EUS-guided through-the-needle biopsy (EUS-TTNB) offers valuable diagnostic insights for pancreatic cysts but carries significant risks that surgeons must navigate.

• Diagnostic adequacy is high at 80.3%, with changes in management seen in 16.3% of cases.
• Adverse events (AEs) occurred in 20.9% of procedures, predominantly acute pancreatitis (15%).
• Intraductal papillary mucinous neoplasm (IPMN) significantly raises AE risk (OR 2.24).

Surgeons should use a risk stratification model to enhance patient selection and mitigate complications.

• Risk categories: low (11.9% AE), moderate (20.6% AE), high (37.0% AE for patients with IPMN).