Pancreatic Pseudocyst Dilemma: Cumulative Multicenter Experience in Management Using Endoscopy,Laparoscopy,and Open Surgery

Abstract

Background:

Pancreatic pseudocyst (PP) is the commonest cystic lesion of the pancreas. Internal drainage of PPs can be accomplished by traditional open or recently by minimally invasive laparoscopic or endoscopic approaches. We aimed to evaluate and compare the clinical outcomes after endoscopic, laparoscopic, and open drainage.

Methods:

Seventy-one patients with PP underwent endoscopic (n = 35), laparoscopic (n = 4), and open surgical drainage (n = 32). The primary outcome was the success rate. The secondary outcomes were the estimated blood loss, operative time, opioid requirement, morbidity and mortality, length of hospital stay, and recurrence rate.

Results:

The primary success rate was significantly higher for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups. There were no significant differences in the morbidity, mortality, requirement of blood transfusion, reinterventions, and recurrence rate between the groups. Endoscopic drainage revealed significantly lower blood loss, operative time, opioid requirement, and hospital stay in comparison to open and laparoscopic drainage.

Conclusion:

Minimally invasive therapeutic techniques, whether endoscopic or laparoscopic for treatment of PP could be considered valuable, competitive, and promising alternatives for open surgery. Moreover, it is less invasive with less hospitalization and rapid return to work.

Introduction

Pancreatic pseudocyst (PP) is a localized peripancreatic fluid collection that results from pancreatic inflammation due to pancreatitis, trauma, or ductal obstruction due to stricture or stone.¹ The fluid is rich in pancreatic secretions that have leaked from the pancreatic ductal system.² They are not true cysts because they lack an epithelial lining. It is surrounded by a wall of fibrous or granulation tissue.³ It accounts for 80% of all pancreatic cysts. It complicates 2%–10% of patients after acute pancreatitis and about 10%–30% of patients after chronic pancreatitis.⁴ The natural history usually is spontaneous resolution, with up to 85% of pseudocyts resolving within 4–6 weeks.^2,5 The two main factors determining the spontaneous regressions are the size and the time of evolution after diagnosis.⁵ The clinical presentation of PP can range from asymptomatic patient up to major life-threatening complications.^6,7 Acute complications include hemorrhage, infection, and rupture. Chronic complications include gastric outlet and biliary obstruction, and splenic or portal vein thrombosis.⁶

Two principle forms of active therapy are available: distal pancreatectomy for distally located PP is indicated in a small proportion of patients, whereas the large majority of these patients will undergo a drainage procedure.² Drainage procedure is indicated for patients with persistent symptoms (>6 weeks), large (>6 cm), rapidly enlarging, or complicated PP.^8,9 Currently, at least three drainage procedures are available, such as percutaneous drainage, endoscopic drainage, and surgical drainage, which is external or internal. As a result, the management varies based on local expertise and feasibility.¹⁰

Percutaneous drainage is rarely indicated as a result of the high morbidity and mortality rates, and should be done for immature PP, temporary management of infected PP, and patients who cannot tolerate surgery.¹ Surgery was the standard treatment for PPs. The surgical options include cystogastrostomy, cystoduodenostomy, and cystojejunostomy depending on the location of the pseudocyst for the best dependent drainage. Recently, minimally invasive techniques (laparoscopy and endoscopy) have been developed and increasingly reported with comparable postoperative results with the standard open surgery.¹¹ The laparoscopic drainage can be achieved by gastropseudocystostomy, jejunopseudocystostomy, or duodenopseudocystostomy and through transgastric, endogastric approaches, as well as Roux-en-Y or simple loop cystojejunostomy. On the other hand, endoscopic drainage can be achieved through a transmural, transpapillary, or the combined approach.^12,13 A transpapillary endoscopic retrograde cholangiopancreatography (ERCP) technique is used when the pseudocyst communicates with the main pancreatic duct with proved successfulness in pancreatic duct disruption, whereas a transgastric or transduodenal technique is used when the pseudocyst is directly adjacent to the gastric or duodenal wall.^5,14

To date, few comparative trials have evaluated the efficacy of open against laparoscopic or endoscopic approaches.¹⁵ This study aimed to compare the therapeutic outcomes for endoscopic and surgical drainage (open and laparoscopy) of PP.

Materials and Methods

From March 2014 to September 2016, patients with PP at three university hospitals were enrolled in this study. The inclusion criteria were (i) diagnosis of PP based on computed tomography (CT) criteria,³ (ii) persistence of the pseudocyst for more than 6 weeks, (iii) pseudocyst of size greater than 6 cm in diameter, (iv) radiological evidence of reasonable wall thickness enough to facilitate its drainage, (v) documented history of acute or chronic pancreatitis, and (vi) symptomatic or complicated pseudocyst. The exclusion criteria were (i) age <18 or >80 years, (ii) American Society of Anesthesiologists (ASA) class IV,¹⁶ (iii) pregnancy, (iv) associated pancreatic necrosis on CT, and (v) multiple pseudocysts.

Routine investigations and surgical fitness were done in all cases. PP was diagnosed by abdominal ultrasound scan and confirmed by abdominal CT (Fig. 1). The CT findings were used to differentiate a PP, in which fluid predominate its contents; from a walled-off pancreatic necrosis in which necrotic tissue predominates.¹⁵ Magnetic resonance cholangiopancreatography was used selectively in patients who presented with jaundice. Upper gastrointestinal (GI) flexible endoscopy was done in patients who presented with features of gastric outlet obstruction. Antibiotic prophylaxis was started with third-generation cephalosporin and metronidazole. The site of the cyst dictates the operative decision. Retrogastric cysts were treated by a posterior cystogastrostomy. On the other hand, cysts around the head of the pancreas close to the duodenum were easily drained by cystoduodenostomy. Large cysts, which enlarge and bulge inferiorly through the transverse mesocolon, were best drained by cystojejunostomy. The study protocol was approved by the local ethics committee of our hospitals. Also, a written informed consent was obtained from all patients' prior recruitment to study.

FIG. 1.

CT scan showing large pancreatic pseudocyst in the lesser sac. CT, computed tomography.

Endoscopic drainage

All endoscopic procedures were performed with ERCP and fluoroscopy guidance while the patient was under conscious sedation. Endoscopic drainage was performed either through the wall of the stomach or duodenum (transmural) or through the pancreatic duct (transpapillary drainage).² Transmural drainage was performed if there is a direct apposition of the PP against the gastric or duodenal wall. PP was confirmed by a needle puncture with injection of a contrast. A stoma was created with a cystotome followed by the passage of a guide wire. The tract was then sequentially dilated with a sphincterotome or an endoscopic dilation balloon. After obtaining an adequate stoma, one pigtail plastic 10F stent was inserted across the cystenteric tract. If the effluxing fluid proved to be thick and passed through the stent very slowly with difficulty, we have the possibility of self-expandable metal stent deployment that can drain debris and thick contents. If it is not feasible, two 10F double pigtail plastic stents are applied plus nasal pseudocystic catheter in separate puncture for washout of these thick contents by direct continuous sterile saline current through the catheter for 1–3 days, then extracted after assurance of pseudocyst collapse by sonar (Figs. 2 –7). Transpapillary drainage was performed when ERCP shows direct communication between the pseudocyst and the main pancreatic duct. A guide wire is passed across the sphincter and the pancreatic duct into the PP. A pancreatic sphincterotomy is performed and a 7F pancreatic stent is passed across the pancreatic duct into the PP.

FIG. 2.

Endoscopic pseudocyst single pigtail stent drainage to the stomach.

FIG. 3.

X-ray film showing double pigtail stent within the stomach.

FIG. 4.

Picture showing double pigtail stent drainage and nasocystic catheter washes for heavily infected cyst with thick content.

FIG. 5.

X-ray film showing double pigtail stent drainage and nasocystic catheter washes for heavily infected cyst with thick content.

FIG. 6.

X-ray film showing guide wire within the pseudocyst cavity, followed by deployment of SEMS for drainage of infected cyst to stomach cavity. SEMS, self-expandable metal stent.

FIG. 7.

Deployment of SEMS for drainage of infected cyst to stomach cavity. SEMS, self-expandable metal stent.

Open drainage

Open PP drainage was achieved through a limited supraumbilical midline or bilateral subcostal incision. In cases of cystogastrostomy, a 2 cm anterior gastrostomy was performed in the position overlying the area in which the cyst was adherent to the posterior wall of the stomach and cyst aspiration for reassurance was done. An 8–10-cm posterior gastrostomy was extended through the cyst wall, and the PP was aspirated and debrided of its contents. A biopsy of the cyst wall was performed. The cystogastrostomy was performed with a running suture between the gastric and cyst walls to complete the anastomosis. The anterior gastrostomy finally was closed. In cases of cystojejunostomy, the jejunum is transected with a mechanical stapler 20 cm from the ligament of Treitz. The distal end is oversewn and brought up to the cyst as a Roux limb. Interrupted 3-0 silk sutures are placed between the cyst wall and the posterior jejunal wall for 4–5 cm or longer and tied down. A cystostomy and jejunostomy are made and a biopsy is taken of the cyst wall. An interrupted single layer of 3-0 silk sutures is placed between the cyst and the jejunum to create an anterior wall (Fig. 8). Abdominal drains and nasogastric decompression of the stomach were not used routinely, and when used they were removed as early judged suitable by the surgical team.

FIG. 8.

Operative photo showing open cystojejunostomy operation.

Laparoscopic drainage

Laparoscopic cystogastrostomy principle was similar to the open technique. The camera port (10 mm) was placed in the midline, 3 cm above the umbilicus. The right hand working port (5 mm) was placed in the left hypochondrium of the patient and the left hand working port (5 mm) was placed in the right paramedian position, both these ports being cranial in relation to the camera port. An additional fourth port (5 mm), if required, was placed in the subxiphoid area for the liver retraction. With the transgastric approach, access to the posterior gastric wall is established through an anterior gastrostomy. A needle is introduced to confirm the location of the PP and to sample the fluid. The ultrasonically activated scalpel is used to create a stoma ∼4–5 cm in size between the adherent posterior gastric wall and the anterior wall of the PP. Hemostatic sutures were placed between the posterior gastric wall and the anterior cyst wall. The cyst cavity was examined and all the necrotic material was debrided followed by irrigation through a nasogastric tube previously placed within the cyst. Intracorporeal sutures were used to close the anterior gastrostomy. The peritoneal cavity was lavaged and a drainage tube placed. Laparoscopic cystojejunostomy was performed with three or four ports in a similar fashion as for laparoscopic cystogastrostomy. After debridement, wide (5 cm), hand-sewn pseudocystojejunal anastomosis was performed with continuous sutures (Fig. 9). A drainage tube was kept in the left paracolic gutter.

FIG. 9.

(A) Laparoscopic trocar application prior cystojejunostomy; (B) Laparoscopic identification of the cyst; (C) Laparoscopic puncture of the pseudocyst; (D) Laparoscopic preparation of the jejunal loop; (E) Laparoscopic anastomosis between the pseudocyst and the jejunal loop; (F) Laparoscopic pseudocystojejunostomy completed.

Postprocedure follow-up

A fixed analgesia protocol with intravenous non-narcotic (ketorolac tromethamine 30 mg) was used twice daily. An opioid (Pethidine hydrochloride 50 mg) was added when the pain cannot be tolerable. Nasogastric tube was removed on the first postoperative day and oral diet was started after the bowels moved. During postoperative follow-up, the patients were evaluated by clinical examination and ultrasound of the abdomen after 15 days, 1 month, 3 months, 6 months, and yearly thereafter. At the 3-month follow-up evaluation, transmural stents were removed if the pseudocyst had resolved on the CT scan. If the pseudocyst was persistent, additional drainage was performed by placement of another stent. If endoscopic drainage failed, patients treated with open drainage. Patient demographics, procedural and operative reports, postoperative outcomes, and clinical follow-up data were recorded.

Primary success was defined as clinical or radiographic cyst resolution after the index intervention. Overall success was defined as clinical or radiographic cyst resolution at the last clinical follow-up assessment regardless of the number of trial or methods of intervention. Length of hospital stay was defined as the time from the day of treatment to the day of discharge.¹¹ Treatment failure was defined as conversion from one to another modality or repeated intervention. Reintervention was defined as the need for repeat intervention due to persistent symptoms in association with a residual pseudocyst that was not less than half of the original size on follow-up imaging.¹⁷ Recurrence was defined as new-onset abdominal pain in the presence of a pancreatic fluid collection on CT imaging after complete resolution.² Postoperative morbidity and mortality included all complications or deaths that developed within 30 days of intervention.¹⁸

The primary outcome was the success rate (primary and overall). The secondary outcomes were the estimated blood loss, blood transfusion, operative time, opioid requirement, morbidity and mortality, length of hospital stay, and recurrence rate. Continuous data were expressed as mean ± standard deviation and range and were compared using a two-sample t-test. Categorical data were expressed as frequencies and percentages and were compared using the chi-square. Statistical significance was determined as a P value of .05 or less.

Results

Between March 2014 and September 2016, 71 patients underwent PP drainage that included endoscopic (n = 35), laparoscopic (n = 4), and open (n = 32) approach. There were no significant differences in the mean age, sex, body mass index, etiology of pancreatitis, size of PP, and ASA score between the groups (Table 1). In this study, endoscopic techniques included cystogastrostomy, cystoduodenostomy, and transampullary drainage, and open and laparoscopic techniques included open and laparoscopic cystogastrostomy and cystojejunostomy as shown in Table 2. Patient's outcomes are shown in Table 3.

Table 1.

Patient Demographic Data

Patient data	Endoscopy (n = 35)	Laparoscopy (n = 4)	Open (n = 32)	P
Age (years), mean ± SD	49.2 ± 3.8	51.8 ± 1.9	48.8 ± 2.3	.91
Male: Female	1.3:1	1:1	1.5:1	.73
BMI (kg/m²), mean ± SD	28.2 ± 1.9	27.3 ± 1.7	29.1 ± 1.3	.62
Cause of pancreatitis
Gallstone	20	1	19
Traumatic	9	3	8
Idiopathic	6	0	5
PP size (cm); mean ± SD	10.3 ± 0.7	10.1 ± 0.8	9.9 ± 1.1	.51
ASA	2	2	2	.9

ASA, American Society of Anesthesiologists; BMI, body mass index; PP, pancreatic pseudocyst; SD, standard deviation.

Table 2.

Type of Drainage Procedures

Type of procedures	Endoscopy, n (%)	Laparoscopy, n (%)	Open, n (%)
Cystogastrostomy with single pigtail stent drainage	3 (5.1)
Cystogastrostomy with double pigtail stent drainage	11 (18.6)
Cystogastrostomy with single pigtail stent and catheter drainage	14 (23.7)
Cystogastrostomy with covered self-expandable metal stent	2 (3.4)
Cystoduodenostomy with single pigtail stent	3 (5.1)
Transampullary drainage with single stent	2 (3.4)
Cystogastrostomy		2 (50)	25 (78.1)
Cystojejunostomy		2 (50)	7 (21.9)

Table 3.

Patient Outcomes

Patient outcomes	Endoscopy	Laparoscopy	Open	P
Primary success rate, n (%)	29 (82.9)	4 (100)	32 (100)	.01
Overall success rate, n (%)	32 (91.4)	4 (100)	32 (100)	.87
Reintervention, n (%)	3 (8.6)	0 (0)	0 (0)	.21
Estimated blood loss (mL)	15 (8–25)	85 (30–240)	100 (55–220)	.006
Blood transfusion (U)	0	0	0	1
Operative time (minutes)	37 (22–55)	113 (88–176)	92 (76–118)	.001
Opioid requirement, n (%)	0 (0)	2 (50)	25 (78.1)	.001
Hospital stay (days)	3.9	5.2	9	.001
Morbidity, n (%)	3 (8.6)	1 (25)	6 (18.8)	.08
Mortality	0	0	0	1
Recurrence rate, n (%)	4 (11.4)	0 (0)	1 (3.1)	.78

Endoscopic drainage of PPs

In our study, 35 patients underwent an endoscopic drainage procedure with different modalities. The primary success rate was 82.9%. Of the six primary endoscopic failures, three patients (8.6%) were managed successfully by a repeat endoscopic drainage procedure. Therefore, finally 32 patients (91.4%) were managed successfully with endoscopic drainage and three patients (8.6%) with primary endoscopic failures was salvaged by open surgical procedure. Three patients (8.6%) developed grade 2 or greater complications according to Clavien–Dindo classification. Two patients had bleeding from the cystogastrostomy that was controlled endoscopically, and one patient had hematemesis that resolved with conservative measures.

The transgastric stents were removed endoscopically in 26 of 32 patients. Recurrence of a PP was diagnosed in four patients (11.4%) at 7–13 months after cystogastrostomy with single stent drainage (two patients) and transampullary drainage (two patients); these were redrained endoscopically through the previous cystogastrostomy with double pigtail stent and with transampullary drainage with double stent, and have not recurred on a further follow up of 12 months after stent removal.

Laparoscopic drainage of PPs

Treatment was successful in all four patients (100%). Laparoscopic pancreatic cystogastrostomy was performed in two patients (50%) and laparoscopic pancreatic cystojejunostomy (Roux-en-Y) was performed in two patients (50%). There were no conversions to open procedure. No patients underwent a simultaneous laparoscopic procedure. One patient (25%) after laparoscopic cystogastrostomy developed upper GI bleeding managed conservatively by 2 U of fresh blood transfusion. There was no symptomatic recurrence of PP on the follow-up.

Open drainage of PPs

Open cystogastrostomy (25 patients) and cystojejunostomy (7 patients) were performed. No patients underwent a simultaneous procedure. The primary and overall success rate was 100%. Six patients (18.8%) suffered grade 2 or greater complications according to Clavien–Dindo classification. One patient experienced multisystem organ dysfunction and respiratory failure requiring prolonged ventilatory support and a tracheostomy. This patient had a prolonged hospital stay (39 days). Two patients developed a wound infection that was treated by antibiotic and repeated dressing, one patient developed intraabdominal infection, which required prolonged parenteral antibiotics, one patient developed a small bowel obstruction secondary to paralytic ileus that was managed with conservative measures, and finally one patient presented with a residual PP that did not require drainage. One patient developed pseudocyst recurrence at 6 months after surgery. He was managed endoscopically with covered self-expandable metal stent, and has not recurred on a further follow-up of 10 months after stent insertion.

Comparison of the three methods for PP drainage showed a primary success rate of 82.9%, 100%, and 100% for endoscopic, laparoscopic, and open drainage, respectively. The primary success rates were significantly higher (P = .01) for the surgical procedures. Nevertheless, the overall success rates were not significantly different (P = .87) between the endoscopic (91.4%), laparoscopic (100%), and open (100%) drainage. Furthermore, the incidence of complications after the primary procedure were not significantly different (P = .08) among the endoscopic (8.6%), laparoscopic (25%), and open (18.8%) PP drainage. No mortality was documented among the three groups. There were no differences in rates of recurrence and reintervention between groups; however, blood loss, operative time, opioid requirement, and hospital stay was significantly lower in the endoscopic drainage group.

Discussion

Symptomatic or complicated PPs are the two main indications for drainage procedures.¹⁹ Open surgical drainage was the gold standard treatment of PPs¹³ since the first open pseudocystogastrostomy was performed in 1921²⁰ until 1985, where Kozarek et al.²¹ reported the first successful endoscopic PP drainage. The minimally invasive methods of internal PP drainage have become increasingly preferred among both patients and surgeons because of their reported safety and decreased length of postprocedural convalescence. Compared with conventional open surgery, which carries a mortality rate of 5.8% and a complication rate of 24%–40%,²² minimally invasive PP drainage is shown in selected patients to relieve the pain of chronic pancreatitis and to recover pancreatic function with significantly less morbidity than the traditional open surgery.²³

Endoscopic drainage may be performed by transmural (transgastric), the commonest method in our study, transpapillary, or a combination of both techniques.²⁴ The decision of one approach over the other depends on the size of the collection, proximity to the stomach or duodenum, and ability to enter the pancreatic duct, and/or reach the area of disruption. The decision to use combined transmural and transpapillary approach for large collections is individualized. The combined approach has not been shown to be superior to transmural drainage alone.²⁴ Endoscopic treatment of PPs is advised in all chronic unilocular cysts causing bulge in the luminal aspect of the gut as mandated by inclusion criteria, in most cases it is usually containing serous reaction with little debris and easily drained by regular plastic endoscopic stents unless secondary infected, before treatment (as evident by constitutional symptom of sepsis, or presence of gas foci within its lumen by X-ray, or evident debris by sonar), or infected after endoscopic treatment by blockage of the deployed stents, or insufficient collapse after 3 days posttreatment. Whatever be the amount of serous fluid within the pseudocyst cavity, it can be drained through the deployed regular plastic stents 10F in diameter, double pigtail or self-expandable metal stent.

Laparoscopic drainage is the method in which the pseudocyst is drained through anastomosis either to the stomach, duodenum, or the jejunum wall with a linear stapler or with laparoscopic suturing techniques. Laparoscopic drainage includes pseudocystogastrostomy, pseudocystoduodenostomy, and pseudocystojejunostomy.^2,25 To date, no prospective controlled studies have compared directly different drainage approaches. As a result, the management varies based on local expertise.¹⁹

The reported primary success rates ranged from 51.1% to 95% in the endoscopic group, and 81.2% to 100% in the surgical group, whereas the overall treatment success rates in the endoscopic group and surgical groups were 77.7%, and 91.2%, respectively.¹¹ Aljarabah and Ammori reported 98.3% and 80.8% overall success rate in laparoscopic and endoscopic groups.² A previous study evaluating the primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open PPs drainage revealed that the primary success rates were significantly higher for the laparoscopic and open drainage procedure (51.1%, 87.5%, 81.8% for endoscopic, laparoscopic, and open drainage, respectively; P < .01), whereas the overall success rates were not significantly different between the endoscopic (84.6%), laparoscopic (93.8%), and open (90.9%) drainage.¹ The previous results were comparable with our results, which reported a significant primary success rate (P = .01) of 82.9%, 100%, and 100% for the endoscopic, laparoscopic, and open groups, whereas reported a nonsignificant overall success rate (P = .87) of 91.4%, 100%, and 100% for the same groups. The higher primary laparoscopic drainage success rate may be explained by the large size of cystenteric stoma drainage (a 4–5-cm cystogastrostomy or cystojejunostomy) and complete debridement of the underlying pancreatic and peripancreatic necrosis. We try to avoid the previous limitations by the use of double stent, self-expandable metallic stent or single stent with catheter drainage.

However, blood loss was significantly lower in the endoscopic group versus the other two groups, it was minimal and none required blood transfusion. Estimated blood loss was not reported in previous studies for endoscopic drainage. Khaled et al.,¹⁵ reported minimal blood loss (<100 mL per procedure) without requiring blood transfusion in both laparoscopic and open surgical drainage. In our opinion, our study may be the first study to report the estimated blood loss and blood transfusion requirement between endoscopic and surgical drainage. We revealed a significant difference regarding blood loss (0.006) between endoscopic (15 mL) and surgical drainage (85 and 100 mL), although no patient required blood transfusion in the three groups.

In our study, the operative time was significantly lower in the endoscopic group versus the other groups. The longer operative time in the open group might be explained by the added time of opening and closing the abdomen at laparotomy, whereas in the laparoscopic group may be explained by the early learning curve of the surgeon.

The median operating time of laparoscopic drainage was significantly shorter than that of open drainage.¹⁵ There are no available data in the literature regarding the operative time of endoscopic drainage, whereas the operative time ranged from 60 to 305 minutes (mean, 152) for the laparoscopic drainage.² Our study revealed significantly shorter operative time regarding the endoscopic drainage versus surgical drainage (laparoscopic or open). Although operative time was shorter in the open drainage than laparoscopic drainage, it was insignificant. Our study is the first study to have reported the opioid requirement for patient after different drainage procedures for PP. No patient required opioid for postoperative pain in the endoscopic group, whereas 50% and 78.1% of patients required postoperative opioid in the laparoscopic and open drainage groups, respectively, with significant difference between them and the endoscopic group.

A recent meta analysis reported that the endoscopic group experienced an evidently shorter length of hospital stay than did the surgical group.¹⁵ Also a recent systemic review revealed that the mean postoperative hospital stay was 5.7 days (range, 2–32 days), in laparoscopy versus 4.5 and 5 days in endoscopy.² On the contrary, in the previous studies we reported significantly shorter hospital stay for the endoscopic and laparoscopic drainage.

The morbidity rates of endoscopic and surgical treatment reported in the literature are highly variable. A meta analysis reported that the complication rate in the endoscopic group was 12% and in the laparoscopic group it was 4.2%, with no significant difference.² While another one reported that the overall adverse event incidences in the endoscopic group were 11.5% and in the surgical group it were 18% with no significant difference.¹¹ Similarly, our study revealed no significant difference between all groups.

Also, the mortality rates of endoscopic and surgical treatment reported in the literature are highly variable. Our study revealed no operative mortality in all groups, and in this regard, we note that the previously published literature review of open cystogastrostomy²⁶ reported a mortality rate of 5% in contrast to 0% in the laparoscopic cystogastrostomy²⁷ and a mortality rate of 0% in laparoscopic drainage versus 0.4% for endoscopic drainage of PP.²

A recent meta-analysis reported the overall recurrence rate was 3.1% in the endoscopic group and 3.2% in the surgical group with no statistical significance.¹¹ Our study revealed no recurrence (0%) in the laparoscopic group with a low recurrence rate in the endoscopic and open group (11.4% and 3.1%) with no significant differences. Disconnected duct syndrome has been considered a major factor leading to pseudocyst recurrence.¹⁷ Hence, some authors advocate the combined procedure of transpapillary pancreatic stenting of any ductal disruption or stricture before endoscopic cystogastrostomy, and thereby minimize chances of pseudocyst recurrence.²⁸ The time for stent removal is another factor. In a randomized trial that compared removal versus nonremoval of transmural stents, the rate of recurrence following stent removal was significantly higher.²⁹ Another study also showed that short duration of stents was associated with high recurrence.³⁰ We agree with Zhao et al. that further investigation is needed to determine the duration of stents.¹¹ Although we did not compare the hospital cost regarding the three groups, many recent studies and meta-analysis clearly demonstrated that the hospital cost in the endoscopic group was significantly less than in the surgical group.^11,17

Walled off pancreatic necrosis pseudocyst or acute pseudocysts are better treated by surgery as necrosectomy is rarely sufficient passively without scavenger procedures as suction, moping, curettage, etc. and endoscopy is rarely needed in special situation only as academic researches, clinical trials, or workshops, as a demonstration. Also surgery is resorted to in the absence of gut intraluminal plugs of the cyst without EUS guide, independent endoscopic drainage procedures as cysts bulge in the infracolic space and the root of the mesentery, or if the cyst is a multiloculated one. Surgery may also be indicated in the absence of endoscopic facilities or expertise in the center.

Conclusion

In conclusion, treatment of PP is in an era of reevaluation. Relatively new and minimally invasive techniques have been introduced as alternatives to the standard conventional open surgical management. Endoscopic procedures have been increasingly used with excellent results. Laparoscopic approach, although difficult, appears to be promising. However, large-scale comparative studies of the three different therapeutic modalities are highly recommended.

Footnotes

Acknowledgments

The authors express their appreciation to all staff of the General Surgery Department of Sohag University Hospitals, Assuit University Hospitals, and Qena University Hospitals, Egypt for their help during the conduct of this study.

Disclosure Statement

This work is investigator initiated with no external funding or support. The authors have no conflicts of interest to disclose.

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