Mural nodules are important features to consider when evaluating pancreatic cysts. These nodules are predictors of malignancy in certain types of cystic neoplasms of the pancreas, including intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs). Here are some key points:

1. Mural Nodules and Malignancy:

   • Mural nodules are abnormal growths or protrusions within the cystic lesions.
   • Their presence is a consensus criterion for considering surgical resection of these cysts.
   • Although histologic findings of an epithelial nodule (found during surgery) are strongly associated with malignancy, mural nodules are primarily diagnosed through imaging studies.
   • The accuracy of preoperative imaging modalities in diagnosing these lesions can vary.

2. Risk Factors and Surgical Considerations:

   • High-risk stigmata that indicate a need for resection include:
     • Obstructive jaundice: When the cyst compresses the bile duct.
     • Enhancing mural nodule: A nodule within the cyst that enhances on imaging.
     • Main pancreatic duct (MPD) dilatation: If the MPD is 1 cm or greater without another cause of obstruction.
   • Surgical decisions are based on guidelines developed by international experts. These guidelines consider specific features of IPMNs:
     • Worrisome features (indicating the need for close monitoring):
       • Cyst size > 3 centimeters.
       • Thickened cyst wall.
       • Main pancreatic duct > 5 millimeters.
       • Cyst growth rate > 5 millimeters over two years.
     • High-risk features (indicating the need for surgery):
       • Enhancing mural nodule.
       • Main pancreatic duct ≥ 1 centimeter.

3. Surgical Procedures:

   • The type of surgery depends on the location of the IPMN within the pancreas:
     • For cysts in the body or tail, surgeons perform a distal pancreatectomy (usually minimally invasive).
     • For IPMNs in the head or neck, surgeons perform a Whipple procedure (also minimally invasive) — a refined operation pioneered by John Cameron at Johns Hopkins.

Remember that most pancreatic cysts, including IPMNs, are asymptomatic and found incidentally through imaging. Regular monitoring and assessment by a specialized team are crucial to determine the appropriate management strategy based on individual risk factors. If you have any specific concerns or need further information, I recommend consulting with a healthcare professional. 

For more detailed information, you can refer to the following sources:

• Johns Hopkins Medicine: Leading in the Treatment of Pancreatic Cysts
• Histologic and Imaging Features of Mural Nodules in Mucinous Pancreatic Neoplasms
• Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and Management