Minimally Invasive Approaches to the Management of Pancreatic Pseudocysts

Abstract

Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross-references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.

Drainage of Pancreatic Abscesses and Cysts Under Ultrasound Control

“…Percutaneous drainage in the case of pancreatic cysts is in 67-90% of cases the final method of treatment, which was confirmed in our study (89.5%) (1,5,6,7,(10)(11)(12)(13)(14). It should be noted that the basis for drainage removal (when the release is below 10ml/day) is the completion of fistulography via the drain.…”

“…Thus, despite the tremendous differences in the clinical courses of these two conditions, treatment by means of percutaneous drainage is considered together for these two complications. Since endoscopic ultrasound (EUS) permits imaging local anatomical relations, it introduced new possibilities for performing endoscopic drainage of post-inflammatory pancreatic liquid cisterns (5,9).…”

Totally Laparoscopic Roux-en-Y Cystojejunostomy for Large Pancreatic Pseudocyst

“…External drainage is a simple method and mainly applied in emergency cases of secondary infection, rupture, or hemorrhage, but it is reported that recurrence is more likely to occur with high rate of infection and pancreatic fistula. 3,4 Endoscopic internal drainage is an alternative; however, the effect of drainage is not always satisfactory due to the inadequate communication created, and hemorrhage and perforation often happen. All these disadvantages of endoscopic drainage lead to a high rate of failure and recurrence.…”

Long-Term Outcome of Laparoscopic Cystogastrostomy Performed Using a Posterior Approach with a Stapling Device

“…In addition, various laparoscopic techniques have been described [8,9,10,11,12,13]. Our indication for this procedure is that the pseudocyst is >6 cm and has persisted beyond 6 weeks [14,15,16,17]. Three patients were treated conservatively with pseudocysts <6 cm.…”

“…The median size of pancreatic pseudocysts was 16.6 cm (range 12–19). Our indication for this procedure is that the pseudocyst is >6 cm and has persisted beyond 6 weeks [14,15,16,17]. …”