The role of surgery in pancreatic pseudocyst

Objective: Surgery was the only option available for management of pancreatic pseudocyst (PP) for many years. Recently, new methods, such as percutaneous drainage, endoscopic transenteric drainage and transpapaillary drainage, have been used for treatment of a pseudocyst. However, no single technique offers the desired combination of 100% success and no complications. We present our surgical experience with PP over the past 14 years. Patients and Methods: A total of 22 patients were treated for PP in our departments in Dalin and Hualien Tzu Chi General Hospitals within the last 14 years. They were retrospectively reviewed and followed up. Results: There were 14 (63.6%) men and 8 (36.4%) women between 15 and 79-years-old (mean age 38.2 years). Dominating symptoms in most patients were epigastric pain, palpable mass, nausea, vomiting, fever and leukocytosis, and persistent elevation of serum amylase. Imaging studies, such as ultrasound, computed tomography scan, and endoscopic retrograde cholangiopancreaticography, were helpful in establishing the diagnosis. In addition to symptomatic persistent large (> 6 cm) pseudocysts, various complications, including infection, GI obstruction, rupture into the GI tract, peritonitis, GI bleeding, internal bleeding, and pancreatic ascites were indications for surgery in our cases. Operative procedures consisted of external drainage (ED, 9 cases), internal drainage using cystojejunostomy (CJ, 4 cases)and cystogastrostomy (CG, 8 cases), and distal pancreatectomy (1 case). There were ten complications (45.5%) including recurrence of cyst (1 patient with ED and 1 with CJ), recurrence with pancreaticopleural fistula (1 with ED), colon perforation (1 with ED), delayed massive bleeding (1 with CG), pancreatic fistula (3 with ED), pancreatic abscess (1 with CJ) and persistent pain (1 with CG). Repeat surgery was needed to stop bleeding (1 patient with CG) and to construct a proximal colostomy for a colon injury (1 with ED). One patient had a CJ for recurrence of pseudocyst 9 years after the first surgery. Percutaneous drainage with a wide bore tube was effective for pancreatic abscess (1 with CJ) and transpapillary drainage with a stent was used to relieve pleural effusion with respiratory failure (1 with ED). No deaths occurred in this series. Conclusion: Although complications do occur in surgical treatment, we believe that it is still important in the management of selected cases of pseudocyst of the pancreas. Surgical intervention, endoscopic drainage, and percutaneous drainage are complementary rather than competing alternatives both for simple and complicated pseudocysts.