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Pancreatic Pseudocysts - SNguyen

Pancreatic Pseudocysts - SNguyen - Patient S.C Patient S.C...

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Unformatted text preview: Patient S.C. Patient S.C. 60M h/o alcoholism, chronic pancreatitis, HTN, CAD Reduced Etoh intake 2000, still binge drinks Persistant, intermittent epigastric pain x 1­2 years Past 1­2 months, pain worsening, assoc w/ 20 lb wt loss, anorexia, n/v Chronically moderately elevated amylase CT ­ pseudocyst CT ­ pseudocyst 2/03 5 x 8 cm thick walled pseudocyst in tail of pancreas 5/03 Pseudocyst slightly decreased in size 1/04 New Pseudocyst 8 x 7 cm posterior to stomach Patient C.S. Patient C.S. 1/12 Open Cystgastrostomy ~200 cc of greenish/brown fluid drained Anterior wall of stomach opened to expose posterior wall Hand sewn anastamosis of cyst wall to posterior wall of stomach Pancreatic Pseudocysts Pancreatic Pseudocysts Scott Nguyen Bronx VA Hospital Jan 15, 2004 Definition Definition Localized collection pancreatic secretions Within or adjacent to pancreas Enclosed by a nonepithelialized wall Associated w/ pancreatic duct disruption Etiology Etiology Acute Pancreatitis More associated w/ alcohol related pancreatitis Chronic pancreatitis Pancreatic trauma Pancreatic neoplasm Pathogenesis Pathogenesis Acute Pancreatitis Pancreatic necrosis causes ductular disruption, resulting in leakage of pancreatic juice from inflamed area of gland, accumulates in space adjacent to pancreas Inflammatory response induces formation of distinct cyst wall composed of granulation tissue, organizes w/ connective tissue and fibrosis Pathogenesis Pathogenesis Chronic Pancreatitis Pancreatic duct chronically obstructed ongoing proximal pancreatic secretion leads to saccular dilation of duct – true retention cyst Formed microcysts can eventually coalesce and lose epithelial lining as enlarge Characteristics Characteristics Single or multiple (90% single) Size 2 to 30 cm, 50 to 6000 cc Smooth and rounded Mostly anterior to pancreas, in lesser sac Also can extend to pararenal space, mediastinum, retroperitoneum Large Pseudocyst Large Pseudocyst Multiple Pseudocysts Multiple Pseudocysts Acute Pancreatic Fluid Collections Acute Pancreatic Fluid Collections Fluid collection forming secondary to moderate­severe pancreatitis Lack well defined wall, irregular shape Serous or exudative reaction to pancreatic injury No communication w/ pancreatic duct Don’t contain pancreatic enzymes 65% regress spontaneously May go on to become pseudocyst (> 3wks) Acute Fluid Collection Acute Fluid Collection Symptoms and Signs Symptoms and Signs Insidious midepigastrium pain, radiation to back Pain aggravated by food n/v, abdominal fullness Small to moderate cysts can be assymptomatic Palpable mass in epigstrium if large Jaundice only in 10% Also may have pleural effusion, chylous ascites, portal hypertension Diagnosis Diagnosis Clinically suspect a pseudocyst Episode of pancreatitis fails to resolve Amylase levels persistantly high Persistant abdominal pain Epigastric mass palpated after pancreatitis Diagnosis Diagnosis Labs Plain X­ray Not very useful Ultrasound Persistently elevated serum amylase 75 ­90% sensitive CT Most accurate (sensit 90­100%) ERCP in workup of Pseudocyst ERCP in workup of Pseudocyst Controversy whether if should be done routinely 95% demonstrates pancreatic ductal abnormalities 20% incidence of unsuspected multiplicity 80% demonstrates duct­pseudocyst communication Can exacerbate acute pancreatitis Risk of causing secondary infection of pseudocyst Natural History of Pseudocyst Natural History of Pseudocyst ~50% resolve spontaneously Size Nearly all <4cm resolve spontaneously >6cm 60­80% persist, necessitate intervention Cause Traumatic, chronic pancreatitis <10% resolve Multiple cysts – few spont resolve Duration ­ Less likely to resolve if persist > 6­ 8 weeks Persistant Pseudocysts Persistant Pseudocysts New Pseudocyst should be observed for 4­6wks Intervention indicated if Increases in size Cyst becomes infected Persistantly symptomatic Complications arise Immediate drainage if arises in chronic pancreatitis, or if already have a mature wall If assymptomatic, non­enlarging can be monitored Pseudocyst complications Pseudocyst complications Infection Rupture Pancreatic Ascites Pseudoaneurysm Bowel Obstruction Jaundice Other Cystic Lesions of Pancreas Other Cystic Lesions of Pancreas Pseudocysts comprise 75% of cystic lesions 10% ­ Retention cysts 5% ­ Congenital cysts 10% ­ Cystic neoplasms Neoplastic Cysts Neoplastic Cysts 10% pancreatic cysts – serous cystadenomas, mucinous cystadenomas, mucinous cystadenocarcinomas Differentiation from pseudocysts is essential for management More likely a neoplastic cyst if: No preceding hx of acute or chronic pancreatitis ERCP showed normal pancreatogram Neoplastic cysts Neoplastic cysts Percutaneous Cyst fluid aspiration and analysis – CA­125 and CEA elevated Amylase low Cytology helpful in mucinous neoplasms Biopsy of cyst wall– 80% accurate Potential risk of peritonitis and tumor seeding after cyst puncture Therapeutic Options Therapeutic Options Percutaneous Drainage Endoscopic Drainage Surgical Intervention Percutaneous Drainage Percutaneous Drainage Aspiration / Catheter Drainage under Radiographic guidance Percutaneous aspiration Ideal for diagnosis, ineffective for therapy Cysts w/ thick walls won’t collapse Cysts w/ ductal communication will reacumulate fluid w/in 24 hrs Percutaneous Drainage Percutaneous Drainage Catheter Drainage 70­90% successful Complications – persistant pancreatic fistula necessitating surgery Adjunctive octeotride decreases drainage Good for poor­risk patients, immature cysts, infected pseudocysts Endoscopic Drainage Endoscopic Drainage Transpapillary Drainage Endoscopic Cystgastrostomy Endoscopic Cystduodenostomy Up to 60­80% successful in drainage of pseudocyst 10­20% recurrence Transpapillary Drainage Transpapillary Drainage Only sucessful if pseudocyst communicates w/ pancreatic duct…. Guidwire placed into pancreatic duct to pseudocyst, then stent passed Success in 85%, Recurrence 10% Technically demanding Risk – acute pancreatitis Complications – stent breakage, blockage, infection Endoscopic Cystgastrostomy and Endoscopic Cystgastrostomy and Cystduodenostomy Ideal for pseudocysts firmly adhered to stomach or duodenum Puncture cyst from bowel lumen, place stents over wire…left in place until cyst resolution Sucessful 80­90%, Recurrance 20% Complications – bleeding, perforation Surgical Intervention Surgical Intervention External Drainage Internal Drainage Cystgastrostomy, Cystduodenostomy, Cystjejunostomy Traditionally treatment of choice Allows biopsy of cyst wall to r/o neoplasm External Drainage External Drainage Open drainage of cyst Immature cysts – thin, nonfibrous wall that won’t hold stitches Grossly infected cysts Ruptured cysts Pts in poor medical condition, unable to withstand complicated surgical procedure May result in persistant pancreaticocutaneous fistula External Drainage External Drainage Internal Drainage Internal Drainage Suturing cyst to bowel lumen Cystgastrostomy – for cysts adhered to posterior wall of stomach Cystduodenostomy – cysts in head and uncinate process of pancreas Cystjejunostomy – via Roux­en Y limb, for cysts adhered elsewhere i.e. to transverse mesocolon Cyst­jejunostomy Cyst­jejunostomy Surgical Intervention Surgical Intervention Successful Drainage in 80­90% Recurrence 10­20% Which is the preferred intervention? Which is the preferred intervention? Surgical drainage is the traditional approach – gold standart Percutaneous catheter drainage – high chance of persistant pancreatic fistula Endoscopic drainage ­ less invasive, becoming more popular, technically demanding Surgery necessary in complicated pseudocyts, failed nonsurgical, and multiple pseudocysts ...
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