Pancreatic Pseudocyst -Operative Strategy CHARLES F. FREY, M.D.*
The experience with 131 patients with 157 pseudocysts is reported. One hundred and twenty patients with 146 pseudocysts underwent 165 operations. There were ten operative deaths (8.3%) three of which were not attributable to the pseudocyst or its operative management. Sixteen patients died six months to 14 years after operation. Deaths in six of the 16 patients were in part attributable to pancreatitis or complications of pseudocyst management. The operative mortality was highest in patients undergoing incision and drainage and cystoduodenostomy. Other factors influencing mortality unfavorably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or fistulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pseudoaneurysms associated with their pseudocysts. Incision and drainage of pseudocysts is associated with a high rate of recurrence of the cyst and continued pain. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. The presence of a pseudoaneurysm visualized on preoperative visceral angiography is an indication for an excisional operation as are the presence of multiple cysts, compression of the common duct or duodenum by the cyst, evidence of left sided portal hypertension, recurrent cysts or evidence of chronic pancreatitis. R ECENT REPORTS ON THE MANAGEMENT of pan-
creatic pseudocysts do not show results which should lead to complacency20 by surgeons dealing with these patients. The operative mortality rate is in the range of 3-1 1% 48,9,14,16,18,20,21 and postoperative complications develop frequently, 37%,17 34%19 often requiring reoperation. Preoperative complications of pseudocysts afflict 30-55% of patients. 1'8"14 The recurrence rate, or persistence of unrecognized or de novo pseudocysts or ascites ranges from 11 -20%1 13,16 and pain due to chronic pancreatitis sufficient to require * Chief, Surgical Service, Veterans Administration Hospital, Martinez, California, Professor and Vice Chairman, Department of Surgery, University of California, Davis, California. Reprint requests: Charles F. Frey, M.D., Department of Surgery, Veterans Administration Hospital, 150 Muir Road, Martinez, California 94553. Submitted for publication: December 5, 1977.
From the University of Michigan Medical Center, Ann Arbor, Michigan
reoperation or rehospitalization occurs in up to 48%8 of patients. Authors in recent years have focused attention on some of the preoperative complications which effect 30-55% of patients with pseudocysts. The mortality and morbidity is the highest in patients with these preoperative complications. For example, in 1975 Sankaran and Walt'4 reported on their experience with 1 12 patients with pseudocysts, "Four of seven patients (57%) with preoperative bleeding and seven of eleven (64%) with postoperative bleeding died . . . ten of 14 patients in the entire series who died bleed either pre or postoperatively." The same authors reported pancreatic ascites in 14.5% of their patients. The recurrence rate of cysts was particularly high (40%) in patients with both a pseudocyst and ascites. In Bradley and Clements 1976 report3 on transenteric rupture of 37 pancreatic pseudocysts the incidence of this complication was estimated to involve 5% of all patients with pseudocysts. One third of their patients with transenteric rupture concomitantly developed massive hemorrhage. All patients with transenteric rupture who died (37%) died from hemorrhage. Based on our experience at the University of Michigan we believe rational operative management of pseudocysts, particularly the choice of the appropriate operative procedure, depends particularly on a knowledge of preoperative complications, whether the cysts are multiple, recurrent or associated with chronic pancreatitis, the optimal time of operation, the size and location of the cyst, its adherence to surrounding structures and the disease initiating pancreatic inflammation. Clinical Material At the University of Michigan Medical Center and affiliated hospitals between the years 1959-1976 the diagnosis of pseudocyst of the pancreas was established in 131 patients. No operation was performed in 11 patients, four of whom died. Death was attributed to a ruptured pseudocyst in one of the four patients. The
0003-4932/78/1100/0652 $01.05 © J. B. Lippincott Company
652
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PANCREATIC PSEUDOCYST
presence of a pseudocyst was an incidental finding at autopsy in the other three patients. One hundred and 20 patients were subjected to operative intervention for 147 pseudocysts. Of the 131 patients, 86 were male and 45 female. The average age at operation was 42 years and ranged from 8-83 years. Eighty-seven (66%) patients were alcoholic, four of whom also had gallstones. No known cause of pancreatic disease was identified in 19 patients. Eleven patients developed pseudocysts following trauma, one of whom was an alcoholic and another of whom had gallstones. Six patients had gallstones, five familial pancreatitis or congenital abnormalities of the pancreas and biliary tract, and three disorders of lipid metabolism.
Patient Presentation Most patients with pseudocysts requiring operation other than those with trauma had had previous experience with pancreatitis. Seventy four per cent of patients had more than one episode of pancreatitis and 28% had had persistent pain for more than three months prior to operation. In only 2% of patients did the first episode of pancreatitis associated with pseudocyst result in operation. Twenty-four per cent of patients had had four previous hospitalizations for pancreatitis, 67% two to three hospitalizations and in only 9% was the first hospitalization associated with an operation. The history of an episode of pancreatitis or blunt abdominal trauma followed by persistence or recurrence of the signs and symptoms and clinical evidence of pancreatitis after 10-14 days including the appearance of an abdominal mass were features which often accompanied the development of a pseudocyst.
Symptoms and Signs Most patients (91%) with pseudocysts had episodes of abdominal pain often with radiation to the back, 63% an abdominal mass and 21% were jaundiced. Less frequently noted were preoperative gastrointestinal hemorrhage 7.5%, pleural effusion 11%, fever 10%, and ascites 7%. In addition continuous or recurring episodes of pain, evidence of diabetes and calcification of the pancreas were considered suggestive of chronic pancreatitis.
Laboratory Data At the time of the hospital admission associated with operative treatment of the pseudocyst the serum amylase levels were elevated in 77% of patients and the white count was elevated in 40% of patients. The hematocrit was below 38 in 17% of patients some of whom had bled into the G.I. tract. Conversely, the hematocrit
653
was elevated above 50% in 6% of patients most of whom had been under replenished with fluids subsequent to an exacerbation of pancreatitis. Evidence of extra hepatic obstruction with elevation of alkaline phosphatase or bilirubin was noted in 21% of patients. Liver chemistries, SGOT, SGPT were abnormal in 10% of patients and visceral protein stores depleted in 12% evidenced by an albumin of under 3.5 g 100 ml. The serum calcium was depressed below 8.5 mg% in 12% of patients most of whom were admitted during an acute exacerbation of pancreatitis. One patient had an elevated serum Ca++ level and was subsequently found to have hyperparathyroidism.
Diagnostic Studies Most of our patients were managed prior to the availability of endoscopy and ultrasound. Confirmation of the presence of a pseudocyst suspected on the basis of an abdominal mass detected on physical examination or suspected on the basis of the patient's clinical course was dependent on chest x-rays, flat plate, upright abdominal films and G.I. series 67%, and angiographic findings 28%. Operative Findings Thirty-eight per cent ofthe pseudocysts were located in the head or uncinate process and 37% in the body of the pancreas. Fourteen per cent of the pseudocysts were found in the tail of the pancreas and 3% of the cysts occupied parts of the head, body and tail. Four per cent of patients had cysts located in the small and large bowel mesentery which appeared unconnected to the pancreas. The incidence of multiple pseudocysts was 11%. Size of Cyst The cyst's size was estimated by the operating surgeon to exceed 10 cm in 30% of the patients. Contents of Cyst The cysts when opened or aspirated at operation were found to contain blood in 10% of patients, toothpaste like debris in 11%, or a liquid in 79% which was clear or straw colored in 88% and opaque or brownish red in 12%. In 18% of patients cyst fluid amylase levels were determined. These values ranged from 600 to over 5,000 somogyi units.
Other Findings Ascitic fluid was found at operation in 7% of patients with pseudocysts. However, in only three patients was ascites a significant factor in the clinical course and
654
FREY
TABLE 1. Initial Operative Treatment (Incision and Drainage, 34 Patients)
Ann. Surg.
*
November 1978
rather than on the thickness of the cyst wall as visualized at operation.
Av. Years
No. Pts.
%
Status
Follow-up
6 1 1 1 3
17.6 2.9 2.9 2.9 8.8
4.4 6 3 9
17
50.
4 1
11.8 2.9
34
100
Alive, working, well Alive, not working, well Alive, not working, pain Alive, working, pain Lost to follow-up (3-alive, working, well) Failure-requiring reoperation beca.use of recurrence of pain Deaths Operative Late -not related to pancreatic disease Total
9
100
Celiotomy Failure requiring reoperation
4
1
operative indications. Six patients were noted on the basis of arteriography, operative or autopsy findings to have splenic vein thrombosis. Operative Indications Documentation of the presence of a pseudocyst after 10-21 days of symptoms by ultrasound, E.R.C.P., or radiographic techniques including angiography and gastrointestinal barium contrast studies was not necessarily an indication for operative intervention. For remission of symptoms and spontaneous resolution of the cyst may occur as happened with eight of our patients. Because ofthe possibility of spontaneous resolution of the cyst, operation was most often postponed until symptoms or findings of an abdominal mass persisted six weeks or more unless concern about the possibility of an abscess prompted earlier operative intervention.
Celiotomy -Table I Besides the 34 patients initially undergoing incision and drainage an additional nine patients underwent celiotomy to rule out a surgically correctable cause of their abdominal signs and symptoms such as perforated ulcer or acute cholecystitis, pseudocyst or intraabdominal abscess. Internal Decompression Forty-two patients came to operation initially after a period of illness averaging six months (Tables 2-4). The decision to decompress the pseudocyst was based on the thickness of the cyst wall which could be verified at operation. The specific mode of decompression at operation was determined by the cysts location and whether it was adherent to the stomach or duodenum. In 17 of 24 patients undergoing cystogastrostomy the cyst was known to have been adherent to the posterior wall of the stomach at the time of operation. Cysts not in close proximity to the stomach or duodenum were treated by Roux-en-Y cystojejunostomy in 13 patients. The Roux-en-Y limb was 18-24 cm in length.
Excisional Operations-Table 5 Excisional operations, proximal or distal, were initially utilized in the management of 31 patients with pseudocysts principally because of preoperative complications or evidence of pre-existing chronic pancreatitis. Preoperative complications necessitating or making more desirable an excisional operation consisted of gastrointestinal hemorrhage from pseudoaneurysms of the mesenteric vessels in four patients, common duct obstruction in four patients and multiple cysts in five patients. Technical inability to drain a cyst in the
Choice of the Initial Operation Incision and Drainage -Table I
Thirty-four patients at the time of initial operative intervention underwent incision and drainage of a pseudocyst. Most of these patients were operated on less than the usually recommended six weeks after the onset of symptoms from their most recent exacerbation of pancreatitis. Low grade fever, persistent ileus, weight loss, abdominal pain and tenderness and distension were sufficiently severe as to raise the spector of a pancreatic abscess or perforated ulcer. The decision to externally drain the pseudocyst encountered was sometimes inappropriately based on the elapsed time from the onset of symptoms of pancreatitis until operation
TABLE 2. Initial Operative Treatment (Cystogastrostomy, 24 Patients) Av. Years
No. Pts.
%
7 2 1 4
29.2 8.3 4.2 16.6
9
37.5
1
4.2
24
100
Status
Alive, working, well Alive, not working, well Alive, not working, pain Lost to follow-up (3-alive working well) (1-alive not working pain) Failure-requiring reoperation because of recurrence of pain Death In part due to pancreatitis Total
Follow-up 3.3 2 1 I 2
2 months
VOl. 188.o NO. S
uncinate process necessitated excision of the pseudocyst in three patients as did duodenal obstruction in two patients. Proximal resection of the pancreas was performed in five patients and distal resection in 26. Fifteen of the 31 patients with pseudocysts who underwent an excisional operation had no preoperative complications other than evidence of chronic pancreatitis. In eight patients an excisional operation was performed to relieve pain. Sometimes only late in the dissection in an enlarged indurated inflamed gland was a cyst noted to be present. Pancreatectomy was deemed the operation of choice by the operating surgeon in the other seven patients with pseudocysts. Results
The results of the initial operative intervention are reported by operations in Tables 1-5 and summarized in Table 6. Information about the patient's status on follow-up was obtained through a hospital visit, or from the patient by phone call or written questionnaire or the patient's physician. Patients were considered to be well if they remained free of pain, recurrent bouts of pancreatitis or a recurrence of their pseudocyst. Some patients survived the operative management of their pseudocysts and were free of pain but did not return to work usually as a result of malnutrition, alcoholism, or diabetes. These patients along with those who continued to have the pain of chronic pancreatitis were classified as doing poorly. Other patients were doing well at their last follow-up or until death from a cause unrelated to pancreatitis. Reoperation Due to Persistent, Recurrent or New Cyst Formation or Chronic Pancreatitis Forty patients required a second operation and five patients had a third operation. Of those 40 patients undergoing a second operation, 26 had recurrent, persistent or new cysts. Eleven patients were operated on because of pain. Of the five patients requiring a third operation, four were operated on for pain associated TABLE 3. Initial Operative Treatment (Cystojejunostomy, 13 Patients)
No. Pts.
%
Status
7
53.8 23.1
Alive, working, well Lost to follow-up 2 alive, working, well 1 alive, not working, well Failure requiring reoperation
3 3 13
655
PANCREATIC PSEUDOCYST
23.1 100
Total
Av. Years Follow-up
TABLE 4. Initial Operative Treatment (Cystoduodenostomy, 5 Patients) No. Pts.
%
Status
1 1
20 20
1
20
2
40
Alive, working, well Lost to follow-up 1 alive, working, well Failure requiring reoperation Death Operative
5
100
Av. Years Follow-up 9
Total
with chronic pancreatitis and one for either a persistent, recurrent or new cyst. The necessity of a second and sometimes a third operation was most likely to be required after celiotomy or incision and drainage. The operative solution most frequently resorted to at reoperation was excision of the cyst (25 patients), cystojejunostomies (eight patients), and cystogastrostomies (six patients). These were the same operations which provided the most success following the initial operative procedure. The results of all the original operations plus reoperations are shown in Table 7. Of the 56 excisional operations, five were pancreaticoduodenectomies, one a total pancreatectomy, 20 (80-95%) distal pancreatectomies and 28 (40-80%) distal pancreatectomies. Exocrine and Endocrine Insufficiency
Diabetes was a sequela of 80-95% distal pancreatectomy about three times as often as after 40-80% distal resection or pancreaticoduodenectomy (Table 8). Clinically troublesome steatorrhea was most frequent after pancreaticoduodenectomy. The combination of a partial pancreatectomy and hemigastrectomy was most likely to produce steatorrhea. Patients having 80-95% TABLE 5. Initial Operative Treatment (Excisional Therapy, 31 Patients) Av. Years
No. Pts.
%
13 2 2 1 4
42.0 6.4 6.4 3.2 13.0
Status
Follow-up
working, well not working, well not working, pain working, pain Lost to follow-up 3 alive, working, well 1 alive, not working, well Failure requiring reoperation
3 3 4.5 1.0
Alive, Alive, Alive, Alive,
4.7
5
16.2
2.0 4.0
2
6.4
Operative
6.4
Late Not due to pancreatitis
Death 2 31
100
Total
2.5 2.0
656
FREY
Ann. Surg. * November 1978
TABLE 6.
Status
Failure Requiring reoperation Deaths Operative Late Due to pancreatitis Not due to pancreatitis Alive & well Alive, not working, well Alive, not working, pain Alive, working, pain Lost to follow-up Alive, well, working Alive, working, pain Total
No.
%
No.
%
No.
%
No.
%
No.
%
No.
%
17
50.9
9
100
9
37.5
3
23.1
1
20
5
16.2
3
75
4
11.76
2
40
2
6.4
1
2.94
1
4.2
6 1 1 1
17.64 2.94 2.94 2.94
7 2 1
29.2 8.3 4.2
7
53.8
1
20
2 13 2 2 1
6.4 42.0 6.4 6.4 3.2
1
25
3
8.82
3 1 24
12.4 4.2 100
2 1 13
15.4 7.7 100
1
20
5
100
3 1 31
9.75 3.20 100
4
100
34
100
9
100
Initial
Miscellaneous
Operations
Misc.
Excision
%
TABLE 7.
Celiotomy Cystogastrostomy Cystojejunostomy Cystoduodenostomy Excision
Cystduod
No.
resections were more prone to have trouble attaining their preoperative weight. Postoperative Complications Postoperative complications and morbidity after the initial operative procedure requiring reoperation affected 18 patients (15%) (Table 9). Hemorrhage from the cyst and G.I. tract were most frequently noted after incision and drainage, cystogastrostomies and cystojejunostomies. Intra-abdominal abscesses were most common following excisional operations. Peritonitis and hemorrhage resulted after a breakdown of the cystoduodenotomy anastomosis in two patients. The cyst and duodenum had been unfused in both patients (Table 4). Among the 40 patients undergoing a second operative procedure to relieve the pain of chronic pancreatitis or a recurrent, persistent or new pseudocyst 15 (37%) developed complications. Abscesses occurred in 13 patients, eight after an excisional operation. Short lived episodes of pancreatic drainage were frequent from the distal pancreatic stump. Most of these fistulas were short lived and required no reoperation.
I&D
Cystjej
Cystgast
Celiotomy
I&D
Operation 120 Patients
Reoperation 40 Patients
Total 120 Patients
34 9 24 13 5 31 4 120
4
38 9 29 21 57* 4 4 165
5 8 2 26 0 45
* Pancreaticoduodenectomy (5); total pancreatectomy (1); 8095% distal pancreatectomy (21); 40-80% distal pancreatectomy (30).
Postoperative Gastrointestinal Hemorrhage
Ten patients developed massive gastrointestinal hemorrhage or intra-abdominal hemorrhage following operative decompression of their pseudocyst (Table 10). Five of the patients died without leaving the hospital, a sixth patient died shortly after discharge from a cerebral vascular accident. Of the five patients who died in the hospital three bled into the gastrointestinal tract and two intraabdominally. The source of hemorrhage was not identified in the two patients, one of whom had a cystoduodenotomy and the other a cystogastrostomy. A patient treated with external drainage bled from a pseudoaneurysm of the inferior pancreaticoduodenal artery. The two patients who bled after distal pancreatectomy had multiple pseudocysts. The source of hemorrhage was from unresected cysts in the head of the pancreas. Neither was subjected to arteriography. Pseudoaneurysms were associated with the inferior pancreaticoduodenal artery in one patient and the gastroduodenal artery in the other. Of the four survivors, two bled into the G.I. tract and two intra-abdominally. Cystoduodenotomy and cystogastrostomy in one patient each and an excisional operation in two patients were associated with hemorrhage. Bleeding was controlled by arterial ligation in two patients. Hemorrhage ceased spontaneously in two patients. The patient who died from a cerebrovascular accident three months after cystogastrostomy bled from the G.I. tract. Hemorrhage was controlled by arterial ligation. Those most at risk from the complications associated with pseudocysts were patients with hemorrhage occurring postoperatively and in whom bleeding originated from the inferior pancreaticoduodenal or gastroduodenal artery. Patients with multiple cysts, particu-
VOl. 188 . NO. S
Operative Procedure
20 19 20 6 28
Incision & drainage Cystogastrostomy Cystojejunostomy Cystoduodenostomy 40-80% pancreatectomy distal 80-95% pancreatectomy distal Panc. duodenectomy Total
S 1
118
Overall
Insulin
Diet & Oral No. Pts. *
19
657
PANCREATIC PSEUDOCYST TABLE 8. Incidence & Severity of Diabetes Pre & Postoperatively
Pre
Post
Pre
Post
4 2 2 1
4 3 5 2
0
1
1
2
4 2 3 1
3
4
1
5
4 14.2%
5 1 1
2 1 0
0
1
19
21
2
24
Post
Pre
20% 10.5% 15% 16.6%
5 25% 1 20% 1 100%
15
21
5 3 7 2
25% 15% 35% 33%
9 32%
17 89% 1 20% 1 100%
45
* Number in whom information was available.
larly those located in the head of the pancreas complicated by bleeding or common duct obstruction were also a high risk group.
junostomy dismantling in a third. All ten patients with preoperative hemorrhage. survived. Common Duct Obstruction
Rupture of the Pseudocyst Rupture of the pseudocyst into the peritoneal cavity was a rare event in our experience though it resulted in the death of the only patient in whom it occurred. More commonly noted were rupture or fistulization of cysts into the gastrointestinal tract (seven patients). In three patients rupture occurred into stomach or duodenum. Two of these three patients died from hemorrhage associated with a pseudoaneurysm in the cyst wall. Rupture occurred into the colon of two patients both of whom survived. Another patient survived rupture into the small bowel and another survived rupture into the chest.
Preoperative Complications of Pseudocyst In ten patients with pseudocysts, hemorrhage was the presenting symptom (Table 11). Two bled intraabdominally and seven into the G.I. tract. One person bled both intra-abdominally and into the gastrointestinal tract. Hemorrhage entered the gastrointestinal tract presumably through the pancreatic ductal system in continuity with the pseudocyst, or as occurs more frequently, by fistulization or erosion of the pseudocyst into the stomach or duodenum. The source of hemorrhage was a pseudoaneurysm of the splenic artery in six patients. The inferior pancreaticoduodenal artery two patients and the right gastroepiploic artery in one patient. The source of hemorrhage was unknown in one patient. Hemorrhage was controlled by an excisional operation in five patients, i.e., one pancreaticoduodenectomy and four distal pancreatectomies. Ligation of the bleeding site was employed successfully in two patients, cystogastrectomy in a second and cystoje-
Twenty patients with pseudocysts were hospitalized with jaundice secondary to common duct obstruction. Obstruction resulted from compression of the distal common bile duct by the cyst. Five of the 20 patients whose common duct obstruction resulted from pseudocysts died. However, three of the five who died also had had postoperative hemorrhage. A sixth patient with common duct obstruction died later after leaving the hospital. Death was in part attributable to sequelae of his pseudocyst and
pancreatitis. Five surviving patients underwent excisional operation. Pancreaticoduodenectomy was performed in three patients because of multiple cysts or cysts in the uncinate process in which decompression was technically impossible, or because of a pseudoaneurysm associated with the cyst. Two patients undergoing TABLE 9. Complications Requiring Operative Intervention
Initial Operation 120 Patients 120 Operations No. Patients Hemorrhage Peritonitis + hemorrhage Abscesses Common duct stricture Small bowel obstruction Colonic necrosis Common duct stricture plus hemorrhage Colonic fistula and abscess
6 2 6 2 1 1 0 0 18 (15%)
Reoperation 40 Patients 45 Operations No. Patients 1 0 12 0 0 0
1 1 15 (37%)
658
FREY
Ann. Surg. o November 1978
TABLE 10. Hemorrhage (10 Patients Postoperative)
Original Operation
Hemorrhage
H.
External drainage
Intraabdominal
L.
Gastrointestinal
R.
Distal panc & I&D abscess for pseudocyst Cystoduodenostomy
G.
Choledochojejunostomy
Gastrointestinal
F. Mc
Cystogastrostomy Cystogastrostomy
Gastrointestinal Gastrointestinal
G.
Cystoduodenostomy
Gastrointestinal
M.
Cystogastrostomy
Intraabdominal
A.
50% distal panc.
Gastrointestinal
J.
80%-Cyst in head unroofed
Intraabdominal
Intraabdominal
Autopsy
Vessel
Pseudoaneurysm Pseudoaneurysm ?
Inf. panc. Duod. Inf. panc. Duod. Coagulopathy No operation Gastroduodenal ? ?
Art. ligat.
Op death
No operation Art. ligat.
Op death Late death C.V.A.
?
No operation
S*
Art. ligat.
S
Ceased spontaneously 2 mo. later Cystojejunostomy No operation
S
Pseudoaneurysm ? ? No pseudoaneurysm Pseudoaneurysm ?
Splenic
No pseudoaneurysm
?
Treatment
Outcome
Art. ligat.
Op death
Art. ligat.
Op death Op death
S
* S-Survival.
distal resection for common duct obstruction also had a history of chronic pancreatitis. Operative Deaths
There were ten operative deaths (8.33%) among the 120 patients in whom the pseudocyst was treated surgically (Table 12). Three patients developed cysts within three to six weeks of an episode of hemorrhagic necrosis of the pancreas. The cysts developed in the head of the pancreas in two patients and produced common duct obstruction in one patient, and duodenal obstruction as well as common duct obstruction in the other. These three patients died more from hemorrhagic necrosis of
the pancreas than from complications of the pseudocyst or its operative management (Table 12). A patient with cirrhosis and portal hypertension died at the time of attempted 95% pancreatectomy. His problems could have been better managed by porta caval shunt and pancreaticoduodenectomy. Three patients died from complications attributable to operative technique and judgment. Dehiscence of an anastomosis not in an area of fusion resulted in lateral duodenal fistulas and peritonitis in two patients. In the third patient, wound dehiscence peritonitis and sepsis was followed by a lethal gastrointestinal hemorrhage. Three patients died as a result of massive postoperative gastrointestinal hemorrhage from a pseudoaneurysm in the cyst wall. The preoperative and operative
TABLE 11. Preoperative Hemorrhage in Ten Patients
Hemorrhage
Autopsy or Angiography Findings
D. B. C.
Intra-abdominal Gastrointestinal Gastrointestinal
Pseudoaneurysm Pseudoaneurysm
Splenic Splenic
Mc H.
Gastrointestinal Gastrointestinal
Pseudoaneurysm Pseudoaneurysm
Inf. panc. Duod. R. Gastric
J.
Gastrointestinal Intra-abdominal Gastrointestinal Gastrointestinal Gastrointestinal Intra-abdominal
Pseudoaneurysm
Splenic
Distal resection
S
Pseudoaneurysm Pseudoaneurysm Pseudoaneurysm Pseudoaneurysm
Splenic Inf. panc. Duod. Splenic
Distal resection
Pancreaticoduodenostomy
Splenic
Distal resection
S S S S
B. L. A. T.
* S-Survival.
Artery
Treatment
Cystogastrostomy Artery ligation Cystogastrostomy & artery ligation Cystojejunostomy Cystojejunostomy dismantling
Distal resection
Outcome S*
S S S S
659
PANCREATIC PSEUDOCYST
VOl. 188.9 NO. S
TABLE 12. Operative Deaths: Ten
Patient Age
Sex
Preoperative Complication
41
F
42
M
59
F
Hemorrhagic pancreatitis, shock, renal & pulmonary failure Hemorrhagic pancreatitis shock, renal & pulmonary failure Hemorrhagic pancreatitis renal & pulmonary failure, 'jaundice
52
M
47
F
51 47 32 45
M M M M
Celiotomy wound dehiscence
38
M
I & D x2 50% distal
Cirrhosis and portal hypertension
(8.3%o) Postoperative Complication
Operation Pseudocyst
Autopsy
I&D
Hemorrhagic ascites necrotizing pancreatitis
I&D
Ascites, pleural effusion necrotizing pancreatitis, undrained cyst Ascites, bilateral pleural effusion, common duct & duodenum obstructed by an unrecognized pseudocyst in the head of the pancreas
I&D
95%
Operative hemorrhage
Cystoduodenostomy
Anastomatic dehiscence
Cystoduodenostomy Cystogastrostomy I&D Distal pancreatectomy for infected pseudocyst Multiple
Anastomatic dehiscence Sepsis Hemorrhage I & D subhepatic abscess G.I. hemorrhage
diagnosis of pseudoaneurysm was not suspected. None of the patients had undergone selective preoperative angiography. None of the pseudocysts were excised as we recommend when associated with a pseudoaneurysm. Late Deaths There were 16 late deaths from operative decompression or excision of a pseudocyst.
Symptomatic Group In six patients it was felt the patient's operation or persisting pancreatitis contributed in part to the pa-
tient's death (Table 13).
G.I. hemorrhage, peritonitis Peritonitis G.I. hemorrhage Pseudoaneurysm Pseudoaneurysm Pseudoaneurysm
G.I. hemorrhage
there is convincing evidence of a pancreatic abscess characterized by a septic febrile course or some complication of a pseudocyst patients should not be subjected to operations in under six to eight weeks from the onset of the exacerbation of pancreatitis for several reasons. 1) In a very significant number of instances the acute cyst associated with an episode of pancreatitis demonstrated on ultrasound or visualized on E.R.C.P. will spontaneously resolve making the operation unnecessary. The exact incidence of spontaneous resolution is unknown but far higher than our reported 6% which preceded the use of ultrasound and E.R.C.P. Czaza5 reported 70% of acute cysts resolve without operative TABLE 13. Late Deaths Symptomatic Group (Six Patients) Interval
Symptom Free Group Ten patients died from 1-11 years after operative decompression or excision of a pseudocyst. All were symptom free from problems unrelated to the operation on the cyst, alcoholism or pancreatectomy (Table 14). Comments
The age of the cyst is an important factor influencing the timing of operation. However, it is sometimes impossible to be certain of the age of the cyst in patients with alcoholic pancreatitis having frequent exacerbations of their disease. The presence of the cyst may have antedated the most recent episode of pancreatitis which brought the patient under medical care. Unless
Operation to Age
Operation
Cause of Death
39 M Celiotomy, 95% distal Malnutrition, alcoholism resection 44 M Cystjejunostomy, 85% Alcoholism, distal resection exsanguination during porta caval shunt 49 M Celiotomy, 50% distal Alcoholism, drug overdose resection and common duct
exploration 35 F
50% distal resection
39 F Cystgastrectomy 35 M Cystgastrostomy,
cystjejunostomy
Pain and
alcoholism, died laminectomy Pain, CVA Alcoholic hepatitis
Death-Years 3 2
7
11
3 months 2
660
FREY
TABLE 14. Late Deaths Symptom Free Group (Ten Patients)
No. Pts.
Cause of Death
Interval Operation to Death Years
3 1 1 1 1 2 1
Cerebral vascular accident Intestinal obstruction Peritonitis post D & C Pneumonia Pulmonary embolus Myocardial infarction Pulmonary emphysema
2, 4, 5 2 2 5 1 1 3
therapy. 2) Operative management of an acute cyst precludes the use of internal decompression the procedure of choice if the cyst wall is not sufficiently thick and mature to hold sutures. In experimental animals, according to Warren's22 work, it required four to six weeks for a cyst wall to mature. This assumption has been challenged by Grace and Jordan,6 based on their experience with a patient found to have a mature cyst who at an operation three weeks earlier had no cyst. However, most cysts require a longer period of maturation before their walls lend themselves to suturing. Sankaran and Walt'4 described four patients operated on less than four weeks after an acute attack three of whom had cysts which were thin walled and incompatible for internal drainage. We support the opinion expressed by Grace and Jordan8 that should one encounter at emergency operation a pseudocyst two to three weeks after an exacerbation of pancreatitis in which the wall is thick, the maturation of the wall and its ability to hold sutures should be the criteria as to whether internal decompression is feasible not the time interval from the acute exacerbation to operation. 3) When the cyst wall is too immature to hold sutures, external drainage in spite of its limitations must be employed. External drainage is associated with a high rate of complications or death in 60-80% of patients. This high morbidity and mortality may more often reflect the severity of the complications encountered and cannot always be attributed to the operation.4 However, external drainage in our experience is not a definitive operation in the patient with either an acute or mature pseudocyst in over half the instances in which it is employed due to the high incidence of recurrent cysts and persistent symptoms necessitating reoperation. This has also been the experience of Scharplatz. 17 Some unnecessary operations in the form of external drainage have been performed because the cyst fluid visualized at operation resembled the contents of an abscess. In order to avoid an unnecessary external drainage procedure the contents ofthe cyst at operation should be smeared and gram stained. When a cyst is known to have been present for a
Ann. Surg. a November 1978
period of six weeks prompt operative intervention is indicated. The only non-operative death occurred in a patient whose cyst of long standing ruptured. Evidence of expansion of an existing cyst is an indication for prompt operative intervention. Spontaneous hemorrhage and rupture are the most frequent causes of nonoperative deaths.1" 9 We recommend selective angiography of the superior mesenteric and coeliac arteries as part of the preoperative evaluation of all patients with pseudocysts. Pseudoaneurysms were identified in 13 (10.8%) of our operative cases. Hemorrhage is a significant factor in the majority of deaths of patients with pseudocysts. 13,9"14"16"19 We feel preoperative arteriography is an essential step in the selection of the most appropriate operation to avoid this preventable complication. All pseudocysts having an associated pseudoaneurysm should, whenever possible, be treated by excision. Preoperative or postoperative persistent massive hemorrhage from the pseudocyst did not occur in the absence of a pseudoaneurysm in any of our 13 patients evaluated by arteriography. In the absence of arteriography the source of hemorrhage was not known in seven instances. Failure to establish the presence of a pseudoaneurysm in conjunction with a pseudocyst may contribute to a fatal outcome (Table 12). At operation three of our patients, none of whom had bled preoperatively or had evidence of blood in their cysts at operation, underwent external drainage or internal decompression. Postoperatively all three exsanguinated. Pseudoaneurysms in the cyst wall were the source of hemorrhage. Preoperative angiography and an excisional operation would have eliminated the pseudoaneurysm and the possibility of postoperative hemorrhage from it. We had no mortality and successfully terminated the hemorrhage in all five patients treated by excisional operations. In contrast two of four of our patients treated by non-operative methods died and four of nine patients treated by local ligation of vessels died. Local control or ligation of the feeding vessel of a pseudoaneurysm embedded in a chronically inflamed pseudocyst wall is not always effective or technically feasible and the result is a 28% mortality from infection and rebleeding according to Stanley et al. 18 The success of excisional operations in reducing mortality of hemorrhage associated with pseudocysts pertains whether the hemorrhage originates from vessels in the head or tail of the gland. In our experience and that of others pancreaticoduodenectomy and distal pancreatectomy are equally effective and technically feasible in the treatment of the patient with a pseudocyst complicated by a pseudoaneurysm in the wall of the cyst.18 In those patients thought too ill to withstand operative intervention intra-arterial embolization with gelfoam or autologous clot should be considered as a temporizing procedure.
Vol. 188 * No. 5
Grace8 reported the presence of blood or even active bleeding found at the time of operation as determined by needle aspiration of the pseudocyst did not expose the patient to any special risk of postoperative bleeding. We had the same experience in six patients but feel such a course is rational only if preoperative angiography has eliminated the possibility of an associated pseudoaneurysm. This distinction is crucial. In the absence of an associated pseudoaneurysm we do not feel it necessary to proceed with an excisional operation in cysts containing blood. Internal decompression of the uncomplicated mature single pseudocyst by cystogastrostomy or cystojejunostomy are the procedures of choice (Tables 1-6). We recommend cystogastrostomy when the anastomosis can be performed through an area of fusion between the cyst and the posterior wall of the stomach. We employ a 10 cm long incision including a small ellipse of cyst wall. This ellipse of cyst wall is sent as a biopsy to rule out cystadenocarcinoma. While there is debate as to the appropriate size of the cystogastrostomy anastomosis, we were unable to demonstrate any difference in the rate of recurrence when a smaller anastomosis of 5-7 cm without an ellipse was employed. Hemorrhage from the edge of the anastomosis, as was reported by Huston"' and Folk,6 has not been a problem in our experience or that of Van Heerden.20 We place multiple mattress sutures of permanent material circumferentially around the anastomosis in the area of fusion. When the pseudocyst is not fused to the posterior wall of the stomach we believe a Roux-en-Y cystojejunostomy is the procedure of choice. The consequences of a dehiscence of a long Roux-en-Y cystojejunostomy are less catastrophic than a breakdown of an unfused cystogastrostomy or cystoduodenostomy. Warshaw23 recommends the limb of the cystojejunostomy be at least 35 cm long presumably to alleviate the consequences of a dehiscence. We did not find any correlation between cyst recurrence and the length of the cystojejunostomy limb. Sankaran 4 reported good results with cystoduodenostomy as did Mercadier12 though the latter patients according to Scharplatz and White17 were apparently not followed beyond nine months. We do not recomment cystoduodenostomy on the basis of our limited but unsatisfactory experience which included two deaths (Table 4) and one recurrence with this operation. Both deaths occurred in patients in whom the duodenum was not fused to the cyst as is recommended. Failure to follow accepted practice perhaps explains the events which led to dehiscence of the cystoduodenostomy anastomosis. However, Scharplatz17 and also Grace8 reported dissatisfaction with the long-term
results of cystoduodenostomy.
661
PANCREATIC PSEUDOCYST
Indications for an excisional operation in addition to a pseudoaneurysm associated with the pseudocyst includes patients having multiple pseudocysts, or cysts located in the uncinate process or head of the pancreas in which internal decompression is not technically feasible. Common duct or duodenal obstruction frequently cannot be relieved except by a pancreaticoduodenectomy due to the presence of one or more small cysts which do not lend themselves to internal drainage. Yet a small cyst or cysts in the head of the pancreas may initiate and perpetuate pancreatic inflammation and as Sankaran14 and Nardi'3 have noted can produce very troublesome persistent symptoms. Sometimes these small cysts are not appreciated on E.R.C.P. and are impossible to identify by palpation at operation and are only recognized after pancreaticoduodenectomy is well under way. Left sided portal hypertension from splenic vein thrombosis due to pericystic inflammation and compression by the cyst is best treated by distal pancreatectomy and splenectomy which relieves both symptoms of the cyst and left sided portal hypertension.15 Rupture or enteric fistulization of the pseudocyst in our experience was more common (six patients) than free intra-abdominal perforation (one patient), or extension into the chest (one patient). Enteric fistulization in itself was a benign process unless accompanied by hemorrhage secondary to pseudoaneurysm formation. The combination is lethal.1'2'3'14'19 Twenty-six of our patients have undergone operative decompression of a pseudocyst and subsequently required another operation for a pseudocyst. At the second operation it is often impossible to know if the cyst is new, recurrent, persistent, or overlooked at the first operation. For patients continuing to experience pain after internal decompression or an excisional operation (Table 7), the choice of which excisional operation proximal or distal pancreatectomy is most appropriate for the patient depends on whether the cyst, ductal obstruction or inflammation of the pancreas are confined to the head or tail of the pancreas. Pancreatic Function Distal resection of 80% or more of the pancreas is likely to cause insulin dependent diabetes in 79% of patients (Table 7). Pancreaticoduodenectomy preserves more endocrine function than distal pancreatectomy due to the retention of a greater mass of tissue in the tail of the pancreas which has a higher concentration of islets than the head or body.7
References 1. Becker, W. F., Pratt, H. S. and Gangi, H.: Pseudocysts of the
Pancreas. Surgery, 20 127:744, 1968.
662
FREY
2. Berne, T. V. and Edmondson, A. A.: Colonic Fistulization due to Pancreatitis. Am. J. Surg., 111:359, 1966. 3. Bradley, E. L. and Clements, J. L.: Transenteric Rupture of Pancreatic Pseudocysts, Management of Pseudocyst Enteric Fistulas. Am. Surg., 42:827, 1976. 4. Cerilli, J. and Faris, T. D.: Pancreatic Pseudocysts, Delayed versus Immediate Treatment. Surgery, 61:541, 1967. 5. Czaza, A. J., Fisher, M. and Marin, G.: Spontaneous Resolution of Pancreatic Masses (Pseudocysts?). Arch. Int. Med., 135: 558, 1975. 6. Folk, F. A. and Freeark, R. J.: Reoperations for Pancreatic Pseudocysts. Arch. Surg., 100:430, 1970. 7. Frey, C. F., Child, C. G. and Fry, W.: Pancreatectomy for Chronic Pancreatitis. Ann. Surg., 184:403, 1976. 8. Grace, R. R. and Jordan, Jr., P. H.: Unresolved Problems of Pancreatic Pseudocysts. Ann. Surg., 184:16, 1976. 9. Hanna, W. A.: Rupture of Pancreatic Cysts: Report of Case and Review of Literature. Br. J. Surg., 47:495, 1960. 10. Hillson, R. F. and Taube, R. R.: Surgical Management of Pancreatic Pseudocysts in Infants and Children. Ann. Surg., 182: 590, 1976. 11. Huston, D. G., Zeppa, R. and Warren, D. W.: Prevention of Postoperative Hemorrhage after Pancreatic Cystogastrostomy. Ann. Surg., 177:689, 1973. 12. Mercedier, M. P., Clot, J. P. and Russel, R. T.: Chronic Recurrent Pancreatitis and Pancreatic Pseudocysts. Curr. Probl. Surg., July 1973. 13. Narid, G. L., Lyon, D. C., Sheiner, H. J. and Bartlett, M. K.:
14. 15. 16. 17.
18. 19.
20. 21.
22.
23.
Ann. Surg. * November 1978
Solitary Occult Retention Cysts of the Pancreas. N. Engl. J. Med., 280:11, 1969. Sankaran, S. and Walt, A. J.: The Natural and Unnatural History of Pancreatic Pseudocysts. Br. J. Surg., 62:37044, 1975. Saubier, E. C., Partensky, L., Brault, A., et al.: Les Collections Enkystees d'origine Pancreatique (Analyse de 30 observations) Lyon Med., 231:587, 1974. Schecter, L. W., Gordon, H. E. and Passaro, Jr., E.: Massive Hemorrhage from the Celiac Axis in Pancreatitis. Am. J. Surg., 128:301, 1974. Scharplatz, P. and White, T.: A Review of 64 Patients with Pancreatic Cysts. Ann. Surg., 176:638, 1972. Stanley, J. C., Frey, C. F., Miller, T. A., et al.: Major Arterial Hemorrhage: A Complication of Pancreatic Pseudocysts and Chronic Pancreatitis. Arch. Surg., 111:435, 1976. Thomford, N. R. and Joseph, J. E.: Pseudocyst of the Pancreas, A Review of 50 Cases. Am. J. Surg., 118:86, 1969. Van Heerden, J. A. and Remine, W. H.: Pseudocysts of the Pancreas. Arch. Surg., 110:500, 1975. Warren, K. W., Athanassiades, S., Frederick, P., et al.: Surgical Treatment of Pancreatic Cysts. Review of 183 Cases. Ann. Surg., 163:886, 1966. Warren, W. P., Marsh, W. H. and Muller, Jr., W. H.: Experimental Production of Pseudocysts of the Pancreas with Preliminary Observations of Internal Drainage. Surg. Gynecol. Obstet., 105:385, 1957. Warshaw, A. L.: Inflammatory Masses Following Acute Pancreatitis Phlegmon, Pseudocysts, Abscesses. Surg. Clin. North Am., 54:621, 1974.
Announcement The appearance of the code at the bottom of the first page of an article in this journal indicates the copyright owner's consent that copies of the article may be made for personal or internal use, or for personal or internal use of specific clients. This consent is given on the condition, however, that the copier pay the stated per-copy fee through the Copyright Clearance Center Inc., P.O. Box 765, Schenectady, N.Y. 12301, for copying beyond that permitted by Sections 107 or 108 of the U.S. Copyright Law. This consent does not extend to other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale.
The experience with 131 patients with 157 pseudocysts is reported. One hundred and twenty patients with 146 pseudocysts underwent 165 operations. There were ten operative deaths (8.3%) three of which were not attributable to the pseudocyst or its operative management. Sixteen patients died six months to 14 years after operation. Deaths in six of the 16 patients were in part attributable to pancreatitis or complications of pseudocyst management. The operative mortality was highest in patients undergoing incision and drainage and cystoduodenostomy. Other factors influencing mortality unfavorably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or fistulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pseudoaneurysms associated with their pseudocysts. Incision and drainage of pseudocysts is associated with a high rate of recurrence of the cyst and continued pain. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. The presence of a pseudoaneurysm visualized on preoperative visceral angiography is an indication for an excisional operation as are the presence of multiple cysts, compression of the common duct or duodenum by the cyst, evidence of left sided portal hypertension, recurrent cysts or evidence of chronic pancreatitis. R ECENT REPORTS ON THE MANAGEMENT of pan-
creatic pseudocysts do not show results which should lead to complacency20 by surgeons dealing with these patients. The operative mortality rate is in the range of 3-1 1% 48,9,14,16,18,20,21 and postoperative complications develop frequently, 37%,17 34%19 often requiring reoperation. Preoperative complications of pseudocysts afflict 30-55% of patients. 1'8"14 The recurrence rate, or persistence of unrecognized or de novo pseudocysts or ascites ranges from 11 -20%1 13,16 and pain due to chronic pancreatitis sufficient to require * Chief, Surgical Service, Veterans Administration Hospital, Martinez, California, Professor and Vice Chairman, Department of Surgery, University of California, Davis, California. Reprint requests: Charles F. Frey, M.D., Department of Surgery, Veterans Administration Hospital, 150 Muir Road, Martinez, California 94553. Submitted for publication: December 5, 1977.
From the University of Michigan Medical Center, Ann Arbor, Michigan
reoperation or rehospitalization occurs in up to 48%8 of patients. Authors in recent years have focused attention on some of the preoperative complications which effect 30-55% of patients with pseudocysts. The mortality and morbidity is the highest in patients with these preoperative complications. For example, in 1975 Sankaran and Walt'4 reported on their experience with 1 12 patients with pseudocysts, "Four of seven patients (57%) with preoperative bleeding and seven of eleven (64%) with postoperative bleeding died . . . ten of 14 patients in the entire series who died bleed either pre or postoperatively." The same authors reported pancreatic ascites in 14.5% of their patients. The recurrence rate of cysts was particularly high (40%) in patients with both a pseudocyst and ascites. In Bradley and Clements 1976 report3 on transenteric rupture of 37 pancreatic pseudocysts the incidence of this complication was estimated to involve 5% of all patients with pseudocysts. One third of their patients with transenteric rupture concomitantly developed massive hemorrhage. All patients with transenteric rupture who died (37%) died from hemorrhage. Based on our experience at the University of Michigan we believe rational operative management of pseudocysts, particularly the choice of the appropriate operative procedure, depends particularly on a knowledge of preoperative complications, whether the cysts are multiple, recurrent or associated with chronic pancreatitis, the optimal time of operation, the size and location of the cyst, its adherence to surrounding structures and the disease initiating pancreatic inflammation. Clinical Material At the University of Michigan Medical Center and affiliated hospitals between the years 1959-1976 the diagnosis of pseudocyst of the pancreas was established in 131 patients. No operation was performed in 11 patients, four of whom died. Death was attributed to a ruptured pseudocyst in one of the four patients. The
0003-4932/78/1100/0652 $01.05 © J. B. Lippincott Company
652
Vol. 188
o
No. S
PANCREATIC PSEUDOCYST
presence of a pseudocyst was an incidental finding at autopsy in the other three patients. One hundred and 20 patients were subjected to operative intervention for 147 pseudocysts. Of the 131 patients, 86 were male and 45 female. The average age at operation was 42 years and ranged from 8-83 years. Eighty-seven (66%) patients were alcoholic, four of whom also had gallstones. No known cause of pancreatic disease was identified in 19 patients. Eleven patients developed pseudocysts following trauma, one of whom was an alcoholic and another of whom had gallstones. Six patients had gallstones, five familial pancreatitis or congenital abnormalities of the pancreas and biliary tract, and three disorders of lipid metabolism.
Patient Presentation Most patients with pseudocysts requiring operation other than those with trauma had had previous experience with pancreatitis. Seventy four per cent of patients had more than one episode of pancreatitis and 28% had had persistent pain for more than three months prior to operation. In only 2% of patients did the first episode of pancreatitis associated with pseudocyst result in operation. Twenty-four per cent of patients had had four previous hospitalizations for pancreatitis, 67% two to three hospitalizations and in only 9% was the first hospitalization associated with an operation. The history of an episode of pancreatitis or blunt abdominal trauma followed by persistence or recurrence of the signs and symptoms and clinical evidence of pancreatitis after 10-14 days including the appearance of an abdominal mass were features which often accompanied the development of a pseudocyst.
Symptoms and Signs Most patients (91%) with pseudocysts had episodes of abdominal pain often with radiation to the back, 63% an abdominal mass and 21% were jaundiced. Less frequently noted were preoperative gastrointestinal hemorrhage 7.5%, pleural effusion 11%, fever 10%, and ascites 7%. In addition continuous or recurring episodes of pain, evidence of diabetes and calcification of the pancreas were considered suggestive of chronic pancreatitis.
Laboratory Data At the time of the hospital admission associated with operative treatment of the pseudocyst the serum amylase levels were elevated in 77% of patients and the white count was elevated in 40% of patients. The hematocrit was below 38 in 17% of patients some of whom had bled into the G.I. tract. Conversely, the hematocrit
653
was elevated above 50% in 6% of patients most of whom had been under replenished with fluids subsequent to an exacerbation of pancreatitis. Evidence of extra hepatic obstruction with elevation of alkaline phosphatase or bilirubin was noted in 21% of patients. Liver chemistries, SGOT, SGPT were abnormal in 10% of patients and visceral protein stores depleted in 12% evidenced by an albumin of under 3.5 g 100 ml. The serum calcium was depressed below 8.5 mg% in 12% of patients most of whom were admitted during an acute exacerbation of pancreatitis. One patient had an elevated serum Ca++ level and was subsequently found to have hyperparathyroidism.
Diagnostic Studies Most of our patients were managed prior to the availability of endoscopy and ultrasound. Confirmation of the presence of a pseudocyst suspected on the basis of an abdominal mass detected on physical examination or suspected on the basis of the patient's clinical course was dependent on chest x-rays, flat plate, upright abdominal films and G.I. series 67%, and angiographic findings 28%. Operative Findings Thirty-eight per cent ofthe pseudocysts were located in the head or uncinate process and 37% in the body of the pancreas. Fourteen per cent of the pseudocysts were found in the tail of the pancreas and 3% of the cysts occupied parts of the head, body and tail. Four per cent of patients had cysts located in the small and large bowel mesentery which appeared unconnected to the pancreas. The incidence of multiple pseudocysts was 11%. Size of Cyst The cyst's size was estimated by the operating surgeon to exceed 10 cm in 30% of the patients. Contents of Cyst The cysts when opened or aspirated at operation were found to contain blood in 10% of patients, toothpaste like debris in 11%, or a liquid in 79% which was clear or straw colored in 88% and opaque or brownish red in 12%. In 18% of patients cyst fluid amylase levels were determined. These values ranged from 600 to over 5,000 somogyi units.
Other Findings Ascitic fluid was found at operation in 7% of patients with pseudocysts. However, in only three patients was ascites a significant factor in the clinical course and
654
FREY
TABLE 1. Initial Operative Treatment (Incision and Drainage, 34 Patients)
Ann. Surg.
*
November 1978
rather than on the thickness of the cyst wall as visualized at operation.
Av. Years
No. Pts.
%
Status
Follow-up
6 1 1 1 3
17.6 2.9 2.9 2.9 8.8
4.4 6 3 9
17
50.
4 1
11.8 2.9
34
100
Alive, working, well Alive, not working, well Alive, not working, pain Alive, working, pain Lost to follow-up (3-alive, working, well) Failure-requiring reoperation beca.use of recurrence of pain Deaths Operative Late -not related to pancreatic disease Total
9
100
Celiotomy Failure requiring reoperation
4
1
operative indications. Six patients were noted on the basis of arteriography, operative or autopsy findings to have splenic vein thrombosis. Operative Indications Documentation of the presence of a pseudocyst after 10-21 days of symptoms by ultrasound, E.R.C.P., or radiographic techniques including angiography and gastrointestinal barium contrast studies was not necessarily an indication for operative intervention. For remission of symptoms and spontaneous resolution of the cyst may occur as happened with eight of our patients. Because ofthe possibility of spontaneous resolution of the cyst, operation was most often postponed until symptoms or findings of an abdominal mass persisted six weeks or more unless concern about the possibility of an abscess prompted earlier operative intervention.
Celiotomy -Table I Besides the 34 patients initially undergoing incision and drainage an additional nine patients underwent celiotomy to rule out a surgically correctable cause of their abdominal signs and symptoms such as perforated ulcer or acute cholecystitis, pseudocyst or intraabdominal abscess. Internal Decompression Forty-two patients came to operation initially after a period of illness averaging six months (Tables 2-4). The decision to decompress the pseudocyst was based on the thickness of the cyst wall which could be verified at operation. The specific mode of decompression at operation was determined by the cysts location and whether it was adherent to the stomach or duodenum. In 17 of 24 patients undergoing cystogastrostomy the cyst was known to have been adherent to the posterior wall of the stomach at the time of operation. Cysts not in close proximity to the stomach or duodenum were treated by Roux-en-Y cystojejunostomy in 13 patients. The Roux-en-Y limb was 18-24 cm in length.
Excisional Operations-Table 5 Excisional operations, proximal or distal, were initially utilized in the management of 31 patients with pseudocysts principally because of preoperative complications or evidence of pre-existing chronic pancreatitis. Preoperative complications necessitating or making more desirable an excisional operation consisted of gastrointestinal hemorrhage from pseudoaneurysms of the mesenteric vessels in four patients, common duct obstruction in four patients and multiple cysts in five patients. Technical inability to drain a cyst in the
Choice of the Initial Operation Incision and Drainage -Table I
Thirty-four patients at the time of initial operative intervention underwent incision and drainage of a pseudocyst. Most of these patients were operated on less than the usually recommended six weeks after the onset of symptoms from their most recent exacerbation of pancreatitis. Low grade fever, persistent ileus, weight loss, abdominal pain and tenderness and distension were sufficiently severe as to raise the spector of a pancreatic abscess or perforated ulcer. The decision to externally drain the pseudocyst encountered was sometimes inappropriately based on the elapsed time from the onset of symptoms of pancreatitis until operation
TABLE 2. Initial Operative Treatment (Cystogastrostomy, 24 Patients) Av. Years
No. Pts.
%
7 2 1 4
29.2 8.3 4.2 16.6
9
37.5
1
4.2
24
100
Status
Alive, working, well Alive, not working, well Alive, not working, pain Lost to follow-up (3-alive working well) (1-alive not working pain) Failure-requiring reoperation because of recurrence of pain Death In part due to pancreatitis Total
Follow-up 3.3 2 1 I 2
2 months
VOl. 188.o NO. S
uncinate process necessitated excision of the pseudocyst in three patients as did duodenal obstruction in two patients. Proximal resection of the pancreas was performed in five patients and distal resection in 26. Fifteen of the 31 patients with pseudocysts who underwent an excisional operation had no preoperative complications other than evidence of chronic pancreatitis. In eight patients an excisional operation was performed to relieve pain. Sometimes only late in the dissection in an enlarged indurated inflamed gland was a cyst noted to be present. Pancreatectomy was deemed the operation of choice by the operating surgeon in the other seven patients with pseudocysts. Results
The results of the initial operative intervention are reported by operations in Tables 1-5 and summarized in Table 6. Information about the patient's status on follow-up was obtained through a hospital visit, or from the patient by phone call or written questionnaire or the patient's physician. Patients were considered to be well if they remained free of pain, recurrent bouts of pancreatitis or a recurrence of their pseudocyst. Some patients survived the operative management of their pseudocysts and were free of pain but did not return to work usually as a result of malnutrition, alcoholism, or diabetes. These patients along with those who continued to have the pain of chronic pancreatitis were classified as doing poorly. Other patients were doing well at their last follow-up or until death from a cause unrelated to pancreatitis. Reoperation Due to Persistent, Recurrent or New Cyst Formation or Chronic Pancreatitis Forty patients required a second operation and five patients had a third operation. Of those 40 patients undergoing a second operation, 26 had recurrent, persistent or new cysts. Eleven patients were operated on because of pain. Of the five patients requiring a third operation, four were operated on for pain associated TABLE 3. Initial Operative Treatment (Cystojejunostomy, 13 Patients)
No. Pts.
%
Status
7
53.8 23.1
Alive, working, well Lost to follow-up 2 alive, working, well 1 alive, not working, well Failure requiring reoperation
3 3 13
655
PANCREATIC PSEUDOCYST
23.1 100
Total
Av. Years Follow-up
TABLE 4. Initial Operative Treatment (Cystoduodenostomy, 5 Patients) No. Pts.
%
Status
1 1
20 20
1
20
2
40
Alive, working, well Lost to follow-up 1 alive, working, well Failure requiring reoperation Death Operative
5
100
Av. Years Follow-up 9
Total
with chronic pancreatitis and one for either a persistent, recurrent or new cyst. The necessity of a second and sometimes a third operation was most likely to be required after celiotomy or incision and drainage. The operative solution most frequently resorted to at reoperation was excision of the cyst (25 patients), cystojejunostomies (eight patients), and cystogastrostomies (six patients). These were the same operations which provided the most success following the initial operative procedure. The results of all the original operations plus reoperations are shown in Table 7. Of the 56 excisional operations, five were pancreaticoduodenectomies, one a total pancreatectomy, 20 (80-95%) distal pancreatectomies and 28 (40-80%) distal pancreatectomies. Exocrine and Endocrine Insufficiency
Diabetes was a sequela of 80-95% distal pancreatectomy about three times as often as after 40-80% distal resection or pancreaticoduodenectomy (Table 8). Clinically troublesome steatorrhea was most frequent after pancreaticoduodenectomy. The combination of a partial pancreatectomy and hemigastrectomy was most likely to produce steatorrhea. Patients having 80-95% TABLE 5. Initial Operative Treatment (Excisional Therapy, 31 Patients) Av. Years
No. Pts.
%
13 2 2 1 4
42.0 6.4 6.4 3.2 13.0
Status
Follow-up
working, well not working, well not working, pain working, pain Lost to follow-up 3 alive, working, well 1 alive, not working, well Failure requiring reoperation
3 3 4.5 1.0
Alive, Alive, Alive, Alive,
4.7
5
16.2
2.0 4.0
2
6.4
Operative
6.4
Late Not due to pancreatitis
Death 2 31
100
Total
2.5 2.0
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FREY
Ann. Surg. * November 1978
TABLE 6.
Status
Failure Requiring reoperation Deaths Operative Late Due to pancreatitis Not due to pancreatitis Alive & well Alive, not working, well Alive, not working, pain Alive, working, pain Lost to follow-up Alive, well, working Alive, working, pain Total
No.
%
No.
%
No.
%
No.
%
No.
%
No.
%
17
50.9
9
100
9
37.5
3
23.1
1
20
5
16.2
3
75
4
11.76
2
40
2
6.4
1
2.94
1
4.2
6 1 1 1
17.64 2.94 2.94 2.94
7 2 1
29.2 8.3 4.2
7
53.8
1
20
2 13 2 2 1
6.4 42.0 6.4 6.4 3.2
1
25
3
8.82
3 1 24
12.4 4.2 100
2 1 13
15.4 7.7 100
1
20
5
100
3 1 31
9.75 3.20 100
4
100
34
100
9
100
Initial
Miscellaneous
Operations
Misc.
Excision
%
TABLE 7.
Celiotomy Cystogastrostomy Cystojejunostomy Cystoduodenostomy Excision
Cystduod
No.
resections were more prone to have trouble attaining their preoperative weight. Postoperative Complications Postoperative complications and morbidity after the initial operative procedure requiring reoperation affected 18 patients (15%) (Table 9). Hemorrhage from the cyst and G.I. tract were most frequently noted after incision and drainage, cystogastrostomies and cystojejunostomies. Intra-abdominal abscesses were most common following excisional operations. Peritonitis and hemorrhage resulted after a breakdown of the cystoduodenotomy anastomosis in two patients. The cyst and duodenum had been unfused in both patients (Table 4). Among the 40 patients undergoing a second operative procedure to relieve the pain of chronic pancreatitis or a recurrent, persistent or new pseudocyst 15 (37%) developed complications. Abscesses occurred in 13 patients, eight after an excisional operation. Short lived episodes of pancreatic drainage were frequent from the distal pancreatic stump. Most of these fistulas were short lived and required no reoperation.
I&D
Cystjej
Cystgast
Celiotomy
I&D
Operation 120 Patients
Reoperation 40 Patients
Total 120 Patients
34 9 24 13 5 31 4 120
4
38 9 29 21 57* 4 4 165
5 8 2 26 0 45
* Pancreaticoduodenectomy (5); total pancreatectomy (1); 8095% distal pancreatectomy (21); 40-80% distal pancreatectomy (30).
Postoperative Gastrointestinal Hemorrhage
Ten patients developed massive gastrointestinal hemorrhage or intra-abdominal hemorrhage following operative decompression of their pseudocyst (Table 10). Five of the patients died without leaving the hospital, a sixth patient died shortly after discharge from a cerebral vascular accident. Of the five patients who died in the hospital three bled into the gastrointestinal tract and two intraabdominally. The source of hemorrhage was not identified in the two patients, one of whom had a cystoduodenotomy and the other a cystogastrostomy. A patient treated with external drainage bled from a pseudoaneurysm of the inferior pancreaticoduodenal artery. The two patients who bled after distal pancreatectomy had multiple pseudocysts. The source of hemorrhage was from unresected cysts in the head of the pancreas. Neither was subjected to arteriography. Pseudoaneurysms were associated with the inferior pancreaticoduodenal artery in one patient and the gastroduodenal artery in the other. Of the four survivors, two bled into the G.I. tract and two intra-abdominally. Cystoduodenotomy and cystogastrostomy in one patient each and an excisional operation in two patients were associated with hemorrhage. Bleeding was controlled by arterial ligation in two patients. Hemorrhage ceased spontaneously in two patients. The patient who died from a cerebrovascular accident three months after cystogastrostomy bled from the G.I. tract. Hemorrhage was controlled by arterial ligation. Those most at risk from the complications associated with pseudocysts were patients with hemorrhage occurring postoperatively and in whom bleeding originated from the inferior pancreaticoduodenal or gastroduodenal artery. Patients with multiple cysts, particu-
VOl. 188 . NO. S
Operative Procedure
20 19 20 6 28
Incision & drainage Cystogastrostomy Cystojejunostomy Cystoduodenostomy 40-80% pancreatectomy distal 80-95% pancreatectomy distal Panc. duodenectomy Total
S 1
118
Overall
Insulin
Diet & Oral No. Pts. *
19
657
PANCREATIC PSEUDOCYST TABLE 8. Incidence & Severity of Diabetes Pre & Postoperatively
Pre
Post
Pre
Post
4 2 2 1
4 3 5 2
0
1
1
2
4 2 3 1
3
4
1
5
4 14.2%
5 1 1
2 1 0
0
1
19
21
2
24
Post
Pre
20% 10.5% 15% 16.6%
5 25% 1 20% 1 100%
15
21
5 3 7 2
25% 15% 35% 33%
9 32%
17 89% 1 20% 1 100%
45
* Number in whom information was available.
larly those located in the head of the pancreas complicated by bleeding or common duct obstruction were also a high risk group.
junostomy dismantling in a third. All ten patients with preoperative hemorrhage. survived. Common Duct Obstruction
Rupture of the Pseudocyst Rupture of the pseudocyst into the peritoneal cavity was a rare event in our experience though it resulted in the death of the only patient in whom it occurred. More commonly noted were rupture or fistulization of cysts into the gastrointestinal tract (seven patients). In three patients rupture occurred into stomach or duodenum. Two of these three patients died from hemorrhage associated with a pseudoaneurysm in the cyst wall. Rupture occurred into the colon of two patients both of whom survived. Another patient survived rupture into the small bowel and another survived rupture into the chest.
Preoperative Complications of Pseudocyst In ten patients with pseudocysts, hemorrhage was the presenting symptom (Table 11). Two bled intraabdominally and seven into the G.I. tract. One person bled both intra-abdominally and into the gastrointestinal tract. Hemorrhage entered the gastrointestinal tract presumably through the pancreatic ductal system in continuity with the pseudocyst, or as occurs more frequently, by fistulization or erosion of the pseudocyst into the stomach or duodenum. The source of hemorrhage was a pseudoaneurysm of the splenic artery in six patients. The inferior pancreaticoduodenal artery two patients and the right gastroepiploic artery in one patient. The source of hemorrhage was unknown in one patient. Hemorrhage was controlled by an excisional operation in five patients, i.e., one pancreaticoduodenectomy and four distal pancreatectomies. Ligation of the bleeding site was employed successfully in two patients, cystogastrectomy in a second and cystoje-
Twenty patients with pseudocysts were hospitalized with jaundice secondary to common duct obstruction. Obstruction resulted from compression of the distal common bile duct by the cyst. Five of the 20 patients whose common duct obstruction resulted from pseudocysts died. However, three of the five who died also had had postoperative hemorrhage. A sixth patient with common duct obstruction died later after leaving the hospital. Death was in part attributable to sequelae of his pseudocyst and
pancreatitis. Five surviving patients underwent excisional operation. Pancreaticoduodenectomy was performed in three patients because of multiple cysts or cysts in the uncinate process in which decompression was technically impossible, or because of a pseudoaneurysm associated with the cyst. Two patients undergoing TABLE 9. Complications Requiring Operative Intervention
Initial Operation 120 Patients 120 Operations No. Patients Hemorrhage Peritonitis + hemorrhage Abscesses Common duct stricture Small bowel obstruction Colonic necrosis Common duct stricture plus hemorrhage Colonic fistula and abscess
6 2 6 2 1 1 0 0 18 (15%)
Reoperation 40 Patients 45 Operations No. Patients 1 0 12 0 0 0
1 1 15 (37%)
658
FREY
Ann. Surg. o November 1978
TABLE 10. Hemorrhage (10 Patients Postoperative)
Original Operation
Hemorrhage
H.
External drainage
Intraabdominal
L.
Gastrointestinal
R.
Distal panc & I&D abscess for pseudocyst Cystoduodenostomy
G.
Choledochojejunostomy
Gastrointestinal
F. Mc
Cystogastrostomy Cystogastrostomy
Gastrointestinal Gastrointestinal
G.
Cystoduodenostomy
Gastrointestinal
M.
Cystogastrostomy
Intraabdominal
A.
50% distal panc.
Gastrointestinal
J.
80%-Cyst in head unroofed
Intraabdominal
Intraabdominal
Autopsy
Vessel
Pseudoaneurysm Pseudoaneurysm ?
Inf. panc. Duod. Inf. panc. Duod. Coagulopathy No operation Gastroduodenal ? ?
Art. ligat.
Op death
No operation Art. ligat.
Op death Late death C.V.A.
?
No operation
S*
Art. ligat.
S
Ceased spontaneously 2 mo. later Cystojejunostomy No operation
S
Pseudoaneurysm ? ? No pseudoaneurysm Pseudoaneurysm ?
Splenic
No pseudoaneurysm
?
Treatment
Outcome
Art. ligat.
Op death
Art. ligat.
Op death Op death
S
* S-Survival.
distal resection for common duct obstruction also had a history of chronic pancreatitis. Operative Deaths
There were ten operative deaths (8.33%) among the 120 patients in whom the pseudocyst was treated surgically (Table 12). Three patients developed cysts within three to six weeks of an episode of hemorrhagic necrosis of the pancreas. The cysts developed in the head of the pancreas in two patients and produced common duct obstruction in one patient, and duodenal obstruction as well as common duct obstruction in the other. These three patients died more from hemorrhagic necrosis of
the pancreas than from complications of the pseudocyst or its operative management (Table 12). A patient with cirrhosis and portal hypertension died at the time of attempted 95% pancreatectomy. His problems could have been better managed by porta caval shunt and pancreaticoduodenectomy. Three patients died from complications attributable to operative technique and judgment. Dehiscence of an anastomosis not in an area of fusion resulted in lateral duodenal fistulas and peritonitis in two patients. In the third patient, wound dehiscence peritonitis and sepsis was followed by a lethal gastrointestinal hemorrhage. Three patients died as a result of massive postoperative gastrointestinal hemorrhage from a pseudoaneurysm in the cyst wall. The preoperative and operative
TABLE 11. Preoperative Hemorrhage in Ten Patients
Hemorrhage
Autopsy or Angiography Findings
D. B. C.
Intra-abdominal Gastrointestinal Gastrointestinal
Pseudoaneurysm Pseudoaneurysm
Splenic Splenic
Mc H.
Gastrointestinal Gastrointestinal
Pseudoaneurysm Pseudoaneurysm
Inf. panc. Duod. R. Gastric
J.
Gastrointestinal Intra-abdominal Gastrointestinal Gastrointestinal Gastrointestinal Intra-abdominal
Pseudoaneurysm
Splenic
Distal resection
S
Pseudoaneurysm Pseudoaneurysm Pseudoaneurysm Pseudoaneurysm
Splenic Inf. panc. Duod. Splenic
Distal resection
Pancreaticoduodenostomy
Splenic
Distal resection
S S S S
B. L. A. T.
* S-Survival.
Artery
Treatment
Cystogastrostomy Artery ligation Cystogastrostomy & artery ligation Cystojejunostomy Cystojejunostomy dismantling
Distal resection
Outcome S*
S S S S
659
PANCREATIC PSEUDOCYST
VOl. 188.9 NO. S
TABLE 12. Operative Deaths: Ten
Patient Age
Sex
Preoperative Complication
41
F
42
M
59
F
Hemorrhagic pancreatitis, shock, renal & pulmonary failure Hemorrhagic pancreatitis shock, renal & pulmonary failure Hemorrhagic pancreatitis renal & pulmonary failure, 'jaundice
52
M
47
F
51 47 32 45
M M M M
Celiotomy wound dehiscence
38
M
I & D x2 50% distal
Cirrhosis and portal hypertension
(8.3%o) Postoperative Complication
Operation Pseudocyst
Autopsy
I&D
Hemorrhagic ascites necrotizing pancreatitis
I&D
Ascites, pleural effusion necrotizing pancreatitis, undrained cyst Ascites, bilateral pleural effusion, common duct & duodenum obstructed by an unrecognized pseudocyst in the head of the pancreas
I&D
95%
Operative hemorrhage
Cystoduodenostomy
Anastomatic dehiscence
Cystoduodenostomy Cystogastrostomy I&D Distal pancreatectomy for infected pseudocyst Multiple
Anastomatic dehiscence Sepsis Hemorrhage I & D subhepatic abscess G.I. hemorrhage
diagnosis of pseudoaneurysm was not suspected. None of the patients had undergone selective preoperative angiography. None of the pseudocysts were excised as we recommend when associated with a pseudoaneurysm. Late Deaths There were 16 late deaths from operative decompression or excision of a pseudocyst.
Symptomatic Group In six patients it was felt the patient's operation or persisting pancreatitis contributed in part to the pa-
tient's death (Table 13).
G.I. hemorrhage, peritonitis Peritonitis G.I. hemorrhage Pseudoaneurysm Pseudoaneurysm Pseudoaneurysm
G.I. hemorrhage
there is convincing evidence of a pancreatic abscess characterized by a septic febrile course or some complication of a pseudocyst patients should not be subjected to operations in under six to eight weeks from the onset of the exacerbation of pancreatitis for several reasons. 1) In a very significant number of instances the acute cyst associated with an episode of pancreatitis demonstrated on ultrasound or visualized on E.R.C.P. will spontaneously resolve making the operation unnecessary. The exact incidence of spontaneous resolution is unknown but far higher than our reported 6% which preceded the use of ultrasound and E.R.C.P. Czaza5 reported 70% of acute cysts resolve without operative TABLE 13. Late Deaths Symptomatic Group (Six Patients) Interval
Symptom Free Group Ten patients died from 1-11 years after operative decompression or excision of a pseudocyst. All were symptom free from problems unrelated to the operation on the cyst, alcoholism or pancreatectomy (Table 14). Comments
The age of the cyst is an important factor influencing the timing of operation. However, it is sometimes impossible to be certain of the age of the cyst in patients with alcoholic pancreatitis having frequent exacerbations of their disease. The presence of the cyst may have antedated the most recent episode of pancreatitis which brought the patient under medical care. Unless
Operation to Age
Operation
Cause of Death
39 M Celiotomy, 95% distal Malnutrition, alcoholism resection 44 M Cystjejunostomy, 85% Alcoholism, distal resection exsanguination during porta caval shunt 49 M Celiotomy, 50% distal Alcoholism, drug overdose resection and common duct
exploration 35 F
50% distal resection
39 F Cystgastrectomy 35 M Cystgastrostomy,
cystjejunostomy
Pain and
alcoholism, died laminectomy Pain, CVA Alcoholic hepatitis
Death-Years 3 2
7
11
3 months 2
660
FREY
TABLE 14. Late Deaths Symptom Free Group (Ten Patients)
No. Pts.
Cause of Death
Interval Operation to Death Years
3 1 1 1 1 2 1
Cerebral vascular accident Intestinal obstruction Peritonitis post D & C Pneumonia Pulmonary embolus Myocardial infarction Pulmonary emphysema
2, 4, 5 2 2 5 1 1 3
therapy. 2) Operative management of an acute cyst precludes the use of internal decompression the procedure of choice if the cyst wall is not sufficiently thick and mature to hold sutures. In experimental animals, according to Warren's22 work, it required four to six weeks for a cyst wall to mature. This assumption has been challenged by Grace and Jordan,6 based on their experience with a patient found to have a mature cyst who at an operation three weeks earlier had no cyst. However, most cysts require a longer period of maturation before their walls lend themselves to suturing. Sankaran and Walt'4 described four patients operated on less than four weeks after an acute attack three of whom had cysts which were thin walled and incompatible for internal drainage. We support the opinion expressed by Grace and Jordan8 that should one encounter at emergency operation a pseudocyst two to three weeks after an exacerbation of pancreatitis in which the wall is thick, the maturation of the wall and its ability to hold sutures should be the criteria as to whether internal decompression is feasible not the time interval from the acute exacerbation to operation. 3) When the cyst wall is too immature to hold sutures, external drainage in spite of its limitations must be employed. External drainage is associated with a high rate of complications or death in 60-80% of patients. This high morbidity and mortality may more often reflect the severity of the complications encountered and cannot always be attributed to the operation.4 However, external drainage in our experience is not a definitive operation in the patient with either an acute or mature pseudocyst in over half the instances in which it is employed due to the high incidence of recurrent cysts and persistent symptoms necessitating reoperation. This has also been the experience of Scharplatz. 17 Some unnecessary operations in the form of external drainage have been performed because the cyst fluid visualized at operation resembled the contents of an abscess. In order to avoid an unnecessary external drainage procedure the contents ofthe cyst at operation should be smeared and gram stained. When a cyst is known to have been present for a
Ann. Surg. a November 1978
period of six weeks prompt operative intervention is indicated. The only non-operative death occurred in a patient whose cyst of long standing ruptured. Evidence of expansion of an existing cyst is an indication for prompt operative intervention. Spontaneous hemorrhage and rupture are the most frequent causes of nonoperative deaths.1" 9 We recommend selective angiography of the superior mesenteric and coeliac arteries as part of the preoperative evaluation of all patients with pseudocysts. Pseudoaneurysms were identified in 13 (10.8%) of our operative cases. Hemorrhage is a significant factor in the majority of deaths of patients with pseudocysts. 13,9"14"16"19 We feel preoperative arteriography is an essential step in the selection of the most appropriate operation to avoid this preventable complication. All pseudocysts having an associated pseudoaneurysm should, whenever possible, be treated by excision. Preoperative or postoperative persistent massive hemorrhage from the pseudocyst did not occur in the absence of a pseudoaneurysm in any of our 13 patients evaluated by arteriography. In the absence of arteriography the source of hemorrhage was not known in seven instances. Failure to establish the presence of a pseudoaneurysm in conjunction with a pseudocyst may contribute to a fatal outcome (Table 12). At operation three of our patients, none of whom had bled preoperatively or had evidence of blood in their cysts at operation, underwent external drainage or internal decompression. Postoperatively all three exsanguinated. Pseudoaneurysms in the cyst wall were the source of hemorrhage. Preoperative angiography and an excisional operation would have eliminated the pseudoaneurysm and the possibility of postoperative hemorrhage from it. We had no mortality and successfully terminated the hemorrhage in all five patients treated by excisional operations. In contrast two of four of our patients treated by non-operative methods died and four of nine patients treated by local ligation of vessels died. Local control or ligation of the feeding vessel of a pseudoaneurysm embedded in a chronically inflamed pseudocyst wall is not always effective or technically feasible and the result is a 28% mortality from infection and rebleeding according to Stanley et al. 18 The success of excisional operations in reducing mortality of hemorrhage associated with pseudocysts pertains whether the hemorrhage originates from vessels in the head or tail of the gland. In our experience and that of others pancreaticoduodenectomy and distal pancreatectomy are equally effective and technically feasible in the treatment of the patient with a pseudocyst complicated by a pseudoaneurysm in the wall of the cyst.18 In those patients thought too ill to withstand operative intervention intra-arterial embolization with gelfoam or autologous clot should be considered as a temporizing procedure.
Vol. 188 * No. 5
Grace8 reported the presence of blood or even active bleeding found at the time of operation as determined by needle aspiration of the pseudocyst did not expose the patient to any special risk of postoperative bleeding. We had the same experience in six patients but feel such a course is rational only if preoperative angiography has eliminated the possibility of an associated pseudoaneurysm. This distinction is crucial. In the absence of an associated pseudoaneurysm we do not feel it necessary to proceed with an excisional operation in cysts containing blood. Internal decompression of the uncomplicated mature single pseudocyst by cystogastrostomy or cystojejunostomy are the procedures of choice (Tables 1-6). We recommend cystogastrostomy when the anastomosis can be performed through an area of fusion between the cyst and the posterior wall of the stomach. We employ a 10 cm long incision including a small ellipse of cyst wall. This ellipse of cyst wall is sent as a biopsy to rule out cystadenocarcinoma. While there is debate as to the appropriate size of the cystogastrostomy anastomosis, we were unable to demonstrate any difference in the rate of recurrence when a smaller anastomosis of 5-7 cm without an ellipse was employed. Hemorrhage from the edge of the anastomosis, as was reported by Huston"' and Folk,6 has not been a problem in our experience or that of Van Heerden.20 We place multiple mattress sutures of permanent material circumferentially around the anastomosis in the area of fusion. When the pseudocyst is not fused to the posterior wall of the stomach we believe a Roux-en-Y cystojejunostomy is the procedure of choice. The consequences of a dehiscence of a long Roux-en-Y cystojejunostomy are less catastrophic than a breakdown of an unfused cystogastrostomy or cystoduodenostomy. Warshaw23 recommends the limb of the cystojejunostomy be at least 35 cm long presumably to alleviate the consequences of a dehiscence. We did not find any correlation between cyst recurrence and the length of the cystojejunostomy limb. Sankaran 4 reported good results with cystoduodenostomy as did Mercadier12 though the latter patients according to Scharplatz and White17 were apparently not followed beyond nine months. We do not recomment cystoduodenostomy on the basis of our limited but unsatisfactory experience which included two deaths (Table 4) and one recurrence with this operation. Both deaths occurred in patients in whom the duodenum was not fused to the cyst as is recommended. Failure to follow accepted practice perhaps explains the events which led to dehiscence of the cystoduodenostomy anastomosis. However, Scharplatz17 and also Grace8 reported dissatisfaction with the long-term
results of cystoduodenostomy.
661
PANCREATIC PSEUDOCYST
Indications for an excisional operation in addition to a pseudoaneurysm associated with the pseudocyst includes patients having multiple pseudocysts, or cysts located in the uncinate process or head of the pancreas in which internal decompression is not technically feasible. Common duct or duodenal obstruction frequently cannot be relieved except by a pancreaticoduodenectomy due to the presence of one or more small cysts which do not lend themselves to internal drainage. Yet a small cyst or cysts in the head of the pancreas may initiate and perpetuate pancreatic inflammation and as Sankaran14 and Nardi'3 have noted can produce very troublesome persistent symptoms. Sometimes these small cysts are not appreciated on E.R.C.P. and are impossible to identify by palpation at operation and are only recognized after pancreaticoduodenectomy is well under way. Left sided portal hypertension from splenic vein thrombosis due to pericystic inflammation and compression by the cyst is best treated by distal pancreatectomy and splenectomy which relieves both symptoms of the cyst and left sided portal hypertension.15 Rupture or enteric fistulization of the pseudocyst in our experience was more common (six patients) than free intra-abdominal perforation (one patient), or extension into the chest (one patient). Enteric fistulization in itself was a benign process unless accompanied by hemorrhage secondary to pseudoaneurysm formation. The combination is lethal.1'2'3'14'19 Twenty-six of our patients have undergone operative decompression of a pseudocyst and subsequently required another operation for a pseudocyst. At the second operation it is often impossible to know if the cyst is new, recurrent, persistent, or overlooked at the first operation. For patients continuing to experience pain after internal decompression or an excisional operation (Table 7), the choice of which excisional operation proximal or distal pancreatectomy is most appropriate for the patient depends on whether the cyst, ductal obstruction or inflammation of the pancreas are confined to the head or tail of the pancreas. Pancreatic Function Distal resection of 80% or more of the pancreas is likely to cause insulin dependent diabetes in 79% of patients (Table 7). Pancreaticoduodenectomy preserves more endocrine function than distal pancreatectomy due to the retention of a greater mass of tissue in the tail of the pancreas which has a higher concentration of islets than the head or body.7
References 1. Becker, W. F., Pratt, H. S. and Gangi, H.: Pseudocysts of the
Pancreas. Surgery, 20 127:744, 1968.
662
FREY
2. Berne, T. V. and Edmondson, A. A.: Colonic Fistulization due to Pancreatitis. Am. J. Surg., 111:359, 1966. 3. Bradley, E. L. and Clements, J. L.: Transenteric Rupture of Pancreatic Pseudocysts, Management of Pseudocyst Enteric Fistulas. Am. Surg., 42:827, 1976. 4. Cerilli, J. and Faris, T. D.: Pancreatic Pseudocysts, Delayed versus Immediate Treatment. Surgery, 61:541, 1967. 5. Czaza, A. J., Fisher, M. and Marin, G.: Spontaneous Resolution of Pancreatic Masses (Pseudocysts?). Arch. Int. Med., 135: 558, 1975. 6. Folk, F. A. and Freeark, R. J.: Reoperations for Pancreatic Pseudocysts. Arch. Surg., 100:430, 1970. 7. Frey, C. F., Child, C. G. and Fry, W.: Pancreatectomy for Chronic Pancreatitis. Ann. Surg., 184:403, 1976. 8. Grace, R. R. and Jordan, Jr., P. H.: Unresolved Problems of Pancreatic Pseudocysts. Ann. Surg., 184:16, 1976. 9. Hanna, W. A.: Rupture of Pancreatic Cysts: Report of Case and Review of Literature. Br. J. Surg., 47:495, 1960. 10. Hillson, R. F. and Taube, R. R.: Surgical Management of Pancreatic Pseudocysts in Infants and Children. Ann. Surg., 182: 590, 1976. 11. Huston, D. G., Zeppa, R. and Warren, D. W.: Prevention of Postoperative Hemorrhage after Pancreatic Cystogastrostomy. Ann. Surg., 177:689, 1973. 12. Mercedier, M. P., Clot, J. P. and Russel, R. T.: Chronic Recurrent Pancreatitis and Pancreatic Pseudocysts. Curr. Probl. Surg., July 1973. 13. Narid, G. L., Lyon, D. C., Sheiner, H. J. and Bartlett, M. K.:
14. 15. 16. 17.
18. 19.
20. 21.
22.
23.
Ann. Surg. * November 1978
Solitary Occult Retention Cysts of the Pancreas. N. Engl. J. Med., 280:11, 1969. Sankaran, S. and Walt, A. J.: The Natural and Unnatural History of Pancreatic Pseudocysts. Br. J. Surg., 62:37044, 1975. Saubier, E. C., Partensky, L., Brault, A., et al.: Les Collections Enkystees d'origine Pancreatique (Analyse de 30 observations) Lyon Med., 231:587, 1974. Schecter, L. W., Gordon, H. E. and Passaro, Jr., E.: Massive Hemorrhage from the Celiac Axis in Pancreatitis. Am. J. Surg., 128:301, 1974. Scharplatz, P. and White, T.: A Review of 64 Patients with Pancreatic Cysts. Ann. Surg., 176:638, 1972. Stanley, J. C., Frey, C. F., Miller, T. A., et al.: Major Arterial Hemorrhage: A Complication of Pancreatic Pseudocysts and Chronic Pancreatitis. Arch. Surg., 111:435, 1976. Thomford, N. R. and Joseph, J. E.: Pseudocyst of the Pancreas, A Review of 50 Cases. Am. J. Surg., 118:86, 1969. Van Heerden, J. A. and Remine, W. H.: Pseudocysts of the Pancreas. Arch. Surg., 110:500, 1975. Warren, K. W., Athanassiades, S., Frederick, P., et al.: Surgical Treatment of Pancreatic Cysts. Review of 183 Cases. Ann. Surg., 163:886, 1966. Warren, W. P., Marsh, W. H. and Muller, Jr., W. H.: Experimental Production of Pseudocysts of the Pancreas with Preliminary Observations of Internal Drainage. Surg. Gynecol. Obstet., 105:385, 1957. Warshaw, A. L.: Inflammatory Masses Following Acute Pancreatitis Phlegmon, Pseudocysts, Abscesses. Surg. Clin. North Am., 54:621, 1974.
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