Pancreatic pseudocysts--when and how to treat?

Abstract

Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Currently several classification systems are in use that are based on the origin of the pseudocyst, their relation to pancreatic duct anatomy and a possible pseudocyst-duct communication. Diagnosis is accomplished most often by CT scanning, by endoscopic retrograde cholangiopancreaticography (ERCP) or by ultrasound, and rapid progress in the improvement of diagnostic tools has enabled detection with high sensitivity and specificity. There are different therapeutic strategies: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means.

Figure 1.

A 42-year-old man presented with an acute episode of alcoholic chronic pancreatitis. During the course of the disease he developed an infected pancreatic pseudocyst as shown on the CT scan (A and B). To achieve rapid drainage a percutaneous CT-guided catheter was inserted (C, plain radiograph), but this did not lead to resolution of the cyst. In a second step a pigtail catheter was inserted via puncture of the duodenal wall (D, plain radiograph). The pigtail catheter spontaneously dislocated into the cyst. By needle knife incision from the duodenum into the cyst we recovered the dislocated stent and endoscopically cleared and rinsed the cystic cavity every other day (E and F). The patient was discharged without any further complications 8 days after the salvage of the pigtail catheter. Three months later transabdominal ultrasound examination revealed a small residual cyst (G), as well as a dialated pancreatic duct (H) but no further complication.

Figure 2.

Clinical algorithm used at the University of Greifswald for the treatment of pancreatic pseudocysts. Pancreatic pseudocysts result from acute pancreatitis, chronic pancreatitis or pancreatic injury. The primary decision for or against treatment of pancreatic pseudocysts depends on size and localization of the cyst and the occurrence of secondary complications. In case of a small cyst (<5 cm) or absent secondary complications the strategy is to wait and observe. If size exceeds 5 cm and/or complications occur the cyst can be treated either surgically or endoscopically with equal outcome.