Validation of an endoscopic retrograde cholangiopancreatography (ERCP)-based algorithm for the management of pancreatic pseudocysts (PP)

Background: Our previously published algorithm for management of PP¹ assumed that (a) recurrence rates after percutaneous management are related to the presence of pancreatic duct (PD) obstruction or PP communication with the PD and (b) surgical management results in fewer recurrences but more complications. It followed that percutaneous management might best be reserved for patients (pts) without these findings. Since we published the algorithm, greater than 90% of elective PP pts have undergone ERCP in order to validate these assumptions. In an effort to challenge the assumptions, percutaneous management was used when possible. Methods: The records of 111 pts with PP treated since 1991 were reviewed. Health status, comorbidities, PP characteristics, PD anatomy, management strategy, and outcome (success, recurrence, or complication) were assessed. Results: 21/111 pts did not have PD imaging (7 emergent, 8 failed, 6 not attempted). 6/18 pts with obstruction, communication or both who were managed percutaneously succeeded (no recurrence or complication). 22/32 pts with these abnormalities who were managed surgically or with endoscopic cystgastrostomy or duodenostomy succeeded. 8/12 pts without significant ductal abnormalities were successfully managed percutaneously, although 2 successes required post procedure drain manipulation. 6/7 surgically managed pts without PD abnormalities succeeded. 7 pts were managed with endoscopic stents (2 failures) and 14 pts were observed with success. Overall, 33/44 (75%) interventions that followed and 17/32 (53%) interventions that did not follow the algorithm succeeded (p = < 0.05). Pts in the two groups were well matched in terms of age, physical status, comorbidities and size, number and location of PP. Conclusions: Our review confirms the assumptions of the previously published algorithm that pts with PD obstruction or PP communication with the PD do poorly with percutaneous management and are better managed surgically or by endoscopic decompression in selected cases. Pts without these abnormalities may warrant percutaneous management as a first approach.