Treatment of persistent and complicated pancreatic pseudocysts

In a review of 1895 patients admitted with pancreatitis during a 4-year period, 241 (12.7%) were identified as having pseudocysts. The majority of these were treated without operation, but 59 patients (24.5%) needed surgical intervention because of persistence (17 cases) or development of complications (biliary obstruction in 16, infection in 12, duodenal obstruction in ten and haemorrhage in four). Most cysts (68%) resulted from alcohol-related chronic pancreatitis. Blunt abdominal trauma was the cause in three. Operations included internal drainage in 35 (cystogastrostomy in 23, cystojejunostomy with Roux-en-Y in ten and cystoduodenostomy in two), external drainage in 20, pancreatic resection in two, and gastroenteric or bilioenteric bypass in ten. There were six postoperative deaths (10.2%), one after internal drainage (3%) and 5 (25%) after external drainage (P < 0.01, Fisher's exact test). Pseudocyst decompression failed to relieve biliary obstruction in half of the patients and biliary-enteric anastomosis was necessary because of a stricture in the distal bile duct. Massive bleeding from pseudocyst-related false aneurysms was successfully controlled by transcatheter angiographic embolization in four patients. During 1-5 years' follow-up, 24 of the 53 surviving patients (45%) were readmitted with pancreatitis and three of these died. Pseudocysts recurred in three patients, with spontaneous resolution in two and need for operation in one. It is concluded that operative treatment of complicated pseudocysts carries a substantial mortality rate. The need for additional biliary-enteric bypass after cyst decompression should be carefully assessed during operation. Angiographic embolization of pseudocyst haemorrhage is a valuable therapeutic manoeuvre.