A pancreatic pseudocyst is one of the most common cystic lesion of the pancreas, it is a localized collection of fluid rich in amylase enclosed by a non-epithelialized wall, occurring as a result of acute or chronic pancreatitis, pancreatic trauma, or pancreatic duct obstruction.

Currently, at least 3 major forms of therapy are available: percutaneous drainage, surgical intervention, and endoscopic drainage. Controversy exists concerning which of these techniques should be offered to the patient as initial therapy.

Three options exist for the surgical management of pancreatic pseudocysts: excision, external drainage, and internal drainage. Surgery, which was traditionally the major treatment approach for pancreatic pseudocysts, has been challenged by latest endoscopic techniques.

Addition of endoscopic ultrasonography (EUS) for endoscopic drainage is a new and exciting development and may decrease the risks associated with endoscopic drainage.

Complications, a recurrence, success, and mortality rate for each procedure is described. The basic approach to pancreatic pseudocyst management is described in the form of an algorithm.

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Pseudocysts may complicate 7% to 15% of episodes of acute pancreatitis and 20% to 25% of cases of chronic pancreatitis. Although the spontaneous resolution of pseudocysts occurs in about 85% of cases of acute pancreatitis, resolution occurs in less than 10% of patients with chronic pancreatitis.

Persistent pseudocysts may lead to a variety of serious complications, including infection, abscess formation, bleeding from erosion into adjacent vasculatures, rupture into adjacent viscera or into the digestive tract, and compression of adjacent organs.

The timing of drainage is a controversial issue. Traditional surgical teaching was based on a classic study, which noted that pseudocysts persisting beyond 6 weeks rarely resolved and had a complication rate of nearly 50% during continued observation.

Two subsequent reviews, however, support a more conservative approach, with expectant follow-up in patients who do not have a cystic neoplasm, pseudoaneurysm, enlarging cyst, or more than minimal symptoms.

Another review recommended more prompt intervention when the pseudocyst is associated with common duct obstruction, infection, or hemorrhage.

A similar experience was noted in another series of 75 patients. In summary, then, patients with the absolute need for interventional therapy can usually be identified by symptoms of pain, gastric outlet obstruction, an inability to tolerate oral feeding, and fever or jaundice due to bile duct obstruction. Acute pancreatic pseudocysts that are symptomatic, large, or expanding usually necessitate intervention.

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Because of the severity of complications arising from chronic pseudocysts and the relative infrequency of their spontaneous resolution, it is recommended that they are drained shortly after diagnosis.

External drainage, although frequently used in the past, has few current indications. It is used mainly when a misdiagnosis has been made, when the risk of anastomotic dehiscence is high because of an unanticipated infected pseudocyst, or when an unexpectedly immature wall is discovered that is judged to be incapable of holding sutures.

The main disadvantages to external drainage are the potential for hemorrhage from mechanical abrasion by the drainage tube, the frequent development of secondary infection, persistent pancreatic fistula (in 10% of cases) that may necessitate a distal pancreatectomy, disease recurrence rate of 18%, and high mortality rate of 10%. The high mortality rate is often due to the poor condition of the patient in whom the procedure is attempted.

EUS-assisted pancreatic pseudocyst drainage is the latest addition to the armamentarium of the endoscopist for drainage of pancreatic pseudocysts. EUS has been used in the management of pancreatic pseudocyst drainage in 1989.

Currently, prototype "hot stents" are under development. Mounted on a needle-knife cutting device, they have the advantage of deploying directly after a transmural incision is made, thus obviating the need for pseudocyst guidewire placement and subsequent stent deployment.

EUS has important applications in aiding pancreatic pseudocyst drainage. These applications include:

• accurately measuring the distance from the gastrointestinal wall to the pseudocyst (a distance > 1 cm is considered a relative contraindication)
• identifying gastric varices associated with pancreatitis (endoscopic drainage should not be performed when varices are present)
• imaging gastric vessels
• identifying pseudoaneurysms
• identifying debris within pseudocysts that may not be drainable and may increase the risk of infection
• differentiating pseudocysts from other cystic lesions of the pancreas
• identifying septated cysts and
• Localizing the puncture site in the absence of a visible luminal bulge.

Thus, this technique has the theoretical advantage of reducing the risk of bleeding, perforation, and, potentially, infection. Although the risk of bleeding is reduced with the use of EUS, it is not completely eliminated.

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