Pancreatic pseudocysts: Interventional or surgical drainage?

Pancreatic pseudocyst, the most common cystic lesion of the pancreas, is a localized collection of fluid rich in amylase within or adjacent to the pancreas, enclosed by a nonepithelialized wall. Pseudocysts are a frequent complication of both acute and chronic pancreatitis, pancreatic trauma or a result of pancreatic duct obstruction. Most pseudocysts are asymptomatic, and spontaneous regression may occur. Treatment is indicated only in cases of bleeding, rupture or infection of the pseudocyst, compression of surrounding organs (i.e., main bile duct, duodenum, portal vein) by the pseudocyst, when a pseudocyst is the main cause of pain or when suspicion of a cystic tumour exists. The size of a pseudocyst is no criterion for therapeutic decisions. Treatment options include percutaneous external drainage, endoscopic transgastric or transduodenal internal drainage, and surgical internal drainage or resection. Interventional procedures seem to be the first choice in emergency situations and in critically ill patients. Elective surgery may be of advantage when there is additional pancreatic (duct) pathology or suspicion of a tumour. Comparative studies between surgical, endoscopic and percutaneous interventional therapies are still missing. The potential role of octreotide either as monotherapy or in combination with the above-mentioned therapies needs to be further evaluated in controlled studies. Thus, the choice of the therapeutic procedure is frequently influenced by local conditions such as availability of the respective method and expertise of the radiologist, endoscopist, and surgeon.