Cystogastrostomy for Pancreatic Pseudocyst Drainage
Cystogastrostomy for Pancreatic Pseudocyst Drainage
Background & Aims Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage.
Methods Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs.
Results At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003).
Conclusions In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost. Trial Registration: ClinicalTrials.gov: NCT00826501.
Pancreatic pseudocysts can occur as a consequence of inflammatory pancreatitis or ductal leakage. The most common indications for treatment include a pseudocyst that is associated with pain, infection, or obstruction of the gastric outlet or biliary tract. Decompression of the pseudocyst by internal or percutaneous drainage is advocated for symptomatic patients and internal drainage can in turn be performed by endoscopic or surgical cystogastrostomy. Endoscopic cystogastrostomy is accomplished by the creation of a fistula and stent placement between the pseudocyst and the stomach and has technical and treatment success rates of 89%–100% and 82%–100%, respectively, and a mortality rate of less than 1%. Surgical cystogastrostomy involves creating an anastomosis between the pancreatic pseudocyst and the stomach and has technical and treatment success rates of greater than 90% and a mortality rate of 5%–10%. Although the median time to pseudocyst recurrence for patients treated by surgery was reported to be more than 5 years, the median time to pseudocyst recurrence for patients treated by endoscopy was unclear because these studies used treatment protocols that were not well defined, lacked long-term follow-up evaluation, and, most importantly, were noncomparative.
We conducted a single-center, open-label, randomized trial to compare endoscopic and surgical drainage of pancreatic pseudocysts with respect to recurrence of pseudocysts, treatment success, treatment failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and costs.
Abstract and Introduction
Abstract
Background & Aims Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage.
Methods Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs.
Results At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003).
Conclusions In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost. Trial Registration: ClinicalTrials.gov: NCT00826501.
Introduction
Pancreatic pseudocysts can occur as a consequence of inflammatory pancreatitis or ductal leakage. The most common indications for treatment include a pseudocyst that is associated with pain, infection, or obstruction of the gastric outlet or biliary tract. Decompression of the pseudocyst by internal or percutaneous drainage is advocated for symptomatic patients and internal drainage can in turn be performed by endoscopic or surgical cystogastrostomy. Endoscopic cystogastrostomy is accomplished by the creation of a fistula and stent placement between the pseudocyst and the stomach and has technical and treatment success rates of 89%–100% and 82%–100%, respectively, and a mortality rate of less than 1%. Surgical cystogastrostomy involves creating an anastomosis between the pancreatic pseudocyst and the stomach and has technical and treatment success rates of greater than 90% and a mortality rate of 5%–10%. Although the median time to pseudocyst recurrence for patients treated by surgery was reported to be more than 5 years, the median time to pseudocyst recurrence for patients treated by endoscopy was unclear because these studies used treatment protocols that were not well defined, lacked long-term follow-up evaluation, and, most importantly, were noncomparative.
We conducted a single-center, open-label, randomized trial to compare endoscopic and surgical drainage of pancreatic pseudocysts with respect to recurrence of pseudocysts, treatment success, treatment failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and costs.
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