Evidence-based approach to the diagnosis, management and surveillance of pancreatic cystic lesions: from the guidelines to the clinical practice
Rodica Gincul, Bertrand Napoleon
Best Pract Res Clin Gastroenterol. 2026 Mar:81:102104. doi: 10.1016/j.bpg.2026.102104. Epub 2026 Apr 29.
Abstract
Pancreatic cystic lesions are increasingly detected in routine practice, yet their management remains difficult because diagnosis is often presumptive, malignant potential is heterogeneous, and pancreatic surgery carries substantial morbidity. This review critically compares the major international guidelines for mucinous pancreatic cystic lesions, focusing on diagnostic strategy, indications for surgery, operative management, surveillance, postoperative follow-up, and the risk of concomitant pancreatic ductal adenocarcinoma. Across guidelines, broad agreement exists on the central role of MRI/MRCP, the selective use of EUS, and the need to individualize decisions according to surgical fitness. However, important differences persist regarding the weight assigned to worrisome features, the role of contrast-enhanced EUS and cytology, thresholds for surgery, and the possibility of stopping surveillance. Recent evidence supports a more risk-adapted approach for selected low-risk branch-duct IPMNs, but the practical application of guidelines remains limited by divergent frameworks, modest evidence quality, and unequal access to advanced diagnostics. Overall, the field is moving toward more multimodal and individualized care, while still requiring stronger evidence and greater pragmatism to improve real-world applicability.