PANCREATIC PSEUDOCYSTS. Madhuri Rao MD PGY-5 Kings County Hospital Center

Transcription

1 PANCREATIC PSEUDOCYSTS Madhuri Rao MD PGY-5 Kings County Hospital Center

2 34 yo M Case Presentation PMH: Chronic pancreatitis (ETOH related) PSH: Nil Meds: Nil NKDA Symptoms o Chronic abdominal pain o Nausea, vomiting and early satiety

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8 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

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16 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

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

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

19 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)

20 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

21 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

22 Pathophysiology Type I Type II Context Acute postnecrotic pancreatitis Acute-on-chronic pancreatitis D egidio Classification Pancreatic Duct Normal Duct-Pseudocyst Communication No Abnormal (no stricture) 50:50 Type III Chronic pancreatitis Abnormal (stricture) Yes

23 Asymptomatic Symptomatic Pain Nausea/Vomiting Early satiety Palpable mass Clinical Features Complications Infection Mass effect biliary/duodenal obstruction Fistula formation pancreatic ascites, pleural effusion Bleeding pseudoaneurysm, UGI bleeding

24 Diagnosis History Imaging CT, MRI PP o Delineate anatomy o Therapeutic options Well circumscribed Extrahepatic Homogenous WOPN Well circumscribed Extra or intrahepatic Heterogenous

25 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:

26 Diagnosis Differential Diagnosis Pancreatic Cystic Neoplasms History CT No inflammatory changes EUS with FNA o Internal septae o Amylase > 1000 IU/L

27 Management Expectant Management vs. Intervention Indications for intervention Traditional criteria o > 6 cm o > 6 weeks Current Criteria o o o o Symptomatic Prevent and treat complications Ductal anatomy in relation to cyst Changing size criteria Mehta R, et al. Natural course of asymptomatic pancreatic pseudocyst: a prospective study. Indian J Gastroenterol. 2004;23: Johnson MD, et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol. 2009; 43: Varadarajulu S, et al. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc. 2008;68:

28 Treatment Approaches

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

30 Surgical Drainage Internal drainage Cystgastrostomy Cystjejunostomy

31 Surgical Drainage Lateral pancreaticojejunostomy Chronic pancreatitis with dilated duct Distal pancreatectomy o Small duct disease with stricture o Disconnected left pancreatic remnant

32 Surgical Drainage External drainage o Critically ill o Immature ruptured cyst o Bleeding pseudocyst

33 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

34 Endoscopic Drainage Contraindications Pancreatic necrosis Lack of mature wall Pseudoaneurysm

35 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

36 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: ; discussion Varadarajulu S,, et al. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc 2008;68: 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.

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38 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

39 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

40 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

41 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

42 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

43 Thank You