演題

IS-8-7

Surgical treatment strategy for IPMN of the pancreas based on Fukuoka consensus guidelines 2012

[演者] 大塚 隆生:1
[著者] 田村 公二:1, 宮坂 義浩:1, 高畑 俊一:1, 田中 雅夫:1
1:九州大学臨床・腫瘍外科

International consensus guidelines for the management of IPMN 2012 (Fukuoka guidelines) recommend all main duct IPMNs (MD-IPMNs) to be resected because of high prevalence of malignancy. We have recently reported that the prevalence of malignant MD-IPMNs was 64% and MD-IPMNs can be treated by partial pancreatectomy rather than prophylactic total pancreatectomy if the surgical margin is negative, and remnant total pancreatectomy would lead to favorable prognosis even in the patients having recurrence in the remnant pancreas (Ann Surg 2014). Fukuoka guidelines also provide 3 categories of malignancy predictors of branch duct IPMNs (BD-IPMNs), namely 'high risk stigmata', 'worrisome feature', and 'low risk'. Our study demonstrated that the sensitivities to predict malignant IPMN of 'high risk stigmata', 'worrisome feature', and 'low risk' were 61%, 26%, and 0%, respectively, thus indicating adequacy of this stratification, and the sensitivity of preoperative pancreatic juice cytology (PJC) in patients with IPMNs having 'worrisome features' was 100% (WJS 2014). We also reported the usefulness of preoperative PJC (JHBPS 2013) and intraoperative irrigation cytology (Surgery 2014) to detect unexpected PDAC concomitant with 'low risk' IPMNs which were not detected by preoperative imaging. Taken together, all MD-IPMNs, BD-IPMNs having 'high risk stigmata' or 'worrisome features' with positive PJC should be treated by pancreatectomy with lymph node dissection. BD-IPMNs with 'worrisome features' but negative PJC can be treated by minimally invasive surgery or observed without resection. 'Low risk' BD-IPMNs can also be observed without resection; however, careful attention should be paid to the possible occurence of concomitant PDAC.
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