Effect of Percutaneous Catheterization and Negative Pressure Drainage in the Treatment of Giant Pancreatic Pseudocyst ()
1. Introduction
Pancreatic pseudocysts (PPCs) stand as one of the principal complications following acute pancreatitis, occasionally arising also from chronic pancreatitis [1]. Although many PPCs are asymptomatic, some can trigger persistent abdominal pain, bleeding, malabsorption, intracystic infection, and even obstructions in the digestive tract [2]. While smaller PPCs (diameter < 6 cm) are often absorbed spontaneously by the body, larger ones (diameter > 10 cm) typically fail to resolve and necessitate surgical intervention [3]. Traditional treatments for PPCs include both internal and external drainage; however, historical perspectives favored internal drainage as the primary treatment, fearing that external drainage might lead to pancreatic leakage and recurrence, thus diminishing its role in PPC management. Since 2004, our hospital has employed percutaneous catheter negative pressure drainage for large PPCs with considerable success, amassing substantial expertise in the process. The following report details our experiences and outcomes with this approach.
2. Materials and Methods
2.1. Patient Selection Criteria
Included in this study were 132 patients diagnosed with giant pancreatic pseudocysts admitted to the Affiliated Hospital of Rightjiang National Medical College between 2004 and 2022. All selected patients presented with varying degrees of refractory abdominal pain, digestive tract obstruction, etc., identified as having pancreatic pseudocysts via ultrasound and CT scans, and confirmed as giant pancreatic pseudocysts without contraindications for surgery. Among them, there were 95 males and 37 females, with an average age of (45.91 ± 3.07) years old, and pseudocyst sizes averaging (14.24 ± 2.06) cm.
2.2. Method
Negative Pressure Drainage via Percutaneous Catheter Placement: The procedure began with real-time image guidance using either ultrasound or CT to determine the appropriate puncture site. Local anesthesia was administered at the puncture location, carefully avoiding major abdominal vessels and organs such as the stomach, spleen, and intestines. Using a needle, the pseudocyst was punctured, and upon confirming fluid exit, the needle core was withdrawn. A drainage catheter was then inserted into the base of the cyst, secured in place, and all cystic fluid aspirated using a 50 mL syringe. The catheter was connected to a negative pressure drainage ball, initiating the negative pressure drainage process (Figure 1 and Figure 2).
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Figure 1. A 75-year-old female patient presented with a large pancreatic pseudocyst in the left upper abdomen identified via magnetic resonance imaging (MRI); She was successfully treated with percutaneous catheter negative pressure drainage. MRI revealed a massive cystic mass in the upper abdomen.
Figure 2. Depicts the puncture tube and the negative pressure drainage device used in the treatment.
2.3. Outcome Measures and Evaluation Standards
General patient condition, mean operative time, healing period, drainage duration, resumption of diet, occurrence of postoperative complications (hemorrhage, infection, pancreatic fistula, recurrence, anastomotic leakage, etc.), length of hospital stay, cost, and follow-up status were recorded.
2.4. Statistical Analysis
Statistical analyses were performed using SPSS software. Normally distributed quantitative data were expressed as (mean ± standard deviation). Comparisons of categorical variables were analyzed using the chi-square (χ2) test. A p-value less than 0.05 indicated statistically significant differences.
3. Results
Of the 132 patients with giant pancreatic pseudocysts included in the study: Average operative time: 32.4 ± 2.1 minutes; drainage catheter retention period: 30 ± 1.8 days; postoperative resumption of diet: No fasting necessary post-peripheral drainage surgery under local anesthesia; incidence of postoperative complications (bleeding, infection, pancreatic leakage, recurrence, anastomotic leakage, etc.): Two patients experienced recurrence of the pseudocyst, which was resolved through subsequent percutaneous catheter negative pressure drainage; length of hospital stay: 6 ± 1.1 days; cost: 11200 ± 1300 yuan; follow-up situation: Follow-up periods ranged from 1 to 3 years, with no discomfort reported by followed patients.
4. Discussion
Pancreatic pseudocysts result from the stimulation effect of exudates from pancreatitis on surrounding fibrocytes, leading to proliferation of fibrous tissue encapsulating the exudate, eventually forming a cyst-like structure. They differ from true pancreatic cysts due to the absence of epithelial cells lining their walls [4]. Some patients with pancreatic pseudocysts present asymptomatically and can be managed conservatively, with spontaneous absorption of the cyst contents possible over extended periods—Up to 12 weeks [5] [6]. However, patients with giant pancreatic pseudocysts often suffer from refractory abdominal pain, malabsorption, intracystic infections, and digestive tract obstructions, symptoms unlikely to self-resolve. These individuals exhibit higher complication rates (53%) and generally require surgical intervention [7]. As understanding of pancreatic pseudocysts advances, treatment approaches have increasingly trended toward minimally invasive techniques. Common surgical options for pancreatic pseudocysts include: Internal drainage: 1) After the pseudocyst wall matures (typically after 6 weeks), internal drainage can be performed. Roux-en-Y gastrojejunostomy is commonly used for this purpose, with direct anastomosis of the cyst to the gastric posterior wall if located appropriately. Such surgeries can now be accomplished using laparoscopic or endoscopic methods. 2) External drainage: Historically viewed as associated with high complication rates and recurrence in the ninth edition of the textbook of surgery, this method is less frequently utilized. It serves primarily as a rescue measure for infected pseudocysts resistant to percutaneous drainage attempts or in cases of cyst rupture.
If opting for laparoscopic internal drainage to treat patients, they must wait until the cyst has matured before undergoing the procedure, enduring ongoing discomfort from the cyst during this period while also facing risks of rupture, bleeding, and infection [8]. In instances of acute cyst rupture, emergency surgery is typically required [9] [10]. Though laparoscopic internal drainage often results in shorter durations of catheter placement in uncomplicated cases [11], this approach inflicts greater physical harm to the patient, prolongs hospitalization, and delays recovery relative to percutaneous catheter external drainage. For those undergoing percutaneous catheter negative pressure drainage, there’s less emphasis on the maturity of the cyst wall, allowing earlier intervention once diagnosed with a pancreatic pseudocyst and ruled out for surgical contraindications. For infected pseudocysts, percutaneous drainage not only achieves curative goals but also serves as a temporary stabilization measure prior to definitive surgery when the patient's condition allows [12]. In our study, we did not merely perform conventional percutaneous drainage but added a negative pressure component to enhance the drainage of cyst fluid. We hypothesized that negative pressure would promote adhesion of the cyst walls, effectively eliminating the space enclosing the cyst fluid. Utilizing ultrasound or CT guidance ensured accurate placement of the catheter deep within the cyst [13], optimizing fluid evacuation and minimizing secondary injury to the patient. Percutaneous catheter negative pressure drainage can be conducted under local anesthesia, whereas laparoscopic surgery requires general anesthesia—a factor prohibitive to certain patients with contraindications to general anesthesia, increasing procedural risk and imposing additional financial strain on families. Our investigation revealed that the cost of treating patients with percutaneous catheter negative pressure drainage averaged (11,200 ± 1300) yuan.
Some scholars argue that percutaneous drainage is closely associated with the occurrence of pancreatic fistulas. Although percutaneous drainage is simple to perform, it is not recommended for patients with pancreatic duct abnormalities, communication between the cyst and the main pancreatic duct, or a high risk of pancreatic fistula, especially in cases of chronic pancreatitis combined with pseudocyst formation [14]. However, in our study, none of the 132 patients undergoing percutaneous catheter negative pressure drainage developed a pancreatic leak.
Laparoscopic surgery for pancreatic pseudocysts has gained wide acceptance due to its small incision size, cosmetic benefits, rapid postoperative recovery, significant therapeutic effects, and lower incidence of complications [15]. However, laparoscopic procedures, particularly laparoscopic internal drainage of pancreatic pseudocysts, demand high technical proficiency from surgeons [16]. In contrast, percutaneous catheter negative pressure drainage presents fewer requirements for operator skill, making it accessible to a wider range of practitioners, including resident physicians.
Endoscopic drainage, introduced recently, represents another treatment option for pancreatic pseudocysts, characterized by minimal invasiveness, fewer complications, and a low mortality rate. When considering endoscopic drainage for patients with pancreatic pseudocysts, assessments involve: Distinguishing between cystic tumors and other pancreatic cystic lesions, Evaluating the presence of solid components within the cyst, Determining the anatomical relationship between the cyst and adjacent organs, and Identifying underlying causes [17]. While endoscopic drainage can effectively drain cystic fluid, the technique itself is complex, requiring advanced skills, specialized equipment, and can cause damage to the stomach or other organs, thereby elevating the risk of adverse events. These factors add complexity to the treatment strategy and limit its accessibility compared to percutaneous catheter negative pressure drainage.
In summary, the notion that external drainage leads to frequent recurrences or pancreatic fistulas in the management of pancreatic pseudocysts warrants further investigation. Based on our study, percutaneous catheter negative pressure drainage proves to be an effective treatment for giant pancreatic pseudocysts, presenting with lower operational complexity, expedited patient recovery, and minimal bodily harm. Consequently, encountering giant pancreatic pseudocysts clinically, we advocate prioritizing percutaneous catheter negative pressure drainage as the initial therapeutic choice. This study adopted a retrospective design without a control group. Future research incorporating alternative treatment modalities for pancreatic pseudocysts may yield more compelling results.