Management of pancreatic pseudocysts

Opinion statement Pancreatic pseudocysts continue to pose a diagnostic and therapeutic challenge. They should be observed with regular follow-up by ultrasound examination of the abdomen. The old teaching that cysts more than 6 weeks old or 6 cm in size should be drained is no longer true. Indications for drainage are pain, enlargement of cyst, and complications (infection, hemorrhage, rupture, and obstruction), or suspicion of malignancy. The available forms of therapy include percutaneous drainage, transendoscopic approach, and surgery. The choice of the procedure depends on a number of factors. Those related to the patient include general condition, size, number and location of cysts, presence or absence of communication with the pancreatic duct, presence or absence of infection, and suspicion of malignancy. Endoscopist expertise is a major deciding factor in the choice of therapy. Surgical treatment has been the traditional approach, and it still enjoys a large degree of acceptance in most centers. However, percutaneous catheter drainage is safe, effective, and has recently been advocated as the therapy of first choice. A point of caution: Since radiologic diagnosis of “pseudocysts” may be inaccurate in up to 20% of cases, it is imperative that the physician be sure the cystic structure is not a neoplasm before percutaneous or endoscopic drainage is attempted. There have been no prospective randomized trials that have evaluated the results of the three major modalities of therapy (percutaneous, endoscopic, and surgical). Before one can recommend percutaneous drainage or endoscopic approach as the preferred initial mode of therapy, further studies are needed.