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Scandinavian Journal of Surgery 94: 165–175, 2005
TREATMENT OF PANCREATIC PSEUDOCYSTS
Å. Andrén-Sandberg1, C. Ansorge1, K. Eiriksson1, T. Glomsaker1, A. Maleckas2
1
2
Department of Surgery, Stavanger University Hospital, Stavanger, Norway
Department of Surgery, Kaunas Medical University Hospital, Kaunas, Lithuania
ABSTRACT
According to the Atlanta classification an acute pseudocyst is a collection of pancreatic
juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence
of acute pancreatitis or pancreatic trauma, whereas a chronic pseudocyst is a collection
of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a
consequence of chronic pancreatitis and lack an antecedent episode of acute pancreatitis.
It is generally agreed that acute and chronic pseudocysts have a different natural history, though many reports do not differentiate between pseudocysts that complicate
acute pancreatitis and those that complicate chronic disease. Observation – “conservative treatment” – of a patient with a pseudocyst is preponderantly based on the knowledge that spontaneous resolution can occur. It must, however, be admitted that there is
substantial risk of complications or even death; first of all due to bleeding.
There are no randomized studies for the management protocols for pancreatic pseudocysts. Therefore, today we have to rely on best clinical practice, but still certain advice may be given. First of all it is important to differentiate acute from chronic pseudocysts for management, but at the same time not miss cystic neoplasias. Conservative
treatment should always be considered the first option (pseudocysts should not be treated just because they are there). However, if intervention is needed, a procedure that is
well known should always be considered first. The results of percutaneous or endoscopic drainage are probably more dependent on the experience of the interventionist
than the choice of procedure and if surgery is needed, an intern anastomosis can hold
sutures not until several weeks (if possible 6 weeks).
Key words: Pancreatic pseudocyst; acute pancreatitis; chronic pancreatitis; treatment
Pseudocysts are localised collections of fluid from the
pancreatic gland surrounded by nonepithelialised
granulation tissue. The fluid collection follows an insult to the pancreas. Pancreatic pseudocysts are not
common, and rarely does a single surgeon acquire a
Correspondence:
Åke Andrén-Sandberg, M.D.
Department of Surgery
Stavanger University Hospital
NO - 4068 Stavanger
Norway
Email: [email protected]
large experience concerning their management. The
pathogenesis of the pseudocysts has earlier been
rather superficially described and the epidemiology
and natural history have most often been studied in
a limited way. However, the development of diagnostic ultrasound and computed tomography, CT,
has changed this drastically. An increased frequency of cystic pancreatic lesions are on the same time
seen today – probably not due to an increased incidence totally, but an increased incidence of symptom-poor lesions. This has given new knowledge and
an improved interest for research on the disease, and
means that the previous knowledge of pancreatic
pseudocysts only refers to those giving symptoms.
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Å. Andrén-Sandberg, C. Ansorge, K. Eiriksson, T. Glomsaker, A. Maleckas
Previously clinical examination, laparotomy, barium
studies and angiography only detected cysts big
enough to cause morphologic abnormalities in adjacent viscera. Now we also see small and asymptomatic pseudocysts. However, with more pseudocysts
discovered we have to evidence-based answer the
basic questions on optimal diagnostics and treatment
– or no treatment at all – in all these cases.
Not many years ago the management of pancreatic
pseudocysts was thought to be relatively simple: internal drainage. The major controversy was whether
to intervene surgically early – which might result in
an unwanted external drainage – or to wait until
maturation of the wall of the pseudocyst, i.e. when
the wall could hold sutures. However, technological
advances such as percutaneous and endoscopic
drainage technique have made treatment of pancreatic pseudocysts more complex. Now the Atlanta
classification system has provided us with the
required definitions, but still they are not always
used (1).
CLASSIFICATION
There is a certain confusion in the literature on the
terms “acute” and “chronic” with regard to pseudocysts. According to the Atlanta classification (1) an
acute pseudocyst is a collection of pancreatic juice
enclosed by a wall of fibrous or granulation tissue,
which arises as a consequence of acute pancreatitis
or pancreatic trauma, whereas a chronic pseudocyst
is a collection of pancreatic juice enclosed by a wall
of fibrous or granulation tissue, which arises as a consequence of chronic pancreatitis and lack an antecedent episode of acute pancreatitis. This means that the
terms acute and chronic regarding pseudocysts is
used otherwise in some respects than how these
words are used in other medical conditions.
Sometimes classification of the pseudocysts into
acute and chronic types is – unfortunately – based
on the time interval (usually 4–6 weeks from the
acute attack) in an attempt to help decide the timing
of surgical intervention and in these cases does not
take the underlying disease into account. With this
use of the term acute pseudocysts occur in acute pancreatitis but can develop also in chronic pancreatitis
after an acute exacerbation. On the other hand,
chronic pseudocysts are usually associated with
chronic pancreatitis but may develop after an episode
of acute pancreatitis as well (2). The situation is
somehow confusing and some attempts have been
made to set it clear by classifying pseudocysts according to pathological changes underlying acute or
chronic pancreatitis.
As early as 1961 Sarles and colleagues (3, 4) proposed a classification of pancreatic pseudocysts depending on whether they were associated with acute
or chronic pancreatitis. Pseudocysts associated with
acute pancreatitis were called necrotic pseudocysts
because they resulted from pancreatic necrosis and
extravasation of pancreatic juice. Based on pathological studies pseudocysts originating from chronic
pancreatitis were called retention pseudocysts. Pathological examinations revealed that intrapancreatic
fluid collections associated with chronic pancreatitis
sometimes were true cysts caused by dilation of pancreatic ducts behind calculi, plugs, or strictures. Extrapancreatic pseudocysts complicating chronic pancreatitis were more frequently caused by a rupture
of these pseudocysts into peripancreatic tissues (retention pseudocysts) rather than by acute necrotic
pancreatitis complicating the chronic lesion (5). There
are no absolute borders between acute and chronic
pseudocysts, but in the obvious cases there are clear
differences (Table 1).
NATURAL HISTORY
The widespread application of ultrasonography and
CT has advanced our knowledge of the natural history of pancreatic pseudocysts. It is generally agreed
that acute and chronic pseudocysts have a different
natural history, though many reports do not differentiate between pseudocysts that complicate acute
pancreatitis and those that complicate chronic disease.
There are few, if any at all, reliable data on the
mechanisms of spontaneous resolution of pancreatic
pseudocysts. The only documented way is spontaneous rupture of a pancreatic pseudocyst into the
adjacent organs (6, 7).
Factors found to reduce the likelihood of spontaneous resolution of cystic lesions are multiple cysts
(8), pseudocyst location in the tail of the pancreas (9),
thicker pseudocyst wall (10, 11), a communication
with the pancreatic duct with an associated proximal
stricture of the pancreatic duct (11), increase in size
on follow-up examination (8), biliary or postopera-
TABLE 1
Typical differences between acute and chronic pseudocysts
Acute pseudocysts
Chronic pseudocysts
First notice
acute (after a bout of acute pancreatitis)
during investigation of long-standing pain
Number of pseudocysts
seldom more than one
often multiple
Size
may be large, seldom small
seldom large
Changing size
may be changing rather quickly
slow changes in both directions
Intra/extrapancreatic
may be any or combined
always intrapancreatic
Treatment of pancreatic pseudocysts
tive etiology of pancreatitis (12), and extrapancreatic
development in chronic alcoholic pancreatitis (13).
Severity of acute pancreatitis as well as extent of pancreatic necrosis was found to influence spontaneous
resolution rate. In Neoptolemos’ and colleagues’
study all pseudocysts resolved spontaneously if they
resulted after mild acute pancreatitis or severe pancreatitis with less than 25 percent of pancreas necrosis (14).
ACUTE PSEUDOCYSTS
Earlier studies suggest that spontaneous resolution
of an acute pseudocyst occurred in from 8 and up to
70 percent of patients (15-20). The more patients with
diagnosed acute pseudocyst will actually have acute
fluid collections the higher resolution rate will be.
The situation has not changed even with the advent
of ultrasonography as there in these reports most often has not been precise definition of the pseudocyst.
Therefore, the possibility that the results of resolution of acute fluid collections and acute pseudocysts
were presented together should be encountered.
From a clinical point of view it is of course of interest if there are prognostic factors can give at least
a hint of which pseudocysts are probable to regress – and which will not resolve. Warshaw and
Rattner (10) reported that no cyst that presented
more than 6 weeks following an attack of acute pancreatitis resolved. On the other hand, the authors noted that the size of the cyst did not seem to affect the
chance of resolution. Similarly, Bradley and colleagues followed the natural history of pseudocysts
in 93 patients, 31 of who had acute pancreatitis and
62 had chronic disease. Spontaneous resolution occurred in ten (42 %) of 24 patients in whom a pseudocyst was present for more than 6 weeks. By contrast, of 13 pseudocysts that had been present for 7–
12 weeks, only one (8 %) resolved spontaneously.
Spontaneous resolution did not occur in any of the
remaining 12 patients followed for up to 18 weeks.
The clear implication was that pseudocysts still
present at 6 weeks are unlikely to resolve spontaneously (20).
This conclusion was challenged by the results of
more recent studies. In Vitas’ and Sarr’s (21) series
of 68 patients treated with expectant approach overall resolution of the pseudocyst occurred in 57 percent of the 24 patients with satisfactory radiographic
follow-up, and 38 percent resolved more than 6
months after diagnosis. O’Malley and colleagues (22)
noted that pseudocysts of more than 4 cm resolved
spontaneously at a mean of 3 months after diagnosis, although in one case resolution did not occur until 28 months. Maringhini and colleagues (9) found
that within one year after diagnosis 65 percent of
acute pseudocysts resolved.
CHRONIC PSEUDOCYSTS
Aranha and colleagues (8) noted that patients with
pancreatic calcifications and evidence of chronic pancreatitis had no resolution of their pancreatic pseudocyst. Warshaw and Rattner (10) from their series
167
of 42 patients with pancreatic pseudocysts also concluded that evidence of chronic pancreatitis and pancreatic duct abnormality other than communication
with the pseudocyst were criteria suggesting that a
pseudocyst will not resolve spontaneously.
Gouyon and colleagues observed pseudocyst resolution rate of 26 percent in patients with chronic alcoholic pancreatitis. The median time to regression
was 29 weeks (range 2–143) and independent predictive factor of pseudocyst resolution or asymptomatic
course was size less than 4 cm (13).
McConnell and colleagues (17) reported resolution
rate in only 3 percent of cases with chronic pancreatic pseudocysts. Bourliere and Sarles reviewed 77 consecutive patients with pseudocysts of the pancreas
associated with chronic pancreatitis. Ultrasonography and/or CT scans showed that 9 percent of them
resolved spontaneously. The main diameter of chronic pancreatic pseudocysts that resolved was 3 cm (5).
RISK FOR COMPLICATIONS IN UNTREATED PANCREATIC
PSEUDOCYSTS
Observation – “conservative treatment” – of a patient
with a pseudocyst is preponderantly based on the
knowledge that spontaneous resolution can occur.
The doctor who is very enthusiastic about observation, however, must admit that there is substantial
risk of complications or even death.
In Bradley’s and colleagues’ series the incidence
of complications correlated directly with the length
of time the pseudocyst was present: 20 percent of patients with early pseudocyst (< 6 weeks) had a complication, as opposed to 46 percent with cysts that
were 7–12 weeks old and 75 percent of those with
chronic cysts (beyond 13 weeks). Of particular interest is the observation that each of the seven deaths
(12 %) occurred as a direct result of the pseudocyst
and that their complications developed an average
of thirteen and a half weeks after the presumed initial development of the pseudocyst (20).
More recently, Yeo and colleagues in Baltimore,
used serial CT to observe the natural history of pancreatic pseudocysts in 75 patients; their findings challenge the conclusion of Bradley and colleagues that
delay is at best fruitless and at worst hazardous. Thirty-six patients who were asymptomatic were managed without operation and were observed for a
mean of 1 year. Of these, 60 percent had complete
resolution of the pseudocyst and 40 percent had
pseudocysts that remained stable or reduced in size.
Only one patient of the 36 treated expectantly, i.e.
without operation, developed a complication from
the pseudocyst in the form of a transient intracystic
haemorrhage (23).
Vitas and Sarr reported 68 patients initially treated selectively with a nonoperative, expectant approach. Severe, life-threatening complications in this
group followed up for a mean of 46 months occurred
in only 6 patients (9 %), including intracystic haemorrhage in 3, perforation in 2, and cyst infection in 1.
Nineteen (28 %) patients eventually underwent elective operation directed at either the pseudocyst or
other complications related to pancreatitis (21).
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Å. Andrén-Sandberg, C. Ansorge, K. Eiriksson, T. Glomsaker, A. Maleckas
Maringhini and colleagues analysed the natural
history of 83 non-alcoholic patients with fluid collections and/or pseudocysts in which a chronic pancreatitis was accurately excluded. In the first six weeks
of follow-up spontaneous disappearance was observed in 12 (15 %) and complications in 19 (23 %) of
83 patients. The complications observed were pain
in 12 patients, infection in 4, fistula in 2, and rupture
in one patient. Only two patients died. After the first
six weeks of follow up, the pseudocyst spontaneously disappeared in 31 and complications occurred in
14 of 48 patients. Eleven of the patients with complications had pain, while three presented fistula (9).
The cumulative experience suggests that asymptomatic pseudocysts, which remain stable or diminish in size, can be safely managed with a nonoperative approach. Close monitoring of such patients is,
however, mandatory in order to detect enlarging or
symptomatic pseudocysts early in their course, before occurrence of severe complications. In such cases immediate surgical intervention should be considered.
THERAPY OPTIONS
Currently, at least three principle forms of active
therapy are available: percutaneous drainage, endoscopic drainage, and surgical interventions: excision,
external drainage, and internal drainage. Surgery,
which traditionally was the major treatment approach for pancreatic pseudocysts, has been challenged by the newer endoscopic techniques. Given
the low complication and mortality rates and the
high success rate of percutaneous and endoscopic
drainage when compared with surgery, surgical intervention should be reserved only for certain cases.
Addition of endoscopic ultrasonography, EUS, for
endoscopic drainage is a new development and may
decrease the risks associated with endoscopic drainage (24).
Resolution rates after surgical and non-surgical
methods are comparable, but clinical and technical
aspects may mandate either method. Each patient
requires an individual, multidisciplinary approach,
thereby obtaining optimal treatment-outcome.
PERCUTANEOUS CATHETER DRAINAGE
Percutaneous catheter drainage of symptomatic pancreatic pseudocysts under computed tomography or
ultrasonographic guidance is a valuable adjunct or
alternative to operative pseudocyst management and
has today many advocates (25–27) and is well evaluated. Insertion of a pigtail catheter allows the cyst to
remain collapsed, and up to 90 percent of pseudocysts may be drained successfully in this way (28).
However, long-term outcome in larger series remains
to be awaited (29).
Diagnostic percutaneous aspiration of peripancreatic collections is readily performed, but needle aspiration alone is generally ineffective as a therapy
(except as a temporary measure) (30–32).
INDICATIONS AND CONTRAINDICATIONS
According to the current practice indications for percutaneous catheter drainage of pseudocysts are essentially the same as those for surgical treatment.
Persistent pain, sepsis (infection), increasing size, involvement of contiguous organs or structures, and
common bile duct obstruction have been accepted as
indications for this procedure (33). It may be especially useful in the management of immature symptomatic pseudocyst (34) and this type of drainage can
be performed in all patients, including those at highrisk (35).
However, if patients are critically ill or have a high
operative risk, then temporary palliation achieved
with percutaneous drainage can be vital also in cases with obvious contraindications (31, 41).
TIMING OF PERCUTANEOUS DRAINAGE
Operation for noninfected pseudocyst generally requires 6-week delay to allow the pseudocyst wall to
thicken and mature (42, 43). This delay is not essential with the percutaneous approach, which is an advantage of the latter technique. Timing is not relevant for percutaneous drainage, other than the initial interval for sequential imaging. Therefore, the
only criterion for timing is clinical or imaging proof
that pseudocyst does indeed require drainage, in
other words, that it is symptomatic or is not resolving spontaneously (28).
RESULTS OF PERCUTANEOUS ASPIRATION
Percutaneous aspiration is ideal and safe for diagnosis but is usually ineffective for therapy. Especially
chronic pseudocysts have thick walls and are surrounded by a fibrotic parenchyma, and needle aspiration may not be effective in collapsing the walls.
TABLE 2
Contraindications to catheter drainage of pseudocysts (33, 36, 37).
• collections associated with a solid or non-drainable pancreatic mass or with subtotal gland necrosis (more than 50 % parenchymal
necrosis) (32, 38, 39)
• suspicion of malignancy
• lack of a safe access route
• recent or active haemorrhage into the collection, the presence of an arterial pseudoaneurysm
• collections associated with obstruction of the main pancreatic duct (especially complete cut-off) (37, 40)
Treatment of pancreatic pseudocysts
The pseudocysts with ductal communication, which
may be in 40 percent to 70 percent of cases, reaccumulate fluid usually within 24 hours of aspiration
(44).
Some authors (31, 45, 46) suggest that diagnostic
and therapeutic procedure in a pseudocyst that does
not communicate with the pancreatic duct can be
started with a fine-needle evacuation. It can have several advantages: instantaneous pain relief and clinical improvement, the risk of introducing infections
by indwelling catheter is eliminated, the risk of fistula formation is negligible, and in case of recurrence,
the choice between other treatment methods still remains. Furthermore, possible differential diagnoses
must be kept in mind. In the case where the pseudocyst content is pus or when the cyst fluid is difficult
to evacuate completely, the catheter should be inserted immediately (46).
PERCUTANEOUS CATHETER DRAINAGE
Henriksen and Hanke have a large reported experience – maybe the largest – of percutaneous gastropseudocystostomies with ultrasound guidance (n =
74) (47). Three quarters of their patients had chronic
pancreatitis. 8.5F stent placement was successful in
92 percent of cases. In four (5 %) patients immediate
complications occurred that required surgical intervention (3 cases of incorrect position of the stent and
1 bile leak into the peritoneum). Eight patients (11 %)
developed sepsis and abscess formation within the
cyst, shortly after stent placement. All of them had
debris and cloud material at needle puncture and
authors believe that this was the cause of stent occlusion and stasis that gave rise to infection. Currently they use 10F stents to facilitate better drainage.
There was one (1 %) death in the series due to acute
myocardial infarction. During the mean observation
period of 27 months 7 patients (10 %) had pseudocyst recurrence. Furthermore, half of their patients
were pain free during the follow-up period and 38
percent had improved, which means that about eight
of nine were helped. The results are about similar to
those achieved by surgical internal drainage in patients with chronic pancreatitis pseudocyst (48–50).
From a retrospective analysis of 102 patients,
Ahearne and co-workers advocated an ERCP-based
algorithm for the management of pseudocysts. The
algorithm focuses on pancreatic duct anatomy to assign treatment; therefore, the presence of pancreatic
duct obstruction and pseudocyst communication are
used to triage patients to operative management or
percutaneous drainage. Percutaneous drainage was
used if the main pancreatic duct was not obstructed
and if no communication with the pseudocyst existed. The algorithm was evaluated by retrospectively
applying it to 40 elective cases in which pre-treatment ERCPs were performed. Twenty-six treatments
followed the algorithm, while 14 did not. Treatment
that followed the algorithm had a significantly lower incidence of adverse outcome than those that did
not (12 % vs 43 %) (51).
The major complication rate varies from study to
study and is in a range from 0 percent to 17 percent.
169
Haemorrhage, sepsis, pneumonia, pneumothorax,
empyema, myocardial infarction, ileus, pancreatocolonic fistula, spleen injury – all have been reported
(2, 25, 28, 52–54). Bacterial superinfection is of special concern (25, 28, 31, 55, 56). These patients may
have clinical findings indicating infection, including
fever or leukocytosis, and shall be treated with antibiotics. There are authors claiming that these infections are caused by skin contaminants, based on the
high number of infections caused by resident normal
flora of the skin.
ENDOSCOPIC DRAINAGE
The crucial anatomic fact that makes endoscopic
drainage of pseudocysts feasible is that a pseudocyst
does not have its own structure; rather, it is a space
delineated by the normal anatomic structures adjacent to the inflammatory process – the stomach, intestine, liver, spleen, or transverse mesocolon (and
part of the pancreas). The wall of the stomach or the
duodenum is often common wall of the pseudocyst
between which a thick inflammatory peel forms a
poorly defined interface. This allows an enterostomy
to be performed without concern for a potential space
between the pseudocyst and the stomach and duodenum, which could develop if the pseudocyst and
digestive walls were simply in close apposition (57).
Endoscopic drainage of pancreatic pseudocyst appears to be a safe, effective, and definitive treatment
for patients in whom anatomic considerations allow
its use (58) and should therefore be understood and
utilized appropriately by the surgical community
(59).
INDICATIONS AND BASIC PRINCIPLES
Endoscopic methods for draining pseudocysts are
extensions of the ERCP techniques that rely on the
use of the therapeutic duodenoscope and ERCP accessories. Publications on endoscopic drainage consist primarily of case series (60–68). This cumulative
experience has led to the development of certain basic principles.
TABLE 3
Proposed guidelines for endoscopic pancreatic pseudocyst
drainage (69).
Allow pseudocyst time to mature
Identify and address pseudoaneurysms
Evaluate for the presence of portal hypertension and gastric
varices
Ensure that the pseudocyst is in close apposition to the gastric or
duodenal wall
Perform pancreatography first
Identify debris within pseudocyst
Use a transpapillary approach whenever feasible
Use aspirating needle catheter to test for blood before puncture
Clinical findings should be consistent with a pseudocyst
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Å. Andrén-Sandberg, C. Ansorge, K. Eiriksson, T. Glomsaker, A. Maleckas
With all drainage techniques, except percutaneous
catheter drainage, it is important to allow the capsule of the pseudocyst time to ”mature”. Pseudoaneurysms can occur as a consequence of pancreatitis,
and these should be carefully looked for before any
puncture (70). Portal hypertension may accompany
inflammatory pancreatitis, and identification of gastric varices will help avoid haemorrhage related to
inadvertent puncture. Pancreatography is also important before any attempt at drainage is made (51).
Whenever possible, anatomic abnormalities such as
distal strictures, duct disruptions, or pancreatic duct
stones should be addressed by endoscopic techniques
to ensure long-term success.
Two endoscopic approaches (transmural and
transpapillary) can be utilised to treat pseudocysts.
The choice of therapy is in part dependent on whether the cyst communicates with the pancreatic duct or
is in close apposition to the gut lumen. Transpapillary drainage should be preferred, because it carries
the least morbidity (60, 71–73).
SHORT TERM RESULTS
The endoscopic transpapillary drainage can be successfully performed in almost all cases (60, 68). Initial success, resolution of pseudocysts, was observed
in 81–94 percent of cases (60, 66–68). After mean follow-up of 16–37 months were 58–83 percent of the
patients free of recurrence (60, 61, 66–68). From 6 percent to 39 percent of patients required surgery (60,
66–68).
The lowest overall success rate was in Smits’ and
co-workers’ study; 58 percent (61) while other studies have demonstrated almost similar results. Free of
pseudocyst recurrence were 75–83 percent of patients
(60, 66–68). These figures perhaps can be accepted as
a standard for this procedure.
The (re)operation rates after endoscopic transpapillary drainage depends on various factors, not only
on the recurrence of the pseudocyst. As in all cases
with chronic pancreatitis, the presence or absence of
chronic abdominal pain is very important. In Kozarek’s (66) study there was highest surgery rate after
pseudocyst drainage; 39 percent. However, 3 of 7
patients who required surgery had it due to ongoing
pain. The long-term results of this technique appear
to be related in part to the initial diagnosis. The patients with acute pancreatitis and persistent duct disruptions seem to benefit from this treatment. The fluid collections resolve and in most cases they are
asymptomatic on long-term follow-up. The patients
with chronic pancreatitis are more likely to require
surgery.
Location of the pseudocysts appears to be important, as 5 of 7 F transpapillary drainage failures were
associated with a pseudocyst located in the body or
tail of the pancreas. Nevertheless, pseudocysts located in the tail of pancreas may also disappear after
transpapillary drainage (8 cases among 12 pseudocysts located in the body or tail of the pancreas) (67).
Similar results were presented in Catalano study (73).
The pseudocyst drainage was successful in 60 percent of pseudocysts located in the tail of the pancre-
as versus 78–86 percent when pseudocysts were located in the body or head of the pancreas (73).
LONG-TERM RESULTS
In a comparative study outcomes after endoscopic
drainage complete endoscopic resolution was
achieved in 113 of 138 patients (82 %). Resolution was
significantly more frequent in patients with chronic
pseudocysts (59/64, 92 %) than acute pseudocysts
(23/31, 74 %) or necrosis (31/43, 72 %). Complications were also significantly more common in patients with necrosis (16/43, 37 %) than in chronic cases (11/64, 17 %) but not for those with acute pseudocysts (6/31, 19 %). At a median follow-up of 2
years after successful endoscopic treatment (resolution), pancreatic fluid collections had recurred in 18
of 113 patients (16 %). Recurrences developed more
commonly in patients with necrosis (9/31, 29 %) than
acute pseudocysts (2/23, 9 %) or chronic pseudocysts
(7/59, 12 %). This underlines that further studies of
endoscopic drainage of pancreatic fluid collections
must use defined terminology to allow meaningful
comparisons (74).
In yet another long-term outcome study of endoscopic management of pancreatic pseudocyst there
was a minimum follow-up of 2 years for a total of 38
consecutive patients. There were 27 endoscopic gastropseudocystostomies, 6 endoscopic duodenopseudocystostomies and 5 transpapillary drainages. Patients were monitored at 1 and 3 months after drainage, and finally between 24 and 80 months. Upper
gastrointestinal endoscopy was done at 1 and 3
months after drainage while ultrasound was done at
3 months and at the end of follow-up. All forms of
endoscopic drainage were effective in treating pancreatic pseudocyst and there was complete disappearance of the cyst within 3 months of drainage, irrespective of cause (alcohol, gallstone or trauma).
Over a mean follow-up of 44 months (24–80 months)
3 patients had symptomatic recurrences while 3 had
asymptomatic recurrences; all had alcohol-induced
pancreatitis. No recurrences were seen in the biliary
pancreatitis and trauma group. All symptomatic recurrences were successfully managed with endoscopic gastropseudocystostomy and stenting. A massive
bleed in one patient required surgery while stent
block and cyst infection in three patients and perforation in one patient were managed conservatively
(75).
SURGERY
Surgery remains the standard for drainage of pseudocysts against which new methods have been compared – but this must now be seriously questioned
as so few of these procedures are performed today. Surgical operations usually consist of a gastropseudocystostomy, a duodenopseudocystostomy, or a
Roux-en-Y-jejunopseudocystostomy. These operative
procedures carry a 10–30 percent morbidity rate, a
1–5 percent mortality rate, and a 10–20 percent rate
of recurrence (76–78), thus endoscopic drainage
Treatment of pancreatic pseudocysts
compare favourably with this surgical ”standard”
(60–68). However, the role of surgery in pancreatic
pseudocysts has changed for several reasons (79).
First of all endoscopic and percutaneous drainage
techniques have become refined and universally
available. Also, the natural history of pseudocysts
has disclosed that most asymptomatic pseudocysts
need no treatment.
In general, the operative management of pancreatic pseudocyst aims to evacuate the pseudocyst contents and prevent serious complications. If the pseudocyst cavity is decompressed, it is likely to become
obliterated with the passage of time. For acute pancreatitis there is a choice between external and internal drainage, but in chronic pancreatitis there is also
a possibility of cyst resection or lateral pancreaticojejunostomy. On the other hand, pancreatic resection
is appropriate in nondilated pancreatic ducts with
strictures in the left part of the head, and body and
tail region. The specific type of pancreatic resection
depends on the exact location of the stricture. The
pseudocyst is only one feature of underlying disease
and the decision between resection and drainage is
influenced by the extent of surrounding inflammation, vascular involvement and duct ectasia (80).
Some authors have highlighted the importance of
ductal stricture in planning surgical management (81,
82). Duct abnormalities present in retention pseudocyst is thought to be an indication for definitive operations such as resection of the pancreas or Puestow
operation (longitudinal pancreaticojejunostomy) (2,
50, 83, 84).
INDICATIONS FOR SURGERY OF PANCREATIC
PSEUDOCYSTS
Most surgeons would agree that an open surgical
approach is usually chosen for the patients with recurrent pseudocysts, pseudocysts combined with
common bile duct or duodenal stenosis, symptomatic
pseudocysts associated with a dilated pancreatic
duct, and those “pseudocysts” for which a diagnosis
of cystic neoplasm cannot be excluded (36, 85).
TIMING OF INTERVENTION
The timing of intervention is a critical matter that requires considerable judgement. If operation is undertaken too early the pseudocyst wall will be friable
and unable to hold sutures, necessitating external
drainage with its attendant increase in morbidity and
mortality rates (49, 86).
However, the pseudocysts of chronic pancreatitis
may be drained surgically as soon as they are diagnosed, in the confident expectation of finding a mature cyst wall capable of holding sutures. The optimal timing of intervention in acute or traumatic
pseudocyst is more difficult to determine (87). Studies in dogs have shown that a period of 4–6 weeks is
required for development of a mature pseudocyst
wall (88). Because it is frequently impossible to date
the onset of pseudocyst formation, some authors
have recommended waiting 6 weeks from the time
of diagnosis (49). Several authors have used a 4-week
171
waiting period with good result (89). The consensus
is that a minimum of 4–6 weeks from the time of diagnosis of an acute pseudocyst is required for the
wall to become sufficiently mature for safe internal
drainage (20, 90). If infection or pressure symptoms
demand decompression of the pseudocyst before that
time, external drainage can be performed either percutaneously or at operation.
EXTERNAL DRAINAGE
Although frequently used in the past, external drainage has few current adherents (91). The principal disadvantages of external drainage are (85):
– the potential for hemorrhage from mechanical
abrasion by the drainage tube
– the frequent development of secondary infection
– creation of a long-term pancreatic fistula.
As a result of these deficiencies, today external drainage is used principally when a misdiagnosis has been
made, when the risk of anastomotic dehiscence is
high because of an unanticipated infected pseudocyst, when an unexpectedly immature wall is discovered that is judged to be incapable of holding sutures,
when free rupture of the pseudocyst is discovered
during emergency laparotomy or after direct suture
ligation of the bleeding vessel or vessels in the pseudocyst (85).
INTERNAL DRAINAGE
Internal drainage establishes a controlled fistula into
the gastrointestinal tract and is the method of choice
for all mature uncomplicated pseudocysts – if surgery is chosen. Gastropseudocystostomy and jejunopseudocystostomy are alternative procedures for
establishing internal decompression (49); duodenopseudocystostomy is occasionally indicated for a small
cyst in the pancreatic head (92). The mortality rate
for the collected series of 1280 cases of internal drainage reported from 1969 to 1983 was 5 percent, with
no significant differences between gastropseudocystostomy, jejunopseudocystostomy Roux-en-Y, or duodenopseudocystostomy (if performed by the transduodenal approach) (93). So, if open operation is considered, uncomplicated chronic pseudocysts are best
drained internally into the most convenient adjacent
segment of intestine (49, 94–96).
CHOICE OF INTERNAL DRAINAGE PROCEDURE
Controversy surrounds the question of which viscus
should be used for pseudocyst drainage: stomach,
duodenum or a Roux loop of jejunum. Some favour
gastropseudocystostomy (95) and others jejunopseudocystostomy (97, 98). There are also advocates of
individualised approach when operation is chosen
according to the particular anatomy and condition of
the patient (84). For example gastropseudocystostomy is recommended when the anastomosis can be
performed through an area of fusion between the
pseudocyst and the posterior wall of the stomach.
When the pseudocyst is not fused to the posterior
172
Å. Andrén-Sandberg, C. Ansorge, K. Eiriksson, T. Glomsaker, A. Maleckas
wall of the stomach a Roux-en-Y jejunopseudocystostomy is more likely to be the procedure of choice,
because the consequences of the dehiscence of a long
Roux-en-Y jejunopseudocystostomy are less catastrophic than a breakdown of an unfused gastropseudocystostomy or duodenopseudocystostomy (49).
Whether postoperative hemorrhage can be reducing with oversewing a gastropseudocystostomy is a
matter of debate. Some authors recommend oversewing it in the manner of an anastomosis with running
suture (95, 98, 99), whereas others place multiple
mattress sutures of permanent material circumferentially around the anastomosis in the area of fusion
(49). There is also reported case of the use of disposable stapler for creation of gastropseudocystostomy
(100). Hutson and colleagues (101) compared postoperative complications in patients with and without running sutures applied to the gastropseudocystic stomas. Two (33 %) of 6 patients in the suture
group experienced postoperative bleeding as compared to none in the same size non-suture group.
Authors suggested that oversewing the margins
might interfere with gastric mucosal prolapse, which
should serve as an effective mucosal valve preventing reflux of gastric contents into the cyst. When gastropseudocystic reflux occurs, the corrosive effects of
gastric acid on the inflamed surface of the cyst wall
might provoke hemorrhage. Contrary to the report
of Hutson and colleagues (101) only 3 percent of the
patients experienced bleeding from the sutured anastomosis between the stomach and the pseudocyst in
the other published series (86, 95, 99).
The incidence of major morbidity and of death
seems to be similar between internal drainage procedures (49). In one series (102) two of 39 patients
who underwent gastropseudocystostomy and two of
59 patients who underwent jejunopseudocystostomy
died (operative mortality 5 % and 3 %, respectively).
These statistics compare favourably to the 7 percent,
4 percent and 4 percent mortality rates after gastropseudocystostomy, jejunopseudocystostomy and duodenopseudocystostomy, respectively, found in the
collective review of the literature. Morbidity rate was
then 24 percent, 18 percent and 23 percent, respectively.
RECURRENCE OF PSEUDOCYSTS
Newell and colleagues (102) found no difference in
pseudocyst recurrence with gastropseudocystostomy
compared to jejunopseudocystostomy. Pseudocyst
recurrence was 10 percent with gastropseudocystostomy and 7 percent with jejunopseudocystostomy.
These rates compare favourably with the results of
the other studies. In a review of 1020 patients, the
cyst recurrence rate was 3 percent after gastropseudocystostomy and 5 percent after jejunopseudocystostomy (103). Mitty and colleagues (104) reported
from the literature a recurrence rate of 6 percent in
365 cases after jejunopseudocystostomy, 3 percent in
415 cases after gastropseudocystostomy and 8 percent in 75 cases after duodenopseudocystostomy.
Recurrence rates may indicate the true reappearance of pseudocysts treated with an enteropseudo-
cystic anastomosis. However, development of newly formed pseudocysts due to a progression of pancreatic disease is also possible. As an aspect of the
underlying chronic pancreatitis a high rate of attacks
of acute pancreatitis after cyst drainage (33 %) can
be observed (20, 50, 105, 106). Therefore, some of the
reported “recurrences” may represent the progression of coexisting pseudocysts which were unappreciated at the time of the original drainage procedure
(107). In the others loculated pseudocysts may recur
due to failure to drain the most dependent part of
the cyst, or failure to provide an adequate pseudocyst-enteric anastomosis. Thus, at the second operation it is often impossible to know if the pseudocyst
is new, recurrent, persistent, or overlooked at the first
operation (49).
LAPAROSCOPIC TREATMENT
Laparoscopic surgery has been recommended as a
safe, reliable, and minimally invasive treatment for
managing pancreatic pseudocyst (108) as advances
in laparoscopic surgical technique and instrumentation have furthered our ability to perform more complex laparoscopic procedures (109). The minimally
invasive approach to gastropseudocystostomy allows
for wide drainage of the pancreatic pseudocysts and
might avoid the greater morbidity and longer recovery from an open surgical procedure (110). Reports
to date have consisted of case series, often with limited follow-up (109).
A computerized search using the search words
“pancreatic” and “pseudocysts” in 2003 showed that
laparoscopic gastropseudocystostomy and jejunopseudocystostomy achieve adequate internal drainage,
facilitate concomitant debridement of necrotic tissue
within acute pseudocysts, and achieve good results
with minimal morbidity (111).
PSEUDOCYST RESECTION; RESECTION OF
BODY AND TAIL OF PANCREAS
Pancreatic resection – including the pseudocyst – is
an alternative to internal drainage for chronic pseudocysts of moderate proportions, especially those
that have largely replaced a portion of the pancreas.
However, in most cases pseudocysts are surrounded
by an intense inflammatory reaction, which produces dense adherence of adjacent organs to the cyst and
obscures normal anatomic relationships (94). Therefore, pseudocysts localised to the neck and body of
the gland are often densely adherent to the portal
and superior mesenteric vessels posteriorly, and resection represents a difficult undertaking with cumulative results which are less acceptable than those
occurring after internal drainage of gastropseudocystostomy or jejunopseudocystostomy (103).
Indications for pancreatic resections include pseudoaneurysms associated with a pseudocyst, patients
having multiple pseudocysts, or pseudocysts located in the uncinate process or head of the pancreas in
which internal decompression is not technically fea-
Treatment of pancreatic pseudocysts
sible. Common duct or duodenal obstruction frequently cannot be relieved except by a pancreaticoduodenectomy due to the presence of one or smaller pseudocysts, which do not lend themselves to internal drainage. There are also advocates that also a
small pseudocyst or pseudocysts in the head of the
pancreas may initiate and perpetuate pancreatic inflammation and as Sankaran (6) and Nardi (112) have
noted can produce very troublesome persistent
symptoms. Sometimes these small cysts are not appreciated on ERCP and are impossible to identify by
palpation at operation and are only recognised after
pancreaticoduodenectomy is well under way (49).
LEFT-SIDED RESECTIONS
Left-sided resection, or distal pancreatectomy, are
terms applied to resection of the portion of the pancreas extending to the left of the midline and not including the duodenum and distal bile duct.
Despite the length of time distal pancreatectomy
has been in existence the rate of morbidity is still
quite significant with one-quarter to one-third of patients experiencing a postoperative complication
(113, 114). However, early postoperative results of all
kinds of pancreatic resections have improved dramatically over the two last decades, with decreased
mortality and morbidity. This is not only due to advances in pancreatic surgery but also to better anesthesiology and perioperative care. Data concerning
postoperative morbidity after pancreatic left resection show a wide range, with rates varying between
10 and 40 percent (115–120). In a French retrospective study, the morbidity among all the resected patients was 32 percent (121). Distal pancreatectomy
should be performed with almost nil mortality (122–
124).
Distal pancreatectomy can nowadays also be performed laparoscopically (125–127).
RECOMMENDATIONS
There are no randomized studies for the management protocols for pancreatic pseudocysts, and maybe it is seldom appropriate to randomize in this disease as it is difficult to find suitable patients where
experience tell that any of types of management have
the same possibility of a good outcome. Therefore,
today we have to rely on best clinical practice, but
still certain advice may be given:
– differentiate acute from chronic pseudocysts for
management
– do not miss cystic neoplasias
– always consider conservative treatment (do not
treat pseudocysts just because they are there)
– if intervention is needed, first consider a procedure
that is well known; the results of percutaneous or
endoscopic drainage are probably more dependent on the experience of the interventionist than
the choice of procedure
– if surgery is needed, wait until an intern anastomosis can hold sutures (if possible 6 weeks)
173
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Received: June 6th, 2005