Oria et al nicely describe the essential elements for successful internal drainage of giant acute pancreatic pseudocysts: removal of necrotic tissue from the pseudocyst cavity and establishment of dependent drainage. It is presumably due to the lack of dependent drainage of the pseudocyst cavity that the complication rate following cystgastrostomy is as high as 50% in these patients.1 Even when dependent drainage is established, the failure to debride necrotic material in conjunction with an enteric communication can lead to life-threatening retroperitoneal sepsis as was experienced by the authors prior to their introduction of video-assisted debridement. Oria et al allude to the Atlanta International Symposium classification system for acute pancreatitis2 that attempts to provide a rational terminology for the protean morphologic manifestations of acute pancreatitis. While the definitions adopted by the Atlanta International Symposium are helpful for descriptive purposes, in reality the surgeon is faced with a spectrum of changes along an evolving process of tissue destruction, sequestration, and resorption. In an individual patient, there may be elements of a pseudocyst and pancreatic necrosis or even a pancreatic abscess. While some pseudocysts are truly round fluid collections without any solid component, others are a stew of solid and liquid components as is illustrated by the case depicted in Figure 2 in the Oria et al article. Because it is very difficult to know in advance whether a pseudocyst is purely fluid or not, exploration of the cyst cavity and debridement is an essential aspect of therapy. Video-assisted debridement can be combined with open surgery, laparoscopic surgery, or even endoscopic approaches. Whatever access route is chosen to drain the pseudocyst, the surgeon or endoscopist must have the capability to carry out adequate debridement.
Rattner DW. Internal Drainage of Giant Acute Pseudocysts—Invited Critique. Arch Surg. 2000;135(2):141. doi:10.1001/archsurg.135.2.141