Pancreatic pathologies include the diverse entities of pancreatic fluid collections and cystic pancreatic lesions of which the pseudocyst pancreas embodies an important component. Accounting for about 75% of cystic lesions of the pancreas [1], they are classically differentiated from other peripancreatic fluid collections (cystic neoplasms and congenital, parasitic, and extrapancreatic cysts) by their lack of an epithelial lining, high concentration of pancreatic enzymes within the pseudo pancreatic cyst commonly forming after an episode of pancreatitis or pancreatic trauma.

The revised Atlanta classification in 2012 has improved standardized reporting and effective communication between radiologists and clinicians by the first categorization of the type of acute pancreatitis into necrotizing pancreatitis and interstitial edematous pancreatitis (IEP), based on the presence or absence of necrosis, respectively, and further identifying distinct pancreatic collection subtype according to the time elapsed since the onset of pancreatitis. Such precise description of pancreatitis pseudocysts can now be defined as cystic collections after Interstitial Edematous Pancreatitis (IEP) in more than 4 weeks with a well-defined wall and absence of any solid component or necrotic debris [2].

The revision has maneuvered a rational change in the operational use of the term pseudocyst pancreas. A better understanding of the natural course of Pseudocyst Pancreas and an increasing focus on minimally invasive procedures has also led to a dramatic shift from an unquestioned aggressive approach to the exploration of cautious conservative options. In the last two decades, diagnosis and management have increasingly been supplemented by endoscopy, mostly reducing open surgery to a salvage intervention in case of failure and complication. However, the lack of endoscopic facilities and dedicated gastroenterology units especially in developing countries with the high patient load still necessitates the utilization of open techniques and their role as such cannot be overlooked.

But overall treatment planning remains variable, and apart from a few clear indications like infection of the cyst or biliary obstruction, intervention, and management strategies are neither well defined nor standardized in the published data [3].

Patients admitted from Feb 2017- Jan 2019 were closely followed and evaluated prospectively.

Case data included detailed clinical history including evaluation of precipitating Acute or Chronic Pancreatitis based on presentation, the pattern of a single episode or recurrent acute exacerbation of symptoms, and time since the first onset. Radiological characteristics of the pseudocyst were assessed and re-evaluated in the light of newer criteria for the diagnosis of pseudocysts especially in those diagnosed before 2012.

Ethical consideration and permission: Institute’s Ethical Committee approval and permission to undertake the study were taken through the proper protocol. Informed consent from patients included in the prospective part of the study was obtained and permission for waiver of consent for cases collected retrospectively was granted by the board.

Statistical Analysis: The statistical analyses of the data was performed using SPSS version 25.0. The graphs were plotted using Sigma Plot 12.0 and MS Excel. The qualitative characteristics were analyzed using Chi-Square and Fisher’s Exact test. The results on quantitative parameters were computed and their mean and standard deviations were obtained. Variables were assessed for their effect on the clinical outcome using Statistical models to evaluate factors predictive of therapeutic decisions.

The majority of patients were 30-50 years of age with a mean age of 38.9 years. Overall affection in males was considerably high (male/female: 85/15). 78% of patients were from Low and Upper Lower socio-economic class as per Modified Kuppuswamy Scale. Rest belonged to the lower middle class.

Various clinical, etiological, radiological, and biochemical parameters are summarised in Table 1. The most common presenting complaint was abdominal pain (40%) associated with an array of upper gastrointestinal symptoms like nausea, bloating, indigestion, etc. Clinical jaundice, palpable lump, and subjective weight loss were also reported.

Table-1: Clinical, etiological, radiological, and biochemical parameters.

Fig-1: CECT Scan images: A) Well defined, homogenously hypodense lesion about the pancreatic neck, body, and tail, extending into the lesser sac, displacing stomach anteriorly) in Axial View. B) Well defined, a homogenously hypodense lesion about the pancreatic neck, body, and tail, extending into the lesser sac, compressing stomach anteriorly

In those managed conservatively, 40% of patients required an eventual intervention and 60% underwent complete resolution.

The mean time of follow-up was 6 weeks. Management Schemes in our patients are represented in Table 2.

Table-2: Management strategies (n=100).

Of 85 patients who underwent primary surgical intervention, Cystogastrostomy (Figures 4-8) was the most commonly performed surgical intervention done in 52 (61.1%) patients of which 48 were performed with an open approach and the rest were done laparoscopically (Figures 7-8). Cholecystectomy was done simultaneously in 3 patients.

Cystojejunostomy was done in 11(12.9%) patients and cystoduodenostomy in 3(3.5%). Open External Drainage was done in 14(16.5%) where intraperitoneal adhesions, infected pseudocysts, and thin immature pseudocyst wall prohibited internal drainage.

4(4.8%) patients with poor general condition underwent Percutaneous Ultrasound-guided External Drainage. Recurrence was noted in 2 of the patients after percutaneous aspiration and cystogastrostomy was performed eventually.

Fig-4: Patient with pseudocyst pancreas presenting with a lump in the upper abdomen.

The larger size and volume of the pseudocyst is attributable to its connection with the main pancreatic duct which acts as a conduit for continuous drainage of pancreatic secretions, preventing its spontaneous regression. Interestingly, 100% of these patients underwent surgical intervention which was statistically significant (p=0.002).

The current study evaluated our data for the two lines of management: Conservative or Interventional (Surgical drainage). 85% of the patients underwent procedures for surgical drainage, rest were given conservative support. All patients were evaluated for resolution at 6 weeks. In those managed conservatively, 60% underwent complete resolution, and 40% of patients required an eventual intervention for increasing the size of the cyst.

Current therapeutic strategies include endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. In a large systematic review and meta-analysis published in 2019, Galileu et al [11] analyzed data from numerous studies comparing endoscopic versus surgical treatment for pancreatic pseudocysts and reported no significant difference between surgical and endoscopic treatment success rates, adverse events, and recurrence for pseudocyst.

Laparoscopy has contributed enormously in the management of pseudocysts and excellent outcomes are achieved with minimally invasive procedures. The present study notes the lack of endoscopic procedures in the management of pseudocyst at our center, however, in most centers throughout the developing world surgery remains the primary intervention technique and its importance cannot be disregarded as endoscopic treatment facilities are either non-existent or lack specialists prevent its widespread use.

The spectrum of presentation of pancreatic pseudocysts ranges from completely asymptomatic lesions to multiple pseudocysts with pancreatic and bile duct obstruction. The latter are traditionally considered to require immediate endoscopic or surgical intervention to prevent secondary complications. Up to 50% of pancreatic pseudocysts resolve without interventions [12].

However, the selection of the right patient for conservative management is important as the prediction of the timepoint of the development of complications is uncertain.

The major limitation of the present study is the retrospective nature for collection of a major portion of data and assessment of optimal management, whether conservative or interventional, relying on the availability of follow up case notes. Further prospective studies with a larger sample size considering the new operational definition for pseudocysts will help evaluate the objective utilization of clinical and radiological features alone at the time of presentation for deciding the best course of management.

The introduction of new and sensitive imaging techniques permits the detection of more pancreatic cystic lesions with better evaluation of adjacent structures and therefore, better treatment planning. Radiological characteristics are objective and should be considered in addition to the clinical picture to decide the time point of intervention for minimal complications. The risk of complications increases with time and drainage of large pseudocysts (≥6 cm and ≥60cc volume) especially with the communication channel connecting the cyst with the main pancreatic duct should not be postponed. Thus, surgical management of pseudocysts remains an important component especially if the pseudocyst is part of a more complex pathology. Endoscopic drainage being minimally invasive should be considered as the first line of management however the choice between surgical and endoscopic therapy remains to be made based on resource availability, individual experience, and specific characteristics of the pancreatic pseudocyst.

The study proposes correlative use of radiological findings of pseudocyst volume (≥60cc) and communication with the main pancreatic duct in addition to cyst diameter (≥6 cm) to decide the time point of intervention in the pseudocyst pancreas when the clinical picture is equivocal. An early intervention even in an asymptomatic patient with the above radiological parameters will reduce the risk of further morbidity and complications.

Dr. MC Songra and Dr. Mahim Koshariya conceived the idea, designed and supervised the overall project.