ORIGINAL ARTICLE: Clinical Endoscopy EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts Shyam Varadarajulu, MD, Tercio L. Lopes, MD, MSPH, C. Mel Wilcox, MD, Ernesto R. Drelichman, MD, Meredith L. Kilgore, PhD, John D. Christein, MD Birmingham, Alabama, USA Background: Although EUS-guided cyst-gastrostomy is increasingly being performed, there are no studies that compare the clinical outcomes and cost-effectiveness with surgical cyst-gastrostomy. Objectives: To compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for the management of patients with uncomplicated pancreatic pseudocysts and to perform a cost analysis of each treatment modality. Design: A retrospective case-controlled study. Setting: A tertiary-referral center. Patients: Consecutive patients with uncomplicated pancreatic pseudocysts managed by surgical and EUS- guided cyst-gastrostomy. Methods: An independent observer blinded to all clinic outcomes matched each patient who underwent a sur- gical cyst-gastrostomy with 2 patients who underwent an EUS-guided cyst-gastrostomy for age, etiology of pan- creatitis, and the size of the pseudocyst. Main Outcome Measurements: Rates of treatment success, complications, and reinterventions; length of postprocedure hospital stay; and cost associated with each treatment modality. Results: Ten patients (6 men; mean age 42.3 years, range 22-65 years) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent an EUS-guided cyst-gastrostomy. There were no significant dif- ferences in demographics, major comorbidities, and clinical characteristics between both cohorts. Although there were no significant differences in rates of treatment success (100% vs 95%, P Z .36), procedural compli- cations (none in either cohort), or reinterventions (10% vs 0%, P Z.13) between surgery versus an EUS-guided cyst-gastrostomy, the mean length of a postprocedure hospital stay for an EUS-guided cyst-gastrostomy was sig- nificantly shorter than for surgical cyst-gastrostomy (2.65 vs 6.5 days, P Z.008). The average direct cost per case for EUS-guided cyst-gastrostomy was significantly less when compared with surgical cyst-gastrostomy ($9077 vs $14,815, P Z .01), which corresponded to a cost savings of $5738 per patient. Limitations: Retrospective, nonrandomized design; patients with pancreatic abscess or necrosis were not eval- uated; a limited sample size and a short duration of follow-up. Conclusions: EUS-guided cyst-gastrostomy should be considered as a first-line treatment approach for patients with uncomplicated pancreatic pseudocysts, because the procedure is cost saving and is associated with a shorter length of a postprocedure hospital stay when compared with surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities. (Gastrointest Endosc 2008;68:649-55.) Management of pancreatic pseudocysts has tradition- ally been surgical. 1-3 More recently, transmural endoscopic drainage of pancreatic pseudocysts has been increasingly accepted as a minimally invasive alternative to surgical drainage, with good clinical outcomes in patients in whom it is technically successful. 4-6 The procedure entails the creation of a fistula between the pseudocyst and the Abbreviations: CBD, common bile duct; DPEJ, direct percutaneous jeju- nostomy; IV, intravenous; PFC, peripancreatic fluid collections; UAB, University of Alabama at Birmingham. See CME section; p. 731. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.02.057 www.giejournal.org Volume 68, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 649