The Role of Surgery in Pancreatic Pseudocyst

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1 Pncres The Role of Surgery in Pncretic Pseudocyst Wen-Yo Yin, Hw-Tzong Chen 3, Shih-Ming Hung 3, Chih-Wen Lin 1, Shih-Pin Lin, Dh-Wen Shyu, Chng-Kuo Wei, Ming-Che Lee 3, An-Ling Chou 2, Kuo-Chih Tseng 2, Yo-Jen Chng 3 Deprtment of Surgery, 1 Rdiology, nd 2 Medicine, Buddhist Dlin Tzu Chi Generl Hospitl, Chiyi; 3Deprtment of Surgery, Buddhist Tzu Chi Buddhist Generl Hospitl, Hulien, Tiwn Corresponding Author: Dr. Wen-Yo Yin, Deprtment of Surgery, Buddhist Dlin Tzu Chi Generl Hospitl 2, Min Sheng Rod, Dlin, Chiyi, Tiwn Tel: Ext. 5906/5242, Fx: , E-mil: Yowen@mil.tcu.edu.tw Originl Pper ABSTRACT Bckground/Aims: Surgery hs een the only option ville for mny yers for treting pseudocyst of the pncres. Recently, new methods, such s percutneous dringe, endoscopic trnsenteric dringe nd trnsppillry dringe, egn to e used for tretment of the pseudocyst. But we hve to gree tht no single technique offers the desired comintion of 100% success nd no complictions. We'd like to present our surgicl experience in the pst 14 yers. Methodology: A totl of 22 ptients were treted for pncretic pseudocyst (PP) in our deprtments in Dlin nd Hulien Tzu-Chi Generl Hospitl within the lst 14 yers. They were retrospectively reviewed nd followed up until recently. Results: There were 14 (63.6%) mles nd 8 (36.4%) femles ged etween 15 nd 79 yers old (men ge 38.2 yers). Dominting symptoms in most ptients were epigstric pin, plple mss, nuse, vomiting, fever nd leukocytosis, nd persistent elevtion of serum mylse. Imging studies, such s ultrsound, computed tomogrphy (CT) scn, nd endoscopic retrogrde cholngiopncretogrphy (ERCP), were helpful in estlishing dignosis. In ddition to symptomtic persistent lrge (>6cm) pseudocyst, vrious types of compliction including infection, gstrointestinl (GI) ostruction, rupture into GI trct, peritonitis, GI leeding, internl leeding, nd pncretic scites were indictions for surgery in our cses. Opertive procedures composed of externl dringe (ED, 9 cses), internl dringe using cystojejunostomy (CJ, 4 cses) nd cystogstrostomy (CG, 8 cses), nd distl pncretectomy (1 cse). Ten complictions (45.5%) included recurrence of cyst (1 in ED nd 1 in CJ), recurrence with pncreticopleurl fistul (1 in ED), colon perfortion (1 in ED), delyed mssive leeding (1 in CG), pncretic fistul (3 in ED), pncretic scess (1 in CJ) nd persistent pin (1 in CG). Reopertion ws needed for check leeding (1 in CG) nd proximl colostomy for colon injury (1 in ED). A cse received CJ for recurrence of pseudocyst 9 yers lter (1 in CJ). Percutneous dringe with wide ore tue ws effective for pncretic scess (1 in CJ) nd trnsppillry dringe with stent ws used to relieve pleurl effusion with respirtory filure (1 in ED). No mortlity occurred in this series. Conclusions: We elieve tht surgery, though without flws, still plys n importnt role in the mngement of selected cses of pseudocyst of the pncres. Surgicl intervention, endoscopic dringe, nd percutneous dringe were complementry rther thn conflicting lterntives oth for the simple nd complicted pseudocysts. KEY WORDS: Pncretic pseudocyst; Internl dringe; Externl dringe; Percutneous dringe; Trnsppillry dringe ABBREVIATIONS: Pncretic Pseudocyst (PP); Computed Tomogrphy (CT); Endoscopic Retrogrde Cholngiopncretogrphy (ERCP); Externl Dringe (ED); Cystojejunostomy (CJ); Cystogstrostomy (CG); Gstrointestinl (GI); Common Bile Duct (CBD) INTRODUCTION In 1862, Le Dentu (1) proclimed tht cysts of the pncres "should e relegted to the list of ffecttions for which the heling id is impotent". Fortuntely, for the ptient in whom pseudocyst develops s compliction of pncretitis, this prediction hs een proved incorrect. Despite more thn 100 yers of surgicl experience with this disese entity, controversy continues to surround the timing of opertive intervention s well s indictions for specific procedures. Surgery ws the only option ville for mny yers. In the opinions of most surgeons nd mny senior gstroenterologists, surgicl dringe is still the tretment of choice. It hs een minsty for the mngement of the pseudocyst ecuse of recurrent or persistent pseudocyst, presenting s complictions such s rupture of cyst, comintion with common ile Hepto-Gstroenterology 2005; 52: H.G.E. Updte Medicl Pulishing S.A., Athens-Stuttgrt duct (CBD) or duodenl stenosis, ssocition with dilted pncretic duct, nd suspicion of neoplsm. Recently, new methods, such s percutneous dringe, endoscopic cystoenterostomy, nd endoscopic trnsppillry dringe hve een developed to tret the pseudocyst. However it is not widely used for its technicl demnd s well s indequcy of endoscopic internl dringe (10-50% with men of 23% require surgery) (2), nd percutneous dringe (50-60% of ptients treted needed further tretment) (3). But we hve to gree tht no single technique offers the desired comintion of 100% success nd no compliction. We reviewed the results of surgicl therpy for pncretic pseudocysts including vrious complictions t our institutions y the sme surgicl tem over the lst 14 consecutive yers. Only few ppers in this field hve een pulished in this fshion

2 1268 Hepto-Gstroenterology 52 (2005) W-Y Yin, H-T Chen, S-M Hung, et l. FIGURE 1 Both the sonogrphic nd CT were eqully good for dignosis of PP. () Sonogrphic finding of huge pseudocyst. () A ig cyst t the til of pncres in CT scn. FIGURE 2 Sonogrphy ws s good s CT in postopertive followup. () Shrinkge of the cyst seen in sonogrphy. () No definite cyst ws seen ehind the stomch. during lst two decdes (4-7). One of the most importnt resons is tht such cses were not so common in our surgicl prctice. The im of this pper is to shre our surgicl experience with this disese entity with our collegues. METHODOLOGY A totl of 22 ptients treted for pncretic pseudocyst presenting with different mnifesttions in surgicl deprtments oth in Hulien nd Dlin Tzu Chi Generl hospitls in the pst 14 yers since 1989 through 2003, were collected retrospectively. Pncretic pseudocysts were confirmed y their lck of epithelil lining in the cyst wll iopsy, the high concentrtion of pncretic enzymes, nd their formtion t lest 4 weeks fter n episode of cute pncretitis or pncretic trum. Only the ptients who needed opertion due to cute compliction such s infection, peritonitis, scites, or leeding nd symptomtic PP, were included in this study. The sizes of the PPs were recorded from opertive findings or mesurement of the PPs in CT imge. Pertinent dt included ge, sex, ssocited diseses, clinicl findings, opertive procedures performed, nd postopertive course. Durtion of follow-up ws 2 months to 14 yers with the verge of 5.91 yers RESULTS From 1989 through 2000, 17 ptients with pncretic pseudocysts in Hulien Tzuchi Generl Hospitl, nd from 2001 through 2003, 5 ptients in Dlin Tzuchi Genrel Hospitl, were treted y the sme Generl Surgicl tem. Mle to femle rtio ws 14:8. The men ge ws 38.2 yers (rnge yers). The etiology is listed in Tle 1 nd lcoholism ws the most common cuse for pseudocyst. Regrding clinicl mnifesttions, dominl pin or fullness existed for 95.5% (n=21) nd fever nd leukocytosis ws detected in most of the complicted cses nd few uncomplicted cysts (n=10, 45.5%), nd seven cses presented with plple mss in the domen (31.8%). There were lso some nonspecific GI symptoms such s nuse nd vomiting in nerly hlf of the cses. Ojective documenttion of pncretic pseudocyst ws otined y ultrsonogrphy (n=17, 77.2%) (Figure 1), computed xil tomogrphy (n=18, 81.8%) (Figure 1) or endoscopic retrogrde pncretogrphy (n=5, 22.7%). Most of the PPs resolved nd were followed y sonogrphy (Figure 2) nd CT (Figure 2). The indictions for surgery nd the procedure performed re summrized in Tles 2 nd 3 respectively. The sizes of the PP could e recorded for 13 elective cses nd 7 emergency cses. All of the PP mesured more thn 6cm in size nd the verge size ws 8.2cm. 11 cses showed more thn 10cm in size. The lrgest one mesured 40x30x15cm in size nd occupyed more thn hlf of the domen including the TABLE 1 Presumed Cuse of Pncretic Pseudocyst Cuse Numer (%) Alcohol 10 (45.5%) Biliry 2 (9.1%) Alcoholic nd trum 2 (9.1%) Trum 3 (13.6%) Hyperlipidemi 1 (4.5%) Idiopthic 4 (18.2%) Totl 22 (100%)

3 Pncretic Pseudocyst Hepto-Gstroenterology 52 (2005) 1269 pelvic cvity. ERCP ws performed in 5 cses nd four were done preopertively. One of them ws done for ptient with recurrent cyst complicted with respirtory filure from mssive pleurl effusion secondry to pncreticopleurl fistul. The prolem ws solved y trnsppillry dringe y n endoscopist. The cyst ws infected in cse following ERCP nd urgent lprotomy with externl dringe ws performed. Percutneous dringe under sonogrphy or CT ws done in 4 cses nd hlf of them were used in postopertive pncretic scess nd recurrent pseudocyst respectively. Preopertive usge in one cse ws unfortuntely complicted with lekge of pncretic juice round the ctheter leding to diffuse peritonitis. Opertive procedures used in these ptients re listed in Tle 3. All of the complicted cysts except one infected cyst were operted y externl dringe. Internl dringe ws crried out in nother 12 symptomtic mtured pseudocysts nd distl pncretectomy ws done in ptient with PP t the til. CG ws performed in more thn hlf of the ptients (66.6%, Figure 3). Suture ligtion outside the cyst for leeding pseudoneurysm ws done in two cses nd prtil gstrectomy ws dded for cse presenting with cyst perfortion into the stomch Significnt moridity occurred in 10 of 22 ptients (45.5%) nd six of them (60%) hppened in ptients with externl dringe: Three cses with pncreticocutneous fistul, 2 cses with recurrence of pseudocyst, nd one cse of colon perfortion occurred in the ED group. All three fistuls closed spontneously with conservtive mngement including totl prenterl nutrition followed y enterl feeding. One of the recurrent pseudocysts ws treted first with percutneous dringe. Endoscopic stenting t initil ttempt filed. Unfortuntely, it recurred (Figure 4-c) nd ws complicted with pncreticopleurl fistul ssocited mssive pleurl effusion nd respirtory filure eight months lter (Figure 5-c). However, it finlly responded well to the successful trnsppillry stent insertion (Figure 5d). Urgent proximl colostomy ws done for colon perfortion nd reconstruction ws crried out hlf yer lter. Two recurrences occurred in the CJ group nd only one of them needed second internl enteric dringe gin 9 yers lter ecuse of iliry ostruction. The other ptient didn't need opertion fter spirtion percutneously. A delyed TABLE 2 Indictions for Surgery Type of Presenttion Numer 1. Symptomtic, persistent lrge pseudocyst (>6cm) Vrious types of compliction. Infected cyst 6. Free rupture with peritonitis 1 c. Rupture into stomch with peritonitis 1 d. Ruptured pseudoneurysm (gstroduodenl) 2 into duodenum or peritonel cvity e. Pncretic scites 1 Totl 22 TABLE 3 Opertive Procedures Procedures Numer (%) 1. Externl dringe 9 (40.9%) 2. Internl dringe Cystogstrostomy 8 (36.4%) Cystojejunostomy 4 (18.2%) 3. Distl pncretectomy 1 (4.5%) Totl 22 (100%) mssive leeding ws found in the CG group. He ws prompted to hve n opertion for cesstion of nstomotic leeding on the seventh postopertive dy. A cse with gint cyst (Figure 6) treted y CJ technique ws complicted with pncretic scess formtion nd it ws finlly solved y percutneous dringe with lrge ore drin tue (Figure 6 nd c). No opertive deth occurred. DISCUSSION Acute destructive pncretitis cn led to the formtion nd development of pseudocysts (8-10). A pncretic pseudocyst is n extrvsted collection of exocrine pncretic juice surrounded y firous memrne mde of djcent viscer nd prietl wll devoid of n epithelil lining. Surgicl tretment of pncretic pseudocysts is still controversil regrding the optiml time for intervention, the choice of surgicl technique nd the choice of mngement in cses of complictions. In ddition to the surgicl pproch, pproprite usge of the dignostic imging studies nd nonopertive techniques re the fundmentls of success in the mngement of the pncretic pseudo- FIGURE 3 Cystogstrostomy. () Locliztion of the PP y trnsgstric pproch. () Cystogstrostomy ws done y nonsorle interlocking sutures.

4 1270 Hepto-Gstroenterology 52 (2005) W-Y Yin, H-T Chen, S-M Hung, et l. cyst. Pncretic pseudocysts re recognized in over 10% of cses of pncretitis. They occur s result of pncretic inflmmtion, trum, or duct ostruction. As is the cse with most series, lcohol-relted pncretitis ws the entity most commonly ssocited with pseudocysts in our series (5). Although we hve two cses llocted in comined etiology of lcohol nd trum, they sustined dominl trum one to four yers efore the opertion. Pncretic pseudocyst should e suspected in ptients with cute pncretitis whose symptoms fil to resolve within 7 to 10 dys or in ptients with chronic pncretitis who complin of persistent pin, nuse, or vomiting. As in the most series in the literture, epigstric pin or fullness ccounted for 95.5%. But less percentge (n=7, 31.8%) of plple dominl mss ws noted in our series. The most relile wy of mking dignosis is y ultrsound or CT scnning. Hessel found ultrsound to e 90% ccurte nd 98% specific when the pncres could e visulized. Unfortuntely gs oscures the pncres in nerly one third of the ptients. CT scn hve incresed sensitivity nd specificity nd provided dditionl informtion out retroperitonel extension nd the reltionship etween cyst nd djcent enteric lumen (11). Computed xil tomogrphy (CT) nd ultrsound re eqully ccurte for cysts in our cses s most of them were >5cm in dimeter (Figure 1). But they were used only in 80% of our cses for dignosis nd cses in emergency sitution were immeditely operted. An initil preopertive CT scn with correlted sonogrphy followed y seril sonogrphic exmintions ws noted to e very effective for oservtion of the cyst condition efore nd fter the opertive tretment. We used this method in our cses nd most of them could clerly demonstrte the resolution (Figure 2) or recurrence of the cyst (Figure 4). Routine use of ERCP is still controversil. ERCP demonstrtes normlities of the pncretic duct in up to 90% of the ptients with pseudocyst nd nerly two-thirds of the pseudocysts communicte with the pncretic duct. So ERCP my provide vlule informtion concerning the nturl course of pseudocysts nd selection of suitle cndidtes for nonopertive mngement. Severl studies suggest tht routine ERCP should e considered in ll ptients with pseudocysts to optimize tretment strtegy (8,12). Neolon et l. (8) reported tht routine ERCP chnged the opertive mngement in nerly 60% of their ptients nd improved their outcome. But it is still ssocited with excertion of cute pncretitis, infection of pseudocyst, nd other endoscopic relted complictions. A cse in our series contrcted infection of the pseudocyst with sepsis severl hours following investigtion. We use ERCP only in elective symptomtic cses ut mturtion of the wll in CT ws not enough for cyst-enteric nstomosis, s the mngement will vry ccording to the findings. In such cses, percutneous dringe my e considered if ERCP showed no communiction etween the cyst nd pncretic duct. Trnsppillry pncretic stenting my e plnned for cses with connection. We my lso rrnge it in ptients with suspected pncretic cncer nd reluctnce for opertion. Otherwise, pproprite opertive procedure ws chosen stright forwrd for mture nd uncomplicted cses. Therefore, ERCP ws not routinely done y us nd ws performed only in selected cses. If done, it should e performed within hours efore plnned dringe procedure under the umrell of ntiiotics. Angiogrphy is generlly not useful for dignosis of pseudocyst. We elieve tht using these modlities only in complementry fshion my give us the est result with ggregte specificity pproching 100%. The dvent of sonogrphy nd CT scn of the domen in the 1970s hs clerly estlished tht pproximtely 50% of pseudocysts resolve spontneously (6,13-15). A review of the literture lso revels tht up to 40% of ptients with untreted pseudocyst develop complictions lthough some previous studies were predicted on ptients who were identified ecuse of symptoms (11). Resolution of pncretic pseudocyst nd development of complictions were therefore thought to e function of time. As mtter of fct, it is gret chllenge for surgeon to decide when to operte on the ptient with PP in order to void unnecessry consequences. However, there re few longitudinl studies of pseudocysts. The Myo clinic experience reported y Vits nd Srr (6) review 68 ptients with symptomtic pncretic pseudocysts. At men follow-up of 51 months, 63% remined symptomtic. In 6 ptients (9%) significnt c FIGURE 4 Recurrence of PP. () Sonogrphic finding fter ED. () CT finding fter ED. (c) CT finding fter percutneous dringe.

5 Pncretic Pseudocyst Hepto-Gstroenterology 52 (2005) 1271 FIGURE 5 Pncreticopleurl fistul following ED. () Mssive pleurl effusion. () CT finding of mrkedly collpsed right lung. (c) ERCP showed pncretic ductl lekge. (d) Resolution of PP fter trnsppillry dringe. c d complictions developed, including intrcystic hemorrhge, perfortion, nd infection. Of the 35% who required therpy, five cses were emergent nd the remining were elective, with either pin, cyst enlrgement, or gstric or iliry ostruction. The men size of the pseudocyst ws less thn 6cm, nd only surgicl therpy ws used. A similr study y Yeo et l. (15) t Johns Hopkins University included 36 ptients with pncretic pseudocysts. Spontneous resolution occurred in 69% of the cses t 1-yer follow-up. In 40% of the cses, pncretic pseudocysts were stle or smller. These ppers encourged expectnt tretment of the pncretic pseudocysts. However oth studies were short in follow-up durtion (1 to 4 yers) nd the PP were smll in verge size. In Vits series, there were significnt mount of cse with the cyst ge of <6 weeks (31%) nd indeterminte durtion (41%) in his group II who were ssigned to undergo nonopertive noninterventionl expectnt mngement. In ddition, only 24 of 43 ptients were followed completely y rdiogrphic surveillnce nd the risk of eventul opertion tretment incresed in prllel with incresing size of PP (28 to 57%). In the Myo series, they still encountered significnt mount of cses with complictions necessry for emergent opertion. On the other hnd, Brdley et l. (16) hve ffirmed the vlue of witing period. Their dt suggested tht spontneous resolution occured in 40% of the cute pncretitis cses with durtion less thn 6 weeks, nd the compliction rte ws only 20%. A witing period greter thn 7 weeks, however, ws ssocited with 56% compliction rte nd spontneous resolution ws oserved in only 1 of 25 ptients from 7-18 weeks. But current review of recent studies y Pitchumoni nd Agrwl (17) pointed tht one solute, n dge of surgicl trining tht 6-cm pseudocyst present for 6 weeks or more requires surgery, is solutely untrue. We hve 50% (11/22) of complicted cses in our series either preopertively or postopertively. Although there ws no mortlity, they were often ssocited with severe moridity. As they ll were dignosed t the first visit, we could not know the ge of the PP efore tht episode. Even in the elective cses, those with lrger pseudocysts were finlly involved with some complictions. Two cses with huge PP (>15cm) sustined pncretic infection following ERCP in one cse nd lekge of pncretic juice round the dringe ctheter with diffuse peritonitis following percutneous dringe in the other ptient. The third cse contrcted severe hemodynmic chnge nd pncretic scess following internl dringe due to sudden mssive fluid loss with indequte replcement nd poor dringe respectively. So we should keep in mind tht huge PP my e more difficult to hndle thn n verge sized PP (6cm to 10cm) in every step of tretment. The other fctor we could trce in our ptients is tht the complicted cses were much more relted with lcoholic history (7/11). Therefore, we would like to ssume tht incresed wreness nd erly intervention should e crried out in cses presenting with huge PP especilly with n lcoholic history. We lso hve pinful experience of opertion in symptomtic ptient with n immture cyst wll who ended up with recurrence

6 1272 Hepto-Gstroenterology 52 (2005) W-Y Yin, H-T Chen, S-M Hung, et l. fter externl dringe (Figure 4-c) nd severe pulmonry effusion due to pncreticopulmonry fistul even fter percutneous dringe ws done (Figure 5-c). It ws ultimtely treted uneventfully y trnsppillry dringe (Figure 5d). So we do gree tht Pitchumoni's considertion is resonle nd rtionl ut the old 6cm-6 weeks criteri for intervention should still e reltive indictor rther thn n solute one. Surgicl dringe hs een the gold stndrd for mnging PP. However, it is ssocited with significnt moridity nd mortlity s mentioned ove. Despite reltively limited experience with percutneous dringe nd despite recurrence nd filure rtes rnging s high s 25% to 79%, these methods re recommended incresingly s the first line of tretment (3,18-22). vonsonnenerg et l. reported 94% cure rte of 51 ptients with infected PP treted y percutneous dringe. The fistul usully closed in less thn 30 dys (21). Adms nd Anderson (22) reviewed 52 ptients who underwent CT-guided dringe. All ptients hd pncretic fistuls nd hd n verge hospitl sty of 40 dys. The verge durtion of fistul dringe ws 42.1 dys, nd in 48% of the ptients it ws further prolonged y drin trct infection. Sometimes these ptients filed to respond to conservtive tretment nd required opertive intervention (23). Roert Ro in his interesting pper concluded tht filed nonopertive dringe is ssocited with protrcted illness nd cries risk of incresed moridity fter opertive intervention. They lso pointed out tht 39% of their ptients undergoing pncretic duct dringe for chronic pncretitis hd PP. So they suggested these two coexisting prolems e treted t the sme time whenever possile. We used percutneous dringe in ptient crrying lrge infected PP with systemic toxemi including fever nd leukocytosis. But it ws complicted with lekge round the ctheter with diffuse peritonitis. It, on the hnd, relly helped to control postopertive pncretic scess with sepsis y effective dringe through wide ore drin tue. Theoreticlly, endoscopic dringe of PP more closely mimics opertive internl dringe. But n inherent prolem with endoscopic dringe is tht not ll the PP re continuous with stomch or duodenum. In ddition, it is techniclly demnding nd widely known for initil success ut erly recurrence (24). Similrly, cse in the ED group who sustined recurrent PP complicted with pncreticopleurl fistul even fter postopertive percutneous dringe ws relieved y trnsppillry dringe lter nd it remined stle until recent follow-up. We therefore stick to the surgicl intervention s n initil tretment of choice in generl for cses with indiction s well s eing fit for nesthesi nd opertion. For selected cses such s those with infected PP nd with frile thin wll, unstle clinicl condition, or suspect mlignncy, we my rrnge percutneous dringe to control the cute episode. Then further imging study will e followed efore definitive surgicl tretment. For the ptients, who re dignosed incidentlly, they re put on list for regulr follow-up especilly for lrge PP. Appernce of symptoms or increse in the size of PP will e n indictor for the intervention. Percutneous or endoscopic trnsppillry pproch my lso e chosen for the symptomtic cses with thin wll or reluctnce to c FIGURE 6 Clinicl course of gint PP. () A huge PP occupying hlf of the domen including pelvis. () Percutneous dringe with pigtil ctheter in pncretic scess. (c) Multiple drins including wide ore tue in different loctions for etter dringe.

7 Pncretic Pseudocyst Hepto-Gstroenterology 52 (2005) 1273 TABLE 4 Postopertive Moridity nd Mngement with Different Opertive Methods Procedures Complictions Numer (%) Mngement 1. Externl dringe 1. Recurrence 1 Aspirtion 2. Recurrence with pncreticopleurl fistul 1 Trnsppillry dringe 3. Colon perfortion 1 Colostomy 4. Pncretic fistul 3 Conservtive Sutotl 6 (60%) 2. Internl dringe Cystogstrostomy (CG) 1. Internl leeding 1 Reopen one week lter 2. Persistent pin 1 Conservtive Cystojejunostomy (CJ) 1. Recurrence 1 Cystojejunostomy 2. Pncretic scess 1 Percutneous dringe 3. Resection Sutotl 4 (40%) Distl pncretectomy Nil Nil Totl 10 (100%) undergo opertive procedures t their first ttempt. Complete dependent dringe is criticl in ny internl dringe procedure nd solid mteril lining pseudocyst should e thoroughly derided t the time of internl dringe. Cystogstrostomy ws chosen when the cyst wll ws dherent to the posterior gstric wll (Figure 4). If the cyst wll is dherent to the duodenl wll, cystoduodenostomy should e performed. Cystojejunostomy ws used when the cyst ws not closely dherent to the upper gstrointestinl trct nd ws locted t the se of the trnsverse mesocolon. It is lso suggested for extremely lrge PP (>15cm) so s to chieve dependent dringe (11,17). An infected pseudocyst presents s secondry infection of previously sterile pseudocyst. The chnce of progression from sterile to n infected pseudocyst increses with time nd occurs in pproximtely 10-15% of PP (16). Infection my e due to trnsloction of cteri from the GI trct, secondry infection of n intrcystic hemtom or my e itrogenic fter puncture or ERCP (25). Externl dringe is the trditionl surgicl therpy for infected pseudocyst nd is thought to e preferle to cystoenterostomy, since the cretion of nstomosis in n infected field is thought to e unsfe with the risk of postopertive scess formtion. But development of pncreticocutneous fistul hs een descried to occur in 12-20% of ptients fter externl dringe (26). Djmil Boerm (27) proved in his series tht surgicl internl dringe is sfe nd effective in selected cses tht hd firm cyst wll nd could hold nstomosis well. We used this technique only in one ptient out of 5 cses with infected PP ecuse of diffuse peritonitis or ssocited systemic toxemi in other 4 ptients. The ptient who used ID recovered uneventfully in the postopertive period. In contrst, out of the remining 4 cses, one ended up with colon perfortion in nd two with prolonged hospitl sty for pncretic fistul. So we would lso like to encourge the use of ID in those cses tht possess mture cyst wll ut do not revel systemic toxemi nor diffuse peritonitis. The mortlity nd recurrence rte for ED nd ID re 10% vs. 3% nd 18% vs. 8% respectively (17). 10% of persistent pncretic fistul in ED my necessitte distl pncretectomy or dringe into Roux lim of owel. In our series, ID ws ssocited with higher moridity thn internl dringe (n=6, 66.6% vs. n=3, 25%) if the cses tht got persistent pin, proly due to chronic pncretitis precipitted y continued lcoholic drinking, were excluded (Tle 4). It is significntly higher thn the 23% y Blfour (28) nd quite similr to 72.7% nd 61% noted in Brin et l. (4) nd Shtney's (29) series respectively. But we elieve tht opertive technique should not e the sole responsile fctor for this negtive result. We used this procedure in most of the emergency nd complicted ptients. It might e siclly due to complex stte of the disese itself t the time of opertion nd lck of the chnce of evlution of the pncretic ductl condition preopertively in such emergent nd cutely ill ED ptients. Fortuntely, only one cse in ech group needed reopertion in the sme dmission due to leeding nd indvertent colon injury with perfortion respectively. Endoscopic intervention (trnsppillry dringe) of ptient with pncreticopleurl fistul in the ED group nd rdiologic intervention (percutneous dringe) in ptient with postopertive pncretic scess in the ID group prevented oth of them from undergoing reopertion. Therefore multidisciplinry pproch y well-experienced tem composed of surgeon, endoscopist, nd rdiologist is fundmentl for the est outcomes % of the fistuls will close spontneously within 4 months. But high output (>200cc/dy) ppers to extend the durtion of closure (30). Three in our ED group confronted pncretic fistul nd they were mnged y totl prentl nutrition (TPN) in the erly dys followed y jejunostomy feeding in ll ptients. Noody needed reopertion or prolonged TPN. All fistuls closed within 1-2 months. Consequently, less intervention ws needed in the ID group (33.3%) in contrst to the ID group (50%) (AUTHOR plese specify which should e ID nd which should e ED). If ll need for reoper-

8 1274 Hepto-Gstroenterology 52 (2005) W-Y Yin, H-T Chen, S-M Hung, et l. tion ws included, significntly lower incidence of only 16.6% (one out of 6 cses) in the ED group compred to 75% (3 out of 4) in the ID group ws found. So erly TPN comined with routine use of erly jejunostomy feeding my e the most importnt strtegy for this result. A well-orgnized surgicl nutrition tem should e grnted gret credit for this wonderful gin. We encountered mssive leeding from nstomosis of cystogstrotomy 7 dys fter opertion nd needed emergency reopertion for hemostsis. It is quite common to find few cses s in our studies nd most series (31) with higher incidence of up to 50% (32) though there re lso few studies without this life-thretening compliction (4). This hs een ttriuted to reflux of digestive juices with enzymtic ctivtion (33). Use of sorle suture might e the cuse for such trgedy. Non-sorle sutures with interlocking suturing method my secure hemostsis etter long the cyst-enteric nstomosis. No such compliction occurred in our lter cses. Interestingly, recurrence of pseudocyst hppened in one cse 9 yers fter initil opertion with cystojejunostomy nd it ws ssocited with iliry ostruction. Adominl discomfort nd repeted jundice prompted him to receive second cystojejunostomy. It might e due to the stenotic chnge of the initil cystoenteric nstomosis nd persistent ductl lekge. Another prolem we met in our ptients pertining to the opertive technique ws the mngement of relly huge nd widely situted gint PP. It ws universlly greed tht gint cyst should e dependently drined y ID (11,17). But it led to severe complictions with sudden hemodynmic chnge nd pncretic scess in the erly postopertive dys (Figure 6, ). Mssive fluid loss nd indequte dringe with contmintion of the PP y drop of intestinl content from the disfunctioning lim of the Roux loop into the cvity should explin this unplesnt compliction. Such sorrowful dverse outcome ws reported y Johnson et l. in their four ptients with gint PP (>15cm). Three of four ptients hd life-thretening postopertive complictions s result of incomplete emptying of the cyst, nd two ptients died. They concluded tht CG my not e n pproprite tretment for the gint PP ecuse it filed to provide dependent dringe (34). Actully, it is impossile to drin internlly for such widely situted gint PP. Usge of trnsppillry dringe in comintion with percutneous dringe my e good lterntive in such cses if we cn prove presence of communiction etween the PP nd pncretic duct. It might hve precluded such severe dverse effect s mentioned ove. If we choose surgery, externl dringe rther thn internl dringe should e plced on first priority for such prticulr condition. Opertive mortlity ws high in erly times (8.6% to 16%) nd reduces significntly in recent yers with the rnge of 0% to 5% (35,36). We didn't hve ny mortlity in our series though complicted cses with emergency opertion were included. In summry, we treted 22 symptomtic cses of pseudocyst of the pncres including ptients with complictions y surgicl intervention s primry tretment from 1989 through 2003 t our hospitls nd most of them recovered uneventfully. The clinicl findings re vrile nd most of them presented with dominl pin or fullness. Ultrsonogrphy nd CT were eqully effective for dignosis ut sonogrphy ws noninvsive, chep nd useful for follow-up. Computed tomogrphic scnning ws lso helpful for evlution of locliztion, extent, correltion with surrounding structures, nd n imge guide to drin the cyst. Externl dringe of the PP ws ssocited with higher moridity thn ID. But only one in ech group needed to undergo reopertion. Percutneous dringe or endoscopic dringe my e good tool oth in the preopertive nd postopertive period. 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