Pancreatic Pseudocyst -KSherafgan

Pancreatic Pseudocyst -KSherafgan - Pancreatic Pseudocyst...

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Unformatted text preview: Pancreatic Pseudocyst Pancreatic Kashaf Sherafgan, MD Surgery IV Conference May 5th 2006 Pancreatic Pseudocyst Pancreatic A fluid collection contained within a welldefined capsule of fibrous or granulation defined tissue or a combination of both tissue Does not possess an epithelial lining Persists > 4 weeks May develop in the setting of acute or May chronic pancreatitis chronic Bradley III et al. A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Arch Surg. 1993;128:586-590 Pancreatic Pseudocyst Pancreatic Most Most common cystic lesions of the pancreas, accounting for 75-80% of such masses accounting Location Lesser peritoneal sac in proximity to the Lesser pancreas pancreas Large pseudocysts can extend into the Large paracolic gutters, pelvis, mediastinum, neck or scrotum scrotum May be loculated Composition Composition Thick Thick fibrous capsule – not a true epithelial lining lining Pseudocyst fluid Similar electrolyte concentrations to plasma High concentration of amylase, lipase, and High enterokinases such as trypsin enterokinases Pathophysiology Pathophysiology Pancreatic Acute Acute ductal disruption 2° to pancreatitis – Necrosis Chronic pancreatitis – Elevated pancreatic Chronic duct pressures from strictures or ductal calculi Trauma Ductal obstruction and pancreatic neoplasms Presentation Presentation Symptoms Abdominal pain > 3 weeks (80 – 90%) Nausea / vomiting Early satiety Bloating, indigestion Signs Tenderness Abdominal fullness Cohen et al: Pancreatic pseudocyst. In: Cameron JL, ed. Current Surgical Therapy. 7th ed.; 2001: 543-7 Diagnosis Diagnosis CT scan MRI / MRCP Ultrasonography Endoscopic Ultrasonography (EUS) ERCP Pseudocyst compressing the stomach wall posteriorly stomach Sonographic evaluation Sonographic EUS showing pseudocyst EUS Complications Complications Infection S/S S/S – Fever, worsening abd pain, systemic signs of sepsis CT – Thickening of fibrous wall or air within the cavity GI obstruction Perforation Hemorrhage Thrombosis – SV (most common) Pseudoaneurysm formation – Splenic artery Pseudoaneurysm (most common), GDA, PDA (most Treatment Treatment Initial NPO TPN Octreotide Antibiotics if infected 1/3 – 1/2 resolve spontaneously Intervention Intervention Indications for drainage Presence of symptoms (> 6 wks) Enlargement of pseudocyst ( > 6 cm) Complications Suspicion of malignancy Intervention Intervention Percutaneous drainage Endoscopic drainage Surgical drainage Percutaneous Drainage Percutaneous Continuous Continuous drainage until output < 50 ml/day + amylase activity ↓ Failure Failure rate 16% Recurrence rates 7% Recurrence Complications Conversion into an infected pseudocyst (10%) Catheter-site cellulitis Catheter-site Damage to adjacent organs Pancreatico-cutaneous fistula GI hemorrhage Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43 Endoscopic Management Endoscopic Indications Mature cyst wall < 1 cm thick Adherent to the duodenum or posterior gastric wall Previous abd surgery or significant comorbidities Contraindications Bleeding dyscrasias Gastric varices Acute inflammatory changes that may prevent cyst Acute from adhering to the enteric wall from CT findings Thick debris Thick Multiloculated pseudocysts Endoscopic Drainage Endoscopic Transenteric drainage Cystogastrostomy Cystoduodenostomy Transpapillary 40-70% 40-70% drainage of pseudocysts communicate with pancreatic duct pancreatic ERCP with sphincterotomy, balloon dilatation ERCP of pancreatic duct strictures, and stent placement beyond strictures placement Surgical Options Surgical Excision Tail Tail of gland & a/w proximal strictures – distal pancreatectomy & splenectomy pancreatectomy Head of gland with strictures of pancreatic or bile Head ducts – pancreaticoduodenectomy ducts External drainage Internal drainage Cystogastrostomy Cystogastrostomy Cystojejunostomy Permanent patients* resolution confirmed in b/w 91%–97% of Cystoduodenostomy Can Can be complicated by duodenal fistula and bleeding at Nealon et al, Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. anastomotic site anastomotic Ann Surg. 2001;233:793–800 Laparoscopic Management Laparoscopic The The interface b/w the cyst and the enteric lumen must be ≥ 5 cm for adequate drainage drainage Approaches 2° to biliary etiology → extraluminal approach w/ concurrent laparoscopic cholecystectomy laparoscopic Non-biliary origin → intraluminal (combined Non-biliary laparoscopic/endoscopic) approach Pancreatitis Enucleation of Pseudocyst Enucleation Surgical management of complications a/w percutaneous and/or endoscopic management of pseudocyst of the pancreas pseudocyst Nealon et al Ann Surg. 2005 Jun;241(6):948-57 2005 Methods Methods 10-year prospective study examining complications of endoscopic, percutaneous and surgical drainage and their operative management Collected data ICU monitoring Hemorrhage Shock (SBP < 90 mm Hg) Renal failure Ventilator support Duration of fistula drainage following percutaneous drainage Necessity for urgent or emergent operation Pancreatic ductal anatomy evaluated by means of ERCP or MRCP Results – Non-operative group Results 79 patients with complications of PD, E, or both 66/79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent Mean elapsed time from diagnosis to nonoperative intervention was 18.1 days Mean 3.1±0.7 hospitalizations (range, 1–7) and length-of-stay 42.7±4.1 days 63/79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct Results – Surgical group Results Complications occurred in 6/100 (6%) Elective operation performed a mean interval of 42.7 days after diagnosis of pseudocyst Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients CT imaging obtained at least 6 months after intervention 91% complete resolution 9% with cystic structures < 2 cm In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions < 2 cm in diameter Pseudocyst Characteristics Pseudocyst Interval From Episode of Acute Pancreatitis to Intervention Postprocedure Complications Postprocedure Specific modalities employed Specific Endoscopic management Transmural stents – 14/34 patients Transpapillary drainage – 20/34 patients Indications for Operation in Patients with Complications of Percutaneous or Endoscopic management Endoscopic Operation for Failed Nonoperative Measures Categories of Ductal Anatomy Categories Type 1 – Normal PD with a noncommunicating pseudocyst represented by the dotted mass Type 2 – Normal duct with cyst communication Type 5 – Isolated pancreatic segment Types 6 and 7 – Chronic pancreatitis Impact of Early Intervention on Complications and Outcomes in Endoscopic/Percutaneous Drainage Outcomes Discussion Discussion Morbidity rates of operative management of pseudocyst range from 4% – 30% Success rates Endoscopic/percutaneous Surgical – 94%–99% – 60%–90% Discussion, cont. Discussion, Patients who failed non-operative measures should have a period of stabilization prior to operation Important to reverse sepsis and to improve nutritional status prior to intervention Technically challenging to operate on patients who failed nonoperative measures Necessary to completely abolish the prior cystic structure once it has been decompressed and the walls have fused Dissection is more challenging than the dissection involved in simply defining a pseudocyst and draining it Management Recommendations Management Without evidence of complications, simple observation x min 6 wks Infected pseudocysts should be managed with percutaneous drainage until the patient is stabilized Severe nutritional deficits, at times an indication for percutaneous drainage, should be addressed Once the pseudocyst is established as persistent, observe truly asymptomatic patients with small cysts Management Recommendations, cont. Management Intervention in all pseudocysts > 6 cm, symptomatic patients Use ductal anatomy to guide choice of modality Types V, VI, and VII ductal injuries are all managed operatively Types I and II are always managed nonoperatively Types III and IV are still under debate Significant complications are likely to occur should nonoperative measures be used in patients most likely to sustain complications References References Swayer et al. Pancreatic pseudocyst. http://www.emedicine.com/radio/topic576.htm Bradley III et al. A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Arch Surg. 1993;128:586-590 Cohen et al. Pancreatic pseudocyst. In: Cameron JL, ed. Current Surgical Therapy. 7th ed.; 2001: 543-7 Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43 Nealon et al, Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. Ann Surg. 2001;233:793–800 Nealon et al. Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas. Ann Surg. 2005 Jun;241(6):948-57 ...
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