Percutaneous Drainage of Pancreatic Pseudocysts Is Associated With a Higher Failure Rate Than Surgical Treatment in Unselected Patients

Abstract

Objective

The primary aim was to compare directly the effectiveness of percutaneous drainage versus surgical treatment of pancreatic pseudocysts in unselected patients. The authors also wished to identify factors that may predict a successful outcome with percutaneous drainage.

Summary Background Data

Pancreatic pseudocysts are a common complication of pancreatitis, and recent data suggest that many pseudocysts may be observed or treated successfully by percutaneous drainage. Failures with percutaneous drainage have been recognized increasingly, and a direct comparison of percutaneous and surgical treatment was initiated to identify factors that may affect outcome with these approaches.

Methods

A computerized index search of the medical records of patients with a diagnosis of pancreatic pseudocyst was performed from 1984 to 1995. One hundred seventy-three patients were identified retrospectively and assigned to treatment groups: observation (n = 41), percutaneous drainage (n = 66), or surgical treatment (n = 66). Data on demographics, clinical presentation, pseudocyst etiology and characteristics, diagnostic evaluation, management, and outcome were obtained. Treatment failure was defined as persistence of a symptomatic pseudocyst or the need for additional intervention other than the original treatment.

Results

The etiology of pancreatitis, clinical presentation, and diagnostic evaluation did not differ between groups. Twenty-seven percent had documented chronic pancreatitis, and the etiology of pancreatitis was alcohol in 61% of patients. Mean pseudocyst size was 4.2 ± 1 cm, 8.2 ± 1.1 cm, and 7.4 ± 1.3 cm in the observed, percutaneously treated, and surgically treated groups, respectively. Expectant treatment was successful in 93% of patients. Percutaneous drainage was successful in 42% of patients, whereas surgical treatment resulted in a success rate of 88%. Patients treated by percutaneous drainage had a higher mortality rate (16% vs. 0%), a higher incidence of complications (64% vs. 27%), and a longer hospital stay (45 ± 5 days vs. 18 ± 2 days) than patients treated by surgery. Eighty-seven percent of patients in whom percutaneous drainage failed required surgical salvage therapy. Multiple logistic regression analysis failed to reveal any factors significantly associated with a successful outcome after percutaneous drainage.

Conclusions

Percutaneous drainage results in higher mortality and morbidity rates and a longer hospital stay than surgical treatment of pancreatic pseudocysts. The clinical benefit of percutaneous drainage of pancreatic pseudocysts in unselected patients has not been realized, and the role of this treatment should be established in a clinical trial.

Pancreatic pseudocysts were considered an uncommon complication of pancreatitis until the advent of computed tomography (CT), but they now are a recognized complication of 16% to 50% of cases of acute pancreatitis and 20% to 40% of cases of chronic pancreatitis. ¹ The natural history of pancreatic pseudocysts includes an early phase of approximately 6 weeks when spontaneous resolution is most likely. Maturation of the pseudocyst wall and a decreased likelihood of spontaneous resolution occur with pseudocyst persistence. Untreated persistent pseudocysts have been associated with a 40% complication rate, including abscesses, fistulas, spontaneous rupture, massive hemorrhage, and death. ² More recent data suggest that select pancreatic pseudocysts may be treated expectantly with a lower morbidity rate, and surgical or percutaneous drainage is unnecessary in selected patients with asymptomatic pseudocysts. ^3,4

The management of symptomatic pseudocysts includes surgical pseudocyst decompression by external or internal drainage into the alimentary tract and infrequently pancreatic resection. Recently, CT- or ultrasound-guided percutaneous catheter drainage has been used as an alternative to surgical drainage, with early studies reporting a 70% to 90% success rate. ^5–12 Subsequent studies with longer follow-up indicate that pseudocyst persistence or recurrence after percutaneous drainage is significantly higher than reported previously. ^13–16 No reliable method of selecting patients likely to respond favorably to percutaneous drainage exists, and the clinical indications for percutaneous drainage remain unclear. Although several studies have compared percutaneous drainage and surgical treatment, this is the largest retrospective series to compare these treatment modalities. 8,12,14,15,17

The aim of this study was to compare the effectiveness of percutaneous catheter drainage versus surgical management of pancreatic pseudocysts. A secondary end point was to identify factors that predict a successful outcome after percutaneous drainage of a pseudocyst.

PATIENTS AND METHODS

A computerized index search of the University of North Carolina Hospitals medical records from December 1984 through May 1995 using the key word “pseudocyst” identified 255 patients. Records for each of these 255 patients were reviewed. Data on demographics, clinical presentation, pseudocyst characteristics, diagnostic evaluation, treatment, and immediate complications and late sequelae were obtained. After thorough review, 173 patients had a well-documented pancreatic pseudocyst(s). The remaining 82 patients were excluded because of transfer from other hospitals with insufficient information, incomplete data, or a misdiagnosis of pancreatic pseudocyst. The definition of pancreatic pseudocyst formulated by the Atlanta International Symposium was applied retrospectively to CT and ultrasound reports for a uniform definition of a pancreatic pseudocyst. ¹⁸

The 173 patients were assigned to groups based on initial hospital treatment (observation, percutaneous drainage, or surgery) and outcome (success, failure). Observation was defined by lack of intervention other than fluid management and pain control. Percutaneous drainage was defined as nonoperative, ultrasound- or CT-guided percutaneous placement of a catheter for pseudocyst drainage. Surgical intervention included internal or external drainage, longitudinal pancreaticojejunostomy, or distal pancreatectomy.

For patients who were observed, success was defined as either radiographic resolution of the pseudocyst or symptom abatement; failure was defined as radiographic persistence of a symptomatic pseudocyst. Successful percutaneous drainage required pseudocyst resolution without surgery; failure was defined as a persistent symptomatic pseudocyst that required surgery. Surgical success required pseudocyst resolution with one surgical procedure; failure was defined as a persistent symptomatic pseudocyst requiring two or more surgical procedures, or the need for percutaneous drainage after surgery. Thus, the six groups of patients were as follows: observed success (OS), observed failure (OF), percutaneous success (PS), percutaneous failure (PF), surgical success (SS), and surgical failure (SF).

Data are presented as the mean ± SEM. Multiple logistic regression analysis for factors predicting successful percutaneous treatment was performed; this included patient age, sex, and body mass index; pseudocyst size, number, and location; acute versus chronic pancreatitis; and performance of a preprocedure endoscopic retrograde cholangiopancreatography (ERCP) as variables. An α value of p < 0.05 was chosen as significant.

RESULTS

The cohort (n = 173 patients) had a mean age of 45 ± 1 years at presentation; 64% were men. Twenty-seven percent had documented chronic pancreatitis. The etiology of the pancreatitis was alcohol in 61% of patients, gallstones in 10%, and miscellaneous causes in 29%. Abdominal pain (71%) and nausea and vomiting (39%) were the most common symptoms at presentation, with abdominal tenderness (68%) the most common physical finding. Evaluation included CT, abdominal ultrasound, and ERCP in 83%, 43%, and 29% of patients, respectively. Forty-one patients (24%) were initially treated by observation, 66 (38%) by percutaneous drainage, and 66 (38%) by surgery (Fig. 1).

Figure 1. Outcome of 173 patients with pancreatic pseudocysts treated by observation, percutaneous drainage, or surgery.

The six groups of patients had similar ratios of men to women and mean age at presentation (Table 1). The percentage of patients with chronic pancreatitis and the etiology of pancreatitis did not differ among the groups. The clinical presentation and the diagnostic evaluation of patients in the six groups were similar. Indications for treatment were similar among groups and included persistent pain, infection, bleeding, and miscellaneous symptoms.

Table 1. Demographics and Indications for Treatment of Pancreatic Pseudocysts^*

Patients treated by observation tended to have smaller pseudocysts (mean size 4.2 ± 0.4 cm) and were less likely to have multiple pseudocysts or immediate complications than patients treated by percutaneous drainage or surgery (Tables 2 and 3). There were only three observation failures as a result of persistent, symptomatic pseudocysts, and subsequent treatment included transpapillary stenting in a single patient with pancreas divisum, and no further treatment in two patients.

Table 2. Pseudocyst Characteristics^*

Table 3. Complications and Late Sequelae of Treatment of, Pancreatic Pseudocysts^*

Percutaneous drainage of pancreatic pseudocysts was successful in 28 patients (42%); the remaining 38 patients (58%) required further treatment (see Fig. 1). Patients treated by percutaneous drainage on average required slightly more than two percutaneous catheter changes, with no difference in the number of catheter changes between those treated successfully and those in whom percutaneous treatment failed (Table 4). The duration of catheter drainage was 27 ± 7 days in the PS group but 51 ± 15 days in the PF group. Similarly, the duration of hospital stay was 31 ± 5 days in the PS group and 56 ± 8 days in the PF group (Fig. 2). Thirty-three (87%) of the 38 patients in whom percutaneous drainage failed required surgery. Twenty-three (70%) of these 33 patients had successful surgery, whereas 10 patients had surgery complicated by death (n = 4), repeat percutaneous drainage or revisional surgery (n = 5), or a persistent pseudocyst (n = 1).

Table 4. Results of Percutaneous Drainage

Figure 2. Hospital stay in all patients treated by percutaneous drainage (All PD) or surgery (All ST) and those who had successful percutaneous drainage (PS) and failed surgical treatment (SF).

Of the 66 patients treated initially by surgery, 58 patients (88%) were treated successfully and 8 patients (12%) required further treatment (see Fig. 1). Patients treated by surgery most often underwent a cystjejunostomy or a cystgastrostomy (Table 5). Distal pancreatectomy, lateral pancreatojejunostomy, and external drainage were performed less commonly. The mean hospital stay was 17 ± 2 days for the SS group and 24 ± 6 days for the SF groups, substantially shorter than for patients treated by percutaneous drainage (see Fig. 2). Of the eight patients in whom initial surgical treatment was unsuccessful, five underwent percutaneous drainage, with a successful outcome in three patients. Three patients had additional surgery, with a successful outcome in two patients. The three patients in whom further therapy failed had infectious (n = 2) or hemorrhagic (n = 1) complications necessitating reoperation.

Table 5. Procedures Performed And Results of Surgical Treatment^*

For the entire cohort, the mortality rate was 3.5%; however, the mortality rate in the PF group was 16%. No patient in the surgical group died. The most common complications were infection (25%) and pseudocyst persistence (19%); the morbidity rate was 20%, 64%, and 27% in observed, percutaneously drained, and surgically treated patients, respectively. The group-specific morbidity rate was OS 13%, OF 100%, PS 43%, PF 79%, SS 21%, and SF 75%. Infectious complications were more common in the percutaneously treated patients, especially those in whom percutaneous drainage failed (see Table 3). Notably, even one third of patients who were successfully treated by percutaneous drainage had an early infectious complication. Bleeding, fistulas, and renal and pulmonary complications were observed less commonly. All complications were more common in patients whose initial treatment was percutaneous rather than surgical. Late sequelae (after hospital discharge) most commonly observed were the recurrence of pancreatitis or a pseudocyst (see Table 3). More than 70% of patients in the PS and SS groups did not have late sequelae, as did one third of the patients in the PF and SF groups. Late sequelae were more common in failure groups and in patients initially treated by percutaneous drainage.

Multiple logistic regression analysis was performed to identify factors predictive of a successful outcome after percutaneous treatment. Patient age, sex, and body mass index; pseudocyst size, number, and location; acute versus chronic pancreatitis; and preprocedure ERCP were examined as potential variables predictive of success, but none of these factors proved significant.

DISCUSSION

Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis, and management of pseudocysts has evolved over the past 20 years. Pseudocysts that fail to resolve within 6 weeks were formerly thought to have an inordinately high risk of complication, but recent natural history studies have suggested that selected patients with asymptomatic pseudocysts can be treated by observation without increased risk. ^3,4 Symptomatic pseudocysts have been treated by percutaneous drainage or surgical therapy. We reviewed our experience with 173 patients with pancreatic pseudocysts with the aim of retrospectively comparing the effectiveness of percutaneous drainage with surgical therapy. We found that selected patients with small, asymptomatic pancreatic pseudocysts can be observed safely with a high likelihood of pseudocyst resolution. Percutaneous drainage was associated with a higher failure rate than surgical therapy, with increased mortality and morbidity rates and a longer hospital stay when compared with surgical therapy. Surgical treatment had a high probability of success, but a proportion of patients clearly had a good outcome with percutaneous drainage. Multiple logistic regression analysis, however, failed to identify associated factors likely to predict success after percutaneous drainage. These findings indicate that surgical treatment of pancreatic pseudocysts should be the primary therapy.

Our findings confirm that a subset of patients with pancreatic pseudocysts can be treated expectantly. Forty-one patients were treated by observation, and in only three did treatment fail because of persistent symptomatic pseudocysts. In an early natural history study, Bradley et al ² found that complications occurred in 41% of patients with pseudocysts >6 cm. They, therefore, advocated surgical treatment of pseudocysts >6 cm when the pseudocyst wall had matured. Recent studies by Vitas and Sarr ³ and Yeo et al ⁴ have demonstrated that selected patients can be managed by observation. Although Yeo et al showed that pseudocysts <6 cm were more appropriately managed expectantly, Vitas and Sarr found that observation was successful in three patients with pseudocysts >10 cm. These studies provide evidence that the previously held dogma of mandatory surgery for pancreatic pseudocysts is untrue in selected patients. Our data are in accord with those of Vitas and Sarr and Yeo et al in that selected asymptomatic patients with small pancreatic pseudocysts can be managed safely without intervention. Notably, patients observed successfully tended to have smaller pseudocysts (<6 cm), as described in both of the previous studies. Our high rate of success with expectant management is likely the result of the small size (4 cm) of pseudocysts managed by this approach. In addition, Behrman et al ¹⁹ recently showed that patients with giant pseudocysts (≥10 cm) complicating acute pancreatitis tended to have higher morbidity and mortality rates and therefore should be managed with surgery.

Recently, symptomatic and asymptomatic pancreatic pseudocysts have been treated by percutaneous catheter drainage. Early studies were enthusiastic about this nonsurgical approach to pseudocysts, with several studies reporting 70% to 90% resolution of pancreatic pseudocysts. ^5–12 An earlier report from our institution, however, showed that the likelihood of a persistent pseudocyst was high, and percutaneous drainage should not be considered definitive treatment for pancreatic pseudocysts. ¹³ Other studies have shown that percutaneous drainage is associated with increased pseudocyst persistence and complications. ^14–16 Several studies have directly compared percutaneous drainage with surgery for the treatment of pseudocysts, with findings that suggest either good ^8,12,17 or poor ^14,15 outcomes after percutaneous drainage. Our study demonstrated that nearly 60% of patients treated by percutaneous drainage required further interventional therapy, with increased mortality and morbidity rates and a longer hospital stay than patients treated by a surgical approach. In fact, surgical treatment of pancreatic pseudocysts was successful in 88% of our patients, with no deaths and a lower morbidity rate. Our findings differ from those of Adams and Anderson, ⁸ who compared percutaneous drainage with surgical internal drainage and noted that the mortality rate was higher in surgically treated patients (7% vs. 0%). Patients in their study treated by percutaneous drainage had drainage catheters in place for 42 days, and 50% had a drain track infection. Further, 19% of the patients who had percutaneous drainage required subsequent surgical therapy, compared with 10% in the surgery group. More recently, Spivak et al ¹⁴ found that one third of patients with pancreatic pseudocysts treated by percutaneous drainage needed salvage surgical procedures; in the current study, 50% of patients treated with percutaneous drainage required further treatment. Moreover, Sanfey et al ¹⁵ demonstrated that pancreatic pseudocysts arising after gallstone-induced acute pancreatitis responded poorly to percutaneous drainage. Pseudocysts arising after biliary pancreatitis often do not have a ductal communication and, thus, are generally thought to be best treated by percutaneous drainage. These findings suggest that even “ideal” pseudocysts may have a poor outcome after percutaneous drainage. Finally, Rao et al ¹⁶ have shown that surgical morbidity is increased after failed nonsurgical intervention, and they advocate a surgical approach to the treatment of pancreatic pseudocysts.

Historically, the surgical treatment of pancreatic pseudocysts has included internal drainage into the stomach, duodenum, or jejunum, external drainage, or resection. Surgical treatment has been associated with mortality rates of 0% to 13% and morbidity rates of 10% to 30%. ¹ Reoperation is not uncommon, especially in patients with chronic pancreatitis and persistent alcohol abuse. In this study, there were no deaths in the surgical group, and postoperative bleeding, infection, fistula, and persistent cyst occurred in <12% of the patients successfully treated by surgery. In addition, only eight (12%) of our patients required further therapy after surgical treatment. These findings indicate that surgical therapy for properly selected patients can be performed with low mortality rates and few complications and late sequelae. Caution should be exercised, however, in patients with chronic pancreatitis and continued alcohol use, because persistent changes in the pancreatic ductal structure are likely, and internal drainage of pseudocysts in these patients may not be definitive treatment.

Although surgical treatment was superior to percutaneous drainage in unselected patients with pancreatic pseudocysts, percutaneous treatment was successful in >40% of our patients. In an attempt to determine the factors that may predict a successful outcome after percutaneous drainage, we performed multiple logistic regression analysis. We failed to identify any factors predictive of a successful outcome after percutaneous drainage. To date, no study has identified characteristics of pseudocysts that accurately predict a successful outcome after percutaneous drainage.

This retrospective study contains several inherent biases that should be addressed. The patients in this study were unselected for treatment modality or disease activity at the time of treatment, and the definition of a pancreatic pseudocyst was applied retrospectively to CT and ultrasound imaging reports. In addition, the etiology of pancreatitis was not clearly delineated in all patients; therefore, patients with a history of alcohol abuse and chronic pancreatitis may be underrepresented. Thus, a strict definition of acute versus chronic pancreatitis was not possible in all patients, and this may affect the likelihood of successful percutaneous or surgical treatment.

This study confirmed that selected patients with small (<6 cm) pancreatic pseudocysts may be treated safely by expectant management. We also showed that unselected patients with pancreatic pseudocysts treated with percutaneous drainage had a higher failure rate than patients treated with surgery. Patients treated by percutaneous drainage had increased mortality and morbidity rates and more long-term sequelae compared with those treated surgically. The hospital stay was substantially longer and the likelihood for salvage surgery was high for patients treated with percutaneous drainage. The clinical effectiveness of percutaneous drainage for pancreatic pseudocysts has not been clearly established, and we recommend the use of percutaneous drainage only in the setting of a prospective trial comparing percutaneous drainage with surgical treatment or in patients who are not candidates for surgery.

Acknowledgment

The authors thank Angela Glover and Ellen Hughes for their excellent secretarial assistance.

Discussion

Dr. Charles J. Yeo (Baltimore, Maryland): In the context of this retrospective review, they have appropriately applied the Atlanta Symposium Criteria. They have included a group that have been managed expectantly or by observation, and they have carefully analyzed the groups managed by percutaneous catheter drainage and surgery.

Beware, however, that the treatment groups are not strictly comparable, because those patients treated percutaneously or by operative drainage clearly had a higher incidence of bleeding and infection and, i.e., had pseudocysts that were different than those treated by expectant therapy only. This comment notwithstanding, their results largely support my biases to some degree, and that is, that asymptomatic pseudocysts can be observed, that those that are clearly infected pseudocysts and not abscesses or necrosis can typically be managed percutaneously, and others require operative therapy.

I have three questions for the authors. Number one—and I think very critical here—tell us about the services that these patients were on, i.e., the surgical service versus the medical service. Because the management can be very different, and there can be a terrific amount of confounding in this database, as it often occurs that those treated by percutaneous catheter drainage on the medical service, catheters are left in place for long periods of time with little output, and follow-up imaging studies are forgotten about or not performed. Thus, who managed these patients? Did it matter who managed the patients? Did it influence the length of stay, as I suspect it did?

Question number two: you touched upon the role of ERCP. What should be its role for the management of these patients? Is ERCP predictive of success or failure of percutaneous catheter drainage, in your experience?

And question number three: In the multiple logistic regression analysis, you evaluated many factors but didn’t look at the duration of the pseudocyst, the percent of pancreatic enhancement or necrosis associated with the pseudocyst or the clinical setting, that is, infection versus noninfection. Could you speculate as to whether any of these things would be predictive of success or failure of percutaneous catheter drainage?

Dr. David B. Adams (Charleston, South Carolina): My task this morning is to attempt to explain why the information that was explained today supports a view that is exactly opposite to that which Dr. Anderson and I reached about 7 years ago in a report we presented to this Association. We found that PCD had no mortality and, on the contrary, that internal drainage had a 7% mortality.

The answers, I think, relate a lot to my bias in the classification systems of pancreatic inflammatory disease. The authors here carefully describe their adherence to the Atlanta International Symposium definition of pancreatic pseudocyst in an attempt to exclude acute fluid collections, necrosis, and abscesses. I believe that these classification systems work well when described in a hotel room in Atlanta, but I don’t think they are useful in evaluating patients when you see them in an emergency room with fluid collections.

Nature, I think, in natural or unnatural disorders, works in a continuum, and so that there is not a single point in time when an acute fluid collection becomes a pseudocyst or a pseudocyst becomes an infected pseudocyst, or an infected pseudocyst becomes an abscess. And so that by using the Atlanta radiologic classification system, I think you are going to misclassify a number of patients, and I think that’s a point that Dr. Yeo has already referred to.

The other point he has referred to is a second issue I want to bring up, and that is related to the titlist paper which says these are unselected patients. There really is no way that you can do a retrospective study on pseudocyst patients and have them be unselected. The patients are selected in the prehospital setting; they are selected for you in the emergency room and in the ICUs. And certain patients end up on different services and different algorithms. And so, again, the fact comes back down to what Dr. Yeo related to, which is how many of these patients were actually managed by the surgical service?

So my questions, therefore, are three.

How many patients who were treated with percutaneous catheter drainage were managed—or shall we say mismanaged—on the medical service?

The second question is what are all these percutaneous catheter drainage patients doing in the hospital for so long? When we manage them with percutaneous catheter drainage, they may be in the hospital for 72 hours, and then home with their drainage catheter, taking an oral diet.

And my third question is, in the patients who failed percutaneous catheter drainage, what ductal disorders were most common when they were evaluated with ERCP? Because we continue to believe that patients may be managed equally well with operative internal drainage or percutaneous catheter drainage. The bottom line is what is the underlying ductal disorder. And you will have recurrences with either technique, but to manage them in a rational fashion, you really need to understand the underlying ductal disorder.

Dr. Hunter H. McGuire, Jr. (Richmond, Virginia): We have presented 52 consecutive operations for chronic pseudocysts in chronic alcoholic patients. Thirty-two of them were for persistent painful cysts and the rest for bleeding, infection, or duodenal obstruction. And the operations are the usual—most of them internal drainage, but for the emergency operations, we either resected the tail or did external drainage.

And the results in hospital are that none died, one required reoperation for a persistent duodenal obstruction not relieved by drainage, and the average length of stay was ten-and-a-half days, which was pretty good for a domestically destitute population.

And the long-term follow-up is that one cyst that was drained externally recurred in the same year, and seven patients had new cysts develop over a year postoperatively in other parts of the pancreas. And, most important, none of the patients developed the complications of bleeding, infection, or ascites, for which the operations were designed to cure or prevent.

So from this, we conclude that for chronic pseudocysts, surgical drainage is so safe and so effective that for any other treatment to be competitive must be perfect. And that percutaneous catheter drainage for a chronic pseudocyst clearly is not perfect. It may have a place for drainage of acute fluid collections, but acute fluid collections are probably best observed because most of them resolve spontaneously, as they did in Chapel Hill.

The key to managing these patients, I think, is to distinguish between acute pancreatitis and acute fluid collections and chronic pancreatitis. I don’t think this is hard to do, I don’t think we have to get too much entangled in the Atlanta classifications. The way to distinguish acute from chronic is to follow President Griffen’s advice and to hear and touch your patients before treating with CT scans.

Dr. Josef E. Fischer (Cincinnati Ohio): President Griffen, I apologize for getting up so soon again, but as I told Dr. Meyer before his superbly presented paper, we have recently completed a study of a slightly smaller group over a shorter period of time. And our conclusions are similar to his. This is not an abstract we turned in for this meeting. If you look at the data, the best treatment is observation, and our failure rate is 7%, exactly as the failure rate he reported. They were a very different group of patients, and they really should not be confused with the other group of patients. I really have two questions:

First, I am a little surprised that the size and the multiloculation was not a determinant for success or failure. And I wonder whether the reason for that is because, since 70% of the failures were operated upon, that at the end, depending on how you analyze the statistics, that the outcomes would not be distinguishable unless you took the size multiloculation and analyzed it on the intent to treat.

Now as Blake Haney said recently, at the American Surgical, that if you torture data enough, it will confess to anything. But I think this is a valid way of analyzing this data, and I wonder whether they did so. And if they did, is this a distinguishing characteristic?

The second question really has to do with another approach to pancreatic pseudocysts, which I believe is very dangerous and which is rampant on medical services, and this the endoscopic approach to internal drainage. Those are the most dangerous in our series of any attempt to treat patients and resulted in hemorrhage, sepsis, and just about every other complication that you can think of. And I just wondered whether or not—this ended in 1995, so it may be that that particular epidemic which seems to be rampant out our way didn’t hit Chapel Hill, but if it did—what is your experience with that particular group of patients?

Dr. Henry L. Laws (Birmingham, Alabama): I would like to recommend to you or to commend endoscopic transgastric drainage, which was first introduced to me by Dr. Way in San Francisco. An infraumbilical cord is placed to—the stomach is distended and two transgastric cannulas are placed into the stomach after creating an orifice in the back wall, a hole into the pseudocyst. The 3.5-cm endoscopic stapler can be introduced and you can make an anastomosis from 3 to 7 or 8 cm quite easily.

If the patient is chosen appropriately where the stomach is intimately adherent to the pseudocyst, it is quite straightforward. And so I would like to ask Dr. Meyer, have you had experience doing transgastric endoscopic drainage? Or do you intend to attempt that thing?

President Griffen: Before you sit down, Henry, have your gastroenterologists started doing the same thing that you have just described?

Dr. Laws: I would agree absolutely with Dr. Fischer that the endoscopic way of doing it is not the way to go. Because if you look right in the stomach with two large cannulas, you can create an enormous hole and be able to handle whatever you need to handle right at the time. It’s a completely different technique.

President Griffen: I wish you would discuss a little bit the details of what you term “surgical drainage.” Did you supervise some?

Dr. Kevin E. Behrns (Closing Discussion): First, Dr. Yeo, these patients were managed on a variety of either medical or surgical services, which is definitely suboptimal. Pancreatic pseudocysts are a surgical disease and should be treated by surgeons, and we will attempt to treat more of these patients on the surgical service. I don’t know if it makes a difference in their outcome, but anecdotally, these patients will often be treated for several days with percutaneous drain in the hospital, and then a surgical consult is obtained only after failure of percutaneous drainage.

What is the role of ERCP in patients with pancreatic pseudocysts? I think it depends a little bit upon whether you suspect that they have acute pancreatitis as the etiology of the pseudocyst or they have a history of alcohol use and chronic pancreatitis. I think patients that have a suggestion of chronic pancreatitis need to have an ERCP or maybe a magnetic resonance cholangiopancreaticductography to look at the pancreatic duct.

But in this retrospective review, only 29% of our patients had pancreaticductography, and that is a potential limitation of this study.

We looked at several factors in multiple logistic regression to attempt to identify patients who could be treated successfully by percutaneous drainage. We did not look at infection or necrosis because, by definition, these patients were excluded from the study, since necrosis is a different disease than true pancreatic pseudocyst, as defined by the Atlanta International Symposium. And we adhere to these criteria mainly because they are the best available criteria, and we thought it would be helpful to have a uniform definition of pancreatic and peripancreatic fluid collections.

Dr. Adams, I appreciate your comments about percutaneous drainage and the length of hospital stay. And, again, that’s largely related to patients who are on a medical service and physicians who are unaccustomed to treating patients with drains on an outpatient basis. And I think that certainly now several patients, most patients, can go home with percutaneous drains in place if that is the method of treatment.

And, again, the shortcoming of the study was the low incidence of ERCP in patients with chronic pancreatitis. So it is difficult to clearly define patients that had chronic pancreatitis versus acute pancreatitis based on ductal changes.

Dr. Fischer, we did analyze these patients on an intent-to-treat basis and did not find that size or loculation influenced the likelihood of success by percutaneous drainage. And we are a little bit behind the times in Chapel Hill and have not embraced endoscopic drainage. And we do not intend to do so. In a similar vein, we have not performed laparoscopic transgastric drainage of pancreatic pseudocysts. I don’t have any experience with that. It may be a viable option, but I cannot comment on it.

Dr. McGuire, I’d like to thank you for your comments and confirmation of our findings, and I’d like to thank you for sharing your data in Richmond with us.

President Griffen: Although you may not get involved in endoscopic drainage, I’m afraid your gastroenterologists might, and they are going to give you a lot more business.