Pseudocyst Drainage: ERCP and EUS Approaches

Pancreatic pseudocysts and peripancreatic fluid collections form after an episode of acute pancreatitis, in patients with chronic pancreatitis, with pancreatic duct obstruction, or after pancreatic trauma. Symptoms typically include abdominal pain, early satiety, or nausea, or may be those related to biliary compression. Mature pseudocysts should be drained when large and/or symptomatic or when infected. When planning a pseudocyst drainage procedure, it is important to be certain that the cyst is indeed a pseudocyst and not a cystic neoplasm. It is also important to exclude a pseudoaneurysm before drainage in select clinical situations. The traditional approach to drainage is surgical, with cystenterostomy and/or pancreatic resection, and may be done laparoscopically in expert hands. Over time, this has evolved to include percutaneous approaches, such as percutaneous drain placement or percutaneous cystenterostomy. Over the past 10 to 15 years, endoscopic approaches to pseudocyst drainage have gained acceptance and have become the primary means of pseudocyst drainage. This article will briefly review the indications for pseudocyst drainage as well as the percutaneous and surgical approaches to pseudocyst drainage. The primary focus, however, will be on the endoscopic drainage of pseudocysts. The technical aspects of transpapillary and transluminal drainage will be reviewed in detail, and we will briefly discuss the management of complications. We favor the single-step endoscopic ultrasound-guided approach to pseudocyst enterostomy, and this will be presented with detailed illustrations.