Since Endoscopic ultrasound (EUS) was introduced in the 1980s, EUS has evolved from a diagnostic tool to a therapeutic modality for patients with pancreatic neoplasms. Traditionally, treatment policy of pancreatic benign neoplasms (PBN) has been a dichotomous approach to observation or surgery. However, EUS guided treatment provides an alternative option with minimally invasiveness for patients with PBN. This review aimed to provide the role of EUS guided treatment for PBN.

The incidence of small and asymptomatic pancreatic neuroendocrine neoplasms (PNENs) has been increased due to the widespread use of high-resolution imaging techniques and endoscopic procedures in screening programmes. Most of PNENs are indolent neoplasms with slow-growing. However, sometimes, PNENs show local invasion or metastasis with poor prognosis. The management of small, nonfunctioning PNENs remain under debate. The National Comprehensive Cancer Network guidelines recommend observation in selected cases of small PNENs less than 2 cm. Pancreatic surgeons are divided into two factions: “the hawks,” who indicate the high risk of malignancy even in small PNENs and, therefore, the need for an aggressive surgical treatment, and the “the doves,” who accepts the risk of malignancy in some ≤ 2 cm PNENs, advocate that the risk of overtreating many benign ≤ 2 cm PNENs would be much higher. As the pancreatic surgery remains a high-risk operation with a 28–30% morbidity and 1% mortality, the decision for small PNENs is challenging.

Although many guidelines for pancreatic cystic neoplasms focus on the management of intraductal papillary mucinous neoplasm of the pancreas (IPMN) at the highest oncological risk, there are many issues that surgeons need to consider at the time to plan the surgical procedures based on characteristics of IPMN subtypes, such as multiplicity of branch duct-IPMN (BDIPMN) and intraductal spreading of main duct-IPMN (MD-IPMN). For multifocal BD-IPMN, partial pancreatectomy would be selected to remove BD-IPMN with predictors of malignancy, while the other lesions without risk factors can be left, although total pancreatectomy might be considered if the patients have a strong family history of pancreatic cancer. Partial pancreatectomy would be also adequate procedure for MD-IPMN if negative surgical margin for highgrade dysplasia or invasive carcinoma were achieved. It has become to be well-known that patients with BD-IPMN are at increased risk for developing not only IPMN-associated pancreatic ductal adenocarcinoma (PDAC) but also PDAC independent from the IPMN. Hence, the detection of a concomitant PDAC is also an important focus for strategies after resection of BDIPMNs. Our recent analysis of patients after partial pancreatectomy for MD-IPMN with negative surgical margin identified an unexpected recurrence pattern, which we called “monoclonal skip” recurrence. MD-IPMN seems to be disseminated in the pancreatic ductal systems and MD-IPMN with identical genetic background was detected in the remnant pancreas even in a long time after index surgery. We proposed strategies of postoperative surveillance based on characteristics and natural history of each morphological subtype.

The length, the frequency, and the methods of surveillance for intraductal papillary mucinous neoplasm (IPMN) of the pancreas are still debating. According to the recent guidelines, IPMN is stratified into “high-risk stigmata” or absolute indication and “worrisome features” or relative indication as a guide in managing these patients, either those with resection of the lesion or those under surveillance. The risk of malignant transformation was quite low for branch duct-IPMNs without worrisome features or high risk stigmata. However, because the incidence rate of pancreatic cancer in these patients increase linearly with time, continued long-term surveillance is therefore important for patients with low-risk, as well as higher-risk, IPMN.Considering the high prevalence of malignancy, main duct-IPMN should be treated by surgical resection. Among patients with these type IPMNs, segmental dilatation of the main pancreatic duct without any mural nodules and larger than 10 mm of main pancreatic duct might not be immediately resected and need very careful examination and observation. The risk related to a major pancreatic resection must balance the risk of surveillance in patients with IPMN of the pancreas who have co-morbidity and are elderly.

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