Therapy

Majority of pancreatic pseudocysts regress spontaneously. Earlier studies have indicated that cysts less than 6 wk old have a resolution rate of approx 40% in contrast with a resolution rate of 8% for cysts present for 7-12 wk. Beyond 13 wk, no further resolution occurred and the complication rate increased from 20% to 46% and 75%, respectively (5). Based on these findings, surgery has been a widely accepted approach for cysts that persist beyond 6 wk. However, two additional reviews advocate a more conservative approach with expectant follow-up. In a retrospective review of 68 patients with asymptomatic pseudocysts, approx 63% of patients either had spontaneous pseudocyst resolution or remained asymptomatic at a mean follow-up averaging 51 mo. There was a 9% incidence of serious complications including pseudoaneursym formation in three, perforation in two, and spontaneous abscess formation in one. Thirty-five percent of patients underwent operative therapy, generally for cyst enlargement associated with pain or gastric and biliary obstruction (24). In another series of 75 patients, 39 patients underwent surgery for severe abdominal pain; complications or progressive cyst enlargement, whereas the remaining 36 patients were followed conservatively with serial CT scans. Approx 60% of patients in the latter group had complete resolution at 1 yr with only one pseudocyst-related complication of intracystic hemorrhage with no reported mortality (25).

Pseudocyst drainage is indicated in: 1) symptomatic patients; 2) pseudocysts greater than 6 cm in size or in progressively enlarging cysts; and 3) infected pseudocysts (4). Immediate drainage can be accomplished safely in patients with mature cysts walls or with cysts that occur in the setting of chronic pancreatitis (26).

Surgery remains the standard drainage procedure of choice despite the availability of less-invasive procedures. Surgery is associated with a morbidity rate of 10% to 30%, mortality rate of 1% to 5%, and 10% to 20% recurrence rate (27,28). Endoscopic drainage procedures compare favorably to standard operative techniques. Similar success rates of 50% and 52% were reported in a retrospective review evaluating surgical management to endoscopic therapy (29). Comparably, equal rates were found in 71 cases of endoscopic drainage and 73 cases of surgical drainage, with a reported resolution rate of 72%, morbidity of 15%, and mortality of1% (30). These procedures should, however, be performed on selected patients in experienced centers where surgical back-up is available.

Endoscopic drainage procedures are extensions of ERCP techniques and consist of: 1) tanspapillary; and 2) transenteric or transmural approaches.

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