From the Guidelines
Endoscopic ultrasonography (EUS)-guided drainage is the optimal approach for managing pancreatic pseudocysts, particularly for those located adjacent to the stomach or duodenum, as it offers improved precision, reduced hospital stay, and enhanced quality of life compared to other methods 1.
Key Considerations for Management
- Pseudocysts should be drained if they persist for more than 4–6 weeks, have a mature wall, and are ≥6 cm in size, causing symptoms or complications 1.
- Pre-drainage evaluation includes contrast-enhanced computed tomography (CECT) or magnetic resonance cholangiopancreatography (MRCP) and occasionally prior EUS to decide on the best approach for drainage 1.
- Prophylactic antibiotics are recommended and should be continued post-procedurally, and the use of fluoroscopy is advised during EUS-guided pseudocyst drainage 1.
Drainage Approach
- EUS-guided drainage is preferred for uncomplicated pseudocysts adjacent to the stomach or duodenum, with one or two plastic pigtail stents inserted to maintain the patency of the cystogastrostomy 1.
- The use of metallic stents for pancreatic pseudocyst drainage outside a clinical trial is not recommended, and nasocystic catheters are suggested for large or infected pseudocysts 1.
Complications and Training
- Centres performing the procedure should have multidisciplinary support, including interventional radiologists, surgeons, and anaesthesiologists, to prevent and manage complications 1.
- Skills in EUS-guided pseudocyst drainage are best acquired through observation, hands-on training in the porcine model, and then performance of the procedure in patients, with competency gained after 5–10 supervised procedures 1.
From the Research
Definition and Management of Pancreatic Pseudocysts
- Pancreatic pseudocysts (PPs) are fluid collections in the peripancreatic tissues associated with acute or chronic pancreatitis 2.
- The management of PPs demands the co-operation of surgeons, radiologists, and gastroenterologists, and has historically been treated either conservatively or surgically 3.
Diagnostic and Therapeutic Tools
- Recent advances in radiology and endoscopy have led to the implementation of percutaneous and endoscopic drainage (ED) into treatment algorithms 3.
- Endoscopic ultrasound (EUS)-guided drainage has become an established indication, with better results compared to percutaneous drainage, nonguided endoscopic drainage, or surgical drainage 2.
- The choice of technique is likely best predicated by individual patient presentation and local expertise 4.
Prognostic Factors and Spontaneous Resolution
- Prognostic factors for the development of pancreatic pseudocysts include alcohol abuse and an initial severe course of the disease 5.
- Spontaneous complete resolution of the pancreatic pseudocysts occurred in 31% of patients, with prognostic factors including no or mild symptoms and a maximal cyst diameter of <4 cm 5.
- Patients with a first severe attack of acute pancreatitis and fluid collections at discharge should be checked by ultrasonography for pancreatic pseudocysts 3 months later 5.
Endoscopic Management
- Endoscopic drainage is the first-line therapy in the management of pancreatic pseudocysts, and should be performed as part of a multidisciplinary approach in close cooperation with surgeons and interventional radiologists 6.
- Drainage may be performed either via a transpapillary approach or a transmural approach, and endoscopic necrosectomy may be performed for patients with walled-off necrosis 6.