Issues in Management of Pancreatic Pseudocysts. Dinesh Singhal 1 , Rahul Kakodkar 1 , Randhir Sud 2 , Adarsh Chaudhary 1 Departments of 1 Surgical and 2 Medical Gastroenterology, Sir Ganga Ram Hospital. New Delhi, India. Abstract.
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Dinesh Singhal1, Rahul Kakodkar1, Randhir Sud2, Adarsh Chaudhary1
Departments of 1Surgical and 2Medical Gastroenterology,Sir Ganga Ram Hospital. New Delhi, India
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.
Cystic tumor erroneously drained by ‘cystogastrostomy’
Enhancing walls, solidcontent, evidence of neoplasm
Cystic tumour misinterpreted
Imaging (CT, US):
No septae or solid components
Thin wall (<4mm)
No history of pancreatitis
Septae or solid components+
MRCP/EUS ± FNA /ERCPPseudocyst vs. Cystic Tumor
Duct-cyst connectionin 65%
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No imaging is infallible !
It is better to resect a pseudocystthan to drain a tumor !
 Kahaleh M, et al. Endoscopy 2006; 38:355-9.
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 Sriram PV, et al. Endoscopy 2005; 37:231-5.
Pseudocyst with mature wallbulging into the stomach
Anterior Gastric Wall
Pseudocyst openedthrough posteriorgastric wall
Large pseudocystin infracolic position
Pseudocyst withdilated mainpancreatic duct
Duct-cyst communication (forcep)
Infected pseudocyst ‘Abscess’
(Risk of pancreatic fistula morbidity:10-15%)
 Adams DB, Anderson MC. Ann Surg 1992; 215:571-8.
 Heider R, et al. Ann Surg 1999; 229:781-7.
Pseudocyst with immature walls
(Risk of pancreatic fistula morbidity:10-15%)
Drained percutaneouslythrough safe infracolic window
Mature pseudocyst abuttingstomach and causingbiliary obstruction
Obstruction relievedafter cystogastrostomy
Collaterals in splenic hilum
Splenectomy +Ductal drainage
Pseudocyst causing extrinsiccompression of the duodenum
Abbreviations MCA: mucinous cystadenoma; MCAC: mucinous cystadenocarcinoma; SCA: serous cystadenoma
CorrespondenceAdarsh ChaudharyDepartment of Surgical GastroenterologySir Ganga Ram HospitalNew DelhiIndia 110060Phone: +91-11.4225.2226Fax: +91-11.4225.2224E-mail: firstname.lastname@example.org