PANCREATIC PSEUDOCYST

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Etiology, presentation, investigations and management of pancreatic pseudocyst

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Pancreatic Pseudocyst:

Pancreatic Pseudocyst Dr. Naeem Shahzad Post graduate resident Surgical unit 1 SHL

Pancreatic Pseudocyst:

Pancreatic Pseudocyst Pseudocysts are best defined as a localized fluid collection that is rich in amylase and other pancreatic enzymes, that has a nonepithelialized wall consisting of fibrous and granulation tissue, and that usually appears several weeks after the onset of pancreatitis*. * Brun A, Agarwal N, Pitchumoni CS. Fluid collections in and around the pancreas in acute pancreatitis. J Clin Gastroenterol . Aug 2011;45(7):614-25.

Pancreatic Pseudocyst:

Pancreatic Pseudocyst Most common cystic lesions of the pancreas, accounting for 75-80% of such masses Location One third of cysts are in the head region and two third in the region of body of pancreas Lesser peritoneal sac in proximity to the pancreas Large pseudocysts can extend into the paracolic gutters, pelvis, mediastinum May be loculated May be single or multiple

Composition:

Composition Thick fibrous capsule – not a true epithelial lining Pseudocyst fluid Similar electrolyte concentrations to plasma High concentration of amylase, lipase, and enterokinases such as trypsin

Pathophysiology:

Pathophysiology Pancreatic ductal disruption 2  to Acute pancreatitis – N ecrosis Chronic pancreatitis – Elevated pancreatic duct pressures from strictures or ductal calculi Trauma Ductal obstruction and pancreatic neoplasms

Pathophysiology:

Pathophysiology Acute Pancreatitis Pancreatic necrosis causes ductular disruption, resulting in leakage of pancreatic juice from inflamed area of gland, accumulates in space adjacent to pancreas Inflammatory response induces formation of distinct cyst wall composed of granulation tissue, organizes with connective tissue and fibrosis

Pathophysiology:

Pathophysiology Chronic Pancreatitis Pancreatic duct chronically obstructed  ongoing proximal pancreatic secretion leads to secular dilation of duct – true retention cyst Formed micro cysts can eventually coalesce and lose epithelial lining as enlarge

Presentation:

Presentation Symptoms Abdominal pain > 3 weeks (80 – 90%) Nausea / vomiting Early satiety Bloating, indigestion Signs Tenderness Abdominal fullness/mass Icterus / pleural effusion Peritoneal signs indicate ruptured or infected cyst Cohen et al: Pancreatic pseudocyst . In: Cameron JL, ed. Current Surgical Therapy. 7th ed.; 2001: 543-7

Diagnosis:

Diagnosis Clinically suspect a pseudocyst Episode of pancreatitis fails to resolve Amylase levels persistantly high Persistant abdominal pain Epigastric mass palpated after pancreatitis

Work up:

Work up Amylase and lipase levels are often elevated but may be within reference ranges. Bilirubin and liver function test (LFTs) findings may be elevated if the biliary tree is involved. Analysis of the cyst fluid may help differentiate pseudocysts from tumors. Attempt to exclude tumors in any patient who does not have a clear history of pancreatitis. Carcinoembryonic antigen (CEA) and carcinoembryonic antigen-125 (CEA-125) tumor marker levels are low in pseudocysts and elevated in tumors.

Sonographic evaluation:

Sonographic evaluation cystic fluid collections in and around the pancreas may be visualized by ultrasound 75 -90% sensitive the technique is limited by the operator’s skill the patient's habitus any overlying bowel gas.

Abdominal CT scan:

Abdominal CT scan It has a sensitivity of 90-100% and is not operator dependent. The pancreas may appear irregular or have calcifications. The CT scan provides a very good appreciation of the wall thickness of the pseudocyst and billiary or enteric obstruction which is useful in planning therapy. Pseudocyst compressing the stomach wall posteriorly

Endoscopic ultrasound (EUS):

Endoscopic ultrasound (EUS) EUS is not necessary to establish a diagnosis but is very important in planning therapy, particularly if endoscopic drainage is contemplated. Transmural drainage may be performed only when the symptomatic pseudocyst is positioned next to the gut wall

ERCP Vs. MRCP:

ERCP Vs. MRCP ERCP is not necessary in diagnosing pseudocysts ; however, it is useful in planning drainage strategy. MRCP to establish the relationship of the pseudocyst to the pancreatic ducts

Classification Based on Duct Anatomy:

Classification Based on Duct Anatomy Type I: normal duct/no communication with cyst. Type II: normal duct with duct-cyst communication. Type III: otherwise normal duct with stricture and no duct-cyst communication. Type IV: otherwise normal duct with stricture and duct-cyst communication. Type V: otherwise normal duct with complete cut-off. Type VI: chronic pancreatitis, no duct-cyst communication. Type VII: chronic pancreatitis with duct-cyst communication

Natural History of Pseudocyst:

Natural History of Pseudocyst ~50% resolve spontaneously Size Nearly all <4cm resolve spontaneously >6cm 60-80% persist, necessitate intervention Cause Traumatic, chronic pancreatitis <10% resolve Multiple cysts – few spontaneously resolve Duration - Less likely to resolve if persist > 6-8 weeks

Differential Diagnosis:

Differential Diagnosis Acute fluid collections Pancreatic cancer Pancreatic necrosis and pancreatic abscess Von Hippel-Lindau Disease Pancreatic pseudoaneurysm

Treatment:

Treatment Initial NPO TPN Octreotide Antibiotics if infected 1/3 – 1/2 resolve spontaneously

Medication:

Medication No medications are specific to the treatment of pancreatic pseudocysts . Antibiotics are an adjunct to drainage of infected pseudocysts . Octreotide can be useful as an adjunct to catheter drainage. Used to reduce pancreatic exocrine secretion.

Intervention:

Intervention Indications for drainage Presence of symptoms (> 6 wks) Enlargement of pseudocyst ( > 6 cm) Complications Suspicion of malignancy

Intervention:

Intervention External Drainage Percutaneous drainage Open Drainage Internal Drainage Endoscopic Transpapillary Drainage Transmural drainage ( Transgastric or Transduodenal ) Laparoscopic Drainage Cysto-gastrostomy Cysto-jejunostomy Open Surgical drainage Cysto-gastrostomy Cysto-jejunostom (Roux-en-Y) Pancreatic Rescection Excision of the pseudocyst Pancreaticoduodenectomy

Percutaneous Drainage:

Percutaneous Drainage Continuous drainage until output < 50 ml/day + amylase activity ↓ Failure rate 16% Recurrence rates 7% Complications Conversion into an infected pseudocyst (10%) Catheter-site cellulitis Damage to adjacent organs Pancreatico-cutaneous fistula GI hemorrhage Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43

External Drainage:

External Drainage

Endoscopic Management:

Endoscopic Management Indications Mature cyst wall < 1 cm thick Adherent to the duodenum or posterior gastric wall Previous abd surgery or significant comorbidities Contraindications Bleeding dyscrasias Gastric varices Acute inflammatory changes that may prevent cyst from adhering to the enteric wall CT findings Thick debris Multiloculated pseudocysts

Endoscopic Drainage:

Endoscopic Drainage Transenteric drainage Cystogastrostomy Cystoduodenostomy Transpapillary drainage 40-70% of pseudocysts communicate with pancreatic duct ERCP with sphincterotomy , balloon dilatation of pancreatic duct strictures and stent placement beyond strictures

Laparoscopic Management:

Laparoscopic Management The interface b/w the cyst and the enteric lumen must be ≥ 5 cm for adequate drainage Approaches Anterior Transgastric cystgastrostomy Intragastric cyst gastrostomy Combined laproscopic / endoscopic cystgasrostomy

Anterior Transgastric Cystogastrostomy:

Anterior Transgastric Cystogastrostomy

Open Surgical Options:

Open Surgical Options Internal drainage Cystogastrostomy Cystojejunostomy Permanent resolution confirmed in b/w 91%–97% of patients* Cystoduodenostomy Can be complicated by duodenal fistula and bleeding at anastomotic site

Pancreatic Resection:

Pancreatic Resection Tail of & pancreas along with proximal strictures – distal pancreatectomy & splenectomy Enucleation of Pseudocyst Pseudocyst of Head of pancreas with strictures of pancreatic or bile ducts need pancreaticoduodenectomy

Which is the preferred intervention?:

Which is the preferred intervention? Surgical drainage with laproscopic or traditional approach – gold standard. Percutaneous catheter drainage – high chance of persistant pancreatic fistula. Endoscopic drainage - less invasive, becoming more popular, technically demanding .Surgery necessary in complicated pseudocyts , failed nonsurgical, and multiple pseudocysts .

Follow up:

Follow up Dietry Advice: Patients may eat a low-fat diet as tolerated. Patients who have endoscopically placed stents must be monitored via serial CT scans to observe resolution of the cyst. Stents may then be endoscopically removed after resolution. Closely monitor patients with percutaneous drains for pain , infection , or catheter migration . Remove the drain when drainage ceases

Complications:

Complications Infection S/S – Fever, worsening abd pain, systemic signs of sepsis CT – Thickening of fibrous wall or air within the cavity GI obstruction Perforation Hemorrhage Thrombosis – SV (most common) Pseudoaneurysm formation – Splenic artery (most common), GDA, PDA

Prognosis:

Prognosis Most pseudocysts resolve without interference, and patients do well without intervention. Outcome is much worse for patients who develop complications. The presence of pancreatic necrosis is a poor prognostic sign. The failure rate for drainage procedures is about 10%, the recurrence rate is about 15%, and the complication rate is 15-20%.

REFERENCES:

REFERENCES Fischer's Mastery of Surgery 5 th edition Medscape Surgery

THANKS:

THANKS

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