Issues in management of pancreatic pseudocysts

Pancreatic pseudocysts (PPs) comprise more than 80% of the cystic lesions of the pancreas and cause complications in 7-25% of patients with pancreatitis or pancreatic trauma. The first step in the management of PPs is to exclude a cystic tumor. A history of pancreatitis, no septation, solid components or mural calcification on CT scan and high amylase content at aspiration favor a diagnosis of PP. Endoscopic ultrasound (EUS)-guided FNAC is a valuable diagnostic aid. Intervention is indicated for PPs which are symptomatic, in a phase of growth, complicated (infected, hemorrhage, biliary or bowel obstruction) or in those occurring together with chronic pancreatitis and when malignancy cannot be unequivocally excluded. The current options include percutaneous catheter drainage, endoscopy and surgery. The choice depends on the mode of presentation, the cystic morphology and available technical expertise. Percutaneous catheter drainage is recommended as a temporizing measure in poor surgical candidates with immature, complicated or infected PPs. The limitations include secondary infection and pancreatic fistula in 10-20% of patients which increase complications following eventual definitive surgery. Endoscopic therapy for PPs including cystic-enteric drainage (and transpapillary drainage), is an option for PPs which bulge into the enteric lumen which have a wall thickness of less than 1 cm and the absence of major vascular structures on EUS in the proposed tract or those which communicate with the pancreatic duct above a stricture. Surgical internal drainage remains the gold standard and is the procedure of choice for cysts which are symptomatic or complicated or those having a mature wall,. Being more versatile, a cystojejunostomy is preferred for giant pseudocysts (>15 cm) which are predominantly inframesocolic or are in an unusual location. In PPs with coexisting chronic pancreatitis and a dilated pancreatic duct, duct drainage procedures (such as longitudinal pancreaticojejunostomy) should be preferred to a cyst drainage procedure.