Surgical Management of Pseudocyst of Pancreas

Introduction:

Pancreatic pseudocysts are a kind of cystic pancreatic lesions and are considered a complication of acute or chronic pancreatitis. The development of new diagnostic and treatment options has allowed for the management of pancreatic pseudocysts with different approaches. Pancreatic pseudocysts can have various clinical presentations, varying from completely asymptomatic lesions to multiple pseudocysts with bile and pancreatic duct obstruction.

Generally, the management of pancreatic pseudocysts depends on the etiology. Cystic pancreatic lesions, occurring as a result of acute pancreatitis, might resolve on their own over a period of four to six weeks without treatment. However, in chronic pancreatitis, spontaneous pseudocyst resolution is rarely seen as maturation of the cyst wall is already complete.

What Are Pancreatic Pseudocysts?

Pancreatic pseudocysts occur when fluid collects in the pancreatic tissue or close to the pancreatic space. It is encircled by a well-defined wall and composed of no solid material. Pancreatic pseudocysts mostly occur as a consequence of acute pancreatitis.

Sometimes, they can be seen in chronic pancreatitis, postoperatively, or after pancreatic trauma. Pseudocysts might be asymptomatic or might show various symptoms like pain, upper gastrointestinal bleeding, nausea, and vomiting. The pancreatic pseudocysts mature in around two to six weeks, and during this time, 33 percent of the cysts generally resolve. However, treatment is required in a large number of cases where the cysts persist and can cause complications like hemorrhage, infection, and cyst rupture.

What Is the Diagnostic Process for Pancreatic Pseudocysts?

During diagnosis, the doctor will inquire about the patient’s medical history, symptoms, and any underlying health issues. An abdominal examination will also be conducted. Other steps involved in the diagnosis of pancreatic pseudocyst are mentioned below:

• Laboratory Tests: To confirm pancreatitis, various tests may be conducted. These can include assessing levels of pancreatic enzymes in the blood and also analyzing other substances like sodium, potassium, and glucose. Tests to identify the root cause of pancreatitis, such as examinations for blood fats, may also be carried out.

• Imaging Tests: Imaging tests like abdominal ultrasound or CT (computed tomography) scans will be utilized to confirm the presence of pancreatic pseudocysts.

  1. Confirmation of a pancreatic pseudocyst is done with the help of imaging tests like CT or MRI (magnetic resonance imaging).

  2. In some cases, a specialized internal ultrasound known as an endoscopic ultrasound may be employed.

• If the diagnosis remains uncertain, a sample of the cyst fluid may be collected using a long, thin needle guided by imaging. This procedure aims to distinguish between a pseudocyst, an abscess, or a true pancreatic cyst (which could indicate cancer).

• Differential Diagnosis: The doctor will rule out other potential causes of symptoms, checking for conditions like ulcers, gallbladder inflammation, and pancreatic cancer.

How Are Pancreatic Pseudocysts Managed Surgically?

The most frequently used surgical approaches are internal drainage and pseudocyst resection, which have shown positive outcomes. Pancreatic pseudocyst treatment in chronic pancreatitis is effective by both endoscopic and surgical means. Certain changes have been seen in pancreatic pseudocyst surgery. Percutaneous drainage and endoscopic techniques have become more refined and are available everywhere. The three surgical procedures that have been used traditionally for the treatment of pancreatic pseudocysts are as follows:

1. External drainage.

2. Internal drainage.

3. Surgical excision.

What Are the Surgical Methods Used for the Management of the Pseudocyst of the Pancreas?

• Endoscopic Drainage: Endoscopic drainage may be either transpapillary, that is, through endoscopic retrograde cholangiopancreatography (ERCP), or transmural. They require proper patient selection to make sure that the surgery is successful and safe.

• Transpapillary Drainage: This procedure might be challenging because it requires wire passage and stenting via the pancreatic duct to the pseudocyst. The success rate is about 80 percent. Transpapillary drainage involves cyst communication with the pancreatic duct. It is safe and more effective than transmural drainage. The recurrence rate is 10 to 14 percent. In most cases, the complication rate is approximately 13 percent. The main complication is pancreatitis.

• Catheter Drainage: Catheter drainage is useful for establishing a diagnosis or as a temporary measure. The recurrence rate is 63 percent, and the failure rate is recorded as 54 percent. This drainage has a relatively greater risk of infecting the pseudocyst. There is a higher complication rate and patient mortality rate with surgical drainage.

Catheter drainage is the treatment of choice for the treatment of infected pseudocysts, allowing for rapid drainage of the cyst and identification of the microbial organism. The rate of recurrence and failure is high, but catheter drainage might be a good temporary option.

Catheter drainage is usually contraindicated in the following patients:

1. Patients who cannot follow the instructions and manage a catheter at home.

2. In patients with cysts containing solid or bloody substances.

3. In patients with main pancreatic duct strictures.

• Transmural Drainage: Endoscopic transmural drainage can also be performed. In this technique, an endoscopy is performed to locate a bulge in the lumen of the duodenum or stomach caused by compression of the pseudocyst. Usually, a needle knife is used to enter the cyst by cutting through the gastric or duodenal wall. The communication is made by placing a number of pigtail stents. This technique is usually adopted to avoid diathermy (a surgical technique that involves the production of heat by high-frequency electric currents in a part of the body to destroy unhealthy tissue, relieve pain, or clot bleeding vessels), thereby decreasing complications. The complication rate is around 20 percent; the most common complication is bleeding. The success rate of this method with experienced surgeons is 82 to 89 percent.

Certain reports revealed that the complication rate was reduced, and the efficacy increased with experience. The recurrent rate of pancreatic pseudocysts is 6 to 18 percent. Certain studies show that stents were successful 90.9 percent of the time, the implanted stents were successfully placed in place for the duration of treatment in 97 percent of the patients, and the stents remained open to allow drainage for the duration of treatment in 93 percent of the patients, and in 86 percent of the treated pseudocysts, their size was reduced by around 50 percent.

The Food and Drug Administration (FDA) approved the marketing of the stent and delivery system in December 2013 for the treatment of pancreatic pseudocysts. A study by Weckman reported the following results with endoscopic drainage:

1. Success Rate: 86 percent.

2. Complication Rate: 10 percent.

3. Failure Rate: 14 percent.

4. Recurrence Rate: 15 percent.

Not much difference was reported in the outcome when treated with a transpapillary or transmural approach.

• Surgical Drainage: Internal drainage is generally the treatment of choice. A laparoscopic technique is used in certain cases with good results. In most cases, the complication rate is approximately 24 percent, the mortality rate is around 3 percent, and the success rate is 85 to 90 percent. It has been documented that a laparoscopic approach to drainage shows a higher success rate and a low morbidity rate.

Conclusion:

For more than four decades, pancreatic pseudocysts have been treated surgically. New technological developments are evolving techniques, like internal drainage through cystogastrostomy and cyst jejunostomy. The permanent resolution of pseudocysts has been reported in 91 to 97 percent of patients. The efficacy of operative treatment for pancreatic pseudocysts is high. However, complications might occur in 4 to 30 percent of the cases. Some researchers suggest that a nonoperative approach like endoscopic drainage can be preferred as it is a minimally invasive technique, has an efficacy comparable to that of surgery, and shows a cyst resolution rate of 60 to 90 percent