What is the optimal treatment for pancreatic pseudocysts?

We commend Heinzow et al. for an interesting original article about the evaluation of technical results and clinical outcome rates of the singlestep versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts (PPC) of >4 cm size [1]. In a retrospective design of the study, they compared the results of 16 patients with PPC who had undergone single-step EUSguided transmural drainage with a cohort of 22 patients who had undergone multi-step EUSguided transmural drainage of PPC. Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the singlestep group compared with 62 ± 12 min for the multi-step access (p < 0.001). They concluded that the use of single-step cystostomy appears useful in managing selected patients with symptomatic PPC as it is effective and time-saving. We congratulate the authors for their excellent results and low complication rate, without major complications.However,wewish to highlight certain issues regarding the design and discussion section of the study. It is very surprising that the authors compared the clinical outcome and procedure time between singleand multi-step groups because they are very similarmethods to achieve the clinical outcomes and it is clear that multi-step procedure must last longer. The recovery of disrupted pancreatic duct has been recognized as the main prognostic factor for successful treatment of PPC regardless of the treatment used. We believe that prolonged catheter drainage leads to the recovery of pancreatic duct and resolution of PPC in majority of cases regardless of the type of drainage performed, i.e., percutaneous or endoscopic. In the introduction and discussion section, authors specified that surgery has been the therapy of choice in the treatment of symptomatic PPC for many years. However, this treatment involves considerable surgical trauma and general anesthesia, accompanied by substantial morbidity and mortality [1]. In Figure 1, the authors specified that several pseudocyst recurrences were treated by percutaneous catheter drainage (PCD). However, PCD was not discussed as an alternative method in the treatment of PPC despite the fact that several reports evaluated the efficacy of percutaneous management of PPC, with good results [2–7]. Besides, PCD is performed in local anesthesia and with procedure time between 5 and 15 min, only. It is true that the advantage of endoscopic approach is that it creates a permanent pseudocysto-gastric track, with no spillage of pancreatic enzymes in contrast to PCD, thereby reducing the risk of formation of pancreatico-cutaneous fistulas. However, in the case of infective complications or other drainage problems, the monitoring, catheter manipulation and the analysis of cystic content are very difficult or impossible with endoscopic, unlike with PCD approach.