Pancreatic pseudocyst: The past, the present, and the future

Abstract

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.

Keywords: Cystic pancreatic lesions; Endoscopic ultrasound; Pancreatic fluid collection; Pancreatic pseudocyst; Pancreatitis.

Figure 1

Transabdominal ultrasonography. A: Pseudocyst of the body-tail of the pancreas in the setting of chronic pancreatitis (indicated by an arrow); B: Pseudocyst of the head of the pancreas (indicated by an arrow).

Figure 2

Computed tomography scan image showing pseudocyst at the tail of the pancreas (indicated by an arrow).

Figure 3

Endoscopic ultrasound utility in diagnosis and management of pancreas pseudocyst. A: Appearance of pseudocyst on endoscopic ultrasound; B: Endoscopic ultrasound-guided fine-needle aspiration of pseudocyst; C: Decrease in size of pseudocyst after aspiration of cyst fluid.

Figure 4

Angiogram. A: Bleeding into the pseudocyst cavity from gastroduodenal artery (indicated by an arrow); B: Bleeding into the pseudocyst cavity (“cut off” of the left gastric artery, indicated by an arrow); C: Embolization was performed distal and proximal to the erosion zone; D: A stent graft was placed in the common hepatic artery.

Figure 5

Transmural cystogastroanastomosis with external-internal drainage. Arrow 1 shows cystonasal drainage, arrow 2 shows internal stent, and arrow 3 shows cystogastroanastomosis.

Figure 6

Endoscopic images. A: Balloon dilatation of a lumen-apposing metal stent; B: The view inside the walled-off necrosis cavity after cystgastrostomy; C: Direct endoscopic necrosectomy with removal of debris using an endoscopic snare device; D: Bleeding within walled-off necrosis cavity during direct endoscopic necrosectomy.

Figure 7

Endoscopic ultrasound images. A: Absence of Doppler signal within walled-off necrosis cavity, ruling out presence of vessels or pseudoaneurysm; B: Solid debris (labelled with arrow) seen within walled-off necrosis cavity; C: Post deployment of lumen-apposing metal stent (labelled with arrow).

Figure 8

Percutaneous drain and dye study in pancreas pseudocyst management. A: Percutaneous drainage of an infected pancreatic pseudocyst via a pigtail drain; B: Lavage of the cavity of the infected pseudocyst; C: Cystography in which the cavity of the pseudocyst was visualized, and the pigtail drainage was established.