Surgery is currently the only means of eradicating IPMN once diagnosis is established. The indication for surgery in IPMN depends on the risk of malignant transformation as well as patients’ symptoms. The type and extent of surgery should be tailored to the extent of IPMN involvement: size, mural nodules, multifocality, location and the presence of field change.
Surgical resection ranges from local “enucleation” to regional resection such as pancreatic, tail, body or head resection. Total pancreatectomy is reserved for multifocal field change, or recurrent disease. Palliative resection or drainage procedure is rare for symptom control.
The work up for resection involves MRCP, Endoscopic ultrasound with or without FNA for cytology, mucin, CEA and other tumour markers. Triphasic CT scan is required in cases where malignant transformation is suspected to check for vascular invasion. Chest CT may be required to check for metastases. The use of PET CT scan to evaluate the IPMN has been described.
The extent of surgical resection depends on size of the IPMN, the likely presence of malignant transformation as well presence of multifocal tumour. For main branch IPMN, regional resection usually in the form of Whipple’s resection or distal pancreatectomy to include splenic vein and splenectomy is warranted due to higher incidence of malignancies. Frozen section need to be performed to check for adequacy of the ductal resection margin. For side branch IPMN, a less extensive resection may be acceptable especially if the cyst demonstrated no suspicious feature. Regional resection with or without resection of splenic vein depending on the location should be considered. The aim here is to achieve a clear resection margin. In patient with multifocal side branch IPMNs, surgery should be tailored to the individual based on the likelihood of malignant transformation versus that of pancreatic exocrine and endocrine insufficiency if total pancreatectomy is contemplated.