Pancreatic Masses in Children: A Single-Center Experience Over Two Decades

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L. H. McRae, Humza Thobani, Marla A. Sacks, Steven L. Raymond, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4681885/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Aug, 2024 Read the published version in European Journal of Pediatrics → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose : Pancreatic masses are extremely rare in pediatric patients, with limited data available. This lack of data makes the diagnosis and management of these tumors in children extremely challenging. Therefore, we aimed to describe the presentations, clinical course, and outcomes of children with pancreatic tumors at our center. Methods : A retrospective analysis was performed of all pediatric patients diagnosed with pancreatic masses between 2003 and 2022 in an academic freestanding children’s hospital. Data including demographics, clinical presentation, workup, management, and subsequent morbidity and mortality, were collected and aggregated. Furthermore, we reviewed cases of pancreatic tumor resections in the National Surgical Quality Improvement Program – Pediatric (NSQIP-P) database to identify common adverse outcomes and measures for quality improvement. Results : In total, 17 patients were identified at our institution. Diagnoses included Solid Pseudopapillary (n=9), Gastrinoma (n=1), Rhabdomyosarcoma (n=2), Pancreatoblastoma (n=2), Insulinoma (n=1). Two patients did not have a histopathologic diagnosis and were excluded from subsequent analysis. Overall, 12 patients underwent surgical intervention, with the most common procedures being pancreaticoduodenectomy and distal pancreatectomy, and all 12 were known to be alive at last contact. There were 3 deaths, all due to complications related to metastatic disease. Furthermore, 30-day postoperative outcomes in the NSQIP-P dataset are excellent, with negligible morbidity and no mortalities after the index surgery. Conclusions : Children with pancreatic tumors amenable to surgical resection appear to have adequate long-term survival. Short-term outcomes at diagnosis are excellent and mainly appear to be influenced by the presence of metastatic disease at initial presentation. Pancreatic Masses Solid Pseudopapillary Tumor Insulinoma Pancreatoblastoma Gastrinoma Rhabdomyosarcoma Introduction Pancreatic tumors in children are extremely rare, with malignant tumors being even more infrequent. Two large epidemiologic data sets (n = 228) and (n = 109) have shown malignant pancreatic tumors to have an incidence of 0.46 per million children, with neuroblastoma and pancreatoblastoma arising more commonly in younger children, and adenocarcinoma and solid pseudopapillary tumors in older children 1 2 . The low incidence of pediatric pancreatic tumors has made early identification of incident cases, and the creation of treatment guidelines extremely challenging. Curative efforts typically involve an aggressive surgical approach with resection of the primary tumor and its metastases 3 . Long-term survival in these cases is highly dependent on the histological type of the tumor with solid pseudopapillary tumor having a favorable prognosis, however the low incidence of pancreatic tumors makes it difficult to consolidate high quality survival data after operative intervention. This study's purpose was therefore to describe the short-term postoperative outcomes and long-term survival of children with pancreatic tumors in our region. Furthermore, we aimed to analyze and benchmark surgical safety and quality indicators for children undergoing pancreatic resection procedures for pancreatic tumors. To do so, we reviewed the National Surgical Quality Improvement Program – Pediatric (NSQIP-P) database, a nationally validated and risk adjusted dataset to benchmark the outcomes of pancreatic solid tumor resections in children. Methods Hospital Cohort Clinical and Outcomes Data Extraction This was a single center retrospective observational study conducted at the Loma Linda University Children’s Hospital, a 364-bed, tertiary care medical center that provides care to more than 1.2 million children in the region. The study was approved by the Institutional Review Board [IRB# 5200422] prior to initiation. Patients were identified from the Pediatric Surgery Division database at Loma Linda University Children’s Hospital for pediatric patients with a suspected or confirmed diagnosis of Solid Pseudopapillary tumor (SPT), Gastrinoma, Rhabdomyosarcoma (RMS), Pancreatoblastoma (PBL), Insulinoma or Miscellaneous Tumors located in the Pancreas. Patients under 18 years of age who had pathological or clinical confirmation of a pancreatic mass at the study institution from January 2003 to November 2022 were included. The electronic medical records (EMR) of inpatient and outpatient encounters were accessed. Information detailing their demographics, clinical presentations, clinical courses, surgical management, histopathologic diagnosis, imaging findings, hospital courses, and follow ups were abstracted. All patient details were de-identified prior to data extraction and analysis. The primary clinical outcome was mortality at last contact. Secondary clinical outcomes included short term and long-term outcomes of interest including operative time, estimated blood loss, need for intraoperative blood transfusion, length of total parenteral nutrition (TPN), time to initiation of enteral nutrition, length of stay, postoperative complications, and disease recurrence. NSQIP-P Surgical Safety and Quality Analysis In addition to reviewing our institutional experiences with pancreatic tumors in children, we assessed nationwide surgical outcomes for operative pancreatic tumor resections using the NSQIP-P database. We queried NSQIP-P for all patients aged 0–18 with a diagnosis of a benign or malignant lesion of the pancreas (ICD9: 211.6, 157, ICD10: D13.6, C25) who underwent a distal, subtotal, or total pancreatectomy or pancreatic excisional procedure (CPT: 48120, 48140–48146) from 2012 till 2019. Overall, 30-day outcomes after the index operative procedure were compiled and aggregated. As NSQIP-P does not capture histological data, tumor subtype or oncologic stage, we stratified outcomes by procedure type only. Results Hospital Cohort Clinical Characteristics and Outcomes Seventeen patients were identified and met all study criteria. The mean age was 13.3 years with a female predominance (76%). Nearly all patients presented with non-specific symptoms such as abdominal pain, nausea, and weight loss. Table 1 outlines the demographics and presenting symptoms of all the patients in our study cohort. On postoperative histopathology, 9 (52%) patients were found to have SPT, 2 (12%) had PBL, 2 (12%) had RMS, 1 (6%) had a gastrinoma and 1 (6%) had an insulinoma. Definitive histopathology data was not available for 2 patients (12%), as one was lost to follow-up while the other was suspected to have lymphoepithelial cyst and was managed conservatively with surveillance imaging. These patients were classified as having miscellaneous lesions of the pancreas and were excluded from subsequent analysis. Table 1 Hospital Cohort Demographics and Presenting Features Case ID. Tumor Type Age at Presentation Sex BMI Presenting Symptoms Imaging Workup Preoperative Biopsy Done 1 Solid Pseudopapillary 8 yrs, 2 mo F 21.1 Emesis CT, EGD FNA 2 Solid Pseudopapillary 14 yrs, 6 mo F 22.8 Abdominal Pain, Nausea CT, AUS, MRI, EUS FNA 3 Solid Pseudopapillary 15 yrs, 3 mo F 21.3 Abdominal Pain, Nausea CT, MRI N 4 Solid Pseudopapillary 15 yrs, 10 mo F 25.4 Abdominal Pain CT, AUS, MRI N 5 Solid Pseudopapillary 12 yrs, 4 mo F 35.7 Acute Epigastric Pain CT, AUS, MRI N 6 Solid Pseudopapillary 13 yrs, 3 mo F 19.8 Abdominal Pain, Back Pain, Nausea CT, MRI, EUS FNA 7 Solid Pseudopapillary 16 yrs, 0 mo F 24.4 Abdominal Pain, Emesis CT N 8 Solid Pseudopapillary 11 yrs, 11 mo F 23.8 Epigastric Pain after meals, Emesis CT N 9 Solid Pseudopapillary 15 yrs, 6 mo F 19.8 Asymptomatic (Incidental Finding) AUS, MRI N 10 Pancreatoblastoma 15 yrs, 1 mo M 15.6 Epigastric pain, Intractable Vomiting, Weight Loss CT, AUS, EGD FNA 11 Pancreatoblastoma 0 yrs, 4 mo F N/A * Palpable Abdominal Mass, Fever, Diarrhea AUS, MRI N 12 Rhabdomyosarcoma 8 year, 5 mo F 15.3 Axillary Mass, Weight Loss CT, AUS, MRI CNB 13 Rhabdomyosarcoma 12 year, 2 mo F 20.5 Abdominal Pain, Scleral Icterus, Facial Jaundice CT, AUS, MRI OB 14 Gastrinoma 16 year, 2 mo F 26.5 Abdominal Pain, Recurrent Pancreatitis CT, AUS, MRI, EGD, EUS CNB 15 Insulinoma 17 year, 7 mo M 28.0 Symptomatic Hypoglycemia CT, AUS, EUS FNA 16 Miscellaneous Lesion ^ 14 year, 11 mo F 19.3 Abdominal Pain, Diarrhea, Weight Loss CT, AUS, MRI, EGD, EUS FNA 17 Miscellaneous Lesion ^ 17 year, 2 mo M 23.1 Emesis, Back Pain, Weight Loss CT, AUS, MRI N Abbreviations : CT, Computerized Tomography; AUS, Abdominal Ultrasound, MRI, Magnetic Resonance Imaging, EGD, Esophagogastroduodenoscopy; EUS, Endoscopic Ultrasound; FNA, Fine Needle Aspiration; CNB, Core Needle Biopsy; OB, Open Biopsy *Patient less than 2 years, growth chart not available ^Patients with Miscellaneous Lesions received no further treatment and are excluded from subsequent tables Table 2 outlines the interventions in our study cohort. Twelve of the patients were managed with surgery. The postoperative, in-hospital and post-discharge outcomes for all patients are compiled in Table 3 . Table 2 Hospital Cohort Medical Management and Operative Interventions Case ID. Operative Intervention Tumor Greatest Dimension (mm) * Operative Time (min) Estimated Blood Loss (mL) Feeding Tube Placement Lymph Nodes Examined (Positive) Other Medical Treatment 1 Distal Pancreatectomy with Splenectomy and Lymph Node Sampling 78 270 50 None 12 (0) None 2 Pancreaticoduodenectomy 72 430 150 J-Tube 16 (0) None 3 Resection of Pancreatic Mass 60 105 Nil None 0 (0) None 4 Robot-Assisted Distal Pancreatectomy with Splenectomy 38 260 100 None 12 (0) None 5 Pancreaticoduodenectomy 84 780 1000 J-Tube 14 (0) None 6 Pylorus Preserving Pancreaticoduodenectomy, Partial Pancreatectomy 40 380 75 J-Tube 5 (0) None 7 Distal Pancreatectomy with Splenectomy 105 360 450 None N/A None 8 Distal Pancreatectomy with Splenectomy and En Bloc Mesocolic Resection 80 280 100 None 18 ( 2 ) None 9 Pylorus-Preserving Pancreaticoduodenectomy 47 400 20 None 2 (0) None 10 None 40 - - - Chemotherapy 11 Resection of Pancreatic Cyst 100 125 Nil None 1 (0) None 12 None NR - - - Chemotherapy, Radiation, Palliative Care 13 None NR - - - Chemotherapy, Radiation, Palliative Care 14 Pancreaticoduodenectomy 40 475 150 GJ-Tube 7 ( 1 ) None 15 Distal Pancreatectomy NR NR 200 None NR None Abbreviations : NR, Not Reported; J-Tube, Jejunostomy Tube, GJ-Tube, Gastrojejunostomy Tube *All tumor sizes based on surgical histopathology, except for cases which did not undergo surgery, in which reported tumor size is based on imaging Table 3 Hospital Cohort Postoperative Outcomes and Long-Term Follow-up Case ID. Postoperative In-Hospital Complications Days of TPN Use Days till Full PO Feeds Length of Stay (days) Days from Discharge till Last Contact Disease Related Complications After Discharge Recurrence at Last Contact Disposition at Last Contact 1 None 5 8 17 1288 Uncontrolled pain requiring readmission N Deceased 2 Postoperative Ileus 0 12 13 643 None N Alive 3 None 4 8 11 43 None N Alive 4 None 0 1 2 27 None N Alive 5 Pancreatic leak, Gastroparesis 20 10 30 70 Leak around J-Tube site N Alive 6 Gastroparesis, G-Tube Placement NR 20 36 868 Adhesive SBO requiring lysis of adhesions N Alive 7 None 0 3 7 No Contact No Contact No Contact Not Known 8 None 0 6 8 12 None N Alive 9 Lymphatic leak, gastroparesis 15 6 21 35 None N Alive 10 - > 60 - 84 - - - Deceased 11 None 2 4 10 1350 Partial SBO and pancreatic fluid collection requiring IR drainage and additional 15 days of TPN N Alive 12 - - - NR - - - Deceased 13 - - - NR - - - Deceased 14 Postoperative Ileus 0 9 15 2000 Posterior partial hepatectomy for liver metastases and conversion to Roux-en-Y Y Alive 15 Postoperative Ileus, Atelectasis 0 2 8 1011 Pancreatic pseudocyst requiring IR drainage, DVT at LUE PICC site, Eventual Roux-en-Y pancreatic cyst-jejunostomy N Alive Abbreviations : NR, Not Reported; PO, Per Oral; TPN, Total Parenteral Nutrition, G-Tube, Gastrostomy Tube; SBO, Small Bowel Obstruction; IR, Interventional Radiology; DVT, Deep Vein Thrombosis; LUE, Left Upper Extremity, PICC, Peripherally Inserted Central Catheter Solid Pseudopapillary Tumor Cases Of the 9 patients with SPTs, only 3 underwent preoperative biopsies, out of which only 1 provided a definitive histopathologic diagnosis. All patients with solid pseudopapillary tumors were managed surgically with four receiving pancreaticoduodenectomies, four distal pancreatectomies with splenectomies and one mass resection. All but one patient received epidural analgesia. One patient undergoing pancreaticoduodenectomy required blood transfusion intraoperatively. Surgical drains at the site of resection margin were placed in seven patients and jejunostomy tubes were placed in three of four pancreaticoduodenectomies. All but one had negative lymph nodes and one had evidence of metastasis in an omental lesion. Within the index surgical admission, the mean hospital length of stay was 16 days. Four patients required postoperative parenteral nutrition. The mean time to starting a clear liquid diet was 8 days. Immediate postoperative complications for this cohort included ileus, gastroparesis, gastric outlet obstruction, pancreatic leak, lymphatic leak, and a need for a delayed gastrostomy tube placement. Eight of the nine patients with SPT were followed. The time to last contact ranged from 13 to 1288 days, with only 3 patients followed for over 1 year. The ninth patient elected to follow up at a hospital closer to his home. All eight that have been followed are alive with no recurrences. Five of these patients had no post discharge complications and no unplanned visits or readmissions. One patient was readmitted on post operative day 66 for pancreatitis. Nearly 1.5 years later, she was admitted for pancreatic insufficiency and small bowel obstruction requiring exploratory laparotomy with lysis of adhesions. Two other patients had emergency room visits for leaking at the skin at the jejunostomy feeding tube site and another for uncontrolled pain. Pancreatoblastoma Cases One patient with PBL was found to have extensive metastases and underwent chemotherapy prior to succumbing to his disease 3 months after diagnosis within the same hospitalization. The second patient with PBL underwent a resection of the body of pancreas with minimal blood loss, no drain or feeding tube placed, and no metastasis identified. She required TPN for two days, started clear liquid diet on postoperative day 3 and was discharged on postoperative day 10 with no immediate complications. She was later readmitted for poor oral intake requiring TPN secondary to a partial small bowel obstruction and required Interventional Radiology (IR) drainage of a pancreatic pseudocyst. After discharge from that admission, she had one additional emergency room visit for a partially dislodged surgical drain that was removed at bedside without complications and no additional unplanned admissions. Rhabdomyosarcoma Cases Both patients with RMS were diagnosed with metastatic disease and were admitted for chemotherapy and radiation. Both opted for palliative care without an opportunity for surgical intervention and died due to disease related complications. Gastrinoma Case The patient with gastrinoma underwent a pancreaticoduodenectomy with gastrojejunostomy and a surgical drain placed. She received epidural analgesia. Of seven lymph nodes sampled, one had metastasis. She developed ileus during her immediate postoperative course but eventually tolerated tube feeds and was able to start a clear liquid diet by postoperative day 9 with discharge on postoperative day 15. She was later found to have lesions within the liver and underwent an additional metastasectomy of the liver. Furthermore, after discharge, she three additional interventions at an outside hospital including: a conversion to a Roux-en-y two years after her initial operation, a partial hepatectomy of segments 2, 3, 5 and 6 for concerning metastatic lesions and a revision of her prior gastrojejunostomy, partial gastrectomy, partial small bowel resection and re-revision of her Roux-en-y a few months later. There are limited records on the cause of the reoperations. Over five years postoperatively from index surgery, she was alive without known recurrence. Insulinoma Case The patient with insulinoma underwent a distal pancreatectomy with surgical drain placement and epidural analgesia with no metastasis discovered. He also developed a superficial wound infection and documented atelectasis. He started a clear liquid diet on postoperative day 2 with discharge on postoperative day 8. He later developed a pancreatic pseudocyst three months after the index operation and was readmitted for IR drainage of the cyst. Six months after index operation, he returned for a Roux-en-Y pancreatic cyst-jejunostomy. After the final operation, there were no other known complications, and he was living over 3 years since his initial diagnosis. NSQIP-P Results A total of 260 patients underwent one of the four pancreatic excision procedures under study. Of these, only 29 patients were diagnosed as having a benign or malignant pancreatic neoplasm and were included in subsequent analysis. Fifteen (51.7%) underwent distal subtotal pancreatectomy without a pancreaticojejunostomy, 12 (41.4%) patients underwent an excision of pancreatic lesion, and 2 (6.9%) patients underwent a near total pancreatectomy with preservation of the duodenum. There were no recorded cases of a patient undergoing a distal pancreatectomy with a pancreaticojejunostomy. The mean age of included patients was 13.7 years and 86% of the patients were female. Table 4 outlines the overall demographics and 30-day outcomes for this cohort of patients. Approximately a third of cases (31%) were attempted laparoscopically. Outcomes were excellent with no major perioperative complications prior to discharge, except for one patient who developed a wound dehiscence. There were no recorded reoperations, readmissions, or mortalities within 30-days of the index procedure. Table 4 NSQIP-P Data Excision Procedures on the Pancreas Pancreatectomy, Distal Subtotal, with or without Splenectomy, without pancreatico-jejunostomy Pancreatectomy, Distal, Near-Total with preservation of duodenum Combined Cohort CPT Code 48140 48140 48146 # Cases Recorded 12 15 2 29 % Female Patients 83% 93% 50% 86% Average Age (Years) 14.6 13.3 12.2 13.7 Range of Ages in Years 5.5–17.5 3.1–17.1 10.6–13.9 5.5–17.1 % Major or Severe Cardiac Risk Factors 0% 0% 0% 0% % Current Diagnosis of Cancer 25% 60% 0% 45% % ASA Class 3 or Higher 17% 40% 50% 24% Operative Time Average (minutes) 159 258 176 211 Range of Operative Tine 55–326 88–552 137–215 55–552 % Laparoscopic Only 25% 33% 1 0% 2 31% % Mortality in 30 days 0% 0% 0% 0% % Superficial Skin Infection 0% 0% 0% 0% % Post Op Wound Dehiscence 0% 6.7% 0% 3.4% % Post Op Pneumonia 0% 0% 0% 0% % Post Op Reintubation 0% 0% 0% 0% % Post Op CVA resulting in neuro deficits 0% 0% 0% 0% % Operations requiring a Blood Transfusion 0% 0% 0% 0% Average Days from Operation To DC 7.1 8.6 6 7.8 Range of days from operation to DC 5–22 0–35 6–6 0–35 %Reoperation 8.3% 3 0 0% 3.4% 3 %Readmission 16.7% 5 6.7% 0% 10.3% 4 Postoperative Diagnosis Neoplasm of Unspecified Behavior/Location 33.3% 26.7% 50% 31% Benign neoplasm of pancreas 33.3% 26.7% 50% 31% Malignant Neoplasm of Endocrine Pancreas 33.3% 46.6% 0 38% Footnote : 1 3 entries not recorded (NR). 2 1 entry NR. 3 6 entries NR. 4 5 entries NR. Discussion The results of this study highlight the diagnostic and management challenges in children with pancreatic tumors. These findings thus contribute to a limited pool of literature on the overall presentation and outcomes of pancreatic masses in the pediatric population 4 5 . The initial presentation of nearly all patients in our cohort consisted of non-specific symptoms such as abdominal pain, emesis, nausea, and weight loss. One patient was entirely asymptomatic, and the mass was noted on incidental imaging. Abdominal ultrasonography was extensively utilized in the diagnostic workup of the patients in our study cohort, and likely represents a radiation-free and minimally invasive imaging study to bridge the diagnostic gap between initial clinical evaluation and higher risk modalities such as Computed Tomography (CT) or Esophagogastroduodenoscopy (EGD). Of the 15 patients who were included (excluding the 2 patients with miscellaneous lesions), 12 successfully underwent operative resection and were alive at the point of last contact. Of these, 6 patients were followed for more than a year. The remaining three did not undergo surgery due to metastatic disease and died within their index hospital admission. These findings indicate that children with pancreatic tumors amenable to surgical resection have generally good long-term survival, which is in line with data from the Surveillance, Epidemiology and End Results (SEER) cancer program 6 . This may in part because most cases were SPTs which generally have excellent survival 6 . However, the patients with PBL, gastrinoma and insulinoma who underwent operative intervention also survived over 3 years and were still living at the point of last contact. The patient with insulinoma underwent resection for liver metastases as well, underscoring the importance of debulking metastatic lesions. The type of procedure did not appear to influence immediate postoperative complications, disease recurrence or mortality, however a previous study demonstrated that organ sparing resection provided good long-term outcome at the expense of short-term complications such as pancreatic fistula, delayed gastric emptying, intraabdominal infection, and post-pancreatectomy hemorrhage 7 . Similarly, our analysis of patients undergoing pancreatic excision procedures for pancreatic tumors in the NSQIP-P database demonstrated that 30-day outcomes are excellent as well, with low rates of adverse outcomes and adequate quality indicator benchmarks regardless of operative type or approach. An overview of tumor types and current management practices is described below: Solid Pseudopapillary Tumors Solid pseudopapillary tumors are solid tumors of epithelial origin, with an indolent course that can progress to invasion into surrounding tissues, vessels, or adjacent organs 8 9 . They are the most common pancreatic tumor in children with an increased prevalence in females 10 . Although the majority of SPTs are not malignant, Hwang et al noted that predominantly solid tumors on CT scan were associated with increased malignant potential 8 . It is thought that in children, SPTs are more likely to be located in the head of the pancreas while more common in the tail in adults 9 . In a systematic review, over 99% of patients with SPTs were alive with a mean follow up of 51 months and 88% required with surgical treatment 11 . In one review, pancreaticoduodenectomy was the most common surgical option (36%) followed by spleen preserving distal pancreaticoduodenectomy (24.5%), distal pancreatectomy and splenectomy (18.9%), central pancreatectomy (11.3%) and tumor enucleation (9.1%) 11 . Pancreatoblastomas Pancreatoblastoma is an epithelial tumor derived from exocrine cells that are postulated to arise from persistence of fetal pancreatic acinar cells during embryonic development, containing squamoid corpuscles that are islands of cells composed of basophilic or clear cytoplasm arranged in varying formations 12 13 . They are extremely rare but most likely to be found in younger children, with a mean age of 5 years old 12 . Although not explicitly related, one systematic review found a nearly 10% association of PBL with Beckwith-Wiedemann Syndrome 11 . Pre-operative work up includes assessment of Alpha Fetoprotein (AFP) levels due to its potential elevation in these patients, but it is more often used as an indicator for treatment response 3 . Although surgical excision is a mainstay of treatment, the EXPeRT trial demonstrated that PBLs are sensitive to chemotherapy, with a 73% response rate reported in 18 patients treated with PLADO (cisplatin + doxorubicin) 14 . Thus, in cases of inoperable tumors, chemotherapy can potentially debulk the tumor to allow for successful resection 3 . Rhabdomyosarcomas Rhabdomyosarcoma (RMS) is a malignant tumor derived from embryonic mesenchyme that can differentiate into skeletal muscle and is the most common soft tissue sarcoma in children 15 . Approximately 250–300 cases arise every year and prognostication is dependent on the location of the primary tumor 15 . There are two major subtypes: alveolar (ARMS) and embryonal (ERMS) which are delineated by features on histologic examination and genetic markers 16 . ARMS has been found to be more common in the trunk and extremities with increased aggressiveness, while ERMS is more common in head, neck and genitourinary areas 16 . RMS usually presents with a painless mass that is discovered in various locations in the body, and distant metastasis to lung, bone, or bone marrow via lymphatic or hematogenous routes are present on initial workup in approximately 20% of children 17 . The 5-year survival rate of RMS in children is 70%, however outcomes of metastatic disease are incredibly poor with survival rates at 3 years being < 30% 17 . Treatment is initially dependent on the TNM pre-treatment staging system determined by the site and size of the primary tumor 18 . The first step in treatment is usually surgical resection of the primary site of tumor with negative margins after which a clinical group assignment is made based on the success of the resection to determine adjuvant treatment options 18 . However, if the resection is not feasible, chemotherapy and radiation are the only management strategies remaining 18 . Gastrinomas Gastrinomas are neuroendocrine tumors composed of G cells which secretes pathologic levels of gastrin, which in turn leads to diarrhea, weight loss, anemia, and chronic abdominal pain secondary to recurrent gastrointestinal ulcers (Zollinger-Ellison Syndrome) 19 . Due to these non-specific symptoms, diagnosis can be delayed by years and metastasis is frequent 19 . The location of a gastrinoma has been described as the Passaro’s/Gastrinoma triangle with the superior border at the cystic and common bile ducts, inferior border at the second and third parts of the duodenum and the medial border at the neck and body of the pancreas 20 . It is often sporadic but can be associated with Multiple Endocrine Neoplasia 1 (MEN-1) 21 . Evaluation of a possible gastrinoma includes fasting serum gastrin, secretin stimulation test, MEN-1 work up and CT imaging 19 . As with the other pancreatic tumors, the management of gastrinomas involves surgical intervention, with excellent long-term survival 10 11 . Insulinomas Insulinoma is another neuroendocrine tumor that involves overproduction of insulin. It is debated as to whether the source of insulin is from neoplastic proliferation of islet beta-cells or from the acinar ductal system of the pancreas 22 . Classically, patients present in the 5th decade of life with hyperinsulinemia hypoglycemia, or the “Whipple Triad” of symptoms related to hypoglycemia, low plasma glucose and relief of symptoms with correction of glucose levels. A series of nine children over 12 years from Manchester, England demonstrated that diagnosis of these patients is often delayed with an average of 10 months of symptomatic hypoglycemia prior to definitive diagnosis and an increase in neuroglycopenic symptoms such as of seizures and syncope at time of diagnosis suggesting an increased symptom severity at presentation 23 . In a smaller series, two adolescent patients were misdiagnosed with epilepsy and migraine, respectfully, prior to definitive diagnosis 24 . All patients in the former cohort were treated with diazoxide with only four patients demonstrating meaningful response, and all eventually treated with surgical intervention 23 . Study Limitations This case series is limited as it was conducted at a single center with a small number of total cases for each type of pancreatic tumor. Due to this low sample size, we were unable to stratify and compare patient outcomes or survival by histologic type. Additionally, some cases presented prior to the deployment of the current EMR with the documentation available only including scanned, handwritten documentation from the patient’s hospitalization. Conclusion This study revealed a high rate of survival following operative resection of pancreatic tumors in children in both the hospital cohort and the NSQIP-P databse. The only mortalities were in children with aggressive tumor subtypes and metastatic disease at presentation. Solid pseudopapillary tumors accounted for most pancreatic tumors found in children. Future research with a focus on long-term follow-up beyond 5 or 10 years would allow a more holistic assessment of survival following pancreatic tumor resections in children. Statements and Declarations Acknowledgements None Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions JM, MS and FK conceived the idea for the project. JM and MS abstracted data. JM and HT produced the manuscript. SR, AR and FK provided critical feedback for the manuscript. All authors contributed to final manuscript. FK supervised the project. 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Pediatr Surg Int. 2008;24(9):1083-1085. Vortmeyer AO, Huang S, Lubensky I, Zhuang Z. Non-Islet Origin of Pancreatic Islet Cell Tumors. The Journal of Clinical Endocrinology & Metabolism. 2004;89(4):1934-1938. Padidela R, Fiest M, Arya V, et al. Insulinoma in childhood: clinical, radiological, molecular and histological aspects of nine patients. Eur J Endocrinol. 2014;170(5):741-747. Gozzi Graf T, Brandle M, Clerici T, l'Allemand D. Insulinoma: only in adults?-case reports and literature review. Eur J Pediatr. 2014;173(5):567-574. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Aug, 2024 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 16 Jul, 2024 Reviews received at journal 16 Jul, 2024 Reviews received at journal 15 Jul, 2024 Reviewers agreed at journal 11 Jul, 2024 Reviewers agreed at journal 07 Jul, 2024 Reviewers invited by journal 05 Jul, 2024 Editor assigned by journal 04 Jul, 2024 Submission checks completed at journal 04 Jul, 2024 First submitted to journal 03 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4681885","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327821633,"identity":"7878299b-da3f-492f-aced-0acae6f0758f","order_by":0,"name":"Joyce J. L. H. McRae","email":"","orcid":"","institution":"Loma Linda University Children’s Health","correspondingAuthor":false,"prefix":"","firstName":"Joyce","middleName":"J. L. H.","lastName":"McRae","suffix":""},{"id":327821634,"identity":"6640be37-cdd7-4e27-b5a6-8ad41ff436ff","order_by":1,"name":"Humza Thobani","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Humza","middleName":"","lastName":"Thobani","suffix":""},{"id":327821637,"identity":"e7399c82-fee1-4519-8e38-ee1240772cc0","order_by":2,"name":"Marla A. Sacks","email":"","orcid":"","institution":"SUNY Downstate Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Marla","middleName":"A.","lastName":"Sacks","suffix":""},{"id":327821638,"identity":"5381ff8d-fd88-47d5-91fe-9bdbef31ba51","order_by":3,"name":"Steven L. Raymond","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"L.","lastName":"Raymond","suffix":""},{"id":327821641,"identity":"c7812a3d-d5ff-4f42-8c55-07817bf80f0a","order_by":4,"name":"Adil Shah","email":"","orcid":"","institution":"Children’s Nebraska","correspondingAuthor":false,"prefix":"","firstName":"Adil","middleName":"","lastName":"Shah","suffix":""},{"id":327821643,"identity":"17522b6a-32dc-4a19-9fbf-637a6b3a3287","order_by":5,"name":"Andrei Radulescu","email":"","orcid":"","institution":"Loma Linda University Children’s Health","correspondingAuthor":false,"prefix":"","firstName":"Andrei","middleName":"","lastName":"Radulescu","suffix":""},{"id":327821645,"identity":"aac6c75e-0827-4e40-bda7-63b08142cb5e","order_by":6,"name":"Faraz A. Khan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYBAC+wNsbEBKQg7Mq2BgYGxgYDDAq8WAAazFwpgBRJ0hQUtFYgPxWtiPpT34uUMiff785mcPDlTck21gb94mgdcvPGnHDXvPSORuOMZmbnDgTLFxA8+xMrxaDBjS2yR424Ba2BjMpD+2JSQ2SOSY4dfC/7xN8m+bRLp8G/s3iYMgLfJvCGiRSDsmDbQlgeEYjxlEiwQPIS3P0qRl2yQMNxzLKZM4cCbBuI0nrdgCv8PSzCTfttXJyzcf3yZxoCJBtp/98MYb+LRgAjbSlI+CUTAKRsEowAYAq6BGx5CLFqgAAAAASUVORK5CYII=","orcid":"","institution":"Stanford University","correspondingAuthor":true,"prefix":"","firstName":"Faraz","middleName":"A.","lastName":"Khan","suffix":""}],"badges":[],"createdAt":"2024-07-03 16:46:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4681885/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4681885/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-024-05731-z","type":"published","date":"2024-08-15T15:57:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63071310,"identity":"14c41583-0688-45cd-955a-5f48b50a6778","added_by":"auto","created_at":"2024-08-22 20:06:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1010345,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4681885/v1/9e60f407-817a-4167-b406-ab08ea7dd633.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pancreatic Masses in Children: A Single-Center Experience Over Two Decades","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePancreatic tumors in children are extremely rare, with malignant tumors being even more infrequent. Two large epidemiologic data sets (n\u0026thinsp;=\u0026thinsp;228) and (n\u0026thinsp;=\u0026thinsp;109) have shown malignant pancreatic tumors to have an incidence of 0.46 per million children, with neuroblastoma and pancreatoblastoma arising more commonly in younger children, and adenocarcinoma and solid pseudopapillary tumors in older children\u003csup\u003e1 2\u003c/sup\u003e. The low incidence of pediatric pancreatic tumors has made early identification of incident cases, and the creation of treatment guidelines extremely challenging. Curative efforts typically involve an aggressive surgical approach with resection of the primary tumor and its metastases\u003csup\u003e3\u003c/sup\u003e. Long-term survival in these cases is highly dependent on the histological type of the tumor with solid pseudopapillary tumor having a favorable prognosis, however the low incidence of pancreatic tumors makes it difficult to consolidate high quality survival data after operative intervention. This study's purpose was therefore to describe the short-term postoperative outcomes and long-term survival of children with pancreatic tumors in our region. Furthermore, we aimed to analyze and benchmark surgical safety and quality indicators for children undergoing pancreatic resection procedures for pancreatic tumors. To do so, we reviewed the National Surgical Quality Improvement Program \u0026ndash; Pediatric (NSQIP-P) database, a nationally validated and risk adjusted dataset to benchmark the outcomes of pancreatic solid tumor resections in children.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHospital Cohort Clinical and Outcomes Data Extraction\u003c/h2\u003e \u003cp\u003e This was a single center retrospective observational study conducted at the Loma Linda University Children\u0026rsquo;s Hospital, a 364-bed, tertiary care medical center that provides care to more than 1.2\u0026nbsp;million children in the region. The study was approved by the Institutional Review Board [IRB# 5200422] prior to initiation. Patients were identified from the Pediatric Surgery Division database at Loma Linda University Children\u0026rsquo;s Hospital for pediatric patients with a suspected or confirmed diagnosis of Solid Pseudopapillary tumor (SPT), Gastrinoma, Rhabdomyosarcoma (RMS), Pancreatoblastoma (PBL), Insulinoma or Miscellaneous Tumors located in the Pancreas. Patients under 18 years of age who had pathological or clinical confirmation of a pancreatic mass at the study institution from January 2003 to November 2022 were included. The electronic medical records (EMR) of inpatient and outpatient encounters were accessed. Information detailing their demographics, clinical presentations, clinical courses, surgical management, histopathologic diagnosis, imaging findings, hospital courses, and follow ups were abstracted. All patient details were de-identified prior to data extraction and analysis. The primary clinical outcome was mortality at last contact. Secondary clinical outcomes included short term and long-term outcomes of interest including operative time, estimated blood loss, need for intraoperative blood transfusion, length of total parenteral nutrition (TPN), time to initiation of enteral nutrition, length of stay, postoperative complications, and disease recurrence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eNSQIP-P Surgical Safety and Quality Analysis\u003c/h2\u003e \u003cp\u003e In addition to reviewing our institutional experiences with pancreatic tumors in children, we assessed nationwide surgical outcomes for operative pancreatic tumor resections using the NSQIP-P database. We queried NSQIP-P for all patients aged 0\u0026ndash;18 with a diagnosis of a benign or malignant lesion of the pancreas (ICD9: 211.6, 157, ICD10: D13.6, C25) who underwent a distal, subtotal, or total pancreatectomy or pancreatic excisional procedure (CPT: 48120, 48140\u0026ndash;48146) from 2012 till 2019. Overall, 30-day outcomes after the index operative procedure were compiled and aggregated. As NSQIP-P does not capture histological data, tumor subtype or oncologic stage, we stratified outcomes by procedure type only.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eHospital Cohort Clinical Characteristics and Outcomes\u003c/h2\u003e \u003cp\u003eSeventeen patients were identified and met all study criteria. The mean age was 13.3 years with a female predominance (76%). Nearly all patients presented with non-specific symptoms such as abdominal pain, nausea, and weight loss. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the demographics and presenting symptoms of all the patients in our study cohort. On postoperative histopathology, 9 (52%) patients were found to have SPT, 2 (12%) had PBL, 2 (12%) had RMS, 1 (6%) had a gastrinoma and 1 (6%) had an insulinoma. Definitive histopathology data was not available for 2 patients (12%), as one was lost to follow-up while the other was suspected to have lymphoepithelial cyst and was managed conservatively with surveillance imaging. These patients were classified as having miscellaneous lesions of the pancreas and were excluded from subsequent analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospital Cohort Demographics and Presenting Features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase ID.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumor Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge at Presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePresenting Symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImaging Workup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePreoperative Biopsy Done\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 yrs, 2 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, EGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 yrs, 6 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI, EUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 yrs, 3 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 yrs, 10 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 yrs, 4 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute Epigastric Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 yrs, 3 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Back Pain, Nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, MRI, EUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 yrs, 0 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Emesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 yrs, 11 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEpigastric Pain after meals, Emesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolid Pseudopapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 yrs, 6 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAsymptomatic (Incidental Finding)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePancreatoblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 yrs, 1 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEpigastric pain, Intractable Vomiting, Weight Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, EGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePancreatoblastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 yrs, 4 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePalpable Abdominal Mass, Fever, Diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRhabdomyosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u0026nbsp;year, 5 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAxillary Mass, Weight Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCNB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRhabdomyosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u0026nbsp;year, 2 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Scleral Icterus, Facial Jaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGastrinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u0026nbsp;year, 2 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Recurrent Pancreatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI, EGD, EUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCNB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsulinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u0026nbsp;year, 7 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSymptomatic Hypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, EUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiscellaneous Lesion ^\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026nbsp;year, 11 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbdominal Pain, Diarrhea, Weight Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI, EGD, EUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiscellaneous Lesion ^\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u0026nbsp;year, 2 mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmesis, Back Pain, Weight Loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT, AUS, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: \u003cem\u003eCT, Computerized Tomography; AUS, Abdominal Ultrasound, MRI, Magnetic Resonance Imaging, EGD, Esophagogastroduodenoscopy; EUS, Endoscopic Ultrasound; FNA, Fine Needle Aspiration; CNB, Core Needle Biopsy; OB, Open Biopsy\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e*Patient less than 2 years, growth chart not available\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e^Patients with Miscellaneous Lesions received no further treatment and are excluded from subsequent tables\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the interventions in our study cohort. Twelve of the patients were managed with surgery. The postoperative, in-hospital and post-discharge outcomes for all patients are compiled in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospital Cohort Medical Management and Operative Interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase ID.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperative Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTumor Greatest Dimension (mm) *\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOperative Time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstimated Blood Loss (mL)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFeeding Tube Placement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLymph Nodes Examined (Positive)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOther Medical Treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistal Pancreatectomy with Splenectomy and Lymph Node Sampling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eJ-Tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResection of Pancreatic Mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRobot-Assisted Distal Pancreatectomy with Splenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eJ-Tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePylorus Preserving Pancreaticoduodenectomy, Partial Pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eJ-Tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistal Pancreatectomy with Splenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistal Pancreatectomy with Splenectomy and En Bloc Mesocolic Resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePylorus-Preserving Pancreaticoduodenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResection of Pancreatic Cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChemotherapy, Radiation, Palliative Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChemotherapy, Radiation, Palliative Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGJ-Tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistal Pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: \u003cem\u003eNR, Not Reported; J-Tube, Jejunostomy Tube, GJ-Tube, Gastrojejunostomy Tube\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e*All tumor sizes based on surgical histopathology, except for cases which did not undergo surgery, in which reported tumor size is based on imaging\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospital Cohort Postoperative Outcomes and Long-Term Follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase ID.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative In-Hospital Complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDays of TPN Use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDays till Full PO Feeds\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLength of Stay (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDays from Discharge till Last Contact\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDisease Related Complications After Discharge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRecurrence at Last Contact\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDisposition at Last Contact\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUncontrolled pain requiring readmission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDeceased\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative Ileus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePancreatic leak, Gastroparesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLeak around J-Tube site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGastroparesis, G-Tube Placement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdhesive SBO requiring lysis of adhesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo Contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo Contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNot Known\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLymphatic leak, gastroparesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDeceased\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePartial SBO and pancreatic fluid collection requiring IR drainage and additional 15 days of TPN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDeceased\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDeceased\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative Ileus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePosterior partial hepatectomy for liver metastases and conversion to Roux-en-Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative Ileus, Atelectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePancreatic pseudocyst requiring IR drainage, DVT at LUE PICC site, Eventual Roux-en-Y pancreatic cyst-jejunostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: \u003cem\u003eNR, Not Reported; PO, Per Oral; TPN, Total Parenteral Nutrition, G-Tube, Gastrostomy Tube; SBO, Small Bowel Obstruction; IR, Interventional Radiology; DVT, Deep Vein Thrombosis; LUE, Left Upper Extremity, PICC, Peripherally Inserted Central Catheter\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSolid Pseudopapillary Tumor Cases\u003c/h2\u003e \u003cp\u003eOf the 9 patients with SPTs, only 3 underwent preoperative biopsies, out of which only 1 provided a definitive histopathologic diagnosis. All patients with solid pseudopapillary tumors were managed surgically with four receiving pancreaticoduodenectomies, four distal pancreatectomies with splenectomies and one mass resection. All but one patient received epidural analgesia. One patient undergoing pancreaticoduodenectomy required blood transfusion intraoperatively. Surgical drains at the site of resection margin were placed in seven patients and jejunostomy tubes were placed in three of four pancreaticoduodenectomies. All but one had negative lymph nodes and one had evidence of metastasis in an omental lesion.\u003c/p\u003e \u003cp\u003eWithin the index surgical admission, the mean hospital length of stay was 16 days. Four patients required postoperative parenteral nutrition. The mean time to starting a clear liquid diet was 8 days. Immediate postoperative complications for this cohort included ileus, gastroparesis, gastric outlet obstruction, pancreatic leak, lymphatic leak, and a need for a delayed gastrostomy tube placement. Eight of the nine patients with SPT were followed. The time to last contact ranged from 13 to 1288 days, with only 3 patients followed for over 1 year. The ninth patient elected to follow up at a hospital closer to his home. All eight that have been followed are alive with no recurrences. Five of these patients had no post discharge complications and no unplanned visits or readmissions. One patient was readmitted on post operative day 66 for pancreatitis. Nearly 1.5 years later, she was admitted for pancreatic insufficiency and small bowel obstruction requiring exploratory laparotomy with lysis of adhesions. Two other patients had emergency room visits for leaking at the skin at the jejunostomy feeding tube site and another for uncontrolled pain.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePancreatoblastoma Cases\u003c/h2\u003e \u003cp\u003eOne patient with PBL was found to have extensive metastases and underwent chemotherapy prior to succumbing to his disease 3 months after diagnosis within the same hospitalization. The second patient with PBL underwent a resection of the body of pancreas with minimal blood loss, no drain or feeding tube placed, and no metastasis identified. She required TPN for two days, started clear liquid diet on postoperative day 3 and was discharged on postoperative day 10 with no immediate complications. She was later readmitted for poor oral intake requiring TPN secondary to a partial small bowel obstruction and required Interventional Radiology (IR) drainage of a pancreatic pseudocyst. After discharge from that admission, she had one additional emergency room visit for a partially dislodged surgical drain that was removed at bedside without complications and no additional unplanned admissions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eRhabdomyosarcoma Cases\u003c/h2\u003e \u003cp\u003eBoth patients with RMS were diagnosed with metastatic disease and were admitted for chemotherapy and radiation. Both opted for palliative care without an opportunity for surgical intervention and died due to disease related complications.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eGastrinoma Case\u003c/h2\u003e \u003cp\u003eThe patient with gastrinoma underwent a pancreaticoduodenectomy with gastrojejunostomy and a surgical drain placed. She received epidural analgesia. Of seven lymph nodes sampled, one had metastasis. She developed ileus during her immediate postoperative course but eventually tolerated tube feeds and was able to start a clear liquid diet by postoperative day 9 with discharge on postoperative day 15. She was later found to have lesions within the liver and underwent an additional metastasectomy of the liver. Furthermore, after discharge, she three additional interventions at an outside hospital including: a conversion to a Roux-en-y two years after her initial operation, a partial hepatectomy of segments 2, 3, 5 and 6 for concerning metastatic lesions and a revision of her prior gastrojejunostomy, partial gastrectomy, partial small bowel resection and re-revision of her Roux-en-y a few months later. There are limited records on the cause of the reoperations. Over five years postoperatively from index surgery, she was alive without known recurrence.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInsulinoma Case\u003c/h2\u003e \u003cp\u003eThe patient with insulinoma underwent a distal pancreatectomy with surgical drain placement and epidural analgesia with no metastasis discovered. He also developed a superficial wound infection and documented atelectasis. He started a clear liquid diet on postoperative day 2 with discharge on postoperative day 8. He later developed a pancreatic pseudocyst three months after the index operation and was readmitted for IR drainage of the cyst. Six months after index operation, he returned for a Roux-en-Y pancreatic cyst-jejunostomy. After the final operation, there were no other known complications, and he was living over 3 years since his initial diagnosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eNSQIP-P Results\u003c/h2\u003e \u003cp\u003eA total of 260 patients underwent one of the four pancreatic excision procedures under study. Of these, only 29 patients were diagnosed as having a benign or malignant pancreatic neoplasm and were included in subsequent analysis. Fifteen (51.7%) underwent distal subtotal pancreatectomy without a pancreaticojejunostomy, 12 (41.4%) patients underwent an excision of pancreatic lesion, and 2 (6.9%) patients underwent a near total pancreatectomy with preservation of the duodenum. There were no recorded cases of a patient undergoing a distal pancreatectomy with a pancreaticojejunostomy.\u003c/p\u003e \u003cp\u003eThe mean age of included patients was 13.7 years and 86% of the patients were female. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e outlines the overall demographics and 30-day outcomes for this cohort of patients. Approximately a third of cases (31%) were attempted laparoscopically. Outcomes were excellent with no major perioperative complications prior to discharge, except for one patient who developed a wound dehiscence. There were no recorded reoperations, readmissions, or mortalities within 30-days of the index procedure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNSQIP-P Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcision Procedures on the Pancreas\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePancreatectomy, Distal Subtotal, with or without Splenectomy, without pancreatico-jejunostomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePancreatectomy, Distal, Near-Total with preservation of duodenum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCombined Cohort\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPT Code\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e# Cases Recorded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Female Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage Age (Years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange of Ages in Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5\u0026ndash;17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u0026ndash;17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.6\u0026ndash;13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.5\u0026ndash;17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Major or Severe Cardiac Risk Factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Current Diagnosis of Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% ASA Class 3 or Higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Time Average (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange of Operative Tine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u0026ndash;326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88\u0026ndash;552\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e137\u0026ndash;215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55\u0026ndash;552\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Laparoscopic Only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33%\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Mortality in 30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Superficial Skin Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Post Op Wound Dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Post Op Pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Post Op Reintubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Post Op CVA resulting in neuro deficits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Operations requiring a Blood Transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage Days from Operation To DC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange of days from operation to DC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e%Reoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.3%\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4%\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e%Readmission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.7%\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.3%\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoplasm of Unspecified Behavior/Location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign neoplasm of pancreas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant Neoplasm of Endocrine Pancreas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFootnote\u003c/b\u003e: \u003csup\u003e1\u003c/sup\u003e 3 entries not recorded (NR). \u003csup\u003e2\u003c/sup\u003e 1 entry NR. \u003csup\u003e3\u003c/sup\u003e 6 entries NR. \u003csup\u003e4\u003c/sup\u003e 5 entries NR.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study highlight the diagnostic and management challenges in children with pancreatic tumors. These findings thus contribute to a limited pool of literature on the overall presentation and outcomes of pancreatic masses in the pediatric population\u003csup\u003e4 5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe initial presentation of nearly all patients in our cohort consisted of non-specific symptoms such as abdominal pain, emesis, nausea, and weight loss. One patient was entirely asymptomatic, and the mass was noted on incidental imaging. Abdominal ultrasonography was extensively utilized in the diagnostic workup of the patients in our study cohort, and likely represents a radiation-free and minimally invasive imaging study to bridge the diagnostic gap between initial clinical evaluation and higher risk modalities such as Computed Tomography (CT) or Esophagogastroduodenoscopy (EGD).\u003c/p\u003e \u003cp\u003eOf the 15 patients who were included (excluding the 2 patients with miscellaneous lesions), 12 successfully underwent operative resection and were alive at the point of last contact. Of these, 6 patients were followed for more than a year. The remaining three did not undergo surgery due to metastatic disease and died within their index hospital admission. These findings indicate that children with pancreatic tumors amenable to surgical resection have generally good long-term survival, which is in line with data from the Surveillance, Epidemiology and End Results (SEER) cancer program\u003csup\u003e6\u003c/sup\u003e. This may in part because most cases were SPTs which generally have excellent survival\u003csup\u003e6\u003c/sup\u003e. However, the patients with PBL, gastrinoma and insulinoma who underwent operative intervention also survived over 3 years and were still living at the point of last contact. The patient with insulinoma underwent resection for liver metastases as well, underscoring the importance of debulking metastatic lesions.\u003c/p\u003e \u003cp\u003eThe type of procedure did not appear to influence immediate postoperative complications, disease recurrence or mortality, however a previous study demonstrated that organ sparing resection provided good long-term outcome at the expense of short-term complications such as pancreatic fistula, delayed gastric emptying, intraabdominal infection, and post-pancreatectomy hemorrhage\u003csup\u003e\u003cb\u003e7\u003c/b\u003e\u003c/sup\u003e. Similarly, our analysis of patients undergoing pancreatic excision procedures for pancreatic tumors in the NSQIP-P database demonstrated that 30-day outcomes are excellent as well, with low rates of adverse outcomes and adequate quality indicator benchmarks regardless of operative type or approach. An overview of tumor types and current management practices is described below:\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSolid Pseudopapillary Tumors\u003c/h2\u003e \u003cp\u003eSolid pseudopapillary tumors are solid tumors of epithelial origin, with an indolent course that can progress to invasion into surrounding tissues, vessels, or adjacent organs\u003csup\u003e8 9\u003c/sup\u003e. They are the most common pancreatic tumor in children with an increased prevalence in females\u003csup\u003e10\u003c/sup\u003e. Although the majority of SPTs are not malignant, Hwang et al noted that predominantly solid tumors on CT scan were associated with increased malignant potential\u003csup\u003e8\u003c/sup\u003e. It is thought that in children, SPTs are more likely to be located in the head of the pancreas while more common in the tail in adults\u003csup\u003e9\u003c/sup\u003e. In a systematic review, over 99% of patients with SPTs were alive with a mean follow up of 51 months and 88% required with surgical treatment\u003csup\u003e11\u003c/sup\u003e. In one review, pancreaticoduodenectomy was the most common surgical option (36%) followed by spleen preserving distal pancreaticoduodenectomy (24.5%), distal pancreatectomy and splenectomy (18.9%), central pancreatectomy (11.3%) and tumor enucleation (9.1%)\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePancreatoblastomas\u003c/h2\u003e \u003cp\u003ePancreatoblastoma is an epithelial tumor derived from exocrine cells that are postulated to arise from persistence of fetal pancreatic acinar cells during embryonic development, containing squamoid corpuscles that are islands of cells composed of basophilic or clear cytoplasm arranged in varying formations \u003csup\u003e12 13\u003c/sup\u003e. They are extremely rare but most likely to be found in younger children, with a mean age of 5 years old\u003csup\u003e12\u003c/sup\u003e. Although not explicitly related, one systematic review found a nearly 10% association of PBL with Beckwith-Wiedemann Syndrome\u003csup\u003e11\u003c/sup\u003e. Pre-operative work up includes assessment of Alpha Fetoprotein (AFP) levels due to its potential elevation in these patients, but it is more often used as an indicator for treatment response\u003csup\u003e3\u003c/sup\u003e. Although surgical excision is a mainstay of treatment, the EXPeRT trial demonstrated that PBLs are sensitive to chemotherapy, with a 73% response rate reported in 18 patients treated with PLADO (cisplatin\u0026thinsp;+\u0026thinsp;doxorubicin)\u003csup\u003e14\u003c/sup\u003e. Thus, in cases of inoperable tumors, chemotherapy can potentially debulk the tumor to allow for successful resection\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRhabdomyosarcomas\u003c/h2\u003e \u003cp\u003eRhabdomyosarcoma (RMS) is a malignant tumor derived from embryonic mesenchyme that can differentiate into skeletal muscle and is the most common soft tissue sarcoma in children\u003csup\u003e15\u003c/sup\u003e. Approximately 250\u0026ndash;300 cases arise every year and prognostication is dependent on the location of the primary tumor\u003csup\u003e15\u003c/sup\u003e. There are two major subtypes: alveolar (ARMS) and embryonal (ERMS) which are delineated by features on histologic examination and genetic markers\u003csup\u003e16\u003c/sup\u003e. ARMS has been found to be more common in the trunk and extremities with increased aggressiveness, while ERMS is more common in head, neck and genitourinary areas\u003csup\u003e16\u003c/sup\u003e. RMS usually presents with a painless mass that is discovered in various locations in the body, and distant metastasis to lung, bone, or bone marrow via lymphatic or hematogenous routes are present on initial workup in approximately 20% of children\u003csup\u003e17\u003c/sup\u003e. The 5-year survival rate of RMS in children is 70%, however outcomes of metastatic disease are incredibly poor with survival rates at 3 years being \u0026lt;\u0026thinsp;30%\u003csup\u003e17\u003c/sup\u003e. Treatment is initially dependent on the TNM pre-treatment staging system determined by the site and size of the primary tumor\u003csup\u003e18\u003c/sup\u003e. The first step in treatment is usually surgical resection of the primary site of tumor with negative margins after which a clinical group assignment is made based on the success of the resection to determine adjuvant treatment options\u003csup\u003e18\u003c/sup\u003e. However, if the resection is not feasible, chemotherapy and radiation are the only management strategies remaining\u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eGastrinomas\u003c/h2\u003e \u003cp\u003eGastrinomas are neuroendocrine tumors composed of G cells which secretes pathologic levels of gastrin, which in turn leads to diarrhea, weight loss, anemia, and chronic abdominal pain secondary to recurrent gastrointestinal ulcers (Zollinger-Ellison Syndrome)\u003csup\u003e19\u003c/sup\u003e. Due to these non-specific symptoms, diagnosis can be delayed by years and metastasis is frequent\u003csup\u003e19\u003c/sup\u003e. The location of a gastrinoma has been described as the Passaro\u0026rsquo;s/Gastrinoma triangle with the superior border at the cystic and common bile ducts, inferior border at the second and third parts of the duodenum and the medial border at the neck and body of the pancreas\u003csup\u003e20\u003c/sup\u003e. It is often sporadic but can be associated with Multiple Endocrine Neoplasia 1 (MEN-1)\u003csup\u003e21\u003c/sup\u003e. Evaluation of a possible gastrinoma includes fasting serum gastrin, secretin stimulation test, MEN-1 work up and CT imaging\u003csup\u003e19\u003c/sup\u003e. As with the other pancreatic tumors, the management of gastrinomas involves surgical intervention, with excellent long-term survival\u003csup\u003e10 11\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInsulinomas\u003c/h2\u003e \u003cp\u003eInsulinoma is another neuroendocrine tumor that involves overproduction of insulin. It is debated as to whether the source of insulin is from neoplastic proliferation of islet beta-cells or from the acinar ductal system of the pancreas\u003csup\u003e22\u003c/sup\u003e. Classically, patients present in the 5th decade of life with hyperinsulinemia hypoglycemia, or the \u0026ldquo;Whipple Triad\u0026rdquo; of symptoms related to hypoglycemia, low plasma glucose and relief of symptoms with correction of glucose levels. A series of nine children over 12 years from Manchester, England demonstrated that diagnosis of these patients is often delayed with an average of 10 months of symptomatic hypoglycemia prior to definitive diagnosis and an increase in neuroglycopenic symptoms such as of seizures and syncope at time of diagnosis suggesting an increased symptom severity at presentation\u003csup\u003e23\u003c/sup\u003e. In a smaller series, two adolescent patients were misdiagnosed with epilepsy and migraine, respectfully, prior to definitive diagnosis\u003csup\u003e24\u003c/sup\u003e. All patients in the former cohort were treated with diazoxide with only four patients demonstrating meaningful response, and all eventually treated with surgical intervention\u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThis case series is limited as it was conducted at a single center with a small number of total cases for each type of pancreatic tumor. Due to this low sample size, we were unable to stratify and compare patient outcomes or survival by histologic type. Additionally, some cases presented prior to the deployment of the current EMR with the documentation available only including scanned, handwritten documentation from the patient\u0026rsquo;s hospitalization.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed a high rate of survival following operative resection of pancreatic tumors in children in both the hospital cohort and the NSQIP-P databse. The only mortalities were in children with aggressive tumor subtypes and metastatic disease at presentation. Solid pseudopapillary tumors accounted for most pancreatic tumors found in children. Future research with a focus on long-term follow-up beyond 5 or 10 years would allow a more holistic assessment of survival following pancreatic tumor resections in children.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJM, MS and FK conceived the idea for the project. JM and MS abstracted data. JM and HT produced the manuscript. SR, AR and FK provided critical feedback for the manuscript. All authors contributed to final manuscript. FK supervised the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Loma Linda University Health Institutional Review Board [IRB# 5200422] prior to initiation. Informed consent considered exempt due to nature of study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrecht IB, Schneider DT, Kloppel G, von Schweinitz D, Barthlen W, Hamre MR. Malignant pancreatic tumors in children and young adults: evaluation of 228 patients identified through the Surveillance, Epidemiology, and End Result (SEER) database. \u003cem\u003eKlin Padiatr. \u003c/em\u003e2011;223(6):341-345.\u003c/li\u003e\n\u003cli\u003ePicado O, Ferrantella A, Zabalo C, et al. Treatment patterns and outcomes for pancreatic tumors in children: an analysis of the National Cancer Database. \u003cem\u003ePediatric Surgery International. \u003c/em\u003e2020;36(3):357-363.\u003c/li\u003e\n\u003cli\u003eSacco Casamassima MG, Gause CD, Goldstein SD, et al. Pancreatic surgery for tumors in children and adolescents. \u003cem\u003ePediatric Surgery International. \u003c/em\u003e2016;32(8):779-788.\u003c/li\u003e\n\u003cli\u003eParedes O, Kawaguchi Y, Ruiz E, Payet E, Berrospi F. Surgery of pancreas tumors in pediatric and adolescent patients: a single institution experience in South America. \u003cem\u003ePediatric Surgery International. \u003c/em\u003e2021;37(8):1041-1047.\u003c/li\u003e\n\u003cli\u003eNasher O, Hall NJ, Sebire NJ, de Coppi P, Pierro A. Pancreatic tumours in children: diagnosis, treatment and outcome. \u003cem\u003ePediatric Surgery International. \u003c/em\u003e2015;31(9):831-835.\u003c/li\u003e\n\u003cli\u003eQi X, Zhou B, Liang F, Wang X. 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Solid Pseudopapillary Neoplasm of the Pancreas in a Young Pediatric Patient: A Case Report and Systematic Review of the Literature. \u003cem\u003ePancreas. \u003c/em\u003e2018;47(10):1364-1368.\u003c/li\u003e\n\u003cli\u003ePicado O, Ferrantella A, Zabalo C, et al. Treatment patterns and outcomes for pancreatic tumors in children: an analysis of the National Cancer Database. \u003cem\u003ePediatr Surg Int. \u003c/em\u003e2020;36(3):357-363.\u003c/li\u003e\n\u003cli\u003eMylonas KS, Doulamis IP, Tsilimigras DI, et al. Solid pseudopapillary and malignant pancreatic tumors in childhood: A systematic review and evidence quality assessment. \u003cem\u003ePediatr Blood Cancer. \u003c/em\u003e2018;65(10):e27114.\u003c/li\u003e\n\u003cli\u003eGlick RD, Pashankar FD, Pappo A, Laquaglia MP. Management of pancreatoblastoma in children and young adults. \u003cem\u003eJ Pediatr Hematol Oncol. \u003c/em\u003e2012;34 Suppl 2:S47-50.\u003c/li\u003e\n\u003cli\u003eChung EM, Travis MD, Conran RM. 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Rhabdomyosarcoma. \u003cem\u003eSeminars in Pediatric Surgery. \u003c/em\u003e2016;25(5):276-283.\u003c/li\u003e\n\u003cli\u003eStawarski A, Maleika P. Neuroendocrine tumors of the gastrointestinal tract and pancreas: Is it also a challenge for pediatricians? \u003cem\u003eAdv Clin Exp Med. \u003c/em\u003e2020;29(2):265-270.\u003c/li\u003e\n\u003cli\u003eStabile BE, Morrow DJ, Passaro E, Jr. The gastrinoma triangle: operative implications. \u003cem\u003eAm J Surg. \u003c/em\u003e1984;147(1):25-31.\u003c/li\u003e\n\u003cli\u003eKattepura S, Das K, Correa MM, Devarabhavi H. Giant gastrinoma in a child: case report and review. \u003cem\u003ePediatr Surg Int. \u003c/em\u003e2008;24(9):1083-1085.\u003c/li\u003e\n\u003cli\u003eVortmeyer AO, Huang S, Lubensky I, Zhuang Z. Non-Islet Origin of Pancreatic Islet Cell Tumors. \u003cem\u003eThe Journal of Clinical Endocrinology \u0026amp; Metabolism. \u003c/em\u003e2004;89(4):1934-1938.\u003c/li\u003e\n\u003cli\u003ePadidela R, Fiest M, Arya V, et al. Insulinoma in childhood: clinical, radiological, molecular and histological aspects of nine patients. \u003cem\u003eEur J Endocrinol. \u003c/em\u003e2014;170(5):741-747.\u003c/li\u003e\n\u003cli\u003eGozzi Graf T, Brandle M, Clerici T, l\u0026apos;Allemand D. Insulinoma: only in adults?-case reports and literature review. \u003cem\u003eEur J Pediatr. \u003c/em\u003e2014;173(5):567-574.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pancreatic Masses, Solid Pseudopapillary Tumor, Insulinoma, Pancreatoblastoma, Gastrinoma, Rhabdomyosarcoma","lastPublishedDoi":"10.21203/rs.3.rs-4681885/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4681885/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/em\u003e: Pancreatic masses are extremely rare in pediatric patients, with limited data available. This lack of data makes the diagnosis and management of these tumors in children extremely challenging. Therefore, we aimed to describe the presentations, clinical course, and outcomes of children with pancreatic tumors at our center.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e: A retrospective analysis was performed of all pediatric patients diagnosed with pancreatic masses between 2003 and 2022 in an academic freestanding children’s hospital. Data including demographics, clinical presentation, workup, management, and subsequent morbidity and mortality, were collected and aggregated. Furthermore, we reviewed cases of pancreatic tumor resections in the National Surgical Quality Improvement Program – Pediatric (NSQIP-P) database to identify common adverse outcomes and measures for quality improvement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e: In total, 17 patients were identified at our institution. Diagnoses included Solid Pseudopapillary (n=9), Gastrinoma (n=1), Rhabdomyosarcoma (n=2), Pancreatoblastoma (n=2), Insulinoma (n=1). Two patients did not have a histopathologic diagnosis and were excluded from subsequent analysis. Overall, 12 patients underwent surgical intervention, with the most common procedures being pancreaticoduodenectomy and distal pancreatectomy, and all 12 were known to be alive at last contact. There were 3 deaths, all due to complications related to metastatic disease. Furthermore, 30-day postoperative outcomes in the NSQIP-P dataset are excellent, with negligible morbidity and no mortalities after the index surgery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e: Children with pancreatic tumors amenable to surgical resection appear to have adequate long-term survival. Short-term outcomes at diagnosis are excellent and mainly appear to be influenced by the presence of metastatic disease at initial presentation.\u003c/p\u003e","manuscriptTitle":"Pancreatic Masses in Children: A Single-Center Experience Over Two Decades","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-29 04:07:01","doi":"10.21203/rs.3.rs-4681885/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-16T17:04:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T09:24:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T02:26:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81408467782522886705607427301654008742","date":"2024-07-11T06:43:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118885724979950649077739109443704110733","date":"2024-07-07T23:45:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-05T20:05:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-05T03:23:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-05T03:22:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2024-07-03T16:44:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"63854e1d-3283-44a7-8161-f037b9975144","owner":[],"postedDate":"July 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-22T19:34:39+00:00","versionOfRecord":{"articleIdentity":"rs-4681885","link":"https://doi.org/10.1007/s00431-024-05731-z","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2024-08-15 15:57:24","publishedOnDateReadable":"August 15th, 2024"},"versionCreatedAt":"2024-07-29 04:07:01","video":"","vorDoi":"10.1007/s00431-024-05731-z","vorDoiUrl":"https://doi.org/10.1007/s00431-024-05731-z","workflowStages":[]},"version":"v1","identity":"rs-4681885","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4681885","identity":"rs-4681885","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}