Review of management options for pancreatic pseudocysts

Abstract

Pancreatic pseudocysts (PPs) present a challenging problem for physicians dealing with pancreatic disorders. Their management demands the co-operation of surgeons, radiologists and gastroenterologists. Historically, they have been treated either conservatively or surgically, with acceptable rates of complications and recurrence. However, recent advances in radiology and endoscopy, have leaded physicians to implement percutaneous and endoscopic drainage (ED) into their treatment algorithms. Moreover, laparoscopic surgery, with its advantages, has become an attractive alternative choice when surgical drainage (SD) is required. The aim of this review is to summarize the main diagnostic and therapeutic tools in the management of pseudocysts and to present the main studies that compare the three different types of pseudocyst drainage.

Therapeutical Aspects Regarding Pancreatic Pseudocysts

“…When referring to a pancreatic pseudocyst we should consider any fluid collection located in the peripancreatic tissues (occasionally partly or wholly intrapancreatic located) (2). The location, size and age of the pseudocyst as well as the presence of complications are to be considered when implementing a therapeutical technique (3,4). The lack of guidelines regarding the optimal treatment of pancreatic pseudocysts and their rather rare appearance are reasons for which continuous dilemmas are raised about their optimal management (3).…”

“…According to the latest data, the indications of drainage of a pancreatic pseudocyst are the presence of symptoms like pain attributable to pseudocyst, discomfort, vomit, along with the development of complications like infection, bleeding or rupture in the adjacent organs (3). Furthermore, biliary, gastric or duodenal obstruction also call for drainage, as does the increasing size of the pseudocyst at follow-up or the imagistic finding on a non-complicated pseudocyst of over 6 cm in diameter (3).…”

“…Furthermore, biliary, gastric or duodenal obstruction also call for drainage, as does the increasing size of the pseudocyst at follow-up or the imagistic finding on a non-complicated pseudocyst of over 6 cm in diameter (3).…”

“…The technical options for internal drainage of a pancreatic pseudocyst include cystogastrostomy, cystoduodenostomy and cystojejunostomy using a Roux-en-Y pseudocyst-jejunal anastomosis. The type of the operation is chosen according to the pseudocysts location and to the nearest by organ pertaining to the gastrointestinal tract (3,74). For pancreatic pseudocysts densely adherent to the posterior wall of the stomach, cystogastrostomy is of choice (75).…”

“…In the late postoperative period, patients may develop diabetes, chronic pancreatic fistulas or chronic pancreatic insufficiency (76). External surgical drainage, although frequently performed in the past, nowadays has few indications (3,76). In cases in which anastomotic dehiscence is very likely to occur (because of either unexpectedly infected pseudocyst or unanticipated immature wall, incapable of holding sutures or in case of misdiagnosis) external drainage may still be used (3,76).…”