Surgical management of main duct IPMN and mixed type IPMN: an international survey and case-vignette study among experts

Background: The risk of malignancy increases up to 60% if the main duct (MD) is involved in intraductal papillary mucinous neoplasms (IPMNs). Therefore most guidelines advice resection in surgically fit patients with MD-IPMNs or mixed type (MT) IPMN but consensus on partial or total pancreatectomy as optimal treatment is lacking. A survey was performed to identify the surgical strategy of international pancreatologists in order to guide the design of future studies and guidelines. Methods: An online survey including case-vignettes was sent to 210 pancreatologists who had published on IPMN. Diagnostic approach, treatment- and surgical strategy were evaluated. Results: Overall 59 surgeons (28.1%) and 27 gastroenterologists (12.9%) replied, 41% response rate. The majority worked in an academic hospital (93%), with a median of 15 years’ experience in treating patients with IPMN. PD dilatation (>5mm, < 10mm) in the total pancreas was considered a prerequisite for surgical resection by respectively 51.2% of the respondents. Of these, 47.8% would perform a total pancreatectomy, 21.7% a partial resection with frozen section and 26.1% a pancreatodoudenectomy. PD dilatation ( >5mm, <10mm) in the head or tail was considered a prerequisite for surgical resection by 30.2% and 41.9% of the respondents. Conclusion: This survey identified lack of consensus amongst international pancreatologists regarding the treatment- and surgical strategy in patients with MT- or MD-IPMN which should be addressed in future studies and guidelines.