Endoscopic management of pancreatic pseudocyst: a long-term follow-up.

BACKGROUND AND STUDY AIMS: No studies with real long-term follow-up after endoscopic drainage of pancreatic pseudocysts are available. The present study was undertaken to investigate the long-term outcome of endoscopic management of pancreatic pseudocyst with a minimum follow-up of 2 years.

PATIENTS AND METHODS: A total of 38 consecutive patients with pancreatic pseudocyst underwent endoscopic cystogastrostomy (n = 27), endoscopic cystoduodenostomy (n = 6) and transpapillary drainage (n = 5). Patients were monitored at 1 and 3 months after drainage, and finally between 24 and 80 months. Upper gastrointestinal endoscopy was done at 1 and 3 months after drainage while ultrasound was done at 3 months and at the end of follow-up. Endoscopic retrograde cholangiopancreatography (ERCP) was only done before cyst drainage if no cyst bulge was visible in the stomach or duodenum or if obstructive jaundice was present.

RESULTS: Biliary pancreatitis was responsible for the pseudocyst in 19 cases while the remaining occurrences were caused by alcohol (n = 12) and trauma (n = 7). All forms of endoscopic drainage were effective in treating pancreatic pseudocyst and there was complete disappearance of the cyst within 3 months of drainage, irrespective of cause. Over a mean follow-up of 44.23 months (24 - 80 months). Three patients had symptomatic recurrences while three had asymptomatic recurrences; all had alcohol-induced pancreatitis. No recurrences were seen in the biliary pancreatitis and trauma group. All symptomatic recurrences were successfully managed with endoscopic cystogastrostomy and stenting. A massive bleed in one patient required surgery while stent block and cyst infection in three patients and perforation in one patient were managed conservatively. ERCP was done before cyst drainage in eight patients because there was no visible bulge into the stomach or duodenum (n = 5), or because obstructive jaundice was present (n = 3). In five patients ERCP revealed cyst duct communication. All these patients were managed by transpapillary drainage and there was only one asymptomatic recurrence in this group.

CONCLUSION: Endoscopic management of pancreatic pseudocyst is quite an effective and safe mode of treatment in experienced hands. ERCP before the procedure is only required when the cyst does not bulge into gut lumen, for a decision about the feasibility of transpancreatic drainage. On long-term follow-up, recurrences were seen only in the alcoholic pancreatitis group. In the biliary pancreatitis group, no recurrences were seen after cholecystectomy and removal of common bile duct (CBD) stones if present. No recurrences were seen in the trauma group.