Risk of advanced lesions in patients with branch-duct IPMN and relative indications for surgery according to European evidence-based guidelines

European evidence-based guidelines proposed surgery for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) based on the presence of 1–2 relative indications, depending on the comorbidity burden. To assess the accuracy of the guidelines in patients with relative indications in a surgical cohort of demonstrated BD-IPMNs. This report describes a multi-centre, observational, retrospective study. All consecutive patients with relative indications and histologically confirmed BD-IPMN were included. The main outcome was risk of invasive carcinoma in patients with relative indications. Ninety-one patients with BD-IPMN underwent surgery because of absolute (n = 21), relative (n = 60), or no formal indications (n = 10). In total, there were 60 patients (mean age: 66 ± 9, 50% male) with one (n = 35, 58.3%) or ≥2 relative indications (n = 25, 41.7%). The global advanced lesion and invasive carcinoma rates were 40% and 13.3%, respectively. No risk factor was associated with high-grade dysplasia or invasive carcinoma. Patients with one indication had a lower risk of invasive carcinoma than did those with ≥2 relative indications (5.7% vs. 24%, respectively, p = 0.048); however, the advanced lesion rates were comparable (37.1% vs. 44%, p = 0.593). Invasive carcinoma is considerably more frequent in patients with two or more relative indications. The surgical strategy in these selected cases should be decided on an individual basis.