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Surgical Management of Complicated Pancreatic Pseudocysts Following Acute Pancreatitis
Stephen W. Behrman*, Katy a. Marino, Leah E. Hendrick
Surgery, Univ. of Tennessee, Memphis, TN
Endoscopic drainage of pancreatic pseudocysts (PP) is considered first line management but may not be effective or safe in certain circumstances such as locations in areas outside the lesser sac, infection or when portal venous (PV) occlusion is present causing perigastric varices.
Methods: Patients having primary internal drainage of PP (defined according to the revised Atlanta classification) following acute pancreatitis from 2004-14. Management and outcome were assessed relative to location, presence of infection and/or PV occlusion. Anatomic areas of pseudocyst involvement outside the lesser sac were categorized by preoperative computed tomography (CT) and included the right and left paracolic gutters, base of mesentery and the subhepatic space. Infection was defined as those previously stable PP that developed signs of sepsis preoperatively and had culture positive fluid obtained at the time of surgery. Splenic and/or portal vein occlusion with associated perigastric varices was identified when observed on preoperative CT imaging and at the time of surgical exploration. The need for any post-operative therapeutic intervention, radiologic surveillance or readmission was recorded. Post-operative morbidity and length of stay (LOS) was noted.
Results: Forty-eight patients had internal drainage of PP during the study period including 9 with PV occlusion, 11 with infection and 24 that extended to anatomic regions beyond the lesser sac. No patient required transfusion, reimaging was performed in 1, median post-operative length of stay was 6 days and there were no readmissions and no procedure related morbidity in those with PV occlusion. Five infected PP extended beyond the lesser sac. Six had postoperative imaging, 4 readmission and 2 required adjunct postoperative percutaneous drainage for definitive management. Overall morbidity was 45% and median post-operative LOS was 10 days (range 5-32). Gram positive and fungal organisms predominated. All but 2 with PP beyond the lesser sac had Roux-en-y cystjejunostomy to maximize dependent drainage with 4 requiring 2 separate anastomoses. Eight and 4 required reimaging and readmission respectively. Five patients required intervention beyond the index procedure for definitive management of their initial pseudocyst: 3 percutaneous drainage, 1 endoscopic drainage and 1 both percutaneous and repeat operative drainage. Median LOS was 7 days (range 5-75) and 29% suffered at least 1 post-operative complication.
Conclusions: 1) Open PP drainage in the face of PV occlusion confers a low risk of bleeding and a minimal need for reimaging or readmission; 2) Internal drainage of infected PP is a viable option to external drainage. 3) PP that extend beyond the lesser sac can most often be managed successfully by Roux-en-y drainage but may require additional intervention for definitive PP resolution
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