EUS-Guided Pancreatic Pseudocyst Drainage: Review and Experience at Harbor-UCLA Medical Center

Mehrdad Vosoghi, MD; Shahid Sial, MD; Benedict Garrett, MD; Jack Feng, MD; Tonny Lee, MD; Bruce E. Stabile, MD; Viktor E. Eysselein, MD

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As discussed above, there are many different techniques for pancreatic pseudocyst drainage, including surgical methods, and transcutaneous, transpapillary, and transenteric approaches, with and without EUS. Controversy exists regarding which specifically is the best method of pancreatic pseudocyst drainage. In this review, we have outlined the advantages and disadvantages of the various modalities and compared their complication, recurrence, success, and mortality rates ( Table 4 ). Earlier surgical reports have the highest complication and mortality rates. With the advances in surgical procedures and better management of both intra- and postoperative surgical complications, the mortality rate for all surgical procedures has declined dramatically in the more recent reports. However, the complication rates for surgical management of pseudocysts are still very high, even in the most recent studies. Given the low complication, recurrence, and mortality rates associated with endoscopic drainages, in addition to its acceptable success rates, we believe that surgery should be reserved for cases of endoscopic failure, endoscopic-related complications that cannot be managed endoscopically (such as uncontrolled bleeding), complicated pseudocysts, pseudocysts with high suspicion for cancer, multiple and septated cysts, cystic tumors of the pancreas, uncontrolled hemorrhagic pseudocyst, and severe pancreatic necrosis (Figure 4).

Algorithm for the management of pancreatic pseudocysts. ERCP = endoscopic retrograde cholangiopancreatography; EUS = endoscopic ultrasonography; CA = cancer

Endoscopic methods of pancreatic pseudocyst drainage are associated with a low mortality rate and acceptable success rates. EUS-guided drainage carries the least recurrence and complication rates ( Table 4 ). Although the complication rate associated with EUS-guided drainage is much lower than that associated with transpapillary drainage, EUS-guided complications are more serious (ie, bleeding and perforation vs pancreatitis).

After extensive review of the literature, we propose an algorithm for the management of pancreatic pseudocysts, as outlined in Figure 4. We agree with many experts and recommend EUS as a first step in management of pancreatic pseudocysts because it is a very low-risk procedure and its findings affect the subsequent management of patients. Norton and colleagues[30] demonstrated that EUS is useful for assessing the applicability of endoscopic drainage of pancreatic pseudocysts. In their study, EUS affected the management of 3 patients (18%). These 3 patients did not undergo endoscopic drainage because of inadequate apposition with the gut wall in 1 case, presence of extensive extragastric collateral vessels in another, and spontaneous reduction in size of the pseudocyst in the remaining case. Horst and colleagues[31] summarized their experience with EUS in 86 patients with pseudocysts. Seventeen (20%) patients were determined not to be suitable for pseudocyst enterostomy because of diffuse necrosis in 12, wall thickness of more than 1 cm in 4, and demonstration of cystic tumor in 1 patient. Fockens and associates[32] reported that a pseudocyst was not seen with EUS in 9% (3 of 32) of patients. Moreover, they changed the diagnosis in 6% of patients from pseudocyst to another cystic lesion, based on EUS findings. It should be emphasized that hypodense areas on CT may look like pseudocysts; however, on EUS, liquefied necrosis with debris may be present. These lesions should not be drained endoscopically because the risk of infection is high due to the presence of necrosis and nondrainable debris.[20] Rather, a transcutaneous approach with placement of large-bore catheters is advisable in this setting.

If the pseudocyst cannot be found on EUS or if there is spontaneous reduction in the size of the pseudocyst, no drainage procedure should be done and the pseudocyst should be followed by repeated EUS -- preferably in 1 month. If EUS findings include the presence of extensive extragastric collateral vessels and gastric varices, inadequate apposition of the pseudocyst with the gut wall, pseudocyst wall > 1 cm, pseudocyst distance from enteric wall > 1 cm, or pseudoaneurysm, we recommend that transmural drainage be avoided because of high risk of bleeding. In these cases, ERCP should be done, and if there is communication between the pseudocyst and pancreatic duct, a transpapillary approach is recommended. If that fails, the patient should be evaluated for surgical drainage.

If EUS locates the pseudocyst in the tail of the pancreas, we recommend EUS-guided transenteric drainage as the first choice of drainage technique because it would be more difficult to drain such lesions using the transpapillary method. However, when the pseudocyst is located in the head or body of the pancreas, the choice of drainage method employed first -- transpapillary or EUS-guided transenteric -- is more controversial. In this latter setting, we recommend that ERCP be performed first. If there is a communication between the pseudocyst and pancreatic duct and if the pseudocyst is small (arbitrarily defined as < 9 cm),[20] a transpapillary approach should be attempted first. Larger cysts may not drain adequately with small-diameter (7 FR) pancreatic stents. As indicated earlier, the transpapillary method is associated with less severe complications than the transenteric approach (pancreatitis vs bleeding and perforation). Thus, if the transpapillary approach fails or if the pseudocyst is not communicating with the pancreatic duct or if it is > 9 cm, then an EUS-guided transenteric drainage should be done. Finally, if the latter fails, the patient should be evaluated for surgical drainage.

With respect to pseudocysts complicated by sepsis, it is not very clear which method is the most effective -- transpapillary or transenteric. Some clinicians believe that pancreatic abscesses should be drained via an EUS-guided transenteric approach[33] because only 1 stent (usually with a small-caliber) can be placed by the transpapillary method; the thick debris could rapidly occlude these stents. Placement of a nasocystic drain is recommended to allow continuous drainage and flushing and to ensure that the drain is not occluded. An alternative to the latter is the transabdominal approach, with placement of large-bore catheters.


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