A pancreatic pseudocyst is defined as a well-circumscribed, encapsulated collection of homogenous fluid with minimal or no necrotic material, enclosed within a wall of fibrous and granulation tissue lacking an epithelial lining—hence the term "pseudo" cyst [1]. These fluid collections typically arise as a complication of pancreatitis and are more frequently associated with chronic pancreatitis than acute forms. The development of pseudocysts is primarily due to disruption or damage to the pancreatic ducts, often precipitated by etiologies such as biliary calculi or chronic alcohol consumption. This disruption leads to leakage of pancreatic enzymes and fluid, which accumulates and becomes encapsulated over time [2].

Pancreatic pseudocysts are commonly located in the lesser sac but may also extend into adjacent areas such as the paracolic gutters or retroperitoneum, depending on their size and chronicity. Clinically, patients may present with non-specific symptoms such as vague abdominal pain, nausea, vomiting, early satiety, or obstructive jaundice. However, in individuals with a known history of pancreatitis, the presence of a thick-walled, well-defined, fluid-filled lesion near the pancreas on imaging is considered almost pathognomonic of a pancreatic pseudocyst.

Diagnosis is largely radiological, as laboratory findings are generally non-specific and unhelpful in isolation. Ultrasonography (USG), contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) are the primary modalities used for the identification and monitoring of pseudocysts. Occasionally, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may be utilized, especially when diagnostic uncertainty exists or therapeutic intervention is planned [4].

While many pseudocysts resolve spontaneously over time and can be managed conservatively, especially if asymptomatic and smaller than 6 cm, others may enlarge, become symptomatic, or develop complications. These complications include secondary infection, intracystic hemorrhage, rupture into adjacent structures, or pancreatic ductal disruptions, all of which warrant active intervention [3]. Therefore, regular clinical and radiological follow-up is advised, with particular attention to cyst size and symptom progression.

Treatment is tailored to the patient’s clinical profile and the risk-benefit analysis of potential interventions. Minimally invasive approaches are preferred whenever feasible. Ultrasound- or CT-guided percutaneous drainage may be considered in high-risk surgical candidates or in those with infected collections. Endoscopic drainage—either trans gastric or trans duodenal—has emerged as a less invasive alternative with favorable outcomes. Laparoscopic drainage offers another minimally invasive option with the advantages of reduced postoperative pain and quicker recovery. Despite the growing popularity of endoscopic and laparoscopic techniques, surgical drainage remains the gold standard, particularly for large, recurrent, or complicated pseudocysts [5].

An interdisciplinary approach involving gastroenterologists, radiologists, endoscopists, and surgeons is essential for optimal management. The choice of treatment should be guided by the patient's symptoms, cyst characteristics, underlying pancreatic pathology, and overall clinical condition to achieve the best possible outcomes. So, the aim of the present study is to assess the clinical outcomes of various therapeutic approaches employed in the management of pancreatic pseudocysts at our institute.

This prospective observational study was conducted in the Department of General Surgery at a tertiary care center (General Hospital), Ahmedabad, Gujarat. The study population comprised all patients diagnosed with symptomatic pancreatic pseudocysts who were registered and managed at the institution between March 2022 and August 2024. Ethical approval was obtained from the ethics committee of the institution.

Inclusion criteria consisted of male and female patients above 18 years of age with symptomatic pancreatic pseudocysts, managed either conservatively or through interventional procedures. Exclusion criteria included patients below 18 years of age, those unwilling to undergo further management, and patients diagnosed with pancreatic cystic lesions other than pseudocysts.

A total of 40 patients were enrolled using a convenient sampling method. Data collection involved a detailed clinical history and physical examination. Demographic information and relevant clinical parameters were recorded. Routine hematological and biochemical investigations were performed for all patients. Imaging studies included ultrasonography (USG) and contrast-enhanced computed tomography (CECT) of the abdomen to assess pseudocyst morphology, size, extent, anatomical relation to the pancreas, and proximity to the gastrointestinal tract for accessibility.

Based on radiological and clinical assessment, patients were categorized according to the type of pseudocyst and the modality of treatment received—either conservative management or interventional procedures. Interventional approaches included ultrasound-guided percutaneous drainage, endoscopic drainage, and surgical drainage. Indications for surgical intervention included non-resolving symptomatic pseudocysts, enlargement of the pseudocyst beyond 6 cm, wall thickness greater than 6 mm, or the presence of complications such as infection, hemorrhage, or rupture. In cases of endoscopic and surgical drainage, biopsy samples were obtained to confirm the diagnosis.

Collected data were validated and systematically entered into Microsoft Excel spreadsheets. Statistical analysis was performed using standard analytical methods to interpret the results and draw clinically relevant conclusions.

Table 1. Demographic data of study participants

Table 1 summarizes the demographic profile of the study participants. The majority of patients (37.5%) were aged between 31–40 years, followed by 20% each in the 41–50 and 51–60 age groups. A smaller proportion were above 60 years (7.5%), while no cases were reported in individuals aged 20 or below. The study population was predominantly male (82.5%), with females comprising 17.5%.

Table 2. Pancreatic pseudocyst and related characteristics

Alcohol-related pancreatitis was the predominant cause, observed in 70% of cases, followed by biliary causes (12.5%), combined alcohol and biliary etiology (7.5%), idiopathic origin (7.5%), and trauma (2.5%). In terms of management, 62.5% of patients required interventional treatment, while 37.5% were managed conservatively. Among those undergoing intervention (n=25), the most common indication was persistent pain (32%), followed by gastric compressive symptoms (20%). Other indications included infected cysts (12%), sepsis (12%), multiple cysts (12%), obstructive jaundice (8%), and miscellaneous causes (4%). These findings highlight alcohol as the leading etiological factor and emphasize that a majority of cases necessitate intervention, primarily due to persistent symptoms and complications.

Table 3. Types of intervention in pancreatic pseudocyst patients

Table 3 illustrates the distribution of interventional modalities used in the management of pancreatic pseudocysts among 25 patients. Surgical interventions were the most commonly employed, accounting for 68% of cases. Among these, Cystogastrostomy was the predominant procedure (52%), followed by Cystojejunostomy (12%), and a combination of Cystogastrostomy with Cystoduodenostomy in 4% of cases. Ultrasound-guided interventions were performed in 24% of patients, equally divided between aspiration (12%) and percutaneous drainage (12%). Endoscopic procedures were utilized in 8% of cases, with transgastric and transpapillary approaches each contributing 4%. These findings indicate a strong preference for surgical management, particularly Cystogastrostomy, in cases requiring intervention for pancreatic pseudocysts.

Table 4. Complication in various interventions

Table 4 details the complications associated with various interventional procedures for pancreatic pseudocyst. Among patients who underwent USG-guided drainage (n=6), the most frequent complication was recurrence (4 cases), followed by pleural effusion (2 cases), and sepsis with multi-organ dysfunction syndrome (MODS) leading to 1 mortality. In the endoscopic group (n=2), one patient developed sepsis with MODS, resulting in mortality. Among the surgical cases (n=17), cystogastrostomy (n=13) was associated with 2 recurrences, 1 case of bleeding, and 1 case of sepsis with MODS, the latter resulting in mortality. In cystojejunostomy (n=3), there was 1 recurrence, while no complications were reported in the single case that underwent combined cystogastrostomy and cystoduodenostomy. Overall, complications were observed across all modalities, with recurrence being most common in USG-guided procedures, while sepsis-related mortality occurred in both endoscopic and surgical groups.

Table 5. Comparison of complications of USG versus Surgical intervention

Table 5 compares the complication rates between USG-guided drainage and surgical intervention in pancreatic pseudocyst management. Out of 6 patients who underwent USG-guided drainage, 5 (83.3%) experienced complications. In contrast, among 17 patients who received surgical intervention, complications were noted in 5 cases (29.4%). This comparison indicates a significantly higher complication rate associated with USG-guided procedures compared to surgical management.

Figure 1. Comparison of complications of USG versus Surgical intervention

Table 6. Comparison of complications of Endoscopic versus Surgical intervention

Table 6 presents a comparison of complication rates between endoscopic and surgical interventions for pancreatic pseudocyst. Among the 2 patients who underwent endoscopic drainage, 1 (50%) developed complications. In comparison, complications were observed in 5 out of 17 patients (29.4%) who underwent surgical drainage. These findings suggest that while both modalities carry risks, the complication rate was higher with endoscopic drainage in this cohort. However, the small sample size in the endoscopic group limits the generalizability of this comparison.

Figure 2. Comparison of complications of Endoscopic versus Surgical intervention

Table 7. Recurrence of Pancreatic Pseudocyst in Conservative versus Interventional Management

Table 7 compares the recurrence rates of pancreatic pseudocysts among patients managed conservatively versus those who underwent various interventional procedures. Among patients treated conservatively, 46.6% (7 out of 15) experienced recurrence. Recurrence was notably high in those managed with USG-guided percutaneous drainage, with 100% (3 out of 3) of patients affected. USG-guided aspiration showed a recurrence rate of 33.3%, whereas no recurrences were observed in the endoscopic drainage group (0 out of 2).

In contrast, surgical drainage had the lowest recurrence rate among interventional modalities, with 17.6% (3 out of 17). These results suggest that surgical and endoscopic interventions are more effective in minimizing recurrence compared to conservative and USG-guided approaches.

This prospective observational study was conducted at a tertiary care hospital from March 2022 to August 2024, including a three-month follow-up period. The primary aim was to assess the clinical presentation, management modalities, complications, and recurrence rates of pancreatic pseudocyst (PPC), comparing conservative versus interventional approaches.

The study revealed that the majority of patients were between 31–40 years (37.5%), followed by the 41–50 and 51–60 age groups (20% each). These findings align with Sreenivasulu et al. [6], who also reported a concentration of cases between the third and fifth decades of life. This age range corresponds with peak incidence of alcohol consumption and biliary pathology, the predominant etiologies of pancreatitis.

A significant male predominance was observed (82.5% male vs. 17.5% female), similar to the findings by Maureen G et al. [7], who reported 93.54% males. This is likely due to the higher prevalence of alcohol use among males in the studied population.

Alcohol was the leading cause of PPC in 70% of patients, followed by biliary pathology in 12.5%. A mixed etiology (alcohol + biliary) accounted for 7.5%, while trauma and idiopathic causes made up the remaining 10%. These trends are consistent with Rasch S et al. [8] and Walt AJ et al. [9], who also reported alcohol-related pancreatitis as the leading cause of pseudocyst formation. One patient with dual etiology died despite endoscopic drainage, and another post-traumatic case required surgery after conservative treatment failed, underscoring the complexity of such presentations.

In our study, 15 patients (37.5%) were managed conservatively, while 25 (62.5%) underwent interventional procedures. Conservative management was employed in patients with small cysts (<6 cm), thin walls, and no compressive symptoms. However, this group showed the highest recurrence (46.6%) and lower resolution rates. These outcomes are similar to those in studies by Almaiman et al. [10] and Usman et al. [11], which support conservative management for selected cases but emphasize a high failure rate.

Intervention was indicated in cases with persistent pain (32%), compressive symptoms (20%), sepsis (12%), jaundice (8%), multiple cysts (12%), and cyst–duct communication (4%). These indications mirror those reported by Rasch S et al. [12] and Parks WR et al. [13].

Three main interventions were performed: USG-guided drainage, endoscopic drainage, and surgical procedures.

• USG-Guided Drainage: Performed in 6 patients (15%), with aspiration or percutaneous drainage, often in emergency settings. Complications occurred in 83.3% of cases, and recurrence was noted in 66.6%. Lerch MM et al. [14] also observed significant complication and recurrence rates with percutaneous methods.
• Endoscopic Drainage: Used in 2 patients (5%). One patient underwent transmural drainage and the other transpapillary drainage. While no recurrences were seen, one patient developed multi-organ failure and died post-procedure. These findings suggest that although minimally invasive, endoscopic approaches are not without risk and depend heavily on operator expertise.
• Surgical Drainage: The most common intervention, used in 17 patients (42.5%). Most underwent cystogastrostomy, with a few undergoing cystojejunostomy or combined procedures. These patients had mature cyst walls (>6 mm) and underwent elective surgery. Complication rate was 29.4%, and recurrence was 17.6%. These figures are consistent with global literature that supports surgery as the definitive treatment with the lowest recurrence.

Ultrasonography (USG) was the initial modality in all cases. CECT was performed in most patients, except for five with renal dysfunction. CECT was critical for defining pseudocyst morphology and guiding management. EUS was used for those undergoing endoscopic drainage. Agalianos C et al. [15] supported this sequence, with USG offering initial screening and CECT or EUS providing more definitive characterization.

Wall thickness influenced management choice. Thin-walled cysts (<6 mm) were managed conservatively or with USG-guided drainage, while thick-walled cysts (>6 mm) underwent surgery. Surlin V et al. [16] also advocated for surgical management in mature pseudocysts due to the low likelihood of spontaneous resolution.

Elevated serum amylase and lipase were common in patients requiring intervention, particularly in emergency cases. However, their predictive value is limited due to variability in enzyme levels, as noted by Pezilli et al. [17].

Early enteral feeding was initiated within 48–72 hours for conservatively and percutaneously treated patients, and by postoperative day 4–5 in surgical cases. Two patients who underwent surgery were able to tolerate feeding by day 3. These findings support Tyberg A et al. [18], who emphasized the role of early nutrition in reducing infection and enhancing recovery.

Surgical site infection occurred in 23.5% of surgical cases, all managed successfully. Secondary closure was effective in patients with septic presentations, minimizing long-term morbidity. Recurrence was highest in conservatively managed patients (46.6%), followed by USG-guided drainage (66.6%), and lowest in surgical drainage (17.6%). These findings are consistent with Boerma D et al. [19], who reported recurrence rates of 40% with conservative management versus 10% with surgical treatment.

Pancreatic pseudocysts require timely identification, classification, and intervention to reduce complications, though mortality may not always be preventable. Predominantly affecting males aged 31–40 years, alcohol remains the leading cause. Persistent abdominal pain is the most common presenting symptom. CECT is the preferred diagnostic tool, while small, uncomplicated pseudocysts can be managed conservatively. Larger, symptomatic or complicated cysts require intervention—surgical drainage remains the most definitive approach with lower recurrence. Endoscopic and ultrasound-guided drainages are emerging alternatives with varying success. Timely management of complications and early nutritional support improve outcomes. Patient counselling and rational resource use are essential for optimal care. Treatment should be individualized, based on clinical status, cyst characteristics, and available expertise.

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