Management of an asymptomatic pancreatic cyst >5 cm in diameter

What should be the management of an asymptomatic pancreatic cyst >5 cm in diameter?

Miroslav Vujasinovic, MD, PhD: I noticed that there is a problem in understanding of the guidelines [from United European Gastroenterology]. Maybe it was written in a cumbersome way.

These patients are very demanding. In our center in Stockholm, twice per week we have a pancreas conference with a multidisciplinary team and we have an individual approach.

Generally, if the cysts are <5 cm in diameter and if the patient is asymptomatic, we are just observing the patient. We watch and wait. We usually perform either magnetic resonance imaging or endoscopic ultrasound every 6 months. But we warn the patient that if some symptoms occur, they should contact us as soon as possible.

Generally, the larger the cyst, the higher the risk of complications: perforations, bleeding, infections. Also, especially if the cyst is producing strictures, if they push on the structures in that area, that means the stomach, duodenum, or bile ducts, then it is absolutely an indication [for surgery].

We also are very concerned about other diseases connected with pancreas disease and the age of the patient. In older patients in whom anesthesia may be risky, maybe we are a little bit more restrictive.

But generally, in all cysts that are >6 cm we are recommending the drainage. We can discuss if it will be transpapillary or transmural and it is the matter of the conference; we are then deciding individually. But generally, it is nice to perform drainage of all cysts >6 cm in size.