With the popularity of routine medical checkups, people are often found to have a “cyst” on the top of the pancreas by ultrasound or CT, and some studies have reported that nearly 20% of the general population will be found to have a “pancreatic cyst” when they have a pancreatic exam. The so-called “pancreatic cysts” is actually not medically accurate and cannot simply be described as “benign” or “malignant”, but actually includes a large category of pancreatic In fact, it includes a large category of pancreatic “cystic diseases” or “cystic occupations” of the pancreas, ranging from completely benign lesions, to low-grade malignant lesions, to malignant cystic adenocarcinoma. To understand its nature, the following questions should be clarified. “Is it a true cyst or a pseudocyst? A “pseudocyst” is a cyst without epithelial coating, and is usually secondary to: pancreatitis (acute pancreatitis, chronic pancreatitis), pancreatic trauma, or after pancreatic surgery. “True cysts” are cysts with overlying epithelium, which can be divided into “non-neoplastic” and “neoplastic cysts”. “Non-neoplastic” cysts: they are rare, but there are some congenital diseases such as cystic fibrosis, multicystic diseases (e.g. VHL syndrome, multiple hepatopancreatic cysts) that can cause multiple pancreatic cysts, as well as storage cysts caused by pancreatic duct blockage, parasitic and dermatomycotic cysts. “Tumorigenic” cysts, which are relatively common, contain four main types of pancreatic cystic tumors. 1. plasmacytoid cystadenoma (SCN) 2. mucinous cystadenoma (MCN) and cystic adenocarcinoma 3. solid pseudopapillary neoplasm (SPN) 4. intraductal papillary mucinous neoplasm of the pancreas (IPMN) and secondary carcinoma of IPMN How to identify “true cyst” or “pseudocyst “true cyst” or “false cyst”? “Non-neoplastic” and “neoplastic cysts”? The differentiation includes medical history (e.g. gender, certain cystic tumors are more common in women; new or occasional, history of pancreatitis and trauma), whether the cyst causes symptoms: epigastric pain, fullness and discomfort, imaging manifestations of the cyst (whether it is single or multiple, location, single or multiple cysts, size of the cyst, short-term changes, dilatation of the pancreatic duct, etc.), and whether the tumor markers are elevated. If a few patients suspect cystic tumor but have difficulty in undergoing surgery, they can consider ultrasound endoscopic puncture for cyst fluid analysis to further clarify the diagnosis. What should I do if I find a “pancreatic cyst”? In summary, there are many types of so-called pancreatic cysts, and their nature varies greatly from benign to malignant. After all, most pancreatic cysts are benign and low-grade malignant. In general, pseudocysts and non-neoplastic cysts among true cysts do not require surgery, while tumor cysts, except for small plasmacytic cystadenomas and small IPMN, all require surgery. There is a misconception that cysts <75px< span=""> should not be treated, which is inaccurate. Mucinous cystadenomas and solid pseudopapillary tumors require surgical excision regardless of size. Surgical approach to cystic tumors of the pancreas Since most “pancreatic cysts” are benign and low-grade malignant, local or segmental resection of the pancreas is recommended in most cases to preserve as much pancreatic tissue and adjacent organs as possible. In one study, the rate of new diabetes after caudal resection of the pancreas was about 18%, while the rate was as high as 40% if the patient had chronic inflammation of the pancreas itself. Therefore, it is very important to try to preserve the pancreatic tissue while removing the lesion. Cystic tumors of the head of the pancreas: try to do local excision (excision) Tumors of the neck and body of the pancreas: try to do mid-pancreatic resection Tumors of the tail of the pancreas: try to do pancreatic body and tail resection with preservation of the spleen. Minimally invasive-laparoscopic surgery for cystic tumors of pancreas Minimally invasive-laparoscopic surgery not only has the advantages of minimally invasive with small incision and quick recovery, but also has magnified field of view and finer anatomy for better identification of fine anatomical structures such as blood vessels and pancreatic ducts, which is the development trend and tomorrow of pancreatic surgery. The following content is for professional doctors: Based on: There are currently two latest international guidelines (surgery): 2013 European guidelines, European experts consensus statement on cystic tumours of the pancreasDigestive and Liver Disease 45 (2013) 703C 711 2011 International Pancreatic Collaborative Group guidelines, International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas, Pancreatology 12 (2012) 183e197 In addition, the 2015 domestic guidelines (Ruijin Hospital, Peng Chenghong, lead author) were published in the Chinese Journal of Practical Surgery, September 2015, Vol. 35, No. 9 We at the Pancreatic Center of the First Affiliated Hospital of Nanjing Medical University participated in the revision, and the revised opinion for the management process included: 1) Definition of imaging danger signs: thickened cystic wall with enhancement, nodules in the attached wall (without enhancement), main pancreatic duct >5 mm , truncated pancreatic duct, distal pancreatic atrophy, enlarged lymph nodes; short-term follow-up growth. 2) Diagnostic process: <1cm, no further examination required >1cm, CT/MRI + MRCP; MRI: more advantageous for cyst wall ＼segmentation ＼nodules ＼pancreatic duct traffic >3cm, high-risk signs, no further examination by ultrasound endoscopy EUS <3cm, risk signs, or >3cm, no suspicious signs: ultrasound endoscopy EUS EUS cyst fluid analysis: as a second-line examination, can identify SCN, pseudocysts, cannot identify IPMN and MCN ERCP and brush examination: not recommended 3) Management and indication for surgery: the importance of having symptoms, and imaging risk factors should be emphasized among the indications for surgery. Since some PCNs are difficult to categorize preoperatively, it is recommended that those that cannot be categorized be delineated by 75px, the presence or absence of imaging risk factors, and the presence or absence of symptoms. For those that can be categorized, surgical indications are determined by category. Symptomatic, surgery is generally recommended; asymptomatic: follow-up, further examination or surgery SCN: regardless of diameter, the presence or absence of symptoms and risk factors should prevail. MCN, SPT: surgery in any diameter IMPN: MD of main pancreatic duct type is recommended to be bounded by 5mm or more, BD of branch pancreatic duct type: >75px, and risk signs as indications. Difficult to distinguish mainly include SCN, MCN, BD-IPMN The typical imaging of SCN is honeycomb, central calcification; the typical imaging of MCN is single cyst, IPMN is “grape bunch-like” For a clear preoperative diagnosis, only through EUS-FNA aspiration cyst fluid testing, through the cyst fluid CEA high and low, can To distinguish SCN from mucinous tumor. However, EUS-FNA is invasive and is a second-line test and is not recommended. (4) Surgery: laparoscopic surgery is preferred if available, and surgery with preservation of organs and pancreatic function is preferred. or middle pancreatectomy? According to a recent article in Annual surgery, the chance of new onset diabetes after caudal pancreatectomy is 14% (39% if there is pancreatitis), so it is important to treasure the pancreatic tissue. Mesopancreatic resection, which is less invasive but more complicated, requires a pancreaticenteric anastomosis. However, this pancreaticenteric anastomosis is less windy, and even if a pancreatic fistula occurs, it rarely causes clinical symptoms such as infection because there is no bile activation. Our center currently has the largest number of reported cases of mid-pancreatic resection in China, and we also have rich experience and good results in laparoscopic mid-pancreatic resection.