The detection rate of pancreatic disease is increasing with the spread of targeted screening techniques and increased awareness of related issues. The lack of relevant knowledge makes surgery a desperate choice for many patients, and some patients pay a high price for it. Which lesions require surgery? Can surgery be beneficial? In this article, we discuss our experience on this issue. There is a wide variety of pancreatic diseases and treatments involved, many lesions do not require surgical treatment, and a few lesions only require surgical intervention under specific conditions. The author divides these variants and diseases that do not directly benefit from surgical intervention into the following categories: normal variants (n = 4) The pancreas is formed by the fusion of the ventral pancreas and dorsal pancreas, and any subtle changes during development can make the morphology and density of the pancreas different from those of most pancreases. The abnormal protrusion of the pancreas is quite common, with the abnormal protrusion of the head and neck of the pancreas being the most common, followed by the widening of the tail of the pancreas, and the widening of the body of the pancreas is rare and often mistaken for a “pancreatic mass”. abnormalities. The pancreatic hypoplasia/hypoplasia: Rarely, ventral pancreatic hypoplasia leads to rotation of the dorsal pancreas to form a pseudo “pancreatic head mass”, while dorsal pancreatic hypoplasia forms a thick and short pancreas, and the point of differentiation in imaging is similar to that of abnormal pancreatic protrusion. 3, pancreatic head enlargement: clinically not uncommon, most of the causes are unknown, some patients are compensatory enlargement of the pancreatic head due to atrophy of the tail of the pancreatic body. On imaging, the pancreatic head is full in shape, spherical or lobulated, different from the common triangular shape, with a maximum diameter of >75px, but with normal texture and no bile duct or pancreatic duct lesions, with no abnormal findings in clinical manifestations and laboratory tests. 4. Circumferential pancreas: When the abdominal pancreas is poorly rotated, ectopic pancreatic tissue masses can be formed around the duodenum, and imaging shows pancreatic tissue on the outside or around the duodenum. If there is no combined duodenal obstruction or pancreatitis or pancreatic cancer, surgery is not required. Non-neoplastic diseases (n = 3) Mainly include congenital/genetic diseases, metabolic diseases, and inflammatory diseases. Most of them are not difficult to diagnose with appropriate clinical and laboratory tests and imaging knowledge. Most patients do not require surgical treatment except for a few severe cases of necrotizing pancreatitis and active/acute hematoma. 1, congenital/hereditary diseases: including true cysts of the pancreas, multicystic pancreas, cystic fibrosis of the pancreas. 2, metabolic diseases: hemochromatosis (mostly manifested as hepatic iron-containing heme deposition, which occurs in the pancreas, very rarely, and is manifested as a consistent decrease in pancreatic signal on T1WI images and a slight increase in pancreatic density on CT scan). 3. Inflammatory diseases: acute edematous pancreatitis (mostly biliary in origin, patients usually only have elevated amylase without imaging abnormalities, a few patients have a full pancreatic morphology with hypotonic T1WI signal, and most patients can rapidly return to normal with conservative medical treatment), chronic pancreatitis, pancreatic pseudocysts, uneven fatty deposits in the pancreas, autoimmune pancreatitis, and pancreatic abscesses. Benign tumors (n=3) Specifically, those benign tumors or tumor-like lesions that do not become malignant. Pancreatic lipomas are the most common (Figure 16, fat-dense mass in the parenchyma of the pancreas with well-defined margins and irregular morphology, without complications such as bile duct/pancreatic duct dilatation and obstructive pancreatitis), and hemangiomas and lymphangioleiomas are rare. Some potentially malignant tumors (n=5) The detection rate of this category of tumors has increased significantly with the popularization of physical examination and imaging knowledge. Because of their malignant potential, surgery is the clinical choice in most cases, and it accounts for an increasing proportion of daily surgical workload. The overall incidence of this group of tumors is not low, but the rate of malignant transformation varies greatly, and even if malignant, its evolution is much slower than that of pancreatic ductal adenocarcinoma. Considering the patient’s age, lesion location, surgical risk, malignancy rate and other factors, not every patient can benefit from surgery. At least, we should communicate with patients repeatedly and obtain consensus before elective surgery. Some advanced pancreatic malignancies (n=3) Pancreatic ductal adenocarcinoma, pancreatic metastatic carcinoma, pancreatic lymphoma, and other pancreatic malignancies with local (vascular, lymph node, retroperitoneal interstitium, adrenal gland, local lymph node) and distant metastases, the possibility of trying to remove the tumor completely is almost impossible. Clinically, except for some patients who can benefit from palliative surgery, most choose medical or adjuvant treatment such as radiotherapy, chemotherapy, and Chinese medicine. Benign parapancreatic lesions (n=11) Due to the complexity of pancreatic adjacency and limited anatomical knowledge, diseases of peripancreatic origin are often mistaken for pancreatic lesions in clinical practice (especially parapancreatic lymph node lesions are most commonly mistaken for pancreatic tumors), among which the more common non-neoplastic lesions are the following: 1. distal bile duct origin: congenital common bile duct cyst type III, common bile duct stones, cholangitis. Small intestine origin: duodenal diverticulum, peri-duodenitis, duodenal duplication malformation, jejunum (the pancreas is tortuous and filled with the surrounding jejunal intestine, forming a “pancreatic mass” on cross-sectional images, which is easily recognized on serial images or multiplanar reconstruction images (MPR)). 3. Lymph node origin: lymphadenitis, lymph node tuberculosis, and giant lymph node hyperplasia. 4.Spleen origin: parasplenium, intra-pancreatic tail ectopic spleen. 5, Interstitial origin: retroperitoneal fibrosis. 6. Vascular origin: portal vein/splenic vein aneurysmal dilatation, splenic artery/pancreatic-duodenal aneurysm. Clinically, there are more than 60 types of regional structures or lesions of the pancreas that can be diagnosed as “pancreatic masses”, and many of them do not require surgery or have limited benefit from surgery from the perspective of pathology, regression and availability. Radical surgery is different. Preoperative diagnosis is the basic prerequisite for surgery or not. With standardized imaging, clinical and laboratory examinations, most of the pancreatic masses can be diagnosed after MDT discussion, and for those who cannot be diagnosed temporarily, it is not difficult to reach a more accurate diagnosis after regular follow-up and puncture biopsy. Due to the limitation of space, it is not possible to discuss the specific imaging manifestations, diagnostic and differential criteria of each disease in this article.