Pancreatic pseudocysts

Made by : roll no 31-40Aarushi agarwal batch

Group leader : roll no. 32Sajangiri goswami

Normal Anatomy by CT

Pancreas arcing anteriorly over spine

Head adjacent to duodenum

Tail extending toward spleen

Splenic vein posterior to body and tail

Portal vein confluence immediately posterior & left of pancreatic neck

Normal Morphology by CT

Pancreatic acini → lobulated contour No capsule AP dimensions

Head 2-2.5 cm Body and tail 1-2 cm

Pancreatic duct Maximal diameter 3 mm in adults (5 mm

in elderly) Empties into ampulla of Vater, along medial

aspect of 2nd portion of duodenum

Definition

What is a pancreatic pseudocyst?

A pancreatic pseudocyst is a collection of fluid around the pancreas. The fluid in the cyst is usually pancreatic juice that has leaked out of a damaged pancreatic duct. Pancreatic pseudocysts arise after acute pancreatitis or chronic pancreatitis. In some patients the pseudocyst may develop soon after an attack of acute pancreatitis. Often the patient can present many weeks or months after recovery from of an attack of acute or chronic pancreatitis.

How do patients present with pancreatic pseudocysts?

The common symptoms that patients present are pain in the abdomen, the feeling of bloating or poor digestion of food, a deep ache in the abdomen or complications related to the pseudocyst such as infection of the pseudocyst with a pancreatic abscess, bleeding into the pseudocyst or blockage of parts of the intestine by the pseudocyst.

28 year-old man with pseudocyst

Image demonstrates a pseudocyst (arrow) in the tail of the pancreas surrounded by a thick enhancing wall. The lesion appears heterogeneous

with central areas of higher attenuation, which is suggestive of fresh hemorrhage. Note infiltration (arrowheads) of the peripancreatic fat.

How are pancreatic pseudocysts diagnosed?

The diagnosis is usually made by a CT scan. A typical picture is seen on CT of a fluid filled mass around the pancreas. It is important to note that in some patients, cystic tumors such as mucinous cystadenoma may look exactly like a pseudocyst. An evaluation by an experience radiologist and a surgeon to evaluate the cyst is important for appropriate care?

Evaluation by CT

Management

How are pancreatic pseudocysts treated?

All cysts do not require treatment. In many cases the pseudocysts may improve and go away on their own. In a patient with a small (less than 6cm) cyst that is not causing any symptoms, careful observation of the cyst with periodic CT scans is indicated. In a significant number of patients the cyst will get better and resolve. If a pseudocyst is persistent over many moths or causing symptoms then treatment of the cyst is required.

Treatment of pseudocysts

A number of different types of treatments are available for pseudocysts. The treatment of pancreatic pseudocyst is complex and should be performed in an institution where a multidisciplinary team of experienced pancreatic surgeons, gastroenterologists and radiologist work together. The optimal procedure whether it is performed by the surgeon, gastroenterologist or the radiologist is therefore provided to the patient.

Surgical treatment of pancreatic pseudocyst

The majority of patients who require treatment for their pseudocysts are treated by surgery. In the surgical procedure for the treatment of pseudocyst a connection is created between the cyst and an adjacent intestinal organ to which the cyst is adherent to such as the stomach. This connection allows the cyst to drain into the stomach. Since in many patients the cyst is formed by continuous leakage of pancreatic juice into the cyst this allows the pancreatic juice to be rerouted into the intestine through the connection.

Cystgastrostomy: In this surgical procedure a connection is created between the back wall of the stomach and the cyst such that the cyst drains into the stomach.

Cystjejunostomy: In this procedure a connection is created between the cyst and the small intestine so that the cyst fluid directly into the small intestine.

Cystduodenostomy: In this procedure a connection is created between the duodenum (the first part of the intestine) and the cyst to allow drainage of the cyst content into duodenum

The type of surgical procedure depends on the location of the cyst. For cysts that occur in the body and tail of the pancreas either a cystjejunostomy or cystgastrostomy is performed depending on the location of the cyst in the abdomen. For pseudocysts that occur in the head of the pancreas a cystduodenostomy is usually performed.

Laparoscopic treatment for pseudocysts

At USC we have developed a laparoscopic procedure for treatment of pancreatic pseudocysts. In this procedure a cystjejunostomy or cystgastrostomy is performed utilizing minimal access techniques. Patients recover rapidly from this procedure usually discharged home on the second day post-operatively.

Drainage of the pseudocyst by a radiologist:

In this procedure a radiologist inserts a thin needle into the pseudocyst under guidance with an CT x-ray and to drain all the fluid. While sometimes this technique is successful, often this technique may give rise to a significant number of complications such as persistent leakage from the drain that the radiologist places to drain the cyst over many weeks or months, infection of the pseudocyst and repeated procedures to have the drain changed. Because of the multiple problems associated with this treatment we seldom recommend this treatment for drainage of pseudocyst.

Drainage of the pseudocyst by endoscopic techniques

In this procedure a gastroenterologist drains the pseudocyst through the stomach by creating a small opening between the cyst and the stomach during endoscopy. In selected patients this treatment can successfully treat pseudocyst. The disadvantage of this technique is that if there is dead tissue in the pseudocyst cavity or if the cyst is very large then infection or recurrence of pseudocyst with this technique may occur.

Insertion of a pancreatic stent: In this technique the gastroenterologist may insert a drain into the cyst during a procedure called ERCP. If the drain is placed directly into the cyst then the fluid from the cyst is drained into the intestine through this tube.

Outlook (Prognosis)

The outcome is generally good with treatment. It is important to make sure that it is not a pancreatic cancer that starts in a cyst, which has a worse outcome.

Complications

A pancreatic abscess can develop if the pseudocyst becomes infected.

The pseudocyst can break open (rupture), which can be a serious complication because shock and excess bleeding (hemorrhage) may develop.

The pseudocyst may press down on (compress) nearby organs.

References

Forsmark CE. Pancreatitis. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 146.

Forsmark Ce, Baillie J. AGA Institute Technical Review on acute pancreatitis. Gastroenterology. 2007;132:2022-2044.

THANK YOU!!!