Giant Pancreatic Pseudocysts: Procedures in Management

Johnson, L.B., Rattner, D.W. and Warshaw, A.L. The effect of size of giant pancreatic pseudocysts on the outcome of internal drainage procedures. Surgery Gynecology & Obstetrics 173, 111m174. Pancreatic pseudocysts (PP) that fail to resolve spontaneously are optimally treated by internal drainage to a viscus. Pseudocysts adherent to the stomach are usually drained by way of cystgastrostomy. Recent experience with giant pseudocysts > 15 centimeters), however, challenges this approach. Fifty-two patients with pancreatic pseudocysts of various sizes were treated from 1982 to 1986 at the Massachusetts General Hospital. Twenty-eight PP were suitable for internal drainage. The postoperative complication rate was directly proportional to the size of the pseudocyst. Four patients had giant PP, three of which occurred after an attack of acute pancreatitis. All four were treated by cystgastrostomy. Three of four patients with giant pseudocysts had life-threatening postoperative complications as a result of incomplete emptying of the cyst, and two patients died. No evidence of anastomotic leakage could be demonstrated by upper gastrointestinal series or computed tomographic scans. Transgastric drainage tubes in these three instances were not protective. We conclude that cystgastrostomy may not be appropriate for the treatment of giant pancreatic pseudocysts because it fails to provide dependent drainage of a large cyst cavity. If internal drainage is performed, the cyst should be anastomosed to a defunctionalized loop of jejunum in a dependent position. In some instances, external drainage of giant pancreatic pseudocysts may be safer than cystgastrostomy.