An audit of pancreatic pseudocyst management and the role of endoscopic pancreatography.

Background: A rational algorithm for the management of symptomatic pancreatic pseudocysts is necessary with the increasing availability of radiological, surgical and endoscopic methods of treatment.

Methods: A retrospective audit of the management and outcome of all patients who presented with symptomatic pancreatic pseudocysts to the Auckland Hospital over a 9-year period (1988-96) was made.

Results: There were 44 patients (28 men, 16 women; median age 50; range 18-81) in this series. Initial management was not based on pseudocyst size, duration, location, wall thickness, the patients' symptoms and comorbidity, or the aetiology of pancreatitis. Of the 27 patients who had initial conservative management, 15 pseudocysts (56%) completely resolved. Of the 17 patients who were initially or subsequently treated with percutaneous catheter drainage (PCD), 10 pseudocysts (59%) completely resolved without additional treatment. Of the 13 patients initially or subsequently treated by surgery, all but one completely resolved after the first procedure. Two patients were successfully treated with endoscopic pancreatic stent placement. Complications arose in eight patients treated with PCD (47%) and four patients treated with surgery (31%). There was no mortality. The decision for active treatment was not preceded by delineation of the pancreatic duct by ERCP (endoscopic retrograde cholangiopancreatography) in 60% of patients.

Conclusions: More than one-third of all patients with symptomatic pancreatic pseudocysts can be managed conservatively. Surgery yields excellent results but PCD has a high failure rate in patients with an underlying pancreatic duct stricture. A rational management algorithm is presented, based on pre-intervention ERCP, which should improve patient selection and outcome.