: Are they all 'chronic pancreatitis'?

• Published in: The American journal of surgical pathology Vol. 27; no. 1; pp. 110 - 120
• Main Authors: ABRAHAM, Susan C, WILENTZ, Robb E, YEO, Charles J, SOHN, Taylor A, CAMERON, John L, BOITNOTT, John K, HRUBAN, Ralph H
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 2003
• Subjects: Adult; Aged; Aged, 80 and over; Biliary Tract Diseases - pathology; Biliary Tract Diseases - surgery; Biological and medical sciences; Carcinoma in Situ - pathology; Carcinoma in Situ - surgery; Chronic Disease; Female; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Liver, biliary tract, pancreas, portal circulation, spleen; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Male; Medical sciences; Middle Aged; Other diseases. Semiology; Pancreatic Neoplasms - pathology; Pancreatic Neoplasms - surgery; Pancreaticoduodenectomy; Pancreatitis - classification; Pancreatitis - pathology; Pancreatitis - surgery; Retrospective Studies; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Human; Premalignant lesion; Pancreas-Pancreaticoduodenectomy- Whipple-Sclerosing cholangitis-Chronic pancreatitis- Sclerosing pancreatitis; Duodenum; Pancreatitis; Biliary tract disease; Pathology; Chronic; Surgery; Digestive diseases; Frequency; Diagnosis; Sclerosing cholangitis; Intraepithelial neoplasia; Pancreas; Pancreatic disease; Pancreatoduodenectomy
• ISSN: 0147-5185; 1532-0979
• DOI: 10.1097/00000478-200301000-00012

Pancreaticoduodenectomy (Whipple resection) has evolved into a safe procedure in major high-volume medical centers for the treatment of pancreatic adenocarcinoma and refractory chronic pancreatitis. However, some Whipple resections performed for a clinical suspicion of malignancy reveal only benign disease on pathologic examination. We evaluated the frequency of such Whipple resections without tumor in a large series of pancreaticoduodenectomies and classified the diverse pancreatic and biliary tract diseases present in these specimens. Of 442 Whipple resections performed during 1999-2001, 47 (10.6%) were negative for neoplastic disease and, in 40 cases, had been performed for a clinical suspicion of malignancy. Most Whipple resections revealed benign pancreatic disease, including 8 (17%) alcohol-associated chronic pancreatitis, 4 (8.5%) gallstone-associated pancreatitis, 1 (2.1%) pancreas divisum, 6 (12.8%) "ordinary" chronic pancreatitis of unknown etiology, and 11 (23.4%) lymphoplasmacytic sclerosing pancreatitis. In particular, patients with lymphoplasmacytic sclerosing pancreatitis were all thought to harbor malignancy, whereas only 13 of 19 (68.4%) of Whipple resections showing histologically "ordinary" forms of chronic pancreatitis were performed for a clinical suspicion of malignancy. Benign biliary tract disease, including three cases of primary sclerosing cholangitis, two cases of choledocholithiasis-associated chronic biliary tract disease, and four fibroinflammatory strictures isolated to the intrapancreatic common bile duct, was a common etiology for clinically suspicious Whipple resections (22.5% of cases). Pancreatic intraepithelial neoplasia (PanIN) was a common finding among all pancreata, whether involved by pancreatitis or histologically normal. Overall, PanIN 1A/1B was present in 68.1%, PanIN 2 in 40.4%, and PanIN 3 in just 2.1%. These findings indicate that "benign but clinically suspicious" Whipple resections are relatively common in high-volume centers (9.2%) and reveal a diverse group of clinicopathologically distinctive pancreatic and biliary tract disease.