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Pancreatic pseudocyst

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This document summarizes information about pancreatic pseudocysts. It defines pancreatic pseudocysts as fluid collections contained by fibrous tissue that develop more than 4 weeks after acute or chronic pancreatitis. It describes the typical location, composition, and pathophysiology of pseudocysts. It also outlines the clinical presentation, diagnostic approach, natural history, potential complications, and treatment options for pancreatic pseudocysts, including percutaneous drainage, endoscopic drainage, and surgical drainage. The preferred intervention is typically endoscopic drainage given its less invasive nature, though surgery may be necessary for complicated or failed non-surgical cases.

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Dr. Abrar Ahmad Post graduate resident Surgical unit 1 BVH Bahawalpur
Pancreatic Pseudocyst A fluid collection contained within a well-defined capsule of fibrous or granulation tissue or a combination of both Does not possess an epithelial lining Persists > 4 weeks May develop in the setting of acute or chronic pancreatitis 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 Most common cystic lesions of the pancreas, accounting for 75-80% of such masses Location Lesser peritoneal sac in proximity to the pancreas Large pseudocysts can extend into the paracolic gutters, pelvis, mediastinum, neck or scrotum May be loculated
Composition Thick fibrous capsule – not a true epithelial lining Pseudocyst fluid Similar electrolyte concentrations to plasma High concentration of amylase, lipase, and enterokinases such as trypsin
Pathophysiology Pancreatic ductal disruption 2° to 1. Acute pancreatitis – Necrosis 2. Chronic pancreatitis – Elevated pancreatic duct pressures from strictures or ductal calculi 3. Trauma 4. Ductal obstruction and pancreatic neoplasms
Pathophysiology 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 with connective tissue and fibrosis
Pathophysiology Chronic Pancreatitis Pancreatic duct chronically obstructed  ongoing proximal pancreatic secretion leads to secular dilation of duct – true retention cyst Formed micro cysts can eventually coalesce and lose epithelial lining as enlarge
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 Clinically suspect a pseudocyst Episode of pancreatitis fails to resolve Amylase levels persistantly high Persistant abdominal pain Epigastric mass palpated after pancreatitis
Diagnosis Labs Persistently elevated serum amylase Plain X-ray Not very useful Ultrasound 75 -90% sensitive CT Most accurate (sensitivity 90-100%)
Pseudocyst compressing the stomach wall posteriorly
Sonographic evaluation
EUS showing pseudocyst
Natural History of Pseudocyst ~50% resolve spontaneously Size Nearly all <4cm resolve spontaneously >6cm 60-80% persist, necessitate intervention Cause Traumatic, chronic pancreatitis <10% resolve Multiple cysts – few spont resolve Duration - Less likely to resolve if persist > 6-8 weeks
Complications Infection 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 (most common), GDA, PDA
Treatment Initial NPO TPN Octreotide Antibiotics if infected 1/3 – 1/2 resolve spontaneously
Intervention Indications for drainage Presence of symptoms (> 6 wks) Enlargement of pseudocyst ( > 6 cm) Complications Suspicion of malignancy Intervention Percutaneous drainage Endoscopic drainage Surgical drainage
Percutaneous Drainage Continuous drainage until output < 50 ml/day + amylase activity ↓ Failure rate 16% Recurrence rates 7% Complications Conversion into an infected pseudocyst (10%) Catheter-site cellulitis Damage to adjacent organs Pancreatico-cutaneous fistula GI hemorrhage Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43
Endoscopic Management 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 from adhering to the enteric wall CT findings  Thick debris  Multiloculated pseudocysts
Endoscopic Drainage Transenteric drainage Cystogastrostomy Cystoduodenostomy Transpapillary drainage 40-70% of pseudocysts communicate with pancreatic duct ERCP with sphincterotomy, balloon dilatation of pancreatic duct strictures, and stent placement beyond strictures
Surgical Options Excision Tail of gland & along with proximal strictures – distal pancreatectomy & splenectomy Head of gland with strictures of pancreatic or bile ducts – pancreaticoduodenectomy External drainage Internal drainage Cystogastrostomy Cystojejunostomy  Permanent resolution confirmed in b/w 91%–97% of patients* Cystoduodenostomy  Can be complicated by duodenal fistula and bleeding at anastomotic site
External Drainage
Cysto-jejunostomy
Enucleation of Pseudocyst
Laparoscopic Management The interface b/w the cyst and the enteric lumen must be ≥ 5 cm for adequate drainage Approaches Pancreatitis 2° to biliary etiology → extraluminal approach with concurrent laparoscopic cholecystectomy Non-biliary origin → intraluminal (combined laparoscopic/endoscopic) approach.
Which is the preferred intervention? Surgical drainage is the traditional approach – gold standard. 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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Pancreatic pseudocyst

  • 1. Dr. Abrar Ahmad Post graduate resident Surgical unit 1 BVH Bahawalpur
  • 2. Pancreatic Pseudocyst A fluid collection contained within a well-defined capsule of fibrous or granulation tissue or a combination of both Does not possess an epithelial lining Persists > 4 weeks May develop in the setting of acute or chronic pancreatitis 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
  • 3. Pancreatic Pseudocyst Most common cystic lesions of the pancreas, accounting for 75-80% of such masses Location Lesser peritoneal sac in proximity to the pancreas Large pseudocysts can extend into the paracolic gutters, pelvis, mediastinum, neck or scrotum May be loculated
  • 4. Composition Thick fibrous capsule – not a true epithelial lining Pseudocyst fluid Similar electrolyte concentrations to plasma High concentration of amylase, lipase, and enterokinases such as trypsin
  • 5. Pathophysiology Pancreatic ductal disruption 2° to 1. Acute pancreatitis – Necrosis 2. Chronic pancreatitis – Elevated pancreatic duct pressures from strictures or ductal calculi 3. Trauma 4. Ductal obstruction and pancreatic neoplasms
  • 6. Pathophysiology 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 with connective tissue and fibrosis
  • 7. Pathophysiology Chronic Pancreatitis Pancreatic duct chronically obstructed  ongoing proximal pancreatic secretion leads to secular dilation of duct – true retention cyst Formed micro cysts can eventually coalesce and lose epithelial lining as enlarge
  • 8. 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
  • 9. Diagnosis Clinically suspect a pseudocyst Episode of pancreatitis fails to resolve Amylase levels persistantly high Persistant abdominal pain Epigastric mass palpated after pancreatitis
  • 10. Diagnosis Labs Persistently elevated serum amylase Plain X-ray Not very useful Ultrasound 75 -90% sensitive CT Most accurate (sensitivity 90-100%)
  • 11. Pseudocyst compressing the stomach wall posteriorly
  • 14. Natural History of Pseudocyst ~50% resolve spontaneously Size Nearly all <4cm resolve spontaneously >6cm 60-80% persist, necessitate intervention Cause Traumatic, chronic pancreatitis <10% resolve Multiple cysts – few spont resolve Duration - Less likely to resolve if persist > 6-8 weeks
  • 15. Complications Infection 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 (most common), GDA, PDA
  • 16. Treatment Initial NPO TPN Octreotide Antibiotics if infected 1/3 – 1/2 resolve spontaneously
  • 17. Intervention Indications for drainage Presence of symptoms (> 6 wks) Enlargement of pseudocyst ( > 6 cm) Complications Suspicion of malignancy Intervention Percutaneous drainage Endoscopic drainage Surgical drainage
  • 18. Percutaneous Drainage Continuous drainage until output < 50 ml/day + amylase activity ↓ Failure rate 16% Recurrence rates 7% Complications Conversion into an infected pseudocyst (10%) Catheter-site cellulitis Damage to adjacent organs Pancreatico-cutaneous fistula GI hemorrhage Gumaste et al: Pancreatic pseudocyst. Gastroenterologist 1996 Mar; 4(1): 33-43
  • 19. Endoscopic Management 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 from adhering to the enteric wall CT findings  Thick debris  Multiloculated pseudocysts
  • 20. Endoscopic Drainage Transenteric drainage Cystogastrostomy Cystoduodenostomy Transpapillary drainage 40-70% of pseudocysts communicate with pancreatic duct ERCP with sphincterotomy, balloon dilatation of pancreatic duct strictures, and stent placement beyond strictures
  • 21. Surgical Options Excision Tail of gland & along with proximal strictures – distal pancreatectomy & splenectomy Head of gland with strictures of pancreatic or bile ducts – pancreaticoduodenectomy External drainage Internal drainage Cystogastrostomy Cystojejunostomy  Permanent resolution confirmed in b/w 91%–97% of patients* Cystoduodenostomy  Can be complicated by duodenal fistula and bleeding at anastomotic site
  • 25. Laparoscopic Management The interface b/w the cyst and the enteric lumen must be ≥ 5 cm for adequate drainage Approaches Pancreatitis 2° to biliary etiology → extraluminal approach with concurrent laparoscopic cholecystectomy Non-biliary origin → intraluminal (combined laparoscopic/endoscopic) approach.
  • 26. Which is the preferred intervention? Surgical drainage is the traditional approach – gold standard. 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.