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Endoscopic drainage of pancreatic pseudocysts
0016-5107/85/3105-0322$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1985 by the American Society for Gastrointestinal Endoscopy
Endoscopic drainage of pancreatic pseudocysts R. A. Kozarek, MD, c. M. Brayko, MD J. Harlan, MD, R. A. Sanowski, MD I. Cintora, MD, A. Kovac, MD Phoenix, Arizona
Enlarging pancreatic pseudocysts, as well as those that develop complications such as bleeding, leak, infection, and intestinal or biliary obstruction, require treatment. This treatment is usually surgical and consists of internal or external drainage or, less commonly, excision. Transcutaneous aspiration with or without drain placement has also been reported. We describe four cases of endoscopic cystogastrostomy and cystoduodenostomy undertaken in high risk patients who had either failed previous surgery (two) or were initially refused surgery because of prohibitive operative risk (two). Technique, limitations, and potential use of this procedure are discussed.
The treatment of acute and chronic pancreatic pseudocyst has been hotly debated. Small, asymptomatic pseudocysts, particularly less than 5 cm in diameter, seldom complicate and can be watched medically.! Symptomatic pseudocysts and those cysts that develop complications (bleeding, abscess formation, intestinal or biliary obstruction), as well as pseudocysts which are increasing in size, usually require drainage. 2- 4 Such drainage may be internal (cystogastrostomy, cystoenterostomy) or external or rarely may be effected by excision of a suitably situated lesion. 5- 7 Abdominal CT or ultrasonographically guided percutaneous cyst aspiration has also been reported and is being used in some centers.8-11 We describe an additional modality, endoscopic cystostomy, in four high risk patients in whom surgery had been either unsuccessful or was felt to be contraindicated. CASE REPORTS Patient 1
A 39-year-old white man was initially seen at the Phoenix VA Medical Center in April 1982 for intractable epigastric pain and enlarging pancreatic pseudocyst. Past medical history was significant for hypertension controlled with propranolol and multiple episodes of pancreatitis since March 1981. Workup at that time included a negative gallbladder From the Department of Medicine, Gastroenterology Section, Departments of Surgery and Radiology, Veterans Administration Medical Center, Phoenix, Arizona. Reprint requests: R. A. Kozarek, MD, The Mason Clinic, 1100 Ninth Avenue, P.O. Box 900, Seattle, Washington 98111.
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series and gallbladder ultrasound. ERCP demonstrated a ventral pancreas but failed to visualize the common bile duct. A diagnosis of acute relapsing pancreatitis related to ventral pancreas and exacerbated by 2 to 3 ounces of daily alcohol was made, and minor sphincterotomy was recommended. Subsequent surgery in October 1981 included cholecystectomy and common bile duct exploration. The gallbladder and common bile duct were normal and the minor ampulla was not found. The initial postoperative course was uncomplicated, but recurrent pancreatitis, intractable pain, and a pseudocyst necessitated a second operation 2 months later. At this time, a repeat common duct exploration was undertaken and sphincterotomy of the ampulla of Vater was done. Attempt at internal pseudocyst drainage was complicated by bleeding from the pancreatic bed necessitating 6 units of blood transfused intraoperatively. Postoperatively, the patient's course was complicated by gastric outlet obstruction and ongoing pancreatitis requiring 4 weeks of hyperalimentation. Over the ensuing 4 months, the patient had intractable epigastric pain, a 40-lb weight loss, and an enlarging pseudocyst, estimated by abdominal CT at presentation to be 8 cm2 (Fig. lA). Subsequent workup revealed a thin man with multiple abdominal scars. There was a large pulsatile epigastric and left upper quadrant mass which was exquisitely tender, plus a left upper quadrant bruit. Laboratory data revealed a serum amylase of 800 ~/dl (normal, <200); cholesterol, 99 mg/dl (normal, 150 to 300); and total protein, 5.9 g/dl (normal, 6.0 to 8.5). Other laboratory data were unremarkable. ERCP demonstrated a large extrinsic pressure defect on the greater curvature of the stomach, moderate gastritis, a prominent minor ampulla, sphincteroplasty of the ampulla of Vater, and a ventral pancreas. The minor ampulla could not be cannulated and the pseudocyst was GASTROINTESTINAL ENDOSCOPY
Figure 2. Endoscopic gastrocystostomy site (arrow).
site, and over the ensuing 3 days hematocrit fell from 42% to 33% before stabilizing. After the second drainage procedure, the patient became asymptomatic, and he was discharged after a total hospitalization period of 14 days. Subsequent ultrasound and CT scan revealed a 2-cm residual cyst which had resolved completely by 4 months after the procedure (Fig. IB). The patient subsequently regained 30 Ib and was free of recurrence 23 months after the endoscopic cystostomy.
Figure 1. A, Marker delineates large pancreatic pseudocyst contiguous to a contrast-filled stomach. B, Repeat abdominal CT in patient 1, 3 months postendoscopic cystostomy. The pseudocyst has resolved; there is persistent enlargement of the pan,creatic body (arrows).
Patient 2
not filled. Because of the patient's poor nutritional status, two previous unsuccessful surgeries, and his extreme reluctance to accept additional surgery, endoscopic pseudocyst decompression was undertaken after informed consent and surgical backup were obtained. Technically, the procedure was done in a fluoroscopy suite using an Olympus JFB-3 side-viewing endoscope inserted through an overtube. A modified straight wire sphincterotome (fistulotome), with 8 mm of wire exposed, and cutting current were used to make a 2- to 3-mm cut into the bulge on the posterior gastric wall. Entrance into the pseudocyst was ascertained by contrast injection. Thereafter, the cut was extended 1.5 cm (Fig. 2). Fluid subsequently obtained was greenish yellow and had 1100 WBC/dl (60% lymphocytes, 40% polys) and an amylase of 1560 ~/dl. It subsequently grew Clostridium perfringens. After the procedure, the patient experienced some symptomatic relief and the cyst decreased to 6 X 6.6 cm by ultrasound. Because drainage was felt to be inadequate and because the pseudocyst was infected, the patient was treated with antibiotics and underwent a second drainage attempt 7 days later. At this time, 2 additionall-cm cuts were made between the posterior stomach wall into the pseudocyst. The second cut resulted in bleeding from the cystogastrostomy
A 42-year-old white woman with a history of alcoholic cirrhosis was admitted with nausea, vomiting, abdominal pain, shortness of breath, and increased abdominal girth. Physical examination revealed jaundice, a right pleural effusion, and tense ascites. Serum amylase was 640 ~/dl; urinary amylase, 24 ~/min (normal 0.66 to 5.43); and WBC/ dl, 15,000 (77 polys, 10 bands); hemoglobin/hematocrit, 10.0/30.1; total bilirubin, 2.7 mg/dl (normal, <1.2); SGOT, 65 V/liter (normal, <41); alkaline phosphatase, 189 ~/liter (normal, <115); and calcium, 7.5 mg/dl (normal, 8.5 to 10.5). Other laboratory data included fibrin split products, >40 mg% (normal, <10); PT, 18 (control, 12); PTT, 65 (control, 34); platelet count, 100,000 (normal, 130 to 400,000); and paracentesis fluid containing 2,600 WBC/dl (96% polys), an amylase of 1,500 ~/dl, and protein of 978 mg/dl. Thoracentesis fluid, in turn, contained 40,000 RBC/dl, 8,000 WBC/ dl (80% polys), amylase of 2,600 ~/dl, and LDH of 179 V/ liter. Gram stain and culture of both fluids were negative. A diagnosis of hemorrhagic pancreatitis, pancreatitic ascites, sympathetic pleural effusion, and disseminated intravascular coagulation was made. The patient was treated with nasogastric suction, repeated thoracentesis for respiratory embarrassment, multiple transfusions for coagulopathy, and calcium for progressive hypocalcemia. Over the ensuing 6
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weeks, she developed progressive liver impairment (maximum bilirubin, 21.2), ongoing leukemoid reaction, recurrent ventricular tachycardia, endoscopically documented variceal hemorrhage, enlarging pancreatic pseudocyst, and Pseudomonas peritonitis. The pseudocyst, which was 15 X 9 cm by ultrasound (Fig. 3A), was felt to be infected, but because of ongoing variceal bleed and liver failure, surgery was deemed inadvisable. Accordingly, endoscopic cystogastrostomy was undertaken after abdominal CT showed the cyst to be contiguous with the posterior stomach wall, a finding confirmed by endoscopy. After informed consent, the patient had two 1-cm incisions made between the stomach and cyst using the technique described for Patient 1. Fluid was chocolate brown, contained 1,000 WBC/dl (all polys) and 185,000 Il/ dl of amylase, and was positive from gram-negative rods on gram stain. Subsequent cultures grew Pseudomonas aeruginosa, Pseudomonas maltophilia, and the anaerobic bacteria Veillonella parvula and Bacteroides melaninogenicus. Despite antibiotic initiation and decrease in abscess size to 10 X 5 cm and 8 X 4 cm after a second drainage attempt (Fig. 3B), the patient had a progressive downhill course and died as a result of liver failure from variceal hemorrhage. Autopsy revealed old clot in the abscess cavity from erosion into a branch ofthe splenic artery. There was also severe cirrhosis
Figure 4. Small arrows depict course of transnasal pancreatic drain in place in genu of pancreatic duct (patient 3). Large arrow delineates pancreatic pseudocyst contiguous to the duodenal C loop. The gallbladder is seen lateral to the duodenum.
and portal hypertension, pulmonary edema, and right lower lobe bronchopneumonia. Patient 3
A 50-year-old white man had been explored at another institution for weight loss, fever, and intractable pain. An 8 X 3 cm mass was noted in the pancreatic head, and although felt to be clinically malignant, surgical biopsy revealed only chronic inflammation. Because of continued pain and a 40Ib weight loss, the patient was referred for an ERCP 3 months postoperatively. This showed a mildly dilated common bile duct, normal gallbladder, dilated pancreatic duct consistent with chronic pancreatitis, and a 3-cm cystic mass in the pancreatic head. Because it was uncertain whether this was a pseudocyst or cavitating neoplasm, a transnasal pancreatic drain was placed into the pancreatic duct and cytology was collected, which proved to be class II. Simultaneous upper gastrointestinal series and pancreatogram demonstrated that the cystic lesion was contiguous with the duodenal sweep and amenable to endoscopic therapy (Fig. 4). The latter was carried out using the side-viewing endoscope and fistulotome, making a 0.5-cm cut 3 cm superior to the ampulla of Vater. Postprocedure, there was complete resolution of the pseudocyst, and in 22 months the patient regained 24 Ib of weight, requiring only mild analgesia for pain relief. Patient 4
Figure 3. A, Markers delineate 15 X 8.9 cm pancreatic pseudocyst detected by ultrasound (patient 2). B, Pancreatic
pseudocyst in patient 2, 24 hours after initial endoscopic decompression. Size has decreased to 10 X 5 cm. 324
A 67-year-old alcoholic white man was admitted with a 3-week history of abdominal pain and vomiting. Physical examination revealed an elderly, unkempt man, febrile to 101.5°F with a 15-cm tender liver and diffuse abdominal tenderness. Amylase was 1,700 Il/dl; urinary amylase, 150 Il/min; calcium, 7.3 mg/dl; hematocrit, 52%; WBC/dl, 31,900 (56 polys, 30 bands); and albumin, 2.6 mg/dl (normal, 3.0 to 5.5). Chest x-ray revealed a left pleural effusion plus left lower lobe infiltrate, and blood gases showed a p02 51, pC0 2 34, and pH 7.52. Abdominal ultrasound suggested a multiGASTROINTESTINAL ENDOSCOPY
loculated pseudocyst and sputum culture grew Klebsiella. A diagnosis of severe pancreatitis, pseudocyst, and Klebsiella pneumoniae was made, and treatment consisting of antibiotics, nasogastric suction, intravenous fluids, and calcium was initiated. The patient's hospital course was subsequently complicated by loss of a subclavian catheter tip into the right heart followed by ventricular tachycardia, hypotension, and left pneumothorax at time of retrieval. Over the ensuing 7 days, the patient had progressive abdominal pain, as well as recurrent hypotensive episodes necessitating a dopamine drip, required two chest tubes for ongoing pneumothorax leak, and developed an increase in pseudocyst size such that two cysts, 10 X 8 and 12 X 4 cm, were detected ultrasonographically. In addition, his hematocrit had fallen from 52 to 31, raising the question of a bleeding pseudocyst. Abdominal angiography was undertaken, demonstrating a single 8 X 10 cm cyst compressing the gastric antrum (Fig. 5) and gastroesophageal varices. No splenic vein thrombosis or active bleeding was noted. Upper gastrointestinal series, in turn, suggested a second pseudocyst in the region of the gastric fundus. Because of the patient's precarious cardiopulmonary and nutritional status, endoscopic cystogastrostomy was undertaken as described for patient 1. Two cystogastrostomy incisions were possible in the fundus and 400 ml of cloudy white fluid were obtained. A third incision was made into the antrum into the second cyst. At this point,
Figure 6. Transnasal drain in place in pancreatic pseudocyst (arrows) in patient 4.
the wire from the fistulotome was removed and a 300-cm angiographic guide wire was inserted through the plastic fistulotome sheath and into the pseudocyst. After removal of the sheath, a 300-cm 5 F pigtail biliary drain was threaded over the wire and into the cyst. Both guide wire and endoscope were subsequently removed, and the drain was transposed to a transnasal position and hooked to gravity drainage (Fig. 6). Pseudocyst drainage had an amylase content of 160,000 ~/dl, 1,600 WBC/dl (all polys), and a negative gram stain. Culture, however, was positive for Escherichia coli. Ultrasonography 12 hours later revealed reduction in the antral cyst to 3.9 X 2.3 cm and a 50% reduction in the fundal cyst. It also suggested a cystic mass in the left lobe of the liver, present in retrospect on the initial ultrasound. Because of the infected nature of the pseudocyst as well as a question of liver abscess, the patient underwent surgical exploration the day following endoscopic cystogastrostomy. This revealed a chronic liver abscess as well as two partially decompressed, infected pseudocysts. He was treated with external drainage plus antibiotics and underwent a prolonged convalescence.
Figure 5. Arrows demonstrate vascular splaying around large pancreatic pseudocyst in patient 4; celiac angiography.
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DISCUSSION Pancreatic pseudocysts, occurring in 7% of acute and 5% to 10% of chronic pancreatitis cases, have an 325
uncertain course. I ,12 With ultrasonographic criteria used as the standard diagnostic modality, up to 85% of acute "pseudocysts" resolve within 2 to 3 weeks and, thereafter, resolution is uncommon. I, 5,13 Pseudocysts occurring in the setting of chronic pancreatic inflammatory disease, on the other hand, seldom resolve spontaneously. Because of this, and because one fourth to one third of such patients will subsequently develop complications of their pseudocyst, many authors recommend decompressive therapy in chronic cysts or those that persist 6 weeks after an attack of acute pancreatitis.4,14,15 In addition, surgical therapy has been recommended earlier for acute pseudocysts that are enlarging on serial ultrasonography or that complicate (leak, bleed, obstruct the biliary or alimentary tract, become infected).4 The ideal treatment in such patients is a matter of some debate. External surgical drainage, introduced over 100 years ago,6 is used less commonly today because of a significant recurrence rate and development of pancreaticocutaneous fistula. 5 In addition, many series show a higher mortality than occurs with internal drainage. 3,14 It remains, however, the treatment of choice in dealing with an infected pseudocyst or a pancreatic abscess. Internal surgical drainage, on the other hand, was introduced in 1915 and has become the treatment of choice of pseudocyst drainage. 1,5,6,16 Associated with an acceptable morbidity and mortality (approximately 25% and 5%, respectively) and a 5% to 6% recurrence rate, cystogastrostomy and cystoenterostomy are the operations most commonly performed. Excision of a localized cyst, usually in the tail of the gland, has also been used but is associated with a 12% perioperative mortality in one collected series. 4 In addition to surgical drainage, percutaneous pseudocyst aspiration or drainage is being used in some centers with increasing frequency. Usually done under CT or ultrasonographic guidance, such drainage has been successful in 50% to 100% of patients. 8,ll,l? Recurrence, however, has been a problem unless an indwelling catheter is left in placeY The complication rate is uncertain, but complications include hemorrhage, abscess formation, fistulization, and pancreatitis. Similar complications are reported in 22% of patients undergoing internal drainage and 78% of patients undergoing external drainage. 6,14,18 In addition to the therapies described above, a single case of transgastric needle aspiration of a pseudocyst through an endoscope has been reported. 19 In this case, the amount of aspirated fluid was small (60 ml) and significant decompression was not effected. An additional case has also been reported in abstract form in which drainage was effected using an Erlanger-type sphincterotome. 2o Our series of endoscopically treated pseudocysts differs from these cases in that a modified 326
straight wire sphincterotome (fistulotome) was inserted through the stomach or bowel wall and into the pseudocyst. Thereafter, a 0.5- to 1.5-cm cut was made in an attempt to improve decompression. Technically, this was accomplished using a side-viewing endoscope and an overtube. The latter allowed rapid removal of the endoscope for suction purposes as entrance into the cyst was usually accompanied by copious outpouring of fluid that precluded visualization. The sideviewing instrument was used for several reasons: (1) it proved impossible to maintain the necessary angle to undertake cystostomy with the forward-viewing scope; (2) the elevator of the instrument allowed better control of the fistulotome; and (3) the huge size of the retrogastric cysts precluded most endoscopic manipulation. Thus, the right angle allowed visualization of large portions of the posterior gastric wall without the necessity of retroflexion. Such retroflexion was technically impossible in all three cases of retrogastric pseudocyst. Selecting the cystogastrostomy-cystoduodenostomy sites in these patients did not prove difficult. All underwent conventional upper gastrointestinal series as well as abdominal CT or ultrasound to delineate cyst relation to the alimentary tract. In addition, patient 3 underwent ERCP and patient 4, angiography, to better define contiguous relationships. More importantly, for all of the retrogastric pseudocysts, a huge defect was noted compressing the posterior stomach wall and allowing proper incision site. Selection was further pinpointed by doing the procedure under fluoroscopic control using postpenetration contrast injection to assure proper placement prior to extension of the cystostomy site. Copious outpouring of pseudocyst fluid was itself confirmatory in all patients. In fact, the latter proved to be a technical problem, often obscuring the endoscopist's visualization and necessitating prolonged suction through the overtube prior to extending the cut. The technical question of need for drain placement after cystostomy remains unanswered. On the one hand, risks of bacterial seeding and subsequent pseudocyst infection must be considered. On the other hand, a single endoscopic procedure was ineffective in patients 1 and 2, and an additional drainage procedure was undertaken. By way of analogy, failure to adequately decompress a pseudocyst or its subsequent reaccumulation is common in transcutaneous aspiration if a drain is not left in place. l1 Endoscopic drainage differs, however, in the size of the cystostomy incision and may be more closely analogous to internal surgical drainage. Complications with endoscopic cystostomy were limited to one episode of significant bleeding in patient 1. In addition, pseudocyst erosion into a branch of the splenic artery was associated with preterminal bleedGASTROINTESTINAL ENDOSCOPY
ing in patient 2. Neither infection nor free perforation was encountered, although the potential for both must be borne in mind. Free perforation would seem unlikely as there is no intervening peritoneal space between the pancreatic pseudocyst and stomach or bowel wall. Infection, on the other hand, probably depends upon the adequacy of the drainage incision, a situation similar to endoscopic sphincterotomy for acute cholangitis. A major drawback of endoscopic pseudocyst decompression may be the preoperative inability to distinguish an uncomplicated cyst from an infected pseudocyst or abscess. For instance, three of the four patients in our series (patients 1,2, and 4) had infected cysts or abscess, and many authors feel such patients require antibiotics plus external drainage. Despite infection, patient 1 responded to antibiotics plus endoscopic cystogastrostomy, whereas patient 4 underwent additional surgical drainage when ultrasound suggested a concomitant liver abscess. Patient 2, with a four-organism pancreatic abscess, died from variceal hemorrhage and liver failure despite antibiotics and internal endoscopic drainage on two occasions. In addition to an inability to distinguish preoperative pseudocyst infection, the question of bleeding into the cyst with formation of pseudoaneurysm needs to be addressed. Cystostomy in this setting may be associated with massive bleeding and patient demise. For this reason, angiography was undertaken in patient 4 (hematocrit drop, 42% to 31%) prior to endoscopic decompression. Despite failure to demonstrate an active bleeding site, such angiography does not exclude former bleeding. It does demonstrate vascular anatomy of the area and may prove invaluable in selecting the proper cystostomy site. All of the above objections to endoscopic drainage are also valid objections to transcutaneous drainage. Because experience in our institution with the latter technique has been less than satisfactory and because it seemed logical to avoid puncture or laceration of the rectus sheath, as well as the anterior gastric or bowel wall, endoscopic drainage seemed a useful idea. In our hands, it was technically successful in all six attempts in the four patients in whom it was undertaken. Complete resolution occurred in two or these four patients (patients 1 and 3). Patient 2, with a pancreatic abscess, stabilized her cyst size at approximately 50% of that predrainage. Infection plus erosion into a branch of the splenic artery may have accounted for lack of subsequent decompression. Patient 4 had 70% and 50% reduction in his pseudocysts 12 hours after the procedure. Liver abscess and infected cysts necessitated postprocedure surgical intervention. Despite the success of endoscopic cystostomy in the patients described above, the authors fully agree that surgical drainage procedures are the mainstay of therVOLUME 31, NO. 5, 1985
apy for the majority of pseudocyst patients in whom treatment is indicated.5 • 6 • 21 Nevertheless, in patients who have failed previous surgery (patients 1 and 3) or who are denied surgery because of prohibitive operative risk (patients 2 and 4), nonsurgical drainage procedures can either temporize or be curative. Transcutaneous pseudocyst aspiration is currently being evaluated in several centers as to short-term and longterm results plus morbidity and mortality.20 What place endoscopic cystostomy has in the place of nonoperative pseudocyst drainage remains to be defined. Anatomically, it requires a pseudocyst in direct contiguity with the stomach or accessible loop of bowel. Technically, it may require cauterization capability to treat iatrogenic bleeding from the cyst margin as well as endoscopic ultrasound to enhance localization. This small series raises a number of questions. Particularly, questions regarding acute complications versus longterm resolution rate need to be answered. In addition, the risks of, and need for, internal or external (transnasal) drain placement after cystostomy must be addressed before the authors recommend its use in patients who are otherwise good surgical candidates.
REFERENCES 1. Bradley EL III, Clements JL Jr, Gonazales AC. The natural history of pancreatic pseudocysts: a unified concept of management. Am J Surg 1979;137:135-41. 2. Elliott DW. Pancreatic pseudocysts. Surg Clin North Am 1975;55:339-62. 3. Joyce DL, Toledo-Pereyra LH, Humphrey EW. Pancreatic pseudocyst: a clinical review. Am Surg 1979;45:453-61. 4. Winship D. Pancreatitis: pancreatic pseudocysts and their complications. Gastroenterology 1977;73:593-603. 5. Bradley EL III. Diagnosis and management of pancreatic pseudocysts: current concepts. Compr Ther 1980;6:58-65. 6. Martin EW Jr, Catalano P, Cooperman M, et al. Surgical decision-making in the treatment of pancreatic pseudocysts. Internal versus external drainage. Am J Surg 1979;138:821-4. 7. Sandy JT, Taylor RH, Christensen RM, et al. Pancreatic pseudocyst. Changing concepts in management. Am J Surg 1981;141:574--6. 8. Hancke S, Pedersen JF. Percutaneous puncture of pancreatic cysts guided by ultrasound. Surg Gynecol Obstet 1976;142:5512.
9. MacErlean DP, Bryan PJ, Murphy JJ. Pancreatic pseudocyst: management by ultrasonographically guided aspiration. Gastrointest RadioI1980;5:255-7. 10. Wind G. Secretory rate in a pancreatic pseudocyst successfully treated by percutaneous aspiration: case report. Milit Med 1981;146:174-5. 11. Barkin JS, Smith FR, Pereiras R Jr, et aI. Therapeutic percutaneous aspiration of pancreatic pseudocysts. Dig Dis Sci 1981;26:585-6. 12. Shelty AN. Pseudocysts of the pancreas: an overview. South Med J 1980;73:1239-42. 13. Czaja AJ, Fisher M, Marin GA. Spontaneous resolution of pancreatic masses (pseudocysts?) appearing after acute alcholic pancreatitis. Arch Intern Med 1975;135:558-62. 14. Grace RR, Jordan PH. Unresolved problems of pancreatic pseudocysts. Ann Surg 1976;184:16-21. 15. Crass RA, Way LW. Acute and chronic pancreatic pseudocysts are different. Am J Surg 1981;142:660-3. 16. Pollak EW, Michas CA, Wolfman EF Jr. Pancreatic pseudocyst. Management in fifty-four patients. Am J Surg 1978;135:199201.
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17. McDermott WV, Kane RA, Vollman RW, O'Hara ET. Pseudocysts of the pancreas complicating distal splenorenal shunt. A report of three cases with successful percutaneous drainage. Ann Surg 1981;193:176-9. 18. Elechi EN, Callender 00, Calhoun T, Kurtz LH. Pancreatic abscess: a major complication of cystogastrostomy. J Nat Med Assoc 1980;72:1067-74. 19. Rogers BHG, Cicurel NJ, Seed RW. Transgastric needle aspi-
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ration of pancreatic pseudocyst through an endoscope. Gastrointest Endosc 1975;21:133-4. 20. Khawaja FI, Goldman LP. Endoscopic drainage of a pancreatic pseudocyst and pseudo-gastric fistulae. Gastrointest Endosc 1983;29:171. 21. Cooperman AM. Are pancreatic pseudocysts overtreated? Surg Gynecol Obstet 1980;151:96.
GASTROINTESTINAL ENDOSCOPY
Endoscopic drainage of pancreatic pseudocysts R. A. Kozarek, MD, c. M. Brayko, MD J. Harlan, MD, R. A. Sanowski, MD I. Cintora, MD, A. Kovac, MD Phoenix, Arizona
Enlarging pancreatic pseudocysts, as well as those that develop complications such as bleeding, leak, infection, and intestinal or biliary obstruction, require treatment. This treatment is usually surgical and consists of internal or external drainage or, less commonly, excision. Transcutaneous aspiration with or without drain placement has also been reported. We describe four cases of endoscopic cystogastrostomy and cystoduodenostomy undertaken in high risk patients who had either failed previous surgery (two) or were initially refused surgery because of prohibitive operative risk (two). Technique, limitations, and potential use of this procedure are discussed.
The treatment of acute and chronic pancreatic pseudocyst has been hotly debated. Small, asymptomatic pseudocysts, particularly less than 5 cm in diameter, seldom complicate and can be watched medically.! Symptomatic pseudocysts and those cysts that develop complications (bleeding, abscess formation, intestinal or biliary obstruction), as well as pseudocysts which are increasing in size, usually require drainage. 2- 4 Such drainage may be internal (cystogastrostomy, cystoenterostomy) or external or rarely may be effected by excision of a suitably situated lesion. 5- 7 Abdominal CT or ultrasonographically guided percutaneous cyst aspiration has also been reported and is being used in some centers.8-11 We describe an additional modality, endoscopic cystostomy, in four high risk patients in whom surgery had been either unsuccessful or was felt to be contraindicated. CASE REPORTS Patient 1
A 39-year-old white man was initially seen at the Phoenix VA Medical Center in April 1982 for intractable epigastric pain and enlarging pancreatic pseudocyst. Past medical history was significant for hypertension controlled with propranolol and multiple episodes of pancreatitis since March 1981. Workup at that time included a negative gallbladder From the Department of Medicine, Gastroenterology Section, Departments of Surgery and Radiology, Veterans Administration Medical Center, Phoenix, Arizona. Reprint requests: R. A. Kozarek, MD, The Mason Clinic, 1100 Ninth Avenue, P.O. Box 900, Seattle, Washington 98111.
322
series and gallbladder ultrasound. ERCP demonstrated a ventral pancreas but failed to visualize the common bile duct. A diagnosis of acute relapsing pancreatitis related to ventral pancreas and exacerbated by 2 to 3 ounces of daily alcohol was made, and minor sphincterotomy was recommended. Subsequent surgery in October 1981 included cholecystectomy and common bile duct exploration. The gallbladder and common bile duct were normal and the minor ampulla was not found. The initial postoperative course was uncomplicated, but recurrent pancreatitis, intractable pain, and a pseudocyst necessitated a second operation 2 months later. At this time, a repeat common duct exploration was undertaken and sphincterotomy of the ampulla of Vater was done. Attempt at internal pseudocyst drainage was complicated by bleeding from the pancreatic bed necessitating 6 units of blood transfused intraoperatively. Postoperatively, the patient's course was complicated by gastric outlet obstruction and ongoing pancreatitis requiring 4 weeks of hyperalimentation. Over the ensuing 4 months, the patient had intractable epigastric pain, a 40-lb weight loss, and an enlarging pseudocyst, estimated by abdominal CT at presentation to be 8 cm2 (Fig. lA). Subsequent workup revealed a thin man with multiple abdominal scars. There was a large pulsatile epigastric and left upper quadrant mass which was exquisitely tender, plus a left upper quadrant bruit. Laboratory data revealed a serum amylase of 800 ~/dl (normal, <200); cholesterol, 99 mg/dl (normal, 150 to 300); and total protein, 5.9 g/dl (normal, 6.0 to 8.5). Other laboratory data were unremarkable. ERCP demonstrated a large extrinsic pressure defect on the greater curvature of the stomach, moderate gastritis, a prominent minor ampulla, sphincteroplasty of the ampulla of Vater, and a ventral pancreas. The minor ampulla could not be cannulated and the pseudocyst was GASTROINTESTINAL ENDOSCOPY
Figure 2. Endoscopic gastrocystostomy site (arrow).
site, and over the ensuing 3 days hematocrit fell from 42% to 33% before stabilizing. After the second drainage procedure, the patient became asymptomatic, and he was discharged after a total hospitalization period of 14 days. Subsequent ultrasound and CT scan revealed a 2-cm residual cyst which had resolved completely by 4 months after the procedure (Fig. IB). The patient subsequently regained 30 Ib and was free of recurrence 23 months after the endoscopic cystostomy.
Figure 1. A, Marker delineates large pancreatic pseudocyst contiguous to a contrast-filled stomach. B, Repeat abdominal CT in patient 1, 3 months postendoscopic cystostomy. The pseudocyst has resolved; there is persistent enlargement of the pan,creatic body (arrows).
Patient 2
not filled. Because of the patient's poor nutritional status, two previous unsuccessful surgeries, and his extreme reluctance to accept additional surgery, endoscopic pseudocyst decompression was undertaken after informed consent and surgical backup were obtained. Technically, the procedure was done in a fluoroscopy suite using an Olympus JFB-3 side-viewing endoscope inserted through an overtube. A modified straight wire sphincterotome (fistulotome), with 8 mm of wire exposed, and cutting current were used to make a 2- to 3-mm cut into the bulge on the posterior gastric wall. Entrance into the pseudocyst was ascertained by contrast injection. Thereafter, the cut was extended 1.5 cm (Fig. 2). Fluid subsequently obtained was greenish yellow and had 1100 WBC/dl (60% lymphocytes, 40% polys) and an amylase of 1560 ~/dl. It subsequently grew Clostridium perfringens. After the procedure, the patient experienced some symptomatic relief and the cyst decreased to 6 X 6.6 cm by ultrasound. Because drainage was felt to be inadequate and because the pseudocyst was infected, the patient was treated with antibiotics and underwent a second drainage attempt 7 days later. At this time, 2 additionall-cm cuts were made between the posterior stomach wall into the pseudocyst. The second cut resulted in bleeding from the cystogastrostomy
A 42-year-old white woman with a history of alcoholic cirrhosis was admitted with nausea, vomiting, abdominal pain, shortness of breath, and increased abdominal girth. Physical examination revealed jaundice, a right pleural effusion, and tense ascites. Serum amylase was 640 ~/dl; urinary amylase, 24 ~/min (normal 0.66 to 5.43); and WBC/ dl, 15,000 (77 polys, 10 bands); hemoglobin/hematocrit, 10.0/30.1; total bilirubin, 2.7 mg/dl (normal, <1.2); SGOT, 65 V/liter (normal, <41); alkaline phosphatase, 189 ~/liter (normal, <115); and calcium, 7.5 mg/dl (normal, 8.5 to 10.5). Other laboratory data included fibrin split products, >40 mg% (normal, <10); PT, 18 (control, 12); PTT, 65 (control, 34); platelet count, 100,000 (normal, 130 to 400,000); and paracentesis fluid containing 2,600 WBC/dl (96% polys), an amylase of 1,500 ~/dl, and protein of 978 mg/dl. Thoracentesis fluid, in turn, contained 40,000 RBC/dl, 8,000 WBC/ dl (80% polys), amylase of 2,600 ~/dl, and LDH of 179 V/ liter. Gram stain and culture of both fluids were negative. A diagnosis of hemorrhagic pancreatitis, pancreatitic ascites, sympathetic pleural effusion, and disseminated intravascular coagulation was made. The patient was treated with nasogastric suction, repeated thoracentesis for respiratory embarrassment, multiple transfusions for coagulopathy, and calcium for progressive hypocalcemia. Over the ensuing 6
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weeks, she developed progressive liver impairment (maximum bilirubin, 21.2), ongoing leukemoid reaction, recurrent ventricular tachycardia, endoscopically documented variceal hemorrhage, enlarging pancreatic pseudocyst, and Pseudomonas peritonitis. The pseudocyst, which was 15 X 9 cm by ultrasound (Fig. 3A), was felt to be infected, but because of ongoing variceal bleed and liver failure, surgery was deemed inadvisable. Accordingly, endoscopic cystogastrostomy was undertaken after abdominal CT showed the cyst to be contiguous with the posterior stomach wall, a finding confirmed by endoscopy. After informed consent, the patient had two 1-cm incisions made between the stomach and cyst using the technique described for Patient 1. Fluid was chocolate brown, contained 1,000 WBC/dl (all polys) and 185,000 Il/ dl of amylase, and was positive from gram-negative rods on gram stain. Subsequent cultures grew Pseudomonas aeruginosa, Pseudomonas maltophilia, and the anaerobic bacteria Veillonella parvula and Bacteroides melaninogenicus. Despite antibiotic initiation and decrease in abscess size to 10 X 5 cm and 8 X 4 cm after a second drainage attempt (Fig. 3B), the patient had a progressive downhill course and died as a result of liver failure from variceal hemorrhage. Autopsy revealed old clot in the abscess cavity from erosion into a branch ofthe splenic artery. There was also severe cirrhosis
Figure 4. Small arrows depict course of transnasal pancreatic drain in place in genu of pancreatic duct (patient 3). Large arrow delineates pancreatic pseudocyst contiguous to the duodenal C loop. The gallbladder is seen lateral to the duodenum.
and portal hypertension, pulmonary edema, and right lower lobe bronchopneumonia. Patient 3
A 50-year-old white man had been explored at another institution for weight loss, fever, and intractable pain. An 8 X 3 cm mass was noted in the pancreatic head, and although felt to be clinically malignant, surgical biopsy revealed only chronic inflammation. Because of continued pain and a 40Ib weight loss, the patient was referred for an ERCP 3 months postoperatively. This showed a mildly dilated common bile duct, normal gallbladder, dilated pancreatic duct consistent with chronic pancreatitis, and a 3-cm cystic mass in the pancreatic head. Because it was uncertain whether this was a pseudocyst or cavitating neoplasm, a transnasal pancreatic drain was placed into the pancreatic duct and cytology was collected, which proved to be class II. Simultaneous upper gastrointestinal series and pancreatogram demonstrated that the cystic lesion was contiguous with the duodenal sweep and amenable to endoscopic therapy (Fig. 4). The latter was carried out using the side-viewing endoscope and fistulotome, making a 0.5-cm cut 3 cm superior to the ampulla of Vater. Postprocedure, there was complete resolution of the pseudocyst, and in 22 months the patient regained 24 Ib of weight, requiring only mild analgesia for pain relief. Patient 4
Figure 3. A, Markers delineate 15 X 8.9 cm pancreatic pseudocyst detected by ultrasound (patient 2). B, Pancreatic
pseudocyst in patient 2, 24 hours after initial endoscopic decompression. Size has decreased to 10 X 5 cm. 324
A 67-year-old alcoholic white man was admitted with a 3-week history of abdominal pain and vomiting. Physical examination revealed an elderly, unkempt man, febrile to 101.5°F with a 15-cm tender liver and diffuse abdominal tenderness. Amylase was 1,700 Il/dl; urinary amylase, 150 Il/min; calcium, 7.3 mg/dl; hematocrit, 52%; WBC/dl, 31,900 (56 polys, 30 bands); and albumin, 2.6 mg/dl (normal, 3.0 to 5.5). Chest x-ray revealed a left pleural effusion plus left lower lobe infiltrate, and blood gases showed a p02 51, pC0 2 34, and pH 7.52. Abdominal ultrasound suggested a multiGASTROINTESTINAL ENDOSCOPY
loculated pseudocyst and sputum culture grew Klebsiella. A diagnosis of severe pancreatitis, pseudocyst, and Klebsiella pneumoniae was made, and treatment consisting of antibiotics, nasogastric suction, intravenous fluids, and calcium was initiated. The patient's hospital course was subsequently complicated by loss of a subclavian catheter tip into the right heart followed by ventricular tachycardia, hypotension, and left pneumothorax at time of retrieval. Over the ensuing 7 days, the patient had progressive abdominal pain, as well as recurrent hypotensive episodes necessitating a dopamine drip, required two chest tubes for ongoing pneumothorax leak, and developed an increase in pseudocyst size such that two cysts, 10 X 8 and 12 X 4 cm, were detected ultrasonographically. In addition, his hematocrit had fallen from 52 to 31, raising the question of a bleeding pseudocyst. Abdominal angiography was undertaken, demonstrating a single 8 X 10 cm cyst compressing the gastric antrum (Fig. 5) and gastroesophageal varices. No splenic vein thrombosis or active bleeding was noted. Upper gastrointestinal series, in turn, suggested a second pseudocyst in the region of the gastric fundus. Because of the patient's precarious cardiopulmonary and nutritional status, endoscopic cystogastrostomy was undertaken as described for patient 1. Two cystogastrostomy incisions were possible in the fundus and 400 ml of cloudy white fluid were obtained. A third incision was made into the antrum into the second cyst. At this point,
Figure 6. Transnasal drain in place in pancreatic pseudocyst (arrows) in patient 4.
the wire from the fistulotome was removed and a 300-cm angiographic guide wire was inserted through the plastic fistulotome sheath and into the pseudocyst. After removal of the sheath, a 300-cm 5 F pigtail biliary drain was threaded over the wire and into the cyst. Both guide wire and endoscope were subsequently removed, and the drain was transposed to a transnasal position and hooked to gravity drainage (Fig. 6). Pseudocyst drainage had an amylase content of 160,000 ~/dl, 1,600 WBC/dl (all polys), and a negative gram stain. Culture, however, was positive for Escherichia coli. Ultrasonography 12 hours later revealed reduction in the antral cyst to 3.9 X 2.3 cm and a 50% reduction in the fundal cyst. It also suggested a cystic mass in the left lobe of the liver, present in retrospect on the initial ultrasound. Because of the infected nature of the pseudocyst as well as a question of liver abscess, the patient underwent surgical exploration the day following endoscopic cystogastrostomy. This revealed a chronic liver abscess as well as two partially decompressed, infected pseudocysts. He was treated with external drainage plus antibiotics and underwent a prolonged convalescence.
Figure 5. Arrows demonstrate vascular splaying around large pancreatic pseudocyst in patient 4; celiac angiography.
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DISCUSSION Pancreatic pseudocysts, occurring in 7% of acute and 5% to 10% of chronic pancreatitis cases, have an 325
uncertain course. I ,12 With ultrasonographic criteria used as the standard diagnostic modality, up to 85% of acute "pseudocysts" resolve within 2 to 3 weeks and, thereafter, resolution is uncommon. I, 5,13 Pseudocysts occurring in the setting of chronic pancreatic inflammatory disease, on the other hand, seldom resolve spontaneously. Because of this, and because one fourth to one third of such patients will subsequently develop complications of their pseudocyst, many authors recommend decompressive therapy in chronic cysts or those that persist 6 weeks after an attack of acute pancreatitis.4,14,15 In addition, surgical therapy has been recommended earlier for acute pseudocysts that are enlarging on serial ultrasonography or that complicate (leak, bleed, obstruct the biliary or alimentary tract, become infected).4 The ideal treatment in such patients is a matter of some debate. External surgical drainage, introduced over 100 years ago,6 is used less commonly today because of a significant recurrence rate and development of pancreaticocutaneous fistula. 5 In addition, many series show a higher mortality than occurs with internal drainage. 3,14 It remains, however, the treatment of choice in dealing with an infected pseudocyst or a pancreatic abscess. Internal surgical drainage, on the other hand, was introduced in 1915 and has become the treatment of choice of pseudocyst drainage. 1,5,6,16 Associated with an acceptable morbidity and mortality (approximately 25% and 5%, respectively) and a 5% to 6% recurrence rate, cystogastrostomy and cystoenterostomy are the operations most commonly performed. Excision of a localized cyst, usually in the tail of the gland, has also been used but is associated with a 12% perioperative mortality in one collected series. 4 In addition to surgical drainage, percutaneous pseudocyst aspiration or drainage is being used in some centers with increasing frequency. Usually done under CT or ultrasonographic guidance, such drainage has been successful in 50% to 100% of patients. 8,ll,l? Recurrence, however, has been a problem unless an indwelling catheter is left in placeY The complication rate is uncertain, but complications include hemorrhage, abscess formation, fistulization, and pancreatitis. Similar complications are reported in 22% of patients undergoing internal drainage and 78% of patients undergoing external drainage. 6,14,18 In addition to the therapies described above, a single case of transgastric needle aspiration of a pseudocyst through an endoscope has been reported. 19 In this case, the amount of aspirated fluid was small (60 ml) and significant decompression was not effected. An additional case has also been reported in abstract form in which drainage was effected using an Erlanger-type sphincterotome. 2o Our series of endoscopically treated pseudocysts differs from these cases in that a modified 326
straight wire sphincterotome (fistulotome) was inserted through the stomach or bowel wall and into the pseudocyst. Thereafter, a 0.5- to 1.5-cm cut was made in an attempt to improve decompression. Technically, this was accomplished using a side-viewing endoscope and an overtube. The latter allowed rapid removal of the endoscope for suction purposes as entrance into the cyst was usually accompanied by copious outpouring of fluid that precluded visualization. The sideviewing instrument was used for several reasons: (1) it proved impossible to maintain the necessary angle to undertake cystostomy with the forward-viewing scope; (2) the elevator of the instrument allowed better control of the fistulotome; and (3) the huge size of the retrogastric cysts precluded most endoscopic manipulation. Thus, the right angle allowed visualization of large portions of the posterior gastric wall without the necessity of retroflexion. Such retroflexion was technically impossible in all three cases of retrogastric pseudocyst. Selecting the cystogastrostomy-cystoduodenostomy sites in these patients did not prove difficult. All underwent conventional upper gastrointestinal series as well as abdominal CT or ultrasound to delineate cyst relation to the alimentary tract. In addition, patient 3 underwent ERCP and patient 4, angiography, to better define contiguous relationships. More importantly, for all of the retrogastric pseudocysts, a huge defect was noted compressing the posterior stomach wall and allowing proper incision site. Selection was further pinpointed by doing the procedure under fluoroscopic control using postpenetration contrast injection to assure proper placement prior to extension of the cystostomy site. Copious outpouring of pseudocyst fluid was itself confirmatory in all patients. In fact, the latter proved to be a technical problem, often obscuring the endoscopist's visualization and necessitating prolonged suction through the overtube prior to extending the cut. The technical question of need for drain placement after cystostomy remains unanswered. On the one hand, risks of bacterial seeding and subsequent pseudocyst infection must be considered. On the other hand, a single endoscopic procedure was ineffective in patients 1 and 2, and an additional drainage procedure was undertaken. By way of analogy, failure to adequately decompress a pseudocyst or its subsequent reaccumulation is common in transcutaneous aspiration if a drain is not left in place. l1 Endoscopic drainage differs, however, in the size of the cystostomy incision and may be more closely analogous to internal surgical drainage. Complications with endoscopic cystostomy were limited to one episode of significant bleeding in patient 1. In addition, pseudocyst erosion into a branch of the splenic artery was associated with preterminal bleedGASTROINTESTINAL ENDOSCOPY
ing in patient 2. Neither infection nor free perforation was encountered, although the potential for both must be borne in mind. Free perforation would seem unlikely as there is no intervening peritoneal space between the pancreatic pseudocyst and stomach or bowel wall. Infection, on the other hand, probably depends upon the adequacy of the drainage incision, a situation similar to endoscopic sphincterotomy for acute cholangitis. A major drawback of endoscopic pseudocyst decompression may be the preoperative inability to distinguish an uncomplicated cyst from an infected pseudocyst or abscess. For instance, three of the four patients in our series (patients 1,2, and 4) had infected cysts or abscess, and many authors feel such patients require antibiotics plus external drainage. Despite infection, patient 1 responded to antibiotics plus endoscopic cystogastrostomy, whereas patient 4 underwent additional surgical drainage when ultrasound suggested a concomitant liver abscess. Patient 2, with a four-organism pancreatic abscess, died from variceal hemorrhage and liver failure despite antibiotics and internal endoscopic drainage on two occasions. In addition to an inability to distinguish preoperative pseudocyst infection, the question of bleeding into the cyst with formation of pseudoaneurysm needs to be addressed. Cystostomy in this setting may be associated with massive bleeding and patient demise. For this reason, angiography was undertaken in patient 4 (hematocrit drop, 42% to 31%) prior to endoscopic decompression. Despite failure to demonstrate an active bleeding site, such angiography does not exclude former bleeding. It does demonstrate vascular anatomy of the area and may prove invaluable in selecting the proper cystostomy site. All of the above objections to endoscopic drainage are also valid objections to transcutaneous drainage. Because experience in our institution with the latter technique has been less than satisfactory and because it seemed logical to avoid puncture or laceration of the rectus sheath, as well as the anterior gastric or bowel wall, endoscopic drainage seemed a useful idea. In our hands, it was technically successful in all six attempts in the four patients in whom it was undertaken. Complete resolution occurred in two or these four patients (patients 1 and 3). Patient 2, with a pancreatic abscess, stabilized her cyst size at approximately 50% of that predrainage. Infection plus erosion into a branch of the splenic artery may have accounted for lack of subsequent decompression. Patient 4 had 70% and 50% reduction in his pseudocysts 12 hours after the procedure. Liver abscess and infected cysts necessitated postprocedure surgical intervention. Despite the success of endoscopic cystostomy in the patients described above, the authors fully agree that surgical drainage procedures are the mainstay of therVOLUME 31, NO. 5, 1985
apy for the majority of pseudocyst patients in whom treatment is indicated.5 • 6 • 21 Nevertheless, in patients who have failed previous surgery (patients 1 and 3) or who are denied surgery because of prohibitive operative risk (patients 2 and 4), nonsurgical drainage procedures can either temporize or be curative. Transcutaneous pseudocyst aspiration is currently being evaluated in several centers as to short-term and longterm results plus morbidity and mortality.20 What place endoscopic cystostomy has in the place of nonoperative pseudocyst drainage remains to be defined. Anatomically, it requires a pseudocyst in direct contiguity with the stomach or accessible loop of bowel. Technically, it may require cauterization capability to treat iatrogenic bleeding from the cyst margin as well as endoscopic ultrasound to enhance localization. This small series raises a number of questions. Particularly, questions regarding acute complications versus longterm resolution rate need to be answered. In addition, the risks of, and need for, internal or external (transnasal) drain placement after cystostomy must be addressed before the authors recommend its use in patients who are otherwise good surgical candidates.
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9. MacErlean DP, Bryan PJ, Murphy JJ. Pancreatic pseudocyst: management by ultrasonographically guided aspiration. Gastrointest RadioI1980;5:255-7. 10. Wind G. Secretory rate in a pancreatic pseudocyst successfully treated by percutaneous aspiration: case report. Milit Med 1981;146:174-5. 11. Barkin JS, Smith FR, Pereiras R Jr, et aI. Therapeutic percutaneous aspiration of pancreatic pseudocysts. Dig Dis Sci 1981;26:585-6. 12. Shelty AN. Pseudocysts of the pancreas: an overview. South Med J 1980;73:1239-42. 13. Czaja AJ, Fisher M, Marin GA. Spontaneous resolution of pancreatic masses (pseudocysts?) appearing after acute alcholic pancreatitis. Arch Intern Med 1975;135:558-62. 14. Grace RR, Jordan PH. Unresolved problems of pancreatic pseudocysts. Ann Surg 1976;184:16-21. 15. Crass RA, Way LW. Acute and chronic pancreatic pseudocysts are different. Am J Surg 1981;142:660-3. 16. Pollak EW, Michas CA, Wolfman EF Jr. Pancreatic pseudocyst. Management in fifty-four patients. Am J Surg 1978;135:199201.
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17. McDermott WV, Kane RA, Vollman RW, O'Hara ET. Pseudocysts of the pancreas complicating distal splenorenal shunt. A report of three cases with successful percutaneous drainage. Ann Surg 1981;193:176-9. 18. Elechi EN, Callender 00, Calhoun T, Kurtz LH. Pancreatic abscess: a major complication of cystogastrostomy. J Nat Med Assoc 1980;72:1067-74. 19. Rogers BHG, Cicurel NJ, Seed RW. Transgastric needle aspi-
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