Case Presentation acts as a demo for Abdominal Cases. Outline of Management of Pseudopancreatic cysts Recent Advances

1. CLINICAL MEETING
DR. SHOUPTIK BASU
1ST YEAR POST GRADUATE TRAINEE
Dept. of General Surgery
BSMCH, Bankura

2. • Mr. X , a 30 Year old Male who is a resident of Dhaldanga,
Bankura and a farmer by occupation presented with-
Chief Complaints:
1. Gradual onset upper abdominal swelling
2. Nausea and vomiting
3. Feeling of early satiety.
4. Weakness
6-7 weeks
Last 10
days

3. H/O Present Illness
The patient presented with:
A gradual onset swelling involving the upper abdomen that was
increasing gradually over time (6-7 weeks) and was associated
with a dull aching pain over it. The pain is localized over the upper
abdomen and does not radiate to the back and is also not related to food
intake.
There was a history of nausea and vomiting along with the pain. The
vomitus is non projectile and contains food particles, non bile stained and
no blood, and is not related to food intake. The patient has also
developed an early satiety, since the last 10 days, symptoms are slowly
progressing.
There was a history of sharp stabbing pain that radiated to the patients
back and was relieved on leaning forwards about 6-7 weeks back for
which the patient required hospital admission and treatment.
There was no history of trauma to the abdomen.
The bladder and bowel habits of the patient is normal without any history
of dyspepsia, or bleeding with the stool.
The patient feels weak over the past few days.

4. • Past History: Patient had SEVERAL attacks of abdominal pain in
the past that required hospital admission and treatment.
Patient is a K/C/O Pulmonary Tuberculosis who has completed his
full therapy.
No H/O Bronchial Asthma, Hypertension, Type II DM
No H/O Previous abdominal Surgery.
• Personal History: Patient is an unmarried male belonging to a poor
socioeconomic status, a known smoker and consumes country
liquor.
• Family History: No history of hereditary disorders.
• Treatment History: History of previous hospital admissions, treated
conservatively for his pain (Pancreatitis) and completed a full
course of drug therapy for Pulmonary Tuberculosis
• No history of allergy to known allergens

5. ON EXAMINATION
GENERAL SURVEY:
 Higher functions are normal (Conscious, alert and
Cooperative)
Thin built
Well hydrated
 P0 I0 C0 Cy0 E0
 Afebrile
 Pulse: 90 Beats / min , Regular, Rhytmic, Good Volume
, no radio-radial or radio-femoral delay
 Blood Pressure : 110/78 mm of Hg in Supine Position.
No lymphadenopathy.
No distended neck veins.

6. P/A
• Inspection: Abdomen looks normal with fullness in
the epigastric region and umbilical region. The
umbilicus is pushed downwards slightly.
A lump is found over the upper abdomen in the
epigastric region extending partially into the
umbilical region (size: 8 cm diameter approx) and it
doesnot move with respiration.
The Skin over the abdomen is essentially normal
and it does not bear any scars. There are no visible
pulsations and peristalsis. No dilated veins.
Hernial orifices and External genitalia are normal.

7. • Palpation: The temperature of the abdomen is normal. The
abdomen is soft to touch.
The observed lump is intra-abdominal and retroperitoneal.
 8 cm in size ,
Globular in shape
Localized in the epigastric and extending into the umbilical
regions.
Margins are rounded and well defined and the
Surface is smooth.
The mass is tense cystic in consistency
Appears slightly tender.
Liver and Spleen aren’t palpable, the Kidneys are not ballotable.
• Percussion: Liver and Splenic Span are within normal limits.
Percussion over the lump appears to be dull.
• Auscultation: The lump does not reveal any bruits and IPS is
normal
• Per Rectal Examination: Essentially Normal

8. SYSTEMIC EXAMINATION
• CHEST CLEAR VBS S1 S2 M 0
• CNS: WNL

9. PROVISIONAL DIAGNOSIS
PSEUDO PANCREATIC CYST.
(Causing Gastric Obstruction)

10. DIFFERENTIAL DIAGNOSIS
 GASTRIC OUTLET OBSTRUCTION DUE TO
PEPTIC ULCER DISEASE OR GASTRIC
CARCINOMA
 HYDATID CYST OF LIVER
 LARGE SIMPLE HEPATIC CYST
 CYSTIC NEOPLASM OF THE PANCREAS
 LARGE MESENTRIC CYST

11. Relevant Investigations
• Complete Hemogram:
Hb-11.1 g/dL
TC-5,500 cells/cu mm
DC- N78L14M07E01B0
ESR- 22 mm/hr
Platelets-1.2 lakhs/cu
mm
• Blood Sugar-100mg/dl
• Urea-25 mg/dl
• Creatinine-0.7 mg/dl
• PT-INR – 1.0
• Liver Function Tests:
 ALP-85 IU/l
 ALT-20 IU/l
 AST-14 IU/l
 TOTAL PROTEIN-7.1 g/dl
 BILIRUBIN-0.64
• Electrolytes:
 Na-133 mM/L
 K-3.9 mM/L
• Lipase: 180 U/l
• Amylase:193 U/L
**CEA & CA 19-9 COULDNOT BE DONE DUE TO NON AVAILABILITY

12. • USG W/A
8mm x 6.5 mm peri-
pancreatic collection
with hypoechoic
collections with low-
level echoes seen
representing debris,
confirming a.
MPD approximately
0.86mm
• CECT W/A
• MRCP
Confirms no ductal
communication of the
cystic lesion
AXIAL
CORONAL
ROUND PERIPANCREATIC FLUID
COLLECTION OF HOMOGENEOUSLY LOW
ATTENUATION, SURROUNDED BY A WELL-
DEFINED ENHANCING WALL 4MM WALL
THICKNESS 8.06 X 7.14 CMS LOCATED AT
THE HEAD AND BODY OF THE
PANCREAS.BULKY HETEROGENEOUS
PANCREAS. MPD APPEARS NORMAL.

13. PLAN: Open Surgery Internal Drainage
Ref: Maingot’s Abdominal Operations 12th Ed
TWO IMPORTANT RULES:
1. A CYSTIC LEISON SHOULDNOT BE
TREATED AS A PSEUDOCYST
2. ELECTIVE EXTERNAL DRAINAGE
MAY CAUSE A PANCREATIC
FISTULA
WHY?

14. PRE
OPERATIVE
PREPARATION
(Special considerations)
PATIENT
POSITIONING
&
PREPARATION
CHOICE OF
ANAESTHESIA
• A clear liquid diet is
given on the day
before surgery
• Bowel preparation
• Gastric Lavage
• The patient is placed
in a comfortable
supine position as
near the operator’s
side as possible.
• Skin Prepped with
10% Povidone Iodine
from Midchest to Mid
thigh.
• Draped in a sterile
fashion
• General Anaesthesia
with Endotracheal
intubation

15.  UPPER MIDLINE LAPAROTOMY
 ABDOMINAL CAVITY INSPECTED THOROUGHLY
 A LARGE CYSTIC SWELLING SITUATED BEHIND THE STOMACH IN
THE LESSER SAC
 STAY SUTURES TAKEN ON THE ANTERIOR WALL OF THE STOMACH
 ANTERIOR LONGITUDINAL GASTOSTOMY DONE.
 CONTENTS FROM THE PSEUDOCYST CONFIMED BY NEEDLE
ASPIRATION
 A DISK OF THE POSTERIOR STOMACH WALL WAS EXCISED AND SENT
FOR HPE
 CYSTOGASTROSTOMY PERFORMED AND THE PSEUDOCYST WALL
WAS SUTURED WITH THE POSTERIOR STOMACH WALL.
 ANTERIOR GASTROSTOMY CLOSED.
 A THOROUGH ABDOMINAL LAVAGE WAS GIVEN AND AN ABOMINAL
DRAIN WAS PLACED IN THE MORRISON’S POUCH, AFTER SECURING
HEMOSTASIS
 LAPAROTOMY WAS CLOSED USING THE ROUTINE (JENKIN’S
METHOD- 4:1 SUTURE LENGTH)
 SKIN CLOSED WITH STAPLES.

16. INTRA OPERATIVE:
CYSTOGASTROSTOMY
CRANIAL
Anterior
Stomach Wall
Posterior
Stomach Wall
Pseudocyst
Cavity
Intra-operative photograph of the pseudocyst being drained through the posterior wall of the stomach
just before suturing the posterior wall of the stomach with the cyst. 4 Babcock forceps are holding the
posterior wall of the stomach and the pseudocyst.

17. POST OPERATIVE
• Uneventful
• No Upper GI bleeding.
• Nasogastric suction (4 hrly) was
maintained until gastrointestinal
function (IPS) resumed (first 2
days)
• Blood amylase 27 U/l
• The initial liquid diet was
advanced as tolerated.
• Drain removed on the 5th POD
when no significant collections
came out of it
• Skin Staples removed before
discharge.
FOLLOW UP
• Slides made from the
specimen showed full
thickness sections taken
through the wall of the
stomach
• A specimen of the cystic fluid
showed granular proteinaceous
material with mild
inflammation. No malignancy
was identified. The absence of
epithelial cells within the wall
supported the initial diagnosis
of pseudocyst.
• Biochemical Analysis of the
Fluid: Amylase: 5362 U/l
• Subsequent OPD visits confirm
the patient is doing well.

18. PSEUDO PANCREATIC CYST:
DISCUSSION OF RELEVANT POINTS
• A collection of pancreatic juice enclosed by a
fibrous tissue (Atlanta Classification) [Didn’t mention
whether it can contain a solid component]
• FLUID COLLECTION
NECROSUM +
WALLED OF
NECROSIS (WON)
NECROSUM -
PSEUDOCYST
> 4 weeks< 4 weeks
ACUTE FLUID
COLLECTION
-OR-
POST NECROTIC
FLUID COLLECTION
-OR-
PERI-PANCREATIC
FLUID COLLECTION

19. PATHOGENESIS
Acute Pancreatitis/Trauma/Duct Obstruction/Chronic Pancreatitis
Enzyme Leak
Inflammation
Granulation tissue
Accumulates fibrin
* A Pseudocyst lacks an epithelial lining compared to a true cyst.
Contents: Clear watery
Haemorrhage- clots
Infection- pus

20. COMPLICATIONS
• Infection: may lead to sepsis - Drainage
• Rupture: into the GIT- Fistulization (Cysto-enteric / Pancreato
pleural / Pancreato bronchial)
into the Peritoneum- Peritonitis / Pancreatic Ascites
• Bleeding: Secondary to erosion – Hematemesis & Malena
Pseudoaneurysm formation (Elastase)
• Mass effect: GOO
Biliary stasis

21. TAKE HOME MESSAGES
(As Resident Trainees)
• Develops in the setting of Acute/Chronic Pancreatitis or Trauma.
• It’s important to distinguish between a Pseudocyst and a Cystic
neoplasm of the pancreas.
• USG is considered inferior to CT scan because it is operator
dependant.
• Treatment falls into one of two categories: observation and
intervention. The most significant factors affecting treatment
decisions are maturity, size, associated complications location and
condition of the Main Pancreatic duct (communication).
• Rule of 6 (still used by many surgeons) is still valid - > 6mm in
size , > 6 weeks. (Allows the time for observation, if it resolves or
becomes asymptomatic / the wall is strong enough to hold
sutures.)

22. CLASSIFICATION
Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of
modality for treating pancreatic pseudocysts (surgery versus percutaneous
drainage) Ann Surg. 2002;235:751–758.
D'Egidio A, Schein M. Pancreatic pseudocysts: a proposed
classification and its management implications. Br J
Surg. 1991;78:981–984
Type Ⅰ: normal duct/no communication with the
cyst.
Type Ⅱ: normal duct with duct-cyst communication.
Type Ⅲ: otherwise normal duct with stricture and no
duct-cyst communication.
Type Ⅳ: otherwise normal duct with stricture and
duct-cyst communication.
Type Ⅴ: otherwise normal duct with complete cut-
off.
Type Ⅵ: chronic pancreatitis, no duct-cyst
communication.

23. What’s the best Surgery ?
The Surgical approach is based on anatomy and topography of the pseudocyst and
not by the surgeon’s preference
ROUX-EN- Y
CYSTOJEJUNOSTOMY
For cysts in the body and the
tail.
Best for Chronic Pancreatitis
with dilated duct and calculi,
can be used with a LPJ
CYSTO-
DUODENONOSTOMY
When the pseudocyst is located in
the head of the pancreas and adheres
to the duodenum.
High risk of morbidity
CYSTO-
GASTROSTOMY
The main drawback is that it
doesn't provide a dependant
drainage and a large Pseudocyst
may accumulate gastric debris
Risk of haemorrhage

24. Role of MIS and Endoscopy
• All Open procedures have
been attempted by MIS
• More Recent Advance by
using a Mini-laparoscopic
Cysto-gastrostomy 2mm
intra-luminal scope.
• EUS allows for Pre-Op
assessment and differentiates
between a cystic lesion and a
Pseudocyst. It also allows
FNA.
• ERCP- is good for
communicating Pseudocysts,
but risks the complication of
Pancreatitis.
• Trans-papillary ,Trans-Gastric
or Trans –Duodenal drainage
may be done.

25. Thank you ...