The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN

  • Rachel E. Simpson
  • Eugene P. Ceppa
  • Howard H. Wu
  • Fatih Akisik
  • Michael G. House
  • Nicholas J. Zyromski
  • Attila Nakeeb
  • Mohammad A. Al-Haddad
  • John M. DeWitt
  • Stuart Sherman
  • C. Max SchmidtEmail author
Original Article 2018 SSAT Plenary Presentation



A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance.


Three hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991–2016). Main-duct dilation included those ≥ 5 mm or “dilated” on radiographic reports. Statistics compared groups using Student’s T/Mann-Whitney U tests for continuous variables or chi-square/Fisher’s exact test for categorical variables with P < 0.05 considered significant.


High-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN.


Remnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant.


Pancreatic duct Pancreatic neoplasms Mucinous neoplasms Pancreatic cyst Pancreaticoduodenectomy 


Author Contributions

Drs. Schmidt and Simpson: conception/design of the work; data acquisition, analysis, and interpretation; manuscript drafting/revision/final approval; agreement to accountability.

Drs. Ceppa, Wu, Akisik, House, Zyromski, Nakeeb, Al-Haddad, DeWitt, and Sherman: data acquisition/interpretation; manuscript revision/final approval; agreement to accountability.

Compliance with Ethical Standards

Conflict of Interest

No true conflict of interest relevant to this work. Consultants for Boston Scientific (Dr. Al-Haddad and Dr. Sherman).

Supplementary material

11605_2018_4026_MOESM1_ESM.docx (22 kb)
Supplemental Table 1 (DOCX 21 kb)


  1. 1.
    Ohashi K, Murakami Y, Maruyama M, Takekoshi T, Ohta H. Four cases of mucous secreting pancreatic cancer. Prog Dig Endosc. 1982;20:348–51.Google Scholar
  2. 2.
    Brugge WR, Lauwers GY, Sahani D, Fernandez-del Castillo C, Warshaw AL. Cystic neoplasms of the pancreas. N Engl J Med. 2004;351:1218–26.CrossRefGoogle Scholar
  3. 3.
    Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, Yamaguchi K, Yamao K, Matsuno S. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology. 2006;6:17–32.CrossRefGoogle Scholar
  4. 4.
    Tanaka M, Fernandez-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, Kimura W, Levy P, Pitman MB, Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12:183–97.CrossRefGoogle Scholar
  5. 5.
    Yan L, Siddiqui AA, Laique SN, Saumoy M, Kahaleh M, Yoo J, Kalra A, Mathew A, Sterling J, Rao R, Lieberman M, Cosgrove N, Sharaiha RZ. A large multicenter study of recurrence after surgical resection of branch-duct intraductal papillary mucinous neoplasm of the pancreas. Minerva Gastroenterol Dietol. 2017;63:50–4.PubMedGoogle Scholar
  6. 6.
    Tamura K, Ohtsuka T, Ideno N, Aso T, Shindo K, Aishima S, Ohuchida K, Takahata S, Ushijima Y, Ito T, Oda Y, Mizumoto K, Tanaka M. Treatment strategy for main duct intraductal papillary mucinous neoplasms of the pancreas based on the assessment of recurrence in the remnant pancreas after resection: a retrospective review. Ann Surg. 2014;259:360–8.CrossRefGoogle Scholar
  7. 7.
    Passot G, Lebeau R, Hervieu V, Ponchon T, Pilleul F, Adham M. Recurrences after surgical resection of intraductal papillary mucinous neoplasm of the pancreas: a single-center study of recurrence predictive factors. Pancreas. 2012;41:137–41.CrossRefGoogle Scholar
  8. 8.
    Ohtsuka T, Kono H, Tanabe R, Nagayoshi Y, Mori Y, Sadakari Y, Takahata S, Oda Y, Aishima S, Igarashi H, Ito T, Ishigami K, Nakamura M, Mizumoto K, Tanaka M. Follow-up study after resection of intraductal papillary mucinous neoplasm of the pancreas; special references to the multifocal lesions and development of ductal carcinoma in the remnant pancreas. Am J Surg. 2012;204:44–8.CrossRefGoogle Scholar
  9. 9.
    Moriya T, Traverso W. Fate of the pancreatic remnant after resection for an intraductal papillary mucinous neoplasm: a longitudinal level II cohort study. Arch Surg. 2012;147:528–34.PubMedGoogle Scholar
  10. 10.
    Blackham AU, Doepker MP, Centeno BA, Springett G, Pimiento JM, Malafa M, Hodul PJ. Patterns of recurrence and long-term outcomes in patients who underwent pancreatectomy for intraductal papillary mucinous neoplasms with high grade dysplasia: implications for surveillance and future management guidelines. HPB: the official journal of the International Hepato Pancreato Biliary Association. 2017;19:603–10.CrossRefGoogle Scholar
  11. 11.
    Salvia R, Fernandez-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;239:678–85; discussion 85-7.CrossRefGoogle Scholar
  12. 12.
    Fujii T, Kato K, Kodera Y, Kanda M, Nagai S, Yamada S, Kanzaki A, Sugimoto H, Nomoto S, Takeda S, Morita S, Nakamura S, Nakao A. Prognostic impact of pancreatic margin status in the intraductal papillary mucinous neoplasms of the pancreas. Surgery. 2010;148:285–90.CrossRefGoogle Scholar
  13. 13.
    Park J, Lee KT, Jang TH, Seo YW, Lee KH, Lee JK, Jang KT, Heo JS, Choi SH, Choi DW, Rhee JC. Risk factors associated with the postoperative recurrence of intraductal papillary mucinous neoplasms of the pancreas. Pancreas. 2011;40:46–51.CrossRefGoogle Scholar
  14. 14.
    Tibayan F, Vierra M, Mindelzun B, Tsang D, McClenathan J, Young H, Trueblood HW. Clinical presentation of mucin-secreting tumors of the pancreas. Am J Surg. 2000;179:349–51.CrossRefGoogle Scholar
  15. 15.
    Retter J, Dinter D, Bersch C, Singer MV, Lohr M. Acute recurrent pancreatitis curtaining an intraductal papillary mucinous tumor of the pancreas. J Gastrointestin Liver Dis. 2007;16:445–7.PubMedGoogle Scholar
  16. 16.
    Berger Z, De La Fuente H, Meneses M, Matamala F, Sepulveda M, Rojas C. Association of Chronic Pancreatitis and Malignant Main Duct IPMN: A Rare but Difficult Clinical Problem. Case reports in gastrointestinal medicine. 2017;2017:8705195.CrossRefGoogle Scholar
  17. 17.
    Cioffi JL, McDuffie LA, Roch AM, Zyromski NJ, Ceppa EP, Schmidt CM, Nakeeb A, House MG. Pancreaticojejunostomy Stricture After Pancreatoduodenectomy: Outcomes After Operative Revision. J Gastrointest Surg. 2016;20:293–9.CrossRefGoogle Scholar
  18. 18.
    Miura F, Takada T, Amano H, Yoshida M, Isaka T, Toyota N, Wada K, Takagi K, Kato K. Repeated pancreatectomy after pancreatoduodenectomy. J Gastrointest Surg. 2007;11:179–86.CrossRefGoogle Scholar
  19. 19.
    Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases. Gastrointest Endosc. 2004;59:100–7.CrossRefGoogle Scholar
  20. 20.
    Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg. 2007;11:1704–11.CrossRefGoogle Scholar
  21. 21.
    Ryou M, Mullady DK, Dimaio CJ, Swanson RS, Carr-Locke DL, Thompson CC. Pancreatic antegrade needle-knife (PANK) for treatment of symptomatic pancreatic duct obstruction in Whipple patients (with video). Gastrointest Endosc. 2010;72:1081–8.CrossRefGoogle Scholar
  22. 22.
    Barkay O, Sherman S, McHenry L, Yoo BM, Fogel EL, Watkins JL, DeWitt J, Al-Haddad MA, Lehman GA. Therapeutic EUS-assisted endoscopic retrograde pancreatography after failed pancreatic duct cannulation at ERCP. Gastrointest Endosc. 2010;71:1166–73.CrossRefGoogle Scholar
  23. 23.
    Takikawa T, Kanno A, Masamune A, Hamada S, Nakano E, Miura S, Ariga H, Unno J, Kume K, Kikuta K, Hirota M, Yoshida H, Katayose Y, Unno M, Shimosegawa T. Pancreatic duct drainage using EUS-guided rendezvous technique for stenotic pancreaticojejunostomy. World J Gastroenterol. 2013;19:5182–6.CrossRefGoogle Scholar
  24. 24.
    Dumonceau JM, Cremer M, Baize M, Deviere J. The transduodenal rendezvous: a new approach to deeply cannulate the main pancreatic duct. Gastrointest Endosc. 1999;50:274–6.CrossRefGoogle Scholar
  25. 25.
    Bataille L, Deprez P. A new application for therapeutic EUS: main pancreatic duct drainage with a “pancreatic rendezvous technique”. Gastrointest Endosc. 2002;55:740–3.CrossRefGoogle Scholar
  26. 26.
    Parikh P, Shiloach M, Cohen ME, Bilimoria KY, Ko CY, Hall BL, Pitt HA. Pancreatectomy risk calculator: an ACS-NSQIP resource. HPB: the official journal of the International Hepato Pancreato Biliary Association. 2010;12:488–97.CrossRefGoogle Scholar
  27. 27.
    Demirjian AN, Kent TS, Callery MP, Vollmer CM. The inconsistent nature of symptomatic pancreatico-jejunostomy anastomotic strictures. HPB: the official journal of the International Hepato Pancreato Biliary Association. 2010;12:482–7.CrossRefGoogle Scholar
  28. 28.
    Morgan KA, Fontenot BB, Harvey NR, Adams DB. Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile? HPB: the official journal of the International Hepato Pancreato Biliary Association. 2010;12:211–6.CrossRefGoogle Scholar
  29. 29.
    Mucci-Hennekinne S, Brachet D, Clouston H, Pessaux P, Hamy A, Arnaud JP. Management of a stenotic pancreatico-digestive tract anastomosis following pancreatoduodenectomy. J Hepatobiliary Pancreat Surg. 2007;14:514–7.CrossRefGoogle Scholar
  30. 30.
    Wagle P, Yadav KS, Sali PA, Garg R, Varty P. Is Revision Surgery Justified for Symptomatic Pancreatico-enteric Anastomotic Stenosis in Long-term Survivors Following Pancreaticoduodenectomy for Malignancy? J Gastrointest Surg. 2017;21:339–43.CrossRefGoogle Scholar
  31. 31.
    Brook OR, Abedin S, Mortele KJ. Magnetic resonance imaging of the postoperative pancreas. Semin Ultrasound CT MR. 2013;34:325–35.CrossRefGoogle Scholar
  32. 32.
    Raman SP, Horton KM, Cameron JL, Fishman EK. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol. 2013;201:2–13.CrossRefGoogle Scholar
  33. 33.
    Kim JH, Hong SS, Kim YJ, Kim JK, Eun HW. Intraductal papillary mucinous neoplasm of the pancreas: differentiate from chronic pancreatits by MR imaging. Eur J Radiol. 2012;81:671–6.CrossRefGoogle Scholar
  34. 34.
    Miller JR, Meyer JE, Waters JA, Al-Haddad M, Dewitt J, Sherman S, Lillemoe KD, Schmidt CM. Outcome of the pancreatic remnant following segmental pancreatectomy for non-invasive intraductal papillary mucinous neoplasm. HPB: the official journal of the International Hepato Pancreato Biliary Association. 2011;13:759–66. Author names in bold designate shared co-first authorship. CrossRefGoogle Scholar
  35. 35.
    Nara S, Onaya H, Hiraoka N, Shimada K, Sano T, Sakamoto Y, Esaki M, Kosuge T. Preoperative evaluation of invasive and noninvasive intraductal papillary-mucinous neoplasms of the pancreas: clinical, radiological, and pathological analysis of 123 cases. Pancreas. 2009;38:8–16.CrossRefGoogle Scholar
  36. 36.
    Kitagawa Y, Unger TA, Taylor S, Kozarek RA, Traverso LW. Mucus is a predictor of better prognosis and survival in patients with intraductal papillary mucinous tumor of the pancreas. J Gastrointest Surg. 2003;7:12–9.CrossRefGoogle Scholar
  37. 37.
    Murakami Y, Uemura K, Hayashidani Y, Sudo T, Sueda T. Predictive factors of malignant or invasive intraductal papillary-mucinous neoplasms of the pancreas. J Gastrointest Surg. 2007;11:338–44.CrossRefGoogle Scholar
  38. 38.
    Crippa S, Pergolini I, Rubini C, Castelli P, Partelli S, Zardini C, Marchesini G, Zamboni G, Falconi M. Risk of misdiagnosis and overtreatment in patients with main pancreatic duct dilatation and suspected combined/main-duct intraductal papillary mucinous neoplasms. Surgery. 2016;159:1041–9.CrossRefGoogle Scholar
  39. 39.
    Shen J, Brugge WR, Dimaio CJ, Pitman MB. Molecular analysis of pancreatic cyst fluid: a comparative analysis with current practice of diagnosis. Cancer. 2009;117:217–27.PubMedGoogle Scholar
  40. 40.
    Al-Haddad M, DeWitt J, Sherman S, Schmidt CM, LeBlanc JK, McHenry L, Cote G, El Chafic AH, Luz L, Stuart JS, Johnson CS, Klochan C, Imperiale TF. Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts. Gastrointest Endosc. 2014;79:79–87.CrossRefGoogle Scholar
  41. 41.
    Siddiqui AA, Kowalski TE, Kedika R, Roy A, Loren DE, Ellsworth E, Adler D, Finkelstein SD. EUS-guided pancreatic fluid aspiration for DNA analysis of KRAS and GNAS mutations for the evaluation of pancreatic cystic neoplasia: a pilot study. Gastrointest Endosc. 2013;77:669–70.CrossRefGoogle Scholar
  42. 42.
    Wu J, Matthaei H, Maitra A, Dal Molin M, Wood LD, Eshleman JR, Goggins M, Canto MI, Schulick RD, Edil BH, Wolfgang CL, Klein AP, Diaz LA, Jr., Allen PJ, Schmidt CM, Kinzler KW, Papadopoulos N, Hruban RH, Vogelstein B. Recurrent GNAS mutations define an unexpected pathway for pancreatic cyst development. Sci Transl Med. 2011;3:92ra66. Author names in bold designate shared co-first authorship. CrossRefGoogle Scholar
  43. 43.
    Morris-Stiff G, Lentz G, Chalikonda S, Johnson M, Biscotti C, Stevens T, Matthew Walsh R. Pancreatic cyst aspiration analysis for cystic neoplasms: mucin or carcinoembryonic antigen--which is better? Surgery. 2010;148:638–44; discussion 44-5.CrossRefGoogle Scholar
  44. 44.
    Khalid A, McGrath KM, Zahid M, Wilson M, Brody D, Swalsky P, Moser AJ, Lee KK, Slivka A, Whitcomb DC, Finkelstein S. The role of pancreatic cyst fluid molecular analysis in predicting cyst pathology. Clin Gastroenterol Hepatol. 2005;3:967–73.CrossRefGoogle Scholar
  45. 45.
    Das K, Kochhar R, Mehta SK, Suri S. Ultrasound guided pancreatic ductography. Indian J Gastroenterol. 1990;9:129–30.PubMedGoogle Scholar
  46. 46.
    Xiao SY. Intraductal papillary mucinous neoplasm of the pancreas: an update. Scientifica. 2012;2012:893632.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Rachel E. Simpson
    • 1
  • Eugene P. Ceppa
    • 1
    • 2
  • Howard H. Wu
    • 3
  • Fatih Akisik
    • 4
  • Michael G. House
    • 1
  • Nicholas J. Zyromski
    • 1
  • Attila Nakeeb
    • 1
  • Mohammad A. Al-Haddad
    • 2
    • 5
  • John M. DeWitt
    • 5
  • Stuart Sherman
    • 5
  • C. Max Schmidt
    • 1
    • 2
    • 6
    • 7
    • 8
    Email author
  1. 1.Department of SurgeryIndiana University School of MedicineIndianapolisUSA
  2. 2.Indiana University Health Pancreatic Cyst and Cancer Early Detection CenterIndianapolisUSA
  3. 3.Department of Pathology and Laboratory MedicineIndiana University School of MedicineIndianapolisUSA
  4. 4.Department of RadiologyIndiana University School of MedicineIndianapolisUSA
  5. 5.Department of Medicine, Division of GastroenterologyIndiana University School of MedicineIndianapolisUSA
  6. 6.Department of Biochemistry/Molecular BiologyIndiana University School of MedicineIndianapolisUSA
  7. 7.Walther Oncology CenterIndianapolisUSA
  8. 8.Indiana University Simon Cancer CenterIndianapolisUSA

Personalised recommendations