S157 Comparative Systematic Review of International Guidelines for Pancreatic Cyst Surveillance: Inconsistencies and Evidence Gaps

Introduction: Pancreatic cystic lesions are increasingly detected incidentally due to the widespread use of cross-sectional imaging, with a reported prevalence of 13%–18% in adults. Surveillance of these lesions is critical for identifying those with malignant potential. However, multiple international guidelines offer conflicting recommendations regarding management. This study aims to compare surveillance strategies across major guidelines—including those from the American Gastroenterological Association (AGA, 2015), American College of Gastroenterology (ACG, 2018), American College of Radiology (ACR, 2017), International Association of Pancreatology (IAP/Fukuoka, 2017), European Study Group (2018), and Kyoto (2024)—to identify inconsistencies and evidence gaps. Methods: A systematic literature search (PubMed/Embase/Cochrane through April 2025) identified society guidelines. Parameters compared included: (1) size thresholds for surgery, (2) high-risk/worrisome features, (3) surveillance intervals and duration, (4) imaging modalities, and (5) stopping criteria. Results: Significant variations were observed across international guidelines. For surgical referral, size thresholds for branch-duct IPMN resection ranged from >3 cm (AGA, ACG) to ≥4 cm (European), while main pancreatic duct dilation criteria differed substantially (>5 mm in ACG vs >10 mm in Fukuoka). Surveillance protocols showed marked heterogeneity: initial intervals varied from 6 months (European) to 2 years (AGA for cysts <3 cm), and stopping criteria conflicted sharply (discontinuation after 5 stable years (AGA) vs lifelong surveillance (European)). Risk stratification inconsistencies were prominent, exemplified by new-onset diabetes being considered a relative surgical indication only in European guidelines. Imaging recommendations diverged despite consensus on MRI for surveillance; EUS-FNA indications ranged from requiring ≥2 high-risk features (AGA) to triggering after any single worrisome feature (Fukuoka). Conclusion: Major guidelines exhibit substantial heterogeneity in pancreatic cystic lesions surveillance, driven by low-quality evidence and differing interpretations of existing data. Standardization and prospective studies, particularly on cyst growth rates, molecular biomarkers, and long-term outcomes, are urgently needed to optimize risk stratification and reduce unnecessary interventions.