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Pancreatic pseudocyst
Pancreatic Pseudocyst Changing Concepts in Management
J. Trevor Sandy, MD, FRCS(C), Vancouver, 8ritish Columbia, Canada R. H. Taylor, MD, FRCS(C), Vancouver, British Columbia, Canada Ralph M. Christensen, MD, FRCS(C), Vancouver, British Columbia, Canada C. Scudamore, MD, Vancouver, British Columbia, Canada P. Leckie, MD, Vancouver, British Columbia, Canada
Pseudocyst of the pancreas is a complication of pancreatitis, a poorly understood disease [I]. Fortunately it is rare, occurring in 1 to 2 percent of patients with acute and chronic pancreatitis [2]. Before the advent of ultrasonography the condition was usually diagnosed at an advanced stage when a mass lesion was palpated in the epigastrium. Contrast studies of the gastrointestinal tract usually corroborated its presence by organ displacement. No reliable method of differentiating a solid phlegmon due to pancreatic edema from a collection of fluid was available before the B-scan [3]. While it had always been postulated that the fluid originated from a leak in the pancreatic ductal system, it was only proven when endoscopic retrograde cholangiopancreatography (ERCP) enabled pancreatography in a significant percentage of cases [4]. The other procedure that has greatly increased diagnostic accuracy in retroperitoneal lesions including the pancreas has been the computed tomographic scan. Sonography and computed tomographic scanning, both noninvasive techniques, have been combined with guided needle biopsy and aspiration to provide biochemical and histologic proof of the underlying disease in a large percentage of cases [3]. Clinicians can now diagnose cystic collections accurately at a much earlier stage and for the first time can monitor the natural history of the syndrome of pseudocyst collection. Angiography is believed by some investigators to play an important role in the assessment of pseudoaneurysm formation, and it helps identify cases with major episodes of bleeding [5]. Greater accuracy in diagnosis and monitoring has led to a reexamination of treatment methods. The ability to aspirate major fluid collections with a From the Divison of General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Requests for reprints should be addressed to J. Trevor Sandy, MD, Suite 708, 750 West Broadway, Vancouver, British Columbia V5Z lH6, Canada. Presented at the 67th Annual Meeting of the North Pacific Surgical Association, Tacoma, Washington, November 14-15, 1980.
574
guided needle or tube has led to simpler methods of drainage than were possible in the past. Many recent reports document varying degrees of success in treating pseudocysts in this relatively new way [6]. Clinicians armed with the means to accurately gauge and follow the size of many cystic collections have established that a large percentage of them will absorb spontaneously. Resolution may require many months, but in the absence of infection, even the static collection can be watched safely [7]. Rawlings et al [8] stated that unless some complication intervenes the cysts should be left alone. Traditionally, fear of rupture, abscess formation or bleeding prompted relatively early drainage. Surgeons in the past were frequently disappointed when exploration of pancreatic masses disclosed either phlegmonous swellings or cysts with immature walls that were unsuited for safe drainage internally [9]. Pseudocysts very rarely rupture but they can leak, leading to pancreatic ascites [8]. The rarity of abscess formation was documented at Johns Hopkins, where only 13 cases were found in 1,187 patients with acute and 576 patients with chronic pancreatitis (0.131 percent) [7]. The highest incidence of abscess formation occurs in postoperative pancreatitis. The treatment for abscess formation is external drainage at an early stage
PJOI.
Elechi et al [ll] consider external sump drainage the preferred treatment for most pancreatic pseudocysts if there is no obstruction of the distal part of the pancreatic duct. The latter should be drained internally by a Roux-Y cystojejunostomy. In their series the traditional cystogastrostomy was associated with a high incidence of pancreatic abscess and hemorrhage, whereas external drainage led to 100 percent survival without fistula or abscess. In contrast, Frey [5] found that external drainage is associated with a high rate of complications or death in 60 to 80 percent of patients. He showed that external drainage is not a definitive operation because over 50 percent of patients require reoperation for recurrent cysts [5]. Pollak et al [12] advocate distal pancrea-
TheAmerican
Journal of Surgery
Pancreatic Pseudocyst
tectomy for pseudocyst of the tail. Cooperman [6] in a recent editorial pointed out that the question of what treatment is best remains unanswered [6].
Material and Methods A retrospective chart review of patients with pancreatic pseudocysts at the three hospitals affiliated with the University of British Columbia was conducted over the past decade. The survey utilized a standard protocol to extract the data. One hundred seven patients ranging in age from 1’7 to 79 years were analyzed (mean age 47.9 years). Two thirds of the patients were male. Alcohol was a major cause of pseudocyst in 70 percent of the patients. Calculus alone was the cause in eight patients, and alcohol plus stones in nine others. Major trauma accounted for two cysts and surgical biopsy two others. Four patients had underlying malignancy of the pancreas or common bile duct. One required removal of a parathyroid adenoma to correct hypercalcemia after drainage of a pseudocyst. In eight patients the cause was deemed idiopathic. The major presenting complaints were pain (98 patients), mass (47), nausea and vomiting (28), weight loss (23), jaundice (17) and bleeding (9). Many patients had more than one symptom. In a few asymptomatic patients the cysts were found either by sonography or at autopsy. Ail records contained copious laboratory results. Serum amylase levels were significantly increased in about 70 percent of the patients. However, many patients with proven pseudocysts had normal levels. Urinary amylase levels were not consistently recorded for the entire series. Like many other investigators, we found that biochemical information is too inconsistent to be of much diagnostic value in predicting or following pseudocysts. Diagnosis: Since the introduction of ultrasonography in about 1975, its use has become routine. Of the 64 patients who underwent ultrasonography, cyst was shown 58 times; 6 findings were false-negative. Contrast studies of the upper gastrointestinal tract were recorded for 67 patients; there were positive signs of organ displacement in 46. ERCP in 15 patients revealed positive findings in 11 with no major complications. Angiography gave positive results in all four patients examined. Computed tomographic scanning just became available in 1980 and was used in two patients. Management: Eighty-one pseudocysts were surgically explored, 24 were observed, and 2 were found incidentally at autopsy. In neither of the latter patients was the cyst considered a contributory cause of death. Emergency exploration was required seven times, four for diagnostic purposes and two for rupture. Another patient had multiple indications, including sepsis. All seven underwent external drainage. Elective drainage was done for pain (19 patients), obstruction (7), enlarging masses (13) and various combinations of these. Four elective patients underwent external drainage when immature cyst walls or infection was encountered. Type of operation: External drainage was performed in 10 cases and internal drainage in 60. Three of the patients with external drainage developed fistulas. One fistula healed spontaneously and one patient required drainage of the fistulous tract to a Roux-Y jejunal loop. The third patient with external drainage eventually died from
Volume 141, May 1981
hemorrhage. Of the patients who had elective internal drainage, 43 underwent cystogastrostomy, 11 cystojejunostomy, 2 cystodenostomy, 3 multiple combinations of these. and 1 a Puestow-tvne nancreatic ieiunostomv for chronic pancreatitis with-cyst: Double cysts were drained through two gastric openings in one patient and through a cystogastrostomy and cystoieiunostomg in another. A single large cyst was attached loosely to the head of the pancreas, which was amenable to total excision. Seven pancreatic resections were reviewed, two distal subtotal and one total pancreatectomy. In three patients pseudocysts were noted at the time of surgery for gallstones. These were either ignored or aspirated by needle without drainage. One patient with duodenal obstruction secondary to a pseudocyst was treated by vagotomy and gastroenterostomy without drainage of the cyst. Complications: External drainage in 10 patients was complicated in 9 (90 percent). Internal drainage in 43 patients with cystogastrostomy was complicated 21 times (50 percent). Cystojejunostomy in 11 patients was complicated only once, by recurrent pancreatitis possibly from continued abuse of alcohol. Intraabdominal abscess occurring after internal bypass required external drainage in eight patients, after cystogastrostomy in six, after cystoduodenostomy in one and after partial pancreatic resection in one. Five cystogastrostomies bled postoperatively; two required reexploration for control. One Puestow-type drainage bled from a chronic gastric ulcer that had been unrecognized. Subtotal gastric resection eventually provided successful control. Fistula occurred after external drainage in one patient and after cystogastrostomy in three. Reoperation was required in only one patient for diversion to a Roux-Y loop. Pseudocysts recurred in 10 patients. Thirty percent of the patients with external drainage and less than 10 percent of those with internal drainage had recurrence. Only two of the 107 patients had sudden rupture requiring emergency external drainage. Others have reported a similar low incidence. Recurrent pancreatitis was noted in only five patients, possibly due to difficulty in following up alcoholic patients. The remaining complications were commensurate with the gravity of the surgical procedures and the depleted state of many patients. Many patients had several complications. In summary, external drainage was complicated in 9 of the 10 patients so treated. Internal drainage and resection were complicated in 50 percent of patients. Cystojejunostomy in 11 patients was uncomplicated. This difference was statistically significant. Mortality: Twelve of 107 patients are known to have died, although follow-up data are incomplete. Six patients died within 30 days of surgery, whereas five of the nonoperative group died in the hospital. Sepsis was the major cause of postoperative deaths, whereas multiple organ failure and pneumonia were causes in the group treated conservatively.
Comments Sonography and computed axial tomography are major advances in the diagnosis and monitoring of pancreatic masses. Pseudocysts can now be observed more safely unless complications develop. We feel that because of pancreatic stimulation and infective complications, total parenteral nutrition has largely
575
Sandy et al
replaced feeding jejunostomy for nutritional support. Diagnostic laparotomy resulting in the discovery of phlegmonous masses or cysts with immature walls occurs less frequently [13]. Urgent exploration is still essential for the management of life-threatening complications such as rupture, hemorrhage or abscess although our series, like others, indicates that the incidence is low [9,14]. External drainage is usually the safest procedure because of immaturity of the cyst wall. This series does show high complication and recurrence rates with a frequent need for second explorations in patients with external drainage. This finding differs from that in the series of Elechi et al [11] although they used external drainage in elective as well as urgent cases. For patients who have symptomatic or complicated pseudocysts with mature walls, we believe the procedure of choice is internal drainage. When the stomach is firmly adherent to the collection, cystogastrostomy is appropriate. For others, Roux-Y cystoenterostomy offers a reliable alternative. Pancreatic resection should be reserved for distal fistulas and cysts of the tail provided there is no proximal pancreatic duct obstruction [5]. Recently several investigators have reported preliminary success with catheter drainage of pseudocysts [2,6]. In our single patient with catheter drainage, a persistent fistula required reoperation with cystojejunostomy. Reliable patients with asymptomatic pseudocysts that are not enlarging should be followed up with ultrasonographic monitoring. Cysts that can be shown to decrease in size will likely resolve spontaneously [13,15,16]. Since surgery for pseudocyst carries a significant risk of complications (50 percent in this series), it is important to avoid operation in patients who may be expected to absorb their collections [I 71. Summary One hundred seven patients with pseudocyst managed during the past decade were reviewed. The mortality rate of 11.2 percent compares favorably with the rates in other recent series. Twenty-two percent of the patients were managed conservatively, and 76 underwent exploration. None of the nonoperative patients died from complications of the cyst. In all five patients (4.8 percent) who died, the cause was sepsis and multiorgan failure unrelated to the cyst. Patients with external drainage had a 90 percent complication rate. In addition, in four of five patients attempts at treatment by needle aspiration failed.
576
Internal drainage of all types was complicated in 50 percent of patients, with a surprising absence of complications associated with cystojejunostomy. Asymptomatic pseudocysts may be safely treated conservatively with a good expectation of spontaneous resolution. Eight patients had pseudocysts secondary to biliary tract disease alone. Perhaps the incidence of this complication would have been lower if the biliary disease had been treated. This would support the argument for early surgical intervention in patients with acute pancreatitis secondary to biliary stones. References 1. Joyce LD, Toledo-Pereyra LH, Humphrey EW. Pancreatic pseudocyst: a clinical review. Am Surg 1979;45:453-81. 2. Cooperman AM. Management diseases of pancreas. AudioDigest, Aug 1980. 3. Owens BJ III, Hamit HF. Pancreatic abscess and pseudocyst. Arch Surg 1977;112:42-5. 4. Andersen BN, Hancke S, Nielsen SAD, Schmidt A. The diagnosis of pancreatic cyst by endoscopic retrograde pancreatography and ultrasonic scanning. Am Surg 1977;185: 288-9. 5. Frey CF. Pancreatic pseudocyst: operative strategy. Ann Surg 1978;188:852-82. 8. Cooperman AM. Are pancreatic pseudocysts overtreated? Surg Gynecol Obstet 1980;151:98. 7. Erlichman RJ. Clinical Conferences at the Johns Hopkins Hospital. Pancreatic pseudocyst. Johns Hopkins Med J 1978;143:109-13. 8. Rawlings W, Bynum TE, Pasternak G. Pancreatic ascites: diagnosis of leakage site by endoscopic pancreatography. Surgery 1977;81:383-5. 9. Martin EW, Catalan0 P, Cooperman M. Hecht C, Carey LC. Surgical decision-making in the treatment of pancreatic pseudocysts. Internal versus external drainage. Am J Surg 1979;138:821-4. 10. Shatney CH, Lillehei RC. Surgical treatment pancreatic pseudocysts: analysis of 119 cases. Ann Surg 1979;189:38894. 11. Elechi N, Callender CO, Lefgall LD, Kurtz H. Treatment of pancreatic pseudocysts by external drainage. Surg Gynecol Obstet 1979;148:707-10. 12. Pollak EW, Michas CA, Wolfman EF. Pancreatic pseudocyst. Management of 54 patients. Am J Surg 1978;135:199201. 13. Grace RR, Jordan PH. Unresolved problems of pancreatic pseudocyst. Ann Surg 1978; 184: 18-2 1. 14. Sankaran S, Alexander JW. The natural and unnatural history of pancreatic pseudocyst. Br J Surg 1975;82:37-44. 15. Hastings PR, Nance FC, Becker WF. Changing patterns in management of pancreatic pseudocyst. Ann Surg 1975; 181:548-51. 18. Bradley EL Ill, Clements W. Spontaneous resolution of pancreatic pseudocysts. Implications for timing of operative intervention. Am J Surg 1975;129:23-8. 17. Bodurtha AJ, Dajee H, You CK. Analysis of 29 cases of pancreatic pseudocyst treated surgically. Can J Surg 1980; 231432-4.
The American Journal of Surgery
J. Trevor Sandy, MD, FRCS(C), Vancouver, 8ritish Columbia, Canada R. H. Taylor, MD, FRCS(C), Vancouver, British Columbia, Canada Ralph M. Christensen, MD, FRCS(C), Vancouver, British Columbia, Canada C. Scudamore, MD, Vancouver, British Columbia, Canada P. Leckie, MD, Vancouver, British Columbia, Canada
Pseudocyst of the pancreas is a complication of pancreatitis, a poorly understood disease [I]. Fortunately it is rare, occurring in 1 to 2 percent of patients with acute and chronic pancreatitis [2]. Before the advent of ultrasonography the condition was usually diagnosed at an advanced stage when a mass lesion was palpated in the epigastrium. Contrast studies of the gastrointestinal tract usually corroborated its presence by organ displacement. No reliable method of differentiating a solid phlegmon due to pancreatic edema from a collection of fluid was available before the B-scan [3]. While it had always been postulated that the fluid originated from a leak in the pancreatic ductal system, it was only proven when endoscopic retrograde cholangiopancreatography (ERCP) enabled pancreatography in a significant percentage of cases [4]. The other procedure that has greatly increased diagnostic accuracy in retroperitoneal lesions including the pancreas has been the computed tomographic scan. Sonography and computed tomographic scanning, both noninvasive techniques, have been combined with guided needle biopsy and aspiration to provide biochemical and histologic proof of the underlying disease in a large percentage of cases [3]. Clinicians can now diagnose cystic collections accurately at a much earlier stage and for the first time can monitor the natural history of the syndrome of pseudocyst collection. Angiography is believed by some investigators to play an important role in the assessment of pseudoaneurysm formation, and it helps identify cases with major episodes of bleeding [5]. Greater accuracy in diagnosis and monitoring has led to a reexamination of treatment methods. The ability to aspirate major fluid collections with a From the Divison of General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Requests for reprints should be addressed to J. Trevor Sandy, MD, Suite 708, 750 West Broadway, Vancouver, British Columbia V5Z lH6, Canada. Presented at the 67th Annual Meeting of the North Pacific Surgical Association, Tacoma, Washington, November 14-15, 1980.
574
guided needle or tube has led to simpler methods of drainage than were possible in the past. Many recent reports document varying degrees of success in treating pseudocysts in this relatively new way [6]. Clinicians armed with the means to accurately gauge and follow the size of many cystic collections have established that a large percentage of them will absorb spontaneously. Resolution may require many months, but in the absence of infection, even the static collection can be watched safely [7]. Rawlings et al [8] stated that unless some complication intervenes the cysts should be left alone. Traditionally, fear of rupture, abscess formation or bleeding prompted relatively early drainage. Surgeons in the past were frequently disappointed when exploration of pancreatic masses disclosed either phlegmonous swellings or cysts with immature walls that were unsuited for safe drainage internally [9]. Pseudocysts very rarely rupture but they can leak, leading to pancreatic ascites [8]. The rarity of abscess formation was documented at Johns Hopkins, where only 13 cases were found in 1,187 patients with acute and 576 patients with chronic pancreatitis (0.131 percent) [7]. The highest incidence of abscess formation occurs in postoperative pancreatitis. The treatment for abscess formation is external drainage at an early stage
PJOI.
Elechi et al [ll] consider external sump drainage the preferred treatment for most pancreatic pseudocysts if there is no obstruction of the distal part of the pancreatic duct. The latter should be drained internally by a Roux-Y cystojejunostomy. In their series the traditional cystogastrostomy was associated with a high incidence of pancreatic abscess and hemorrhage, whereas external drainage led to 100 percent survival without fistula or abscess. In contrast, Frey [5] found that external drainage is associated with a high rate of complications or death in 60 to 80 percent of patients. He showed that external drainage is not a definitive operation because over 50 percent of patients require reoperation for recurrent cysts [5]. Pollak et al [12] advocate distal pancrea-
TheAmerican
Journal of Surgery
Pancreatic Pseudocyst
tectomy for pseudocyst of the tail. Cooperman [6] in a recent editorial pointed out that the question of what treatment is best remains unanswered [6].
Material and Methods A retrospective chart review of patients with pancreatic pseudocysts at the three hospitals affiliated with the University of British Columbia was conducted over the past decade. The survey utilized a standard protocol to extract the data. One hundred seven patients ranging in age from 1’7 to 79 years were analyzed (mean age 47.9 years). Two thirds of the patients were male. Alcohol was a major cause of pseudocyst in 70 percent of the patients. Calculus alone was the cause in eight patients, and alcohol plus stones in nine others. Major trauma accounted for two cysts and surgical biopsy two others. Four patients had underlying malignancy of the pancreas or common bile duct. One required removal of a parathyroid adenoma to correct hypercalcemia after drainage of a pseudocyst. In eight patients the cause was deemed idiopathic. The major presenting complaints were pain (98 patients), mass (47), nausea and vomiting (28), weight loss (23), jaundice (17) and bleeding (9). Many patients had more than one symptom. In a few asymptomatic patients the cysts were found either by sonography or at autopsy. Ail records contained copious laboratory results. Serum amylase levels were significantly increased in about 70 percent of the patients. However, many patients with proven pseudocysts had normal levels. Urinary amylase levels were not consistently recorded for the entire series. Like many other investigators, we found that biochemical information is too inconsistent to be of much diagnostic value in predicting or following pseudocysts. Diagnosis: Since the introduction of ultrasonography in about 1975, its use has become routine. Of the 64 patients who underwent ultrasonography, cyst was shown 58 times; 6 findings were false-negative. Contrast studies of the upper gastrointestinal tract were recorded for 67 patients; there were positive signs of organ displacement in 46. ERCP in 15 patients revealed positive findings in 11 with no major complications. Angiography gave positive results in all four patients examined. Computed tomographic scanning just became available in 1980 and was used in two patients. Management: Eighty-one pseudocysts were surgically explored, 24 were observed, and 2 were found incidentally at autopsy. In neither of the latter patients was the cyst considered a contributory cause of death. Emergency exploration was required seven times, four for diagnostic purposes and two for rupture. Another patient had multiple indications, including sepsis. All seven underwent external drainage. Elective drainage was done for pain (19 patients), obstruction (7), enlarging masses (13) and various combinations of these. Four elective patients underwent external drainage when immature cyst walls or infection was encountered. Type of operation: External drainage was performed in 10 cases and internal drainage in 60. Three of the patients with external drainage developed fistulas. One fistula healed spontaneously and one patient required drainage of the fistulous tract to a Roux-Y jejunal loop. The third patient with external drainage eventually died from
Volume 141, May 1981
hemorrhage. Of the patients who had elective internal drainage, 43 underwent cystogastrostomy, 11 cystojejunostomy, 2 cystodenostomy, 3 multiple combinations of these. and 1 a Puestow-tvne nancreatic ieiunostomv for chronic pancreatitis with-cyst: Double cysts were drained through two gastric openings in one patient and through a cystogastrostomy and cystoieiunostomg in another. A single large cyst was attached loosely to the head of the pancreas, which was amenable to total excision. Seven pancreatic resections were reviewed, two distal subtotal and one total pancreatectomy. In three patients pseudocysts were noted at the time of surgery for gallstones. These were either ignored or aspirated by needle without drainage. One patient with duodenal obstruction secondary to a pseudocyst was treated by vagotomy and gastroenterostomy without drainage of the cyst. Complications: External drainage in 10 patients was complicated in 9 (90 percent). Internal drainage in 43 patients with cystogastrostomy was complicated 21 times (50 percent). Cystojejunostomy in 11 patients was complicated only once, by recurrent pancreatitis possibly from continued abuse of alcohol. Intraabdominal abscess occurring after internal bypass required external drainage in eight patients, after cystogastrostomy in six, after cystoduodenostomy in one and after partial pancreatic resection in one. Five cystogastrostomies bled postoperatively; two required reexploration for control. One Puestow-type drainage bled from a chronic gastric ulcer that had been unrecognized. Subtotal gastric resection eventually provided successful control. Fistula occurred after external drainage in one patient and after cystogastrostomy in three. Reoperation was required in only one patient for diversion to a Roux-Y loop. Pseudocysts recurred in 10 patients. Thirty percent of the patients with external drainage and less than 10 percent of those with internal drainage had recurrence. Only two of the 107 patients had sudden rupture requiring emergency external drainage. Others have reported a similar low incidence. Recurrent pancreatitis was noted in only five patients, possibly due to difficulty in following up alcoholic patients. The remaining complications were commensurate with the gravity of the surgical procedures and the depleted state of many patients. Many patients had several complications. In summary, external drainage was complicated in 9 of the 10 patients so treated. Internal drainage and resection were complicated in 50 percent of patients. Cystojejunostomy in 11 patients was uncomplicated. This difference was statistically significant. Mortality: Twelve of 107 patients are known to have died, although follow-up data are incomplete. Six patients died within 30 days of surgery, whereas five of the nonoperative group died in the hospital. Sepsis was the major cause of postoperative deaths, whereas multiple organ failure and pneumonia were causes in the group treated conservatively.
Comments Sonography and computed axial tomography are major advances in the diagnosis and monitoring of pancreatic masses. Pseudocysts can now be observed more safely unless complications develop. We feel that because of pancreatic stimulation and infective complications, total parenteral nutrition has largely
575
Sandy et al
replaced feeding jejunostomy for nutritional support. Diagnostic laparotomy resulting in the discovery of phlegmonous masses or cysts with immature walls occurs less frequently [13]. Urgent exploration is still essential for the management of life-threatening complications such as rupture, hemorrhage or abscess although our series, like others, indicates that the incidence is low [9,14]. External drainage is usually the safest procedure because of immaturity of the cyst wall. This series does show high complication and recurrence rates with a frequent need for second explorations in patients with external drainage. This finding differs from that in the series of Elechi et al [11] although they used external drainage in elective as well as urgent cases. For patients who have symptomatic or complicated pseudocysts with mature walls, we believe the procedure of choice is internal drainage. When the stomach is firmly adherent to the collection, cystogastrostomy is appropriate. For others, Roux-Y cystoenterostomy offers a reliable alternative. Pancreatic resection should be reserved for distal fistulas and cysts of the tail provided there is no proximal pancreatic duct obstruction [5]. Recently several investigators have reported preliminary success with catheter drainage of pseudocysts [2,6]. In our single patient with catheter drainage, a persistent fistula required reoperation with cystojejunostomy. Reliable patients with asymptomatic pseudocysts that are not enlarging should be followed up with ultrasonographic monitoring. Cysts that can be shown to decrease in size will likely resolve spontaneously [13,15,16]. Since surgery for pseudocyst carries a significant risk of complications (50 percent in this series), it is important to avoid operation in patients who may be expected to absorb their collections [I 71. Summary One hundred seven patients with pseudocyst managed during the past decade were reviewed. The mortality rate of 11.2 percent compares favorably with the rates in other recent series. Twenty-two percent of the patients were managed conservatively, and 76 underwent exploration. None of the nonoperative patients died from complications of the cyst. In all five patients (4.8 percent) who died, the cause was sepsis and multiorgan failure unrelated to the cyst. Patients with external drainage had a 90 percent complication rate. In addition, in four of five patients attempts at treatment by needle aspiration failed.
576
Internal drainage of all types was complicated in 50 percent of patients, with a surprising absence of complications associated with cystojejunostomy. Asymptomatic pseudocysts may be safely treated conservatively with a good expectation of spontaneous resolution. Eight patients had pseudocysts secondary to biliary tract disease alone. Perhaps the incidence of this complication would have been lower if the biliary disease had been treated. This would support the argument for early surgical intervention in patients with acute pancreatitis secondary to biliary stones. References 1. Joyce LD, Toledo-Pereyra LH, Humphrey EW. Pancreatic pseudocyst: a clinical review. Am Surg 1979;45:453-81. 2. Cooperman AM. Management diseases of pancreas. AudioDigest, Aug 1980. 3. Owens BJ III, Hamit HF. Pancreatic abscess and pseudocyst. Arch Surg 1977;112:42-5. 4. Andersen BN, Hancke S, Nielsen SAD, Schmidt A. The diagnosis of pancreatic cyst by endoscopic retrograde pancreatography and ultrasonic scanning. Am Surg 1977;185: 288-9. 5. Frey CF. Pancreatic pseudocyst: operative strategy. Ann Surg 1978;188:852-82. 8. Cooperman AM. Are pancreatic pseudocysts overtreated? Surg Gynecol Obstet 1980;151:98. 7. Erlichman RJ. Clinical Conferences at the Johns Hopkins Hospital. Pancreatic pseudocyst. Johns Hopkins Med J 1978;143:109-13. 8. Rawlings W, Bynum TE, Pasternak G. Pancreatic ascites: diagnosis of leakage site by endoscopic pancreatography. Surgery 1977;81:383-5. 9. Martin EW, Catalan0 P, Cooperman M. Hecht C, Carey LC. Surgical decision-making in the treatment of pancreatic pseudocysts. Internal versus external drainage. Am J Surg 1979;138:821-4. 10. Shatney CH, Lillehei RC. Surgical treatment pancreatic pseudocysts: analysis of 119 cases. Ann Surg 1979;189:38894. 11. Elechi N, Callender CO, Lefgall LD, Kurtz H. Treatment of pancreatic pseudocysts by external drainage. Surg Gynecol Obstet 1979;148:707-10. 12. Pollak EW, Michas CA, Wolfman EF. Pancreatic pseudocyst. Management of 54 patients. Am J Surg 1978;135:199201. 13. Grace RR, Jordan PH. Unresolved problems of pancreatic pseudocyst. Ann Surg 1978; 184: 18-2 1. 14. Sankaran S, Alexander JW. The natural and unnatural history of pancreatic pseudocyst. Br J Surg 1975;82:37-44. 15. Hastings PR, Nance FC, Becker WF. Changing patterns in management of pancreatic pseudocyst. Ann Surg 1975; 181:548-51. 18. Bradley EL Ill, Clements W. Spontaneous resolution of pancreatic pseudocysts. Implications for timing of operative intervention. Am J Surg 1975;129:23-8. 17. Bodurtha AJ, Dajee H, You CK. Analysis of 29 cases of pancreatic pseudocyst treated surgically. Can J Surg 1980; 231432-4.
The American Journal of Surgery