Treatment of pseudocysts in acute pancreatitis. Retrospective study of 45 patients]

A total of 55 pancreatic pseudocysts in 45 patients with acute pancreatitis were managed between 1980 and 1990. Six patients were managed conservatively with resolution of pseudocysts in 5 patients. All pancreatic pseudocysts that disappeared were smaller than 35 mm. CT or ultrasound-guided aspiration were performed in 26 patients with a morbidity rate of 5%. Nine among 21 patients (42%) who were initially treated by percutaneous puncture were definitively cured: all pseudocysts were smaller than 55 mm. Nine patients were managed by long-term percutaneous drainage: 3 minor complications occurred and in 7 patients, no other treatment was necessary even for large pseudocysts. Endoscopic cystoenterostomy was performed in 12 patients. Only 15 pseudocysts (27%) bulged into the digestive wall, mainly of the stomach. Three complications (following 2 cystogastrostomies) occurred and one patient died after endoscopic cystogastrostomy. In 7 patients (58%), no other treatment was necessary even for large pancreatic pseudocysts. Surgery was required in 13 patients but only 4 patients underwent surgery as primary treatment. One major complication occurred and one patient died. Percutaneous drainage and endoscopic cystoenterostomy when technically feasible, are effective treatments of pancreatic pseudocysts complicating acute pancreatitis.     

Isoamylase determination by isoelectric focusing in pancreatic disorders. A potential clinical aid

Isoamylase analysis by isoelectric focusing was performed in the serum of 30 healthy volunteers, 65 patients with acute or chronic pancreatic diseases, nine with acute abdomen, four with macroamylasemia, and four with duodenal duplication. In controls, up to four fractions (2 salivary, 2 pancreatic) were found; the pancreatic fractions were as a mean 44.7% (SD 8.6) of total. In chronic pancreatitis, only patients with steatorrhea showed a significant reduction of pancreatic isoamylase (p less than 0.001). In all patients with acute pancreatitis or pseudocysts, an additional fraction (similar to the so-called P3 fraction) was resolved. Moreover, additional isoenzymes were found in all patients with severe acute pancreatitis or pseudocysts, and not in controls or patients with mild forms, acute abdomen or duodenal duplication. A similar pattern was shown in a stored control serum after 10 mo at -20 degrees C. These fractions disappeared after successful surgical drainage. No specific alteration was found in pancreatic cancer. Amylase fractionation by isoelectric focusing can be used to confirm an acute pancreatitis, and to monitor patients with pancreatic pseudocysts and collections after surgical drainage.     

JPN Guidelines for the management of acute pancreatitis:surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

Ultrasonically guided percutaneous drainage of abdominal fluid collections: a long-term study of its therapeutic efficacy

Fifty patients underwent ultrasonically guided percutaneous drainage (US-GPD) either with needle aspiration or catheter drainage. The procedures resulted in 70% complete recovery, 20% partial success and 10% of failures. The same patients were followed with clinical examination and sonography for a mean time of 36.3 months (minimum follow-up: 12 months). During the follow up period, 10 relapses occurred and one patient, considered for surgery after partial percutaneous treatment of a pyogenic liver abscess, recovered completely under conservative treatment. An analysis of the factors potentially related to the recurrence was made. It was found that one-step needle aspiration of abdominal abscesses and percutaneous treatment of chronic pancreatic pseudocysts are more prone to relapses. We conclude that US-GPD is an efficacious therapy for abdominal fluid collections, but an adequate drainage technique and a careful selection of the patients is crucial to avoid the possibility of relapse.     

Pancreatic Pseudocysts

Opinion statement Pseudocysts complicate acute pancreatitis in less than 5% of cases and chronic pancreatitis in 20% to 40% of cases. A pseudocyst is a localized collection of pancreatic fluid surrounded by a wall of granulation tissue and collagen. It takes 4 to 6 weeks for a fluid collection to mature and become a true pseudocyst. Unlike other cystic lesions of the pancreas from which they should be differentiated, pseudocysts lack an epithelial layer. Patients with pseudocysts present with a range of symptoms and signs. Pseudocysts are imaged using transabdominal ultrasound, CT, endoscopic ultrasound (EUS), and MRI. EUS confers an advantage over other imaging modalities in that certain EUS features are suggestive of pseudocysts over other cystic lesions. The diagnostic accuracy of EUS has improved further with the use of EUS-guided fine-needle aspiration. Therapeutic options include watchful observation or intervention. In our opinion, if acute pseudocysts are uncomplicated, asymptomatic, and do not appear to be enlarging on serial imaging, it is preferable to withhold intervention because many of these cysts resolve spontaneously. However, one needs to beware of the possibility of complications such as infection in unresolved pseudocysts. Pseudocysts associated with chronic pancreatitis are less likely to resolve spontaneously and are drained by intervention more frequently. Of the three interventional options, namely endoscopic, percutaneous, and surgical drainage, endoscopic drainage should be the treatment of choice if certain criteria are met. Preinterventional endoscopic retrograde cholangiopancreatography is mandatory to define ductal anatomy. If there is communication between the pseudocyst and the pancreatic duct, a transpapillary approach is preferred. Use of EUS should increase the number of cases in which pseudocysts can be drained endoscopically. Surgery should be reserved for cases in which there is a concern about malignancy or when there is glandular disruption.     

各型胰腺假性囊肿的治疗策略及预后判断

目的 分析各种急性和慢性胰腺假性囊肿(PPs)的特征和预后,探讨侵入性治疗PPs的预测因子.方法 回顾性分析1995年1月至2004年12月日本医科大学诊治的36例PPs患者的临床资料.将患者分成急性胰腺炎并发的PPs自发缓解组(急性缓解组);急性胰腺炎并发的PPs症状持续或有并发症需要侵入治疗组(急性治疗组);慢性胰腺炎并发的PPs自发缓解组(慢性缓解组)和慢性胰腺炎并发的PPs症状持续或有并发症需要侵入治疗组(慢性治疗组),每组9例.结果 36例患者中,女性13例,男性23例.胰腺炎病因:酒精性18例(50.0%),胆源性8例(22.2%),其他原因10例(27.8%).平均随访时间(24.2±18.5)个月.绝大多数囊肿(32/36,88.9%)与主胰管不相交通;各组囊肿数量、部位均无显著差异;慢性缓解组囊肿直径最小,均<4 cm,显著小于其他3组(P<0.05);两缓解组的囊肿多数无增大,而两治疗组的囊肿绝大多数有增大;急性治疗组中4例(44.4%)囊壁增厚(>2～3cm),慢性治疗组中1例(11.1%)囊壁增厚,余囊壁正常.急性PPs的病因多为胆源性,多数位于胰尾,而且这些患者的体表指数、囊肿大小、确诊时有PPs相关症状的例数均显著高于慢性PPs.结论 随访期间PPs体积增大强烈提示需要侵入治疗.慢性PPs囊肿直径<4 cm是预后良好的指标,急性PPs直径<8 cm是自然消退的指标.     

Endoscopic treatment of pseudocysts and abscess in acute pancreatitis

We report on 4 cases of necrotic pseudocysts complicating acute pancreatitis, treated by endoscopic cystostomy (3 cystogastrostomies, 1 cystoduodenostomy). Acute pancreatitis was secondary to biliary stones in 2 cases, post-surgical in one case and post-ERCP in the last case. Endoscopic treatment was performed because of recurrence of pseudocysts after percutaneous drainage guided by ultrasonography or CT scan. In 3 cases, pseudocysts were infected (pancreatic abscesses) and in 2 patients, surgery was contraindicated (severe respiratory and multiple organ failure). The outcome was uneventful in all the 4 cases and pseudocysts disappeared in a few days or weeks in 3 patients. The fourth patient underwent a complementary surgical cystogastrostomy. Endoscopic cystostomy appears to be a safe and efficient technique when performed in pseudocysts located close to the digestive wall and responsible for bulging visible during upper GI endoscopy.     

Management of fluid collections and necrosis in acute pancreatitis

According to the Atlanta classification, the most widely accepted clinically based classification system for acute pancreatitis, four pathologic entities of fluid collections and necrosis are recognized. Acute fluid collections occur early as an exudative reaction to the pancreatic inflammation, have no fibrous wall, and resolve spontaneously. Pancreatic necrosis, the most severe form of acute pancreatitis, is diagnosed on dynamic contrast-enhanced computerized tomography and requires early aggressive cardiorespiratory resuscitation, nutritional support, and appropriate systemic antibiotics to prevent superinfection. Development of infection (infected necrosis) is the indication for operative debridement, preferably as late in the course of the disease as possible. Acute pseudocysts are collections of pancreatic, enzyme-rich fluid caused by pancreatic ductal disruption that occur 3 to 6 weeks after onset of acute pancreatitis and have a well-defined, nonepithelial fibrous wall. If communication with the ductal system is present, internal enteric drainage (either operative or endoscopic) is more effective; if communication is not present, the pseudocysts are amenable to percutaneous drainage. A pancreatic abscess is an infected, circumscribed peripancreatic collection, associated with minimal or no parenchymal necrosis, that occurs late (4 to 6 weeks) after onset of severe pancreatitis and may represent an infected pseudocyst; percutaneous drainage is the treatment of choice.     

Management of fluid collections and necrosis in acute pancreatitis

According to the Atlanta classification, the most widely accepted clinically based classification system for acute pancreatitis, four pathologic entities of fluid collections and necrosis are recognized. Acute fluid collections occur early as an exudative reaction to the pancreatic inflammation, have no fibrous wall, and resolve spontaneously. Pancreatic necrosis, the most severe form of acute pancreatitis, is diagnosed on dynamic contrast-enhanced computerized tomography and requires early aggressive cardiorespiratory resuscitation, nutritional support, and appropriate systemic antibiotics to prevent superinfection. Development of infection (infected necrosis) is the indication for operative debridement, preferably as late in the course of the disease as possible. Acute pseudocysts are collections of pancreatic, enzyme-rich fluid caused by pancreatic ductal disruption that occur 3 to 6 weeks after onset of acute pancreatitis and have a well-defined, nonepithelial fibrous wall. If communication with the ductal system is present, internal enteric drainage (either operative or endoscopic) is more effective; if communication is not present, the pseudocysts are amenable to percutaneous drainage. A pancreatic abscess is an infected, circumscribed peripancreatic collection, associated with minimal or no parenchymal necrosis, that occurs late (4 to 6 weeks) after onset of severe pancreatitis and may represent an infected pseudocyst; percutaneous drainage is the treatment of choice.     

Management of patients after recovering from acute severe biliary pancreatitis

Cholelithiasis is the most common cause of acute pancreatitis,accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned,the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management,including cholecystectomy,endoscopic retrograde cholangiopancreatography(ERCP) and sphincterotomy,or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process,usually not earlier than 6 wk after onset of acute pancreatitis,seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed,but if used for definitive treatment,they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques,if not therapeutic,can be used as a bridge to definitive operative treatment,which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.     

Pancreatic pseudocysts: Prognostic factors for their development and their spontaneous resolution in the setting of acute pancreatitis

Background and aimPrevious studies on the development of pancreatic pseudocysts following acute pancreatitis were monocentric, mostly retrospective, did not fulfil the Atlanta criteria, and featured a mixture of patients with post-acute and chronic pancreatitis. Therefore, the natural course of pancreatic pseudocysts after acute pancreatitis and the reasons for their spontaneous resolution remain unknown.MethodsThis prospective study of 369 patients investigated the prognostic factors for development of pancreatic pseudocysts and for their spontaneous resolution after a first episode of acute pancreatitis.ResultsOn discharge, 124 (34%) patients still had pancreatic fluid collections. The prognostic factor for these fluid collections was severe acute pancreatitis. Follow-up examination 3 and 6 months later showed pancreatic pseudocysts in 36 (10%) patients (30 with and 6 without prior fluid collection), and in 27 (7%) patients (25 with and 2 without pancreatic pseudocyst after 3 months), respectively. The prognostic factors for their development were alcohol abuse and an initial severe course of the disease. Spontaneous complete resolution of the pancreatic pseudocysts occurred in 11 (31%) of the 36 patients. Prognostic factors for the spontaneous resolution were no or mild symptoms (nausea, vomiting, abdominal pain) and a maximal cyst diameter of <4 cm.ConclusionsPatients with a first severe attack of acute pancreatitis and fluid collections at discharge should be checked by ultrasonography for pancreatic pseudocysts 3 months later. In patients with a small pseudocyst and mild symptoms therapy may be postponed for a further 3 months, since spontaneous resolution is possible.     

Endoscopic management of pancreatic pseudocysts and necrosis

Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.     

Management of complicated acute pancreatitis: Impact of computed tomography

The usefulness of computed tomography (CT) in guiding the management of 43 patients who had a complicated clinical course of acute pancreatitis was retrospectively studied. The CT scans were performed when patients had persistent fever, leucocytosis, hyperamylasaemia, palpable abdominal masses or when there was organ failure. The CT scans showed normal findings in six patients, features of pancreatic abscess in three patients, pseudocysts in three patients and inflammatory masses (a mixture of sterile inflammation and necrosis) in 31 patients. Patients with pancreatic abscesses underwent emergency laparotomy, drainage and debridement; patients with pseudocysts had delayed drainage unless complication occurred; patients with normal CT scan or findings of inflammatory masses were managed conservatively. For patients undergoing conservative management, repeated CT scanning and percutaneous aspiration of the inflammatory mass was performed when pancreatic sepsis was strongly suspected. By this approach, basing on careful clinical and CT scan surveillance, five patients with pancreatic sepsis (pancreatic abscess and localized abscess collection in pseudocyst) underwent emergency surgery and four survived, while 25 patients with inflammatory masses were successfully managed conservatively and some who may have been operated on clinical grounds were spared unnecessary early debridement surgery.     

Endoscopic ultrasound-guided drainage of peripancreatic fluid collections: What impacts treatment duration?

Background: Peripancreatic fluid collections(PFCs) are complications resulting from acute or chronic pancreatitis and require treatment in certain clinical conditions. The present study aimed to identify the factors influencing the duration of endoscopic ultrasound(EUS)-guided drainage of symptomatic pancreatic pseudocysts(PPCs), walled-off necrosis(WON), and acute necrotic collections(ANCs). Methods: This was a retrospective cohort study of 68 patients with PFCs who underwent EUS-guided drainag...     

The size of pancreatic pseudocyst does not influence the outcome of invasive treatments

BACKGROUND: Authors generally agree that Giant Pancreatic Pseudocysts (> 10 cm) have a lower spontaneous resolution and are more difficult to treat than smaller pancreatic pseudocysts. This study was carried out on two groups of patients with larger and smaller pancreatic pseudocysts (pancreatic pseudocysts > 10 cm versus pancreatic pseudocysts < 10 cm), and aims to establish whether the size of pancreatic pseudocysts is a factor influencing treatment outcomes. PATIENTS AND METHODS: In a retrospective study, we examined 71 patients with pancreatic pseudocysts following an episode of acute pancreatitis, which were treated in our hospital from 1980 to 2000. Forty-one (57.5%) patients had a large pancreatic pseudocyst. Most patients underwent invasive treatments: 9 (12.6%) had percutaneous drainage, 37 (52.1%) open surgery and 13 (18.3%) endoscopic cyst gastrostomy. 12 patients (16.9%) of the 71 were cured with medical therapy alone. RESULTS: As far as the aetiology of the pancreatitis, location and number of the cysts were concerned, no major differences emerged between the two groups, although large pancreatic pseudocysts followed more severe pancreatitis (P = 0.0005). All giant pancreatic pseudocysts required invasive treatments; 40% of the pancreatic pseudocysts < 10 cm were successfully treated with medical therapy alone. No statistical differences were found regarding hospital mortality, morbidity, recurrence rate and hospital stay among the patients treated invasively. CONCLUSIONS: Giant pancreatic pseudocysts more often require invasive therapy due to persistent symptoms or complications. Treatment outcomes do not seem to be influenced by the size of the pancreatic pseudocysts.     

Pancreatic pseudocyst

Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications （infection, gastric outlet or biliary obstruction, bleeding）. Three different strategies for pancreatic pseudocysts drainage are available： endoscopic （transpapillary or transmural） drainage, percutaneous catheter drainage, or open surgery. To date, no prospective controlled studies have compared directly these approaches. As a result, the management varies based on local expertise, but in general, endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate. A tailored therapeutic approach taking into consideration patient preferences and involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and pancreatic surgeon should be considered in all cases.     

Long term outcome of endoscopic drainage of pancreatic pseudocysts

Objective: Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures. Methods: All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates. Results: Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (>1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%. Conclusion: Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of <1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.     

Endoscopic pancreatic stenting was effective in a case of pancreatic duct disruption and leakage due to pancreatic cancer

A 79-year-old man was admitted on the suspicion of acute pancreatitis. Computed tomography showed acute fluid collection but not typical acute pancreatitis; it formed pseudocysts gradually around the pancreas. Endoscopic retrograde pancreatography (ERP) revealed pancreatic disruption and leakage. Endoscopic nasopancreatic drainage (ENPD) and endoscopic pancreatic stenting (EPS) resulted in collapse of pseudocysts, improvement of symptoms and laboratory data, and a mass in the pancreatic body became distinct. The specimens obtained with endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) showed pancreatic cancer. In conclusion, ENPD and EPS are effective for pancreatic leakage with disruption of the pancreatic duct, and we should take into consideration the possibility of pancreatic cancer when we see patients with pancreatic disruption.     

Endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts

BACKGROUND: Surgery is the traditional treatment for symptomatic pancreatic pseudocysts, but the morbidity is still too high. Minimally invasive endoscopic approaches have been encouraged. AIMS: To evaluate the efficacy of endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts. METHODS: From January, 2003 to August, 2006, 31 consecutive symptomatic patients submitted to 37 procedures at the same endoscopic unit were retrospectively analysed. Chronic and acute pancreatitis were found in, respectively, 17 (54.8%) and 10 (32.3%) cases. Bulging was present in 14 (37.8%) cases. Cystogastrostomy or cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control. By protocol, only a single plastic stent, without nasocystic drain, was used. Straight or double pigtail stents were used in, respectively, 22 (59.5%) and 15 (40.5%) procedures. RESULTS: Endoscopic ultrasound-guided transmural drainage was successful in 29 (93.5%) patients. Two cases needed surgery, both due to procedure-related complications. There was no mortality related to the procedure. Twenty-four patients were followed-up longer than 4 weeks. During a mean follow-up of 12.6 months, there were six (25%) symptomatic recurrences due to stent clogging or migration, with two secondary infections. Median time for developing complications and recurrence of the collections was 3 weeks. These cases were successfully managed with new stents. Complications were more frequent in patients treated with straight stents and in those with a recent episode of acute pancreatitis. CONCLUSIONS: Endoscopic transmural drainage provides an effective approach to the management of pancreatic pseudocysts.     

Pancreatic cysts and pseudocysts associated with acute and chronic pancreatitis

We reviewed 106 consecutive patients with cysts or pseudocysts of the pancreas associated with pancreatitis. A pancreatic fluid collection (PFC) was defined as a limited collection containing pancreatic juice either pure or with pus or blood. Seventy-seven patients presented with chronic pancreatitis (CP) and 29 patients presented with acute pancreatitis (AP). CP-associated PFC was observed in young alcoholic men (mean age 40.8 years) on a high fat, protein, and carbohydrate diet. None of this group had gallstones. In this population, PFC was located in the head of the pancreas in 68% of the cases, was partly extrapancreatic in 22% of the cases, and resolved spontaneously in 9%. AP- associated PFC was as frequent in nonalcoholic men as in nonalcoholic women and presented with gallstones in 48%. They developed later (mean age 53.0 years), resolved spontaneously in 20%, and were located in the body or tail of the gland in 69%. CP-PFC may be designated retention cysts or retention pseudocysts (extrapancreatic); AP-PFC may be designated necrotic pseudocysts.