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Endoscopic ultrasound is increasingly being used for evaluation of pancreatic diseases and pancreatic tumors. Among various pancreatic cystic lesions, cystic degeneration of pancreatic neuroendocrine neoplasm is of the challenge in making diagnosis. Although unique characteristic of each type of pancreatic cystic lesions has been proposed abundantly, typical morphology of cystic degeneration of pancreatic neuroendocrine neoplasm is still unclear. We, herein, reported a case of 66-year-old woman who was incidentally found to have a cystic lesion in the tail of pancreas upon screening transabdominal ultrasonography. A well-defined cystic lesion with rim calcification was noted on subsequent abdominal computed tomography. Endoscopic ultrasound revealed a markedly thick-wall cystic lesion containing solid nodule inside which was not enhanced following contrast-enhanced study. A mucinous cystic neoplasm was suspected and the patient was proceeded with distal pancreatectomy. A definite diagnosis of neuroendocrine neoplasm was confirmed after staining with synaptophysin and chromogranin A. We performed a meticulous review on current literatures focusing on endoscopic characteristics of pancreatic neuroendocrine neoplasms with cystic degeneration.

Competing Interests: Jan Borggrefe erhielt außerhalb dieses spezifischen Projekts Honorare von Philips Healthcare. N. Abdullayev und N. Große Hokamp erklären, dass kein Interessenkonflikt besteht

Background: Lymphoepithelial cysts (LECs) are rare pancreatic cystic lesions. Since LECs are benign, preoperative diagnosis is important to differentiate from a cystic neoplasm and avoid unnecessary surgery. The aim of this study was to identify clinical, radiographic and cytopathologic features associated with LECs., Methods: A retrospective review was performed of patients diagnosed with LEC between 1995 and 2017 at our hospital. Clinicopathologic and radiographic imaging features were documented., Results: Of 29 patients with pancreatic LEC, 22 underwent surgical resection. The majority were male (n = 24) with a median age of 55 years (range, 21-74). During the evaluation, all patients underwent a CT, with endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) biopsy (n = 22) and/or MRI/MRCP (n = 11) performed in a smaller number of patients. A combination of exophytic tumor growth on imaging and the presence of specific cytomorphologic features on the EUS-FNA cytology biopsy led to the correct diagnosis of LEC and prevention of unnecessary surgery in 7 patients., Discussion: Differentiating LECs from premalignant pancreatic cystic neoplasms remains difficult. Findings of an exophytic growth pattern of the lesion on abdominal imaging and the presence of specific cytomorphologic features in the EUS-FNA biopsy could help clinicians diagnose LEC preoperatively., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Option for borderline resectable pancreatic cancer is pancreaticoduodenectomy (PD) with vascular resection and reconstruction. We would like to share our experience of vascular reconstruction. First patient was a 51-year male with pancreatic head carcinoma, involving posterior wall of portal vein (PV) and replacing right hepatic artery (RHA). Along with PD, he underwent PV and RHA resection and reconstruction. Second case was a 33-year female who had distal pancreatic cyst and PV-splenic vein junction involved by tumor. Distal pancreatectomy+splenectomy and PV primary resection-reconstruction was done. Third case was a 72-year male with pancreatic neck adenocarcinoma involving PV-SMV junction. Subtotal pancreatecomy+splenectomy was done along with PV-reconstruction via splenic vein patch graft. Fourth case was a 77-year male with cystic pancreatic head mass involving PV. PD with resection and reconstruction of portal vein was done. Fifth case was a 35-year female with peri-ampullary tumor replacing RHA, coursing through the pancreatic parenchyma. So RHA was resected and reconstructed in an end-to-end fashion. Vascular resection-reconstruction can be done in borderline pancreatic cancer patients, and a considerable survival benefit can be achieved.

Background: Making a specific diagnosis of pancreatic cysts preoperatively is difficult. The new disposable Moray micro forceps biopsy (MFB) device allows tissue sampling from the pancreatic cyst wall/septum and aims to improve diagnosis. This study compares the diagnostic performance of the MFB with the current conventional analysis of pancreatic cyst fluid (PCF)., Methods: A total of 48 patients sampled with MFB were identified. Cysts were classified as mucinous on PCF based on extracellular mucin/mucinous epithelium, carcinoembryonic antigen (CEA) levels ≥192 ng/mL, or KRAS/GNAS mutation. A diagnosis of intraductal papillary mucinous neoplasm was supported by GNAS mutation; a diagnosis of serous cystadenoma was supported by Von Hippel-Lindau tumor suppressor (VHL) mutation. A diagnosis of mucinous cystic neoplasm required the presence of subepithelial ovarian-type stroma. A high-risk cyst was defined as a mucinous cyst with high-grade dysplasia or an adenocarcinoma. Comparisons in diagnostic performance between PCF and MFB were made., Results: The mean age of the patients was 69.6 years (range, 27-90 years); 25 of 48 patients (52.1%) were female. Cysts were in the pancreatic head (13 patients), neck (2 patients), body (20 patients), and tail (13 patients), averaging 3.1 cm (range, 1.2-6.0 cm). There was concordance with mucinous versus nonmucinous classification (60.4% for PCF vs 58.3% for MFB; P = .949). Three high-risk cysts were detected by PCF and 2 were detected by MFB (P = .670). However, MFB diagnosed significantly more specific cysts compared with PCF (50.0% for MFB vs 18.8% for PCF; P<.001)., Conclusions: PCF analysis and MFB have comparable performance in distinguishing between mucinous and nonmucinous cysts and for detecting high-risk cysts. However, MFB was found to be superior for diagnosing specific cyst subtypes, thus adding significant value to preoperative patient management. Cancer Cytopathol 2018;126:414-20. © 2018 American Cancer Society., (© 2018 American Cancer Society.)

Simple mucinous cyst of the pancreas is an unusual pancreatic cyst, first described by Kosmahl et al. in 2002 with 5 cases. We describe a case of simple mucinous cyst of the pancreas, followed by a literature review. The physiopathology of this cyst is still unclear. It is an epithelial cyst, presenting as unilocular cystic lesion of the pancreatic body or tail, with a clear content, and no communication with the pancreatic duct. Microscopically, the cyst is lined by mucin-producing cells with mild atypia, and contains a fibrous wall without ovarian-like stroma. The prognosis is excellent, as no recurrent disease and progression to malignancy have been described. The non neoplastic origin of this lesion is debated, as cases with KRAS mutation and intra-epithelial neoplastic lesions have been recently reported. It is important to distinguish this lesion from macrocystic serous cystadenoma, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms, by clinical, radiological and pathological features, as the treatment varies from simple surveillance to surgical resection., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Pancreatic cystic lymphangioma is an extremely rare tumor. The characteristic imaging findings are poorly defined, and distinguishing between this disease and other pancreatic cyst-related tumors is very difficult. We herein report a case of a Japanese woman in her 50s with this lesion, located in the tail of the pancreas. Pancreatic cystic lymphangioma should therefore be considered in the differential diagnosis of pancreatic cystic lesions. Laparoscopic resection can be a useful, minimally invasive surgical approach for treating these cysts as well as for the treatment of benign or low-grade malignant tumors located in the pancreatic body or tail.

Background and Objectives: The Sendai consensus guidelines (SCG) and Fukuoka consensus guidelines (FCG) have been examined for their roles in predicting advanced neoplasia (AN) in pancreatic cystic neoplasm (PCN) patients with mixed results. We aim to evaluate the utilities of both guidelines in a Chinese cohort with preoperatively diagnosed mucinous PCNs., Methods: One hundred ninety-seven patients who underwent resections from 2008 to 2015 in Zhong Shan Hospital, Fudan University for suspected PCNs were retrospectively reviewed. Receiver operating characteristic (ROC) curves were calculated and compared to measure diagnostic value., Results: Fifty-five patients were diagnosed with AN pathologically. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the SCG high-risk (SCG HR ) criteria were 87.3%, 28.2%, 32.0%, 85.1%, and 44.7%, respectively, and for the FCG high-risk (FCG HR ) criteria, they were 40.0%, 95.8%, 78.6%, 80.5%, and 80.2%, respectively. ROC curve comparison analyses showed that the FCG HR were superior to the SCG HR (P = 0.02). The performance of the FCG HR was enhanced with CA19-9 incorporated (P = 0.004)., Conclusions: The FCG were superior to the SCG in this retrospective analysis, which could be further improved by the incorporation of CA19-9. However, the practical safety remains uncertain because of missed invasive carcinoma cases., (© 2017 Wiley Periodicals, Inc.)

Background: The most widely accepted biochemical test for preoperative differentiation of mucinous from benign, nonmucinous pancreatic cysts is cyst fluid carcinoembryonic antigen. However, the diagnostic accuracy of carcinoembryonic antigen ranges from 70% to 86%. Based on previous work, we hypothesize that pancreatic cyst fluid glucose may be an attractive alternative to carcinoembryonic antigen., Methods: Pancreatic cyst fluid was collected during endoscopic or operative intervention. Diagnoses were pathologically confirmed. Glucose and carcinoembryonic antigen were measured using a patient glucometer and automated analyzer/enzyme-linked immunosorbent assay. Sensitivity, specificity, accuracy, and receiver operator characteristic analyses were performed., Results: Cyst fluid samples from 153 patients were evaluated (mucinous: 25 mucinous cystic neoplasms, 77 intraductal papillary mucinous neoplasms, 4 ductal adenocarcinomas; nonmucinous: 21 serous cystic neoplasms, 9 cystic neuroendocrine tumors, 14 pseudocysts, 3 solid pseudopapillary neoplasms). Median cyst fluid glucose was lower in mucinous versus nonmucinous cysts (19 vs 96 mg/dL; P < .0001). With a threshold of ≤ 50 mg/dL, cyst fluid glucose was 92% sensitive, 87% specific, and 90% accurate in diagnosing mucinous pancreatic cysts. In comparison, cyst fluid carcinoembryonic antigen with a threshold of >192 ng/mL was 58% sensitive, 96% specific, and 69% accurate. Area under the curve for glucose and CEA were similar at 0.91 and 0.92., Conclusion: Cyst fluid glucose has significant advantages over carcinoembryonic antigen and should be considered for use as a routine diagnostic test for pancreatic mucinous cysts., (Copyright © 2017. Published by Elsevier Inc.)

Backgrounds & Aims: Most guidelines for management of patients with intraductal papillary mucinous neoplasms (IPMN) vary in proposed surveillance intervals and durations-these are usually determined based on expert opinions rather than substantial evidence. The progression of and optimal surveillance intervals for branch-duct IPMNs (BD-IPMN) has not been widely studied. We evaluated the progression of BD-IPMN under surveillance at a single center, and determined optimal follow-up intervals and duration., Methods: We performed a retrospective analysis of 1369 patients with BD-IPMN seen at Seoul National University Hospital in Korea from January 2001 through December 2016. We included only patients whose imaging studies showed classical features of BD-IPMN, and collected data from each patient over time periods of at least 3 years. We reviewed radiologic and pathologic findings, and performed linear and binary logistic regressions to estimate cyst growth., Results: The median annual growth rate of the cyst was 0.8 mm over a median follow-up time of 61 months. During surveillance, 46 patients (3.4%) underwent surgery because of disease progression after a median follow-up time (in this group) of 62 months. Worrisome features were observed in 209 patients (15.3%) during surveillance, including cyst size of 3 cm or more (n = 109, 8.0%), cyst wall thickening (n = 51, 3.7%), main pancreatic duct dilatation (n = 77, 5.6%), and mural nodule (n = 43, 3.1%). Along with annual rate of cyst growth, incidences of main pancreatic duct dilatation and mural nodules associated with the sizes of cysts at detection (P < .001)., Conclusions: In a retrospective analysis of patients with BD-IPMN followed for more than 5 years, we found most cysts to be indolent, but some rapidly grew and progressed. Surveillance protocols should therefore be individualized based on initial cyst size and rate of growth., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: Cystic pancreatic neuroendocrine tumors (CPanNETs) represent an uncommon variant of pancreatic neuroendocrine tumors (PanNETs). Due to their rarity, there is a lack of knowledge with regard to clinical features and postoperative outcome., Methods: The prospectively maintained surgical database of a high-volume institution was queried, and 46 resected CPanNETs were detected from 1988 to 2015. Clinical, demographic, and pathological features and survival outcomes of CPanNETs were described and matched with a population of 92 solid PanNETs (SPanNETs) for comparison., Results: CPanNETs accounted for 7.8% of the overall number of resected PanNETs (46/587). CPanNETs were mostly sporadic (n = 42, 91%) and nonfunctioning (39%). Two functioning CPanNETs were detected (4.3%), and they were 2 gastrinomas. The median tumor diameter was 30 mm (range 10-120). All tumors were well differentiated, with 38 (82.6%) G1 and 8 (17.4%) G2 tumors. Overall, no CPanNET showed a Ki-67 >5%. A correct preoperative diagnosis of a CPanNET was made in half of the cases. After a median follow-up of >70 months, the 5- and 10-year overall survival of resected CPanNETs was 93.8 and 62.5%, respectively, compared to 92.7 and 84.6% for SPanNETs (p > 0.05). The 5- and 10-year disease-free survival rates were 94.5 and 88.2% for CPanNETs and 81.8 and 78.9% for SPanNETs, respectively (p > 0.05)., Conclusion: In the setting of a surgical cohort, CPanNETs are rare, nonfunctional, and well-differentiated neoplasms. After surgical resection, they share the excellent outcome of their well-differentiated solid counterparts for both survival and recurrence., (© 2017 S. Karger AG, Basel.)

Chronic pancreatitis complicated by pancreatic duct stones and pancreatic hypertension, post-necrotic cysts and fistulas requires surgical treatment. There are various procedures from minimally invasive to advanced pancreatectomy. Endoscopic interventions and radical open surgery allow to achieve good results. Successful complex treatment of patient with chronic pancreatitis is presented in this report.

Introduction: This study aims to understand patients' perspectives and satisfaction with choosing surgery for the treatment of pancreatic cystic lesions (PCLs)., Methods: A 62-question survey was administered to 113 patients who had a resection for a PCL by 12 surgeons at two pancreatic specialty centers (2004-2016). Patients' final diagnoses and perioperative outcomes were correlated to the survey's results using univariate analysis., Results: Fear of cancer was quite or extremely important in most respondents' decision to have surgery (95.4%). Respondents were quite or fully satisfied with the outcomes of surgery (91.1%) and with the decision-making process (89.3%). Distress from anxiety about the cyst before surgery (58.6%) largely outweighed that from postsurgical lifestyle changes (14.4%). Furthermore, 88.7% of patients with pathologically non-malignant disease were quite or fully satisfied with their decision to have surgery, and patients with mucinous neoplasms reported high satisfaction rates independent of grade of dysplasia or malignancy (p = 0.641)., Conclusion: Patients with a resected PCL are highly satisfied with their decision to have surgery, regardless of the final diagnosis or clinical outcome. Fear of cancer is the main driver in the decision-making process, and the anxiety of harboring a cyst is a greater cause of distress than are postsurgical lifestyle changes.

Aim: To determine the prevalence, characteristics and clinical course of pancreatic cystic neoplasms (PCNs) in liver transplantation (LT) recipients., Methods: We retrospectively studied consecutive patients who underwent LT between January 1998 to April 2016. Clinical and laboratory data were obtained from patient medical records. Imaging findings on computed tomography and magnetic resonance cholangiopancreatography were reviewed by two radiologists., Results: During the study period, 872 patients underwent cadaveric LT. Pancreatic cysts were identified in 53/872 (6.1%) and 31/53 (58.5%) were PCNs [28 intraductal papillary mucinous neoplasm (IPMN), 2 mucinous cystic neoplasm (MCN), 1 serous cystadenoma]. Patients with PCNs exhibited less male predominance (55% vs 73%, P = 0.03) compared to patients without pancreatic cysts. Thirteen patients (42%) were diagnosed with PCN pre-LT while 18 patients (58%) developed PCN post-LT. The median size of PCNs was 13mm [interquartile range (IQR) 10-20 mm]. All IPMNs were side-branch type. Most PCNs were found in the head and body of pancreas (37% each), followed by the tail (25%). Five patients underwent further evaluation with endoscopic ultrasound. Progress imaging was performed on 81% of patients. PCNs remained stable in size and number in all but 2 patients. During a median follow up of 39 mo (IQR 26-58 mo), the 2 (6%) patients with MCN underwent pancreatectomy. No PCN patient developed pancreatic adenocarcinoma, while 5 died from illnesses unrelated to the PCN. Among patients without PCN, 1/841 (0.1%) developed pancreatic adenocarcinoma., Conclusion: The prevalence of PCNs in LT recipients was similar to the general population (3.6%, 31/872). Side-branch IPMNs do not appear to have accelerated malignant potential in post-LT patients, indicating the current surveillance guidelines are applicable to this group., Competing Interests: Conflict-of-interest statement: All authors have no conflicts of interest to declare with respect to this work.

Chronic pancreatitis and incidentally discovered pancreatic lesions present significant diagnostic and therapeutic challenges for surgeons. While both decompressive and resection procedures have been described for treatment of chronic pancreatitis, optimal management must be tailored to each patient's individual disease characteristics, parenchymal morphology, and ductal anatomy. Surgeons should strive to achieve long-lasting pain relief while preserving native pancreatic function. For patients with incidentally discovered pancreatic lesions, differentiating benign, pre-malignant, and malignant lesions is critical as earlier treatment is thought to result in improved survival. The purpose of this evidence-based manuscript is to review the presentation, workup, surgical management, and associated outcomes for patients with chronic pancreatitis or incidentally discovered solid and cystic lesions of the pancreas.

Mucinous cystadenomas are benign tumors with malignant potential. They are often revealed by non-specific abdominal pain, jaundice or an episode of acute pancreatitis. We here report an exceptional case of mucinous cystadenoma doubly complicated by acute pancreatitis and retroperitoneal rupture. The study involved a 30-year old non-weighted female patient, presenting with epigastric pain associated with left hypochondrium evolving over the last three months and which had intensified without fever or jaundice in the last 3 days. Clinical examination showed impingement on palpation of the epigastrium and of the left hypochondrium. There was no palpable mass. Laboratory tests were without abnormalities, except for lipasemia that was 8-times the upper normal. Abdominal CT scan showed bi-loculated cystic mass in the pancreas tail, measuring 111 mm * 73 mm, with a thin wall and a fluid content, associated with an infiltration of the left perirenal fascia. MRI (Panel A) showed mucinous cystadenoma with retroperitoneal rupture. The caudal portion of the main pancreatic duct was slightly dilated and communicated with the pancreatic cyst. The patient underwent surgery via bi-sub-costal approach. A cystic mass in the pancreas tail with retroperitoneal rupture associated with acute pancreatitis (outflow of necrotic content from left anterior prerenal space) was found. Caudal splenopancreatectomy was performed (Panel B). The postoperative course was uneventful. The anatomo-pathological examination of the surgical specimen showed pancreatic mucinous cystadenoma with low-grade dysplasia.

Cystic pancreatic neuroendocrine tumors represent 13% of all neuroendocrine tumors. The aim of this study is to analyze the phenotype and biologic behavior of resected cystic neuroendocrine tumors. A systematic review and meta-analysis were conducted until September 2016 using a search in Medline, Scopus, and EMBASE with the terms "cystic pancreatic endocrine neoplasm", "cystic islets tumors" and "cystic islets neoplasms". From the 795 citations recovered 80 studies reporting on 431 patients were selected. 87.1% (n = 387) were sporadic tumors and 10.3% (n = 40) corresponded to multiple endocrine neoplasia endocrine type 1. Were diagnosed incidentally 44.6% (n = 135). Cytology was found to have a sensitivity of 78.5%. Were non-functional tumors 85% (n = 338), and among the functional tumors, insulinoma was the most frequent. According to the European Neuroendocrine Tumor Society staging, 87.8% were limited to the pancreas (I-IIb), and 12.2% were advanced (III-IV). Disease-free survival at 5 years in stages (I-IIIa) and (IIIb-IV) was 91.5% and 54.2%, respectively; and was significantly lower (p = 0.0001) in functional tumors. In patients with multiple endocrine neoplasia there was a higher incidence of functional (62.5%) and multifocal (28.1%) tumors. Disease-free survival at 5 and 10 years was 60%. Cystic pancreatic neuroendocrine tumors exhibit phenotypical characteristics which are different to those of solid neuroendocrine tumors.

Mortality due to pancreatic ductal adenocarcinoma (PDAC) will increase in the near future. The only curative treatment for PDAC is radical resection; however, even small carcinomas exhibit micrometastases leading to early relapse. Accordingly, detection of premalignant precursor lesions is important. In essence, PDAC develops from three precursor lesions: pancreatic intraepithelial lesions (PanIN), intraductal papillary-mucinous neoplasia (IPMN) and mucinous-cystic neoplasia (MCN). Together with serous cystic neoplasia (SCN) and solid pseudopapillary neoplasia (SPN), these cystic lesions constitute the most common cystic neoplasms in the pancreas. In the case of IPMN, main and branch duct IPMN have to be differentiated because of a markedly different malignancy potential. While main duct IPMN and MCN have a high malignancy transformation rate, branch duct IPMNs are more variable with respect to malignant transformation. This shows that differential diagnosis of cystic lesions is important; however, this is often very difficult to accomplish using conventional imaging. Novel biomarkers and diagnostic tools based on the molecular differences of cystic pancreatic lesions could be helpful to differentiate these lesions and facilitate early diagnosis. The aim is to distinguish the premalignant cysts from strictly benign cystic lesions and a timely detection of malignant transformation. This article provides an overview on the molecular characteristics of cystic pancreatic lesions as a basis for improved diagnostics and the development of new biomarkers.

Background & Aims: Endoscopic ultrasound (EUS)-guided chemoablation with ethanol lavage followed by infusion of paclitaxel is effective for the treatment of mucinous pancreatic cysts. However, complications arise in 3%-10% of patients, presumably linked to the inflammatory effects of ethanol. We aimed to determine whether alcohol is required for effective pancreatic cyst ablation, if removing alcohol from the ablation process would improve complication rates, and whether a multi-agent chemotherapeutic cocktail could increase the rate of complete cyst resolution compared with findings reported from previous trials using alcohol followed by paclitaxel alone., Methods: Between November 2011 and December 2016, we conducted a single-center, prospective, double-blind trial of 39 patients with mucinous-type pancreatic cysts. Patients were randomly assigned to 1 of 2 groups that underwent EUS-guided pancreatic cyst lavage with either 80% ethanol (control) or normal saline (alcohol-free group). Cysts in both groups were then infused with an admixture of paclitaxel and gemcitabine. Primary outcomes were the rates of complete ablation 12 months after the procedure, and rates of serious and minor adverse events within 30 days of the procedure., Results: At 12 months, 67% of patients who underwent alcohol-free EUS-guided cyst chemoablation had complete ablation of cysts compared with 61% of patients in the control group. Serious adverse events occurred in 6% of patients in the control group vs none of the patients in the alcohol-free group. Minor adverse events occurred in 22% of patients in the control group and none of the patients in the alcohol-free group. The overall rate of complete ablation was 64%., Conclusions: In this prospective, randomized, controlled trial, we found that alcohol is not required for effective EUS-guided pancreatic cyst ablation, and when alcohol is removed from the ablation process, there is a significant reduction in associated adverse events. A multi-agent chemotherapeutic ablation admixture did not appear to significantly improve rates of complete ablation compared with the current standard of alcohol lavage followed by paclitaxel alone. ClinicalTrials.gov ID: NCT01475331., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The indications for resection of pancreatic cystic lesions (PCL) are often complex and the operative risk has to be balanced against the risk of malignant transformation. The aim of the study was to provide a synopsis of the current treatment results of minimally invasive surgery for PCL., Methods: A systematic literature search was performed using the Medline database (PubMed). Subsequently, the retrieved literature was selectively reviewed., Results: No published prospective randomized controlled trials have yet addressed the comparison of open and minimally invasive surgery of PCL; however, retrospective case studies have demonstrated the feasibility, safety and a comparable morbidity after minimally invasive distal pancreatectomy (DP), pancreatoduodenectomy (PD), central (CP) or total pancreatectomy and enucleation. Whereas most DPs are performed laparoscopically, the experience of minimally invasive PD has been consolidated for the robot-assisted approach but is concentrated in only a few centers. The number of published reports on minimally invasive organ-sparing pancreas procedures (e. g. CP or enucleation) for PCL is scarce; however, the available (selected) results are promising., Conclusion: Minimally invasive surgery for PCL has the potential to reduce the operative trauma to the patients, while at the same time causing comparable or less morbidity. This requires an increasing specialization of complex minimally invasive resections. The clinical use of robotic systems will grow for the latter cases. A prospective registry of the results should be mandatory for quality management.

Background/objectives: PPH is the main cause of mortality (up to 50%) after pancreatic resection. Due to differences in time of onset, localization and clinical impairment, there is no consistent management algorithm., Methods: Between 1994 and 2014 the occurrence of PPH in 115 out of 1 450 patients from a prospectively collected database was analyzed. The cohort was divided into two time periods: 1994-2009 and 2010-2014. The differences between the two groups were analyzed., Results: The overall incidence of PPH was 7.9%. The main causes of hemorrhage were the pancreatic anastomosis (31.1%) and the splanchnic arteries (23.5%). In the first period, there were more anastomotic hemorrhages (40.0% vs. 20.4%, p = 0.02), while in the second period more hemorrhages from the splanchnic arteries occurred (12.3% vs. 37%, p = 0.002). Bleeding control was achieved by relaparotomy (45.7%), noninterventionally (22.8%), endoscopically (19.7%) and angiographically (13.4%). In the second period, the relevance of interventional angiography significantly increased (24.6% vs. 4.3%, p = 0.001), whereas endoscopy lost importance (7% vs. 30%, p = 0.001). The in-hospital case fatality rate after PPH was 27.4%, with higher case fatality rate following extraluminal hemorrhage (23.9% vs. 3.4%, p < 0.001)., Conclusions: A shift in the management of PPH could be seen over the two periods. Interventional angiography has gained more importance in the treatment of severe extraluminal hemorrhage of the splanchnic arteries. Adequate treatment of PPH is crucial to improve the outcome., (Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

The incidence of cystic neoplasms of the pancreas (CNP) is steadily increasing, most likely due to the commonly increased use of cross-sectional abdominal imaging. Most of these lesions are benign at the time of initial presentation, but some harbor malignant potential that either requires constant surveillance or surgical resection. However, it is still unclear when resection is mandated and when observation is sufficient. Moreover, the extent of resection and the technique used are also a matter of debate since limited resection and minimally invasive procedures are becoming more popular. Therefore, the aim of this review was to assess the role of surgery for the management of CNPs with an emphasis on novel procedures.

Objective: Fukuoka consensus guidelines classify pancreatic cystic lesions (PCLs) presumed to be intraductal papillary mucinous neoplasms (IPMNs) into Fukuoka positive (FP) (subgroups of high-risk (HR) and worrisome features (WFs)) and Fukuoka negative (FN) (non-HR feature/WF cysts). We retrospectively estimated 5-year risk of pancreatic cancer (PC) in FN, WF and HR cysts of patients with PCL-IPMN., Design: From Mayo Clinic databases, we randomly selected 2000 patients reported to have a PCL; we excluded inflammatory or suspected non-IPMN cysts and those without imaging follow-up. We re-reviewed cross-sectional imaging and abstracted clinical and follow-up data on PCL-IPMNs. The study contained 802 patients with FN cysts and 358 with FP cysts., Results: Patients with PCL-IPMN had median (IQR) follow-up of 4.2 (1.8-7.1) years. Among FN cysts, 5-year PC risk was low (2-3%) regardless of cyst size (p=0.67). After excluding events in the first 6 months, 5-year PC risk remained low (0-2%) regardless of cyst size (p=0.61). Among FP cysts, HR cysts (n=66) had greater 5-year PC risk than WF cysts (n=292) (49.7% vs 4.1%; p<0.001). In HR cysts, 3-year PC risk was greatest for obstructive jaundice versus enhancing solid component or main pancreatic duct >10 mm (79.8% vs 37.3% vs 39.4%, respectively; p=0.01)., Conclusions: Fukuoka guidelines accurately stratify PCL-IPMNs for PC risk, with FN cysts having lowest and HR cysts having greatest risk. After 6-month follow-up, WF and FN cysts had a low 5-year PC risk. Surveillance strategies should be tailored appropriately., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: The aim of this study was to evaluate the outcome of patients presumed to have mucinous cysts of the pancreas who were initially selected for radiographic surveillance., Methods: Patients with a pancreatic cyst and a measured cyst fluid carcinoembryonic antigen (CEA) ≥192 ng/mL were included. Patients were stratified by those who underwent initial resection and those who were recommended for radiographic surveillance. The natural history of these two groups was examined., Results: From 1999 to 2014, 227 patients were identified who had a cyst fluid CEA ≥192 ng/mL (median 961, range 192-300,000 ng/mL). Immediate resection was performed on 63 patients (28%). Initial radiographic surveillance was recommended for 164 patients; 87% did not have main pancreatic duct dilation, and 87% met consensus criteria for radiographic surveillance. After a median follow-up of 56 months, 48 of the 164 patients (29%) had undergone resection. Ultimately, there were three cases (2%) of high-grade dysplasia and two cases of invasive carcinoma (1%) within these 164 patients selected for observation. Three of the five cases of either high-grade dysplasia or invasive carcinoma were among the 22 patients followed outside of consensus guidelines., Conclusions: Appropriately selected patients with mucinous pancreatic cysts can be safely followed with serial surveillance with a low risk of malignant progression.

Polycystic disease of the pancreas is very rare and only few cases have been reported in the literature. We report a case of 27 year old female presented with recurrent upper abdominal pain associated with nausea and vomiting. Her ultrasonography of whole abdomen and computed tomography (CT) scan revealed polycystic pancreas associated with hepatic cysts. She underwent distal pancreatectomy with splenectomy. Histological examination revealed typical features of polycystic pancreatic disease in the resected specimen. Previously two of her sisters and her mother were also diagnosed as cases of polycystic pancreatic disease and they all underwent operative treatments. Among them one of those sisters and her mother received treatment under our department in 2009 and 2014 accordingly.

Asymptomatic pancreatic cysts are a common clinical problem but only a minority of these cases progress to cancer. Our aim was to compare the accuracy to detect malignancy of the 2015 American Gastroenterological Association (AGA), the 2012 International Consensus/Fukuoka (Fukuoka guidelines [FG]), and the 2010 American College of Radiology (ACR) guidelines.We conducted a retrospective study at 3 referral centers for all patients who underwent resection for an asymptomatic pancreatic cyst between January 2008 and December 2013. We compared the accuracy of 3 guidelines in predicting high-grade dysplasia (HGD) or cancer in resected cysts. We performed logistic regression analyses to examine the association between cyst features and risk of HGD or cancer.A total of 269 patients met inclusion criteria. A total of 228 (84.8%) had a benign diagnosis or low-grade dysplasia on surgical pathology, and 41 patients (15.2%) had either HGD (n = 14) or invasive cancer (n = 27). Of the 41 patients with HGD or cancer on resection, only 3 patients would have met the AGA guideline's indications for resection based on the preoperative cyst characteristics, whereas 30/41 patients would have met the FG criteria for resection and 22/41 patients met the ACR criteria. The sensitivity, specificity, positive predictive value, negative predictive value of HGD, and/or cancer of the AGA guidelines were 7.3%, 88.2%, 10%, and 84.1%, compared to 73.2%, 45.6%, 19.5%, and 90.4% for the FG and 53.7%, 61%, 19.8%, and 88% for the ACR guidelines. In multivariable analysis, cyst size >3 cm, compared to ≤3 cm, (odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.11, 4.2) and each year increase in age (OR = 1.07, 95% CI = 1.03, 1.11) were positively associated with risk of HGD or cancer on resection.In patients with asymptomatic branch duct-intraductal papillary mucinous neoplasms or mucinous cystic neoplasms who underwent resection, the prevalence rate of HGD or cancer was 15.2%. Using the 2015 AGA criteria for resection would have missed 92.6% of patients with HGD or cancer. The more "inclusive" FG and ACR had a higher sensitivity for HGD or cancer but lower specificity. Given the current deficiencies of these guidelines, it will be important to determine the acceptable rate of false-positives in order to prevent a single true-positive.

Background and study aims  The aim of this study was to investigate the long-term outcomes after endoscopic ultrasound (EUS)-guided pancreatic cyst ablation. Patients and methods  In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts; clinically indeterminate cysts that required EUS fine-needle aspiration; and/or cysts that grew during the observation period. Treatment response was classified as complete resolution, partial resolution, or persistent cyst, with < 5 %, 5 % - 25 %, and 25 % of the original cyst volume, respectively. Results  The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8 %) had adverse events (1 severe, 4 moderate, and 11 mild). Treatment response was as follows: complete resolution in 114 (72.2 %), partial resolution in 31 (19.6 %), and persistent cysts in 13 (8.2 %). Twelve of the 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50 - 85 months) of the 114 patients with complete resolution, only two patients (1.7 %) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR] 7.12, 95 % confidence interval [CI] 2.72 - 18.67) and cyst size less than 35 mm (OR 2.39, 95 %CI 1.11 - 5.16) predicted complete resolution. Conclusion  Among patients with pancreatic cysts in whom complete resolution was achieved after EUS-guided cyst ablation, 98.3 % remained in remission at 6-year follow-up. Unilocular form and small cyst size were predictive of complete resolution. This treatment approach may be an effective and durable alternative to surgery.Trial registered at ClinicalTrials.gov (NCT 00689715)., Competing Interests: Competing interests : None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: In 2015, the American Gastroenterological Association recommended the discontinuation of radiographic surveillance after 5 years for patients with stable pancreatic cysts. The current study evaluated the yield of continued surveillance of pancreatic cysts up to and after 5 years of follow up., Methods: A prospectively maintained registry of patients evaluated for pancreatic cysts was queried (1995-2016). Patients who initially underwent radiographic surveillance were divided into those with <5 years and ≥5 years of follow up. Analyses for the presence of cyst growth (>5 mm increase in diameter), cross-over to resection, and development of carcinoma were performed., Results: A total of 3024 patients were identified, with 2472 (82%) undergoing initial surveillance. The ≥5 year group (n = 596) experienced a greater frequency of cyst growth (44% vs. 20%; P < 0.0001), a lower rate of cross-over to resection (8% vs 11%; P = 0.02), and a similar frequency of progression to carcinoma (2% vs 3%; P = 0.07) compared with the <5 year group (n = 1876). Within the ≥5 year group, 412 patients (69%) had demonstrated radiographic stability at the 5-year time point. This subgroup, when compared with the <5 year group, experienced similar rates of cyst growth (19% vs. 20%; P= 0.95) and lower rates of cross-over to resection (5% vs 11%; P< 0.0001) and development of carcinoma (1% vs 3%; P= 0.008). The observed rate of developing cancer in the group that was stable at the 5-year time point was 31.3 per 100,000 per year, whereas the expected national age-adjusted incidence rate for this same group was 7.04 per 100,000 per year., Conclusion: Cyst size stability at the 5-year time point did not preclude future growth, cross-over to resection, or carcinoma development. Patients who were stable at 5 years had a nearly 3-fold higher risk of developing cancer compared with the general population and should continue long-term surveillance.

Aim: To evaluate the diagnostic value and safety mainly regarding incidents of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic cystic lesions (PCLs)., Methods: A total of 150 consecutive patients with suspected PCLs were prospectively enrolled from April 2015 to November 2016. We finally enrolled 140 patients undergoing EUS-FNA. We compared the diagnostic accuracy of EUS-FNA and pathological diagnosis, which is regarded as the gold standard, for PCLs. Patients undergoing EUS-FNA at least 1 wk preoperatively were monitored for incidents and adverse events to evaluate its safety., Results: There were 88 (62.9%) women and 52 (37.1%) men among 140 patients, with a mean age of 50.1 (± 15.4) years. There were 67 cysts located in the head/uncinate of the pancreas and 67 in the body/tail, and 6 patients had at least 1 cyst in the pancreas. There were 75 patients undergoing surgery and 55 undergoing EUS-FNA with interval at least 1 wk before other operations, with 3 patients undergoing the procedure twice. The accuracy of EUS-FNA in differentiating benign and malignant lesions was 97.3% (73/75), while the accuracy of characterizing PCL subtype was 84.0% (63/75). The incident rate was 37.9% (22/58), whereas only 1 AE was observed in 58 cases., Conclusion: EUS-FNA is effective and safe for diagnosis of PCLs, however procedure-related incidents are common. Caution should be taken in patients undergoing EUS-FNA., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest in relation to this manuscript.

Cystic lesions of the pancreas are increasingly observed due to increased use of abdominal images. The malignant rate of pancreas cystic lesion varies widely between various types. Identification of malignant or high-risk lesions is important when determining the appropriate course of management. Using these image findings, including cyst size, presence of solid components, and pancreatic duct involvement, the 2012 International Association of Pancreatology (IAP) and the 2015 American Gastroenterological Association (AGA) guidelines provide a rationale in identifying higher risk patients requiring further workups using an endoscopic ultrasound (EUS). EUS with fine needle aspiration and cytology allows confirmation of the cyst type and determines the risk of malignancy. Small cysts with no suspicious features may undergo the regular imaging study for regular surveillance due to low risk for malignancy. In this review, the differences between the 2012 IAP and 2015 AGA guidelines are presented, In addition to possible recommendations for management and surveillance.

Due to the widespread use of high-quality cross-sectional imaging, pancreatic cystic neoplasms are being diagnosed with increasing frequency. Clinicians are therefore asked to counsel a growing number of patients with pancreatic cysts diagnosed incidentally at an early, asymptomatic stage. Over the last two decades, accumulating knowledge on the biologic behavior of these neoplasms along with improved diagnostics through imaging and endoscopic cyst fluid analysis have allowed for a selective therapeutic approach toward these neoplasms. On one end of the management spectrum, observation is recommended for typically benign lesions (serous cystadenoma), and on the other end, upfront resection is recommended for likely malignant lesions (main duct IPMN, mucinous cystadenoma, solid pseudopapillary tumor, and cystic pancreatic neuroendocrine tumors). In between, management of premalignant lesions (branch duct IPMN) is dictated by the presence of high-risk features. In general, resection should be considered whenever the risk of malignancy is higher than the risk of the operation. This review aims to describe the evolution and current status of evidence guiding the selection of patients with pancreatic cystic neoplasms for surgical resection, along with a specific discussion on the type of resection required and expected outcomes.

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.

Management of pancreatic cystic lesions relies on patients' clinical presentation, imaging, and endoscopic ultrasound. Current research in basic science, radiology, and endoscopy is evolving and making progress in this condition which is relatively common in the general population. This review focuses on the recent endoscopic ultrasound approaches to the diagnosis of these pancreatic disorders.

Objective: To describe the natural history of pancreatic cysts after long-term follow-up, with an emphasis on the identifying indicators of indolent lesions., Methods: We retrospectively sampled 95 patients with 149 cysts <3 cm detected by CT from 2003 to 2004, and followed them for more than five years (mean 117.5 ± 18.8 months). Two radiologists reviewed the initial CT images, then recorded changes after the follow-up. We compared the cysts' initial characteristics between the surgery and non-surgery patient groups, and also between non-benign lesions and benign lesions., Results: Twelve of the 95 patients, who among them had 16 cysts, underwent surgery. Of the 133 cysts in the 83 nonsurgical patients, 57 cysts (42.9 %) enlarged, although only five cysts increased to larger than 3 cm at the end of observation. The initial size of the cyst was significantly larger in the surgery group than non-surgery group. Also, according to cyst-based analysis, ductal communication, dilatation, and shape correlated with those of non-benign cysts and the non-surgical group. No cysts < 15 mm and without p-duct change showed a significant change within three years., Conclusion: Small pancreatic cysts, without p-duct change, and without a pleomorphic or clubbed shape, may be followed for a longer interval than current consensus., Key Points: • Almost all small cysts < 3 cm were indolent in long term observation. • No cysts < 15 mm, without p-duct change showed significant change within 3 years. • Cyst size, ductal change and shape can be useful in predicting progress. • Only cysts with IPMN- like features and p-duct change need follow-up with cautions.

Aim: This study aimed to report the results of a multicentric survey about laparoscopic treatment of pancreatic tumors in children., Materials and Methods: The data of patients operated using minimally invasive surgery (MIS) for a pancreatic tumor in 5 International centers of Pediatric Surgery in the last 5 years were retrospectively reviewed. We recorded data relating to the clinical presentation, diagnostic evaluation, surgical technique, and outcome., Results: Fifteen patients (average age 2.2 years) were identified. The most common symptoms at presentation were related to the hypoglycemic hyperinsulinism, followed by abdominal pain and vomiting. Tumor types were insulinoma (n = 4), congenital hyperinsulinism of infancy (CHI) diffuse type (n = 3), CHI focal type (n = 3), solid pseudopapillary tumor (n = 2), and cystic malformation (n = 3). The diagnostic assessment was completed using ultrasound associated with computed tomography (CT) scan in all centers; 18F DOPA positron emission tomography in combination with CT was adopted in 2 centers. The MIS procedures performed were as follows: tumor enucleation (n = 4), distal pancreatectomy (n = 8), subtotal pancreatectomy (n = 2), and pancreatico-jejunostomy (n = 1). Average operative time was 110 minutes. As for postoperative complications, we recorded 1 persistent hypoglycemia, requiring redo-surgery (IIIb Clavien-Dindo) and 1 thrombosis of splenic vein, not requiring any treatment (I Clavien-Dindo)., Conclusions: Laparoscopic resection can be considered a safe and effective treatment with minimal morbidity and excellent outcomes for most pediatric pancreatic tumors. Suspension of the stomach with a transparietal stitch and use of new hemostatic devices as Starion TLS3 or Ligasure are key factors for the success of the procedure. A long-term follow-up is mandatory in these patients to evaluate postoperative complications and long-term outcome.

Background: Pancreatic cystic lesions (PCL), including intraductal papillary mucinous neoplasia (IPMN), harbor different malignant potential and the optimal management is often challenging. The present study aims to depict the compliance of experts with current consensus guidelines and the accuracy of treatment recommendations stratified by the medical specialty and hospital volume., Methods: An international survey was conducted using a set of 10 selected cases of PCL that were presented to a cohort of international experts on pancreatology. All presented cases were surgically resected between 2004 and 2015 and histopathological examination was available. Accuracy of the treatment recommendations was based on the European and international consensus guideline algorithms, and the histopathological result., Results: The response rate of the survey was 26% (46 of 177 contacted experts), consisting of 70% surgeons and 30% gastroenterologists/oncologists (GI/Onc). In the case of main-duct IPMN (MD-IPMN), surgeons preferred more often the surgical approach in comparison with the GI/Onc (55 versus 44%). The mean accuracy rate based on the European and international consensus guidelines, and the histopathological result, were 71/76/38% (surgeons), and 70/73/34% (GI/Onc), respectively. High-volume centers achieved insignificantly higher accuracy scores with regard to the histopathology. Small branch-duct IPMN with cysts <2 cm and malignant potential were not identified by the guideline algorithms., Conclusion: The survey underlines the complexity of treatment decisions for patients with PCL; less than 40% of the recommendations were in line with the final histopathology in this selected case panel. Experts and consensus guidelines may fail to predict malignant potential in small PCL., (Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Currently, 3 guidelines are available for the management of pancreatic cysts. These guidelines vary in their indication for resection of high-risk cysts. We retrospectively compared the final pathologic outcome of surgically removed pancreatic cysts with the indications for resection according to 3 different guidelines., Methods: Patients who underwent pancreatic resection were extracted from our prospective pancreatic cyst database (2006-present). The final histopathologic diagnosis was compared with the initial indication for surgery stated by the guidelines of the International Association of Pancreatology (IAP), European Study Group on Cystic tumors of the Pancreas and American Gastroenterological Association (AGA). We considered surgery in retrospect justified for malignancy, high-grade dysplasia, solid pseudopapillary neoplasms, neuroendocrine tumors or symptom improvement. Furthermore, we evaluated the patients with suspected intraductal papillary mucinous neoplasm (IPMN) separately., Results: Overall, 115 patients underwent pancreatic resection. The preoperative diagnosis was correct in 83 of 115 patients (72%) and differentiation between benign and premalignant in 99 of 115 patients (86%). In retrospect, surgery was justified according to the aforementioned criteria in 52 of 115 patients (45%). For patients with suspected IPMN (n = 75) resection was justified in 36 of 67 (54%), 36 of 68 (53%), and 32 of 54 (59%) of patients who would have had surgery based on the IAP, European, or AGA guidelines, respectively. The AGA guideline would have avoided resection in 21 of 75 (28%) patients, versus 8 of 75 (11%) and 7 of 75 (9%) when the IAP or European guideline would have been applied strictly. Nevertheless, 4 of 33 patients (12%) with high-grade dysplasia or malignancy would have been missed with the AGA guidelines, compared with none with the IAP or European guidelines., Conclusion: Although fewer patients undergo unnecessary surgery based on the AGA guidelines, the risk of missing malignancy or high-grade dysplasia with this guideline seems considerably high., (Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Management of solitary mucinous cystic lesions of the pancreas (MCLs) relies on correct differentiation between branch duct intraductal papillary mucinous neoplasm (BD-IPMN) and mucinous cystic neoplasm (MCN). Current international consensus guidelines recommend resection for MCN, and unifocal BD-IPMN can be followed in the absence of worrisome features/high-risk stigmata. We hypothesized that preoperative differentiation of solitary MCLs is suboptimal, and that all solitary MCLs should be treated similarly., Study Design: A retrospective review of an institutional database (2003 to 2016) identified 711 patients who underwent resection for pancreatic cyst. Only lesions that met cytologic or biochemical criteria for diagnosis of MCLs were included. Mucinous cystic neoplasms were defined by presence of ovarian stroma on pathology. Patients with formal preoperative diagnosis of BD-IPMN (multifocality, GNAS mutation) were excluded., Results: One hundred and eighty solitary MCLs were identified on preoperative imaging (mean age 54 years, 24% men). On surgical pathology, 108 were MCNs and 72 BD-IPMNs. There was no difference in invasive rate (7 of 108 [6.5%] MCNs vs 4 of 72 [5.6%] BD-IPMN; p ≈ 1). Pancreatic ductal connectivity was reported on imaging/endoscopy in 10 of 108 (9%) MCNs and 22 of 72 (31%) BD-IPMNs, representing 67% accuracy in differentiating MCNs from BD-IPMNs. On multivariate analysis, typical risk factors failed to predict invasiveness in either MCNs or BD-IPMNs. When all undifferentiated solitary MCLs were analyzed together, older age (p = 0.03) and cyst size (p = 0.04) were associated with increased invasive rate in multivariate analysis., Conclusions: Unreliable differentiation and limited ability to predict invasiveness make solitary MCLs clinically challenging. With similar invasive rates, MCN and unifocal BD-IPMNs should be merged into one new entity for management, the undifferentiated solitary MCL., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

We notice an increasing frequency in the detection and evaluation of pancreatic cystic lesions (PCLs) over the last three decades. They show awide spectrum of imaging and clinical features. The diagnosis and discrimination of these lesions are very important because of the risk for concurrent or later development of malignancy. The main reason is the increased awareness of these lesions and the extensive use of cross-sectional imaging, an always improving technique (1). Commonly, PCLs are diagnosed incidentally during investigation for often unrelated and nonspecific abdominal complaints using state-of-the art abdominal imaging (CT, MRT). The term PCN denotes a histologically heterogeneous collection of neoplasms showing a wide spectrum of diagnoses, ranging from completely benign to potentially malignant, to carcinoma in situ, to frankly invasive and malignant (2,3). In 1978, Compagno and Oertel were the first to recognize the crucial distinction between the serous and the mucinous cystic neoplasms of the pancreas by explaining the importance of identifying the mucinous neoplasms because of their overt or latent malignant potential (4,5). Since then, the interest in PCLs increased markedly, especially so with the recognition of the importance and prevalence of intraductal papillary mucinous neoplasms (IPMNs). Nowadays, PCLs represent a common and often difficult challenge in clinical practice, because of the increase in their detection in asymptomatic patients and our still immature understanding of some aspects of their biologic behavior. Their important differences regarding their outcome and the fact of being increasingly often identified has put a special focus on these neoplasms by surgeons, pathologists, gastroenterologists, radiologists, and oncologists alike. Management of patients with PCNs can be challenging and varies considerably among the various subtypes of PCNs. Their treatment ranges from resection of malignant lesions, to resection and/or surveillance in the case of premalignant lesions, to simple observation in the case of benign or indolent lesions. Under these circumstances, the accurate classification of PCNs becomes crucial. Therapeutic decision making and classification rely mainly on the presenting symptoms and radiologic findings, often without actual histologic tissue. It is of extreme importance to identify suspicious features indicating potential or certain malignancy in order to select the appropriate treatment. The risk of overtreatment (unnecessary pancreatectomy) should he balanced carefully with the risk of under treatment (missing the opportunity to cure a potentially curable malignant or premalignant disease)., (Celsius.)

Pancreatic cystic neoplasms are a growing clinical challenge. They are incidentally discovered with increased frequency. The evaluation and management have evolved over time with increasing need to establish the correct type of cystic neoplasm and understand the unique natural history of each subtype. This review highlights this evolving strategy and an approach to management where treatment is guided by symptoms and features worrisome for high-risk of developing an invasive neoplasm. A thoughtful approach should be taken for an asymptomatic patient where resection needs to show a clear advantage to prevent cancer., (Copyright © 2017. Published by Elsevier Inc.)