Systematic review comparing endoscopic, percutaneous and surgical pancreatic pseudocyst drainage

Table 1 Definition of peri-pancreatic fluid collections according to the revised Atlanta's classification

Name of the collection	Definition
Onset < 4 wk after initial attack
Acute peripancreatic fluid collection	Fluid collections that develop in the early phase of pancreatitis. They do not have a well-defined wall, are homogeneous, are confined by normal fascial planes in the retroperitoneum
Acute necrotic collection	A collection containing variable amounts of fluid and necrotic tissue without a well-defined wall
Onset ≥ 4 wk after initial attack
Pancreatic pseudocyst	A collection of fluid in the peripancreatic tissues surrounded by a well-defined wall and contains no solid material
Walled-of pancreatic necrosis	A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis and has a well-defined inflammatory
Any time after initial attack
Infected necrosis	Presence of superimposed infection of the necrotic pancreas. May be indicated by presence of gas in the collection

Table 2 Characteristics of the included studies

Ref.	Design	Study duration	Follow-up duration1	Interventions	Sample size	Pseudocyst defined	Inclusion criteria or indications for intervention
Varadarajulu et al[8] (United States)	Single center RCT	Jan 2009-Dec 2009	24	EUS vs open cystogastrostomy	20:20	Yes	Pseudocyst > 6 cm and adjacent to stomach
							History of acute or chronic pancreatitis
							Persistent pain
							Complications of pseudocyst
Melman et al[9] (United States)	Single center retrospective	Mar 1999-Aug 2007	9.5	EUS vs laparoscopic vs open cystogastrostomy	45:16:22	Yes	Symptomatic pseudocyst
Varadarajulu et al[10] (United States)	Single center retrospective	Jul 2005-Jun 2007	24	EUS vs Open cystogastrostomy	20:10	Yes	NA
Park et al[11] (South Korea)	Single center RCT	Jan 2004-Dec 2007	25 - 27	EGD ± R-EUS vs EUS	29:31	Yes	Symptomatic pseudocyst > 4 wk
Varadarajulu et al[12] (United States)	Single center RCT	May 2007-Oct 2007	NA	EGD vs EUS	15:15	Yes	Symptomatic pseudocyst > 4 wk
Kahaleh et al[13] (United States)	Single center retrospective	2000-2005	11	EGD vs EUS	53:46	Yes	NA
Morton et al[14] (United States)	National multicenter retrospective	Jan 1997-Dec 2001	NA	Percutaneous vs Surgical drainage	8121:6409	Yes	NA
Heider et al[15] (United States)	Single center retrospective	1984-1995	NA	Percutaneous vs Surgical drainage	66:66	Yes	NA
Adams et al[16] (United States)	Single center retrospective	1965-1991	NA	Percutaneous vs Surgical drainage	52:42	No	Percutaneous drainage: Symptomatic pseudocyst > 5 cm without PD dilation
Lang et al[17] (United States)	Single center retrospective	Jan 1978-Jun 1988	NA	Percutaneous vs Surgical drainage	12:14	Yes	Wall thickness < 3 mm

¹Mean duration of follow-up shown in months. RCT: Randomized controlled trial; NA: Not available; R-EUS: Radial echoendoscope; PD: Pancreatic duct; EGD: Esophagogastroduodenoscopy.

Table 3 Methodological summary of the risk of bias of the included randomized controlled trials

	Random sequence generation	Allocation concealment	Blinding	Incomplete outcome data	Other bias
Varadarajulu et al[8]	Low risk	Low risk	High risk	Low risk	Unclear risk
Park et al[11]	Low risk	Unclear risk	High risk	Low risk	High risk
Varadarajulu et al[12]	Low risk	Unclear risk	High risk	Low risk	Low risk

Assessment of the risk of bias was according to principles of the Cochrane Handbook for systemic reviews of interventions version 5.1.

Table 4 Methodological summary of the risk of bias of the included non-randomized comparative studies

	Selection	Comparability	Outcomes
	(++++)	(++)	(++++)
Melman et al[9]	++		++
Varadarajulu et al[12]	++	+	+++
Kahaleh et al[13]	++		+++
Morton et al[14]	++	++	+++
Heider et al[15]	++	+	++
Adams et al[16]	++		++
Lang et al[17]	++		++

Quality assessment was according to the Newcastle-Ottawa scale for non-randomized trials. +: Higher quality of the studies.

Table 5 Percutaneous vs surgical drainage of pancreatic pseudocysts

Ref.	Sample size	Size (cm)1	Clinical success	Hospital stay (d)1	Reintervention	Mortalities	Adverse events	Bleeding	Intra-abdominal infection
Morton et al[14]	Perc: 8121	-	-	21 (22)2		5.9%2	-	9.64%2	6.8%2
	Surg: 6409	-	-	15 (15)		2.8%	-	8.96%	4.54%
Heider et al[15]	Perc: 66	8.2 (1.1)	42%	45 (5)	50%	9.1%	64%2	9.1%	45.5%
	Surg: 66	7.4 (1.3)	88%	18 (2)	12%	0	27%	4.5%	15.2%
Adams et al[16]	Perc: 52	-	-	36.7	9.5%	2	7.7%	1.9%	1.9%
	Surg: 42	-	-	39.8	19.2%	7.1%	16.7%	4.8%	4.8%
Lang et al[17]	Perc: 26	-	76.9%	-	11.5%	3.8%	3.8%	3.8%	0
	Surg: 26	-	73.1%	-	23.1%	3.8%	0	0	0

¹Values in mean ± SD except otherwise indicated;

²Indicates significant differences between the 2 groups. Perc: Percutaneous drainage; Surg: Surgical drainage.

Table 6 Endoscopic ultrasound vs surgical drainage of pancreatic pseudocysts

Ref.	Sample size	Size (cm)	Clinical success	Hospital stay (d)	Reintervention	Mortalities	Adverse events	Bleeding	Intra-abdominal infection
Varadarajulu et al[8]	EUS: 20	10.5 (9-14.9)1	95%	2 (1-4)13	5%	0	0	0	0
	Open: 20	11 (8.4-14.5)1	100%	6 (5-9)1	5%	0	2%	1	0
Melman et al[9]	EUS: 45	9.1 (0.4)	51.1%2	3.9 (0-25)2	-	0	15.6%	2.2%	0
	Lap: 16	10.4 (0.5)	87.5%	6.9 (3-23)2	-	0	25%	12.5%	0
	Open: 22	9.5 (0.8)	81.2%	10.8 (4-82)2	-	0	22.7%	0	0
Varadarajulu et al[10]	EUS: 20	9.8	95%	2.6 (1-11)23	0	0	0	0	0
	Open: 10	8.9	100%	6.5 (4-20)2	10%	0	0	0	0

¹Values in mean ± interquartile range;

²Values in mean (range) except otherwise indicated;

³Indicates significant differences between the 2 groups. EUS: Endoscopic ultrasound drainage; Lap: Laparoscopic drainage; Open: Open drainage.

Table 7 Endoscopic ultrasound vs esophagogastroduodenoscopy drainage of pancreatic pseudocysts

Ref.	Sample size	Size (cm)1	Clinical success	Hospital stay (d)	Reintervention	Mortalities	Adverse events	Bleeding	Intra-abdominal infection
Park et al[11]	EUS: 31	8.2 (3.8)	89%	-	6.5%	0	7%	3.2%	-
	EGD: 29	7.4 (4)	86%	-	6.5%	0	10%	6.9%	-
Varadarajulu et al[12]	EUS: 15	6.5 (5-12)2	100%5	2 (1-9)2	-	0	0	0	-
	EGD: 15	7 (4.2-13)2	33%4	1 (1-8)2	-	6.7%	13.3%	13.3%	-
Kahaleh et al[13]	EUS: 46	8.6 (4-20)3	84%	-	10.9%	0	19.6%	4.3%	8.7%
	EGD: 53	9.5 (3-20)3	91%	-	9.4%	0	18.9%	1.9%	7.5%

¹Values in mean ± SD;

²Values in mean (interquartile range);

³Values in mean (range);

⁴Values in median (range) except otherwise indicated;

⁵Indicates significant differences between the 2 groups. EUS: Endoscopic ultrasound drainage; EGD: Esophagogastroduodenoscopy drainage.