Endoscopic cystogastrostomy during pregnancy.

Pancreatic pseudocysts occur as a consequence of acute and chronic pancreatitis or abdominal and surgical trauma. The poorly localized fluid collections of acute pancreatitis can heal spontaneously but in about 10% of cases a pseudocyst will develop.1 In these cases, an initial 4to 6-week period of observation is justified in anticipation of spontaneous resolution or development of a mature wall that will allow safe surgical drainage. After this period, asymptomatic patients with small asymptomatic pseudocysts (<4-6 cm in diameter) can be observed, but symptomatic patients and those with larger lesions should be treated with internal drainage because of an increasing risk of complications.2 A retrospective study confirmed that a significant proportion of the patients may be managed conservatively.3 The pseudocysts associated with chronic pancreatitis develop mainly as a result of a rupture of a branch of the pancreatic duct, thus spontaneous resolution cannot be expected. In most such cases, the pseudocyst should be drained because the risk of serious, potentially fatal complications increases with time.4 For drainage, there are 3 alternatives: surgical, percutaneous, and endoscopic. Currently available data suggest that early success with percutaneous drainage is less than that of surgical or endoscopic techniques, and the frequency of incomplete recovery or recurrence, and even the morbidity and mortality due to the pancreatic pseudocyst, is higher.5 Although controlled, randomized, prospective studies comparing the surgical and endoscopic techniques are lacking, it is currently accepted that surgical decompression should be reserved for patients in whom endoscopic therapy is unsuccessful. Pancreatic pseudocysts that arise during pregnancy are a special situation. Pharmacologic treatments, radiologic examinations, and especially operative interventions must be considered with greater caution. Pancreatic pseudocysts during pregnancy are extremely rare, but treatment is difficult because not only the increased risk to the pregnant woman but also that for the fetus has to be considered. This is the report of the use of endoscopic cystogastrostomy with double straight stents to successfully resolve a pancreatic pseudocyst in a pregnant woman before delivery.