ORIGINAL ARTICLE: PANCREATOLOGY
Prevalence, Natural History, and Outcome of Acute Fluid Collection and Pseudocyst in Children With Acute Pancreatitis Rishi Bolia, Anshu Srivastava, Surender Kumar Yachha, Ujjal Poddar, and Sheo Kumar ABSTRACT Objective: Recent years have witnessed an increase in acute pancreatitis (AP) in children; however, the natural history of acute fluid collection (AFC) and pseudocyst is largely unknown. We evaluated the frequency, clinical characteristics, and natural history of pseudocysts in children with AP. Methods: Children with AP admitted at Sanjay Gandhi Postgraduate Institute of Medical Sciences from 2001 to 2011 were enrolled and studied until complete resolution. Subjects with inadequate follow-up, recurrent AP, and chronic pancreatitis were excluded. Results: Of the 58 children (43 boys, median age 14 [1–18] years) with AP, 34 (58.6%) and 22 (38%) developed AFC and pseudocyst, respectively. No difference in age (12 [4–18] vs 13 [1–16] years), etiology (idiopathic 64% vs 47% and traumatic 27.2% vs 22.2%), and systemic complications (pulmonary [18% vs 11%], renal [22.7% vs 11%], and shock [13.6% vs 10%]) was observed between children with and without pseudocyst. A total of 11 of the 22 subjects with pseudocyst underwent drainage, the commonest symptom requiring drainage being gastric outlet obstruction [n ¼ 5] and infection [n ¼ 2]. The 11 of the 22 children with AP and pseudocyst (size 6.4 [3–14.4] cm) showed spontaneous resolution (disappearance [n ¼ 9] and significant reduction in size [n ¼ 2]) during 110 (25–425) days. Symptomatic pseudocysts requiring drainage were more often secondary to traumatic AP (6/6 vs 2/14 [idiopathic], P ¼ 0.0007) than asymptomatic pseudocysts resolving spontaneously. Overall, only 26.4% (9/34) children with AFC required drainage because of symptomatic pseudocyst. Conclusions: Among children with AP, 58.6% developed AFC and 38% developed pseudocysts. Only patients with symptomatic pseudocyst need drainage, and asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection. Key Words: acute fluid collection, acute pancreatitis, children, prevalence, pseudocyst
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P
ancreatic pseudocyst is defined as a collection of pancreatic juice that persists for >4 weeks, is enclosed by fibrous or granulation tissue, and arises as a consequence of acute or chronic pancreatitis (CP) (1). Pseudocysts have a variable presentation, ranging from a totally asymptomatic to symptomatic states Received December 22, 2014; accepted March 18, 2015. From the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Address correspondence and reprint requests to Surender Kumar Yachha, MD, DM, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India (e-mail: [email protected]). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000800
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What Is Known
Natural history of acute fluid collection and pseudocyst in children with acute pancreatitis is largely unknown. Present strategy in adults is to drain only symptomatic pseudocysts, irrespective of size. The applicability of these principles in children is unknown.
What Is New
Among children with acute pancreatitis, 60% develop an acute fluid collection and 40% develop a pseudocyst. Among children with acute pancreatitis and pseudocyst, 40% are symptomatic and require pseudocyst drainage. Children with asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection.
manifesting most often with abdominal pain, vomiting, and fever secondary to cyst infection or jaundice because of the compression of common bile duct. Pseudocysts may also have a catastrophic presentation as sudden-onset anemia with hypotension because of a massive intracystic bleed (2). An increase in the occurrence of acute pancreatitis (AP) in children has been observed in the last decade (3). In addition, there has been a paradigm shift in the management principles of pancreatic pseudocysts. From a size-based approach, the impetus is now on a symptom-based approach in adults (4). Various approaches have been used for drainage of pancreatic pseudocyst, which includes percutaneous radiological drainage, endoscopic drainage, and surgical drainage. There are no studies comparing these modalities with one another, and the choice largely depends upon the availability of expertise at a particular center and pseudocyst location. The information on actual incidence of pseudocyst is, however, scarce (5–8), and there is no literature available regarding the natural history of acute fluid collection (AFC) and pseudocysts in children with AP. Studies in adults have reported 5% to 14.6% incidence of pseudocyst in AP, with spontaneous resolution or decrease in size in 65% to 84.2% of patients (9–11). This information is vital not only for prognosticating children with AP but also for developing an optimal management strategy. The aim of this study was to analyze the incidence, clinical characteristics, risk
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factors for development, and natural course of pancreatic pseudocysts in children with AP.
METHODS An audit of the medical records of children with AP admitted in the Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, from January 2001 to December 2011 was performed. The study was approved by the institutional ethics committee. Patients with CP, recurrent AP (RAP), and those with incomplete medical records were excluded from the study. The diagnosis of AP was based on the presence of 2 of the following: abdominal pain compatible with pancreatitis, serum amylase and/or lipase >3 times the upper limits of normal, and findings of AP on imaging (Philips HD9 Ultrasound System using 3–5 MHz curvilinear transducer or Philips Brilliance 64 Slice CT, Philips, Andover, MA) (12). All of the patients were admitted and managed conservatively with intravenous fluids and analgesics. A complete hemogram, serum electrolytes, liver and renal function tests, and an arterial blood gas analysis were done. Grading of severity of AP was done as per the Atlanta guidelines; patients having organ failure and/or local complications were classified as severe and the remaining as mild (1). Organ failure was defined as follows: respiratory failure as PaO2/FIO2 2 times the upper limit of normal for age or a 2-fold increase in baseline creatinine, and cardiovascular dysfunction as decrease in blood pressure (hypotension) less than the fifth percentile for age or the presence of gastrointestinal bleeding (13). In order to establish the etiology (3), a detailed history regarding antecedent blunt or penetrating trauma, intake of drugs, and infections before the onset of symptoms was taken. If the child was on a drug that is known to cause pancreatitis, then it was attributed to the drug, after exclusion of other causes (14). If the patient had a serum calcium of >11 mg/dL or fasting triglyceride levels of >1000 mg/dL, the etiology was attributed to hypercalcemia and hypertriglyceridemia, respectively. Gallstone pancreatitis was defined as pancreatitis in a child who had gallstones on radiological evaluation (15). An infection was suspected as an etiology of AP if the characteristic features of the infectious agent were present. Structural anomalies causing AP were assessed by imaging whenever applicable. Patients in whom no etiology could be identified were labeled as idiopathic. All patients underwent an abdominal ultrasonography (USG) at admission. A contrast-enhanced computed tomography (CT) scan was performed only for patients with suspected severe pancreatitis or those who failed to show any improvement even after 72 hours of admission. A repeat USG was performed at 4 to 6 weeks of the illness. Patients detected to have a pseudocyst as defined by the Atlanta classifications (1) were thereafter studied by a detailed clinical evaluation and serial USG every 8 to 12 weeks. If at any point of time during the follow-up period the patient developed any symptoms attributable to a pseudocyst, prompt drainage was carried out. Patients’ demographic characteristics, etiology of the pancreatitis, clinical features, management, and clinical course till complete resolution were recorded. Percutaneous catheter drainage (PCD) was the modality of choice at our center because of availability of expertise. All of the procedures were performed by an expert interventional radiologist using ketamine sedation or general anesthesia under USG/CT guidance. The access routes used were the left anterior pararenal space for pseudocysts in the pancreatic tail and transgastric route for access to the body and the lesser sac. Catheters (10.2 F Ultra thane multipurpose drainage catheter [Bloomington, IN] with
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simp-locking loop for transgastric approach and 12–14 F Malecot nephrostomy catheters for nontransgastric approach, Devon Innovations, Bangalore, India) were inserted by the Seldinger technique. Thereafter, catheter drainage output was monitored daily. The catheter was removed when the drain output was 10 mL/day even after 6 weeks of drainage. In such a case, pancreatic ductal anatomy was evaluated using magnetic resonance cholangiopancreatography (MRCP)/endoscopic retrograde cholangiopancreatography (ERCP), and additional interventions were performed based on the findings. Intergroup comparison was done between patients who developed a pancreatic pseudocyst and those who had no pseudocyst to determine the risk factors for pseudocyst development. Patients with pseudocyst who required drainage were compared with patients in whom no drainage of pseudocyst was required.
Statistical Analysis Statistical analysis was performed using SPSS version 17.0 (SPSS Inc, Chicago, IL). Data was presented as median (range) and percentages. Mann-Whitney U test was used to compare continuous variables and Fisher exact test to compare discrete variables. A P < 0.05 was considered significant.
RESULTS Eighty-seven children (61 boys, median age 12 [1–18] years) with AP presented during the study period. Of them, 29 children were excluded (underlying CP [n ¼ 6], RAP [n ¼ 19; pancreas divisum ¼ 3, gallstone ¼ 1, choledochal cyst ¼ 1, idiopathic ¼ 14], no follow-up after discharge [n ¼ 4]). Thus, 58 children (43 boys, median age 14 [1–18] years) were included in the final analysis. They were followed up for a median duration of 5 (2–47) months after discharge from hospital. Of these patients, 66% (38/58) had severe pancreatitis: systemic complications in 23 (Table 1), local complications in 32 (pseudocyst 22 and pancreatic necrosis 10). Overall, of these 38 patients with severe AP, 17 (44.7%) had both local and systemic complications, 15 (39.4%) had only local complications, and 6 (15.7%) had only systemic complications. The remaining 20 patients (34.4%) had mild pancreatitis. Of 58 patients, 34 (58.6%) had an AFC at presentation. Of these, 22 patients developed a pseudocyst on follow-up USG at 40 (32–54) days, and in the remaining 12 patients, there was resolution of the AFC (Fig. 1). The majority (19/22 [86.3%]) of the patients had a single pseudocyst, and 3 patients (13.6%) had multiple pseudocysts (2 in 2 patients, 3 in 1 subject). The most common location of the pseudocyst was in the body (n ¼ 10) followed by the head (n ¼ 9) and tail (n ¼ 7) of pancreas. The median size of the pseudocysts was 6.4 (3–16) cm. There were no differences in age, etiology, and systemic complications in patients with and without a pseudocyst as shown in Table 1. As expected the patients with pseudocysts had a significantly longer duration of hospital stay. The likelihood of development of AFC, evolution into pseudocyst, and need for drainage according to etiology of AP is shown in Table 2. Of the 22 patients with a pseudocyst, 11 required drainage, 9 being symptomatic (gastric outlet obstruction [early satiety, postprandial fullness, and vomiting n ¼ 5], persistent pain [n ¼ 1], www.jpgn.org
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Prevalence, Natural History, and Outcome of AFC and Pseudocyst
TABLE 1. Comparison between patients of AP with and without pseudocyst
Age, y (median with range) Sex (M:F) Etiology (%) Trauma Idiopathic Drugs Infections Gallstones Symptoms (%) Pain in abdomen Nausea/vomiting Jaundice Systemic complications (%) Respiratory failure Renal failure Gastrointestinal bleeding Shock Hospital stay
Pseudocyst (n ¼ 22)
No pseudocyst (n ¼ 36)
P
12 (4–18) 16:6
13 (1–16) 27:9
0.27 0.41
6 (27.2) 14 (63.6) 1 (4.5) 0 (0) 1 (4.5)
8 (22.2) 16 (47) 5 (14) 3 (8.3) 4 (11.1)
0.75 0.18 0.39 0.26 0.64
22 (100) 18 (81.8) 0 (0 )
32 (89) 24 (67) 1 (2.7)
0.26 0.24 1.00
4 (18.1) 5 (22.7) 0 (0) 3 (13.6) 22 (8–60) days
4 (11) 4 (11) 0 (0) 3 (10) 11 (5–60) days
0.42 0.27 1.00 0.44 0.04
AP ¼ acute pancreatitis. Etiology of AP was acute viral hepatitis because of hepatitis A virus.
evidence of infection [n ¼ 2], and intracystic bleeding [n ¼ 1]). Two patients were drained because of the large cyst size (6 and 8.5 cm, respectively) and persistence for 7 weeks in the initial years before the treating unit’s policy of draining only symptomatic pseudocysts. Comparison of patients with pseudocyst requiring drainage with those who did not require drainage (Table 3) showed that patients with traumatic pancreatitis and pseudocyst required drainage more often than those with idiopathic pancreatitis and pseudocyst (6/6 vs 4/14, P ¼ 0.03).
87 patients acute pancreatitis Excluded-29 -Chronic pancreatitis-6 -Recurrent-19 -Lost to follow-up-4
Enrolled 58 children
Mild n = 20 (34.5%)
Severe* n = 38 (65.5%)
No AFC n = 6 (15.8%)
AFC n = 32 (84.2%)
Pseudocyst n = 22 (68.7%)
Intervention n = 11(50%)
No pseudocyst n = 10 (31.3%)
No AFC n = 18 (90%)
AFC n = 2 (10%)
Resloved
No intervention n = 11(50%)
FIGURE 1. Flowchart of children with AP showing frequency of AFC/pseudocyst and need of intervention. Severity classified as per Atlanta criteria (1). AFC ¼ acute fluid collection; AP ¼ acute pancreatitis.
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Ten patients underwent PCD of the pseudocyst, and 1 patient underwent an endoscopic cystogastrostomy. No complications in relation to catheter insertion were seen. In 4 patients the catheter was placed transgastric, which was later internalized in 2 of the 4 patients. The median duration of catheter drainage was 34 (19–60) days. PCD-related complications were seen in 2 patients. One patient (1/10, 10%), who had initially sterile pseudocyst fluid, developed a symptomatic infection with fever. Escherichia coli was the organism isolated in this patient. The infection resolved within 7 to 10 days of intravenous antibiotics. In 1 patient the catheter got accidentally displaced and required repeat insertion. PCD failed as a drainage modality in 3 of the 10 (30%) patients (traumatic ¼ 2, gallstone related ¼ 1). All of the 3 patients showed a pancreatic duct–cyst communication (head region in 2 patients and body in 1 patient) on ERCP (n ¼ 2) and CT scan (n ¼ 1). The pseudocysts resolved during a period of 28, 34, and 52 days in these 3 patients after ERCP and endoscopic papillotomy. In the 11 patients with pseudocyst requiring drainage, 1 patient had a recurrence of pseudocyst (4 cm in the tail region) during a median follow-up of 210 (15–510) days. He has remained asymptomatic during a follow-up of 94 days, however, without any increase in size, and no further intervention was performed. Eleven asymptomatic patients with pseudocysts were followed-up, and in 9 (82%) patients (pseudocyst size of 6.4 [3–14.4] cm) the cyst resolved during a median duration of 110 (25–425) days. There was no correlation between cyst size and number of days for complete resolution (r ¼ 0.096). In the remaining 2 patients, the pseudocysts decreased considerably in size (9–3 cm and 7.8–3.5 cm) at the last follow-up of 1 year and 6 months, respectively. Both these patients are asymptomatic on follow-up. None of our patients who were managed on expectant lines had any complications.
DISCUSSION Information about natural history of AFCs and pancreatic pseudocysts in children is limited. Moreover, the available literature is difficult to interpret because patients with pseudocyst following AP or CP are grouped together, and many reports do not differentiate between AFC and pseudocyst. It is well known that the incidence and resolution of pseudocyst differs in AP and CP (10). We have evaluated children with AP and studied them from first presentation to complete resolution and thereafter also for any recurrence. Children with RAP or CP either at first presentation or in follow-up were excluded to have a uniform group. Of our patients with AP, 58.6% (n ¼ 34) developed AFC, which resolved in the first 4 to 6 weeks in 35% and persisted as pseudocyst in 65% of the patients. Maringhini et al (9) reported resolution of AFC in 42% of their 926 adult patients with nonalcoholic AP, which is similar to our observation. Pseudocysts developed in 38% of our patients with AP. Various pediatric studies have shown pseudocysts in 8% to 41% of subjects with AP (5,16,17). Our observation of 38% is on the higher end of the range and could be because of the fact that our center is a tertiary care hospital, and thus we get to admit more of severe cases. The severity of our AP patients is also evident by the much higher frequency of organ failure (40% vs 0%–26.5%) and pancreatic necrosis (17% vs 0%–8%) compared with the other pediatric studies (18–20). In addition, all our patients had a radiological follow-up so we diagnosed all of the patients of pseudocyst even if they were asymptomatic. Only 40.9% (9/22) patients with pseudocyst developed symptoms and required drainage. The commonest symptoms were features of gastric outlet obstruction (n ¼ 5) followed by persistent pain (n ¼ 1). Three patients had complications of infected cyst
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TABLE 2. Natural history of AFC and pseudocyst by etiology of pancreatitis Etiology
Trauma Drugsy Infectionsz Gallstones Idiopathic Total
No. (n) 14 6 3 5 30 58
AFC (%) 11/14 (78.5) 3/6 (50.0) 1/3 (33.3) 2/5 (40.0) 17/30 (56.6) 34/58 (58.6)
Pseudocyst (%)
Pseudocyst requiring intervention
6/14 (42.8) 1/6 (16.6) 0/3 (0.0) 1/5 (20.0) 14/30 (46.7) 22/58 (37.9)
6/14 (42.8) 0/6 (0.0) 0/3 (0.0) 1/5 (20.0) 4/30 (13.3) 11/58 (18.9)
AFC ¼ acute fluid collection. Trauma: ball (n ¼ 3), cycle handle (n ¼ 4), car steering (n ¼ 1), fall (n ¼ 3), and blunt trauma (n ¼ 3). y Drugs: sodium valproate (n ¼ 4) and L-asparaginase (n ¼ 2). z Infections: hepatitis A virus (n ¼ 2) and hepatitis E virus (n ¼ 1).
(n ¼ 2) and intracystic bleeding (n ¼ 1). Available adult literature shows that approximately 30% patients with pseudocysts need drainage because of development of symptoms, pain being the most common (9) Trauma was the commonest etiology in our study and accounted for 27.2% (6/22) of all of the patients with pseudocysts. No etiology significantly predisposed to the formation of a pseudocyst (Table 2). A drainage procedure was required significantly more often in children with traumatic pancreatitis, however, as compared with the other etiologies. This could be because of the higher chances of pancreatic ductal injury with duct-cyst communication and development of symptomatic pseudocyst. The pancreatic duct was evaluated in 2 of the 6 of our patients with traumatic etiology and pseudocysts, and both had duct-cyst communication. Similar to our observation, Stringer (21) in his series on pancreatic trauma found that all of the children with ductal injury developed a symptomatic pseudocyst requiring intervention. The higher proportion of idiopathic patients in our study may be as result of the fact that because of the cost/invasiveness of testing we do extensive workup (MRCP, endoscopic ultrasound (EUS), genetic testing) only in patients with RAP (2 episodes of AP) at our center. There is lack of pediatric guidelines regarding the extent of workup in the first episode of AP, and even adult guidelines do not recommend invasive investigations in this group of young patients (age 6 cm irrespective of symptoms (24), the present strategy is to drain pseudocysts only when symptomatic, irrespective of size. That is why, 2 of our patients seen earlier underwent drainage only on the basis of their size, whereas the later ones were drained only when symptomatic. Our observation confirms the utility of the present recommendation of a symptom-based therapy in children as in adults (10,11), however, and that conservative management is effective even for cysts of >6 cm size and 6 weeks of duration. The available options for pancreatic pseudocyst drainage include endoscopic (transpapillary or transmural) drainage, PCD, or open/laparoscopic surgery. To date, no prospective controlled studies have directly compared these approaches in children. The variation of management is based on local expertise and individual case scenario. The preferred strategy at our center until recently was percutaneous drainage, which was done in 10 patients. There were no procedure-related complications; 10% of patients developed infection, which settled with antibiotics, and 10% had a recurrence. Sepsis has been reported in 6% to 32% of patients (25–27) and recurrence rate of 30% in adult studies. PCD was successful as a sole modality in 70% patients with the median period of drainage being 32 (19–60) days. This is similar to the success rate of 50% to 80% in various adult studies (25–27); however, patients with both AP and CP have been included in these studies. An underlying ductal disorder (duct cyst communication ¼ 3) was demonstrated in all of our patients who failed PCD. Thus confirming the fact that PCD is best applied to patients with normal ducts, and patients who have pseudocysts communicating with main pancreatic duct should not be subjected to PCD (27,28). These patients are best managed with ERCP and transpapillary drainage with stenting across the duct-cyst communication. This also reaffirms the need of a multidisciplinary approach of www.jpgn.org
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radiological, endoscopic, and surgical intervention in managing children with pancreatic disorders (29). Our study has the limitations of a retrospective study. In addition, because imaging with MRCP/EUS was not done in our patients, we could have missed changes of early CP in a small proportion of our patients. Also, we had more patients with severe pancreatitis in our study so our results may not be representative of the true spectrum of AP in children. A prospective study would be required to verify our results and also to evaluate the effect of the type of fluid collection (acute peripancreatic fluid collection vs acute necrotic collection) on the outcome in view of the revised Atlanta classification (30). To conclude, in children with AP, AFC and pseudocysts are seen in 58.6% and 38%, respectively. Among patients with AP and pseudocyst, only 41% become symptomatic requiring drainage. Pseudocysts developing in the setting of traumatic pancreatitis are more likely to be symptomatic and require drainage. Asymptomatic pseudocysts can be safely followed-up with oral feeding, irrespective of size and duration. Of these, 80% pseudocysts disappear spontaneously whereas the remaining 20% show significant reduction in size. Overall, only 26.4% children with AFC go on to develop symptomatic pseudocyst and need drainage whereas the remaining settle with conservative therapy. Percutaneous drainage is successful in approximately 70% as a sole modality, and assessment of pancreatic ductal anatomy is useful in selecting patients for percutaneous drainage.
REFERENCES 1. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993;128:586–90. 2. Andre?n-Sandberg A, Dervenis C. Pancreatic pseudocysts in the 21st century. Part II: natural history. JOP 2004;5:64–70. 3. Bai HX, Lowe ME, Husain SZ. What have we learned about acute pancreatitis in children? J Pediatr Gastroenterol Nutr 2011;52:262–70. 4. Cheruvu CV, Clarke MG, Prentice M, et al. Conservative treatment as an option in the management of pancreatic pseudocyst. Ann R Coll Surg Engl 2003;85:313–6. 5. Das S, Arora NK, Gupta DK, et al. Pancreatic diseases in children in a north Indian referral hospital. Indian Pediatr 2004;41:704–11. 6. Goh SK, Chui CH, Jacobsen AS. Childhood acute pancreatitis in a children’s hospital. Singapore Med J 2003;44:453–6. 7. Sa´nchez-Ramı´rez CA, Larrosa-Haro A, Flores-Martı´nez S, et al. Acute and recurrent pancreatitis in children: etiological factors. Acta Paediatr 2007;96:534–7. 8. Tiao MM, Chuang JH, Ko SF, et al. Pancreatitis in children: clinical analysis of 61 cases in southern Taiwan. Chang Gung Med J 2002; 25:162–8. 9. Maringhini A, Uomo G, Patti R, et al. Pseudocysts in acute nonalcoholic pancreatitis: incidence and natural history. Dig Dis Sci 1999;44: 1669–73.
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Prevalence, Natural History, and Outcome of AFC and Pseudocyst
10. Kim KO, Kim TN. Acute pancreatic pseudocyst: incidence, risk factors, and clinical outcomes. Pancreas 2012;41:577–81. 11. Cui ML, Kim KH, Kim HG, et al. Incidence, risk factors and clinical course of pancreatic fluid collections in acute pancreatitis. Dig Dis Sci 2014;59:1055–62. 12. Morinville VD, Husain SZ, Bai H, et al. Definitions of pediatric pancreatitis and survey of present clinical practices. J Pediatr Gastroenterol Nutr 2012;55:261–5. 13. Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2–8. 14. Nitsche CJ, Jamieson N, Lerch MM, et al. Drug induced pancreatitis. Best Pract Res Clin Gastroenterol 2010;24:143–55. 15. Sanjay P, Yeeting S, Whigham C, et al. Management guidelines for gallstone pancreatitis. Are the targets achievable? JOP 2009;10:43–7. 16. Raja RA, Schmiegelow K, Albertsen BK, et al. Asparaginase-associated pancreatitis in children with acute lymphoblastic leukaemia in the NOPHO ALL2008 protocol. Br J Haematol 2014;165:126–33. 17. Chen CF, Kong MS, Lai MW, et al. Acute pancreatitis in children: 10year experience in a medical center. Acta Paediatr Taiwan 2006;47: 192–6. 18. Park AJ, Latif SU, Ahmad MU, et al. A comparison of presentation and management trends in acute pancreatitis between infants/toddlers and older children. J Pediatr Gastroenterol Nutr 2010;51:167–70. 19. Pezzilli R, Morselli-Labate AM, Castellano E, et al. Acute pancreatitis in children. An Italian multicentre study. Dig Liver Dis 2002;34:343–8. 20. Lautz TB, Chin AC, Radhakrishnan J. Acute pancreatitis in children: spectrum of disease and predictors of severity. J Pediatr Surg 2011;46:1144–9. 21. Stringer MD. Pancreatic trauma in children. Br J Surg 2005;92:467–70. 22. American Gastroenterological Association (AGA) Institute on ‘‘Management of Acute Pancreatits’’ Clinical Practice and Economics Committee; AGA Institute Governing Board. AGA Institute medical position statement on acute pancreatitis. Gastroenterology 2007;132:2019–21. 23. Spraker HL, Spyridis GP, Pui CH, et al. Conservative management of pancreatic pseudocysts in children with acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2009;31:957–9. 24. Warshaw AL, Rattner DW. Timing of surgical drainage for pancreatic pseudocyst. Clinical and chemical criteria. Ann Surg 1985;202:720–4. 25. Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol 2009;15:38–47. 26. Zerem E, Imamovic´ G, Omerovic´ S, et al. Percutaneous treatment for symptomatic pancreatic pseudocysts: long-term results in a single center. Eur J Intern Med 2010;21:393–7. 27. Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002;235:751–8. 28. Puri SK, Kumar N, Panicker H, et al. Percutaneous catheter drainage in pancreatic pseudocysts. Trop Gastroenterol 1996;17:181–4. 29. Yachha SK, Chetri K, Saraswat VA, et al. Management of childhood pancreatic disorders: a multidisciplinary approach. J Pediatr Gastroenterol Nutr 2003;36:206–12. 30. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–11.
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Prevalence, Natural History, and Outcome of Acute Fluid Collection and Pseudocyst in Children With Acute Pancreatitis Rishi Bolia, Anshu Srivastava, Surender Kumar Yachha, Ujjal Poddar, and Sheo Kumar ABSTRACT Objective: Recent years have witnessed an increase in acute pancreatitis (AP) in children; however, the natural history of acute fluid collection (AFC) and pseudocyst is largely unknown. We evaluated the frequency, clinical characteristics, and natural history of pseudocysts in children with AP. Methods: Children with AP admitted at Sanjay Gandhi Postgraduate Institute of Medical Sciences from 2001 to 2011 were enrolled and studied until complete resolution. Subjects with inadequate follow-up, recurrent AP, and chronic pancreatitis were excluded. Results: Of the 58 children (43 boys, median age 14 [1–18] years) with AP, 34 (58.6%) and 22 (38%) developed AFC and pseudocyst, respectively. No difference in age (12 [4–18] vs 13 [1–16] years), etiology (idiopathic 64% vs 47% and traumatic 27.2% vs 22.2%), and systemic complications (pulmonary [18% vs 11%], renal [22.7% vs 11%], and shock [13.6% vs 10%]) was observed between children with and without pseudocyst. A total of 11 of the 22 subjects with pseudocyst underwent drainage, the commonest symptom requiring drainage being gastric outlet obstruction [n ¼ 5] and infection [n ¼ 2]. The 11 of the 22 children with AP and pseudocyst (size 6.4 [3–14.4] cm) showed spontaneous resolution (disappearance [n ¼ 9] and significant reduction in size [n ¼ 2]) during 110 (25–425) days. Symptomatic pseudocysts requiring drainage were more often secondary to traumatic AP (6/6 vs 2/14 [idiopathic], P ¼ 0.0007) than asymptomatic pseudocysts resolving spontaneously. Overall, only 26.4% (9/34) children with AFC required drainage because of symptomatic pseudocyst. Conclusions: Among children with AP, 58.6% developed AFC and 38% developed pseudocysts. Only patients with symptomatic pseudocyst need drainage, and asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection. Key Words: acute fluid collection, acute pancreatitis, children, prevalence, pseudocyst
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P
ancreatic pseudocyst is defined as a collection of pancreatic juice that persists for >4 weeks, is enclosed by fibrous or granulation tissue, and arises as a consequence of acute or chronic pancreatitis (CP) (1). Pseudocysts have a variable presentation, ranging from a totally asymptomatic to symptomatic states Received December 22, 2014; accepted March 18, 2015. From the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Address correspondence and reprint requests to Surender Kumar Yachha, MD, DM, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India (e-mail: [email protected]). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000800
JPGN
Volume 61, Number 4, October 2015
What Is Known
Natural history of acute fluid collection and pseudocyst in children with acute pancreatitis is largely unknown. Present strategy in adults is to drain only symptomatic pseudocysts, irrespective of size. The applicability of these principles in children is unknown.
What Is New
Among children with acute pancreatitis, 60% develop an acute fluid collection and 40% develop a pseudocyst. Among children with acute pancreatitis and pseudocyst, 40% are symptomatic and require pseudocyst drainage. Children with asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection.
manifesting most often with abdominal pain, vomiting, and fever secondary to cyst infection or jaundice because of the compression of common bile duct. Pseudocysts may also have a catastrophic presentation as sudden-onset anemia with hypotension because of a massive intracystic bleed (2). An increase in the occurrence of acute pancreatitis (AP) in children has been observed in the last decade (3). In addition, there has been a paradigm shift in the management principles of pancreatic pseudocysts. From a size-based approach, the impetus is now on a symptom-based approach in adults (4). Various approaches have been used for drainage of pancreatic pseudocyst, which includes percutaneous radiological drainage, endoscopic drainage, and surgical drainage. There are no studies comparing these modalities with one another, and the choice largely depends upon the availability of expertise at a particular center and pseudocyst location. The information on actual incidence of pseudocyst is, however, scarce (5–8), and there is no literature available regarding the natural history of acute fluid collection (AFC) and pseudocysts in children with AP. Studies in adults have reported 5% to 14.6% incidence of pseudocyst in AP, with spontaneous resolution or decrease in size in 65% to 84.2% of patients (9–11). This information is vital not only for prognosticating children with AP but also for developing an optimal management strategy. The aim of this study was to analyze the incidence, clinical characteristics, risk
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factors for development, and natural course of pancreatic pseudocysts in children with AP.
METHODS An audit of the medical records of children with AP admitted in the Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, from January 2001 to December 2011 was performed. The study was approved by the institutional ethics committee. Patients with CP, recurrent AP (RAP), and those with incomplete medical records were excluded from the study. The diagnosis of AP was based on the presence of 2 of the following: abdominal pain compatible with pancreatitis, serum amylase and/or lipase >3 times the upper limits of normal, and findings of AP on imaging (Philips HD9 Ultrasound System using 3–5 MHz curvilinear transducer or Philips Brilliance 64 Slice CT, Philips, Andover, MA) (12). All of the patients were admitted and managed conservatively with intravenous fluids and analgesics. A complete hemogram, serum electrolytes, liver and renal function tests, and an arterial blood gas analysis were done. Grading of severity of AP was done as per the Atlanta guidelines; patients having organ failure and/or local complications were classified as severe and the remaining as mild (1). Organ failure was defined as follows: respiratory failure as PaO2/FIO2 2 times the upper limit of normal for age or a 2-fold increase in baseline creatinine, and cardiovascular dysfunction as decrease in blood pressure (hypotension) less than the fifth percentile for age or the presence of gastrointestinal bleeding (13). In order to establish the etiology (3), a detailed history regarding antecedent blunt or penetrating trauma, intake of drugs, and infections before the onset of symptoms was taken. If the child was on a drug that is known to cause pancreatitis, then it was attributed to the drug, after exclusion of other causes (14). If the patient had a serum calcium of >11 mg/dL or fasting triglyceride levels of >1000 mg/dL, the etiology was attributed to hypercalcemia and hypertriglyceridemia, respectively. Gallstone pancreatitis was defined as pancreatitis in a child who had gallstones on radiological evaluation (15). An infection was suspected as an etiology of AP if the characteristic features of the infectious agent were present. Structural anomalies causing AP were assessed by imaging whenever applicable. Patients in whom no etiology could be identified were labeled as idiopathic. All patients underwent an abdominal ultrasonography (USG) at admission. A contrast-enhanced computed tomography (CT) scan was performed only for patients with suspected severe pancreatitis or those who failed to show any improvement even after 72 hours of admission. A repeat USG was performed at 4 to 6 weeks of the illness. Patients detected to have a pseudocyst as defined by the Atlanta classifications (1) were thereafter studied by a detailed clinical evaluation and serial USG every 8 to 12 weeks. If at any point of time during the follow-up period the patient developed any symptoms attributable to a pseudocyst, prompt drainage was carried out. Patients’ demographic characteristics, etiology of the pancreatitis, clinical features, management, and clinical course till complete resolution were recorded. Percutaneous catheter drainage (PCD) was the modality of choice at our center because of availability of expertise. All of the procedures were performed by an expert interventional radiologist using ketamine sedation or general anesthesia under USG/CT guidance. The access routes used were the left anterior pararenal space for pseudocysts in the pancreatic tail and transgastric route for access to the body and the lesser sac. Catheters (10.2 F Ultra thane multipurpose drainage catheter [Bloomington, IN] with
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simp-locking loop for transgastric approach and 12–14 F Malecot nephrostomy catheters for nontransgastric approach, Devon Innovations, Bangalore, India) were inserted by the Seldinger technique. Thereafter, catheter drainage output was monitored daily. The catheter was removed when the drain output was 10 mL/day even after 6 weeks of drainage. In such a case, pancreatic ductal anatomy was evaluated using magnetic resonance cholangiopancreatography (MRCP)/endoscopic retrograde cholangiopancreatography (ERCP), and additional interventions were performed based on the findings. Intergroup comparison was done between patients who developed a pancreatic pseudocyst and those who had no pseudocyst to determine the risk factors for pseudocyst development. Patients with pseudocyst who required drainage were compared with patients in whom no drainage of pseudocyst was required.
Statistical Analysis Statistical analysis was performed using SPSS version 17.0 (SPSS Inc, Chicago, IL). Data was presented as median (range) and percentages. Mann-Whitney U test was used to compare continuous variables and Fisher exact test to compare discrete variables. A P < 0.05 was considered significant.
RESULTS Eighty-seven children (61 boys, median age 12 [1–18] years) with AP presented during the study period. Of them, 29 children were excluded (underlying CP [n ¼ 6], RAP [n ¼ 19; pancreas divisum ¼ 3, gallstone ¼ 1, choledochal cyst ¼ 1, idiopathic ¼ 14], no follow-up after discharge [n ¼ 4]). Thus, 58 children (43 boys, median age 14 [1–18] years) were included in the final analysis. They were followed up for a median duration of 5 (2–47) months after discharge from hospital. Of these patients, 66% (38/58) had severe pancreatitis: systemic complications in 23 (Table 1), local complications in 32 (pseudocyst 22 and pancreatic necrosis 10). Overall, of these 38 patients with severe AP, 17 (44.7%) had both local and systemic complications, 15 (39.4%) had only local complications, and 6 (15.7%) had only systemic complications. The remaining 20 patients (34.4%) had mild pancreatitis. Of 58 patients, 34 (58.6%) had an AFC at presentation. Of these, 22 patients developed a pseudocyst on follow-up USG at 40 (32–54) days, and in the remaining 12 patients, there was resolution of the AFC (Fig. 1). The majority (19/22 [86.3%]) of the patients had a single pseudocyst, and 3 patients (13.6%) had multiple pseudocysts (2 in 2 patients, 3 in 1 subject). The most common location of the pseudocyst was in the body (n ¼ 10) followed by the head (n ¼ 9) and tail (n ¼ 7) of pancreas. The median size of the pseudocysts was 6.4 (3–16) cm. There were no differences in age, etiology, and systemic complications in patients with and without a pseudocyst as shown in Table 1. As expected the patients with pseudocysts had a significantly longer duration of hospital stay. The likelihood of development of AFC, evolution into pseudocyst, and need for drainage according to etiology of AP is shown in Table 2. Of the 22 patients with a pseudocyst, 11 required drainage, 9 being symptomatic (gastric outlet obstruction [early satiety, postprandial fullness, and vomiting n ¼ 5], persistent pain [n ¼ 1], www.jpgn.org
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Prevalence, Natural History, and Outcome of AFC and Pseudocyst
TABLE 1. Comparison between patients of AP with and without pseudocyst
Age, y (median with range) Sex (M:F) Etiology (%) Trauma Idiopathic Drugs Infections Gallstones Symptoms (%) Pain in abdomen Nausea/vomiting Jaundice Systemic complications (%) Respiratory failure Renal failure Gastrointestinal bleeding Shock Hospital stay
Pseudocyst (n ¼ 22)
No pseudocyst (n ¼ 36)
P
12 (4–18) 16:6
13 (1–16) 27:9
0.27 0.41
6 (27.2) 14 (63.6) 1 (4.5) 0 (0) 1 (4.5)
8 (22.2) 16 (47) 5 (14) 3 (8.3) 4 (11.1)
0.75 0.18 0.39 0.26 0.64
22 (100) 18 (81.8) 0 (0 )
32 (89) 24 (67) 1 (2.7)
0.26 0.24 1.00
4 (18.1) 5 (22.7) 0 (0) 3 (13.6) 22 (8–60) days
4 (11) 4 (11) 0 (0) 3 (10) 11 (5–60) days
0.42 0.27 1.00 0.44 0.04
AP ¼ acute pancreatitis. Etiology of AP was acute viral hepatitis because of hepatitis A virus.
evidence of infection [n ¼ 2], and intracystic bleeding [n ¼ 1]). Two patients were drained because of the large cyst size (6 and 8.5 cm, respectively) and persistence for 7 weeks in the initial years before the treating unit’s policy of draining only symptomatic pseudocysts. Comparison of patients with pseudocyst requiring drainage with those who did not require drainage (Table 3) showed that patients with traumatic pancreatitis and pseudocyst required drainage more often than those with idiopathic pancreatitis and pseudocyst (6/6 vs 4/14, P ¼ 0.03).
87 patients acute pancreatitis Excluded-29 -Chronic pancreatitis-6 -Recurrent-19 -Lost to follow-up-4
Enrolled 58 children
Mild n = 20 (34.5%)
Severe* n = 38 (65.5%)
No AFC n = 6 (15.8%)
AFC n = 32 (84.2%)
Pseudocyst n = 22 (68.7%)
Intervention n = 11(50%)
No pseudocyst n = 10 (31.3%)
No AFC n = 18 (90%)
AFC n = 2 (10%)
Resloved
No intervention n = 11(50%)
FIGURE 1. Flowchart of children with AP showing frequency of AFC/pseudocyst and need of intervention. Severity classified as per Atlanta criteria (1). AFC ¼ acute fluid collection; AP ¼ acute pancreatitis.
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Ten patients underwent PCD of the pseudocyst, and 1 patient underwent an endoscopic cystogastrostomy. No complications in relation to catheter insertion were seen. In 4 patients the catheter was placed transgastric, which was later internalized in 2 of the 4 patients. The median duration of catheter drainage was 34 (19–60) days. PCD-related complications were seen in 2 patients. One patient (1/10, 10%), who had initially sterile pseudocyst fluid, developed a symptomatic infection with fever. Escherichia coli was the organism isolated in this patient. The infection resolved within 7 to 10 days of intravenous antibiotics. In 1 patient the catheter got accidentally displaced and required repeat insertion. PCD failed as a drainage modality in 3 of the 10 (30%) patients (traumatic ¼ 2, gallstone related ¼ 1). All of the 3 patients showed a pancreatic duct–cyst communication (head region in 2 patients and body in 1 patient) on ERCP (n ¼ 2) and CT scan (n ¼ 1). The pseudocysts resolved during a period of 28, 34, and 52 days in these 3 patients after ERCP and endoscopic papillotomy. In the 11 patients with pseudocyst requiring drainage, 1 patient had a recurrence of pseudocyst (4 cm in the tail region) during a median follow-up of 210 (15–510) days. He has remained asymptomatic during a follow-up of 94 days, however, without any increase in size, and no further intervention was performed. Eleven asymptomatic patients with pseudocysts were followed-up, and in 9 (82%) patients (pseudocyst size of 6.4 [3–14.4] cm) the cyst resolved during a median duration of 110 (25–425) days. There was no correlation between cyst size and number of days for complete resolution (r ¼ 0.096). In the remaining 2 patients, the pseudocysts decreased considerably in size (9–3 cm and 7.8–3.5 cm) at the last follow-up of 1 year and 6 months, respectively. Both these patients are asymptomatic on follow-up. None of our patients who were managed on expectant lines had any complications.
DISCUSSION Information about natural history of AFCs and pancreatic pseudocysts in children is limited. Moreover, the available literature is difficult to interpret because patients with pseudocyst following AP or CP are grouped together, and many reports do not differentiate between AFC and pseudocyst. It is well known that the incidence and resolution of pseudocyst differs in AP and CP (10). We have evaluated children with AP and studied them from first presentation to complete resolution and thereafter also for any recurrence. Children with RAP or CP either at first presentation or in follow-up were excluded to have a uniform group. Of our patients with AP, 58.6% (n ¼ 34) developed AFC, which resolved in the first 4 to 6 weeks in 35% and persisted as pseudocyst in 65% of the patients. Maringhini et al (9) reported resolution of AFC in 42% of their 926 adult patients with nonalcoholic AP, which is similar to our observation. Pseudocysts developed in 38% of our patients with AP. Various pediatric studies have shown pseudocysts in 8% to 41% of subjects with AP (5,16,17). Our observation of 38% is on the higher end of the range and could be because of the fact that our center is a tertiary care hospital, and thus we get to admit more of severe cases. The severity of our AP patients is also evident by the much higher frequency of organ failure (40% vs 0%–26.5%) and pancreatic necrosis (17% vs 0%–8%) compared with the other pediatric studies (18–20). In addition, all our patients had a radiological follow-up so we diagnosed all of the patients of pseudocyst even if they were asymptomatic. Only 40.9% (9/22) patients with pseudocyst developed symptoms and required drainage. The commonest symptoms were features of gastric outlet obstruction (n ¼ 5) followed by persistent pain (n ¼ 1). Three patients had complications of infected cyst
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TABLE 2. Natural history of AFC and pseudocyst by etiology of pancreatitis Etiology
Trauma Drugsy Infectionsz Gallstones Idiopathic Total
No. (n) 14 6 3 5 30 58
AFC (%) 11/14 (78.5) 3/6 (50.0) 1/3 (33.3) 2/5 (40.0) 17/30 (56.6) 34/58 (58.6)
Pseudocyst (%)
Pseudocyst requiring intervention
6/14 (42.8) 1/6 (16.6) 0/3 (0.0) 1/5 (20.0) 14/30 (46.7) 22/58 (37.9)
6/14 (42.8) 0/6 (0.0) 0/3 (0.0) 1/5 (20.0) 4/30 (13.3) 11/58 (18.9)
AFC ¼ acute fluid collection. Trauma: ball (n ¼ 3), cycle handle (n ¼ 4), car steering (n ¼ 1), fall (n ¼ 3), and blunt trauma (n ¼ 3). y Drugs: sodium valproate (n ¼ 4) and L-asparaginase (n ¼ 2). z Infections: hepatitis A virus (n ¼ 2) and hepatitis E virus (n ¼ 1).
(n ¼ 2) and intracystic bleeding (n ¼ 1). Available adult literature shows that approximately 30% patients with pseudocysts need drainage because of development of symptoms, pain being the most common (9) Trauma was the commonest etiology in our study and accounted for 27.2% (6/22) of all of the patients with pseudocysts. No etiology significantly predisposed to the formation of a pseudocyst (Table 2). A drainage procedure was required significantly more often in children with traumatic pancreatitis, however, as compared with the other etiologies. This could be because of the higher chances of pancreatic ductal injury with duct-cyst communication and development of symptomatic pseudocyst. The pancreatic duct was evaluated in 2 of the 6 of our patients with traumatic etiology and pseudocysts, and both had duct-cyst communication. Similar to our observation, Stringer (21) in his series on pancreatic trauma found that all of the children with ductal injury developed a symptomatic pseudocyst requiring intervention. The higher proportion of idiopathic patients in our study may be as result of the fact that because of the cost/invasiveness of testing we do extensive workup (MRCP, endoscopic ultrasound (EUS), genetic testing) only in patients with RAP (2 episodes of AP) at our center. There is lack of pediatric guidelines regarding the extent of workup in the first episode of AP, and even adult guidelines do not recommend invasive investigations in this group of young patients (age 6 cm irrespective of symptoms (24), the present strategy is to drain pseudocysts only when symptomatic, irrespective of size. That is why, 2 of our patients seen earlier underwent drainage only on the basis of their size, whereas the later ones were drained only when symptomatic. Our observation confirms the utility of the present recommendation of a symptom-based therapy in children as in adults (10,11), however, and that conservative management is effective even for cysts of >6 cm size and 6 weeks of duration. The available options for pancreatic pseudocyst drainage include endoscopic (transpapillary or transmural) drainage, PCD, or open/laparoscopic surgery. To date, no prospective controlled studies have directly compared these approaches in children. The variation of management is based on local expertise and individual case scenario. The preferred strategy at our center until recently was percutaneous drainage, which was done in 10 patients. There were no procedure-related complications; 10% of patients developed infection, which settled with antibiotics, and 10% had a recurrence. Sepsis has been reported in 6% to 32% of patients (25–27) and recurrence rate of 30% in adult studies. PCD was successful as a sole modality in 70% patients with the median period of drainage being 32 (19–60) days. This is similar to the success rate of 50% to 80% in various adult studies (25–27); however, patients with both AP and CP have been included in these studies. An underlying ductal disorder (duct cyst communication ¼ 3) was demonstrated in all of our patients who failed PCD. Thus confirming the fact that PCD is best applied to patients with normal ducts, and patients who have pseudocysts communicating with main pancreatic duct should not be subjected to PCD (27,28). These patients are best managed with ERCP and transpapillary drainage with stenting across the duct-cyst communication. This also reaffirms the need of a multidisciplinary approach of www.jpgn.org
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radiological, endoscopic, and surgical intervention in managing children with pancreatic disorders (29). Our study has the limitations of a retrospective study. In addition, because imaging with MRCP/EUS was not done in our patients, we could have missed changes of early CP in a small proportion of our patients. Also, we had more patients with severe pancreatitis in our study so our results may not be representative of the true spectrum of AP in children. A prospective study would be required to verify our results and also to evaluate the effect of the type of fluid collection (acute peripancreatic fluid collection vs acute necrotic collection) on the outcome in view of the revised Atlanta classification (30). To conclude, in children with AP, AFC and pseudocysts are seen in 58.6% and 38%, respectively. Among patients with AP and pseudocyst, only 41% become symptomatic requiring drainage. Pseudocysts developing in the setting of traumatic pancreatitis are more likely to be symptomatic and require drainage. Asymptomatic pseudocysts can be safely followed-up with oral feeding, irrespective of size and duration. Of these, 80% pseudocysts disappear spontaneously whereas the remaining 20% show significant reduction in size. Overall, only 26.4% children with AFC go on to develop symptomatic pseudocyst and need drainage whereas the remaining settle with conservative therapy. Percutaneous drainage is successful in approximately 70% as a sole modality, and assessment of pancreatic ductal anatomy is useful in selecting patients for percutaneous drainage.
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