Assessment of pancreatic pseudocysts followed with endoscopic ultrasonography (EUS); Single center experience

Introduction and Objective The frequency of diagnosis of pancreatic cysts is increasing due to the widespread use of cross-sectional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI). The management of pancreatic cystic lesions (PCL) is often difficult for the clinician to manage. Therefore, history, clinical, laboratory, radiological imaging, cyst fluid analysis obtained by EUS, EUS-FNA and cytopathology data are important for differential diagnosis. The aim of our study is to investigate the contribution of laboratory, radiological, endosonographic and pathological examinations to the diagnosis and treatment of pancreatic pseudocyst management. Materials and Methods 102 patients diagnosed as pancreatic pseudocyst between July 2009 and January 2018 in the Department of Gastroenterology Clinic of Internal Medicine of Dokuz Eylül University Faculty of Medicine were included in the study. Patients' demographic data, clinical features, laboratory data, radiological / EUS image reports and pathological examination results were evaluated retrospectively. Result In 51 (50%) of 102 cases diagnosed with pancreatic pseudocysts, clinical findings (abdominal pain, jaundice, nausea-vomiting, diarrhea, and dyspepsia) were present depending on the location of the cystic lesion. It should be remembered that the majority of the patients were diagnosed incidentally and were asymptomatic. Six of the nine patients who were included in the study had a pre surgery diagnosis of Pseudocyst in EUS; after surgery three were diagnosed with pancreatic adenocarcinoma, one with neuroendocrine neoplasia, one with MCN and one with İPMN. Out of 102 patients diagnosed with pancreatic pseudocyst, 36 underwent drainage. Of them; Cystogastrostomy was performed in 33 patients and cystoduedonostomy in 3 patients. The comparative assessment of patients with and without drainage is as follows: Resection of pseudocysts was successfully performed in 35 (97.22%) of 36 patients who underwent drainage, and 1 (2.78%) patients had partial resolution due to post operative secondary anatomy and post-operative infection. The neutrophil / lymphocyte ratio (NEU / LENF), which is considered as an indicator of subclinical inflammation, was 3.37 in female patients and 5,38 in male patients who underwent procedure. In our study, the higher NEU / LENF ratio; had a correlation with higher chance of cysts to be semptomatic and indicates that the cysts will not spontaneously regress and will require drainage. Radiologically, the percentage of separation of pancreatic cysts as pseudocysts was 58.3% for CT, 70.5% for MR, 84.3% for EUS, and 100% for EUS + FNA. Diagnostic performance of CT was 47.5%, MR 63.1%, EUS 78.4%, EUS + FNA 95%. Discussion and Suggestions The lack of reliable imaging and biomarkers for benign / malignant distinction in cystic lesions of the pancreas has led to the development of clinician-guiding guidelines [35, 42]. In practice,aim of these guidelines is to help the clinician to either follow up the patients with cystic lesions or to refer them to surgical intervention. However, guidelines are inadequate ,due to the lack of reliable imaging techniques and lack of procedure that can analysis cysts that can identify high- or low-risk patients,. Therefore, we believe that the role of EUS in the follow-up of pancreatic cystic lesions should be defined more clearly. Key words: pancreas, pseudocyst, cyst, cystogastrostomy, cystoduodenostomy, endoscopic ultrasonography, neutrophil‐lymphocyte ratio