Is endoscopic ultrasound useful in the management of pancreatic pseudocysts?

Introduction: Pancreatic pseudocysts (PK) are frequent complications of acute or chronic pancreatitis, responsible for severe evolution. Endoscopic ultrasonography (EUS) is an accurate imaging technique useful for the anatomic characterization of PK, for assessing the relation with peridigestive blood vessels and for cyst fluid aspiration. It also facilitates the treatment of PK which does not communicate with the pancreatic duct.

Aim: To evaluate the utility of EUS in the management of PK.

Method: There were selected by transabdominal ultrasound 13 patients with symptomatic PK or questionable PK diagnosis between february 2007 and february 2008. All patients were evaluated by EUS. The fine needle aspiration (FNA) was done in PK larger than 2cm or older than 6 weeks from the episode of acute pancreatitis (8 cases). Ten patients were treated using EUS: transgastric or transduodenal stenting in 4 patients and FNA drainage in 6 patients. All patients were prospectively assessed by transbdominal ultrasound and EUS.

Results: The mean age of the patients was 53 years, nine being males (77%). The mean size of PK was 46.8mm and there were multiple PK in four cases (21%). The etiological context of PK was acute pancreatitis in 4 patients (31%), chronic pancreatitis in 8 patients (61%) and acute pancreatitis due to pancreatic cancer in one patient (8%). PK were localized in the head of the pancreas in 6 cases (39%). EUS description included: thick wall>2mm in 6 cases (43%), intracystic septa were identified in 5 cases (38%) and hyperechoic intracystic mass in 4 cases (31%). The aspect of the cyst fluid was sero-citrin in 5 cases, brownish in 2 cases and pus in one case. From the 6 cases with FNA drainage, in 3 cases the drainage was complete, in one case subsequent stenting was necessary (with favorable outcome) and two cases required surgical management: one due to septic status of the patients and the other due to clinical suspicion of cystadenocarcinoma (not confirmed afterwards). Two of the patients with EUS-guided stenting had full recovery and two were operated: one immediately because of important pneumoperitoneum, the second after 6 weeks because of the infection due to stent migration.

Conclusion: Endoscopic ultrasound offers an efficient non-surgical alternative in the management of PK non communicating with pancreatic duct.