Annals of the Royal College of Surgeons of England (1983) vol.
65
ASPECTS OF PAEDIATRIC SURGERY*
Needle aspiration in the treatment of
pancreatic pseudocyst in childhood
R WINDLE, FRCS
Lecturer in Surgery
D FINLAY, FRCR
Consultant Radiologist
J P NEOPTOLEMOS, FRCS
Senior Registrar in Surgery, Leicester Royal Infirmary
Key words: PANCREAS, PSEUDOCYST; CHILDHOOD; ASPIRATION
Summary
The technique of percutaneous needle aspiration of pancreatic pseudo-
cyst using ultrasound imaging as a guide is reviewed. A modification of
this technique has been used in a child with a post-traumatic pancreatic
pseudocyst.
Introduction
Pancreatic pseudocysts present a therapeutic dilemma. In
children the condition is rare and management is primarily
based upon reported experience with adults. In adults early
drainage is advocated by many surgeons in the belief that
complications arise most frequently during the 4 weeks
following presentation (1). However, at this time the pseudo-
cyst wall is often insufficiently fibrosed to allow a safe visceral
anastomosis to be made (2). Children with pancreatic
pseudocysts are invariably cachectic and unwell and require
early treatment (3).
External drainage, previously unpopular because of the
risk of a chronic pancreatic fistula, has been developed
recently in the form of percutaneous fine needle aspiration
using ultrasound imaging as a guide (4). It is a modification
of this technique which we have used in the treatment of a
child with a post-traumatic pancreatic pseudocyst.
Patient and method
A 13 year old boy had noticed a gradually enlarging
epigastric swelling following a fall at school one month
previously. For one week he had vomited all solid food and
had lost 7 kg in weight. There-was no history to suggest acute
pancreatitis but his serum amylase was raised at 1390 iu/l on
presentation. Ultrasound examination confirmed the pre-
sence of an 8 cm diameter pseudocyst displacing the stomach
downwards. Using local anaesthetic a 20cm 16 gauge teflon
intravenous catheter with needle trocar was introduced
through the anterior abdominal wall into the most super-
ficial part of the pseudocyst. One litre of brown serous fluid
was aspirated and the cannula was removed. The pseudocyst
refilled during the subsequent 10 days and required a second
aspiration at which time the teflon cannula was left in place
overnight to allow complete emptying. Following this the
child's condition improved and there was no further recur-
rence of the cyst.
Correspondence to: Mr R. Windle, Department of Surgery, Clin-
ical Sciences Building, Leicester Royal Infirmary, PO Box 65,
Leicester LE2 7LX.
The Editor would welcome any comments on this paper by readers
* Fellows and Members interested in
submitting papers for consideration for publication
should first write to the Editor
Discussion
Pseudocysts in childhood are commonly due to trauma (3).
Because they are rare, there is no well documented policy for
management and this is usually conducted along the lines
used in the treatment of adult pseudocysts. As many as 50%
of adult pseudocysts may spontaneously regress (5). However
in children the condition is associated with quite severe
systemic upset and pain and this makes early drainage
mandatory (3). Pokorny et al. (3) treated 6 children with
pancreatic pseudocysts by external drainage using firm
rubber or silicone tube drains. The pseudocysts did not recur
in any of these patients, but two patients developed fistulas
which, however, closed spontaneously. In children, the ap-
parent difference in pathogenesis may allow a more rapid
resolution of pancreatic pathology compared with adult
pancreatitis of biliary or alcoholic origin. It has been
suggested that this may reduce the likelihood of pseudocyst
recurrence following drainage procedures (2).
Pancreatic cyst puncture using ultrasound for guidance is
well described in the literature and cysts with diameters of
from 3 to 20 cm have been punctured (4). In a series of 40
patients with pancreatic cysts aspirated with ultrasound
imaging (4) all but 9 resolved after the first aspiration and
the remaining cysts resolved after between 2 and 5 punc-
tures. Long term follow up in 3 of the patients has not
demonstrated a recurrence. However, in this series it was not
stated how many patients had pseudocysts as opposed to true
pancreatic cysts.
In order to reduce the likelihood of recurrence we have
chosen to use an intravenous catheter with needle trocar.
The cyst can be then aspirated and the catheter left in place
to allow complete drainage. This has been well tolerated and
there have been no complications. We therefore feel that this
is a technique which should be considered before internal
drainage of pancreatic pseudocysts, particularly in children.
References
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2 Anderson MC. Management of pancreatic pseudocyst. Am J
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4 Hancke S, Jacobsen C K. Puncture of pancreatic mass lesions.
In: Holm HH and Kristensen JK, (eds). Ultrasonically guided
puncture technique. Copenhagen: Munksgaard, 1980;61-5.
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