Abstract Background Controversy persists regarding the management of patients with IPMN. International consensus guidelines stratify patients into high risk, worrisome, and low risk categories. Study Design The medical records of 7 institutions were reviewed for patients that underwent surgical management of IPMN between 2000-2015. Results 324 patients were included in the analysis. 60.4% of patients had main-duct / mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, while invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n=136). 68.9% of patients with high risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/ IC. Multivariate analysis demonstrated that only one of three high risk features and two of seven worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI = 0.65-0.94) and 0.69 (95% CI= 0.39-0.91), respectively. In the absence of high risk features, HGD/ IC was still present in 57.4% of patients with two or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/ IC in a linear fashion (OR 1.39, 95% CI=1.08-1.80, p<0.01). Conclusions These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.