Endoscopic management of pseudocysts of the pancreas: Efficacy and complications

INTRODUCTION

Endoscopic drainage of pancreatic pseudocysts by expert endoscopists has become an accepted alternative to surgery when intervention is indicated. Its advantages over percutaneous drainage are the ability to place multiple internal drains through one puncture site and the avoidance of the development of a pancreaticocutaneous fistula for pseudocysts that communicate with the pancreatic duct. (See "Diagnosis and management of pseudocysts of the pancreas".)

This topic will review the efficacy and complications of endoscopic drainage of pancreatic pseudocysts. The endoscopic techniques that are used are discussed separately. (See "Endoscopic management of pseudocysts of the pancreas: Technique".)

EFFICACY

A landmark report in 1989 established the effectiveness of endoscopic transmural pseudocyst drainage in the setting of chronic pancreatitis [1]. Techniques have evolved, permitting pseudocyst drainage in selected cases via a transpapillary and/or transmural approaches, even when the pseudocyst does not visibly compress the stomach [2-7].

As a general rule, the endoscopic approaches to pseudocyst drainage have been most successful in the setting of chronic pancreatitis (success rates over 90 percent), followed by acute pancreatitis (success rates over 70 percent). Success rates are much lower in settings associated with pancreatic necrosis due to a higher rate of infectious complications and solid debris that cannot be drained adequately. Recurrence rates exceeding 30 percent have been observed in these settings [6,8]. Differences in success rates across studies may in part be related to variable definitions for infected pseudocysts and necrosis. The need for a more aggressive approach to endoscopic drainage and debridement in the setting of necrosis has established the term "walled off pancreatic necrosis" to distinguish these cases from simple or even complex pseudocysts [9].

Increasing experience with endoscopic pseudocyst drainage has led to its use in increasingly complex clinical settings, such as patients with multiple pseudocysts, underlying infection, or pancreatic necrosis. In addition, endoscopic approaches have been attempted earlier than the traditional six weeks that was previously required to allow the pseudocyst wall to mature. However, series involving such patients have demonstrated somewhat lower success rates and higher complication rates than the initial reports [5,7,10-14].