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Comparison of Society Guidelines for the Management and Surveillance of Pancreatic CystsA Review

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Abstract

Importance  The identification of incidental pancreas cystic lesions (PCLs) has increased in recent decades with the expanded use and improved sensitivity of cross-sectional imaging. Because the overall risk of malignancy associated with PCLs is low, yet the relative morbidity of pancreatic surgery is high, evidence-based guidelines are necessary for appropriate surveillance and management. Therefore, this article provides a review of existing guidelines regarding surveillance and management of PCLs and highlights recent advances in the diagnostic evaluation of cysts and the postresection management of mucinous lesions.

Observations  There are 5 main guidelines related to the management of PCLs: the American Gastrointestinal Association (AGA) guidelines, the American College of Gastroenterology (ACG) guidelines, the American College of Radiology (ACR) recommendations, the European evidence-based guidelines, and the International Association of Pancreatology (IAP)/Fukuoka guidelines. These guidelines are based on retrospective studies that do not account or control for most tumor- and patient-specific factors. These guidelines also vary in scope, recommendations for surgical resection vs surveillance, as well as duration and type of follow-up.

Conclusions and Relevance  PCL guidelines should be viewed within the context of the data limitations on which they are based. PCL subtype-specific guidelines on surveillance and treatment are needed. In the future, the integration of cyst-specific genomic analysis, as well as evolutions in advanced diagnostic tools, such as cyst fluid next-generation sequencing and EUS-guided confocal laser endomicroscopy, may also better inform treatment guidelines. Owing to the current low-quality evidence on which many guidelines are based and the inherent morbidity of pancreas surgery, it is imperative that patients with PCLs are referred to institutions with advanced diagnostics and a multidisciplinary approach to patient surveillance and management.

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Article Information

Accepted for Publication: March 24, 2022.

Published Online: June 22, 2022. doi:10.1001/jamasurg.2022.2232

Corresponding Author: Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA, Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Ste 670, Columbus, OH 43210 (tim.pawlik@osumc.edu).

Author Contributions: Dr Pawlik had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Aziz and Acher are considered co–first authors of this work.

Concept and design: Aziz, Acher, Krishna, Pawlik.

Acquisition, analysis, or interpretation of data: Acher, Cloyd, Pawlik.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Aziz, Acher, Pawlik.

Supervision: Krishna, Pawlik.

Conflict of Interest Disclosures: Dr Krishna reported receiving grants from Mauna Kea Technologies during the conduct of the study. No other disclosures were reported.

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