Diffuse main-duct or mixed-type intraductal papillary mucinous neoplasm (IPMN) creates significant operative complexity. Although guidelines favour segmental resection with frozen-section margin assessment for localised disease (1), diffuse ductal involvement risks remnant dysplasia and carcinoma. A 67-year-old woman with diffuse mixed-type IPMN and near-total cystic pancreatic replacement presented with jaundice. Imaging showed diffuse side-branch ectasia, a 12 mm dilated main duct and parenchymal atrophy. ERCP confirmed a malignant distal biliary stricture. She had recurrent pancreatitis and was nutritionally optimised. At laparotomy, the pancreas was firm, fibrotic and densely adherent, without metastatic disease. Given diffuse ductal pathology and synchronous distal cholangiocarcinoma, total pancreatectomy was performed. Histology demonstrated a moderately differentiated distal bile duct adenocarcinoma (pT2 pN2) with diffuse high-grade IPMN and focal invasive carcinoma. She was discharged on day 13 on basal–bolus insulin with transition to pump therapy. Recent evidence shows total pancreatectomy can be undertaken with low mortality and that closed-loop insulin systems markedly improve postoperative glycaemic control (2). This case highlights how modern metabolic optimisation broadens the functional acceptability of total pancreatectomy when oncologic clearance mandates it. When diffuse main-duct IPMN coexists with distal cholangiocarcinoma, total pancreatectomy may represent the most definitive oncologic solution, provided meticulous pre-operative mapping, multidisciplinary planning and metabolic support are prioritised. References: 1.Ohtsuka T et al. Kyoto evidence-based guidelines for IPMN of the pancreas (2024). Pancreatology. 2024. 2.van Veldhuisen CL et al. Bihormonal artificial pancreas with closed-loop glucose control after total pancreatectomy. JAMA Surg. 2022;157(10):950–957.