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Management of Pancreatic Pseudocysts—A Retrospective Analysis RESEARCH ARTICLE Management of pancreatic pseudocystsÐA retrospective analysis Sebastian Rasch*, BaÈrbel NoÈ tzel, Veit Phillip, Tobias Lahmer, Roland M. Schmid, Hana AlguÈl Klinik und Poliklinik fuÈr Innere Medizin II, Klinikum rechts der Isar, Technische UniversitaÈt MuÈnchen, Munich, Germany * [email protected] Abstract a1111111111 a1111111111 Background a1111111111 Pancreatic pseudocysts arise mostly in patients with alcohol induced chronic pancreatitis a1111111111 causing various symptoms and complications. However, data on the optimal management a1111111111 are rare. To address this problem, we analysed patients with pancreatic pseudocysts treated at our clinic retrospectively. Methods OPEN ACCESS We searched our clinical database for the diagnosis pancreatitis from 2004 till 2014, Citation: Rasch S, NoÈtzel B, Phillip V, Lahmer T, selected patients with pseudocysts larger than 10 mm and entered all relevant information Schmid RM, AlguÈl H (2017) Management of pancreatic pseudocystsÐA retrospective analysis. in a database for statistical analysis. PLoS ONE 12(9): e0184374. https://doi.org/ 10.1371/journal.pone.0184374 Results Editor: Sheng-Nan Lu, Chang Gung Memorial In total, 129 patients with pancreatic pseudocysts were treated at our institution during the Hospital Kaohsiung Branch, TAIWAN study period. Most patients suffered from alcohol induced chronic pancreatitis (43.4%; 56/ Received: June 8, 2017 129). Pseudocysts were more frequent in female than in male (2:1) and were mainly located Accepted: August 22, 2017 in the pancreatic head (47.3%; 61/129). Local complications like obstructive jaundice were Published: September 6, 2017 associated with the diameter of the cysts (AUC 0.697 in ROC-curve analysis). However, Copyright: © 2017 Rasch et al. This is an open even cysts up to a diameter of 160 mm can regress spontaneously. Besides a lower re-inter- access article distributed under the terms of the vention rate in surgically treated patients, endoscopic, percutaneous and surgical drainage Creative Commons Attribution License, which are equally effective. Most treatment related complications occur in large pseudocysts permits unrestricted use, distribution, and located in the pancreatic head. reproduction in any medium, provided the original author and source are credited. Conclusion Data Availability Statement: All relevant data are within the paper and its Supporting Information Conservative management of large pseudocysts is successful in many patients. Therefore, files. indication for treatment should be made carefully considering the presence and risk of local Funding: The authors received no specific funding complications. Endoscopic and surgical drainage are equally effective. for this work. Competing interests: The authors have declared that no competing interests exist. PLOS ONE | https://doi.org/10.1371/journal.pone.0184374 September 6, 2017 1 / 10 Management of pancreatic pseudocysts Introduction Pancreatic pseudocysts belong to the diverse entity of pancreatic fluid collections and cystic pancreatic lesions. As features and complications of the different fluid collections and cystic lesions are variable, a classification system was established in 1992 by a consensus meeting in Atlanta and was revised in 2011.[1, 2] According to the revised Atlanta classification, pancre- atic pseudocysts usually develop with a delay of at least 4 weeks to the initiating event and are characterized by a well defined inflammatory wall and a homogeneous fluid content without necrosis.[1] Particularly small pseudocysts are difficult to differentiate from cystic tumors of the pancreas. About 70% of pancreatic pseudocysts arise in patients with alcohol induced chronic pancre- atitis. In addition, pseudocysts can also evolve after acute pancreatitis, trauma, and surgery.[3± 5] Although symptoms and complications are diverse and heavily depend on localisation and size of the pseudocyst, most frequently patients with pancreatic pseudocysts present with abdominal pain.[6] Accordingly, treatment is variable and apart from a few clear indications like infection of the cyst or biliary obstruction neither well defined nor standardized. As the few published studies on pancreatic pseudocysts rely on relatively few patients and do not use uniform definitions, meta-analysis with a sufficient cohort size are difficult so far.[5, 7] Addi- tionally, endosonographic drainage techniques evolved in the last decade and more and more replace surgical drainage procedures like pseudocystojejunostomyÐthe former standard of therapy. (Fig 1) Although endosonographic drainage has been compared to conventional drainage techniques in randomized controlled trials, in particular the question which patient has to be treated when has hardly been addressed.[7, 8] With this unicenter retrospective analysis we aimed to address this problem by evaluating treatment indication, analysing treatment options and assessing the course of the disease and the outcome. Materials and methods We performed a unicenter retrospective analysis of patients presenting with pancreatic pseu- docysts between 2004 and 2014 at the tertiary referral center Klinikum rechts der Isar der Technischen UniversitaÈt MuÈnchen. We screened our administrative diagnosis database for patients with pancreatitis (International Classification of Diseases (ICD)-10 code K85 and K86; n = 3281). Pancreatic pseudocysts were defined according to the revised Atlanta classifi- cation.[1] Patients with pancreatic pseudocysts larger than 10 mm who presented more than one time were eligible for this study. Patients with cysts suspicious of dysplasia or walled of necrosis were excluded. We reviewed the medical charts of all 3281 patients diagnosed with chronic and acute pancreatitis. Thus, we identified 129 patients with pancreatic pseudocysts that met the inclusion criteria. All patients were registered in a database containing 105 clinical parameters. The study was approved by the local ethics committee (Ethikkommission der FakultaÈt fuÈr Medizin der Technischen UniversitaÈt MuÈnchen, project number 466/14). Written consent was specifically waived by the approving institutional review board. Statistical analysis was performed using IBM SPSS Statistics 22 (SPSS Inc, Chicago, Illinois, USA). To compare qualitative parameters, chi-square test was used and in small samples (expected frequency of test variable less than 5), Fisher's exact test was used. For the analysis of quantitative parameters, Mann-Whitney-U test was employed. All statistical tests were two sided with a level of significance (p-value) of 5%. A binary logistic regression model was used to analyse the effect of patient characteristics on the development of symptomatic cysts or local complications. Factors with a p-value below 0.1 in univariate analysis or a high probability according to our data or the literature were included in regression analysis. The p-value PLOS ONE | https://doi.org/10.1371/journal.pone.0184374 September 6, 2017 2 / 10 Management of pancreatic pseudocysts Fig 1. Abdominal CT-scan with venous contrast: Pancreatic pseudocyst with transgastric drainage. https://doi.org/10.1371/journal.pone.0184374.g001 remained 0.05 after a Benjamini-Hochberg correction to control the false discovery rate, as several regression analyses were performed.[9] Descriptive data are presented as mean ± standard deviation (SD) for normally distributed parameters and median, range and interquartile range (IQR) for not normally distributed parameters. Risk ratios were displayed as odds ratio (OR) with 95% confidence interval (CI). Drainage techniques All endoscopic drainage procedures were performed under endosonographic guidance by a linear scanner. A gastro- or duodenocystostomy was carried out with a cystostome, fluid speci- men were obtained by aspiration and 1±3 double pig tails were placed via a guide wire. For PLOS ONE | https://doi.org/10.1371/journal.pone.0184374 September 6, 2017 3 / 10 Management of pancreatic pseudocysts percutaneous drainage pig tail catheters were placed by Seldinger's technique under sono- graphic or computertomographic guidance. All surgical drainage procedures were cystojeju- nostomies with a Roux-en-Y reconstruction. Results Patients`characteristics Overall, 161 pancreatic pseudocysts in 129 patients were identified. Accordingly, pseudocysts occurred in 3.93% (129/3281) of the patients. Most of the patients`characteristics are summed up in Table 1. The median follow up time was 4.7 months (IQR 1.6±15.1, range 0.2±102). In 6.2% (8/129) of the patients the pseudocyst was an incidental finding, 28.7% (37/129) of the Table 1. Patient characteristics. Patient characteristics, n = 129 Gender (♂: ♀) 1:2 Mean age (years) 52 (±14.9) median follow up in days 141 (IQR 48±452; range 3±3056) Cyst Etiology acute pancreatitis 14.7% (19/129) - alcoholic 42.1% (8/19) - biliary 57.9% (11/19) chronic pancreatitis 65.1% (84/129) - alcoholic 66.7% (56/84) - hereditary 3.6% (3/84) - other/idiopathic 29.8% (25/84) iatrogen and trauma 3.9% (5/129) Idiopathic pseudocysts 16.3% (21/129) median number per patient 1 (IQR 1±2; range 1±5) median diameter (mm) 60 (IQR 32±88; range 10±180) Location Head 47.3% (61/129) Body 27.1% (35/129) Tail 24.8% (32/129) Extrapancreatic 25.6% (33/129) Symptoms abdominal pain 63.6% (82/129) nausea/vomitting 19.4% (25/129) weight loss 18.6% (24/129) Indigestion 6.2% (6/129) Bloating 6.2% (6/129) Jaundice 3.9% (5/129) Local complications pancreatic duct obstruction 17.8% (23/129) blood vessel obstruction
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