Ans. is 'd' ie. USG and follow up Management of Pancreatic Pseudocyst A pancreatic pseudocyst may resolve spontaneously so it is followed with serial ultrasound studies. Indications of Surgical intervention: (Ref: Bailey and Love 25/e 1145; CSDT 13/e p583; Harrison 17/e p) i) Age of cyst more than 12 weeks without resolution ii) Size of cyst greater than 6 cm. iii) Symptomatic iv) Development of complications (eg. haemorrhage, perforation, g.i. obstruction) But note that these indications for intervention are just a generalization used for teaching the undergraduates. These are not specific indications for interventions. Therapeutic interventions are advised (irrespective of size and duration) when - the pseudocyst is symptomatic or - increasing is size on follow up studies, or - any complication (rupture, hemorrhage, or abscess) arise or - there is suspicion of malignancy. Thus expectant management is adequate (irrespective of size) if the patient is asymptomatic and serial u/s studies show that the cyst is resolving. Surgical methods a) Internal Drainage - most preferred surgical management in uncomplicated pseudocyst is internal drainage. The three options are Cystojejunostomy Cystogastrostomy Cystoduodenostomy Internal drainage can be done either open surgical or laparascopic or by percutaneous catheter-based methods (transgastric puncture and stent placement to create a cystogastrostomy) b) Excision of Pseudocyst - is hardly done and is usually limited to pseudocyst involving the tail of the pancreas. c) External drainage - is done in:? - infected pseudocyst - for immature pseudocyst with thin nonfibrous walls that does not allow safe internal drainage. - in an unstable pt. in whom more complex surgical intervention is precluded. d) Transpapillary pancreatic duct stent : Because pseudocysts often communicate with the pancreatic ductal system, two newer approaches to pseudocyst management are based on main duct drainage, rather than pseudocyst drainage per se. A stent is passed into the pseudocyst through the papilla of Vater. this drainage, paicularly when incomplete, can allow bacteria to enter the pseudocyst and lead to development of an infected pseudocyst. Another transpapillary approach involves placing a stent across the duct defect rather than into the cyst through the defect. By excluding pancreatic juice from the pseudocyst, this bridging intraductal stent may permit the duct disruption to heal and the pseudocyst to resolve without drainage (analogous to the use of common bile duct stents in the setting of a cystic duct leak).