Randomized Trial Comparing EUS and Surgery for Pancreatic Pseuodocyst Drainage

Background: Although EUS-guided cystogastrostomy is increasingly performed, surgery is still considered the gold standard technique for management of pancreatic pseudocysts (PC). AIM: Compare treatment outcomes, quality of life (QOL) and costs between EUS and surgery for pancreatic cystogastrostomy.

Methods: Symptomatic patients with PC measuring >6cm in size were randomized to undergo EUS-guided or surgical cystogastrostomy. Pancreatic abscess or necrosis, multiple PC and those PC located distant from the stomach were excluded. The primary endpoint was PC recurrence at 18 months. The secondary endpoints were pain pattern (measured by brief pain inventory), quality of life (assessed by SF-36), total costs, length of post-procedure hospital stay (LOS), complications and reinterventions at end of follow-up. Treatment success was defined as symptom relief without need for repeat intervention during follow-up.

Results: Of 96 screened patients, 40 met inclusion criteria and underwent randomization, 20 to EUS and 20 to surgery. There was no difference in patient demographics, clinical presentation, pseudocyst size, rates of technical (both cohorts, 100%) or treatment success (95% vs. 100%, p=1) and procedural complications (none in both cohorts) between EUS and surgery, respectively. At a median follow-up of 18 months, there was no difference in rates of PC recurrence (0% vs. 5%, p=1) or reinterventions (5% vs. 0%, p=1) between EUS and surgery, respectively. Although there were no long-term differences, when compared to surgery, the average scores for pain (3.3 vs. 1.5, p=0.009), interference of general activity (4.9 vs. 2.3, p=0.007) and mood (4.1 vs. 1.7, p=0.005) were significantly better at 1 week for the EUS cohort. Compared to surgery, the mean QOL scores for general health (50.4 [SD=19.7] vs. 71.4 [19.7], p=0.007), general vitality (47.1 [14.5] vs. 63.8 [12.5], p=0.004) and physical function (57.2 [27.9] vs. 80 [23.9], p=0.008) were significantly better for EUS from post-procedure and up to 3 months. After 3 months, the improvement in QOL was similar between both groups. Compared to surgery, the median LOS (6 vs. 2 days, p<0.0001) and average costs ($22.475 vs. $8110, p<0.0001) were significantly less for EUS-guided cystogastrostomy.

Conclusions: EUS-guided cystogastrostomy should be the preferred treatment approach for patients with uncomplicated symptomatic pancreatic pseudocysts as the procedure is less costly, yields quick pain relief, is associated with shorter length of hospital stay and has long-term clinical outcomes and quality of life comparable to that of surgery.