Similarities and differences in guidelines for the management of pancreatic cysts

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.