Surgical and endoscopic treatment of pancreatic pseudocysts

Not long ago surgery was the only way to treat pancreatic pseudocysts that would not resolve spontaneously. Nowadays minimally invasive methods are gaining popularity, such as percutaneous drainage, endoscopic cystogastrostomy or cystoduodenostomy, and endoscopic transpapillary drainage. The aim of this study was to evaluate these methods in comparison with conventional surgery for pancreatic pseudocysts. From March 1997 to July 2000 we treated at the 2nd Dep. of Surgery, Wrocław Medical University, 52 patients with pancreatic pseudocysts. 30 patients were treated surgically, 15 endoscopically, and 7 medically. For endoscopic treatment we chose patients with "mature" pseudocysts, with a distinct capsule on ultrasonography, adherent to the posterior wall of the stomach, clinically sterile, at least 5-15 cms in diameter. The endoscopic criterion was the appearance of the cyst bulging into the stomach. Surgical treatment was applicable for those patients who had no positive evidence of a direct contact of the pseudocyst and the stomach, those with cysts infected, multiple or filled with dense fluid. The observed complications (infection of the cyst and bleeding) are typically reported for the treatment of pancreatic pseudocysts. The single complication in the form of an inflammatory tumor of the pancreas was probably due to undiagnosed pancreatic necrosis. There was zero mortality in our group. In our opinion endoscopic cystogastrostomy with a double pigtail stent is a valuable alternative to conventional surgery and in selected cases can be the method of choice for the treatment of pancreatic pseudocysts. Conventional surgical methods of treatment still remain valid. They are often less hazardous as they allow full visual evaluation of the cyst and its neighbourhood (for the signs of necrosis). Surgical drainage provides secure anastomosis of the cyst with the GI tract and hemostasis, which may be vital in some cases.