Endoscopic Management of Pancreatic Pseudocysts

Abstract

Recently, endoscopic interventional procedures were introduced for nonsurgical therapy of symptomatic pancreas pseudocysts. We reported 25 patients treated by endoscopic retrograde pancreas drainage (ERPD), endoscopic cystogastrostomy (ECG), or endosopic cystoduodenostomy (ECD). ERPD was performed in 9 patients by placement of a 5 Fr. or 7 Fr. endoprosthesis transpapillary into the cyst or the main pancreatic duct. ECG was carried out in 10 cases, in 7 of these, a double pigtail catheter was additionally inserted. Three patients suffering from pseudocysts of the pancreas head were treated by ECD. In a further 3 cases, ERPD and ECG were combined. All patients reported a dramatic reduction of pain with a simultaneous increase of appetite and body weight. The drainage tubes were removed after disappearance of symptoms, and abnormal clinical and endoscopic findings within 2 to 12 months. In 4 cases, a recurrence of the cyst was found 10 and 22 months later, in 3 cases the endoprostheses had to be renewed because of catheter occlusion or dislocation. 2 patient underwent surgical treatment after insufficient endoscopic drainage due to haemorrhage or recurrence. Endoscopic treatment of pancreatic pseudocysts yielded good results with low rates of recurrence and complications. According to our experiences we think endoscopic interventional techniques will oust surgery from its present dominant position in the next years.

Minimal-access approaches to complications of acute pancreatitis and benign neoplasms of the pancreas

“…This scenario is reported to occur in 40-69% of pseudocysts [65][66][67] and is more common in patients with chronic pancreatitis (49%) than those with acute pancreatitis (20%) [68]. In a review of six studies with a total of 117 patients [68][69][70][71][72][73], initial success rates were 84%, with a long-term success rate of 75% after 2 years. Recurrence was 9% over 2 years.…”

“…A 7-to 10-F stent is often left traversing the cystgastrostomy; it is left in place for 2-4 months, or until imaging verifies pseudocyst resolution. In a combined series of 61 patients [69,72,[76][77][78][79][80], the initial success rate was 77% and long-term success rate was 59%. Recurrence was 18% with a follow-up from 9 to 48 months.…”

Therapeutical Aspects Regarding Pancreatic Pseudocysts

“…Its predictive factors of success include the presence of strictured areas, the pseudocysts size over 6 cm in diameter, location in the body of the pancreas and an evolution of the pseudocyst of less than 6 months (29). As far as the procedure's safety is concerned, there is a low morbidity and no reported mortality in patients submitted to this maneuver (29,(31)(32)(33)(34)(35). Among possible complications, hemorrhage is reported in less than 1% of cases, postprocedural pancreatitis in 5% of cases while stent migration is considered extremely rare (29,(31)(32)(33)(34)(35).…”

“…As far as the procedure's safety is concerned, there is a low morbidity and no reported mortality in patients submitted to this maneuver (29,(31)(32)(33)(34)(35). Among possible complications, hemorrhage is reported in less than 1% of cases, postprocedural pancreatitis in 5% of cases while stent migration is considered extremely rare (29,(31)(32)(33)(34)(35). Some authors reported stent obstruction in secondary infections of the pseudocyst, in which case stent change alone may be the only necessary maneuver (29,34,35).…”

“…The reported cases in the literature reach a success rate between 36-90%, varying with respecting the selection criteria for this particular method (25, 33-36, 40, 44, 49, 51-54). A high rate of success is seen in patients having pseudocysts located in the head and body of the pancreas, pseudocysts with a transmural thickness less than 1 cm as seen on computer tomography or echoendoscopy or complicating chronic pancreatitis rather than an acute necrotizing pancreatitis (25,32,35,(53)(54)(55). Intra-and postprocedural complications (occurring in under 7% of cases) include bleeding, perforation and sepsis (30), the latest being secondary to infection of necrosis within the pancreatic pseudocyst.…”