Main- and Branch-Duct Intraductal Papillary Mucinous Neoplasms: Extent of Surgical Resection

Abstract

Background: Surgical treatment of intraductal papillary mucinous neoplasms (IPMN) requires a differentiated approach regarding indications and extent of resection. Methods: The review summarizes the current literature on indication, timing, and surgical procedures in IPMN. Results: The most important differentiation has to be made between main-duct and branch-duct IPMN as well as mixed-type lesions that biologically mimic main-duct types. In main-duct and mixed-type IPMN, the resection should be indicated by the time of the diagnosis - in accordance with the international consensus guidelines - and should follow oncological principles. Depending on IPMN localization, this implies partial pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy and includes the corresponding types of lymphadenectomy. Furthermore, branch-duct IPMN > 3 cm or bearing high-risk features (mural nodules in magnetic resonance imaging, computed tomography, or endoscopic ultrasound imaging; symptomatic lesions; elevated tumor markers) are similarly treated. As the risk for malignancy in smaller branch-duct IPMN is lower, the decision for surgical treatment is often individually made - despite the updated 2012 guidelines. In these lesions, limited surgical approaches, including enucleation and central pancreatectomy, are possible. Conclusion: Timely and radical resection of IPMN offers the unique opportunity to prevent pancreatic cancer, and even in malignant IPMN surgery can offer a curative approach with excellent long-term outcome in early stages. A structured imaging follow-up should be considered to recognize IPMN recurrence and metachronous pancreatic cancer as well as gastrointestinal neoplasias by endoscopic surveillance.