eMedicine Specialties > Radiology > Gastrointestinal

Pseudocyst, Pancreatic: Follow-up

Author: Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Coauthor(s): Manish K Varma, MD, Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center
Contributor Information and Disclosures

Updated: Aug 30, 2007

Intervention

Controversy exists over the optimal timing for treatment of pancreatic pseudocysts. Authors advocating conservative therapy and observation state that the old rule dictating intervention on all pseudocysts larger than 6 cm that have been present for longer than 6 weeks is not founded on solid scientific data. However, the complication rates associated with pancreatic pseudocysts are, in fact, positively correlated with the duration of the cyst's presence.

Pseudocysts may rupture spontaneously or perforate. If the pseudocyst ruptures into a hollow viscus, it may completely resolve spontaneously. Free perforation into the peritoneal cavity produces the clinical picture of an acute abdomen. The patients are operated on emergently, and the remainder of the cyst is debrided and wide drainage established.

Once a decision is made to treat a patient with a pancreatic pseudocyst, a therapeutic approach is chosen from among the existing options. These include surgical drainage, endoscopic drainage, and percutaneous drainage.

Percutaneous drainage

Percutaneous drainage is an image-guided technique performed by interventional radiologists. CT, US, or fluoroscopy can be used to guide the percutaneous drainage. Formal percutaneous drainage should always be chosen instead of simple percutaneous aspiration because simple percutaneous aspiration is associated with cyst recurrence rates of approximately 63% and overall treatment failure in 54% of patients, according to data published by Gumaste and Pitchumoni.18

Percutaneous drainage involves penetration of the pseudocyst by an image-guided needle. Next, a guidewire is inserted through the needle and into the cyst. Finally, a pigtail catheter, usually 7F to 12F in diameter, is passed over the guidewire. Gumaste and Pitchumoni describe better results with continuous drainage in this manner, with failure rates and recurrence rates of approximately 16% and 7%, respectively.18

Complications associated with percutaneous drainage include catheter-site cellulitis and damage to adjacent organs such as the spleen, stomach, colon and small bowel, with the potential for fistula formation and gastrointestinal tract hemorrhage. The most serious complication associated with percutaneous drainage is the conversion of a sterile pseudocyst into an infected pseudocyst, which is reported to occur in as many as 10% of patients.

Comparison of drainage techniques

A few studies have compared the results of surgical drainage with the results of percutaneous catheter drainage. The findings have been mixed.

Rao and coworkers reported results with 70 patients. Of the patients, 52 underwent surgical drainage, 15 underwent percutaneous catheter drainage, 2 underwent endoscopic drainage, and 1 underwent combined percutaneous and endoscopic approach. The morbidity rate was 33% in the nonsurgical group, compared with 14% in the surgical group. Resolution of the pseudocyst was accomplished at a mean duration of 20 days in the surgical group and 104 days in the nonsurgical group (P = .01).19

Criado et al described long-term success after percutaneous pseudocyst drainage in only 9 (21%) of 42 patients. Ultimately, more than half of the patients required formal surgical drainage.20

In contrast, Adams and Anderson published findings from a retrospective analysis of 94 patients. The study population consisted of 42 patients undergoing internal surgical drainage and 52 patients undergoing percutaneous pseudocyst drainage. Significant complications occurred in 16.7% of the patients undergoing surgery and in 7.7% of the patients undergoing percutaneous drainage (P > .05). A subsequent operation was required in 9.5% of the surgical group and 19.2% of the percutaneous drainage group (P > .05). A significantly higher mortality rate was associated with surgical therapy (9%) than with percutaneous therapy (1%; P < .05).21

A prospective trial conducted by Lang included 26 patients each in surgical and percutaneous drainage treatment groups. Pseudocyst resolution rates were 88% in the surgical group and 77% in the percutaneous drainage groups. Recurrence rates at 6 months were 15% and 12%, respectively. Neither of the differences were statistically significant.22

Medicolegal Pitfalls

  • Failure to diagnose a pancreatic pseudocyst
    • Current profuse usage of abdominal CT scanning and US imaging should make the failure to diagnose a pancreatic pseudocyst a rare occurrence.
    • These imaging modalities should be used liberally in the appropriate clinical scenarios, such as in a patient recovering from acute pancreatitis who presents with persistent abdominal pain or in a patient with chronic pancreatitis who has complaints such as nausea, vomiting, early satiety, or a sudden crescendo in the level of abdominal pain.
  • Failure to recognize the malignant potential of a cystic lesion of the pancreas
    • The lack of a history of pancreatitis should raise concern about the potential for a neoplastic process in a patient with a cystic lesion of the pancreas.
    • The radiologist can image the lesion, but final diagnosis depends on the pathologic examination of an adequate surgical specimen of the cyst wall.
    • Complete excision is usually necessary.
  • Failure to counsel patients adequately and completely regarding potential complications and the need for additional interventional procedures when attempting percutaneous drainage of a pseudocyst
    • Patients in whom percutaneous drainage of a pancreatic pseudocyst is under consideration should have the procedure fully explained to them, along with the risk for minor and major complications and the potential lack of resolution of the pseudocyst or its recurrence.
    • The potential need for subsequent formal operative drainage should be addressed.
 


More on Pseudocyst, Pancreatic

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Imaging: Pseudocyst, Pancreatic
Follow-up: Pseudocyst, Pancreatic
Multimedia: Pseudocyst, Pancreatic
References
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References

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Further Reading

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Keywords

lesser sac fluid collection, acute fluid collection, internal pancreatic fistula, postnecrotic pseudocysts, retention cysts, pancreatic cysts, postnecrotic pseudocysts

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Contributor Information and Disclosures

Author

Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Manish K Varma, MD, Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center
Manish K Varma, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Glenn Krinsky, MD, Chief of Abdominal Imaging Section, Associate Professor, Department of Radiology, New York University School of Medicine
Glenn Krinsky, MD is a member of the following medical societies: Alpha Omega Alpha and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Udo P Schmiedl, MD, PhD, Clinical Professor, Department of Radiology, University of Washington; Consulting Staff, Swedish Medical Center, University of Washington Medical Center, Seattle Radiologists
Udo P Schmiedl, MD, PhD is a member of the following medical societies: American College of Radiology and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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