Due to the extensive use of cross-sectional imaging, the incidence and prevalence of pancreatic cystic neoplasms are gradually increasing. Nevertheless, the accuracy for specific diagnosis remains low. A significant advantage is provided by the endoscopic ultrasound, a second-level technique allowing for high-resolution imaging of the pancreas and the possibility to sample for cytology and cystic fluid. Although existing guidelines are not uniform regarding the indications for surveillance in patients with uncertain features of potential malignant degeneration, there is consistent agreement regarding some strong indications for surgery (obstructive jaundice, enhancing mural nodule ≥5 mm, main pancreatic duct size ≥10 mm, pathological confirmation of invasive cancer, or high-grade dysplasia). However, the debate regarding the possible surveillance discontinuation in stable, “trivial” cysts is still ongoing. A patient-tailored approach based on radiological features, presence of symptoms, and fitness for surgery is mandatory to avoid unnecessary surgery in patients who could potentially never develop malignancy.