Inflammatory Pancreatic Cyst Drainage

INTRODUCTION

Cysts of the pancreas are typically inflammatory in nature or neoplastic. Pancreatic pseudocysts generally occur as a consequence of acute or chronic pancreatitis. Unlike pseudocysts of the pancreas due to chronic pancreatitis, pseudocysts that occur as a result of acute pancreatitis more often can spontaneously resolve over time; however, some of these cysts persist and require intervention. Distinction should be made between a pancreatic pseudocyst with a low viscous liquid fluid and other peripancreatic collections that include phlegmons and tissue necrosis, which are more semisolid or solid in consistency. The consistency of the material encountered greatly influences the appropriate treatment options. Typically for noninfected collections, it is prudent to wait 6 weeks from the inflammatory incident to allow time for the cyst to resolve or for the cyst wall to mature. During this 6-week period, the consistency of the fluid can change dramatically from a toothpaste consistency to pure liquid. The diagnosis of the pseudocyst is typically identified through abdominal imaging. Computed tomography, magnetic resonance imaging, or ultrasound can be used to confirm the diagnosis. One must be cautious to not misdiagnose a cystic neoplasm as a pseudocyst. Suspicion of the diagnosis should occur if there has not been a precedent history of pancreatitis. Clinical signs of infection such as fevers and gas within the collection often warrant early intervention. Although studies utilizing percutaneous drainage as well as endoscopic drainage have reported some success, the selection of the appropriate patient for these treatments is paramount. In general, patients with semisolid or solid components in the collection should be managed with operative drainage. The choices for operative drainage include internal drainage by cystenterostomy or external drainage. Internal drainage is preferred when the cyst is not infected and has low-viscosity fluid. For giant pseudocysts, the author prefers a Roux-en-Y cystgastrostomy performed through the transverse mesocolon. This allows for complete resolution of the cyst through dependent drainage. Although cystgastrostomy is regarded as a mainstay for internal drainage cases, stasis and retroperitoneal sepsis have occurred, especially in large pseudocysts, owing to lack of adequate dependent drainage. External drainage can also be accomplished through a transverse mesocolon approach for patients with phlegmons or infected pseudocysts to allow for manual débridement of the necrotic tissue and placement of large-caliber drains.

Cystgastrostomy or Endoscopic Drainage

INDICATIONS

• Small, less than 5 cm persistent pseudocyst located posterior to stomach

• Low viscosity of cyst fluid

OPERATIVE STEPS

Step 1 Anterior gastrotomy

Step 2 Creation of posterior gastrotomy

Step 3 Cyst wall and posterior stomach anastomosis

Step 4 Closure of anterior gastrotomy

OPERATIVE PROCEDURE

Roux-en-Y Cystjejunostomy

INDICATIONS

• Large, greater than 5 cm persistent pseudocyst.

OPERATIVE STEPS

Step 1 Identification and opening of pseudocyst wall through transverse mesocolon

Step 2 Creation of Roux-en-Y cystjejunostomy

OPERATIVE PROCEDURE

Identification and Opening of the Pseudocyst Wall through the Transverse Mesocolon

Inability to Locate the Cyst

See the section on “Inability to Locate the Cyst,” under “Cystgastrostomy,” earlier. Typically by lifting the transverse mesocolon, one can identify the pseudocyst bulging through the mesocolon. If not, apply the same maneuvers as listed previously.

External Drainage

INDICATIONS

• Infected pseudocyst or phlegmon.

OPERATIVE STEPS

Step 1 Identification and opening of pseudocyst wall through transverse mesocolon

Step 2 Débridement of necrotic or infected tissue

Step 3 Placement of large-bore sump drains

OPERATIVE PROCEDURE

Identification and Opening of the Pseudocyst Wall through the Transverse Mesocolon

Same pitfalls as in the sections on “Inability to Locate the Cyst,” and “Injury to the Mesocolon Vessels,” under “Roux-en-Y Cystjejunostomy,” earlier.

Débridement of Necrotic or Infected Tissue

The fluid and tissue within the phlegmon is typically of a semisolid consistency much like that of toothpaste. As the first step, the author prefers to manually dislodge and remove this tissue through the opening created. The tissue separates fairly easily from the underlying viable pancreatic tissue. Russian forceps can then be used to extricate the hard-to-reach areas. Irrigation with a red rubber catheter can also be employed to remove dislodged particles.

Pancreatic Bed Hemorrhage

Overaggressive débridement can result in hemorrhage from the pancreatic bed. Minor bleeding can occur from surface branches. More substantial bleeding can occur from the pancreatoduodenal vessels or dorsal pancreatic vessels.

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Pancreatic Cyst/Debridement

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