Excision Of Cyst Research Articles

Malignant proliferating trichilemmal tumor in male: A rare case entity with diagnostic dilemma

Abstract Trichilemmal tumor is a rare hair follicle tumor that is, thought to occur from a malignant transformation of a benign trichilemmoma. The tumor develops from the outer root sheath of the hair follicle. The patient underwent a wide local excision with 1 cm clear margin. The defect was covered by split thick skin graft harvested from ipsilateral thigh after consulting the plastic surgery department. Trichilemmal cyst can be misdiagnosed as other cutaneous lesions. Like in our case, initial FNAC was suggestive of a epidermoid cyst but post excision Histopathological examination gave us the real picture of a trichilemmal tumor. Recurrent tumors are very rare and can get misdiagnosed as squamous cell carcinoma. Malignant proliferating trichilemmal tumors are rare cutaneous tumors that are very rare in males. These tumors can be misdiagnosed as squamous cell carcinoma and require external stimuli for malignant conversion from benign counterparts. Wide local excision is sufficient for treatment.

Case Series: Spinal Cord Stimulator Therapy Alleviates Neuropathic Pain in Patients with Failed Back Surgery Syndrome in the Setting of Spinal Cord Injury

BACKGROUND: Spinal cord stimulation (SCS) is a minimally invasive neuromodulation treatment modality primarily indicated for failed back surgery syndrome (FBSS). When FBSS occurs in the setting of spinal cord injury (SCI) it can often be refractory to treatment with opioids and anticonvulsants; in such cases, SCS has demonstrated promising results. Here, we present a case series of 2 patients with FBSS in the setting of SCI who received pain relief with SCS therapy. CASE REPORT: Our first patient is a 49-year-old man with a history of SCI (T10-11) with resulting paraplegia, who presented after failure of conservative management of his neuropathic abdominal and lumbar back pain with radiculopathy to the right groin. Our second patient is a 50-year-old man with a history of insulin-dependent diabetes mellitus, coronary artery disease, and thoracic arachnoid cyst excision, who presented for treatment of worsening intractable neuropathic pain in his thorax, abdomen, and midback. Both patients received SCS therapy with significant improvement in their neuropathic pain. CONCLUSION: By delivering targeted electrical stimulation to the spinal cord, SCS can improve the pain resulting from FBSS. Recent literature has highlighted the successful use of SCS in alleviating neuropathic pain following SCI; our case series further adds to the literature supporting the use of SCS in this pain setting. SCS continues to offer chronic pain physicians alternative, effective options for patients suffering from FBSS in the setting of SCI. KEY WORDS: Spinal cord stimulator, failed back surgery syndrome, spinal cord injury, neuropathy

Cytomegalovirus esophagitis associated with arytenoid cyst in an immunocompetent host

CMV esophagitis is usually encountered in immunocompromised individuals and esophagus is rarely affected in immunocompetent individuals. CMV esophagitis associated with arytenoid cyst has not yet been reported in literature to the best of my knowledge and can be considered in case of recurrence of cyst following excision. The objective of this study is to report the unique presentation of CMV in an immunocompetent patient. A middle-aged immunocompetent lady presenting with dysphagia was diagnosed to have arytenoid cyst. Biopsy from upper esophagus revealed cytomegalovirus inclusion bodies and immunological test were performed to confirm the pathology. The cyst excision lead to recurrence. It was excised again followed by a course of intravenous ganciclovir. Currently, the role of antiviral in treatment of CMV esophagitis in immunocompetent individual is not well established. We have obtained good result in this patient with a course of Ganciclovir following excision of the cyst. The rarity of cytomegaloviral upper esophageal involvement, its association with arytenoid cyst and the utility of antivirus in treatment of an immunocompetent host makes this case report unique and interesting.

Autotransplantation for Restoration of Dentition Defects After Excision of Jaw Cysts.

Bone defect caused by jaw cystectomy has always been the main factor affecting postoperative wound healing and is also the common cause of maxillofacial bone defect, which brings challenges to the subsequent restoration of missing teeth. In this paper, the authors report a 22-year-old young woman who had a mandibular cyst in the left lower posterior tooth area. She underwent mandibular bone cyst excision and simultaneous extraction of teeth 36 and 37. One and two months after the removal of the mandibular bone cyst, autologous tooth transplantation was performed in stages from tooth 28 to tooth 36 and from tooth 18 to tooth 37. The case shows that tooth autotransplantation is a viable option for the restoration of dentition defects after the excision of jaw cysts, which can promote the healing of the bone defect after the operation.

Methylene blue for surgical excision of digital myxoid cysts after sonography: Addressing the challenge of identifying the drainage tract

Methylene blue for surgical excision of digital myxoid cysts after sonography: Addressing the challenge of identifying the drainage tract

Common Presentation of Choledochal Cyst in Adult Female – A Case Report

The Choledochal cyst is a rare disease of unknown etiology. Incidence of diagnosis of choledochal cyst is much higher in children (80%) than in adult (20%). It is prevalent among Asian & female populations & the incidence is 1:100000-150000. We are reporting one such case, a 57-year-old female presenting with recurrent pain with right hypochondriac region and investigations revealed type -1 choledochal cyst. This case was managed successfully by complete excision of cyst & Roux-en-Y hepatico-jejunostomy. Sir Salimullah Med Coll J 2023; 31: 120-123

Epidermal inclusion cyst after uneventful small incision cataract surgery: A diagnostic dilemma

Conjunctival cysts are not so uncommon after surgical procedures. They are usually benign in nature and are filled with serous material and mucous. They may be congenital or acquired in origin. Acquired cysts are mostly seen after ocular surgery and trauma. Hereby, we report two cases of conjunctival inclusion cysts following uneventful manual small incision cataract surgery in two elderly females. Both cases were treated by cyst excision and suturing of the scleral tunnel with interrupted sutures was done. An unstable scleral wound may be a contributory factor in the formation of cysts. Hence, we conclude that closure of the scleral tunnel with overlying tenon and conjunctival apposition is a critical step in controlling such complications of cataract surgery.

Treatment of recurrent pilonidal cysts in children: minimally invasive Gips technique

Introduction. Currently, long-term outcomes after surgical treatment of pilonidal disease are not always satisfactory. In particular, relapses can reach 40% by different authors and pose a big problem for operating surgeons. Repeated surgical interventions are technically more complicated, often require extensive excision and often lead to rough scars, which worsen cosmetic results. The minimally invasive Gips method has no abovementioned disadvantages and can be used in pilonidal cyst relapses. Purpose. To assess the Gips surgery effectiveness in relapses of pilonidal cysts in children.Material and methods. 7 children with relapses of pilonidal cysts have been treated with Gips technique in the surgical department of Ivano-Matreninskaya Children's Clinical Hospital (Irkutsk) since January 2020. All surgeries were performed by the generally accepted Gips technique: local infiltration anesthesia with 1% lidocaine solution; fistula excision with a trepan-circular knife and curettage of the pathological cavity. Then, wounds were processed openly with gauze tampons until complete healing.Results. Gender – 71.4% boys and 28.6% girls. The average age is 16.5 years (12–17 years). Previously performed surgical interventions: excision of the pilonidal cyst – 4 and Gips procedure – 3. Restoration of motor activity – on the first day after surgery. Duration of NSAIDs therapy – 2 days after the procedure. No early postoperative complications were registered. The average length of hospital stay – 4.75 days. Complete healing of postoperative wounds – 4.1 weeks, in average. Catamnesis – 9.5 months , in average; early relapses - in one patient (14.3%).Conclusion. Minimally invasive intervention for treating pilonidal cysts by the Gips technique can be used both in primary and recurrent forms of the disease. The discussed technique provides good cosmetic results and has a minimal number of postoperative complications.

Quadrigeminal plate arachnoid cyst presenting with eye movement related migraine: a rare case report

Type II arachnoid cyst of the quadrigeminal cistern is the rarest type of arachnoid cyst (10% prevalence) in adults and is generally asymptomatic. We reported an unusual case of chronic right-sided migraine provoked by right eye adduction, right eye adduction soreness, and dry eye symptoms in a 47-year-old woman with quadrigeminal arachnoid cyst confirmed by radiological findings with the compression of the tectal plate, vermis, and superomedial cerebellum’s part. She was treated conservatively without improvement for 1 year before surgical intervention was conducted. Microsurgery for cyst excision and fenestration was done, followed by immediate relief from all her complaints after 3 months of follow-up. These findings should help clinicians consider surgical intervention for patients with chronic symptoms related to nerve function that have no improvement with the initial treatment.

The impact of pre-operative cholecystostomy on laparoscopic excision of choledochal cyst in paediatric patients.

This aim of this study was to identify the pre-operative risk factors for conversion during laparoscopic excision of choledochal cyst in paediatric patients. A retrospective single-centre study was carried out. All paediatric patients (< 18years) who had undergone laparoscopic excision of choledochal cyst between 2004 and 2021 were reviewed. The outcome was conversion to open surgery and pre-operative factors that affected the conversion rate were analyzed. Sixty-one patients were included. Conversion was required in 24 cases (39.3%). There was no difference in the conversion rate between the first (before 2012, n = 30) and second (after 2012, n = 31) half of the series (36.7% vs. 42.0%, p = 0.674). Majority was type 1 cyst (86.8%) and the median cyst size was 4.6cm (IQR: 2.2-6.4cm). Antenatal diagnosis was available in 18 patients (29.5%). The median age at operation was 23.0months (IQR: 8.0-72.0months). Pre-operatively, 19 patients (31.1%) suffered from cholangitis and 5 (8.2%) of them required cholecystostomy. Comparing patients with successful laparoscopic surgery (L) and converted cases (C), there were no differences in the age at operation (p = 0.74), cyst size (p = 0.35), availability of antenatal diagnosis (p = 0.23) and cholangitic episodes (p = 0.40). However, a higher percentage of patients required cholecystostomy in the converted group (L vs. C = 2.7% vs. 16.7%, p = 0.05). Using logistic regression analysis, it was also a risk factor for conversion (OR = 3.5 [1.37-5.21], p = 0.05). Pre-operative cholecystostomy is a potential risk factor for conversion during laparoscopic excision of choledochal cyst in children.

Pediatric Thoracoscopy: Ten Years Experience in Tertiary Hospital

Purpose: A minimally invasive Thoracoscopic Surgery (TS) offers several options in diagnosis and surgical treatment in pediatric surgery. This study evaluates experience and outcome of thoracoscopic surgery in pediatrics during 10 years period in tertiary hospital. Patients and methods: This retrospective study conducted at King Faisal Hospital and Research Center, Jeddah, Saudi Arabia from 2012 to 2022. Data of 43 patients who underwent TS were enrolled. Data include patient’s demographic characteristics, co-morbidity, diagnosis, type of thoracoscopic procedures, time of intervention, length of hospital stay, post-operative complications. Results: Mean age of patients was 4.99 years. Females were more than males (55.8 vs. 44.2%). Sixteen (37.2%) patients had comorbidities. Thoracoscopic proce- dures were feasible in 43 children and adolescents with chest diseases including lung empyema (20.9%), congenital lobar emphysema (14.0%), interstitial lung disease (14.0%), congenital pulmonary airway malformation (11.6%), mediastinal mass (9.3%), lung metastasis (11.6%), lymphoma (4.7%), chronic inflamma- tions (7.0%), hemothorax (2.3%), bronchogenic cyst (2.3%), pleural effusion (2.3%) and pulmonary sequestration and right diaphragmatic hernia (2.3%). Proce- dures were made mostly for lung biopsy (25.0%), lobectomy (22.7%), decortication (20.9%), mediastinum mass resection (6.8%), lung metastasectomy (6.8%), lymph node biopsy (4.5%), diagnostic (4.6%), cyst excision (4.6%), diaphragmatic hernia repair (2.3%) and thymectomy (2.3%). Duration of hospital stay ranged from 2-180 days. All of the cases had chest drain (100.0%) and some of them required post-operative intubations (30.2%). Conversion rate to open was (4.7%). Complications were pneumothorax (7.0%), bleeding (2.3%) and air leak (2.3%). Conclusions: Thoracoscopic approach is a challenging method for diagnosis and treatment in pediatrics. However, complications were reported as pneumo- thorax, bleeding and air leak. In order to improve results, conversion rates, and the capacity to handle thoracoscopic complications, proper training is crucial.

Prevalence of thyroid gland tissue in midline neck dermoid cysts in children and a proposed new 'thyroglossal entrainment' hypothesis for their formation.

Thyroglossal duct cysts and dermoid cysts both commonly present as midline neck lumps in children. They are treated as separate entities with different embryological origins. There are isolated reports of thyroid gland tissue in a dermoid cyst, concurrent thyroglossal and dermoid cysts, and cysts with mixed histology. It is not known if these are rare or common. All children undergoing excision of a congenital midline neck cyst between January 2017 and December 2022 were identified. Histopathology slides were reviewed in detail. In 53 children, there were 26 thyroglossal duct cysts, 24 dermoids, 1 lymph node and 2 with no diagnostic material identified. Five dermoids (28 per cent) had associated thyroid gland tissue, and 1 (4 per cent) had hybrid histology with keratinising and respiratory epithelium. Infection occurred in 17 per cent of dermoids prior to excision and 8 per cent of dermoids recurred after excision. Hybrid histology, infection and recurrence are all common in midline neck dermoids. A new theory for their embryological origin is proposed, with the suggestion that some may need more extensive surgery.

SAT197 A Rare Case Of Infected Parathyroid Cyst Associated With Hyperparathyroidism

Abstract Disclosure: B. Ataallah: None. M. Al Tameemi: None. P.R. Orlander: None. Introduction: Parathyroid cysts are considered rare lesions compromising 1-5 % of neck masses. Clinical pictures can range from asymptomatic to symptoms and signs of hyperparathyroidism, and it may lead to compressive symptoms as well. Infection of the parathyroid cyst is not reported in literature. We are presenting a patient with parathyroid cyst and was found to be infected with E-coli. Case presentation: A 59-year-old woman presented with neck swelling and ear pain. She was initially diagnosed with otitis externa and was treated with antibiotics. Her neck swelling worsens over a brief period with associated ear drainage and shortness of breath. Computed tomography (CT) scan of the neck revealed a large cystic lesion up to 10 cm in largest diameter in the region of the thyroid gland with inflammatory changes extending to the prevertebral soft tissues. CT scan of the chest showed a mass effect on the trachea and adjacent structures with possible hemorrhage. Eventually the patient was intubated. Laboratory evaluation revealed parathyroid hormone (PTH) at 455 pg/ml, corrected calcium of 11.3 mg/dl, Ionized calcium of 1.41 mMol/L, and phosphorus at 3.0 mg/dl. Aspiration of the cyst was done prior to surgery and the culture grew E-coli. She started on antibiotics, and eventually underwent a total thyroidectomy with excision of the parathyroid cyst and adenoma. Pathology showed a ruptured cyst with marked inflammation and granulation tissue with hypercellular left superior parathyroid gland. Postoperatively, corrected calcium dropped to 10.1mg/dl and PTH to 38.5 pg/ml. Discussion: Parathyroid cyst (PC) is a relatively rare neck or mediastinal lesion, representing less than 0.5% of parathyroid gland disorders. Most PCs are nonfunctional, but some may produce excess parathyroid hormone or can cause local compressive symptoms like dyspnea, dysphagia, or hoarseness of voice, depending on the size and location of the lesion. There are no distinct clinical or radiological features to differentiate parathyroid cysts, and that makes preoperative diagnosis challenging, and most cases are diagnosed during surgery or postoperatively. Aspiration and fluid analysis can confirm the diagnosis preoperatively, and the treatment can be achieved either by cyst aspiration for small lesions with less than 2.5 cm in diameter, through sclerosing agent injection, or by surgical resection. In this patient, the culture of the aspirated parathyroid cyst surprisingly grew E coli. It is unusual to have an infection with E coli in the neck tissues or the surrounding structures, and it is unknown whether the cyst infection is related to the ear infection that our patient has. Parathyroid cyst infection is not reported in literature reviews, and it is important to consider fluid analysis and culture to confirm the diagnosis preoperatively and to rule out cyst infection Presentation: Saturday, June 17, 2023

Robotic resection of Todani’s cyst type Ic

Choledochal malformation is a rare congenital disease. The current standard of treatment is complete excision of the choledocal cyst followed by reconstruction of the biliointestinal continuity. We report the case of a 45-year-old woman with repeated pancreatitis for Todani’s cyst type Ic. We decided to perform a robotic resection of the common bile duct and a hepatic-jejunal anastomosis. The robotic resection of the common bile duct followed by a hepaticojejunal anastomosis was a safe and feasible procedure.

Wear Rates of Highly Cross-Linked Polyethylene in Total Ankle Arthroplasty at Mean 7-Year Follow- up

Category: Ankle Arthritis; Ankle Introduction/Purpose: Polyethylene (PE) wear particles have been shown to be a contributing factor of osteolysis and aseptic loosening. The use of highly cross-linked polyethylene (HXLPE) liners has been proven to reduce wear rates in hip and knee arthroplasty. To date, no clinical study has investigated the in vivo wear rates of HXLPE in total ankle arthroplasty (TAA). Therefore, the purpose of our study was to evaluate mid- and long-term outcomes and HXLPE wear rates in primary TAA. Methods: We retrospectively identified 49 patients who underwent primary TAA with HXLPE liners at a minimum of 5-year follow up. The average age was 65 years, 57.1% female, and average body mass index was 28.7 kg/m2. Polyethylene wear rates at final follow up were assessed using anteroposterior ankle radiographs and a validated computer assisted software. In addition, overall implant survivorship and complications were recorded. Results: The average polyethylene linear wear rate was 0.073 mm/year (SD, +/- 0.027) at mean 7.6 year (range, 5.1 to 12.2) follow up. Further analysis of patients with greater than 10 year follow up (n=8) demonstrated a linear wear rate of 0.06 mm/year (SD, +/- 0.02) at mean 11.1 year (range, 10.0 to 12.2). There were no instances of linear fracture or dissociation. Survivorship was 98.0% with 1 patient requiring removal of hardware and revision TAA secondary to failure of distal tibial osteotomy which was performed at index procedure. The rate of reoperation was 12.2% (n=6) with the most common indication being symptomatic ankle impingement treated with peri-implant cyst excision, exostectomy, and debridement (n=4). Conclusion: Highly crosslinked polyethylene liners in primary TAA demonstrated low in vivo wear rates and no cases of liner mechanical failures. In addition, our cohort demonstrated low complication and reoperation rates and exceptional survivorship at mid to long-term follow up. Therefore, the use of HXLPE liners is a viable option for surgeons performing TAA.

Parameniscal Cyst Arthroscopic Excision by the Modified Fat Pad Approach Can Shorten Recovery Time-A New Surgical Method with Retrospective Study.

Parameniscal cysts can be removed without meniscectomy, but for large or multiloculated meniscal cysts, traditional arthroscopic excision may leave the meniscus unstable. This study aimed to describe a modified fat pad approach for parameniscal cyst arthroscopic excision that retains a stable structure of the synovial margin of the meniscus and to compare the clinical outcomes between the traditional cyst excision and modified excision techniques. Fifty-six patients with parameniscal cysts between 2014 and 2018 were retrospectively included in this study with 28 patients in each group. All patients underwent arthroscopic parameniscal cyst excisions with traditional and modified excision techniques respectively in each group. The International Knee Documentation Committee subjective (IKDC) score, Lysholm score, visual analogue scale (VAS) score, Tegner score, active range of motion (ROM) and time to recover full ROM were used to evaluate the clinical outcomes by using the t-test. The patient population included 21 males and 35 females, with a mean follow-up of 29 months. Of these, 28 patients underwent traditional arthroscopic cyst excisions and meniscal sutures, and 28 patients underwent arthroscopic excisions by the modified fat pad approach. There were no significant differences in the IKDC score, Lysholm score, Tegner score or VAS score between the traditional and modified excision groups at the final follow-up time point. However, the postoperative time to recover full ROM in the modified excision group was significantly lower than those in the traditional excision group (p < 0.05). Arthroscopic excision with the modified fat pad approach yielded a shorter pain phase and less time to recover full ROM during recovery compared with the traditional arthroscopic excision. The new method seemed to be effective, as evidenced by the positive clinical outcomes of patients.

Screening for Zinner Syndrome in Patients With a Congenitally Solitary Kidney: Lessons Learned.

We determined if serial screening ultrasounds are beneficial in evaluating for the development of Zinner syndrome in males with a congenital solitary kidney. All patients included had their congenital solitary kidney diagnosed at <20 years of age and had to be ≥20 at their last visit. Individuals were seen annually, with pelvic ultrasounds to screen for mesonephric duct cysts obtained at birth and every year of age, divisible by 5. At a median follow-up of 38 years of age (range 20-57), 17% (20/121) developed Zinner syndrome, with 60% (12/20) developing clinical symptoms. The yield for screening ultrasound studies was significantly higher in patients ≤20 years of age at 3.5% (12/340), compared to 0.33% (1/296) in patients >20 years of age (P = .004). Serial ultrasounds reveal the onset of lower urinary tract and cyst-related pain symptoms are associated with the growth of the seminal vesicle cyst to ≥5 cm (P = .0198). Of symptomatic patients, 75% (8/12) had abnormal uroflows. Complete urodynamic studies revealed findings consistent with bladder outlet obstruction in 38% (3/8), equivocal for obstruction in 24% (2/8), and detrusor underactivity in 38% (3/8). Cyst excision effectively resolved voiding symptoms that were obstructive in etiology but failed to resolve symptoms in patients with detrusor underactivity. Serial ultrasound evaluations reveal that cyst growth to ≥5 cm in size is highly related to the onset of clinical symptoms, with the resolution of voiding symptoms by cyst excision directly associated with urodynamic findings.

Surgical excision of an extradural intraspinal synovial cyst at the foramen magnum in a dog

AbstractA 6‐year‐old, female, neutered labrador retriever was presented for investigation of cervical pain. At initial presentation, pain was localised to the cervical region. No neurological deficits were observed. Computed tomography scan and magnetic resonance imaging revealed an extra‐axial cyst‐like lesion at the level of the foramen magnum, with extension into the caudal fossa. Conservative management, which included activity restriction and a 4‐week course of corticosteroids failed to resolve the clinical signs, and the cyst was eventually surgically excised. Histological examination of the sample submitted confirmed a synovial cyst. The dog recovered uneventfully after surgery and remained pain free until the last follow‐up (9 months). Thus, surgical excision of an extradural intraspinal synovial cyst in a dog provided resolution of the clinical signs.

Malignant germ cell tumor of fallopian tube with rhabdomyosarcoma: a case report and literature review

BackgroundMixed germ cell tumors originating from the fallopian tubes are rarely reported, and high-grade rhabdomyosarcoma with differentiated components is even less common. The non-specific clinical manifestations of this tumor are prone to misdiagnosis, and there is still controversy over the treatment plan for this rare differentiated type, and there are limited reports on the prognosis of related diseases.Case presentationHere, we report a 34-year-old woman who presented to our hospital with abdominal pain for two weeks and aggravated for two days. After completing relevant examinations, she underwent transabdominal resection of large tubal masses on the left side of the tube + pelvic lymph node dissection + abdominal paraaortic lymph node dissection + right ovarian cyst excision + greater omentectomy + multipoint peritoneal biopsy. hematoxylin–eosin (H&E) and immunohistochemical (IHC) staining were performed on the surgically resected specimens to further determine the type and nature of the tumor, and 3 cycles of Bleomycin + Etoposide + Cisplatonum (BEP) chemotherapy and 1 cycle of EP(Etoposide + Cisplatonum) chemotherapy were given after surgery.ConclusionUp to now, regular follow-up of the patient's tumor markers and imaging showed no abnormalities, the general condition is good, and the tumor free survival time has reached 24 months.

Bronchogenic cysts: a narrative review.

Bronchogenic cysts represent a rare form of cystic malformation of the respiratory tract. Primarily located in the mediastinum if occurring early in gestation as opposed to the thoracic cavity if arising later in development. However, they can arise from any site along the foregut. They exhibit a variety of clinical and radiologic presentations, representing a diagnostic challenge, especially in areas with endemic hydatid disease. Endoscopic drainage has emerged as a diagnostic and potentially therapeutic option but has been complicated by reports of infection. Surgical excision remains the standard of care allowing for symptomatic resolution and definitive diagnosis via pathologic examination; minimally invasive approaches such as robotic and thoracoscopic approaches aiding treatment. Following complete resection, prognosis is excellent with essentially no recurrence. A review of the available electronic literature was performed from 1975 through 2022, using PubMed and Google Scholar, with an emphasis on more recent series. We included all retrospective series and case reports. A single author identified the studies, and all authors reviewed the selection until there was a consensus on which studies to include. The literature consisted of relatively small series, mixed between adult and pediatric patients, and the consensus remains that all symptomatic lesions should be excised via minimally invasive approach where feasible. Surgical excision of symptomatic bronchogenic cysts remains the gold standard, with endoscopic drainage being reserved for diagnosis or as a temporizing measure in clinically unstable patients.