Management of pancreatic pseudocysts

Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.