- (2006) Volume 7, Issue 5
Dinesh Singhal1, Rahul Kakodkar1, Randhir Sud2, Adarsh Chaudhary1*
Departments of 1Surgical and 2Medical Gastroenterology, Sir Ganga Ram Hospital. New Delhi, India
Received June 1st, 2006 - Accepted July 14th, 2006
Pancreatic pseudocysts (PPs) comprise more than 80 % of the cystic lesions of the pancreas and cause complications in 7-25% of patients with pancreatitis or pancreatic trauma. The first step in the management of PPs is to exclude a cystic tumor. A history of pancreatitis, no septation, solid components or mural calcification on CT scan and high amylase content at aspiration favor a diagnosis of PP. Endoscopic ultrasound (EUS)-guided FNAC is a valuable diagnostic aid. Intervention is indicated for PPs which are symptomatic, in a phase of growth, complicated (infected, hemorrhage, biliary or bowel obstruction) or in those occurring together with chronic pancreatitis and when malignancy cannot be unequivocally excluded. The current options include percutaneous catheter drainage, endoscopy and surgery. The choice depends on the mode of presentation, the cystic morphology and available technical expertise. Percutaneous catheter drainage is recommended as a temporizing measure in poor surgical candidates with immature, complicated or infected PPs. The limitations include secondary infection and pancreatic fistula in 10-20% of patients which increase complications following eventual definitive surgery. Endoscopic therapy for PPs including cystic-enteric drainage (and transpapillary drainage), is an option for PPs which bulge into the enteric lumen which have a wall thickness of less than 1 cm and the absence of major vascular structures on EUS in the proposed tract or those which communicate with the pancreatic duct above a stricture. Surgical internal drainage remains the gold standard and is the procedure of choice for cysts which are symptomatic or complicated or those having a mature wall,. Being more versatile, a cystojejunostomy is preferred for giant pseudocysts (>15cm) which are predominantly inframesocolic or are in an unusual location. In PPs with coexisting chronic pancreatitis and a dilated pancreatic duct, duct drainage procedures (such as longitudinal pancreaticojejunostomy) should be preferred to a cyst drainage procedure.
Cystadenoma; Cysts; Endosonography; Pancreas; Pancreatic Pseudocyst; Surgery
MCA: mucinous cystadenoma; MCAC: mucinous cystadenocarcinoma; SCA: serous cystadenoma
Pancreatic pseudocysts (PPs) comprise more than 80 % of the cystic lesions of the pancreas and cause complications in 7-25% of patients with pancreatitis or pancreatic trauma. The first step in the management of PPs is to exclude a cystic tumor. A history of pancreatitis, no septation, solid components or mural calcification on CT scan and high amylase content at aspiration favor a diagnosis of PP. Endoscopic ultrasound (EUS)-guided FNAC is a valuable diagnostic aid. Intervention is indicated for PPs which are symptomatic, in a phase of growth, complicated (infected, hemorrhage, biliary or bowel obstruction) or in those occurring together with chronic pancreatitis and when malignancy cannot be unequivocally excluded. The current options include percutaneous catheter drainage, endoscopy and surgery. The choice depends on the mode of presentation, the cystic morphology and available technical expertise. Percutaneous catheter drainage is recommended as a temporizing measure in poor surgical candidates with immature, complicated or infected PPs. The limitations include secondary infection and pancreatic fistula in 10-20% of patients which increase complications following eventual definitive surgery. Endoscopic therapy for PPs including cystic-enteric drainage (and transpapillary drainage), is an option for PPs which bulge into the enteric lumen which have a wall thickness of less than 1 cm and the absence of major vascular structures on EUS in the proposed tract or those which communicate with the pancreatic duct above a stricture. Surgical internal drainage remains the gold standard and is the procedure of choice for cysts which are symptomatic or complicated or those having a mature wall,. Being more versatile, a cystojejunostomy is preferred for giant pseudocysts (>15cm) which are predominantly inframesocolic or are in an unusual location. In PPs with coexisting chronic pancreatitis and a dilated pancreatic duct, duct drainage procedures (such as longitudinal pancreaticojejunostomy) should be preferred to a cyst drainage procedure.
* In the setting of chronic pancreatitis, pseudocysts are often thick-walled and associated with morphological changes (disruption, strictures, stones) in the pancreatic duct. Hence they are less likely to undergo spontaneous resolution which is a common occurrence in post-acute pancreatitis pseudocysts.
* Intraductal papillary mucinous tumors (IPMT), which may mimic multiple pseudocysts, are seen as a cystic dilatation of the main or a branch of the pancreatic duct but they usually occur in elderly males, are located in the uncinate process, have septa, communicate with the duct with mural nodules and are characteristically associated with the fish mouth appearance of the papilla spewing mucus. The association of IPMT with pancreatitis is not well understood.
EUS-guided FNA is an adjunct for diagnosis when standard imaging techniques are unable to differentiate between tumor and pseudocyst. ERCP is performed when an IPMT is suspected. Intraductal and/or intracystic biopsy is usually diagnostic.
MCA: mucinous cystadenoma; MCAC: mucinous cystadenocarcinoma; SCA: serous cystadenoma. [1, 2]
* EUS-guided drainage is an option for selected patients with non-bulging cysts or those with left portal hypertension or intervening vessels when performed by an expert. [5, 6, 7]
* Endoscopic cystogastrostomy may be safely performed for cysts which bulge into the stomach when surgical risk is unacceptable, and whenever such endoscopic expertise is available.
External drainage (surgical or image-guided) is employed to stabilize patients with sepsis or complications when definitive surgery is not technically feasible (immature walls). The associated complications are pancreatic fistulas and drain tract infections. External drainage is best suited for patients with normal pancreatic duct without cyst-duct communication. In the setting of chronic pancreatitis, external drainage is more likely to fail and increase complications after subsequent definitive surgery [8, 9].
* Endoscopic cysotduodenostomy can be performed for suitable cysts by expert endoscopists. In some patients with duodenal obstruction and cystic dystrophy of the duodenal wall due to head dominant pancreatitis, a pancreaticoduodenectomy may be considered.
