Experience with patients with pancreatic pseudocysts has led the authors to the hypothesis that preoperative evaluation of the pancreatic and bile ducts by ERCP will define those patients who may be inadequately treated by pseudocyst drainage alone without attention to associated pancreatic and biliary ductal abnormalities. In patients with certain ductal abnormalities, the pseudocyst operation was combined with a definitive operative drainage of the pancreatic duct and/or of the biliary tree where appropriate. A prospective evaluation of routine preoperative ERCP was undertaken over a 36-month period in all patients scheduled for operative treatment of pseudocyst of the pancreas. From an initial group of 44 patients with pseudocysts, three patients who had spontaneous regression of the pseudocyst were excluded. ERCP was successful in 39 of the remaining 41 patients. Among 41 operated patients, 24 were admitted with a diagnosis of pseudocyst that arose after an episode of acute pancreatitis, and 17 had chronic pancreatitis with pseudocyst. Nine patients, initially assumed to have acute pancreatitis, were recognized to have chronic pancreatitis on the basis of ERCP findings. Communication with the main pancreatic duct (MPD) was demonstrated in 18 of 41 pseudocysts, and the rate of communication was similar in patients with acute and chronic pancreatitis. Dilatation of the MPD was seen in 23 of 41 patients and was associated with chronic pancreatitis in 21. Dilatation of the common bile duct was found in 12 patients with chronic pancreatitis. The operative plan was altered by ERCP findings in 24 of 41 patients; 22 of the 24 patients had chronic pancreatitis. There were no complications of ERCP. These data suggest that ERCP should be performed in all patients with pseudocysts to establish correct diagnosis and to allow optimal choice of operation.
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