Table 5.
Indications of surgery for pancreatic cysts
| Absolute indications of surgery | Relative indications of surgery | |
| European guidelines[28] | Intraductal papillary mucinous neoplasm: Cytology positive for malignancy/High-grade dysplasia; Solid mass; Jaundice; Mural nodule ≥ 5 mm; Main pancreatic duct dilation > 10 mm | Cyst growth rate > 5 mm/yr |
| Mucinous cystic neoplasm: Size ≥ 4 cm | Serum CA 19-9 > 37 U/mL | |
| Symptomatic Mural nodule | MPD dilation 5-9 mm | |
| Cyst diameter ≥ 40 mm | ||
| New-onset diabetes mellitus | ||
| Acute pancreatitis related to IPMN | ||
| Mural nodule < 5 mm | ||
| American College of Gastroenterology guidelines[30] | Intraductal papillary mucinous neoplasm or Mucinous cystic neoplasm: | N/A |
| Referral to EUS-FNA/Multidisciplinary; team: | ||
| Jaundice | ||
| Acute pancreatitis | ||
| Significantly elevated CA 19-9 | ||
| Mural nodule | ||
| A solid component in cyst/pancreatic parenchyma | ||
| MPD > 5 mm | ||
| Focal dilation of PD or MD-IPMN | ||
| HGD/Pancreatic cancer on cytology | ||
| American Gastroenterology Association guidelines[31] | Pancreatic cysts: | N/A |
| EUS-FNA cytology positive for - | ||
| HGD/cancer | ||
| Both solid component and dilated PD on MRI and EUS | ||
| Revised IAP 2017 or revised Fukuoka guidelines[32] | Obstructive jaundice with pancreatic head cyst | Pancreatitis |
| Enhancing mural nodule ≥ 5 mm | Enhancing mural nodule < 5 mm | |
| MPD ≥ 10 mm | Thickened/enhancing cyst wall | |
| Main duct size 5-9 mm | ||
| An abrupt change in caliber of the pancreatic duct with distal pancreatic atrophy | ||
| Lymphadenopathy | ||
| Increase in serum level of CA 19-9 | ||
| Cyst growth rate ≥ 5 mm/2 yr | ||
| American College of Radiology guideline[33] | Obstructive jaundice with a cyst in the head of the pancreas | Cyst ≥ 3 cm |
| Enhancing solid component within a cyst | Thickened/enhancing cyst wall | |
| MPD > 10 mm in the absence of obstruction | Non-enhancing mural nodule | |
| MPD ≥ 7 mm |
IPMN: Intraductal papillary mucinous neoplasm; HGD: High-grade dysplasia; MPD Main pancreatic duct; PD: Pancreatic duct; EUS-FNA: Endoscopic ultrasound-Fine needle aspiration.