Pancreas Pseudo Cyst

8/8/2019 Pancreas Pseudo Cyst

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Case PresentationCase Presentation

Litong Du M.D.Litong Du M.D.

10/14/200510/14/2005

Lutheran Medical CenterLutheran Medical Center

SUNY Downstate Medical CenterSUNY Downstate Medical Center


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HistoryHistory

xxxx yoyo female presenting to LMC forfemale presenting to LMC for

pancreaticpancreatic pseudocystpseudocyst resectionresection Patient had one episode of acute alcoholicPatient had one episode of acute alcoholic

pancreatitispancreatitis about 5 months earlier withabout 5 months earlier with

conservative managementconservative management Patient complained of persistent abdominalPatient complained of persistent abdominal

pain and weight loss about 2 mo agopain and weight loss about 2 mo ago

CT showed pancreaticCT showed pancreatic pseudocystspseudocysts Surgery was offered, but was delayed due toSurgery was offered, but was delayed due to

asthma attack and pneumoniaasthma attack and pneumonia


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HistoryHistory

PMH: COPD, asthma, depression,PMH: COPD, asthma, depression,

GERDGERD

FH: NonFH: Non--contributorycontributory

Social: smoking 1Social: smoking 1--22 ppdppd, alcohol use, alcohol usefor 20for 20--30 years, and IVDA30 years, and IVDA

Allergies: NKDAAllergies: NKDA

Medications:Medications: ReglanReglan,, neurotinneurotin,,

PrevacidPrevacid,, ZocorZocor


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Physical ExamPhysical Exam

T 98.7T 98.7 P 87P 87 R 18R 18 BP 96/67BP 96/67

General: good, AA&Ox3General: good, AA&Ox3

Chest: CTABChest: CTAB

CVS: RRR, S1,S2CVS: RRR, S1,S2ABD: soft, ND/NT, BS+, no mass, noABD: soft, ND/NT, BS+, no mass, no

surgical scarsurgical scar

NeuroNeuro: intact: intact


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Labs and studiesLabs and studies

UA: Negative

EKG: WNLCXR: WNL

8.8

8.113.1

39.4

221 10.824

0.8

143 108 14

3.6 29 1.2

134 6.9

4.2

30

21

66

1.6/0.3


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OR CourseOR Course 7/7/20,20, Patient was taken to OR underPatient was taken to OR under

GETAGETA Chevron incision madeChevron incision made

3 large3 large pseudocystspseudocysts located at the tail andlocated at the tail and

body, heavily adherent to surroundingbody, heavily adherent to surroundingstructuresstructures

DistalDistal pancreatectomypancreatectomy andand splenectomysplenectomyperformedperformed

Patient tolerated procedure well, broughtPatient tolerated procedure well, broughtto SICU stillto SICU still intubatedintubated


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Hospital CourseHospital Course

POD#1, patient doing well,POD#1, patient doing well,

extubatedextubated

POD#2, transferred to floor,POD#2, transferred to floor,

ambulatingambulating POD#3, passed gas and BM, startedPOD#3, passed gas and BM, started

dietdiet

POD#4, discharged homePOD#4, discharged home

Office followOffice follow--up: no symptomup: no symptom


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PathologyPathology

PancreaticPancreatic pseudocystspseudocysts: 15x14x5,: 15x14x5,

6x5x1, 3x3x4 with necrotic tissue6x5x1, 3x3x4 with necrotic tissue

Pancreas with mild chronicPancreas with mild chronic

inflammatory changesinflammatory changesSpleen with severeSpleen with severe subcapsularsubcapsular

hemorrhage (due to surgicalhemorrhage (due to surgical

manipulation)manipulation)


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Management ofManagement of

pancreaticpancreatic pseudocystspseudocysts

Litong Du M.D.Litong Du M.D.

Lutheran Medical CenterLutheran Medical Center

SUNY Downstate Medical CenterSUNY Downstate Medical Center


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IntroductionIntroduction Definition:Definition:

A cystic cavity bound to the pancreas byA cystic cavity bound to the pancreas byinflammatory tissueinflammatory tissue

The wall of the cyst lacks an epithelial lining,The wall of the cyst lacks an epithelial lining,consisting of fibrous and granulation tissueconsisting of fibrous and granulation tissue

The cyst contains pancreatic juice or amylaseThe cyst contains pancreatic juice or amylase--rich fluidrich fluid

PseudocystsPseudocysts may be single or multiple, smallmay be single or multiple, smallor large, and can be located either within oror large, and can be located either within or

outside of the pancreasoutside of the pancreas 1/3 head and 2/3 body and tail1/3 head and 2/3 body and tail


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EtiologyEtiology AcuteAcute pancreatitispancreatitis::

PseudocystsPseudocysts occur after an acute attack ofoccur after an acute attack ofpancreatitispancreatitis

ChronicChronic pancreatitispancreatitis::

PseudocystPseudocyst formation can be induced by anformation can be induced by anacute exacerbation of chronicacute exacerbation of chronic pancreatitispancreatitis oror

by progressiveby progressive ductalductal obstructionobstruction

Trauma:Trauma: Blunt or penetrating traumaBlunt or penetrating trauma


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PathophysiologyPathophysiology

The cysts stem from disruption of theThe cysts stem from disruption of the

pancreatic duct andpancreatic duct and extravasationextravasation ofofenzymatic fluidenzymatic fluid

2/3 of patients have demonstrable2/3 of patients have demonstrableconnections to the pancreatic ductconnections to the pancreatic duct

In the other third, inflammatoryIn the other third, inflammatory

reaction is supposed to have sealedreaction is supposed to have sealedthe connectionthe connection


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Clinical presentationClinical presentation Most are asymptomaticMost are asymptomatic

Could cause abdominal pain, bowelCould cause abdominal pain, bowelobstruction, vascular occlusion, fistulaobstruction, vascular occlusion, fistula

formationformation

Could causeCould cause pseudoaneurysmpseudoaneurysm, sudden, suddenexpansion of the cyst, and GI bleedingexpansion of the cyst, and GI bleeding

Could causeCould cause ascitesascites and pleural effusionand pleural effusion

due to rupture or fistula formationdue to rupture or fistula formation


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Physical ExamPhysical Exam

NonNon--specificspecific

Tender abdomen +/Tender abdomen +/--

Palpable mass +/Palpable mass +/--

Fever +/Fever +/--AscitesAscites +/+/--

Pleural effusion +/Pleural effusion +/

--


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DiagnosisDiagnosis

Lab study is limitedLab study is limited

CT is the standard test withCT is the standard test with

sensitivity 90sensitivity 90--100%100%

USUSMRI is useful in differentiatingMRI is useful in differentiating

organized necrosis fromorganized necrosis from pseudocystpseudocyst

EUS forEUS for endoscopicendoscopic drainagedrainage


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Differential diagnosisDifferential diagnosis

Acute fluid collectionAcute fluid collection

Organized pancreaticOrganized pancreatic

necrosis/abscessnecrosis/abscess

PancreaticPancreatic pseudoaneurysmpseudoaneurysmCysticCystic neoplasmsneoplasms


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Management ofManagement of pseudocystspseudocystsConservativeConservative

PercutaneousPercutaneous drainagedrainage

EndoscopicEndoscopic approachapproach

Open surgical managementOpen surgical management Laparoscopic managementLaparoscopic management


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Conservative?Conservative? Bradley et al, 1971 to 1976Bradley et al, 1971 to 1976

54 of 93 patients with54 of 93 patients with pseudocystpseudocyst followedfollowedby clinical exam and USby clinical exam and US

Spontaneous resolution 20%, complicationSpontaneous resolution 20%, complication

rate 41%, and death rate 14%rate 41%, and death rate 14% PseudocystsPseudocysts rarely resolved and highrarely resolved and high

complication rate beyond 7 wkscomplication rate beyond 7 wks

Conclusion: prolonged observationConclusion: prolonged observationexposed patients at unwarranted risksexposed patients at unwarranted risks

Bradley EL et al. : The natural history of pancreatic pseudocysts: a unified concept of

Management Am. J. Surg. 1979 Jan: 137(1): 135-4


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Conservative?Conservative? YeoYeo, et al., 1978 to 1987, et al., 1978 to 1987

36 of 75 patients managed36 of 75 patients managed nonoperativelynonoperativelywith CT follow up for 1 year:with CT follow up for 1 year: 60% complete resolution60% complete resolution

40%pseudocysts remained stable or decreased40%pseudocysts remained stable or decreasedsizesize

Size>6 cm more frequently required surgerySize>6 cm more frequently required surgery(67%(67% vsvs 40%)40%)

Conclusion: A large proportion ofConclusion: A large proportion ofasymptomatic patients can be safelyasymptomatic patients can be safelymanagedmanaged nonoperativelynonoperatively

Yeo et al. The natural history of pancreatic pseudocysts documented by computed

tomography. Surg Gynecol Obstet 1990; 170:411


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Conservative?Conservative? Vitas, et al., 1980 to 1985Vitas, et al., 1980 to 1985

68 of 114 patients initially managed68 of 114 patients initially managednonoperativelynonoperatively with CT followwith CT follow--up for 46 months:up for 46 months:

24 patients eventually underwent operation24 patients eventually underwent operation

43 patients43 patients nonoperativenonoperative

57% resolution and 38% resolving after 657% resolution and 38% resolving after 6months of the diagnosismonths of the diagnosis

Size10cm, no complication

Conclusion: aConclusion: a nonoperativenonoperative approach isapproach iswarranted in selected patientswarranted in selected patients

Vitas et al. Selected management of pancreatic pseudocysts: Operative versus

expectant management. Surgery 1992; 111:123


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ConservativeConservative It is safe to conservatively manageIt is safe to conservatively manage

asymptomatic patients with clinicalasymptomatic patients with clinicaland CT followand CT follow--upup

Therapeutic intervention is warrantedTherapeutic intervention is warranted

in patients with enlarging, infected,in patients with enlarging, infected,

or bleeding cysts; or symptomaticor bleeding cysts; or symptomatic


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PercutaneousPercutaneous drainage (PCD)drainage (PCD) Simple aspirationSimple aspiration

results in recurrenceresults in recurrencein 70%in 70%

Catheter drainageCatheter drainagewith placing a 8with placing a 8--16fr16frcatheter under CT orcatheter under CT orUSUS

Contraindicated inContraindicated inpoor compliantpoor compliantpatients, ductpatients, ductstenosisstenosis, and, andhemorrhagic cysthemorrhagic cyst


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PercutaneousPercutaneous drainage (PCD)drainage (PCD)Adams et al., compared the outcomeAdams et al., compared the outcome

of 92 patients with surgery or PCDof 92 patients with surgery or PCD PCD group with lower mortality ratePCD group with lower mortality rate

(0% versus 7.1%) and similar(0% versus 7.1%) and similar

morbiditymorbidity

PCD group duration of drainage wasPCD group duration of drainage was

42.1 days and drain track infection42.1 days and drain track infectionrate 48.1%rate 48.1%

Adams, DB, Anderson, MC. Percutaneous catheter drainage compared withinternal drainage in the management of pancreatic pseudocysts. Ann Surg

1992; 215:571


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EndoscopicEndoscopic drainagedrainageCremerCremer et al. in 1989, first reportedet al. in 1989, first reported

endoscopicendoscopic cystoenterostomycystoenterostomy in 33in 33patients:patients:

Success rates: 96Success rates: 96--100%100%

Relapse rate 9Relapse rate 9--19%19%

No mortalityNo mortality

Cremer, M, Deviere, J, Engelholm, L. Endoscopic management ofcysts and pseudocysts in chronic pancreatitis: Long-term follow-upafter 7 years of experience. Gastrointest Endosc 1989; 35:1


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EndoscopicEndoscopic drainagedrainage CystCyst--enterostomyenterostomy::

Success rate 85%Success rate 85% 7% complication7% complication

mortality


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Open surgical managementOpen surgical management CystCyst--gastrostomygastrostomy

CystCyst--duodenostomyduodenostomy

RouxRoux--enen--y cysty cyst--

jejunostomyjejunostomy DistalDistal

pancreatectomypancreatectomy


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Open surgical managementOpen surgical management Indication:Indication:

cysts associated with infectioncysts associated with infection necrosisnecrosis

cystic tumorscystic tumors

pseudoaneurysmpseudoaneurysm

require concomitant operative treatment, likerequire concomitant operative treatment, likeobstruction,obstruction, ductalductal stricturestricture

Biopsy of the cyst wall and send fluid forBiopsy of the cyst wall and send fluid for

pathologypathology Complication 11Complication 11--24%, mortality 524%, mortality 5--9%,9%,

recurrence 5recurrence 5--8%8%

Lohr-Happe, A, Peiper, M, Lankisch, PG. Natural course of operatedpseudocysts in chronic pancreatitis. Gut 1994; 35:1479


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Laparoscopic managementLaparoscopic management Way et al. reported the first case in 1994Way et al. reported the first case in 1994

Park, et al., reported 29Park, et al., reported 29 pseudocystpseudocyst patientpatienttreated with laparoscopytreated with laparoscopy

28 of 29 was completed successfully28 of 29 was completed successfully

OprativeOprative time was 2.8 hourstime was 2.8 hours

PostivePostive hospital stay was 4.4 dayshospital stay was 4.4 days

FollowFollow--up of 15.8 months, no symptom, noup of 15.8 months, no symptom, no

recurrencerecurrence

Park AE et al., Advances in surgical technique: therapeutic laparoscopy of

the pancreas. Ann Surg. 2002; 236: 149-158

Way LW et al., laparoscopic pancreatic cystgastrostomy: the first operationin the new field of intraluminal laparoscopic surgery. Surg Ednosc.1994;8:235


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SummarySummary PseudocystPseudocyst formation is commonformation is common

afterafter pancreatitispancreatitisMany will resolve spontaneouslyMany will resolve spontaneously

Observation may be safe forObservation may be safe forasymptomatic patientsasymptomatic patients

Symptomatic or infectedSymptomatic or infected pseudocystspseudocysts

require therapeutic proceduresrequire therapeutic procedures

Pancreas Pseudo Cyst

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