We read with great interest the multinational study by Holmberg et al. 1, which reported excellent survival after preventive resection for intraductal papillary mucinous neoplasm without preoperative signs of cancer, yet also showed that resection frequently yielded low-grade dysplasia and was often undertaken without preceding surveillance. As IPMN care shifts from broad surgical prevention toward risk-adapted observation, the central issue is no longer whether surgery can cure selected lesions, but whether immediate resection provides greater clinical benefit than structured surveillance 2. First, the study is best understood as a surgery-conditioned survival analysis rather than a comparative evaluation of preventive management. By limiting the cohort to resected patients and defining overall survival from the date of surgery, it estimates prognosis after resection, not the benefit conferred by resection over observation in otherwise comparable low-risk patients. In a preventive setting, that distinction is decisive. The relevant question is not survival after surgery alone, but whether immediate resection alters outcomes enough to justify its long-term pancreatic functional consequences. The study therefore clarifies postoperative prognosis, but does not establish whether immediate resection offers superior net clinical benefit over surveillance. Second, the analysis informs prognosis after surgery more than it defines when surgery should occur. Long-term survival was assessed after excluding deaths within 12 months and then stratified by final pathology, while T1a and T1b were combined 3. This conditions inference on both treatment receipt and early survivorship. As a result, the framework may soften early operative liability and reduce resolution at precisely the microinvasive boundary that matters most when deciding whether surveillance can safely continue or should convert to resection 4. Holmberg et al. appropriately return overtreatment to the center of IPMN care. The next advance, however, will require a surveillance-anchored preoperative framework that compares surgery with observation using decision-relevant endpoints, including oncologic progression, loss of resectability, pancreatic functional sequelae, and quality of life. Such a framework would more directly identify which patients can remain under surveillance and which truly benefit from timely resection. This work was supported by the National Natural Science Foundation of China (Grant No. 82203056). The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Sun et al. (Wed,) studied this question.