Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital. Bologna, Italy
Endoscopy; Endosonography; Follow-Up Studies; Pancreatic Pseudocyst; Pancreatitis, Acute Necrotizing; Pancreatitis, Alcoholic; Pancreatitis, Chronic; Surgical Procedures, Operative
Endoscopic and surgical treatment are the two main techniques for the treatment of pancreatitis, mainly represented by the persistent pain not responding to medical treatment and the complications associated with pain, such as pseudocysts and ductal stenosis. However, the dilemma is related to the procedures we use to treat these complications: surgical or endoscopic approach? Probably the treatment of choice is based on the expertise available in the various centers, but we also need an evidence-based approach. Thus, in 2007 , I commented on the paper of Cahen et al.  with enthusiasm for two reasons: the first was that, for the first time, a comparative study on the long term results of endoscopic vs. surgical treatment of chronic pancreatitis patients was carried out, and the second was that the follow-up period was sufficient to assess the results of the two different treatments, not only from a medical point of view but also considering the patient reported outcomes using the SF-36 questionnaire. For the same reasons, I invite you to read, with attention, the paper of Varadarajulu et al.  reporting the data of the clinical outcomes of EUS-guided cystgastrostomy in comparison to surgical cystgastrostomy for the management of patients with uncomplicated pancreatic pseudocysts; the authors also evaluated the cost analysis of each treatment modality. Unfortunately, this was a retrospective case-controlled study carried out in a tertiary-referral center.
Consecutive patients with uncomplicated pancreatic pseudocysts managed by surgical and EUS guided cyst-gastrostomy were considered. An independent observer blinded to all clinic outcomes matched each patient who underwent a surgical cyst-gastrostomy with 2 patients who underwent a EUS-guided cyst-gastrostomy for age, etiology of pancreatitis and size of the pseudocyst. Ten male patients with a mean age of 42.3 years who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent an EUS-guided cyst-gastrostomy. The authors found no significant differences in demographics, major comorbidities, and clinical characteristics between both cohorts. Regarding the evaluation of the two procedures, there were no significant differences in rate of treatment success (100% for the surgical procedure and 95% for the endoscopic procedure), the absence of procedural complications in the two arms, or reinterventions (10% in the surgical arm vs. 0% in the endoscopic arm). The mean length of a post-procedure hospital stay for a EUSguided cyst-gastrostomy was clearly significantly shorter than for surgical cystgastrostomy (2.7 vs. 6.5 days). The average direct cost per case for EUS-guided cystgastrostomy was significantly less when compared with surgical cyst-gastrostomy, which corresponded to a cost savings of $5,738 per patient. EUS-guided cystgastrostomy should be considered as a first authors did not report the reason why these patients underwent a surgical or an endoscopic procedure and what the time was between the appearance of the pseudocyst and the treatment. Taking into account the etiology of pancreatitis, 60% of patients had idiopathic pancreatitis, 20% alcoholic pancreatitis and the remaining 20% had biliary pancreatitis; the further question is: how many patients studied may have chronic pancreatitis? All these points remain unanswered in the study of Varadarajulu et al. . I agree with the authors that the endoscopic approach is an advantage in debilitated patients and those with prohibitive comorbidities but without the need for general anesthesia and the stress of an open abdominal operation, but more attention should be paid to the different etiology of patients having this complication. The fate of pseudocysts in patients with acute pancreatitis and in those with chronic pancreatitis is different . I believe that this study is useful only for raising the need of further prospective and comparative studies in curing pancreatic complications such as pseudocysts. Future studies on this issue should also take into account the patient’s point of view by using a structured quality of life questionnaire.
The authors have no potential conflicts of interest