Pancreatic

Pseudocyst

Presenter: Dr. Abishek Thapa

Resident
Department of Surgery
KMCTH
Pancreatic pseudocyst
CECT criteria
Well circumscribed, usually round or oval
Homogeneous fluid density
No non-liquid component
Well defined wall; that is, completely encapsulated
Maturation usually requires >4 weeks after onset of
acute pancreatitis; occurs after interstitial oedematous
pancreatitis

Banks P et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and
definitions by international consensus. Gut [Internet]. 2013 Jan [cited 2014 Jul 10];62(1):10211.
 Pancreatic pseudocyst
1) Six or Six Rule
>6cm size, >6weeks duration
Unlikely to resolve
High change of infection.

2) Infected PPC

3) Symptomatic PPC

(O'Malley VP, Cannon JP, Postier RG. Pancreatic pseudocysts: cause, therapy, and results. Am J
Surg. 1985;150:680682)
INTERVENTION MODALITIES
SURGICAL
ENDOSCOPIC
Transgastric - Cystogastrostomy
endoscopic drainage Cystoduodenostomy
Transduodenal Roux-en-Y
endoscopic drainage cystojejunostomy
Transpapillary Distal pancreatectomy
pancreatic duct splenectomy
stenting
Laparoscopic Open
Case Series
 Clinical Profile
Age Pre Op Diagnosis Surgery

Lap assisted (5
Pancreatic
ports)
pseudocyst
Case 1 41/M Cystogastrostomy
secondary to acute
with lap
pancreatitis
cholecystectomy

Lap. Assisted
Recurrent cystogastrostomy
Pancreatitis with with right
Case 2 21 Y/F
pancreatic subhepatic drain
pseudocyst with laproscopic
cholecystectomy.
Laparoscopic cystogastrostomy
Video
Clinical profile
Reason for
Age Pre Op Diagnosis Surgery the choice of
surgery

Exploratory laparotomy, Walled off

Pancreatic pseudocyst
43 adhesiolysis, necrosectomy necrosis,
Case 3 with splenic and left
Y/M cholecystectomy,, splenic vein
gastric vein thrombosis
splenectomy thrombosis

Walled off
Lap converted to open necrosis-
Case 4 48Y/F Pseudopancreatic cyst
cystogastrostomy solid
component
Necrosectomy >6 weeks, no
wall
Pancreatic pseudocyst Re- necrosectomy after 2 formation,
Case 5 23Y/F
with pancreatitis weeks, FJ sick patient,
Organized
Re-exploration (Hemorrhage) necrosis
Clinical profile

Reason for
Case Age Pre Op Diagnosis Surgery choice of

Clinical profile Surgery

Exploratory laparotomy Pseudocyst in

Pancreatic Pseudocyst
with distal the tail of
49Y/ with Pancreatic duct
Case 6 pancreatectomy with pancreas
M calculi with Chronic
splenectomy with Freys Chronic
pancreatitis
procedure pancreatitis
Distal end of
pancreas with the
pseudocyst
Specimen: distal of
pancreas with
pseudocyst and
spleen
Pancreatic duct
identified under
USG guidance
Laying open of the pancreatic duct, head coring and lateral pancreatojejunostomy
Review of literature
 Definition
Pancreatic Pseudocyst Walled Off Necrosis Organised necrosis
Definition - >4 weeks of >6weeks duration,
- >4 weeks. necrotising But no mature wall
- Encapsulated pancreatitis formed
collection of fluid - Encapsulated
- well defined / mature heterogeneous
wall collection
- usually outside the - well defined / mature
pancreas wall

Banks PA et al. Classification of acute pancreatitis--2012: revision of the

Atlanta classification and definitions by international consensus. Gut [Internet].
2013 Jan [cited 2014 Jul 10];62(1):10211.
Pancreatic Walled Off
Pseudocyst Necrosis

Banks PA et al. Classification of acute pancreatitis--2012: revision of the Atlanta

classification and definitions by international consensus. Gut [Internet]. 2013 Jan
[cited 2014 Jul 10];62(1):10211.
 Pancreatic Pseudocyst Treatment
Cystogastrostomy
(Sharma D, Kataria S, Pathak R, Barua B, Lal R. Laparoscopic drainage of a large pancreatic
pseudocyst. JSLS [Internet]. [cited 2014 Sep 9];16(4):6757)

Cystoduodenostomy
(Vavrecka A, Kuzela L, Novotna T, Hrcka R, Oltman M. [Endoscopic therapy of pancreatic pseudocysts].
cited 2014 Sep 12];101(2):936 )

Roux-en-Y cystojejunostomy
(Sun Y, Cai H, Bai J, Zhao H, Fu Z, Miao Y. Totally laparoscopic Roux-en-Y cystojejunostomy as a sole
treatment option for pancreatic pseudocysts: a report of four cases. Chin Med J (Engl) [Internet]. 2010
Aug 5 [cited 2014 Sep 12];123(15):21424.)

Distal pancreatectomy splenectomy

(Accetta P, Accetta I, Accetta R, Campos KB, Rodrigues MFO. Pancreatic pseudocyst with splenic
involvement. Case report. Rev Col Bras Cir [Internet]. 2010 Dec [cited 2014 Aug 27];37(6):4579. )
 Walled Off Necrosis Treatment
Percutaneous drainage

Cystogastrostomy + Necrosectomy
(Sasnur P, Nidoni R, Baloorkar R, Sindgikar V, Shankar B. Extended Open Transgastric Necrosectomy (EOTN) as a
Safer Procedure for Necrotizing Pancreatitis. J Clin Diagn Res [Internet]. 2014 Jul)

Direct Endoscopic Necrosectomy

Step up Approach
(Kumar N, Conwell DL, Thompson CC. Direct Endoscopic Necrosectomy Versus Step-Up Approach for Walled-Off
Pancreatic Necrosis: Comparison of Clinical Outcome and Health Care Utilization. Pancreas [Internet]. 2014 Aug 11)

Temporary cystogastrostomy with self-expanding

metallic stent
(Belle S, Collet P, Post S, Kaehler G. Temporary cystogastrostomy with self-expanding metallic stents for pancreatic
necrosis. Endoscopy [Internet]. 2010 Jun )
Conclusion

CECT cannot always differentiate between PPC

and WON

Other modalities such as MRI and EUS with FNA

are advised

Treatment of PPC, WON are different

THANK YOU