Case PresentationCase Presentation

Litong Du M.D.Litong Du M.D.10/14/200510/14/2005

Lutheran Medical CenterLutheran Medical CenterSUNY Downstate Medical CenterSUNY Downstate Medical Center

HistoryHistory

xx xx yoyo female presenting to LMC for female presenting to LMC for pancreatic pancreatic pseudocystpseudocyst resection resection Patient had one episode of acute alcoholic Patient had one episode of acute alcoholic pancreatitispancreatitis about 5 months earlier with about 5 months earlier with conservative management conservative management –– Patient complained of persistent abdominal Patient complained of persistent abdominal

pain and weight loss about 2 mo agopain and weight loss about 2 mo ago–– CT showed pancreatic CT showed pancreatic pseudocystspseudocysts–– Surgery was offered, but was delayed due to Surgery was offered, but was delayed due to

asthma attack and pneumonia asthma attack and pneumonia

HistoryHistory

PMH: COPD, asthma, depression, PMH: COPD, asthma, depression, GERDGERDFH: NonFH: Non--contributorycontributorySocial: smoking 1Social: smoking 1--2 2 ppdppd, alcohol use , alcohol use for 20for 20--30 years, and IVDA30 years, and IVDAAllergies: NKDAAllergies: NKDAMedications: Medications: ReglanReglan, , neurotinneurotin, , PrevacidPrevacid, , ZocorZocor

Physical ExamPhysical Exam

T 98.7T 98.7 P 87P 87 R 18R 18 BP 96/67BP 96/67General: good, AA&Ox3General: good, AA&Ox3Chest: CTABChest: CTABCVS: RRR, S1,S2CVS: RRR, S1,S2ABD: soft, ND/NT, BS+, no mass, no ABD: soft, ND/NT, BS+, no mass, no surgical scarsurgical scarNeuroNeuro: intact: intact

Labs and studiesLabs and studies

UA: Negative

EKG: WNL

CXR: WNL

8.8

8.113.1

39.4221 10.8 24

0.8

143 108 14

3.6 29 1.2134 6.9

4.2

30

21

66

1.6/0.3

OR CourseOR Course7/7/20, 20, Patient was taken to OR under Patient was taken to OR under GETA GETA Chevron incision madeChevron incision made3 large 3 large pseudocystspseudocysts located at the tail and located at the tail and body, heavily adherent to surrounding body, heavily adherent to surrounding structures structures Distal Distal pancreatectomypancreatectomy and and splenectomysplenectomyperformedperformedPatient tolerated procedure well, brought Patient tolerated procedure well, brought to SICU still to SICU still intubatedintubated

Hospital CourseHospital Course

POD#1, patient doing well, POD#1, patient doing well, extubatedextubatedPOD#2, transferred to floor, POD#2, transferred to floor, ambulatingambulatingPOD#3, passed gas and BM, started POD#3, passed gas and BM, started diet diet POD#4, discharged homePOD#4, discharged homeOffice followOffice follow--up: no symptomup: no symptom

PathologyPathology

Pancreatic Pancreatic pseudocystspseudocysts: 15x14x5, : 15x14x5, 6x5x1, 3x3x4 with necrotic tissue6x5x1, 3x3x4 with necrotic tissuePancreas with mild chronic Pancreas with mild chronic inflammatory changesinflammatory changesSpleen with severe Spleen with severe subcapsularsubcapsularhemorrhage (due to surgical hemorrhage (due to surgical manipulation)manipulation)

Management of Management of pancreatic pancreatic pseudocystspseudocysts

Litong Du M.D.Litong Du M.D.Lutheran Medical CenterLutheran Medical Center

SUNY Downstate Medical CenterSUNY Downstate Medical Center

IntroductionIntroductionDefinition:Definition:–– A cystic cavity bound to the pancreas by A cystic cavity bound to the pancreas by

inflammatory 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 tissue consisting 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, small may be single or multiple, small

or large, and can be located either within or or large, and can be located either within or outside of the pancreas outside of the pancreas

–– 1/3 head and 2/3 body and tail 1/3 head and 2/3 body and tail

EtiologyEtiology

Acute Acute pancreatitispancreatitis: : –– PseudocystsPseudocysts occur after an acute attack of occur after an acute attack of

pancreatitispancreatitis

Chronic Chronic pancreatitispancreatitis: : –– PseudocystPseudocyst formation can be induced by an formation can be induced by an

acute exacerbation of chronic acute exacerbation of chronic pancreatitispancreatitis or or by progressive by progressive ductalductal obstructionobstruction

Trauma: Trauma: –– Blunt or penetrating trauma Blunt or penetrating trauma

PathophysiologyPathophysiology

The cysts stem from disruption of the The cysts stem from disruption of the pancreatic duct and pancreatic duct and extravasationextravasation of of enzymatic fluidenzymatic fluid2/3 of patients have demonstrable 2/3 of patients have demonstrable connections to the pancreatic ductconnections to the pancreatic ductIn the other third, inflammatory In the other third, inflammatory reaction is supposed to have sealed reaction is supposed to have sealed the connectionthe connection

Clinical presentationClinical presentation

Most are asymptomaticMost are asymptomaticCould cause abdominal pain, bowel Could cause abdominal pain, bowel obstruction, vascular occlusion, fistula obstruction, vascular occlusion, fistula formationformationCould cause Could cause pseudoaneurysmpseudoaneurysm, sudden , sudden expansion of the cyst, and GI bleedingexpansion of the cyst, and GI bleedingCould cause Could cause ascitesascites and pleural effusion and pleural effusion due to rupture or fistula formationdue to rupture or fistula formation

Physical ExamPhysical Exam

NonNon--specificspecificTender abdomen +/Tender abdomen +/--Palpable mass +/Palpable mass +/--Fever +/Fever +/--AscitesAscites +/+/--Pleural effusion +/Pleural effusion +/--

Diagnosis Diagnosis

Lab study is limitedLab study is limitedCT is the standard test with CT is the standard test with sensitivity 90sensitivity 90--100%100%USUSMRI is useful in differentiating MRI is useful in differentiating organized necrosis from organized necrosis from pseudocystpseudocystEUS for EUS for endoscopicendoscopic drainagedrainage

Differential diagnosisDifferential diagnosis

Acute fluid collectionAcute fluid collectionOrganized pancreatic Organized pancreatic necrosis/abscessnecrosis/abscessPancreatic Pancreatic pseudoaneurysmpseudoaneurysmCystic Cystic neoplasmsneoplasms

Management of Management of pseudocystspseudocysts

ConservativeConservativePercutaneousPercutaneous drainagedrainageEndoscopicEndoscopic approachapproachOpen surgical managementOpen surgical managementLaparoscopic managementLaparoscopic management

Conservative?Conservative?

ObservationObservationTraditional surgical teaching: Traditional surgical teaching: –– 44--6 wks for 6 wks for pseudocystpseudocyst wall to mature wall to mature

to permit suturingto permit suturing–– Up to 50% of cysts will resolve by 6 Up to 50% of cysts will resolve by 6

wks, after which resolution is unlikely wks, after which resolution is unlikely –– Complication rate up to 50% after 6 Complication rate up to 50% after 6

wks: infection, obstruction, perforation, wks: infection, obstruction, perforation, pseudoaneurysmpseudoaneurysm and bleedingand bleeding

Bradley EL et al. : The natural history of pancreatic pseudocysts: a unified concept of Management Am. J. Surg. 1979 Jan: 137(1): 135-4

Conservative?Conservative?

Bradley et al, 1971 to 1976Bradley et al, 1971 to 197654 of 93 patients with 54 of 93 patients with pseudocystpseudocyst followed followed by clinical exam and USby clinical exam and USSpontaneous resolution 20%, complication Spontaneous resolution 20%, complication rate 41%, and death rate 14%rate 41%, and death rate 14%PseudocystsPseudocysts rarely resolved and high rarely resolved and high complication rate beyond 7 wkscomplication rate beyond 7 wksConclusion: prolonged observation Conclusion: prolonged observation exposed 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

Conservative?Conservative?YeoYeo, et al., 1978 to 1987, et al., 1978 to 198736 of 75 patients managed 36 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 decreased 40%pseudocysts remained stable or decreased

sizesize–– Size>6 cm more frequently required surgery Size>6 cm more frequently required surgery

(67% (67% vsvs 40%)40%)

Conclusion: A large proportion of Conclusion: A large proportion of asymptomatic patients can be safely asymptomatic patients can be safely managed managed nonoperativelynonoperatively

Yeo et al. The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet 1990; 170:411

Conservative?Conservative?Vitas, et al., 1980 to 1985Vitas, et al., 1980 to 198568 of 114 patients initially managed 68 of 114 patients initially managed nonoperativelynonoperatively with CT followwith CT follow--up for 46 months:up for 46 months:–– 24 patients eventually underwent operation24 patients eventually underwent operation–– 43 patients 43 patients nonoperativenonoperative–– 57% resolution and 38% resolving after 6 57% resolution and 38% resolving after 6

months of the diagnosismonths of the diagnosis–– Size<5 cm, 83% resolution; over 5 cm, 50%Size<5 cm, 83% resolution; over 5 cm, 50%–– 7 patients with size>10cm, no complication7 patients with size>10cm, no complication

Conclusion: a Conclusion: a nonoperativenonoperative approach is approach is warranted in selected patientswarranted in selected patients

Vitas et al. Selected management of pancreatic pseudocysts: Operative versus expectant management. Surgery 1992; 111:123

ConservativeConservative

It is safe to conservatively manage It is safe to conservatively manage asymptomatic patients with clinical asymptomatic patients with clinical and CT followand CT follow--upupTherapeutic intervention is warranted Therapeutic intervention is warranted in patients with enlarging, infected, in patients with enlarging, infected, or bleeding cysts; or symptomaticor bleeding cysts; or symptomatic

PercutaneousPercutaneous drainage (PCD)drainage (PCD)Simple aspiration Simple aspiration results in recurrence results in recurrence in 70%in 70%Catheter drainage Catheter drainage with placing a 8with placing a 8--16fr 16fr catheter under CT or catheter under CT or USUSContraindicated in Contraindicated in poor compliant poor compliant patients, duct patients, duct stenosisstenosis, and , and hemorrhagic cysthemorrhagic cyst

PercutaneousPercutaneous drainage (PCD)drainage (PCD)

Adams et al., compared the outcome Adams et al., compared the outcome of 92 patients with surgery or PCDof 92 patients with surgery or PCDPCD group with lower mortality rate PCD group with lower mortality rate (0% versus 7.1%) and similar (0% versus 7.1%) and similar morbidity morbidity PCD group duration of drainage was PCD group duration of drainage was 42.1 days and drain track infection 42.1 days and drain track infection rate 48.1%rate 48.1%

Adams, DB, Anderson, MC. Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocysts. Ann Surg1992; 215:571

EndoscopicEndoscopic drainagedrainage

CremerCremer et al. in 1989, first reported et al. in 1989, first reported endoscopicendoscopic cystoenterostomycystoenterostomy in 33 in 33 patients: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 of cysts and pseudocysts in chronic pancreatitis: Long-term follow-up after 7 years of experience. Gastrointest Endosc 1989; 35:1

EndoscopicEndoscopic drainagedrainage

CystCyst--enterostomyenterostomy::–– Success rate 85%Success rate 85%–– 7% complication7% complication–– mortality <1% mortality <1%

TranspapillaryTranspapillary::–– success rate 90%success rate 90%–– 9% recurrence9% recurrence–– complication <15%complication <15%

Beckingham, et al. Long-term outcome of endoscopic drainage of pancreatic pseudocysts. Am J Gastroenterol 1999; 94:71

Open surgical managementOpen surgical management

CystCyst--gastrostomygastrostomyCystCyst--duodenostomyduodenostomyRouxRoux--enen--y cysty cyst--jejunostomyjejunostomyDistal Distal pancreatectomypancreatectomy

Open surgical managementOpen surgical managementIndication: Indication: –– cysts associated with infectioncysts associated with infection–– necrosisnecrosis–– cystic tumors cystic tumors –– pseudoaneurysmpseudoaneurysm–– require concomitant operative treatment, like require concomitant operative treatment, like

obstruction, obstruction, ductalductal stricturestricture

Biopsy of the cyst wall and send fluid for Biopsy of the cyst wall and send fluid for pathologypathologyComplication 11Complication 11--24%, mortality 524%, mortality 5--9%, 9%, recurrence 5recurrence 5--8%8%

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

Laparoscopic managementLaparoscopic managementWay et al. reported the first case in 1994Way et al. reported the first case in 1994Park, et al., reported 29 Park, et al., reported 29 pseudocystpseudocyst patient patient treated 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, no up 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 operation in the new field of intraluminal laparoscopic surgery. Surg Ednosc. 1994;8:235

SummarySummary

PseudocystPseudocyst formation is common formation is common after after pancreatitispancreatitisMany will resolve spontaneouslyMany will resolve spontaneouslyObservation may be safe for Observation may be safe for asymptomatic patientsasymptomatic patientsSymptomatic or infected Symptomatic or infected pseudocystspseudocystsrequire therapeutic procedures require therapeutic procedures