Should the decision on surgical treatment of a pancreatic pseudocyst be based on its size (eg, diameter >5 cm) or symptoms caused by the cyst?
Paul Moayyedi: That is an interesting question. I do not think you can give a definitive answer to this. What I would say, for all cysts no matter what their size, you do not have any good evidence that surgery is helpful. It relies on before-and-after studies where there is a strong placebo component. You have had a very major surgery and of course you are likely to feel better after that surgery once you have recovered. That may not be real, and of course there are no randomized trials in this area. It is not clear to me that surgery has any role. You may say, “If it is so big, it must be causing symptoms.” Well, you can find even bigger cysts that are clearly asymptomatic and just because you happen to find something in someone who has a cyst does not mean that that is the cause of the symptoms. I personally would be very conservative and even at 5 cm I would not automatically suggest surgery.
Of course, cysts can get to a “big enough” size. Most people would—but I would not—use 5 cm as a cutoff. That is pretending you know more than you do about how cysts cause symptoms. If they are very slow growing, chances are that they are probably not causing symptoms. Although, of course, why have the patients got this pseudocyst if they have not had an episode of acute pancreatitis beforehand? You would want to look at their pancreas to exclude things like autoimmune pancreatitis and other pancreatic pathologies that may have led to the pseudocyst developing and, obviously, treat that underlying cause. But to treat the cyst itself with surgery is not something I would rush to.
[As to endoscopic treatment, the decision should be based on], obviously, a threshold for endoscopic treatment, and [it is done] by endoscopic ultrasound through the gastric approach. That is safer, less aggressive, and it is not as definitive as surgery but, obviously, you would have a lower threshold to do that. Also it gives you a good opportunity to ensure that it really is a pseudocyst. This is another challenge with cysts. Again, I am assuming by the question you have a strong belief that this is what it is because of other underlying diseases of the pancreas, such as an episode of acute pancreatitis.