The surgical approach may vary depending on surgeon/gastroenterologist experience. The treatment of pseudocysts can be performed open, laparoscopic, endoscopic, or via interventional radiologic procedure. The three most common open or laparoscopic procedures are pancreatic pseudocystgastrostomy, pseudocystjejunostomy (either loop or Roux-en-Y), and the pseudocystduodenostomy. The strategy for drainage of a benign pancreatic pseudocyst is to create a connection between the cyst and a path of least resistance, which is usually an adjacent part of the gastrointestinal tract (i.e., stomach, duodenum, or jejunum), or via percutaneous drainage when the GI tract is not accessible. In general, percutaneous drainage should be avoided, as a persistent pancreaticocutaneous fistula is possible. Internal drainage is much preferred. Complete excision of a benign pseudocyst has been associated with numerous morbidities compared to drainage alone and thus is not the standard of care.

The type of surgical procedure also depends on the location of the pseudocyst. For pseudocysts that occur in the body and tail of the pancreas, either a pseudocystjejunostomy or pseudocystgastrostomy can be performed. For pseudocysts that occur in the head of the pancreas a cystduodenostomy is usually preferred. For a pseudocyst abutting the stomach, the cystgastrostomy procedure is typically the approach of choice.

Endoscopic transpapillary approaches to the pseudocyst are the least invasive of procedures. Therefore, when a pancreatic pseudocyst is found to have a connection to Wirsung’s duct, the preferred treatment is often transpapillary insertion of a stent for internal drainage. Endoscopic transmural (transgastric or transduodenal) approaches to the pseudocyst are alternatives to transpapillary drainage of the pseudocyst if such drainage is not possible. Transmural drainage can be done for pseudocyst that are both communicating and non-communicating with the pancreatic duct.

Another factor that must be considered when deciding whether to perform surgical or endoscopic drainage of a pseudocyst is the presence of necrotic material within the pseudocyst. Often necrotic debris is best treated with surgical debridement. We have found that discontinuation of acid suppression and exposure of complex cyst contents to gastric acid can aid in the resolution of peripancreatic fluid collections with solid debris or clot. Endoscopic debridement is an option but is less definitive, and often results in multiple procedures [10]. Therefore, we prefer drainage into the stomach as a primary endoscopic or surgical route of drainage whenever possible. Such an approach may be more effective if the patient ceases proton pump inhibitors or H₂ blockers, which many patients with foregut symptoms are commonly prescribed.

NOTES pseudocystgastrostomy, which provides definitive treatment of the pseudocyst, is comparable to previously described surgical approaches but is less invasive than laparoscopic or open pseudocystgastrostomy. Critical to the decision about this approach is the proximity of the pseudocyst to the gastrointestinal junction (Fig. 13.3). In our index case [8], the bulge of the pseudocyst seen posteriorly was about 2 cm from gastroesophageal junction, which made accessing the pseudocyst transorally an ideal approach.

The most common indications for surgical treatment of a pancreatic pseudocyst are unresolving pain, chronic 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 be performed by endoscopic or surgical pseudocystgastrostomy. The majority of patients who require treatment for their pseudocyst are treated by a definitive open, laparoscopic, or endoscopic surgery. Surgical drainage by pseudocystgastrostomy or pseudocystjejunostomy (either by a loop or Roux-en-Y) has been the standard treatment. The success rate is high, but surgical management requires an adequately mature pseudocyst wall that will hold sutures.

Percutaneous drainage has several drawbacks including skin discomfort and infection, and may leave a cutaneous fistula after drainage tube removal. In fact, percutaneous drainage is usually indicated only as an emergency procedure for acute fluid retention or infected cysts, as the recurrence rate after this form of treatment ranges as high as 70%, and percutaneous fistula are common complications (more than 20% of cases) [11].

Although surgery has been the standard technique for permanent drainage of pancreatic pseudocysts, endoscopic methods are increasingly becoming the standard of care. Endoscopic drainage is appealing, because it creates a similar result to internal surgical drainage, is less invasive, and can sometimes be used to treat immature pseudocysts.

In regards to the endoscopic procedure, an endoscopist drains the pseudocyst through the stomach by creating a small opening between the cyst and the stomach. The disadvantage of this technique is that if there is debris in the pseudocyst cavity, or if the cyst is very large, then infection or failure of pseudocyst resolution with this technique may occur. Given that, the cystgastrostomy is typically stented open with double-pigtail stents, which can be removed transorally at a subsequent endoscopic procedure. The application of endoscopic ultrasound to guide pseudocyst puncture through the stomach or duodenal wall has improved the success and safety of endoscopic pseudocyst drainage, and avoids inadvertent puncture of a major vascular structure.

A double-channel endoscope and a linear-array echoendoscope (Olympus America, Center Valley, PA) are used for viewing and locating an avascular area on the pseudocyst wall.

We use a 19-gauge needle (Cook Endoscopy, Winston-Salem, NC) to puncture the gastric/pseudocyst wall, and a 0.035 flexible, Teflon-coated guidewire (Tracer Metro wire, Cook Endoscopy) is passed into the pseudocyst cavity via the needle. Often, a Soehendra stent extractor (Cook Endoscopy) is needed to drill through the fibrotic wall of the pseudocyst. Alternatively, a 4F to 6F step-up biliary dilating catheter can be used to dilate the tract enough to allow passage of an endoscopic balloon dilation catheter across the gastric and cyst walls. The tract is dilated (up to 18 mm) using an esophageal dilation balloon (Microvasive, Boston Scientific, Natick, MA) over the guidewire. Finally, 2 or 3 double-pigtail, 10-French stents are placed to allow the pseudocysts contents to drain into the stomach.

Pseudocyst debridement can be undertaken using devices such as a biliary stone extraction basket (4 wire/2 × 4 cm, or 8 wire/3 × 6 cm web basket, Cook Endoscopy). A Roth net (US Endoscopy, Mentor, OH) can also be deployed to help remove debris.

In our NOTES pseudocyst drainage, the salient feature of the technique is to insert a linear, cutting stapler into the pseudocyst cavity through an existing endoscopically created cystgastrostomy, and performing a stapled cystgastrostomy analogous to that which is created during laparoscopic cystgastrostomy. An overtube is necessary to pass the stapling device transorally. We employed a 20-mm-diameter, gastric-length overtube (U.S. Endoscopy, Mentor, OH) for this purpose. The overtube back loaded onto the gastroscope prior to endoscopy at the time of the NOTES pseudocystgastrostomy.