pancreatic pseudocyst -ksherafgan
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Pancreatic PseudocystPancreatic Pseudocyst
Kashaf Sherafgan, MDKashaf Sherafgan, MD
Surgery IV ConferenceSurgery IV Conference
May 5May 5thth 2006 2006
Pancreatic PseudocystPancreatic Pseudocyst
A fluid collection contained within a well-A fluid collection contained within a well-defined capsule of fibrous or granulation defined capsule of fibrous or granulation tissue or a combination of bothtissue or a combination of both
Does not possess an epithelial liningDoes not possess an epithelial liningPersists > 4 weeksPersists > 4 weeksMay develop in the setting of acute or May develop in the setting of acute or
chronic pancreatitischronic pancreatitis
Bradley III et al. A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Arch Surg. 1993;128:586-590
Pancreatic PseudocystPancreatic Pseudocyst Most common cystic lesions of the pancreas, Most common cystic lesions of the pancreas,
accounting for 75-80% of such massesaccounting for 75-80% of such masses LocationLocation
Lesser peritoneal sac in proximity to the Lesser peritoneal sac in proximity to the pancreaspancreas
Large pseudocysts can extend into the Large pseudocysts can extend into the paracolic gutters, pelvis, mediastinum, neck paracolic gutters, pelvis, mediastinum, neck or scrotumor scrotum
May be loculatedMay be loculated
CompositionComposition
Thick fibrous capsule – not a true epithelial Thick fibrous capsule – not a true epithelial lininglining
Pseudocyst fluidPseudocyst fluidSimilar electrolyte concentrations to plasmaSimilar electrolyte concentrations to plasmaHigh concentration of amylase, lipase, and High concentration of amylase, lipase, and
enterokinases such as trypsinenterokinases such as trypsin
PathophysiologyPathophysiology
Pancreatic ductal disruption 2Pancreatic ductal disruption 2 to toAcute pancreatitis – Necrosis Acute pancreatitis – Necrosis Chronic pancreatitis – Elevated pancreatic Chronic pancreatitis – Elevated pancreatic
duct pressures from strictures or ductal calculi duct pressures from strictures or ductal calculi TraumaTraumaDuctal obstruction and pancreatic neoplasmsDuctal obstruction and pancreatic neoplasms
PresentationPresentation
SymptomsSymptomsAbdominal pain > 3 weeks (80 – 90%)Abdominal pain > 3 weeks (80 – 90%)Nausea / vomitingNausea / vomitingEarly satietyEarly satietyBloating, indigestionBloating, indigestion
SignsSignsTendernessTendernessAbdominal fullnessAbdominal fullness
Cohen et al: Pancreatic pseudocyst. In: Cameron JL, ed. Current Surgical Therapy. 7th ed.; 2001: 543-7
DiagnosisDiagnosis
CT scanCT scanMRI / MRCPMRI / MRCPUltrasonographyUltrasonographyEndoscopic Ultrasonography (EUS)Endoscopic Ultrasonography (EUS)ERCPERCP
Pseudocyst compressing the Pseudocyst compressing the stomach wall posteriorlystomach wall posteriorly
Sonographic evaluationSonographic evaluation
EUS showing pseudocystEUS showing pseudocyst
ComplicationsComplications
InfectionInfection S/S – Fever, worsening abd pain, systemic signs of S/S – Fever, worsening abd pain, systemic signs of
sepsis sepsis CT – Thickening of fibrous wall or air within the cavityCT – Thickening of fibrous wall or air within the cavity
GI obstructionGI obstruction PerforationPerforation HemorrhageHemorrhage Thrombosis – SV (most common)Thrombosis – SV (most common) Pseudoaneurysm formation – Splenic artery Pseudoaneurysm formation – Splenic artery
(most common), GDA, PDA(most common), GDA, PDA
TreatmentTreatment
InitialInitialNPONPOTPNTPNOctreotideOctreotide
Antibiotics if infectedAntibiotics if infected1/3 – 1/2 resolve spontaneously1/3 – 1/2 resolve spontaneously
InterventionIntervention
Indications for drainageIndications for drainagePresence of symptoms (> 6 wks)Presence of symptoms (> 6 wks)Enlargement of pseudocyst ( > 6 cm)Enlargement of pseudocyst ( > 6 cm)ComplicationsComplicationsSuspicion of malignancySuspicion of malignancy
Intervention Intervention Percutaneous drainagePercutaneous drainageEndoscopic drainageEndoscopic drainageSurgical drainageSurgical drainage
Percutaneous DrainagePercutaneous Drainage
Continuous drainage until output < 50 ml/day + Continuous drainage until output < 50 ml/day + amylase activity amylase activity ↓↓ Failure rate 16% Failure rate 16% Recurrence rates 7% Recurrence rates 7%
ComplicationsComplications Conversion into an infected pseudocyst (10%)Conversion into an infected pseudocyst (10%) Catheter-site cellulitis Catheter-site cellulitis Damage to adjacent organsDamage to adjacent organs Pancreatico-cutaneous fistulaPancreatico-cutaneous fistula GI hemorrhageGI hemorrhage
Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43
Endoscopic ManagementEndoscopic Management IndicationsIndications
Mature cyst wall < 1 cm thickMature cyst wall < 1 cm thick Adherent to the duodenum or posterior gastric wallAdherent to the duodenum or posterior gastric wall Previous abd surgery or significant comorbiditiesPrevious abd surgery or significant comorbidities
ContraindicationsContraindications Bleeding dyscrasiasBleeding dyscrasias Gastric varicesGastric varices Acute inflammatory changes that may prevent cyst Acute inflammatory changes that may prevent cyst
from adhering to the enteric wallfrom adhering to the enteric wall CT findingsCT findings
Thick debris Thick debris Multiloculated pseudocystsMultiloculated pseudocysts
Endoscopic DrainageEndoscopic Drainage
Transenteric drainageTransenteric drainageCystogastrostomyCystogastrostomyCystoduodenostomyCystoduodenostomy
Transpapillary drainageTranspapillary drainage40-70% of pseudocysts communicate with 40-70% of pseudocysts communicate with
pancreatic ductpancreatic ductERCP with sphincterotomy, balloon dilatation ERCP with sphincterotomy, balloon dilatation
of pancreatic duct strictures, and stent of pancreatic duct strictures, and stent placement beyond stricturesplacement beyond strictures
Surgical OptionsSurgical Options ExcisionExcision
Tail of gland & a/w proximal strictures – distal Tail of gland & a/w proximal strictures – distal pancreatectomy & splenectomypancreatectomy & splenectomy
Head of gland with strictures of pancreatic or bile Head of gland with strictures of pancreatic or bile ducts – pancreaticoduodenectomyducts – pancreaticoduodenectomy
External drainageExternal drainage Internal drainageInternal drainage
Cystogastrostomy Cystogastrostomy CystojejunostomyCystojejunostomy
Permanent resolution confirmed in b/w 91%–97% of patients* CystoduodenostomyCystoduodenostomy
Can be complicated by duodenal fistula and bleeding at Can be complicated by duodenal fistula and bleeding at anastomotic siteanastomotic site
Nealon et al, Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. Ann Surg. 2001;233:793–800
Laparoscopic ManagementLaparoscopic Management
The interface b/w the cyst and the enteric The interface b/w the cyst and the enteric lumen must be lumen must be ≥≥ 5 cm for adequate 5 cm for adequate drainagedrainage
ApproachesApproachesPancreatitis 2Pancreatitis 2 to biliary etiology to biliary etiology
extraluminal approach w/ concurrent extraluminal approach w/ concurrent laparoscopic cholecystectomylaparoscopic cholecystectomy
Non-biliary origin Non-biliary origin intraluminal (combined intraluminal (combined laparoscopic/endoscopic) approach laparoscopic/endoscopic) approach
Enucleation of PseudocystEnucleation of Pseudocyst
Surgical management of Surgical management of complications a/w complications a/w
percutaneous and/or percutaneous and/or endoscopic management of endoscopic management of pseudocyst of the pancreaspseudocyst of the pancreas
Nealon et alNealon et alAnn SurgAnn Surg. 2005 Jun;241(6):948-57 . 2005 Jun;241(6):948-57
MethodsMethods 10-year prospective study examining complications of
endoscopic, percutaneous and surgical drainage and their operative management
Collected data ICU monitoring Hemorrhage Shock (SBP < 90 mm Hg) Renal failure Ventilator support Duration of fistula drainage following percutaneous drainage Necessity for urgent or emergent operation
Pancreatic ductal anatomy evaluated by means of ERCP or MRCP
Results – Non-operative groupResults – Non-operative group 79 patients with complications of PD, E, or both 66/79 subsequently required operation to
manage their peripancreatic fluid collection, 37 urgent or emergent
Mean elapsed time from diagnosis to nonoperative intervention was 18.1 days
Mean 3.1±0.7 hospitalizations (range, 1–7) and length-of-stay 42.7±4.1 days
63/79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct
Results – Surgical groupResults – Surgical group Complications occurred in 6/100 (6%) Elective operation performed a mean interval of 42.7
days after diagnosis of pseudocyst Hemorrhage, hypotension, renal failure, sepsis,
persistent fistula, or urgent operation all were not seen in the complications associated with operated patients
CT imaging obtained at least 6 months after intervention 91% complete resolution 9% with cystic structures < 2 cm
In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions < 2 cm in diameter
Pseudocyst CharacteristicsPseudocyst Characteristics
Interval From Episode of Acute Pancreatitis to Intervention
Postprocedure ComplicationsPostprocedure Complications
Specific modalities employedSpecific modalities employed
Endoscopic managementTransmural stents – 14/34 patientsTranspapillary drainage – 20/34 patients
Indications for Operation in Patients with Indications for Operation in Patients with Complications of Percutaneous or Complications of Percutaneous or
Endoscopic managementEndoscopic management
Operation for Failed Nonoperative Measures
Categories of Ductal AnatomyCategories of Ductal AnatomyType 1 – Normal PD with a
noncommunicating pseudocyst represented by the dotted mass
Type 2 – Normal duct with cyst communication
Type 5 – Isolated pancreatic segment
Types 6 and 7 – Chronic pancreatitis
Impact of Early Intervention on Complications and Impact of Early Intervention on Complications and Outcomes in Endoscopic/Percutaneous DrainageOutcomes in Endoscopic/Percutaneous Drainage
DiscussionDiscussion
Morbidity rates of operative management of pseudocyst range from 4% – 30%
Success ratesEndoscopic/percutaneous – 60%–90%Surgical – 94%–99%
Discussion, cont.Discussion, cont. Patients who failed non-operative measures
should have a period of stabilization prior to operation Important to reverse sepsis and to improve nutritional
status prior to intervention Technically challenging to operate on patients
who failed nonoperative measures Necessary to completely abolish the prior cystic
structure once it has been decompressed and the walls have fused
Dissection is more challenging than the dissection involved in simply defining a pseudocyst and draining it
Management RecommendationsManagement Recommendations
Without evidence of complications, simple observation x min 6 wks
Infected pseudocysts should be managed with percutaneous drainage until the patient is stabilized
Severe nutritional deficits, at times an indication for percutaneous drainage, should be addressed
Once the pseudocyst is established as persistent, observe truly asymptomatic patients with small cysts
Management Recommendations, cont.Management Recommendations, cont.
Intervention in all pseudocysts > 6 cm, symptomatic patients
Use ductal anatomy to guide choice of modality Types V, VI, and VII ductal injuries are all managed
operatively Types I and II are always managed nonoperatively Types III and IV are still under debate
Significant complications are likely to occur should nonoperative measures be used in patients most likely to sustain complications
ReferencesReferences
Swayer et al. Pancreatic pseudocyst. http://www.emedicine.com/radio/topic576.htm
Bradley III et al. A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Arch Surg. 1993;128:586-590
Cohen et al. Pancreatic pseudocyst. In: Cameron JL, ed. Current Surgical Therapy. 7th ed.; 2001: 543-7
Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43
Nealon et al, Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. Ann Surg. 2001;233:793–800
Nealon et al. Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas. Ann Surg. 2005 Jun;241(6):948-57