The role of surgery in pancreatic pseudocyst

Surgery has been the only option available for many years for treating pseudocyst of the pancreas. Recently, new methods, such as percutaneous drainage, endoscopic transenteric drainage and transpapillary drainage, began to be used for treatment of the pseudocyst. But we have to agree that no single technique offers the desired combination of 100% success and no complications. We'd like to present our surgical experience in the past 14 years.

A total of 22 patients were treated for pancreatic pseudocyst (PP) in our departments in Dalin and Hualien Tzu-Chi General Hospital within the last 14 years. They were retrospectively reviewed and followed up until recently.

There were 14 (63.6%) males and 8 (36.4%) females aged between 15 and 79 years old (mean age 38.2 years). Dominating symptoms in most patients were epigastric pain, palpable mass, nausea, vomiting, fever and leukocytosis, and persistent elevation of serum amylase. Imaging studies, such as ultrasound, computed tomography (CT) scan, and endoscopic retrograde cholangiopancreatography (ERCP), were helpful in establishing diagnosis. In addition to symptomatic persistent large (>6cm) pseudocyst, various types of complication including infection, gastrointestinal (GI) obstruction, rupture into GI tract, peritonitis, GI bleeding, internal bleeding, and pancreatic ascites were indications for surgery in our cases. Operative procedures composed of external drainage (ED, 9 cases), internal drainage using cystojejunostomy (CJ, 4 cases) and cystogastrostomy (CG, 8 cases), and distal pancreatectomy (1 case). Ten complications (45.5%) included recurrence of cyst (1 in-ED and 1 in CJ), recurrence with pancreaticopleural fistula (1 in ED), colon perforation (1 in ED), delayed massive bleeding (1 in CG), pancreatic fistula (3 in ED), pancreatic abscess (1 in CJ) and persistent pain (1 in CG). Reoperation was needed to check bleeding (1 in CG) and proximal colostomy for colon injury (1 in ED). A case received CJ for recurrence of pseudocyst 9 years later (1 in CJ). Percutaneous drainage with wide bore tube was effective for pancreatic abscess (1 in CJ) and transpapillary drainage with stent was used to relieve pleural effusion with respiratory failure (1 in ED). No mortality occurred in this series.

We believe that surgery, though without flaws, still plays an important role in the management of selected cases of pseudocyst of the pancreas. Surgical intervention, endoscopic drainage, and percutaneous drainage were complementary rather than conflicting alternatives both for the simple and complicated pseudocysts.