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Invited Critique |

The Impact of Laparoscopy and Laparoscopic Ultrasound on the Management of Pancreatic Cystic Lesions—Invited Critique

Edward L. Bradley, MD
Arch Surg. 2000;135(3):264. doi:10.1001/archsurg.135.3.264.
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Schachter and his coworkers have presented us with a small but intriguing prospective study of the value of LAPUS in assigning a specific diagnosis to lesions previously diagnosed by conventional imaging techniques as "pancreatic pseudocysts." In their series, 6 of 15 patients were significantly impacted by the additional information provided by laparoscopic ultrasound.

This article directly addresses a currently vexing clinical problem—how to make a precise diagnosis of pancreatic pseudocysts. Despite modern imaging techniques, including CT scanning, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and EUS, a definitive diagnosis of pseudocyst may not be possible. In fact, as many as 15% of "pancreatic pseudocysts" diagnosed by conventional imaging are actually cystic neoplasms. Moreover, when other lesions of the pancreas capable of successfully masquerading as "pseudocysts," such as postnecrotic collections (necromas), cavitated tumors, and rare benign cysts are considered, the potential diagnostic error approaches 20%. It is possible, therefore, that each general surgeon over the course of a career could mistreat one of these lesions under the misdiagnosis of "pseudocyst," if internal drainage were performed. The consequences of maltreatment range from disastrous in the case of a cystic malignancy to recurrence, depending on the precise lesion present.

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