Minimally invasive treatment of pancreatic pseudocysts

Abstract

A pancreatic pseudocyst (PPC) is typically a complication of acute and chronic pancreatitis, trauma or pancreatic duct obstruction. The diagnosis of PPC can be made if an acute fluid collection persists for 4 to 6 wk and is enveloped by a distinct wall. Most PPCs regress spontaneously and require no treatment, whereas some may persist and progress until complications occur. The decision whether to treat a patient who has a PPC, as well as when and with what treatment modalities, is a difficult one. PPCs can be treated with a variety of methods: percutaneous catheter drainage (PCD), endoscopic transpapillary or transmural drainage, laparoscopic surgery, or open pseudocystoenterostomy. The recent trend in the management of symptomatic PPC has moved toward less invasive approaches such as endoscopic- and image-guided PCD. The endoscopic approach is suitable because most PPCs lie adjacent to the stomach. The major advantage of the endoscopic approach is that it creates a permanent pseudocysto-gastric track with no spillage of pancreatic enzymes. However, given the drainage problems, the monitoring, catheter manipulation and the analysis of cystic content are very difficult or impossible to perform endoscopically, unlike in the PCD approach. Several conditions must be met to achieve the complete obliteration of the cyst cavity. Pancreatic duct anatomy is an important factor in the prognosis of the treatment outcome, and the recovery of disrupted pancreatic ducts is the main prognostic factor for successful treatment of PPC, regardless of the treatment method used. In this article, we review and evaluate the minimally invasive approaches in the management of PPCs.

Full text

World Journal of
Gastroenterology
World J Gastroenterol 2015 June 14; 21(22): 6769-7064
ISSN 1007-9327 (print)
ISSN 2219-2840 (online)
Published by Baishideng Publishing Group Inc

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EDITORIAL
6769 Portal vein thrombosis in cirrhosis: Controversies and latest developments
Harding DJ, Perera MTP, Chen F, Olliff S, Tripathi D
6785 Somatostatin analogs for gastric carcinoids: For many, but not all
Massironi S, Zilli A, Conte D
6794 Prognostication and response assessment in liver and pancreatic tumors: The new imaging
De Robertis R, Tinazzi Martini P, Demozzi E, Puntel G, Ortolani S, Cingarlini S, Ruzzenente A, Guglielmi A, Tortora G,
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6817 What are the effects of proton pump inhibitors on the small intestine?
Fujimori S
TOPIC HIGHLIGHT
6820 Cardiovascular risk across the histological spectrum and the clinical manifestations of non-alcoholic fatty
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6835 Predictive roles of intraoperative blood glucose for post-transplant outcomes in liver transplantation
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REVIEW
6842 Endoscopic treatment of gastroparesis
McCarty TR, Rustagi T
6850 Minimally invasive treatment of pancreatic pseudocysts
Zerem E, Hauser G, Loga-Zec S, Kunosić S, Jovanović P, Crnkić D
6861 Advances in the study of Lynch syndrome in China
Lu JY, Sheng JQ
Contents Weekly Volume 21 Number 22 June 14, 2015
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Contents World Journal of Gastroenterology
Volume 21 Number 22 June 14, 2015
ORIGINAL ARTICLE
Basic Study
6872 Induction of endoplasmic reticulum-derived oxidative stress by an occult infection related S surface antigen
variant
Lee IK, Lee SA, Kim H, Won YS, Kim BJ
6884 Downregulation of microRNA-382 is associated with poor outcome of esophageal squamous cell carcinoma
Qi B, Lu JG, Yao WJ, Chang TM, Qin XG, Ji YH, Wang TY, Liu SG, Li HC, Liu YZ, Zhao BS
Case Control Study
6892 Nonalcoholicfattyliverdisease,spleenandpsoriasis:Newaspectsoflow-gradechronicinammation
Balato N, Napolitano M, Ayala F, Patruno C, Megna M, Tarantino G
6898 Association of colorectal cancer susceptibility variants with esophageal cancer in a Chinese population
Geng TT, Xun XJ, Li S, Feng T, Wang LP, Jin TB, Hou P
Retrospective Cohort Study
6905 Clinicopathologic and molecular features associated with patient age in gastric cancer
Seo JY, Jin EH, Jo HJ, Yoon H, Shin CM, Park YS, Kim N, Jung HC, Lee DH
Retrospective Study
6914 Medical training fails to prepare providers to care for patients with chronic hepatitis B infection
Chao SD, Wang BM, Chang ET, Ma L, So SK
6924 Prognostic angiogenic markers (endoglin, VEGF, CD31) and tumor cell proliferation (Ki67) for
gastrointestinal stromal tumors
Basilio-de-Oliveira RP, Nunes Pannain VL
6931 AssessmentofliverbrosisbyFibroscanascomparedtoliverbiopsyinbiliaryatresia
Shen QL, Chen YJ, Wang ZM, Zhang TC, Pang WB, Shu J, Peng CH
6937 Clinical impact of preoperative acute pancreatitis in patients who undergo pancreaticoduodenectomy for
periampullary tumors
Chen YH, Xie SM, Zhang H, Tan CL, Ke NW, Mai G, Liu XB
6944 Study of celiac artery variations and related surgical techniques in gastric cancer
Huang Y, Mu GC, Qin XG, Chen ZB, Lin JL, Zeng YJ
Clinical Trials Study
6952 Prevalence,signicanceandpredictivevalueofantiphospholipidantibodiesinCrohn'sdisease
Sipeki N, Davida L, Palyu E, Altorjay I, Harsfalvi J, Antal Szalmas P, Szabo Z, Veres G, Shums Z, Norman GL, Lakatos PL,
Papp M
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Contents World Journal of Gastroenterology
Volume 21 Number 22 June 14, 2015
6965 EsomeprazoleregimensforreuxsymptomsinChinesepatientswithchronicgastritis
Sun J, Yuan YZ, Hou XH, Zou DW, Lu B, Chen MH, Liu F, Wu KC, Zou XP, Li YQ, Zhou LY
6974 Detectionofsupercialesophagealsquamouscellneoplasiabychromoendoscopy-guidedconfocallaser
endomicroscopy
Huang J, Yang YS, Lu ZS, Wang SF, Yang J, Yuan J
Observational Study
6982 Cardiacautonomicdysfunctioninpatientswithgastroesophagealreuxdisease
Milovanovic B, Filipovic B, Mutavdzin S, Zdravkovic M, Gligorijevic T, Paunovic J, Arsic M
6990 Metabolic surgery and intestinal gene expression: Digestive tract and diabetes evolution considerations
Rodrigues MRS, Santo MA, Favero GM, Vieira EC, Artoni RF, Nogaroto V, Moura EG, Lisboa P, Milleo FQ
Prospective Study
6999 Assessment of the correlation between serum prolidase and alpha-fetoprotein levels in patients with
hepatocellular carcinoma
Uygun Ilikhan S, Bilici M, Sahin H, Demir Akca AS, Can M, Oz II, Guven B, Buyukuysal MC, Ustundag Y
Randomized Controlled Trial
7008 Efcacyofpoly-unsaturatedfattyacidtherapyonpatientswithnonalcoholicsteatohepatitis
Li YH, Yang LH, Sha KH, Liu TG, Zhang LG, Liu XX
SYSTEMATIC REVIEWS
7014 Treatment strategies for colorectal carcinoma with synchronous liver metastases: Which way to go?
Ihnát P, Vávra P, Zonča P
META-ANALYSIS
7022 Standard chemotherapy with cetuximab for treatment of colorectal cancer
Li XX, Liang L, Huang LY, Cai SJ
7036 Sequential
vs
simultaneous revascularization in patients undergoing liver transplantation: A meta-analysis
Wang JZ, Liu Y, Wang JL, Lu L, Zhang YF, Lu HW, Li YM
CASE REPORT
7047 Laparoscopic fenestration of pancreatic serous cystadenoma: Minimally invasive approach for symptomatic
benign disease
Dokmak S, Aussilhou B, Rasoaherinomenjanahary F, Sauvanet A, Vullierme MP, Rebours V, Lévy P
7052 Diagnosticutilityofendoscopicultrasound-guidedne-needleaspirationbiopsyforglomustumorofthe
stomach
Kato S, Kikuchi K, Chinen K, Murakami T, Kunishima F
III June 14, 2015
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Contents World Journal of Gastroenterology
Volume 21 Number 22 June 14, 2015
7059 Abnormal layering of muscularis propria as a cause of chronic intestinal pseudo-obstruction: A case report
and literature review
Angkathunyakul N, Treepongkaruna S, Molagool S, Ruangwattanapaisarn N
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Minimally invasive treatment of pancreatic pseudocysts
Enver Zerem, Goran Hauser, Svjetlana Loga-Zec, Suad Kunosić, Predrag Jovanović, Dino Crnkić
Enver Zerem, Predrag Jovanović, Department of Gastroen-
terology, University Clinical Center Tuzla, 75000 Tuzla, Bosnia
and Herzegovina
Enver Zerem, Department of Medical Sciences, The Academy
of Sciences and Arts of Bosnia and Herzegovina, 71000 Sarajevo,
Bosnia and Herzegovina
Goran Hauser, Department of Internal Medicine, Division of
Gastroenterology, Clinical Hospital Centre Rijeka, 51000 Rijeka,
Croatia
Svjetlana Loga-Zec, Institute of Pharmacology, Medical Faculty,
University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina
Suad Kunosić, Department of Physics, Faculty of Natural
Sciences and Mathematics, University of Tuzla, 75000 Tuzla,
Bosnia and Herzegovina
Dino Crnkić, Faculty of Pharmacology, University of Tuzla,
75000 Tuzla, Bosnia and Herzegovina
Author contributions: Zerem E contributed to the conception
and design of the paper, the writing of the paper and the final
revision; Hauser G contributed to the literature search, the writing
of the paper and the final revision of the paper; Loga-Zec S,
Kunosić S, Jovanović P and Crnkić D contributed to the writing
of the paper and the nal revision of the paper.
Conict-of-interest: All authors have no conicts of interest or
nancial ties to disclose.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Correspondence to: Enver Zerem, MD, PhD, Department of
Gastroenterology, University Clinical Center Tuzla, Trnovac bb,
75000 Tuzla, Bosnia and Herzegovina. zerem@live.com
Telephone: +387-35303300
Fax: +387-35266485
Received: January 24, 2015
Peer-review started: January 25, 2015
First decision: March 10, 2015
Revised: March 29, 2015
Accepted: April 28, 2015
Article in press: April 28, 2015
Published online: June 14, 2015
Abstract
A pancreatic pseudocyst (PPC) is typically a compli-
cation of acute and chronic pancreatitis, trauma or
pancreatic duct obstruction. The diagnosis of PPC
can be made if an acute fluid collection persists
for 4 to 6 wk and is enveloped by a distinct wall.
Most PPCs regress spontaneously and require no
treatment, whereas some may persist and progress
until complications occur. The decision whether to treat
a patient who has a PPC, as well as when and with
what treatment modalities, is a difcult one. PPCs can
be treated with a variety of methods: percutaneous
catheter drainage (PCD), endoscopic transpapillary or
transmural drainage, laparoscopic surgery, or open
pseudocysto enterostomy. The recent trend in the
management of symptomatic PPC has moved toward
less invasive approaches such as endoscopic- and
image-guided PCD. The endoscopic approach is suitable
because most PPCs lie adjacent to the stomach. The
major advantage of the endoscopic approach is that
it creates a permanent pseudocysto-gastric track with
no spillage of pancreatic enzymes. However, given
the drainage problems, the monitoring, catheter
manipulation and the analysis of cystic content are very
difcult or impossible to perform endoscopically, unlike
in the PCD approach. Several conditions must be met
to achieve the complete obliteration of the cyst cavity.
Pancreatic duct anatomy is an important factor in the
prognosis of the treatment outcome, and the recovery
of disrupted pancreatic ducts is the main prognostic
factor for successful treatment of PPC, regardless of
the treatment method used. In this article, we review
and evaluate the minimally invasive approaches in the
management of PPCs.
Key words: Complications; Pseudocyst; Treatment;
Drainage; Outcomes
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DOI: 10.3748/wjg.v21.i22.6850
World J Gastroenterol 2015 June 14; 21(22): 6850-6860
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
© 2015 Baishideng Publishing Group Inc. All rights reserved.
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review article presents and critically evaluates the
minimally invasive approaches for the treatment of
PPCs.
DIAGNOSIS OF PPCS
The distinction between PPC and other similar entities,
such as benign and malignant cystic lesions, vascular
pathology such as pseudoaneurysms and hematomas,
seromas, abscesses, and bilomas, is crucial in the
decision to treat a patient who has a PPC, as well
as when and by which method. This requires the
correlation of often complex and overlapping clinical
presentations and laboratory findings with those of
imaging studies, such as ultrasound (US), computed
tomography (CT), and magnetic resonance imaging
(MRI)[15,16].
Clinical presentation and laboratory ndings
PPC is typically asymptomatic, and its clinical
presentation tends to occur in cases with complications
throughout their clinical course. During physical
examination, the most common presenting symptoms
that might be attributed to the development of
symptomatic PPC are persistent abdominal pain
and/or an epigastric mass with a persistently raised
serum amylase level[17]. Clinical presentations
of PPC complications are infection, rupture and
haemorrhage[7,17]. Infection occurs in approximately
10% of cases and is characterized by fever and
abdominal pain. The leakage of the content from the
PPC into the peritoneum can cause the appearance of
pancreatic ascites. However, sudden rupture of the PPC
into the peritoneum produces severe peritonitis that
is often fatal. Haemorrhage is caused by the erosion
of the small vessels that line the cyst wall or the
erosion of surrounding major blood vessels. Intracystic
bleeding leads to a rapid enlargement of the PPC,
which produces pain and shock. Spontaneous rupture
of the PPC into the gastrointestinal tract can result in
the drainage of its contents into the gastrointestinal
tract and the amelioration of symptoms. However, this
is often associated with vomiting, hematemesis and
melena[17].
Laboratory findings have a limited value in the
diagnosis of PPC. Serum amylase and lipase levels are
persistently elevated in up to 76% of patients with
PPC. When PPC produces a biliary obstruction, the
serum bilirubin level is increased[17].
Imaging evaluation
The diagnosis of a PPC is usually established by
imaging studies, whereby a rapid progress in the
improvement of diagnostic modalities enables
detection with high sensitivity and specicity.
Because transabdominal ultrasonography is a very
inexpensive and noninvasive technique, it should be
performed as a first step in the diagnosis of PPCs.
Zerem E
et al
. Management of pancreatic pseudocysts
6851 June 14, 2015
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© The Author(s) 2015. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: Pancreatic pseudocysts (PPCs) are common
complic ati ons of acute and chroni c p ancreati tis ,
pancreatic trauma, and pancreatic duct obstruction.
They can be treated with a variety of methods: percu-
taneous catheter drainage, endoscopic transpapillary
or transmural drainage, laparoscopic surgery, or open
pseudocystoenterostomy. It is a difficult decision
whether to treat a patient with a PPC and if so, with
what treatment modalities and when. This article
presents and critically evaluates the minimally invasive
approaches for the treatment of PPCs.
Zerem E, Hauser G, Loga-Zec S, Kunosić S, Jovanović P, Crnkić
D. Minimally invasive treatment of pancreatic pseudocysts.
World J Gastroenterol 2015; 21(22): 6850-6860 Available from:
URL: http://www.wjgnet.com/1007-9327/full/v21/i22/6850.htm
DOI: http://dx.doi.org/10.3748/wjg.v21.i22.6850
INTRODUCTION
A pancreatic pseudocyst (PPC) is defined as a collec-
tion of fluid in the peripancreatic or intra-pancreatic
tissues, is surrounded by a well-defined wall and
contains essentially no solid material[ 1]. PPCs are
usually complications of both acute and chronic pancrea-
titis, pancreatic trauma, and pancreatic duct (PD)
obstruction[2-6].
It is a difcult decision whether to treat a patient
who has a PPC, and if so, when and with what
treatment modalities. PPCs should initially be managed
conservatively because many resolve spontaneously
within 4 to 6 wk. Although most PPCs regress spon-
taneously and require no treatment, some (especially
those larger than 6 cm) require treatment to prevent
cystic infection, rupture, haemorrhage, and the
resultant obstruction of the stomach, small bowel,
colon or bile ducts[7,8].
Traditionally, surgical approach was the treatment
of choice for symptomatic PPCs. Although surgery
is effective, complications can occur in up to 35%
of patients, and death from surgery has also been
noted[9]. The recent trend in the management of
symptomatic PPC has been toward less invasive
approaches such as endoscopic and image-guided
percutaneous catheter drainage (PCD)[2-13].
Several conditions must be met to achieve the
complete obliteration of the cyst cavity. PD anatomy
is an important factor for the prognosis and the
treatment outcomes. When PPC-PD communication
is identied, the mean duration of drainage increases
to weeks or months, depending on the condition of
the PD. The recovery of a disrupted PD is the main
prognostic factor for successful treatment of PPC
regardless of the treatment method[2, 11,12,14]. This

US has a diagnostic sensitivity of 75% to 90% in
detecting PPCs and the technique is highly dependent
on the experience of the examiner. It has a limited
role in the assessment of small PPCs (smaller than
10 mm). However, small PPCs are asymptomatic and
without clinical signicance, usually not requiring any
treatment[2,17].
Endoscopic ultrasound (EUS) may typically display
a small PPC, being the best method in distinguishing
acute fluid collections from pancreatic abscesses
and PPCs, with high sensitivity (93% to 100%) and
specificity (92% to 98%)[18,19]. Besides, EUS can
accurately dene the proximity of the PPC to the gut
lumen and surrounding large blood vessels. Limitations
of EUS are its inability to demonstrate large PPCs
which extend into peripancreatic areas in their entirety,
and display PPCs which are more than 1 cm distant
away from the gastric or duodenal wall[20,21].
CT scanning is a standard and precise imaging
modality in the setting of PPCs, with 82% to
100% sensitivity and 98% specificity. CT scan is
more effective than US in detecting the secondary
complications of a PPC, such as infection; hemorrhage,
and involvement of adjacent structures[18,22].
Endoscopic retrograde cholangiopancreatography
(ERCP) may be useful in patients who require
delineation of PD anatomy, helping to devise optimal
therapy. Although ERCP provides less information
regarding the pancreatic size and surrounding visceral
structures than CT and ultrasound, it renders important
information on the anatomy of the pancreatic and
biliary ductal system[14].
Magnetic resonance imaging (MRI) is a good
alternative to CT for detection of PPCs due to its ability
to characterize pancreatic and peripancreatic collections
as partially or fully fluid in consistency. Magnetic
resonance cholangiopancreatography (MRCP) may
replace ERCP in the diagnostic evaluation of pancreatic
duct. However, the diagnosis of PPC-PD communication
is rather difcult because a communication can only be
identied by MRCP if a high-intensity uid tract can be
detected between the pseudocyst and the duct[2,21,23-26].
A plain radiograph of the abdomen is rarely helpful
in diagnosing PPC. Occasionally, it may demonstrate
displacement of the gastric bubble or calcification in
the cyst wall. A chest radiograph may show elevations
of the diaphragm, pleural effusion, or a mediastinal
mass.
Differential diagnosis between pseudocysts and cystic
neoplasms
The differential diagnosis between PPCs and cystic
neoplasms may be difficult i n patients with a
pancreatic uid collection. Clinical criteria such as prior
episodes of acute pancreatitis, and data regarding
chronic pancreatitis or a calcied cystic wall less than
1 cm thick, make the diagnosis of PPC more likely.
On the contrary, weight loss, a palpable abdominal
mass, the lack of pre-existing pancreatic disease, and
multilocular cysts with non-calcied walls thicker than
1 cm, all indicate the likelihood of a cystic malignant
tumour. EUS or US-guided diagnostic puncture and
sampling of the uid content and of the PPC wall helps
to distinguish cystic malignancies from PPCs[27-29].
Research has recently focused on the identication of
new biomarkers for the diagnosis of malignant lesions.
Important criteria for malignancy are a markedly
elevated carcinoembryonic antigen (CEA) value in the
cyst uid (over 192 ng/mL) and increasing viscosity of
the cyst content[18,30].
INDICATIONS FOR TREATMENT OF PPCS
The most important question in clinical practice
related to acute or chronic PPCs is whether and when
they should be treated. A careful preliminary clinical
and imaging evaluation of benign pancreatic fluid
collections can avoid unnecessary interventions. The
majority of the simple PPCs are asymptomatic and
do not require interventional treatment. Treatment is
indicated if the complications are present or whether
intervention is necessary to prevent complications.
The indications for interventional procedures in the
treatment of PPCs are summarized in Table 1.
Symptoms result from biliary obstruction, the
effects of painful or obstructive masses, infection or
haemorrhage into the cyst, pancreaticopleural fistula
or compression of the surrounding major vessels, and
in such cases, interventional treatment is typically
indicated. Treatment is also indicated for symptomatic
PPCs that cause abdominal distension, nausea and
vomiting, pain, or gastrointestinal bleeding (Table 1).
PPCs larger than 4 cm that develop outside the
pancreas can be considered independent predictive
factors of persistent symptoms because they rarely
regress spontaneously and can cause complications[31].
Therefore, if they demonstrate either unchanged size
and morphology or progression over a period of more
than 6 wk of observation, these are relative indications
for treatment[15,31]. A relative indication for treatment
includes PPCs whose wall thickness is between 5 and
10 mm and PPCs caused by the presence of chronic
pancreatitis with duct abnormalities or stones in the
PD. In these patients, constant irritation promotes
inflammation and reduces the rate of spontaneous
regression[18,31,32]. Whenever a malignant tumour is
suspected, surgical treatment is urgently indicated
(Table 1)[33,34]. When an intervention is required, the
best option should be the application of a multidis-
ciplinary approach based on the initial imaging and
clinical ndings.
MINIMALLY INVASIVE APPROACHES TO
THE MANAGEMENT OF PPCS
PPCs as benign fluid collections in the pancreas can
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spontaneous resolution. The majority of pseudocysts
that are over 6 cm in size that persist for over
6 wk have been regarded as unlikely to resolve
spontaneously[17,18,31,36]. However, some large PPCs (>
6 cm) may undergo spontaneous resolution, which
suggests that the size of the PPC alone is not an
indication for drainage[36,37].
Chronicity adversely affects the healing of PPCs
whereby PPCs that persist for 8 to 10 wk are unlikely
to resolve spontaneously. Most PPCs that are likely to
heal do so within 6 wk, but the resolution may occur
after 24 wk or even 28 mo[17]. Chronic pancreatitis
and pancreatic calcications are also poor prognostic
indicators[18,38].
Other factors that indicate that spontaneous
regression is less likely include the presence of multiple
cysts[18,39], location in the tail of the pancreas[37], and
a wall thickness greater than 1 cm[40]. The aetiology
may also have some bearing on the outcome. PPCs
related to alcohol abuse have a more favourable
outcome compared with those of biliary aetiology.
However, traumatic PPCs may have a high percentage
of spontaneous resolution[39].
The setting of non-interventional conservative
management of PPCs is still poorly evaluated. Earlier
studies showed that conservative treatment in the
hope of spontaneous resolution was not without risks.
Several studies have warned against serious, life-
threatening complications related to the conservative
treatment of PPCs[41-44]. However, with improved
medical care, the incidence of complications as well as
the mortality rate has decreased considerably. Several
studies[36,41,45,46] have reported that some patients with
PPCs can be managed conservatively if the presenting
symptoms can be controlled. According to their results,
the complication rates with conservative management
are low (< 1%).
These results suggest that some patients with
PPCs can be managed conservatively and that some
pseudocysts can resolve with supportive medical care.
Medical care includes the use of intravenous fluids,
analgesics and antiemetics to control the presenting
symptoms caused by PPC. For patients who can
tolerate oral intake, a low fat diet is recommended,
whereas for those who cannot tolerate oral nutrition,
support can be provided via nasoenteral feeding or
total parenteral nutrition[47].
Somatostatin (octreotide) has an inhibitory effect
on pancreatic exocrine secretion, and it can be used
to decrease the pancreatic secretion, which leads to
the resolution of PPC. Octreotide has also been used
in conjunction with PCD of PPCs, which results in a
shorter drainage time. The role of somatostatin in
the management of PPCs is not clear because this
treatment has not been adequately tested and only
a handful of case series have been published[47-49].
Prospective controlled trails are necessary to
demonstrate its efcacy.
mimic cystic neoplasms. Therefore, pretreatment
evaluations of pancreatic fluid collections for
appropriate therapeutic intervention should be focused
on the exclusion of cystic neoplasms that masquerade
as pseudocysts[35]. The topic of cystic neoplasms of
the pancreas is broad, and thus this article focuses
primarily on the minimally invasive treatments of
benign PPCs. Once a PPC has been diagnosed, it must
be determined whether it can be treated conservatively
in hopes of a spontaneous resolution, or whether an
intervention is necessary to prevent complications. If
an intervention is necessary, it must be determined
whether surgical, PCD, or endoscopic drainage (ED) is
the best approach.
Conservative management
Based on earlier studies on the clinical course of PPCs,
the rate of spontaneous resolution of PPCs has been
reported to be from 8% to 70%[15,17,18]. This wide range
can be attributed to many factors that inuence PPCs,
including size, chronicity, wall thickness, multiplicity,
and aetiology.
The size of the PPC is an important determinant of
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Table 1 Indications for therapeutic intervention for pancreatic
pseudocysts
Clinical presentations and complications
Local complications
Infection of pancreatic pseudocyst
Hemorrhage into pancreatic pseudocyst
Rupture (can cause pancreatic ascites, shock and peritonitis)
Involving adjacent organs
Gastrointestinal tract:
Esophagus (secondary achalasia, mechanical dysphagia)
Stomach (clinically relevant gastric outlet stenosis, stula, intramural
gastric mass)
Duodenum (clinically relevant duodenal stenosis, stula)
Colon (clinically relevant colonic stenosis and/or rectal bleeding)
Liver (stenosis of the common bile duct with jaundice due to
compression)
Vascular:
Arterial (erosion of gastroduodenal and/or splenic artery)
Venous (thrombosis of portal and/or splenic vein)
Spleen (splenic rupture)
Genitourinary tract (stricture, stula, ureter obstruction)
Chest (pancreaticopleural stula, pleural effusion, mediastinal
extension)
Skin (subcutaneous fat necrosis)
Symptomatic pancreatic pseudocyst
Abdominal distension
Nausea and vomiting
Pain
Upper gastrointestinal bleeding
Relative indications for intervention in asymptomatic pancreatic pseudocyst
Pseudocyst > 5 cm, unchanged in size and morphology for more than
6 wk[15]
Pseudocyst > 4 cm and extrapancreatic complications in patients with
chronic alcoholic pancreatitis[31]
Cyst wall > 5 mm (mature cyst)[32]
Chronic pancreatitis with advanced pancreatic duct changes[31]
Suspected cystic pancreatic tumor (requiring surgery)[33,34]
Zerem E
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. Management of pancreatic pseudocysts

Image-guided percutaneous treatment of PPCs
Image-guided percutaneous drainage of PPCs is a well-
established and relatively inexpensive drainage method
that involves either simple percutaneous aspiration or
PCD. It is most commonly performed under ultrasound
or CT control, and in some cases, under MRI or
uoroscopic guidance (Figure 1)[2,4,8,10,17,21,35,47,50-52].
Single-step needle aspiration of PPCs is associated
with a high recurrence rate (70% or more) and
cannot be considered the optimal treatment[4,8]. The
continuous vacuum drainage system is more effective
because it continuously evacuates the cyst content
and thereby avoids the lytic action of pancreatic
enzymes that may lead to obliteration of the cyst
cavity. This approach has achieved high initial drainage
success rates (70%-100%) and reduced recurrence
rates[4,8,23,53].
Several conditions must be met to achieve the
complete obliteration of the cyst cavity. PD disruption
is the initial pathologic event that triggers PPC
formation, and its anatomy is an important factor
in the prognosis of the complete obliteration of the
cyst cavity. Therefore, the complete removal of liquid
and air, which is necessary to keep the cyst walls in
close contact, constitutes the mechanical aspect of
obliteration. The recovery of a disrupted PD has been
recognized as the main prognostic factor for successful
treatment of PPC regardless of the treatment method
used[8,10,14]. Patients with PPC-PD communication
require a longer duration of drainage, as short-
term drainage results in very high recurrence rates.
However, some authors consider that the risk of septic
complications is potentially increased with prolonged
drainage periods[2,8,14,53-55].
Percutaneous techniques are usually performed
under local anaesthesia and seem technically feasible in
the vast majority of patients with PPCs. Transperitoneal,
retroperitoneal, transhepatic, transgastric, and trans-
duodenal approaches are typically used. The access
route for drainage depends on the size, location, and
the disposition of the surrounding viscera and blood
vessels[2,4,8,23,51]. Depending on the operator’s experience,
the tandem trocar technique or the Seldinger technique
may be used. If the Seldinger technique is used, the
catheter tract should be sequentially dilated over a
guidewire. The use of three-dimensional ultrasound
and colour Doppler may help to guide the catheters
into the cyst cavities and aid in the circumvention of
major vascular structures, which increases the safety of
the procedure[2,4,17,21,47,52].
After complete evacuation of the cystic content, the
catheter should be secured to the skin and connected
to a pressure bag for continuous external drainage.
Catheter exchange may be performed as indicated.
When the PPC has resolved and the drainage output
becomes minimal (less than 10 mL/d), the catheter
should be removed[8]. Percutaneous drainage is a
safe and effective method for treatment of PPCs.
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A B
C D
Pancreatic duct
Residue
Figure 1 Appearance on ultrasound of a pancreatic pseudocyst before, during and after treatment. A: Appearance on ultrasound of a PPC in the tail of
pancreas before treatment; B: Insertion of a catheter into the PPC; C: Residue of PPC with suspected PPC-PD communication (marked by arrows) immediately after
the procedure; D: The appearance of the pancreas several months after the procedure. PPC: Pancreatic pseudocyst; PD: Pancreatic duct.
Zerem E
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. Management of pancreatic pseudocysts

Complications include catheter-related secondary
infections (9%), bleeding (1%-2%), inadvertent
traversing of the pleural space or other viscera
(1%-2%), catheter occlusion, cellulitis at the site of
entry, and sepsis[4,55]. Another limitation of PCD is
the development of pancreaticocutaneous fistulae.
However, the resulting pancreatic-cutaneous fistula
spontaneously resolves with time in 60% to 70%
of patients[4,56]. Moreover, in some cases, the fistula
can be successfully treated by image-guided PCD[57].
In the case of superinfection or drainage problems,
monitoring, catheter manipulation and analysis of the
cystic content can be performed much more easily by
PCD than by an endoscopic approach[8,21,58,59].
Endoscopic drainage of PPCs
ED provides minimally invasive access to the PPC,
which may be performed by a trans-papillary or a
trans-mural approach. Sometimes a combination of
both methods may be necessary to drain a pseudocyst.
ED is suitable because most PPCs lie adjacent to the
stomach; however, both endoscopic and radiologic
skills are required here. The aim of endoscopic
treatment is to create a connection between the
pseudocyst cavity and the gastrointestinal lumen[60].
Transpapillary/transductal endoscopic drainage is
recommended for PPCs that communicate with the
main PD or one of its side branches located in the head
or the body of the pancreas. A limited number of PPCs
may be drained via a transpapillary insertion of a stent
that bridges the main pancreatic duct or a disrupted
side branch. A favourable predictor of successful
therapy is a dilated Wirsung duct above a stenotic area
underneath the stent[4,7,61,62].
This technique involves pancreatic endoscopic
sphincterotomy, balloon dilatation of the commonly
detected PD strictures, and insertion of a guidewire
through the duct directly into the pseudocyst cavity.
Thereafter, a plastic stent of 5 F to 7 F (up to 10 F)
in diameter is inserted over the wire[4,23,63-65]. The
duration of stenting depends on the clinical course of
PPC regression[23,61]. Stents should be left in place for
a longer duration because their removal within 2 mo
is associated with a higher incidence of pseudocyst
recurrence[66]. Some authors have reported on the
routine exchange of stents every 6 to 8 wk for as long
as the PPCs remained unresolved[64].
Transpapillary drainage appears to be a safe and
effective procedure (the immediate success rate is
approximately 85%) with low morbidity (6%) and no
reported mortality. The best results are obtained when
the pseudocyst is older than 6 mo or smaller than
60 mm[64,67]. Haemorrhagic complications occurred in
less than 1% of patients and pancreatitis occurred in
5%. Stent clogging, which can lead to infection, can
be treated with stent changes alone. Broad-spectrum
antibiotics are administered in cases of infected
PPCs[4,23,61,64,65].
Transmural endoscopic drainage (cystogastrostomy
or cystoduodenostomy) is indicated for pseudocysts
that do not communicate with the main PD and that
are compressed against the digestive tract. Drainage
of the cyst fluid by the trans-mural approach is
achieved via the insertion of a stent between the
pseudocyst and the gastric lumen (cystogastrostomy)
or between the pseudocyst and the duodenal lumen
(cy stoduodenostomy). The drainage pro cedure
may be performed either by direct endoscopy as a
“semi-blind” procedure if an impression caused by
the cyst is present, or by EUS guidance. Technically,
cystoduodenostomy should be given preference over
cystogastrostomy if both routes are deemed equally
feasible. Direct endoscopic drainage can be performed
only if the PPC is located next to the gastric or the
duodenal lumen. The site of transmural puncture for a
direct endoscopic intervention should be determined
visually and uoroscopically by an observed bulge that
represents the extrinsic compression of the collection
into the gut lumen[2,68-71]. Once the bulge is located, its
apex can be identied as the optimal needle insertion
site. After needle puncture and aspiration of the
pseudocyst content (for biochemical and cytological
analyses), a guidewire should be inserted along which
an incision can be made with either a diathermic
coagulation probe or a needle-knife papillotome. Once
access has been achieved, a double pigtail catheter
can be introduced into the cyst over the wire. The
European Society of Gastrointestinal Endoscopy (ESGE)
recommends the insertion of at least two double-
pigtail plastic stents. Transmural stents should not be
retrieved before complete resolution of the PPC as
determined by cross-sectional imaging, and not before
2 mo of stenting[23,65-67,72-74].
However, a bulge is often absent with smaller
collections, collections with low serum albumin, and
collections in or near the pancreatic tail. Therefore, to
minimize the risk of complications such as the puncture
of adjacent structures, bleeding, and perforation, EUS
is increasingly used to perform ED[2,75]. Randomized
clinical trials of endoscopic transmural drainage
with and without EUS guidance showed that EUS-
visualization had an advantage over conventional
ED[68,69]. Even in large bulging pseudocysts, the EUS-
guided drainage is superior to the purely endoscopic
approach because the puncture of vascular structures
and bleeding into the collection can be avoided during
and immediately after the procedure by Doppler
sonographic visualization[2,20,76]. The use of EUS-guided
drainage has been reported, especially for PPCs that
do not bulge onto the gut wall or PPCs with parietal
vessels due to portal hypertension[4,32,64,77]. The stent
type used for endoscopic drainage is currently a major
area of interest. Conventional drainage with plastic
stents has its limitations. A covered self-expandable
metallic stent is an alternative to conventional drainage
with plastic stents because it offers the option of access
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to the stula via a larger diameter for drainage, which
may increase the nal success rate. One problem with
covered self expandable metallic stent is dislodgement,
so a metallic stent with ared or looped ends at both
extremities may be the best option[78-80].
The advantages of the endoscopic approach
compared with PCD include internal drainage and
avoidance of external stulae, but limitations include
the need for multiple repeated procedures under
sedation or anaesthesia; it is also necessary that
the location of the PPC be further than 1-1.5 cm
from the gut wall[20,65,67,81]. Moreover, in the case of
superinfection or drainage problems, the monitoring,
catheter manipulation and the analysis of cystic
content are very difcult by ED[8,11,21,82]. A combination
of a percutaneous approach with endoscopic tran-
smural drainage can prevent external fistulae and
avoid repetitive endoscopic interventions[83].
Some authors advocate the use of a combination
of transmural and transpapillary techniques to drain
pseudocysts. They have used ERCP in the same endo-
scopic session to assess and treat any PD leakage;
when PD leaks are evident, ERCP is also used for
the placement of PD stents to bridge the leak site
or stricture. Thus, when the treatment of the cause
of the pseudocyst (i.e., the duct leak) is possible by
placement of concomitant PD stents, this has been
shown to yield better outcomes[13,61,81,84]. Additionally,
in patients with disconnected duct syndrome,
transgastric stent removal results in a lack of a conduit
for drainage of pancreatic secretions, which leads to
pseudocyst recurrence[13,85].
Laparoscopic surgery
The classic open surgical approach for the treatment
of PPC requires a laparotomy with attendant risks of
morbidity and mortality. The development of advanced
laparoscopic techniques and technologies offer new
modalities for the treatment of PPCs. Laparoscopic
surgery is a method in which the lumen of the PPC
is anastomosed either to the posterior stomach wall
or to the jejunum with a linear endoscopic stapler or
with laparoscopic suturing techniques; this provides
ongoing internal drainage and decompression of the
PPC[4,7,23,86,87].
Laparoscopic drainage of mature PPCs is usually
the denitive treatment because it is associated with
a low complication rate and a good outcome in the
postoperative follow-up period. Currently, most PPCs
can be approached and managed by a laparoscopic
approach, which is due to the availability of advanced
imaging systems and cameras, better haemostatic
equipment and excellent suturing skills[23,88]. Laparo-
scopic procedures for PPC include pancreatic pseudocy-
stogastrostomy, pseudocystoduodenostomy, and
pseudocystojejunostomy.
Cystogastrostomy is the most commonly used
laparoscopic procedure, and it can be performed via
the endogastric, transgastric, or exogastric routes. In
cases where pseudocysts contain significant debris
because of the larger size of the stoma that is created,
laparoscopy seems to have a distinct advantage over
endoscopic drainage[4,7,23].
Several authors reported that laparoscopic
drainage was associated with low morbidity (early
postprocedure bleeding and infection), rapid recovery,
and recurrence rates comparable to those reported
for open surgery. The disadvantage of laparoscopic
surgery is that it may not be suitable for patients who
are unt to undergo general anaesthesia or for patients
who had undergone extensive previous abdominal
surgery. Although laparoscopic management has been
reported with encouraging results, long-term follow-up
results have yet to show equivalence to those of open
surgery. Additionally, randomized controlled trials that
compare PCD, laparoscopic and ED techniques for the
management of PPCs are required[7,8,23,89].
CONCLUSION
PPC usually runs asymptomatically and its clinical
presentation mainly occurs in case of complications
during its clinical course. Once a PPC is diagnosed, it
must be determined whether it can be treated conser-
vatively with the hope of spontaneous resolution, or if
an intervention is necessary to prevent complications.
The setting of conservative management of PPCs is
still poorly evaluated. Several studies have reported
that some patients with PPCs can be managed
conservatively with supportive medical care if the
presenting symptoms can be controlled.
If intervention is necessary, it must be determined
whether surgical treatment, PCD, or ED is the best
approach. Much overlap exists in the various treatment
options offered by interventional radiologists, gastro-
enterologists, and surgeons, and often a combined
approach is needed. Several conditions must be met
to achieve the complete obliteration of the cyst cavity.
PD anatomy is an important factor in the results of the
treatment. When PPC-PD communication is identied,
the mean duration of drainage increases to weeks or
months, depending on the condition of the PD. The
recovery of disrupted PD is the main prognostic factor
for successful treatment of PPC regardless of the
treatment method used.
Traditionally, symptomatic PPC has been treated
by surgical internal drainage. However, this treatment
involves considerable surgical trauma and general
anaesthesia.
The recent trend in the management of sympto-
matic PPC has moved toward less invasive approaches
such as ED, image-guided PCD and minimal invasive
surgery.
ED of PPCs may be performed by a trans-papillary
or a trans-mural approach and is suitable because
most PPCs lie adjacent to the stomach. The major
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advantage of the endoscopic approach is that it creates
a permanent pseudocysto-gastric track with no spillage
of pancreatic enzymes, which reduces the risks of
formation of pancreatico-cutaneous stulas; this is in
contrast to PCD. Moreover, PCD that persists too long
is not practical, especially for young and professionally
active patients. Therefore, some authors suggest that
ED should be the preferred modality for PPCs that
are located immediately adjacent to the gastric or
duodenal wall.
However, with these potential drainage problems
(which could appear with both techniques), the
monitoring, manipulation or change of stent, and
the analysis of cystic content are very difficult or
impossible to perform endoscopically, unlike the PCD
approach. Moreover, PCD is less aggressive compared
with surgical and endoscopic (especially with ERCP)
methods, is suitable for the treatment of all PPCs
regardless of their location and can be performed
without general anaesthesia. Therefore, this treatment
option is especially recommended for patients who are
unsuitable for more aggressive methods and for those
at a high risk for complications of general anaesthesia.
Some authors advocate the use of a combination
of transmural and transpapillary techniques to drain
pseudocysts. Some have used ERCP in the same
endoscopic session to assess and treat any PD leakage,
and when PD leaks were evident, ERCP was used for
the placement of PD stents to bridge the leak site or
stricture. However, because it has not been clearly
confirmed that the introduction of stents leads to
permanent recovery of PD and permanent cessation of
the leakage of pancreatic juice after the stent removal,
the use of this intervention is questionable. The reason
for this is that it may represent overtreatment in
these patients, given the mechanical trauma of the
placement and the removal of the PD stent, that the
two demanding interventions (ERCP) are performed
under conscious sedation, and the cost-benet effect.
Laparoscopic management has been reported with
encouraging results, but long-term follow-up results
have yet to show equivalence to open surgery and
other minimally invasive methods. The disadvantage of
laparoscopic surgery is that it may not be suitable for
patients who are unt to undergo general anaesthesia
or for patients with a history of extensive previous
abdominal surgery.
Currently, few randomized controlled studies
have been performed that compare the various
minimally invasive approaches in the management
of PPCs. Several groups worldwide have developed
new minimally invasive approaches for the treatment
of PPC. Applicability of these techniques is highly
dependent on the availability of specialized expertise
and multidisciplinary teams that are dedicated to the
management of pancreatic diseases. This review article
is intended to help physicians base their therapeutic
decisions about minimally invasive management of
PPCs on the current state of therapeutic technology
and published data.
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88 Palanivelu C, Senthilkumar K, Madhankumar MV, Rajan
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P- Reviewer: Bramhall S, Kaneko K, Kawakubo K, Park JY,
Sierzega M
S- Editor: Ma YJ L- Editor: A E- Editor: Ma S
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