Safety and feasibility pilot study of continuous low-dose maternal supplemental oxygen in fetal single ventricle heart disease.

OBJECTIVES: Fetuses with single ventricle physiology (SVP) exhibit reductions in fetal cerebral oxygenation with associated delays in fetal brain growth and neurodevelopmental outcomes. Maternal supplemental oxygen (MSO) has been proposed to improve fetal brain growth but current evidence on dosing, candidacy, and outcomes are limited. In this pilot study, we evaluated the safety and feasibility of continuous low-dose MSO in the setting of SVP. METHODS: This single-centre, open-label, pilot phase 1 safety and feasibility clinical trial included 25 pregnant individuals with a fetal diagnosis of SVP. Participants self-administered continuous supplemental oxygen using medical-grade oxygen concentrators for up to 24 hours per day from the second half of gestation until delivery. The primary aim was the evaluation of the safety profile and feasibility of MSO. A secondary preliminary analysis was performed to assess the impact of MSO on the fetal circulation by echocardiography and late-gestational cardiovascular magnetic resonance, early outcomes including brain growth and pre-operative brain injury, and 18-month neurodevelopmental outcomes by the Bayley Scales of Infant and Toddler Development 3rd Edition compared to a contemporary fetal SVP cohort that received standard of care (SOC). RESULTS: Among 25 participants, the average maternal age at conception was 35 years, and fetal SVP diagnoses included 16 right ventricle dominant, 8 left ventricle dominant, and 1 indeterminant ventricular morphology. Participants started the trial at approximately 29.3 gestational weeks and took MSO for a median 16.1 hours per day for 63 days, cumulating a median 1029 hours of oxygen intake from enrollment until delivery. The only treatment-associated adverse events were nasal complications that were typically resolved by attaching a humidifier unit to the oxygen concentrator. No premature closure of the ductus arteriosus or unexpected fetal demise was observed. In the secondary analysis, MSO was not associated with any changes in fetal growth, middle cerebral artery pulsatility index, cerebroplacental ratio, nor head circumference to abdominal circumference ratio Z-scores over gestation compared to SOC. Although MSO was associated with changes in umbilical artery pulsatility index Z-score over gestation compared to SOC (p=0.02), this was likely due to initial baseline differences in placental resistance. At late-gestational cardiovascular magnetic resonance, MSO was not associated with any significant increase in umbilical vein oxygen saturation, fetal oxygen delivery, or fetal cerebral oxygen delivery. Similarly, we observed no differences in newborn outcomes including brain volume and pre-operative brain injury, nor mortality by 18 months of age, nor neurodevelopmental outcomes at 18 months of age. CONCLUSIONS: This pilot phase 1 clinical trial indicates low-dose maternal supplemental oxygen therapy is safe and well tolerated in pregnancies diagnosed with fetal SVP. However, our protocol was not associated with any significant changes in fetal circulatory physiology or improvements in early neurologic or neurodevelopmental outcomes. This article is protected by copyright. All rights reserved.

Mucoepidermoid carcinoma of upper aerodigestive tract: clinicopathologic study of 78 cases with immunohistochemical analysis of Dicer expression.

MicroRNAs (miR) are small noncoding RNAs that are predicted to regulate up to 30% of protein-encoding genes. miR maturation requires functional microRNA machinery, including the Dicer protein. We review our experience with mucoepidermoid carcinoma (MEC) and characterize the prognostic value of Dicer expression. Expression of Dicer was assessed in 78 MEC by immunohistochemistry. Dicer expression was scored semiquantitatively and relative to the internal controls: large excretory/striated ducts or basal/parabasal layers of normal squamous epithelium (mucosa). Dicer scores were then correlated with clinical and pathologic parameters. Dicer over- and/or under-expression were more commonly seen in high-grade MEC (83%) than in low/intermediate grade MEC (35%; p=0.002) and in stage III/IV MEC (80%) than in stage I/II MEC (41%; p=0.04). Abnormal Dicer expression correlates with high-grade and advanced stage, acting as a univariate predictor of poor disease-specific survival (DSS) in MEC. Age and stage were independent predictors of poor DSS on multivariate analysis. Abnormal immunoexpression of Dicer in aggressive MEC suggests a role for miR and miR machinery in tumor progression.

Role of ancillary techniques in profiling unclassified laryngeal malignancies.

Laryngeal biopsies, contrary to biopsies from many other sites of the body, very often contain minute amounts of tumour tissue that may consist of morphologically undifferentiated tumour only. In haematoxylin- and eosin-stained sections, there may be no indicative features of what specific tumour entity that is present. In the larynx, particularly small round cell neoplasms, primary or metastatic, often cause a diagnostic dilemma and where an incorrect diagnosis can induce substantial clinical consequences for the patient (e.g., primary neuroendocrine carcinomas vs metastatic variants, certain sarcomas). If sufficient/representative material has been obtained, the application of immunohistochemistry and/or molecular techniques should in virtually every case reveal the true nature of the malignancy. In cases with sparse amount of material, and therefore a limited number of sections to be cut, a careful and thoughtful stepwise approach is necessary to ascertain a reliable diagnosis, or at least guide the clinician to the most likely diagnoses. With today's advanced and widely available technology with an abundance of markers to discriminate different tumours, the use of the term "undifferentiated" should be largely unnecessary. In the exceptional, and indeed exceedingly rare cases, when a classification is not possible, even after repeat biopsy, we suggest that the laryngeal neoplasm is better termed "unclassified malignant neoplasm" rather than "undifferentiated malignant neoplasm".

How phenotype guides management of the neuroendocrine carcinomas of the larynx.

OBJECTIVE: This review aimed to critically analyse data pertaining to the clinical presentation and treatment of neuroendocrine carcinomas of the larynx. METHOD: A PubMed search was performed using the term 'neuroendocrine carcinoma'. English-language articles on neuroendocrine carcinoma of the larynx were reviewed in detail.Results and conclusionWhile many historical classifications have been proposed, in contemporary practice these tumours are sub-classified into four subtypes: carcinoid, atypical carcinoid, small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma. These tumours exhibit a wide range of biological behaviour, ranging from the extremely aggressive nature of small and large cell neuroendocrine carcinomas, which usually have a fatal prognosis, to the less aggressive course of carcinoid tumours. In small and large cell neuroendocrine carcinomas, a combination of irradiation and chemotherapy is indicated, while carcinoid and atypical carcinoid tumour management entails conservation surgery.

Detecting genetic predisposition for complicated clinical outcomes after burn injury.

Sepsis, septic shock and organ failure are common among patients with moderate to severe burns. The inability of demographic and clinical factors to identify patients at high risk for such complications suggests that genetic variation may influence clinical outcome. Moreover, the genetic predisposition to death from infection has been estimated to be greater than for cardiovascular disease or cancer . While it is widely accepted that genetic factors influence many complex disease processes, controversy has emerged regarding the most appropriate methods for detection and even the validity of many published allelic associations . This article will review the few studies of genetic predisposition that have been conducted in the setting of burn injury, then discuss some of the obstacles and potential approaches for the discovery of additional allelic associations.

TLR4 and TNF-alpha polymorphisms are associated with an increased risk for severe sepsis following burn injury.

CONTEXT: Sepsis, organ failure, and shock remain common among patients with moderate to severe burn injuries. The inability of clinical factors to identify at-risk patients suggests that genetic variation may influence the risk for serious infection and the outcome from severe injury. OBJECTIVE: Resolution of genetic variants associated with severe sepsis following burn injury. PATIENTS: A total of 159 patients with burns > or =20% of their total body surface area or any smoke inhalation injury without significant non-burn related trauma (injury severity score (ISS)> or =16), traumatic or anoxic brain injury, or spinal cord injury and who survived more than 48 h post-admission. METHODS: Candidate single nucleotide polymorphisms (SNPs) within bacterial recognition (TLR4 +896, CD14 -159) and inflammatory response (TNF-alpha -308, IL-1beta -31, IL-6 -174) loci were evaluated for association with increased risk for severe sepsis (sepsis plus organ dysfunction or septic shock) and mortality. RESULTS: After adjustment for age, full-thickness burn size, ethnicity, and gender, carriage of the TLR4 +896 G-allele imparted at least a 1.8-fold increased risk of developing severe sepsis following a burn injury, relative to AA homozygotes (adjusted odds ratio (aOR) 6.4; 95% confidence interval (CI) 1.8 to 23.2). Carriage of the TNF-alpha -308 A-allele imparted a similarly increased risk, relative to GG homozygotes (aOR = 4.5; 95% CI 1.7 to 12.0). None of the SNPs examined were significantly associated with mortality. CONCLUSIONS: The TLR4 +896 and TNF-alpha -308 polymorphisms were significantly associated with an increased risk for severe sepsis following burn trauma.

Vancomycin elimination in patients with burn injury.

Patients with burns clinically appear to require considerably larger doses of vancomycin than normal to attain therapeutic serum concentrations. It has been presumed that this phenomenon is a result of increased renal elimination of this drug consequent to increased glomerular filtration rates in such patients, as has been documented with aminoglycoside antibiotics. We measured the serum clearance of vancomycin in 10 patients with burns and found this parameter to correlate closely with creatinine clearance (serum clearance = 12.5 + 0.695 creatinine clearance; r = 0.932; P less than 0.001). The slope of this relationship was similar to that reported by other investigators in patients not suffering from thermal injury. We conclude that at all levels of renal function, patients with burns clear vancomycin in a manner similar to that of other patients. Consequently, renal function can be used to select a dosing regimen for vancomycin in such patients.

Differential activation of coronary and pulmonary endothelial cells by thermal injury.

Remote organ dysfunction during resuscitation of severe thermal injury is characterized by early, transient pulmonary insufficiency and cardiac contractile dysfunction. Thermal injury is typified by profound systemic alterations of endothelial immunological, vasoactive, and barrier functions. The unique location of this ubiquitous, fragile monolayer makes it vulnerable to circulating serum factors created at remote cutaneous wounds. We examined endothelial "activation" in 2 distinct cell types, human coronary and pulmonary endothelial cells (EC), after severe thermal injury. By using human serum isolated at specific times after thermal injury ("early" [2 h post-burn] or "late" [26 h post-burn]), the endothelial release of vasoactive mediators, ICAM-1 expression, and monolayer permeability were assessed in vitro. Early burn serum enhanced coronary EC vasoconstrictor (ET-1) release and ICAM expression, inhibited vasodilator (PGI2) release, but had no effect on permeability. Conversely, under similar conditions, pulmonary EC PGI2 release and permeability were enhanced, ET-1 release was diminished, but ICAM was unaffected. Late burn serum enhanced vasodilator (NO) release and permeability to albumin in both coronary and pulmonary EC, whereas ET-1 release was inhibited. Under these conditions, only pulmonary ICAM expression was significantly enhanced. These data suggest that human endothelium isolated from divergent vascular beds are activated by burn injury in a unique manner for time post-burn and vascular site of cell origin.

Glucocorticoid regulation of hepatic TNF production following cecal ligation and puncture sepsis.

Tumor necrosis factor-alpha (TNF) is a critical early mediator in the genesis of a systemic inflammatory response during a septic insult. Many of the harmful effects evident during sepsis are ascribed to excessive endogenous TNF production. Because the liver is an important source of circulating TNF during endotoxicosis, and because glucocorticoids are believed to have a regulatory role in suppressing endogenous TNF production, we evaluated the effect of adrenalectomy on the hepatic production of TNF in an isolated perfused liver model after cecal ligation and puncture (CLP) sepsis. Fasted, male Holtzman rats (n = 4/group) underwent CLP alone, adrenalectomy (ADREX) alone, or CLP plus ADREX (CLP/ADREX). Two hours after the operation, the rat livers were explanted and perfused in an isolated recirculating model. Serum TNF levels were greater in CLP/ADREX rats than in both other groups. TNF production in the perfused liver was greater in the CLP/ADREX rats when compared with either CLP alone or ADREX alone. A separate mortality study was performed (N = 35) that demonstrated a CLP induced mortality of 45%, and a CLP/ADREX mortality of 100%. Thus, adrenalectomy increased circulating TNF and hepatic TNF production as well as mortality in CLP sepsis. These findings suggest an important role for endogenous glucocorticoids in modulating hepatic TNF production during CLP-induced sepsis.

Generalized peritonitis. To irrigate or not to irrigate the abdominal cavity.

The objectives of surgery for generalized peritonitis are to eliminate the source of continual bacterial contamination and to prevent septicemia and intra-abdominal abscess formation. A prospective randomized study of three different operative approaches of treating residual peritoneal contamination was undertaken: group 1, no peritoneal irrigation (14 patients); group 2, intraoperative peritoneal irrigation (15 patients); group 3, both intraoperative and postoperative peritoneal irrigation (15 patients). The mortality in groups 1, 2, and 3 was 28.5%, 26.6%, and 33%, respectively. The overall incidence of septicemia and intra-abdominal abscesses in groups 1, 2, and 3 was 23%, 22%, and 17%, respectively. In those patients who survived, the incidence of intra-abdominal abscesses, wound infection, and septicemia was 6%, 23%, and 13%, respectively. In this series, there was no detectable difference in the mortality and infectious complications between the three treatment groups. The only clinical factors that adversely affected mortality and morbidity were peritonitis originating from the colon and age greater than 60 years. Early surgical intervention with removal of the source of peritonitis, debridement of all necrotic tissue, and drainage of abscesses remain the cornerstones of successful therapy in generalized peritonitis.

Adult assault as a mechanism of burn injury.

Assault by burning is an often unappreciated cause of burn injury. One hundred forty-eight of 3678 adults admitted to a major burn center with acute burn injuries sustained their burns as a result of an assault by another adult. High-risk groups included blacks and alcohol abusers. Patients were extremely reductant to describe the cause of their injury and to identify their assailant. In contrast to child abuse, very few cases go to court due to the patient's failure to press charges. There was no typical burn pattern, although the injury often did not coincide with the initial medical history. The presence of multiple trauma, occurring in 16% of these patients, must be excluded in the assaulted patient.

Pediatric grease burn injury.

OBJECTIVES: To evaluate the incidence and severity of grease and oil burns in children and to discuss prevention. DESIGN: All pediatric patients admitted with hot grease burns were compared with the general pediatric burn population. SETTING: All admissions to a regional burn center during a 20-year period were reviewed using a computerized database. PATIENTS: Eight thousand three hundred sixteen patients with acute burn injuries were admitted. Children less than 15 years old accounted for 31.9% of this population (2651 patients). Two hundred fifteen children had burns caused by hot grease or oil. INTERVENTIONS: Sixty-nine patients (32%) in the pediatric grease burn group were admitted to the intensive care unit. Thirteen patients (6%) required intubation, and six (46%) eventually required tracheostomy. Sixty-three patients (29.3%) required operative procedures for wound care. MAIN OUTCOME MEASURES: Grease burn patients had a significantly higher incidence of full-thickness burns, wound infection, and burns involving the face, neck, chest, and arms but lower mortality compared with the general pediatric burn population. Fifty percent of grease burns were caused by home deep fryers. RESULTS: There was no difference between the groups regarding age, sex, or ethnic distribution, size of injury, length of hospitalization, number of intensive care unit admissions, pulmonary infections, operative procedures, or mechanical ventilator requirements. CONCLUSIONS: Grease burns often result in long-lasting, disfiguring, and debilitating injuries. Home deep fryers are frequently involved in these injuries. Careful use of these appliances is mandatory. Increased public awareness is vital to this effort.

Tracheostomy in the young pediatric burn patient.

OBJECTIVE: To evaluate the incidence of complications in comparison with the benefits of tracheostomy in young pediatric burn patients (newborn to 3 years old). DESIGN: Retrospective survey. SETTING: Tertiary care burn center. PATIENTS: A total of 1549 consecutive pediatric burn patients, of whom 180 were intubated. INTERVENTIONS: Tracheostomy was performed in 76 children. MAIN OUTCOME MEASURES: Duration of mechanical ventilation, mortality, respiratory complications, airway complications, and condition of the airway at discharge from the hospital. RESULTS: Seventy-six patients required tracheostomy. Their mean burn size was 34% total body surface area and mean length of stay in the hospital was 56 days. There were no perioperative complications. Eight patients (10%) could not be decannulated because of airway obstruction. Five of these outgrew their obstruction, 2 required surgery, and 1 continues to be evaluated for laryngeal reconstruction. CONCLUSION: Pediatric tracheostomy can be performed safely with no perioperative complications and acceptable chronic morbidity.

Paranasal sinusitis in burn patients following nasotracheal intubation.

Paranasal sinusitis is a complication of nasotracheal intubation. Of 99 nasally intubated adult patients who survived 48 hours after being burned, 22 who were intubated for more than 7 days underwent a computed tomographic scan of all paranasal sinuses, with timing dictated by the patient's clinical condition. Eight patients had computed tomographic and clinical findings consistent with sinusitis. Treatment consisted of removal of all nasal tubes, oral and topical nasal decongestants, and, when appropriate, culture-specific antibiotics. A subgroup of patients with preexisting sinus disease made up 50% of the patients with sinusitis; early conversion to an oral airway or a tracheostomy should be considered in such patients. Only one patient required surgical drainage of the sinuses. The frequency and morbidity of sinusitis in nasotracheally intubated burn patients does not justify the risk of routine conversion to an oral airway.

Acute electric burns. Current diagnostic and therapeutic approaches to management.

A review of 102 cases of high-voltage electric injuries was performed. The average total body surface area was 15.2%. The average age was 32 years. The mortality was 2.1%. Advances in fluid therapy have virtually eliminated renal failure. Devitalized muscle was accurately identified preoperatively with the use of the technetium Tc 99m pyrophosphate muscle scan. Septic complications were reduced substantially by using the following therapeutic modalities: early excision of the burn eschar and necrotic muscle; quantitative wound biopsies to monitor the bacterial flora; allograft as a temporary coverage of open wounds; and early creation of local and distant flaps. Early institution of physical and occupational therapy are mandatory if the patient is to be restored to his or her maximum postinjury potential.

Acute and chronic traumatic arteriovenous fistulae in civilians. Epidemiology and treatment.

Traumatic arteriovenous fistula (AVF) is an uncommon form of vascular disruption. We reviewed 70 AVFs in 69 patients. Nearly one in ten acute arterial injuries is an AVF. Only half of these lesions, however, are clinically demonstrable. Iatrogenic lesions were present in 13% of patients. Eighty-one percent of lesions were treated surgically. Extracranial-intracranial (EC-IC) vascular bypass was used in over one third of head and high neck AVFs. Embolization was used as an adjunct to surgery in about one fourth of patients, and fewer than one in ten were treated with embolization alone. Since half of these lesions are not clinically detectable, liberal use of angiography is necessary for all traumatic wounds in proximity to a major vascular structure. Embolization was useful both as a primary treatment of AVF and as an adjunct to surgery; EC-IC bypass facilitates treatment of inaccessible fistulae in the head and neck.

Cardiovascular effect of 7.5% sodium chloride-dextran infusion after thermal injury.

HYPOTHESIS: Clinical study can help determine the safety and cardiovascular and systemic effects of an early infusion of 7.5% sodium chloride in 6% dextran-70 (hypertonic saline-dextran-70 [HSD]) given as an adjuvant to a standard resuscitation with lactated Ringer (RL) solution following severe thermal injury. DESIGN: Prospective clinical study. SETTING: Intensive care unit of tertiary referral burn care center. PATIENTS: Eighteen patients with thermal injury over more than 35% of the total body surface area (TBSA) (range, 36%-71%) were studied. INTERVENTIONS: Eight patients (mean +/- SEM, 48.2% +/- 2% TBSA) received a 4-mL/kg HSD infusion approximately 3.5 hours (range, 1.5-5.0 hours) after thermal injury in addition to routine RL resuscitation. Ten patients (46.0% +/- 6% TBSA) received RL resuscitation alone. MAIN OUTCOME MEASURES: Pulmonary artery catheters were employed to monitor cardiac function, while hemodynamic, metabolic, and biochemical measurements were taken for 24 hours. RESULTS: Serum troponin I levels, while detectable in all patients, were significantly lower after HSD compared with RL alone (mean +/- SEM, 0.45 +/- 0.32 vs 1.35 +/- 0.35 microg/L at 8 hours, 0.88 +/- 0.55 vs 2.21 +/- 0.35 microg/L at 12 hours). While cardiac output increased proportionately between 4 and 24 hours in both groups (from 5.79 +/- 0.8 to 9.45 +/- 1.1 L/min [mean +/- SEM] for HSD vs from 5.4 +/- 0.4 to 9.46 +/- 1.22 L/min for RL), filling pressure (central venous pressure and pulmonary capillary wedge pressure) remained low for 12 hours after HSD infusion (P = .048). Total fluid requirements at 8 hours (2.76 +/- 0.7 mL/kg per each 1% TBSA burned [mean +/- SEM] for HSD vs 2.67 +/- 0.24 mL/kg per each 1% TBSA burned for RL) and 24 hours (6.11 +/- 4.4 vs 6.76 +/- 0.75 mL/kg per each 1% TBSA burned) were similar. Blood pressure remained unchanged, and serum sodium levels did not exceed 150 +/- 2 mmol/L (mean +/- SD) in either group. CONCLUSIONS: The absence of deleterious hemodynamic or metabolic side effects following HSD infusion in patients with major thermal injury confirms the safety of this resuscitation strategy. Postburn cardiac dysfunction was demonstrated in all burn patients through the use of cardiospecific serum markers and pulmonary artery catheter monitoring. Early administration of HSD after a severe thermal injury may reduce burn-related cardiac dysfunction, but it had no effect on the volume of resuscitation or serum biochemistry values.

An evaluation of risk factors for mortality after burn trauma and the identification of gender-dependent differences in outcomes.

BACKGROUND: The primary objective of this study was to determine an objective method for estimating the risk of mortality after burn trauma, and secondarily, to evaluate the relationship between gender and mortality, in the setting of a quantifiable inflammatory stimulus. Previously reported estimates of mortality risk after burn trauma may no longer be applicable, given the overall reduction in case-fatality rates after burn trauma. We expect that future advances in burn trauma research will require careful and ongoing quantification of mortality risk factors to measure the importance of newly identified factors and to determine the impact of new therapies. Conflicting clinical reports regarding the impact of gender on survival after sepsis and critical illness may in part, be from different study designs, patient samples, or failure to adequately control for additional factors contributing to the development ofsepsis and mortality. STUDY DESIGN: Data from the prospectively maintained burn registry for patients admitted to the Parkland Memorial Hospital burn unit between January 1, 1989 and December 31, 1998 were analyzed. Logistic regression was used to generate estimates of the probability of death in half of the study sample, and this model was validated on the second half of the sample. Risk factors evaluated for their relationship with mortality were: age, inhalation injury, burn size, body mass (weight), preexisting medical conditions, nonburn injuries, and gender. RESULTS: Of 4,927 patients, 5.3% died. The best model for estimating mortality included the percent of total body surface area burned; the percent of full-thickness burn size; the presence of an inhalation injury; age categories of: < 30 years, 30 to 59 years, > or = 60 years; and gender. The risk of death was approximately two-fold higher in women aged 30 to 59 years compared with men of the same age. CONCLUSIONS: We have provided a detailed method for estimating the risk of mortality after burn trauma, based on a large, contemporary cohort of patients. These estimates were validated on a second sample and proved to predict mortality accurately. We have identified an increased mortality risk in women of 30 to 59 years of age.

Multiple trauma and the burn patient.

Multiple trauma greatly complicates the care of the burn patient, whereas a burn often complicates the diagnosis and treatment of the trauma patient. One hundred seventy-six of 3,550 consecutive acute burn admissions received nonburn trauma. The majority of injuries were sustained in motor vehicle accidents (70), escaping fire (32), electrical burns with falls (24), scald burns associated with assault (22), and explosions (18). Eighty patients received orthopedic injuries, including major (47), minor (25), and multiple (28) fractures, 10 dislocations, and 4 open joints. Soft-tissue injury occurred in 91 patients, head injury in 30, thoracic trauma in 27, and abdominal injury in 15. Unstable orthopedic injuries were major contributors to morbidity. Early internal and external fixation permitted optimal mobilization and wound care. Awareness of the potential for multiple injuries and the team approach to these injuries are the most important factors in appropriate care.

Presentation of pancreatic pseudocysts: implications for timing of surgical intervention.

A review of 115 patients with pancreatic pseudocysts treated surgically between 1976 and 1984 showed four patterns of presentation: pseudocyst alone, pseudocyst and acute pancreatitis, acute pancreatitis alone, or neither apparent on hospital admission. These patterns of presentation were associated with differences in the clinical course and ultimate surgical outcome of each group of patients. Emergency procedures greatly increased the morbidity and mortality of surgery for pseudocysts. A preoperative delay for pseudocyst maturation was expected to decrease the morbidity and mortality of elective pseudocyst drainage, but no benefit was found either for the series as a whole or for any subgroup. We conclude that an arbitrary preoperative delay for pseudocyst maturation (in the absence of acute pancreatitis) exposes patients to the risks of preoperative complications, increases the expense of care for pancreatic pseudocysts, and fails to improve surgical outcome.