Endoscopic management of pancreatic pseudocysts

Pancreatic pseudocyst is a major complication of acute and chronic pancreatitis. Surgical drainage, the mainstay of therapy for this condition, is associated with 5% mortality, 25% morbidity, and 10% recurrence rates. Efforts to improve these figures and reduce the typically long hospitalizations have brought about percutaneous and endoscopic drainages. This article describes the endoscopic techniques and attempts to summarize their results based on a literature review. Before endoscopic drainage is carried out, other cystic lesions must be excluded with clinical history, computed tomography findings, and perhaps cyst fluid CEA content and cytology. Endoscopic techniques include wide transmural incision, transmural puncture and stenting, and transpapillary stenting. Either transgastric or transduodenal drainages can be carried out depending on the proximity of the pseudocyst to the gastrointestinal lumen. Endosonography has become an integral part of the transmural procedure because it can help diagnose cystic neoplasms, localize pseudocysts, detect submucosal vessels, and measure the cyst to mucosal distance for transmural punctures. Temporary nasocystic drains are often used to complement stenting during the initial treatment phase. Overall, the endoscopic experience in expert hands is associated with 94% initial technical success, 90% cyst resolution, and 16% recurrence rates. Additional nonendoscopic interventions, mostly surgical, are necessary in 17% of patients. Complication rate is 20%, with < 1% mortality. These data suggest that endoscopic drainage should become an accepted modality in the treatment of pseudocysts. Because of significant technical difficulty and potential risks, endoscopic drainages should only be carried out by experienced endoscopists and at well-equipped facilities.