Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage)

Abstract

Objective: To test the hypothesis that pancreatic ductal anatomy may predict the likely success of percutaneous drainage of pseudocysts of the pancreas.

Summary background data: Various modalities are currently applied to pseudocysts, with little or no data to aid in the choice of management strategy. Pancreatic ductal anatomy was assessed and a system to categorize ductal changes was established.

Methods: Patients with a diagnosis of pancreatic pseudocyst were evaluated from 1985 to 2000. Two hundred fifty-three patients have been included in this series. Pancreatic ductal anatomy was defined using endoscopic retrograde cholangiopancreatography and categorized as a normal duct, a stricture, or complete cut-off of the pancreatic duct. Communication between the duct and cyst was noted.

Results: Among the 253 patients, 68 (27%) had spontaneous resolution. Fifty of the remaining 185 had percutaneous drainage and 148 (13 of whom failed to respond to percutaneous drainage) had surgery. There were no deaths in either group. Mean length of time with catheter drainage among all percutaneous drainage patients was 79.2 +/- 19.6 days. Patients with normal pancreatic ducts and those with strictures but no communication between the duct and the cyst who had percutaneous drainage had a much shorter length of hospital stay (6.1 +/- 4.6 days) than patients with strictures and duct-cyst communication and patients with complete cut-off of the duct (33.5 +/- 5.2 days and 39.1 +/- 7.9 days, respectively). Length of drainage also correlated with ductal anatomy. All patients with chronic pancreatitis failed to respond to percutaneous drainage.

Conclusions: Pancreatic ductal anatomy provides a clear correlation with the failure and successes of pseudocysts managed by percutaneous drainage as well as predicting the total length of drainage. Percutaneous drainage is best applied to patients with normal ducts and is acceptably applied to patients with stricture but no cyst-duct communication.

Figure 1. Categories of ductal abnormalities seen in patients with pseudocysts. Type I: normal duct/no communication with cyst. Type II: normal duct with duct–cyst communication. Type III: otherwise normal duct with stricture and no duct–cyst communication. Type IV: otherwise normal duct with stricture and duct–cyst communication. Type V: otherwise normal duct with complete cut-off. Type VI: chronic pancreatitis, no duct–cyst communication. Type VII: chronic pancreatitis with duct–cyst communication.