Internal drainage of infected pancreatic pseudocysts: safe or sorry?

Background: External drainage is the traditional surgical therapy for infected pancreatic pseudocyst, although associated with high morbidity and mortality rates. In this study it was determined whether internal drainage is feasible with acceptable postoperative morbidity and recurrence rates.
Methods: A retrospective comparison was made of the outcome of internal versus external drainage of infected pseudocysts in 15 patients. All patients were known to have a (sterile) pseudocyst and presented with symptoms suggestive of infection of the cyst, proven by positive cultures and Gram staining.
Results: Internal drainage was performed in 8 and external drainage in 7 patients. Patient characteristics appeared comparable, as was the time of sterile cyst presence before infection occurred (6 and 9 weeks, respectively). No major complications occurred, although hospital stay was prolonged after external drainage due to development of pancreaticocutaneous fistulas along the drain tract in 4 patients. Enteric microorganisms were cultured in 11 patients, of whom 10 had undergone ERCP just prior to infection. During follow-up no pseudocyst recurred.
Conclusion: Surgical internal drainage of an infected pseudocyst is safe and effective and, in selected patients, is first-choice treatment. ERCP seems to play an important role in the secondary infection of pseudocysts.