Issues in Management of Pancreatic Pseudocysts

1
Issues in Management ofPancreatic Pseudocysts

• Dinesh Singhal1, Rahul Kakodkar1, Randhir Sud2,
  Adarsh Chaudhary1
• Departments of 1Surgical and 2Medical
  Gastroenterology,Sir Ganga Ram Hospital. New
  Delhi, India

2
Abstract

• Pancreatic pseudocysts (PPs) comprise more than
  80 of the cystic lesions of the pancreas and
  cause complications in 7-25 of patients with
  pancreatitis or pancreatic trauma. The first step
  in the management of PPs is to exclude a cystic
  tumor. A history of pancreatitis, no septation,
  solid components or mural calcification on CT
  scan and high amylase content at aspiration favor
  a diagnosis of PP. Endoscopic ultrasound
  (EUS)-guided FNAC is a valuable diagnostic aid.
  Intervention is indicated for PPs which are
  symptomatic, in a phase of growth, complicated
  (infected, hemorrhage, biliary or bowel
  obstruction) or in those occurring together with
  chronic pancreatitis and when malignancy cannot
  be unequivocally excluded. The current options
  include percutaneous catheter drainage, endoscopy
  and surgery. The choice depends on the mode of
  presentation, the cystic morphology and available
  technical expertise. Percutaneous catheter
  drainage is recommended as a temporizing measure
  in poor surgical candidates with immature,
  complicated or infected PPs. The limitations
  include secondary infection and pancreatic
  fistula in 10-20 of patients which increase
  complications following eventual definitive
  surgery. Endoscopic therapy for PPs including
  cystic-enteric drainage (and transpapillary
  drainage), is an option for PPs which bulge into
  the enteric lumen which have a wall thickness of
  less than 1 cm and the absence of major vascular
  structures on EUS in the proposed tract or those
  which communicate with the pancreatic duct above
  a stricture. Surgical internal drainage remains
  the gold standard and is the procedure of choice
  for cysts which are symptomatic or complicated or
  those having a mature wall,. Being more
  versatile, a cystojejunostomy is preferred for
  giant pseudocysts (gt15cm) which are predominantly
  inframesocolic or are in an unusual location. In
  PPs with coexisting chronic pancreatitis and a
  dilated pancreatic duct, duct drainage procedures
  (such as longitudinal pancreaticojejunostomy)
  should be preferred to a cyst drainage procedure.

3
Issues

• Observation or intervention?
• Pseudocyst or tumor ?
• Management strategy
• Endoscopy or surgery ?
• Complicated pseudocyst ?

4
Indications for Intervention

• Absolute indications
• Symptomatic
• Chronic pseudocysts
• In a phase of growth
• Complications
• Malignancy ?

5
Indications for Intervention

• Relative indications
• Duration more than 6 weeks
• Size greater than 6 cm
• Pancreatic duct abnormalities(stricture, stone,
  rupture)
• Multiple cysts

6
Expectant Management

• Asymptomatic
• Uncomplicated
• Stable or decreasing size

7
Beware of a Cystic Tumor !
Cystic tumor erroneously drained by
cystogastrostomy
December 2003
October 2002
Enhancing walls, solidcontent, evidence of
neoplasm
Cystic tumour misinterpreted as pseudocyst
8
Pseudocyst vs. Cystic Tumor

• Previous pancreatitis/trauma
• Imaging (CT, US)
• Single, non-loculated
• No septae or solid components
• Thin wall (lt4mm)
• MRCP/ERCP

• No history of pancreatitis
• Imaging
• Often multilocular
• Septae or solid components
• Thick walled
• MRCP/EUS FNA /ERCP

Duct-cyst connectionin ? 65
Noduct-cyst connection
9
Pseudocyst vs. Cystic Tumor
Pseudocyst
Cystic tumor
10
Cyst Fluid Analysis
1 Lewandrowski KB, et al. Ann Surg 1993,
21741-7. 2 Brugge WR, et al. N Engl J Med
2004, 3511218-26.
11
Pseudocyst vs. Cystic Tumor

• Retrospective study of 21 cystic neoplasms 8
  diagnosed pseudocysts
• Only one patient had a history of pancreatitis
• 7/8 CT scans lacked features which were
  suspicious of neoplasm
• 16/18 investigations ( ERCP, cyst fluid analysis,
  angiography) unhelpful
• A mucinous cystic neoplasm is more likely to be
  misdiagnosed as a pseudocyst
• 5/13 MCA misdiagnosed 2 underwent
  cystenterostomy
• At imaging, classical findings of neoplasia
  (septae, wall calcification and papillary
  projections) were absent in 38 of cases

3 Martin I, et al. Br J Surg 1998 851484-6.
4 Scott J, et al. Clin Radiol 2000, 55187-92.
12
Pseudocyst vs. Cystic Tumor

• No imaging is infallible !

It is better to resect a pseudocystthan to drain
a tumor !
13
Uncomplicated Cyst

• Bulge into stomach/duodenum
• No solid tissue/vessels (EUS)
• Wall thickness 0.5-1cm (EUS)
• Technical expertise available

Pseudocyst entered
Endoscopicdrainage
Tract dilated
Drain placed
5 Kahaleh M, et al. Endoscopy 2006
38355-9. 6 Sanchez Cortes E, et al.
Gastrointest Endosc 2002 56380-6. 7 Sriram
PV, et al. Endoscopy 2005 37231-5.
14
Surgical Strategy (I)

• Symptomatic maturepseudocyst with bulging
  intothe posterior gastric wall

Pseudocyst with mature wallbulging into the
stomach
Anterior Gastric Wall
Pseudocyst openedthrough posteriorgastric wall
Cystogastrostomy
Cystogastrostomy-intraoperative
15
Surgical Strategy (II)

• Symptomatic maturepseudocyst with
  infracolicbulging or giant pseudocyst

Giant pseudocyst
Colon
Cystojejunostomy
Pseudocyst
Large pseudocystin infracolic position
16
Surgical Strategy (III)

• Symptomatic mature pseudocyst dilated main
  pancreatic duct

Pseudocyst withdilated mainpancreatic duct
Partington-Rochelle
17
Surgical Strategy (IV)

• Symptomatic maturemultiple pseudocystsin
  unusual locations dilated mainpancreatic duct

Medistinal pseudocyst
Partington-Rochelle
Duct-cyst communication (forcep)
18
Complications

• Sepsis
• Biliary obstruction
• Hemorrhage
• Sinistral portal hypertension
• Duodenal obstruction

19
Sepsis

• Infected pseudocyst (abscess)not amenable
  toimage-guided drainage

Intracystic air
Infected pseudocyst Abscess
External drainage
Pseudocyst
(Risk of pancreatic fistula morbidity10-15)
Drained externally
8 Adams DB, Anderson MC. Ann Surg 1992
215571-8. 9 Heider R, et al. Ann Surg 1999
229781-7.
20
Biliary Obstruction (I)

• Complicated pseudocystwith immature wall

Pseudocyst with immature walls
External drainage
(Risk of pancreatic fistula morbidity10-15)
Drained percutaneouslythrough safe infracolic
window
21
Biliary Obstruction (II)

• Mature pseudocyst withbiliary obstruction
• Not amenable to ERC

Mature pseudocyst abuttingstomach and
causingbiliary obstruction
Internal drainage (Surgical/Endoscopic)
Obstruction relievedafter cystogastrostomy
22
Hemorrhage (I)

• Intracystic bleeding withmature wall
  (failedangioembolization)

Pseudocyst with bleed
Ligation/Packing
23
Hemorrhage (II)

• Pseudoaneurysmwithout bleeding

Pseudoaneurysm of splenic artery
Angioembolization/Resection
24
Sinistral Portal Hypertension

• Sinistral portal hypertensionwith fundal
  variceal bleeding,dilated main pancreatic
  duct,and pancreatic pain

Dilated MPD
Collaterals in splenic hilum
Splenectomy Ductal drainage
Small pseudocyst
25
Duodenal Obstruction
Pseudocyst causing extrinsiccompression of the
duodenum

• Duodenal obstruction

Duodenal obstruction
Gastrojejunostomy
26
Key Points

• Rule out cystic tumor
• Endoscopic drainage in selected patients
• Surgery - gold standard for pseudocysts
• Giant
• Complicated
• Associated with ductal abnormalities

27

• Keywords Cystadenoma Cysts Endosonography
  Pancreas Pancreatic Pseudocyst Surgery
• Abbreviations MCA mucinous cystadenoma MCAC
  mucinous cystadenocarcinoma SCA serous
  cystadenoma
• CorrespondenceAdarsh ChaudharyDepartment of
  Surgical GastroenterologySir Ganga Ram
  HospitalNew DelhiIndia 110060Phone
  91-11.4225.2226Fax [phone]E-mail
  adarsh_at_nda.vsnl.net.in

28
References

• Lewandrowski KB, et al. Ann Surg 1993,
  21741-7. Full text
• Brugge WR, et al. N Engl J Med 2004,
  3511218-26. Full text
• Martin I, et al. Br J Surg 1998 851484-6. Full
  text
• Scott J, et al. Clin Radiol 2000,
  55187-92. Full text
• Kahaleh M, et al. Endoscopy 2006 38355-9. Full
  text
• Sanchez Cortes E, et al. Gastrointest Endosc
  2002 56380-6. Full text
• Sriram PV et al. Endoscopy 2005 37231-5. Full
  text
• Adams DB, Anderson MC. Ann Surg 1992
  215571-8. Full text
• Heider R, et al. Ann Surg 1999 229781-7. Full
  text