SURGICAL TREATMENT OF PANCREATIC PSEUDOCYSTS

The role of surgery in pancreatic pseudocysts has changed for several reasons. Endoscopic and percutaneous drainage techniques have become refined and universally available.5,7,11,15 The natural history of pseudocysts has disclosed that most asymptomatic pseudocysts need no treatment,15,21 and the results of cyst enteric anastomoses have shown that they function for the short term only.3,4 These technical advances and new insights have altered the indications for surgical treatment of pseudocysts. Traditionally, three surgical procedures have been used to treat pseudocysts: (1) external drainage, (2) internal drainage, and (3) surgical excision.3 Operative excision is performed least frequently. It usually involves distal pancreatectomy with splenectomy for cystic lesions in the distal pancreas. External drainage was used when thin-walled pseudocysts required surgery, usually because of infection or bad operative timing. There was strong concern that sutures placed between the pseudocyst and neighboring viscus would not hold because a thin-walled cyst necessitated placement of external drains (Fig. 1). Percutaneous external drainage was first done in 1867, long before axial body imaging was available.9 This unguided experience ended in fatality. Today, with CT and ultrasonography to guide pseudocyst drainage, there is almost no need for surgical external drainage of complicated pseudocysts because nonsurgical procedures achieve identical results. Fears of pancreatic fistula formation from external drainage have been obviated by endoscopic techniques or octreotide and the knowledge that, in the absence of duct obstruction, these fistula close spontaneously. Joining a pseudocyst to a contiguous viscera, that is, the stomach, duodenum, or jejunum, is the most popular surgical method of decompressing pancreatic pseudocysts (Fig. 2). A biopsy specimen simultaneously is obtained from the cyst wall to rule out neoplasm. In 1921, Jedlicka8 sutured the stomach to a pseudocyst and described the technique of cyst gastrostomy. He simultaneously placed a small catheter into the pseudocyst cavity that was then brought outside of the patient's body. Injecting contrast medium through the catheter at 7-day follow-up, he found that the cyst cavity was reduced by half and, at 14- to 21-day follow-up, the cyst cavity was obliterated. Twenty-five years ago, this author reconfirmed these observations in patients who underwent internal drainage of a pseudocyst to a neighboring viscus. This observation makes sense. Suturing a non–epithelial-lined structure (e.g., a pseudocyst) to an epithelial surface (e.g., the small intestine or stomach) results in an anastomotic stricture.3,4 Because a pseudocyst is non–epithelial lined, it disappears as the anastomosis obliterates. For the past 20 years, on at least two dozen occasions after a pseudocyst had been drained internally to a jejunal Roux limb with nonabsorbable sutures, patients underwent re-exploration for symptomatic pancreatitis and a planned pancreatic duct decompression. At repeat surgery, the Roux limb and suture line were easily identified (Fig. 3). In every instance, neither a patent anastomotic lumen nor a residual pseudocyst was identified. A row of intact unabsorbed sutures was present in each case (Fig. 3). Although this facilitated subsequent pancreatic duct drainage, the finding of a strictured cyst enteric anastomosis should have been anticipated. It was inevitable after uniting a non–epithelial-lined pseudocyst to the intestinal mucosa. Fears of reflux of food, secretions, bile, or enteric secretions into a cyst enterostomy or cyst gastrostomy are generally unfounded because this union is short-lived and peristalsis governs emptying of the stomach and intestine. In 10 consecutive patients who underwent cyst gastrostomy, barium swallow studies showed no reflux into the pseudocyst cavity at 1-week follow-up. At 7 to 10 days postsurgically, endoscopy showed a small or nonpatent lumen (Fig. 4). docysts whose sole indication for surgery was a symptomatic, uncomplicated pancreatic pseudocyst. Instead, in these cases, percutaneously guided drainage and endoscopic internal drainage have been used without regret or failure. The magical "myth of timing" (i.e., 6 weeks) to allow for maturation of a pseudocyst before intervention is neither magical nor truthful, and if a fluid collection or pseudocyst becomes symptomatic, it can safely be drained endoscopically or percutaneously.