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Introduction: Previous reports have concluded that endoscopic drainage (endo) of pancreatic pseudocysts has an advantage over surgical cystgastostomy (open) in terms of both costs and morbidity. No study to date has looked longitudinally at the overall benefit of these two strategies. The purpose of our study was to compare 2-year resource utilization and morbidity between endo and open treatment of pancreatic pseudocyst.
Methods: This study is a single center retrospective case review of patients treated between September 2004 and December 2011 for pancreatic pseudocyst. We extracted clinical data from the initial procedure related admission along with post-procedure emergency department (ED) visits and hospital readmissions for up to two years. We calculated a composite morbidity scale ranging from 1) no intervention to 2) minor intervention (antibiotics), 3) readmission, 4) repeat procedure or ICU care, to 5) death. Fisher's exact tests, t tests and Mann-Whitney U tests were used to compare characteristics between the two groups where appropriate.
Results: We identified 45 patients who had undergone drainage procedures, 17 endo and 28 open. Three endo patients who required conversion to open were classified as endo by intention to treat. Median follow up for the study was 24 months. The two groups had similar etiologies, age, gender and clinical risks (table). The open group had more multicysts and cysts with debris on imaging, but not significantly so. There was a trend toward more gastric varices in the endo group (29.4% vs. 7.1%, P=.09) but venous thromboses were similar in both groups (58.8% vs. 57.1%). While initial morbidity was higher in the open group, readmission occurred more than twice as often in endo patients (70.6% vs. 32.1%, P=.02) and total 2-year hospital days did not differ significantly in the two groups (p=0.23). There was a trend towards increased procedural readmissions in the endo group (p=0.07). In the open group, two patients required subsequent repair of ventral hernias and one patient required two surgeries for postoperative variceal bleeding. In the endo group three patients required repeat percutaneous drainage and one required repeat endo drainage in addition to the three conversions to open mentioned above.
Conclusions: While endoscopic drainage of pancreatic pseudocysts may result in less initial procedure related morbidity and length of stay, it is associated with increased readmissions, increased procedure related admissions due to treatment failure and does not provide significant benefit in overall hospital days when compared to surgical drainage. Further studies are necessary to select which patients are optimal candidates for each approach.
Patient Characteristics, Imaging and Outcomes

Variable	Endo	Open	P-value
No. Patients	17	28
Male/Female	11/6	20/8	0.74
Mean age, y (S.D.)	47.2 (11.3)	50.3 (13.7)	0.42
Current Smoker, Diabetes, COPD and/or Cardiac History	13 (76.5%)	25 (89.3%)	0.40
Etiology			1.00
Anatomic	8 (47.1%)	14 (50.0%)
EtOH	8 (47.1%)	11 (39.3%)
Other (HLD/Trauma)	1 (5.9%)	3 (10.7%)
Imaging
Venous Thrombosis	10 (58.8%)	16 (57.1%)	1.00
Gastric Varices	5 (29.4%)	2 (7.1%)	0.09
Multiple Cysts	2 (11.8%)	9 (32.1%)	0.29
Debris in Cysts	8 (47.1%)	18 (64.3%)	0.35
Outcomes
Readmitted	12 (70.6%)	9 (32.1%)	0.02
Procedural Readmission(s)	7 (41.2%)	4 (14.3%)	0.07
ED visit(s)	5 (29.4%)	3 (10.7%)	0.23
Total Hospital Days Overall, mean (S.D.)	13.6 (18.0)	19.7 (39.7)	0.49
Median Morbidity Score (Interquartile Range)	4 (1.5-4)	2 (1-4)	0.24