Managing Complcations of Pseudocyst of the Pancreas
Managing Complcations of Pseudocyst of the Pancreas
Objective: To study the magnitude of complications associated with the nonoperative management of peripancreatic fluid collections and pseudocysts and to assess the surgical management of these complications. These are compared with complications associated with operative management.
Summary Background Data: Pancreatic pseudocysts and peripancreatic fluid collections associated with acute pancreatitis have been managed with success using nonoperative techniques for more than a decade. When successful, these techniques have clear advantages compared with operative management. There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. Our report focuses on these complications and pseudocysts and on the surgical management. We have been struck by the high percentage of patients who sustain significant and at times life-threatening complications related to the nonoperative management of fluid collections. We further define an association between the main pancreatic ductal anatomy and the likelihood of major complications after nonoperative management.
Methods: Between 1992 and 2003, all patients admitted to our service with peripancreatic fluid collections or pseudocysts were monitored. We evaluated complications patients managed with percutaneous (PD) or endoscopic drainage (E). Data were collected regarding patient characteristics, need for intensive care unit (ICU) stays, hemorrhage, hypotension, renal failure, and ventilator support. We further focused on the duration of fistula drainage from patients who have had a percutaneous drainage, and we assessed the necessity for urgent or emergent operation. By protocol, all patients had pancreatic ductal anatomy evaluated by means of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Patients with complications of E and PD were compared with 100 consecutive patients who underwent operative management of pseudocyst and fluid collections as their sole mode of intervention.
Results: A total of 79 patients with complications of PD, E, or both were studied. There were 41 males and 38 females in the group of patients who sustained complications (mean age 49 years). Sixty-six of the 79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent. The mean elapsed time from diagnosis to nonoperative intervention was 18.1 days. This group of 79 patients had mean 3.1 ± 0.7 hospitalization (range, 1-7) and length-of-stay 42.7 ± 4.1 days. ICU stays were required in 36 of the 79 (46%). A defined episode of clinical sepsis was identified in 72 of 79 (91%) and was by far the most common complication. Hemorrhage requiring transfusion was identified in 16 of the 79 (20%), clinical shock 51 of the 79 (65%), renal failure 16 of the 79 (20%), ventilator support for longer than 24 hours 19 of the 79 (24%). A persistent pancreatic fistula occurred in 66 of the 79 patients (84%); mean duration was 61.4 ± 9.6 days. Sixty-three of the 79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct. Among the 100 operated patients, 69 complications occurred in 6 of the 100 (6%). Operation was initiated electively a mean interval of 42.7 days after diagnosis of pseudocyst. Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients. CT imaging obtained at least 6 months after intervention documented complete resolution after surgery alone in 91 and 9 with cystic structures less than 2 cm. In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions less than 2 cm in diameter.
Conclusion: These data support the premise that a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. It is vital to recognize the magnitude and severity of complications of nonoperative measures as one chooses a modality. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.
A careful reading of the current literature regarding the operative and nonoperative management of pancreatic pseudocysts provides few discrete measures by which to choose one modality over another. Operative management of pseudocyst has a high level of success; however, morbidity rates have ranged from 4% to 30%. In any event, it is clear that a nonoperative measure would be more desirable should there be no significant loss in effectiveness of therapy. Although numbers vary widely, the success rates for both endoscopic and percutaneous management of pseudocyst ranges from 60%-90%, whereas the success rates for surgical drainage is on the order of 94%-99%. Unfortunately, the majority of reports in radiologic and endoscopic series provide data on technically successful drainage rather than success in permanently resolving the pseudocyst. Very few have long-term follow-up, and we have found none which employed cross-sectional imaging more than 6 months after intervention. Variables which must be considered when addressing nonoperative measures include the length of time that the drainage procedures require for complete resolution of pseudocyst, the length of follow-up to confirm that pseudocyst have in fact completely resolved, and the complications that may be associated with nonoperative management.
A generally observed surgical precept is that pseudocysts which persist beyond 4-6 weeks are then candidates for intervention, although there is a literature suggesting that some pseudocysts may be safely followed which are asymptomatic. Expectant management is typically abandoned when a pseudocyst exceeds 7 cm in diameter. A careful evaluation of the literature regarding percutaneous or endoscopic management of pseudocysts fails to reveal any such formula for delay before intervention. It is thus common to see a series of patients managed with nonoperative measures whose cyst or fluid collections have been instrumented less than 4 weeks after initial diagnosis.
The current report is unique in that it focuses on the surgical management of complications of nonoperative measures, with specific focus on the magnitude of these complications, the success of surgical management, the correlation with pancreatic ductal abnormalities, and the timing of the nonoperative measures and the role this variable may play in outcome.
Although patients can often be managed at home with percutaneous drain the need for urgent or emergent rehospitalization for episodes of sepsis is well documented. This fact assumes somewhat greater significance when a patient has had a sterile peripancreatic fluid collection prior to instrumentation. There is generally a lack of definition regarding the details and magnitude of complications.
The earliest reports on endoscopic management of peripancreatic fluid collections employed transmural stent placement. Thus, these techniques were at that time limited to pseudocysts near the stomach. More recently, endoscopic ultrasound has provided a more precise approach to peripancreatic fluid collections. More recently, transpapillary stents have been employed. Kozarek et al have achieved successes even when high-grade ductal injury have been identified. The concept behind the transpapillary stents is the reduction of pressure in the ductal system facilitating drainage of the pseudocyst through the duct and not into the cyst. The success of this modality is consistent with our assumption that successes and failures reflect the underlying ductal anatomy. Multiple endoscopic procedures are often required before success is achieved.
The literature for operative management of pseudocyst spans at least 4 decades. Early reports describing external drainage confirmed a failure rate of 20%-30%. It is striking that the failure of 20%-30% parallels the failure rates of both endoscopic and percutaneous management of pseudocysts and resembles the frequency of moderate/severe acute pancreatitis. Internal drainage via cystgastrostomy or cyst-jejunostomy has been well established, and permanent resolution of pseudocyst is confirmed in between 91%-97% of patients. High success rates are counterbalanced somewhat by the risks of an operative procedure and with the possible complications of the procedure. Postoperative morbidity rates in reports in the 1970s and 1980s occurred at a frequency of approximately 30%. The most common significant complication in these patients was hemorrhage. Fortunately, more recent reports on the operative management of pseudocyst have documented a much lower morbidity rate, typically less than 10%.
The recognition that pancreatic ductal abnormalities play a role in complicated acute pancreatitis can be traced to a report by Rutledge and Warshaw in 1988. In 1989, we proposed the value of ERCP to direct choices of therapy in pancreatic pseudocyst. Kozarek et al confirmed a relationship with their pioneering work on transpapillary stents for pseudocysts in 1991, and Neoptolemos et al added further definition of the role ductal changes played in acute pancreatit is in 2001 after previously exploring the role in 1993. We have recently documented the importance of evaluating main pancreatic ductal anatomy as modalities are chosen for pseudocyst management. In another report, we have further evaluated patients with moderate to severe acute pancreatitis associated with gallstones who developed fluid collections, and the patients whose pseudocysts failed to resolve and who subsequently required a cholecystectomy combined with drainage of the pseudocyst had documented ductal injuries possibly explaining the persistence of the cyst. Howard et al from Indiana have recently documented the high percentage of patients who have survived an episode of necrotizing pancreatitis and have recurrent episodes of acute pancreatitis, afterward having associated main pancreatic ductal abnormalities. We recently documented success in resolving pseudocysts associated with chronic pancreatitis by operative duct drainage alone. All of these data suggest that the management of pancreatic pseudocyst is based most appropriately on an evaluation of the pancreatic ductal anatomy. Itis thus the purpose to of this report to evaluate the magnitude of complications associated with nonoperative measures in pancreatic pseudocyst and to establish a correlation between these complications and the presence of significant pancreatic ductal abnormalities. The recognition of the magnitude of these complications, combined with the fact that ductal anatomy may well predict which patients will have these complications, strongly suggests that some logic may be applied in choosing a modality to treat peripancreatic fluid collections and pseudocysts.
Objective: To study the magnitude of complications associated with the nonoperative management of peripancreatic fluid collections and pseudocysts and to assess the surgical management of these complications. These are compared with complications associated with operative management.
Summary Background Data: Pancreatic pseudocysts and peripancreatic fluid collections associated with acute pancreatitis have been managed with success using nonoperative techniques for more than a decade. When successful, these techniques have clear advantages compared with operative management. There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. Our report focuses on these complications and pseudocysts and on the surgical management. We have been struck by the high percentage of patients who sustain significant and at times life-threatening complications related to the nonoperative management of fluid collections. We further define an association between the main pancreatic ductal anatomy and the likelihood of major complications after nonoperative management.
Methods: Between 1992 and 2003, all patients admitted to our service with peripancreatic fluid collections or pseudocysts were monitored. We evaluated complications patients managed with percutaneous (PD) or endoscopic drainage (E). Data were collected regarding patient characteristics, need for intensive care unit (ICU) stays, hemorrhage, hypotension, renal failure, and ventilator support. We further focused on the duration of fistula drainage from patients who have had a percutaneous drainage, and we assessed the necessity for urgent or emergent operation. By protocol, all patients had pancreatic ductal anatomy evaluated by means of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Patients with complications of E and PD were compared with 100 consecutive patients who underwent operative management of pseudocyst and fluid collections as their sole mode of intervention.
Results: A total of 79 patients with complications of PD, E, or both were studied. There were 41 males and 38 females in the group of patients who sustained complications (mean age 49 years). Sixty-six of the 79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent. The mean elapsed time from diagnosis to nonoperative intervention was 18.1 days. This group of 79 patients had mean 3.1 ± 0.7 hospitalization (range, 1-7) and length-of-stay 42.7 ± 4.1 days. ICU stays were required in 36 of the 79 (46%). A defined episode of clinical sepsis was identified in 72 of 79 (91%) and was by far the most common complication. Hemorrhage requiring transfusion was identified in 16 of the 79 (20%), clinical shock 51 of the 79 (65%), renal failure 16 of the 79 (20%), ventilator support for longer than 24 hours 19 of the 79 (24%). A persistent pancreatic fistula occurred in 66 of the 79 patients (84%); mean duration was 61.4 ± 9.6 days. Sixty-three of the 79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct. Among the 100 operated patients, 69 complications occurred in 6 of the 100 (6%). Operation was initiated electively a mean interval of 42.7 days after diagnosis of pseudocyst. Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients. CT imaging obtained at least 6 months after intervention documented complete resolution after surgery alone in 91 and 9 with cystic structures less than 2 cm. In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions less than 2 cm in diameter.
Conclusion: These data support the premise that a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. It is vital to recognize the magnitude and severity of complications of nonoperative measures as one chooses a modality. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.
A careful reading of the current literature regarding the operative and nonoperative management of pancreatic pseudocysts provides few discrete measures by which to choose one modality over another. Operative management of pseudocyst has a high level of success; however, morbidity rates have ranged from 4% to 30%. In any event, it is clear that a nonoperative measure would be more desirable should there be no significant loss in effectiveness of therapy. Although numbers vary widely, the success rates for both endoscopic and percutaneous management of pseudocyst ranges from 60%-90%, whereas the success rates for surgical drainage is on the order of 94%-99%. Unfortunately, the majority of reports in radiologic and endoscopic series provide data on technically successful drainage rather than success in permanently resolving the pseudocyst. Very few have long-term follow-up, and we have found none which employed cross-sectional imaging more than 6 months after intervention. Variables which must be considered when addressing nonoperative measures include the length of time that the drainage procedures require for complete resolution of pseudocyst, the length of follow-up to confirm that pseudocyst have in fact completely resolved, and the complications that may be associated with nonoperative management.
A generally observed surgical precept is that pseudocysts which persist beyond 4-6 weeks are then candidates for intervention, although there is a literature suggesting that some pseudocysts may be safely followed which are asymptomatic. Expectant management is typically abandoned when a pseudocyst exceeds 7 cm in diameter. A careful evaluation of the literature regarding percutaneous or endoscopic management of pseudocysts fails to reveal any such formula for delay before intervention. It is thus common to see a series of patients managed with nonoperative measures whose cyst or fluid collections have been instrumented less than 4 weeks after initial diagnosis.
The current report is unique in that it focuses on the surgical management of complications of nonoperative measures, with specific focus on the magnitude of these complications, the success of surgical management, the correlation with pancreatic ductal abnormalities, and the timing of the nonoperative measures and the role this variable may play in outcome.
Although patients can often be managed at home with percutaneous drain the need for urgent or emergent rehospitalization for episodes of sepsis is well documented. This fact assumes somewhat greater significance when a patient has had a sterile peripancreatic fluid collection prior to instrumentation. There is generally a lack of definition regarding the details and magnitude of complications.
The earliest reports on endoscopic management of peripancreatic fluid collections employed transmural stent placement. Thus, these techniques were at that time limited to pseudocysts near the stomach. More recently, endoscopic ultrasound has provided a more precise approach to peripancreatic fluid collections. More recently, transpapillary stents have been employed. Kozarek et al have achieved successes even when high-grade ductal injury have been identified. The concept behind the transpapillary stents is the reduction of pressure in the ductal system facilitating drainage of the pseudocyst through the duct and not into the cyst. The success of this modality is consistent with our assumption that successes and failures reflect the underlying ductal anatomy. Multiple endoscopic procedures are often required before success is achieved.
The literature for operative management of pseudocyst spans at least 4 decades. Early reports describing external drainage confirmed a failure rate of 20%-30%. It is striking that the failure of 20%-30% parallels the failure rates of both endoscopic and percutaneous management of pseudocysts and resembles the frequency of moderate/severe acute pancreatitis. Internal drainage via cystgastrostomy or cyst-jejunostomy has been well established, and permanent resolution of pseudocyst is confirmed in between 91%-97% of patients. High success rates are counterbalanced somewhat by the risks of an operative procedure and with the possible complications of the procedure. Postoperative morbidity rates in reports in the 1970s and 1980s occurred at a frequency of approximately 30%. The most common significant complication in these patients was hemorrhage. Fortunately, more recent reports on the operative management of pseudocyst have documented a much lower morbidity rate, typically less than 10%.
The recognition that pancreatic ductal abnormalities play a role in complicated acute pancreatitis can be traced to a report by Rutledge and Warshaw in 1988. In 1989, we proposed the value of ERCP to direct choices of therapy in pancreatic pseudocyst. Kozarek et al confirmed a relationship with their pioneering work on transpapillary stents for pseudocysts in 1991, and Neoptolemos et al added further definition of the role ductal changes played in acute pancreatit is in 2001 after previously exploring the role in 1993. We have recently documented the importance of evaluating main pancreatic ductal anatomy as modalities are chosen for pseudocyst management. In another report, we have further evaluated patients with moderate to severe acute pancreatitis associated with gallstones who developed fluid collections, and the patients whose pseudocysts failed to resolve and who subsequently required a cholecystectomy combined with drainage of the pseudocyst had documented ductal injuries possibly explaining the persistence of the cyst. Howard et al from Indiana have recently documented the high percentage of patients who have survived an episode of necrotizing pancreatitis and have recurrent episodes of acute pancreatitis, afterward having associated main pancreatic ductal abnormalities. We recently documented success in resolving pseudocysts associated with chronic pancreatitis by operative duct drainage alone. All of these data suggest that the management of pancreatic pseudocyst is based most appropriately on an evaluation of the pancreatic ductal anatomy. Itis thus the purpose to of this report to evaluate the magnitude of complications associated with nonoperative measures in pancreatic pseudocyst and to establish a correlation between these complications and the presence of significant pancreatic ductal abnormalities. The recognition of the magnitude of these complications, combined with the fact that ductal anatomy may well predict which patients will have these complications, strongly suggests that some logic may be applied in choosing a modality to treat peripancreatic fluid collections and pseudocysts.
