Intraductal papillary mucinous tumors of the pancreas. Surgical treatment: at what point should we stop?

Abstract

The intraoperative management of the margins of intraductal papillary mucinous tumors (IPMNs) undergoing pancreatic resection is crucial. The surgeon must discontinue the resection whenever the pancreatic margin is negative and, of course, when a total pancreatectomy is indicated.Nevertheless, a wide gray area exists. The real surgical problems are represented by i) IPMNs involving only a segment of the pancreatic gland, thus necessitating intraoperative histological examination of the resection and the decision as to "when to stop the resection"; ii) the intraoperative management of those margins which are neither clearly negative nor clearly positive; iii) the actual indications either for surgery or for follow-up in those patients affected by peripheral IPMNs. In the literature, negative resection margins have a range of between 49 to 81% with a pancreatic recurrence rate of from 0 to 25% in follow-ups ranging from 6 months to 11 years after the first operation. In general, in this disease which mainly involves the head and uncinate process of the gland, decisions are a "balance" between the patient and the disease. In fact, on the one hand, there is the usual elderly patient with possible comorbidities, symptoms and the presence of diabetes; on the other hand, the disease, which usually involves the head and the uncinate process of the gland, tends to grow along the duct and be potentially malignant if carcinoma is not already present.