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Pancreatic cysts are commonly found on cross-sectional imaging. The question arises in determining which lesions are premalignant or malignant and may require further testing, intervention, or follow-up. In pancreatic cysts without obvious malignancy on imaging, we approach them using the Four "S" Criteria. These are (1) symptoms that may be originating from the pancreatic cyst; (2) size of the cyst 2 cm or larger and/or main pancreatic duct greater than 5 mm; (3) survival of the patient, based on comorbidity index to determine surgical fitness; and then endoscopic ultrasound with fine needle aspiration (FNA) recommended to determine (4) solid component presence in the cyst, namely, nodule or thick walls, as well as to perform FNA to obtain cyst content. Current cyst fluid analysis options include use of cytology to determine presence of malignancy and carcinoembryonic antigen and fluid genetics to identify potentially premalignant lesions. The aims of this article are to explore current management guidelines for pancreatic cysts, present a comprehensive approach to pancreatic cysts, and explain the advantages and disadvantages of each option for evaluation of pancreatic cysts including endoscopic ultrasound with FNA with cyst fluid analysis using an evidence-based approach.

Primary treatment for pancreatic pseudocyst is evolving from surgical intervention to needle aspiration with catheter drainage. The latter treatment results in a similar rate of resolution but has less patient morbidity. This study evaluated the adjuvant role of Sandostatin, which inhibits basal and stimulated pancreatic secretion, in the management of three patients with pancreatic pseudocysts who had prolonged catheter drainage subsequent to percutaneous drainage. Inhibition of secretion occurred in all three patients, as evidenced by decrease in catheter output, which allowed the catheter to be removed. All three patients have remained asymptomatic for 9, 10, and 15 months, respectively. In summary, Sandostatin decreased persistent catheter drainage from chronic pancreatic pseudocysts.

The therapeutic efficacy and safety of percutaneous aspiration of chronic pancreatic pseudocysts was evaluated. Eight patients underwent aspiration a total of ten times. Permanent resolution was obtained in two patients and a third nonsurgical candidate was offered an alternative therapeutic modality. This procedure is simple, rapid, and safe and could become the initial approach to selected patients with a chronic pancreatic pseudocyst.

Two cases of gastric outlet obstruction, secondary to a pseudocyst of the pancreas, are described. The striking radiologic pictures are shown. The pathogenesis of this complication is discussed and a greater awareness of this entity is stressed.