Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Case Report

Volume 12, Number 1, February 2019, pages 43-47

Formation of Pancreatoduodenal Fistula in Intraductal Papillary Mucinous Neoplasm of the Pancreas Decreased the Frequency of Recurrent Pancreatitis

Figure 1. This is a section of the pancreatic duct biopsy showing mucinous epithelium with a papillary architecture. The higher power view (inset) shows areas with nuclear hyperchromasia and crowding, consistent with intermediate grade dysplasia.

Figure 2. A sidebranch pancreatic duct within the pancreatic neck communicating with the first portion of the duodenum. It measures 1.6 cm in transverse diameter and represents a pancreaticoduodenal fistula.

Figure 3. ERCP reveals the large pancreaticoduodenal fistula with contrast extravasation from the duodenum into the pancreatic duct.

**Table 1.** Summary of the International Consensus Guidelines and Multi-Institutional Study for the Treatment of Main Duct and Branch Duct IPMN
Management	2006 Sendai Consensus Guidelines	2012 Revision of Guidelines	2017 Multi-institutional study
^aPancreatitis, cyst size > 3 cm, thickened or enhancing cyst wall, non-enhancing mural nodule, duct caliber change, pancreas atrophy, and main duct size between 5 - 9 mm is considered a “worrisome feature”. ^bMPD diameter of ≥ 10 mm is one of the “high-risk stigmata”.
Main duct	Resect the main duct and mixed variant IPMNs as long as the patient is a good surgical candidate with a reasonable life expectancy.	Rest all surgically fit patients with main duct IPMN.	The presence of obstructive jaundice, lymphadenopathy, or pancreatitis had the greatest strength in predicting the presence of high grade dysplasia and invasive cancer.
Branch duct	Asymptomatic: observation	“Worrisome features”^a, “low-risk features” as well as “high-risk stigmata”^b are introduced.	Having multiple worrisome features was additive in predicting high grade dysplasia and invasive cancer, with each additional feature increasing the OR by 1.39.
	Symptomatic: resection not only to alleviate the symptoms, but also because of a higher likelihood of malignancy.	More conservative approach: branch duct IPMN of > 3 cm without “high-risk stigmata” can be observed without immediate resection.
	Individualize decision to treat based on patient preferences and willingness to undergo follow-up studies, and the availability of safe pancreatic resection.

Table 1. Summary of the International Consensus Guidelines and Multi-Institutional Study for the Treatment of Main Duct and Branch Duct IPMN

Management

2006 Sendai Consensus Guidelines

2012 Revision of Guidelines

2017 Multi-institutional study

^aPancreatitis, cyst size > 3 cm, thickened or enhancing cyst wall, non-enhancing mural nodule, duct caliber change, pancreas atrophy, and main duct size between 5 - 9 mm is considered a “worrisome feature”. ^bMPD diameter of ≥ 10 mm is one of the “high-risk stigmata”.

Main duct

Resect the main duct and mixed variant IPMNs as long as the patient is a good surgical candidate with a reasonable life expectancy.

Rest all surgically fit patients with main duct IPMN.

The presence of obstructive jaundice, lymphadenopathy, or pancreatitis had the greatest strength in predicting the presence of high grade dysplasia and invasive cancer.

Branch duct

Asymptomatic: observation

“Worrisome features”^a, “low-risk features” as well as “high-risk stigmata”^b are introduced.

Having multiple worrisome features was additive in predicting high grade dysplasia and invasive cancer, with each additional feature increasing the OR by 1.39.

Symptomatic: resection not only to alleviate the symptoms, but also because of a higher likelihood of malignancy.

More conservative approach: branch duct IPMN of > 3 cm without “high-risk stigmata” can be observed without immediate resection.

Individualize decision to treat based on patient preferences and willingness to undergo follow-up studies, and the availability of safe pancreatic resection.