most cystic tumors consist of serous cystic tumors , mucinous cystic neoplasms , intraductal papillary mucinous neoplasms and solid pseudopapillary tumors . symptomatic cysts , increasing age and multilocular cysts ( with a solid component and thick walls ) are predictors of malignancy , whereas pseudocysts occur following acute pancreatitis , chronic pancreatitis or secondary to pancreatic trauma and have no malignant potential . the complications of pseudocysts are infection , obstructive jaundice , intracystic bleeding , hematoma and rupture . a diameter of > 6 cm and growth of the pseudocysts are important predictors of the need for treatment . for the treatment of pseudocysts , endoscopic drainage instead of surgical or percutaneous drainage as endoscopic drainage , transpapillary drainage and transmural drainage , such as cystogastrostomy and cystoduodenostomy , have been reported . recently , transpapillary drainage without needle puncture has been recommended because of low complication rate . as transpapillary drainage , cyst drainage , in which the stent is inserted into the cyst , and duct drainage , in which the stent is placed in the pancreatic duct , have been reported , but their indications have not yet been established . as stents , the endoprosthesis is generally used , but the nasocystic catheter is also used in some cases . we report a patient with a pseudocyst in the pancreatic tail successfully treated by transpapillary cyst drainage with a nasocystic catheter . a 50-year - old male with a 25-year history of alcohol abuse was admitted to our hospital due to epigastric pain and fever . he had undergone ultrasonography ( us)-guided percutaneous cyst drainage for a pseudocyst associated with chronic pancreatitis 3 months earlier , and the pseudocyst had disappeared . iu / l , -gtp 339 iu / l , alp 440 iu / l , crp 22.6 mg / dl , and elastase 1 1,164 ng / ml . us and computed tomography ( ct ) showed a large pseudocyst measuring 5 cm in diameter and some small cysts in the pancreatic tail ( fig . magnetic resonance cholangiopancreatography revealed a main pancreatic duct stenosis in the pancreatic body and cysts in the pancreatic tail . recurrence of the pseudocyst secondary to alcohol was diagnosed , and conservative treatment was performed for about 3 weeks . the abdominal pain and fever improved , and blood data normalized , but the pseudocyst did not decrease in size . endoscopic retrograde pancreatography showed communication between the pseudocyst and the main pancreatic duct , and a main pancreatic duct stenosis proximal to the pseudocyst ( fig . 2 ) . first , a 5-fr - sized plastic stent ( zimmon pancreatic stent ; wilson - cook medical inc . , winston - salem , n.c . , usa ) was placed beyond the stenosis . transpapillary pancreatic duct drainage was performed for 2 weeks , but the pseudocyst increased , and infection occurred . after removal of the stent , a 5-fr - sized pigtail type nasocystic catheter ( flexima enbd catheter ; microvasive endoscopy , boston scientific corp . , natic , mass . , we irrigated the cystic cavity with saline solution from the endoscopic nasocystic catheter for 1 week . after nasocystic drainage the symptoms improved immediately , and blood data were normal after 1 week . since ct performed after 2 weeks revealed a marked reduction in the size of the pseudocyst , the catheter was kept for 2 weeks and then removed . after the removal , the cyst disappeared . symptomatic pseudocysts and pseudocysts without evidence of regression for longer than 6 weeks are generally an indication for drainage therapy . we abided by this indication . however , this case was not in this indication , as the patient had undergone us - guided percutaneous cyst drainage for the pseudocyst 3 months earlier and the pseudocyst had recurred . previously , surgical drainage was the only effective treatment for pancreatic pseudocysts , but several authors have reported significant procedural morbidity and mortality [ 6 , 7 ] . subsequently , ct- or us - guided percutaneous drainage developed and has been reported to be useful . however , the problems of this drainage method were a high recurrence rate and a high incidence of fistula formation [ 8 , 9 ] . since the first endoscopic treatment for pseudocysts in 1975 , many studies have been reported with advances of endoscopes , devices and technique . as an endoscopic treatment , there are two approaches , i.e. , transpapillary drainage and transmural drainage such as cystogastrostomy and cystoduodenostomy , and an appropriate method is selected based on the anatomical characteristics of the pseudocyst . transpapillary drainage can be performed if the pseudocyst communicates with the main pancreatic duct , and transmural drainage if the pseudocyst is in direct contact with the gastric or duodenal wall . previously , transmural drainage was performed irrespective of the presence or absence of cyst - duct communication , and a high pseudocyst disappearance rate ( 90 - 98% ) was reported . however , this technique is difficult , and the incidence of complications such as hemorrhage and perforation was relatively high . .   performed endoscopic drainage in 53 patients with pseudocysts , of whom 33 underwent transpapillary drainage and the other 20 transmural drainage . the technical success rates were 100 and 80% for transpapillary and transmural drainage , respectively , and the pseudocyst disappearance rate was 94% for both methods . they reported that transpapillary drainage is less invasive and safe , recommending this method as the first choice . based on previous reports , communication between the pseudocyst and main pancreatic duct is observed in 55 - 69% of patients [ 4 , 7 , 12 , 13 ] , and thus transpapillary drainage is indicated in a large proportion of patients with pseudocysts . as transpapillary drainage , cyst drainage in which the stent is placed directly in the pseudocyst , and duct drainage in which the stent is placed in the main pancreatic duct near the cyst , .   performed transpapillary drainage in 30 patients , of whom 12 could be treated by cyst drainage but the other 18 could not be treated by cyst drainage and underwent duct drainage . since the pseudocyst disappearance rate was higher for cyst drainage ( 92% ) than duct drainage ( 67% ) , they recommended that cyst drainage should be performed whenever possible . catalano et al .   performed duct drainage beyond the main pancreatic duct stenosis proximal to the pseudocyst and observed cyst disappearance in 88% , concluding that duct drainage should be selected in the presence of main pancreatic duct stenosis . previous studies have reported a lower success rate in the pancreatic tail ( 60% ) than in the pancreatic head and body ( 80% ) [ 5 , 14 ] . this may be due to technical difficulties in the area apart from the papilla . our patient showed communication between the pseudocyst and the main pancreatic duct accompanied by pancreatic duct stenosis . therefore duct drainage was first performed , but the pseudocyst did not decrease in size . next , the drainage method was changed to cyst drainage using a nasocystic catheter , which resulted in disappearance of pseudocyst . used a nasocystic catheter in cases with heterogeneous pseudocyst , i.e. with associated debris and necrotic tissue or pancreatic abscesses , to allow irrigation of the cystic cavity with saline solution . in our case the cyst content was one of the reasons why the pseudocyst did not regress with pancreatic stent insertion and became infected . duct drainage is technically easier than cyst drainage , but we recommend cyst drainage by a nasocystic catheter as the first choice , especially when the cyst content is heterogeneous . as complications of transpapillary drainage , acute pancreatitis , infection of the pseudocysts and pseudocyst biliary fistula have been reported . kobayashi et al .   reported a case of chronic pancreatitis associated with infected pseudocysts after endoscopic pancreatic stenting . we should take this complication into consideration when performing transpapillary drainage , especially in cases of duct drainage with pancreatic stent . we report a patient with a pseudocyst in the pancreatic tail successfully treated by transpapillary cyst drainage with a nasocystic catheter for a short period of time . this case may provide important information for the selection of two transpapillary drainage techniques in the future .
we report a 50-year - old male with pseudocysts in the pancreatic tail associated with chronic pancreatitis successfully treated by transpapillary cyst drainage . 
 he had previously undergone ultrasonography - guided percutaneous cyst drainage for a pancreatic pseudocyst in our hospital . 
 he was readmitted due to abdominal pain and fever . 
 computed tomography showed recurrence of a pseudocyst in the pancreatic tail measuring 5 cm in diameter . since conservative treatment failed , endoscopic retrograde pancreatography was performed . 
 there was communication between the pseudocyst and the main pancreatic duct , and pancreatic duct stenosis proximal to the pseudocyst . 
 first , transpapillary pancreatic duct drainage was performed using a plastic stent , but the pseudocyst did not decrease in size and became infected . 
 after removal of the stent , a pigtail type nasocystic catheter was placed in the pseudocyst via the pancreatic duct . 
 the pseudocyst infection immediately disappeared , and the pseudocyst gradually decreased and disappeared . 
 after removal of the nasocystic catheter , no recurrence was observed . as transpapillary drainage of pancreatic pseudocyst , cyst drainage and pancreatic duct drainage have been reported . in our patient with pseudocyst in the pancreatic tail 
 , duct drainage was ineffective and the pseudocyst was infected , whereas cyst drainage was very effective . 
 we considered that cyst drainage by a nasocystic catheter was the first - line therapy as the transpapillary drainage of the pancreatic pseudocyst .