Introduction

Until recently, all cystic tumours were treated surgically, including intraductal papillary mucinous neoplasms of the branch type (BD-IPMN). Currently, most patients with BD-IPMN are being followed up.

Aims & Methods

The aims of this study was to estimate the results of treatment of patients with IPMN.
A total of 228 patients with cystic pancreatic tumours who were treated at our department between 2012 and 2023 were included in the analysis. IPMN was diagnosed in 78 (34.2%) patients. All patients with IPMN were divided into two groups. The primary group included 56 patients who underwent surgery between 2018 and 2023 in accordance with the proposed algorithms. The comparison group comprised 22 patients who underwent surgery between 2012 and 2017. The two groups demonstrated comparable demographic characteristics, including age, gender distribution, and pathological structure.
In the diagnostic algorithm, we always perform MRI with the DWI and with magnetic resonance cholangiopancreatography. We also perform endoscopic ultrasound with fine-needle aspiration if required.
Until 2018, all types of IPMN were operated. Since 2018, we have revised our tactics. Indications for surgery were considered to be the presence of central and mixed type of IPMN or branch duct of IPMN with the presence of HRS and WF.
Of the 22 patients in the control group, central type IPMN was diagnosed in 10 patients (adenocarcinoma was diagnosed in 9, 1 patient was unresectable at the time of diagnosis), mixed type in 4 (2 patients had malignant tumours, 1 patient was unresectable at the time of diagnosis, 1 patient did not undergo surgery), and branch type in 8 (4 patients had malignant tumours, 2 patients - benign and in 2 patients we did not perform surgery). 17 patients with IPMN underwent surgery. Pancreatoduodenectomy (PDE) was performed in 9 patients, total pancreatectomy (TPE) in 1, distal pancreatectomy (DPE) in 7. Five patients were not operated: 2 patients had unresectable tumours diagnosed preoperatively, 2 patients with BD-IPMN were offered observation, 1 patient with mixed type IPMN refused surgery.
IPMN was diagnosed in 56 (40.6%) patients in the main group. Adenocarcinoma on the background of IPMN was diagnosed in 21 (37.5%) patients, all patients with central or mixed type of IPMN, of which PDE was performed in 12 patients, DPE with splenectomy in 8 patients, TPE - in 1 patient. IPMN with mild or severe dysplasia was diagnosed in 20 (35.7%) patients. Of these, PDE was performed in 13 patients, TPE in 1 patient and DPE in 6 patients. In 15 (26.8%) patients BD-IPMN without HGD and WF was diagnosed.

Results

In the comparison group, 17 (77.3%) patients underwent resection. Complications occurred in 6 (35.3%) patients, 3 of which were pancreatogenic complications (17.6%). In the main group, 41 (73.2%) patients underwent surgery. Complications occurred in 11 patients (26.8%). There was no mortality among these patients in either group. Of the 2 patients in the comparison group who were followed up, 1 patient had no progression of the disease, 1 patient was lost to follow-up, the outcome is unknown. Of the 15 patients in the main group with BD IPMN who were followed, none had disease progression.

Conclusion

The treatment of IPMN of the pancreas requires an individualized approach. In select patients, surveillance of presumed BD-IPMN can be safely discontinued. When choosing a wait-and-see approach in patients with BD-IPMN, it is imperative that the diagnosis not raise doubts.

Introduction

Despite improvements in the perioperative care of patients with pancreatic cancer the incidence of postoperative complications following pancreatic resections remains high.

Aims & Methods

The objective of this study was to develop surgical techniques to prevent postoperative complications following pancreatoduodenectomy. A retrospective analysis was conducted on the surgical outcomes of 456 patients with resectable pancreatic and periampullary cancer who underwent pancreatoduodenectomy between 2015 and October 2023. Since November 2018, new surgical tactics have been implemented to prevent the occurrence of postoperative pancreatic fistula (POPF) and other postoperative complications. Preliminary data indicates that the development of postoperative complications after pancreatoduodenectomy correlates with postoperative pancreatic fistula, the presence of sarcopenia has been demonstrated to significantly affect the number of clinically relevant postoperative pancreatic fistula and other postoperative complications.
Since that time, we have used new approaches: our modification of the pancreatic fistula risk score, which assesses pancreatic density according to the degree of pancreatic fibrosis. Depending on the risk, we used our surgical tactics. In cases with a high risk of postoperative pancreatic fistula, during pancreaticojejunostomy we used external pancreatic stent. In patients with intermediate risk we performed invaginated duct to mucosa pancreaticojejunostomy. In low-risk patients, the technique of pancreaticojejunostomous anastomosis was considered by the operating surgeon. We performed early removal of abdominal drains in patients with low risk of pancreatic fistula. Prior to surgery, the presence of sarcopenia was assessed, and nutritional support was provided to patients with sarcopenia.
During the period from November 2018 to October 2023, proposed mitigation strategies were applied to 227 patients in the main group. The comparison group consisted of 229 patients who underwent surgery without the use of the developed surgical strategies between January 2015 and October 2018.

Results

The groups were comparable in terms of sex, age, laboratory results, disease stage, American Society of Anesthesiologists score, and comorbidities. In the main group, 26 patients (11.4%) experienced POPF grade B or C. In the comparison group, 64 out of 229 patients (27.9%) experienced a postoperative pancreatic fistula of grade B or C, which is significantly higher than the main group (c²= 19.5, p = 0.0001). Furthermore, the main group had a significantly lower level of postoperative complications compared to the comparison group. A total of 69 patients (30.1%) in the main group experienced complications, while 94 patients (41.0%) in the comparison group did so (c²=5.6, p=0.02). The mortality rate in the main group was reduced from 2.2% to 1.3% due to the developed tactics (c²=0.49, p=0.5).

Conclusion

The surgical tactics developed to prevent postoperative pancreatic fistula after pancreatoduodenectomy were found to significantly reduce its occurrence from 27.9% to 11.4%, postoperative complications from 41.0% to 30.1%, and mortality from 2.2% to 1.3% (c²= 0.49, p = 0.5).

Introduction

Intraductal papillary mucinous neoplasms (IPMN) are the most common type of cystic pancreatic lesions, and are established precancerous lesions. Among them, side-branch IPMN (SB-IPMN) are the most prevalent, and exhibit a low risk of malignant transformation. The Kyoto guidelines, last revised in 2024, define criteria for management and surveillance of IPMN, based on high-risk stigmata and worrisome features. Surveillance intervals for non-resected IPMN, either by MRI/MRCP or EUS, are based on the size of the largest cyst or cyst progression. However, there is considerable variability in clinical practice across physicians and institutions.

Aims & Methods

This study aimed to use an AIgo-based decision-support tool to compare real-life clinical practice at Tel Aviv Sourasky Medical Center with guideline-based management according to the Kyoto criteria, and to evaluate its cost-effectiveness.
​SB-IPMN cases were collected retrospectively. A Sher-AI¹ Algo-based tool based on the Kyoto guidelines², was used as a decision-supporting tool to determine the updated recommended management strategy. Initial MRI/MRCP findings, clinical presentation, and laboratory data were integrated into the platform for each case, and the recommendations were compared with the primary management strategy selected at the time of presentation. Long-term radiological and clinical follow-up data were collected for eventual development of pancreatic ductal adenocarcinoma (PDAC).

Results

Two hundred patients (66% male, 34% female) with a mean age of 66.8±10.6 years were followed up radiologically and clinically for median durations of 55.3±29.5 and 63.5±28.4 months, respectively. Average leading cyst size at presentation was 11±6.9 mm. Following index MRI/MRCP, only 37 patients (18.5%) were managed in accordance with the Kyoto guidelines. The rest were mostly subjected to more rigorous follow-up (n=115, 57.5%), while 48 patients (24%) underwent less intensive monitoring. Most of the patients in the latter group were older (mean age 71.9±9.5 years) and had more comorbidities. Over-rigorous follow-up resulted in an average excess of 0.33 MRI/MRCPS per patient-year. During follow-up, PDAC developed in only one patient from the conservatively managed group, with the latter occurring after five years of cyst stability.

Conclusion

Fewer than 20% of patients with SB-IPMN were managed in alignment with the Kyoto guidelines. Most patients underwent more intensive surveillance, which did not appear to reduce PDAC incidence, inflicting stress on patients and unnecessary use of public health resources. This raises questions about the cost-effectiveness of such an approach and highlights the potential value of Algo-based decision-support tools in standardizing clinical practice.

References

1. sher-ai.com
2. International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas
Takao Ohtsuka et al., Pancreatology, 2024.

Introduction

IPMNs are mucin-producing subtypes of pancreatic cysts considered a potential precursors of pancreatic cancer accounting for 8% of all pancreatic malignancies. The molecular mechanisms and biological factors involved in the progression of IPMN are still unknown. In previous studies, modifiable risk factors (e.g., smoking) and protective factors (e.g., ACE inhibitors) have been investigated to slow down or prevent the IPMN progression. The aim of this study is to investigate the association between modifiable lifestyle factors (smoking and alcohol consumption) and the use of commonly prescribed medications (aspirin, ACE -inhibitors, angiotensin- II -receptor antagonists, and statins) and the progression of IPMN.

Aims & Methods

This was a monocentric retrospective cohort study. The study included patients who underwent radiological and clinical examinations at time 0 and at the 3-year follow-up visits. Demographic data (sex, age, weight, and height), IPMN characteristics (type of IPMN and radiological characteristics at baseline), lifestyle factors (smoking and alcohol consumption), and medication use (aspirin, ACE -I, ARBs, and statins) were recorded. Clinical and radiological characteristics were recorded at the 3-year follow-up to detect progression of IPMN (defined as the presence of high-risk stigmata and/or features of concern). Statistical analysis was performed using SPSS 20. Descriptive data are presented as mean±standard deviation and median with range or percentage. Categorical data were compared using the χ₂ test. Multivariate logistic regression analysis was performed to adjust for confounding factors (age, sex, and IPMN subtype). A p value < 0.05 was considered statistically significant.

Results

126 patients were included in the study. Patient characteristics are summarized in Table 1. Smoking (p 0.036; OR 5.7, IC95% 1.11-29.04), heavy alcohol use (p 0.027; OR 4.8, IC95% 1.10-9.50), and use of ARB (p 0.048; OR 3.52, IC95% 1.85-14.50) were associated with progression of IPMN. Statin use was associated with a lower risk of IPMN progression (p 0.043; OR 0.154, IC95% 0.021-0.978). Body weight, aspirin, ACEi, and low alcohol intake were not statistically associated with IPMN natural history.

Conclusion

With the limitations resulting from the small sample size and retrospective design of the study, smoking, heavy alcohol consumption, and ARBi use appear to be risk factors for progression of IPMN. In contrast, statin use was found to be a protective factor for IPMN progression. Prospective studies are needed to confirm these preliminary data.

Introduction

Patients with suspected main-duct intraductal papillary mucinous neoplasms (MD-IPMN) are frequently referred for surgery due to the high risk of malignancy (as high as 40% to 60% in the literature). However, many present with significant comorbidities or concurrent malignancies, complicating the surgical risk-benefit assessment. In such cases, advanced endoscopic procedures may assist in guiding clinical decision-making.

Aims & Methods

This study aimed to evaluate the role of EUS-guided fine-needle biopsy (EUS-FNB) and pancreatoscopy in individualized risk stratification and management decisions for patients with suspected MD-IPMN. We retrospectively analyzed eight patients treated at our center between March 2020 and March 2025. All patients presented with significant comorbidities or active oncologic disease. Data collected included endoscopic findings, biopsy results, complications, and final management decisions.

Results

Eight patients with suspected main-duct IPMN were included (mean age: 67.6 years; 3 females, 37.5%). The mean main pancreatic duct (MPD) diameter was 9.1 mm. All patients were evaluated in a multidisciplinary setting due to clinical complexity, including comorbidities or concurrent malignancies. EUS-guided fine-needle biopsy (EUS-FNB) was performed in 3 patients, and pancreatoscopy in 5. All procedures were technically successful. Biopsy samples were diagnostic in 2 of 3 EUS-FNB cases and 5 of 5 pancreatoscopy cases and contributed directly to management decisions. In 1 EUS-FNB case, the sample was non-diagnostic. Pancreatoscopy revealed mucin extrusion in 4/5 patients, papillary or villous projections in 3/5, and a 'fish egg' appearance in 2/5. These features supported risk assessment and, in several cases, justified a conservative approach in high-risk patients. Three patients underwent surgery following multidisciplinary review. One had concordant findings (high-grade dysplasia), while two had discordant outcomes: one with low-risk pancreatoscopy findings had invasive adenocarcinoma, and one with EUS-FNB showing low-grade atypia had high-grade dysplasia on final pathology. Five patients were managed with active surveillance. One case of mild post-ERCP pancreatitis occurred; no other complications were reported. Endoscopic findings influenced management in 5 of 8 patients (62.5%).

Conclusion

In this real-world case series, EUS-FNB and pancreatoscopy contributed meaningfully to individualized decision-making in patients with suspected MD-IPMN. However, discordance between endoscopic impressions and final pathology in two cases highlights the limitations of visual and cytologic assessment. These findings reinforce the need for integrating endoscopic data with imaging, clinical context, and multidisciplinary input when evaluating main-duct IPMN.

References

1. Salvia R, Fernández-del Castillo C, Bassi C, Thayer SP, Falconi M, Mantovani W, Pederzoli P, Warshaw AL. Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg. 2004 May;239(5):678-85; discussion 685-7. doi: 10.1097/01.sla.0000124386.54496.15. PMID: 15082972; PMCID: PMC1356276.
2. Sohn TA, Yeo CJ, Cameron JL, Hruban RH, Fukushima N, Campbell KA, Lillemoe KD. Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg. 2004 Jun;239(6):788-97; discussion 797-9. doi: 10.1097/01.sla.0000128306.90650.aa. PMID: 15166958; PMCID: PMC1356287.