pancreatic pseudocysts · • fewer adverse events if ercp -based treatment algorithm is used ....

PANCREATIC PSEUDOCYSTS

Madhuri Rao MD PGY-5

Kings County Hospital Center

www.downstatesurgery.org

Case Presentation • 34 yo M

• PMH: Chronic pancreatitis (ETOH related)

• PSH: Nil

• Meds: Nil

• NKDA • Symptoms

o Chronic abdominal pain o Nausea, vomiting and early satiety


Case Presentation • Signed out AMA in Dec 2013 after being scheduled

for cystgastrostomy

• Presents in March 2014 with increasing pain

• O/E: Soft, fullness in epigastrium, tender

• Labs: WNL


OR details Procedure: Laparoscopic cystgastrostomy

• Ports: Umbilical, epigastric , RUQ, LUQ

• Anterior gastrotomy

• Posterior gastrotomy

• Drainage of pseudocyst

• Thorough inspection of cavity

• Cyst gastrostomy using stapling device

• Closure of anterior gastrotomy with stapling device


Post-Op Course POD 1 • NGT removed • Started on clears POD 2 • Tolerating regular diet • Discharged


Discussion • Definition and terminology • Pathophysiology • Clinical features • Diagnosis • Management • Literature review


Definition and Terminology • Collection of pancreatic exocrine secretions

contained within a fibrous sac of chronic inflammatory cells and fibroblasts

• 2013 revision of Atlanta classification of acute pancreatitis o Acute Interstitial Edematous Pancreatitis (IEP) o Necrotizing Pancreatitis (NP)


Definition and Terminology Peripancreatic Fluid Collections with IEP • Acute Peripancreatic Fluid Collections (APFC)

o < 4 weeks

• Pancreatic Pseudocysts o > 4 weeks

Peripancreatic Fluid Collections with NP • Postnecrotic Peripancreatic Fluid Collection (PNPFC)

o < 4 weeks

• Walled Off Pancreatic Necrosis (WOPN) o > 4 weeks


Pathophysiology Pancreatic duct disruption Natural History: duct heals or persistent fistula or ductal stricture Acute Pancreatitis • 10% • inflammation, ischemia, increased ductal pressure • Necrosis, liquefaction, ductal disruption Chronic Pancreatitis • 20-40% • Post inflammatory fibrosis and obstruction • Acute exacerbation Trauma


Presenter

Presentation Notes

Ductal communication

Pathophysiology

D’egidio Classification

Context Pancreatic Duct Duct-Pseudocyst Communication

Type I Acute postnecrotic pancreatitis Normal No

Type II Acute-on-chronic pancreatitis Abnormal (no stricture) 50:50

Type III Chronic pancreatitis Abnormal (stricture) Yes


Clinical Features Asymptomatic Symptomatic • Pain • Nausea/Vomiting • Early satiety • Palpable mass

Complications • Infection • Mass effect – biliary/duodenal obstruction • Fistula formation – pancreatic ascites, pleural effusion • Bleeding – pseudoaneurysm, UGI bleeding


Diagnosis • History • Imaging – CT, MRI

o Delineate anatomy o Therapeutic options

PP • Well circumscribed • Extrahepatic • Homogenous

WOPN • Well circumscribed • Extra or intrahepatic • Heterogenous


Diagnosis Role of ERCP • Ductal communication • Within 48 hours of planned drainage • Fewer adverse events if ERCP-based treatment

algorithm is used

MRCP with Secretin Injection

Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg. 2002;235:751–758.


Diagnosis Differential Diagnosis – Pancreatic Cystic Neoplasms

• History

• CT – No inflammatory changes

• EUS with FNA

o Internal septae o Amylase > 1000 IU/L


Management Expectant Management vs. Intervention Indications for intervention • Traditional criteria

o > 6 cm o > 6 weeks

• Current Criteria o Symptomatic o Prevent and treat complications o Ductal anatomy in relation to cyst o Changing size criteria

Mehta R, et al. Natural course of asymptomatic pancreatic pseudocyst: a prospective study. Indian J Gastroenterol. 2004;23:140–142. Johnson MD, et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol. 2009; 43:586–590. Varadarajulu S, et al. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc. 2008;68:649–655.


Presenter

Presentation Notes

Size criteria ( 7.5/ 9)- 25,26,27 from maingot

Treatment Approaches www.downstatesurgery.org

Presenter

Presentation Notes

No randomized trials

Surgical Drainage Open, laparoscopic, intraluminal laparoscopic surgery Recurrence 5% Morbidity 25% Location


Surgical Drainage • Internal drainage

Cystgastrostomy Cystjejunostomy


Surgical Drainage • Lateral pancreaticojejunostomy – Chronic

pancreatitis with dilated duct

• Distal pancreatectomy o Small duct disease with stricture o Disconnected left pancreatic remnant


Surgical Drainage • External drainage

o Critically ill o Immature ruptured cyst o Bleeding pseudocyst


Endoscopic Drainage • Local expertise • 90% overall success • 10-15% recurrence rate • 20% morbidity

o Bleeding o Perforation o Infection o Repeat procedures

Transpapillary stenting Transmural drainage


Endoscopic Drainage Contraindications • Pancreatic necrosis • Lack of mature wall • Pseudoaneurysm


Percutaneous Drainage • External drainage • 10-30% morbidity • Octreotide to decrease drainage • Transgastric approach • Indications

o For simple pseudocyst (Type 1 D’egidio) o Temporizing measure in sepsis


Presenter

Presentation Notes

Study from uptodate

Evidence Based Management Endoscopic vs. Surgical drainage • Fewer complications with endoscopic intervention • Shorter hospital length of stay • More cost effective

Percutaneous vs. Surgical drainage • Higher morbidity and mortality • Longer hospital stay • Salvage surgical drainage

Nealon WH, et al.. Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas. Ann Surg 2005;241:948–957; discussion 957–960. Varadarajulu S,, et al. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc 2008;68:649–655. Heider R, et al. Percutaneous Drainage of Pancreatic Pseudocysts Is Associated With a Higher Failure Rate Than Surgical Treatment in Unselected Patients. Ann Surg. Jun 1999; 229(6): 781.


Summary • Types of peripancreatic fluid collections

• Clinical presentation and complications depending

on location and extent

• Diagnosis o History and imaging o Rule out cystic neoplasm

• Management

o Surgical vs. Endoscopic vs. Percutaneous o Symptoms, location, complications


Question 1 CT scan demonstrates a 5 cm peripancreatic fluid collection in a patient 3 weeks after an episode of acute pancreatitis. The patient is eating and has no clinical signs of an infection. What is the recommended treatment? A. Expectant management without intervention B. NPO and TPN C. Percutaneous catheter drainage D. Reimaging in 3-6 weeks and surgery for internal

drainage if collection persists


Question 2 Which of the following is the most important determinant of the need for drainage of a pancreatic pseudocyst? A. Pseudocyst symptoms B. Pseudocyst size C. Pseudocyst duration D. Associated chronic pancreatitis E. Patient age


Thank You


pancreatic pseudocysts · • fewer adverse events if ercp -based treatment algorithm is used ....

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