Surgical Treatments for Pancreatic Pseudocysts

Resumen pancreatic pseudocyst is a localized collection of pancreatic-enzyme-rich fluid, originating from or near the pancreas and is enclosed in a wall of granulation and/or fibrous tissue, which lacks epithelial lining (Rossoa 2003). The incidence of chronic pancreatitis has been increasing and pancreatic pseudocyst is a common complication. Advances in radiological techniques have led to increased diagnosis of pseudocyst and better understanding of associated complications and the natural history of pseudocysts. New modes of treating the ailment have also increased surgical options. Statistics reveal that two-thirds of all pancreatic cystic lesions are pseudocysts, which complicate pancreatitis in 20-40% of patients, and that pseudocysts develop in 10-20% of acute pancreatitis patients. Furthermore, 14 or 14% of 102 consecutive patients with acute pancreatitis developed a pseudocyst within 72 hours from admission (Rossoa).

The purpose of this protocol is to identify the different surgical treatments for pancreatic pseudocysts and to determine if drainage is the best among them.

Findings show that open surgical treatment has been the preferred management of pancreatic pseudocysts (Rossoa 2003). Surgery is indicated in the event of a contraindication or failure of endoscopic and radiological methods, for complex pseudocysts or multiple main pancreatic duct strictures, associated complex pathology, pseudocysts with a main bile duct stricture, venous occlusive disease, multiple pseudocysts, most pseudocysts of the pancreatic tail, hemorrhage inadequately controlled by angiographic transcatheter embolization and suspected neoplastic cysts. The three main surgical treatments available for the treatment of pancreatic pseudocysts are internal drainage, pancreatic resections and external drainage (Rossoa).

These findings conclude that drainage is not the best surgical option for pancreatic pseudocysts, as commonly believed or accepted. Most cases resolve spontaneously and patients do well without intervention (Rossoa 2003). Findings even reveal that patients develop complications or get worse when subjected to drainage and that the failure rate of drainage procedures is approximately 10%, the recurrence rate is about 15% and the rate of complications is 15-20% (Rossoa).

Planteamiento del Problema pancreatic pseudocyst may regress spontaneously persist with or without symptoms or progress to produce complications (Rossoa 2003). In most cases of acute pancreatitis, fluid collections resolve but 10-20% will develop into pseudocysts and out of this number, only 5% became clinically significant. Only pseudocysts with a size index greater than or equal to 15 cm2 needed treatment. Acute or chronic pancreatitis or abdominal trauma causes pseudocysts, 75-85% of which develop from alcohol or gallstone disease-related pancreatitis (Lambiase 2004). It predominates among men and in any age group. Among children, it is observed as a consequence of abdominal trauma. The goal of therapy is the avoidance of complications and it generally accepted that approximately 10% of pseudocysts become infected. Most pseudocysts resolve by themselves and require only supportive care. Studies show that the size of the cyst and the length of time that it has been present in the body are not reliable indicators or predictors of complications. Larger cysts are likelier to be symptomatic or cause complications. The size does not necessarily warrant drainage or intervention.

Because pancreatitis pseudocysts resolve spontaneously and their size does not necessarily indicate or predict complications, the use of drainage is not the best option. Patients who are subjected to drainage also even develop complications or get worse and some surgical interventions also fail, the condition sometimes recur and complications so develop in some cases. The risk of developing life-threatening complications is only around 10% (Rossoa).

Pregunta del Trabajo

The three main surgical treatments available for pancreatic pseudocysts are internal drainage, pancreatic resections, and external drainage (Rossoa 2003). Internal drainage can be by pseudocystduodenostomy or by pseudocystjejunostomy. Pseudocystduodenostomy is preferred for small pseudocysts and its use has reportedly been good with a low failure rate of 5%, low morbidity and low mortality, although only it suits only a few patients. Pancreatic resection is performed for multiple small pseudocysts. And external drainage is the recourse for infected pancreatic pseudocysts and, therefore, does not apply to those with chronic pancreatitis, except with an occurrence of necrotizing pancreatitis (Rossoa).

Percutaneous cystogastrostomy is a safe, minimally invasive procedure that has produced good results at long-term and short-term follow-ups (Andersson and Cwikiel 2002, Cantasdemic 2003). Laparoscopic drainage is also successful for a large symptomatic pseudocyst with minimal morbidity (Pekmezci 2002). Drainage by a radiologist involves the insertion of a thin needle into the pseudocyst, guided by a CT x-ray, in draining the fluid (U.S. Center for Pancreatic and Biliary Diseases 2002). This procedure is sometimes successful but it also produces complications, such as persistent leakage, infection and need to repeat the procedure.

Hipotesis del Trabajo

Complications, the symptoms and concern about possible malignancy are among the factors that influence the choice of surgical treatment of pancreatic pseudocysts. Drainage has been the popular choice of treatment. But most pseudocysts spontaneously resolve or disappear without interference and patients improve without intervention, surgical or non-surgical (Lambiase 2004). Not even drainage becomes necessary.

Materials and Methods retrospective study with prospective follow-up was the design used in the study of percutaneous cystogastrostomy at the University Hospital in Sweden on 16 patients with symptomatic pseudocysts from 1993-1999 (Andersson and Cwikiel 2002). The objective was to evaluate the use of the procedure on the condition secondary to acute or chronic pancreatitis. The subjects were 10 men and 6 women, aged 36-78 with a mean age of 56. The intervention was performed under local anaesthesia and fluoroscopic control by the percutaneous insertion of a double pigtail catheter.

A study on the suitability of laparoscopic cystogastrostomy used an elective cholecystectomy as a day case on a 60-year-old lady (Cutless 2004). After surgery, she was subjected to a CT scan of the abdomen, which confirmed the presence of a big pseudocyst of the pancreas. She underwent laparoscopic cystogastrostomy four weeks later.

A third study also focused on laparoscopic surgery when decompression is indicted. (Pekmesci 2004). Like most laparoscopic procedures, it inserted trocars through the anterior gastric wall and operated intraluminally with gastric insufflation and endoscopic guidance.

A fourth study utilized 30 subject patients, 17 of whom were women, who underwent PCD with the use of a single-step trocar technique with computer tomographic guidance (Cantasdemic 2003). Their ages ranged from 27 to 74, with a mean age of 45. 18 of these patients had acute pancreatitis, 11 had chronic pancreatitis and 1 had surgical trauma.

A fifth study used 29 patients with symptomatic and/or complicated pseudocysts between June 2000 and July 2001 to establish the effects of surgical intervention on the condition (Govil 2004). They were diagnosed based on clinical features, hematological standards and imaging. The diagnosis of infected pseudocyst was made through ultrasound/CT-guided aspiration and documentation. 21 of these patients underwent surgery. Out of 21, 11 had biliary pancreatitis, 2 were alcohol cases, 1 had a malignancy and 7 were idiopathic. Surgeries were performed before 6 weeks in 1 patient at 6-7 weeks in 2 cases, at 7-12 weeks in 8 cases, and after 12 weeks in 10 cases. 10 patients were subjected to internal drainage and external drainage on 11, 7 of whom had infected pseudocyst, 3 with ruptured pseudocysts and 1 with pressure on the common bile duct. The mean external drainage for the patients was 44 days and the mean hospital stay for those who had internal drainage was 14 days.

Resultados

In the first study, 10 patients were diagnosed with acute pancreatitis and 6 had chronic pancreatitis, 13 had pseudocyst and 3 had 2 or more with a median diameter of 11 cm (Andersson and Cwiklie 2004). The procedure was a success, except in 2 patients who complained of pain after the procedure, which did not require specific treatment. Other than this, there were no complications. Their median hospital stay was 2 days and median follow-up was 45 months. All patients had successful drainage, except 2, with the pseudocysts resolved or reduced and a relief of symptoms experienced.

In the second study, the indication and timing for the drainage were based on the symptoms, complications and suspicion of malignancy, the size, number, location, presence or absence of communications with the pancreatic and bile duct and of infection. The cyst could be drained laparoscopically as well as endoscopically and can be approached in the same direction.

In the third study, laparoscopic procedures were performed by inserting the trocars through the interior gastric wall and operating intraluminally with gastric insufflation and endoscopic guidance (Pekmesci 2002). A patient was reported to have been successfully treated with laparoscopic stapled cystogastrostomy. The study suggests the feasibility of such a technique performed with a totally abdominal approach (Pekmesci).

The fourth study reported no complications related to the procedure and a success rate of 96% or 20 out of 30 patients (Cantasdemic 2003). There was no recurrence during the follow-up, which was held from the second to the 59th months.

And the fifth study tested and compared the internal and external drainage procedures (Govil et al. 2004). External drainage was and is more commonly used for infected and ruptured pseudocysts. Indications for surgical intervention were painful lump, infected pseudocyst, rupture, intracystic bleeding and obstructive jaundice. External drainage was used in cases of misdiagnosis, high risk of anastomotic dehiscence due to infected pseudocyst, or when the wall is immature. It was considered inferior to internal drainage in that external drainage can cause hemorrhage due to mechanical abrasion by the drainage tube, frequent occurrence of secondary infection, persistent pancreatic fistura, which was 10% of all cases, disease rate at 18% and a high 10% mortality. The study revealed a 9% mortality rate for external drainage, often due in turn to the poor condition of the patient.

This last study pointed to internal drainage as the preferable surgical procedure for all uncomplicated cases of pseudocysts (Govil et al. 2004). Cystogastrostomy is the option for cysts, which densely attach to the posterior stomach walls, while cystoduodenostomy should be for pseudocysts in the head and the uncinate process of the pancreas. The authors found that cystojejunestomy would be appropriate for all other types of cysts and for large pseudocysts for proper drainage. All of its 10 patients who underwent internal drainage survived (Govil).

Discussion

Andersson and Cwiklie (2004) found that pancreatic pseudocysts treated by percutaneous cystogastrostomy yielded good results. They believed that this procedure would be a safe and minimally invasive one that will also produce long-term as well as long-term follow-up results.

Cutress (2004) suggested that the laparoscopic drainage of a pseudocyst of the pancreas would be a straightforward procedure, as it has shown to be successful for a large symptomatic pseudocyst with low morbidity.

Pekmeszci (2002) agreed that laparoscopic surgery could be performed when decompression is indicated. The author reported performing laparoscopic procedures by inserting trocars via the anterior gastric wall and operating intraluminially with gastric insufflation and endoscopic guidance. She stressed on the benefits of discussing the feasibility and features of the technique when performed with a total abdominal approach.

Cantasdemic (2003) believed that the PCD would be a safe and effective front-line treatment for patients with pancreatic pseudocysts.

And Govil and associates (2004) underscored the advantages of choosing internal drainage as the appropriate approach to pancreatic pseudocysts and the efficacy of surgical intervention. Six of those who underwent external drainage later exhibited complications, such as pancreatic fistula, septicemia and infection. However, 19 or the 20 patients were reported as doing well during the follow-ups. In comparison with two other studies on the two procedures, Govil and team claimed that their subjects showed no recurrence and with a low 4.7% mortality rate.

The researchers also said that pseudocysts could complicate 7-15% of episodes of acute pancreatitis and 20-25% of chronic pancreatitis (2004). Persistent pseudocysts, they also concluded, could lead to many serious complications, including infection, abscess, and bleeding from erosions into nearby vessels. The present treatment modalities of choice are percutaneous drainage, surgical intervention and endoscopic drainage (Govil et al.).

But the constant observation has been that most cases of pseudocysts resolve by themselves and without interference and, therefore, most patients will recover without need for intervention (Lambiase 2004). Observed cases also showed that the outcome was worse who developed complications or who resorted to surgical drainage or other surgical interventions to manage their cysts. Moreover, these drainage procedures have a failure rate of about 10%, a recurrence rate of approximately 15% and a complication rate of 15-20%.

Manejo de Hipotehsis

Drainage or any other surgical intervention is not effective or necessary in most cases of pancreatic pseudocysts.

Conclusion

Most cases of pancreatic pseudocysts will resolve by themselves and do not require more than support care. The current surgical modalities also chosen have a high failure level and can lead to complications and infection. There can also be risks of misdiagnosing a cystic neoplasm of the pancreas and treating it as a pseudocyst. On top of everything is the failure to recognize and treat complications of pseudocysts. What is needed is patient education. Patients must learn and understand warning signs of potential complications, such as abdominal pain or fever, which can mean bleeding, fever or the tearing of a pseudocyst.

Bibliography

Andersson, R and W. Cwikiel. Percutaneous Cystogastrostomy in Patients with Pancreatic Pseudocysts, European Journal of Surgery, vol 168 (6) September 1, 2002. Taylor and Francis Ltd. http://ingentaconnect.com/connect/tandf/ssur/2002/00000/68/00000006/art00005

Cantasdemic, M, et al. Percutaneous Drainage for the Treatment of Infected Pancreatic Pseudocysts. Southern Medical Journal, vol 96 (2): 136-1-40, February 2003. http://smalljournalonline.com/pt.re/smi/searchplusresults.htm:jsessionid=CruAvbls0tN28va87ouAqSGITNtLFRuDWtzElV5D

Cutress, Golash. Laparaoscopic Cytogastrostomy for a Giant Pseudocyst of Pancreas, a case report. Department of Surgery: Sultan Qaboos Hospital. The Surgeon, vol 03 (1), February 2005. http://icsed.ac.uk/journal/svol3_1/3010008.html

Govil D. et al. Surgery for Complicated Pancreatic Pseudocysts. Indian Journal of Gastroenterology, vol 23 (1), pp 33-34. (http://www.indianjgastro.com (article.asp?)issn=0254-8860,year=2004,volume=23,issue=1,spage=33,epage=34,aulast=Govil

Lambiase, Louis R. Pancreatic Pseudocysts. Consumer Health: eMedicine.com, June 9, 2004. http://www.emedicine.com/med/topic.2674.htm

Pekmezci, Salih, et al. Total Laparoscopic Cystogastrostomy for Treatment of Pancreatic Pseudocysts. Journal of Laparoendoscopic and Advanced Surgical Techniques, vol 12 (2): pp 119-122, April 2002. Mary Ann Liebert, Inc. http://www.liebertonline.com/doi/abs/10.1089/10926430252939655;jsessionid=jrTURXJhUdH9?cookieSet=19journalCode=/ap

Rossoa, Edoardo, et al. Pancreatic Pseudocysts in Chronic Pancreatitis: Endoscopic and Surgical Treatment. Digestive Surgery Review vol 20 (5), 2003. http://content.karger.com/ProducteDB/producte.asp?Aktion=ShowPDF&ProduktNr=223996&Ausgabe=229428&ArtikelNr=72706

University of Southern California Center for Pancreatic and Biliary Diseases. Pancreatic Pseudocysts. Department of Surgery, 2002. http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/PANCREATITIS/pancreatic%20pseudocys1.html

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