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