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Surgical Management of Pancreatic Cysts
Surgical Management of Pancreatic Cysts KENNETH W. WARREN, M.D. MALCOLM C. VEIDENHEIMER, M.D. SOCRATES ATHANASSIADES, M.D.
Two hundred years of evolution underlie our present-day concepts of the management of pancreatic cysts. Morgagni, in 1761, first described pancreatic cysts seen at necropsy, a finding subsequently enlarged upon by Cleason in 1842. The first surgical procedure for a pancreatic cyst was apparently performed by Le Dentu6 in 1862 when he operated on a patient with a presumptive diagnosis of hepatic cyst and found a large pancreatic cyst which he drained directly to the exterior. This patient died of peritonitis. Lucke and Klebs, 7 in 1866, likewise drained a pancreatic cyst to the exterior, with fatal results. The autopsy of Klebs' case revealed that the pancreatic cyst was associated with a pancreatic carcinoma. The first successful surgical treatment of pancreatic cyst was described by Bozemanl in 1882. That cyst was excised. In the same year Gussenbauer3 first applied the principle of marsupialization to the surgical treatment of pancreatic cysts; this was accomplished by suturing the parietal peritoneum to the skin and the wall of the cyst to the peritoneum. The safety of this method made it popular, and for many years the treatment of choice was marsupialization, despite the disadvantages of recurrent cysts and persistent fistulas with their associated skin irritation and the loss of pancreatic enzymes. Internal drainage of pancreatic cysts was first reported by Umberdan in 1911, who described an operation performed by him three years earlier. Umberdan anastomosed a cyst at the pancreatic head to the duodenum. The patient unfortunately did not survive. It was in 1923 that Jedlicka4 reported for the first time the successful elimination of a pancreatic cyst by anastomosing the cyst to the stomach. Hahn was apparently the first to describe an anastomosis between the cyst and the jejunum. The transgastric technique of pancreaticocystogastrostomy was first described in 1931 by Jurasz5 who made a large opening into the pancreatic cyst by 599
600
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
incising the posterior gastric wall through an anterior gastrotomy. Jurasz pointed out the ease with which this procedure could be performed and the safety resulting from the dense adhesions which form between the cyst and the posterior wall of the stomach. Armed with this heritage of successful operations, the present-day surgeon has a choice of techniques, each appropriate in certain circumstances. The choice of treatment and of surgical procedure, however, must depend upon the nature of the individual case. Because of these choices, pancreatic cysts must be classified. The classification which has proved most useful to us follows: 1. Developmental A. Fibrocystic disease B. Simple cysts C. Dermoid cysts D. Cysts associated with polycystic disease of the viscera 2. Acquired A. Inflammatory (1) Pseudocysts (2) Retention cysts B. Traumatic (1) Nonpenetrating (indirect trauma) (2) Penetrating (direct trauma) C. Neoplastic (1) Cystadenoma (2) Cystadenocarcinoma (3) Teratoma (4) Unusual tumors D. Secondary to obstructing carcinomas E. Parasitic
ETIOLOGY
Developmental Cysts A small number of pancreatic cysts are of developmental ongm. Presumably they result from a faulty fusion of the ductal elements. Occasionally, polycystic changes occur in the pancreas in association with polycystic disease of other visceral structures, and cystic teratomas have been found within the pancreas. Acquired Cysts INFLAMMATORY. A vast majority of pancreatic cysts are acquired and most of these are associated with inflammatory pancreatic disease. Pseudocysis. Pseudocysts are cystic collections whose walls are made up of the viscera and abdominal wall adjacent to the pancreas. These cysts lack a true epithelial lining and lie primarily beyond the confines of the pancreatic gland itself. Retention Cysts. Retention cysts result from obstruction of a pancreatic duct and thus have a communication with the duct. The patient
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
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with chronic pancreatitis may have both retention cysts and pseudocysts in association with his inflamed pancreas. Cystic changes in relationship to the pancreas may be secondary to inflammatory changes in an adjacent organ, and retention cysts are a rare finding in association with a penetrating duodenal ulcer which obstructs the duct of Wirsung. TRAUMATIC. Penetrating wounds of the abdomen or surgical injuries associated with operations in adjacent areas of the abdomen may result in pancreatic cyst formation, usually secondary to division of or damage to one of the major pancreatic ducts. The presence of the rigid and protruding vertebral bodies posterior to the pancreas has resulted in fracture of the pancreas, with division of the pancreatic duct and the development of a pancreatic cyst in association with nonpenetrating abdominal injuries. NEOPLASTIC. Neoplastic changes within the pancreas give rise to cystadenomas, cystadenocarcinomas and, more rarely, teratomas and cystic hemangio-endotheliomas. This neoplastic cyst formation within the pancreas makes proper selection of the surgical procedure important when a pancreatic cyst is treated operatively. A high degree of suspicion will prevent the tragic error of draining a neoplastic lesion. The external appearance of the cystadenoma may not suggest its neoplastic nature, although the multiloculated appearance of many cystadenomas is a useful feature in differentiating this type of lesion and its malignant counterpart, the cystadenocarcinoma, from the benign and non-neoplastic cysts of the pancreas. CYSTS SECONDARY TO OBSTRUCTING CARCINOMAS. 2 Cysts secondary to carcinoma of the pancreas are not very common. The history is usually short, unlike chronic pancreatitis, and suggests a hidden malignant process in association with the benign-appearing cyst. Duct obstruction by a neoplasm must be suspected in the case of the isolated cyst. The treatment is that required for the primary malignant process. PARASITIC. The parasitic cysts of the pancreas are rare and for that reason will not be discussed.
SYMPTOMS
It is obvious from the diversity of etiologic factors associated with pancreatic cyst formation that the symptoms are varied. Approximately one-third of pancreatic cysts present as a palpable mass with no other associated symptoms. Cystic changes associated with chronic pancreatitis are discovered in the course of investigation of the pancreatitis itself; they are associated with attacks of abdominal pain passing through to the back, and occasionally with chills and fever. Large cysts cause symptoms related to the pressure effects they exert upon the adjacent stomach or duodenum and thus may result in nausea and vomiting. It is unusual for a cyst to rupture spontaneously, but this
602
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
unfortunate incident may occur, causing generalized peritoneal irritation. Large cysts pressing upon the diaphragm may result in pleural effusions, and cysts have been known to burrow through the retroperitoneal tissue to the lower portions of the abdomen and pelvis and the upper part of the abdomen even above the diaphragm into the mediastinum. Obstruction of the bile duct by an enlarging cyst results in jaundice. If the cyst occupies a large portion of the pancreas, diabetes may develop. DIAGNOSIS
As with all diseases of the pancreas, an awareness of the constant possibility of pancreatic disease must be shown by the examining physician. A history of trauma or chronic relapsing pancreatitis should lead one to suspect a pancreatic cyst. Tenderness and a palpable mass are found on physical examination. The physician must. remember that the cyst may present in unusual sites sometimes in areas other than the upper portion of the abdomen. Upper gastrointestinal x-ray studies are useful in demonstrating pancreatic enlargement, and large cysts of the head and neck will result in deformity of the duodenum and antrum (Fig. 1). Cysts of the body and
Fig. 1 Fig. 2 Figure 1. Widening of the duodenal loop caused by the presence of a large cyst within the head of the pancreas. Note the flattening of the antral mucosa and the changes on the medial aspect of the duodenum itself. Figure 2. A large cyst of the body of the pancreas has displaced the stomach and flattened the mucosa overlying the cyst.
603
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
Figure 3. A large cyst lying over the neck and body of the pancreas has been entered through a liberal incision and emptied. A de Pezzer catheter is then placed within the cyst. The opening through which the catheter was inserted is closed snugly with interrupted silk sutures to prevent leakage around the catheter. (From Warren, K. W.: Chronic relapsing pancreatitis. In Cooper, P., Ed.: Craft of Surgery. Boston, Little, Brown & Co., 1964, p. 1182.)
tail of the pancreas will cause deviations of the stomach and the region of the ligament of Treitz (Fig. 2). SURGICAL TREATMENT
The diversified nature of pancreatic cysts makes any preconceived plan of surgical treatment potentially dangerous. The selection of treatment must be based upon the findings at operation in that patient and not related to any preoperative decision based upon history or physical examination. Of course, the prime object at the time of surgical treatment is to determine whether the cyst is benign or malignant. Once a cyst has been opened on the operating table, any suspicious protrusions from the lining of the cyst cavity should be examined for malignant degeneration by the frozen section technique.
Drainage The simplest method of managing most cysts
IS
external drainage.
604
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
This is achieved by entering the cystic cavity through a small incision in the cyst itself. The cyst is cleaned of its fluid content and any necrotic pancreas and necrotic inflammatory debris which it might contain. The inner lining of the cyst is carefully inspected to be absolutely certain that there are no papilliferous projections that suggest neoplastic change. The cyst is then drained to the exterior with a de Pezzer catheter (Fig. 3) which may then conduct any future cystic content to the exterior to empty into a bag or other suitable container, thus preventing maceration of the skin about the wound. If the cyst is multilocular, it is important that all locules are emptied by this procedure. This method of treatment is especially useful in the management of cysts that lie in the head of the pancreas or in the uncinate process, for cysts in these sites are not easily treated by internal drainage, and the pancreaticoduodenal resection necessary for their excision is usually not justified. Large cysts and cysts of recent origin with thin walls are better treated by external drainage until such time as the cyst has shrunk to a more manageable size and the walls have become thicker and more easily handled with sutures. Marsupialization Marsupialization has not been used in this clinic for some years because of the disadvantage of skin maceration resulting from the passage of cystic contents onto the anterior abdominal wall. Internal Drainage At this clinic internal drainage has been used in preference to external drainage for many years. Large pseudocysts often occupy the lesser omental sac; in this site the stomach forms part of the anterior wall of the cyst. They are thus ideal for transgastric cystogastrostomy (Fig. 4) which has been used with good effect. Cystogastrostomy has also been employed with good palliative results in patients with inoperable cystadenocarcinoma. A generous anterior gastrotomy is performed, the stomach is cleansed of its contents, and the posterior wall of the stomach is incised, allowing entry into the underlying cystic cavity. The opening between the cyst and stomach should be large in order to allow easy passage of cyst contents and any accumulated food matter from within the cystic cavity back into the stomach. The cystogastrostomy opening is maintained by means of a continuous chromic catgut suture passing around the circumference of the orifice. The anastomosis of the cyst to a defunctionalized loop of jejunum has proved a useful method of treatment in cysts situated away from the stomach and yet not suitable for excisional therapy. For this purpose an anastomosis similar to that described above is performed between the cyst and a loop of jejunum. We prefer to use a loop of jejunum with an accompanying entero-anastomosis sO that the cyst wall may be anastomosed side-to-side with the jejunum, thus allowing a large orifice.
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
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Figure 4. Through an anterior gastrotomy incision held apart with right angle or Deaver retractors, the posterior wall of the stomach has been opened, allowing thorough inspection and evacuation of the cyst lying in the lesser sac. A continuous suture is passed around this posterior hiatus, maintaining the opening and ensuring continuing drainage (From Warren, K.W.: Chronic relapsing pancreatitis. In Cooper, P., Ed.: Craft of Surgery. Boston, Little, Brown & Co., 1964, p. 1182.)
Some cysts lying within the head of the pancreas can be drained by an incision through the medial wall of the second portion of the duodenum into the cyst as it lies within the head. This has been of considerable value in many of our patients. Other cysts lying in close relationship to the pancreatic duct may be drained directly into the pancreatic duct using a transduodenal sphincterotomy as an approach to the duct and passing probes down the duct and forcibly into the cyst through the cyst wall (Fig. 5). A small polyethylene tube is left within the duct of Wirsung and passing into the cyst to maintain the continuity between the cyst, pancreatic duct and the duodenum, ensuring the complete evacuation of the cyst. Excision
Excision remains the treatment of choice in the management of pancreatic cysts and many cysts of surprisingly large size are suitable for excision. Often the cyst lies surrounded by an area of compressed inflammatory tissue, permitting enucleation. If there is continuity between the cyst cavity and a major pancreatic duct, the excision of the cyst should be
606
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
Figure 5. The sphincter has been divided, thus giving access to the common bile duct and the duct of Wirsung through the duodenum. A probe passed up the duct of Wirsung has penetrated into an adjacent cyst, permitting drainage of the cyst contents into the duct of Wirsung and thus into the duodenum. A small polyethylene catheter is placed lying within the duct of Wirsung and entering the cyst at one extremity and the duodenum at the other extremity. The catheter may be anchored at the papilla with a single catgut suture; later it will be passed.
followed by anastomosis between the duct and the stomach, duodenum or a loop of jejunum. Thus, external fistula formation is prevented (Fig. 6). Because of their high incidence of malignant degeneration, cystadenomas should be removed unless they lie in inaccessible portions of the gland. Resection Cysts situated in the distal body and in the tail of the pancreas are resected by distal pancreatectomy and splenectomy. Cysts of traumatic origin, especially those related to fracture of the duct of Wirsung on the vertebral bodies, are satisfactorily dealt with by distal pancreatectomy, since these cysts so often are associated with complete division of the duct and have a great tendency to persist or recur despite drainage procedures (Fig. 7). Pancreaticoduodenal resection has been used in the management of a large number of patients with chronic relapsing pancreatitis with associated cysts. In these instances, however, the operation is performed primarily for the pancreatitis rather than because of the cysts per se. We believe that drainage procedures should be used in preference to pancreaticoduodenal resection for most cysts situated in the head of the gland. Resection
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
607
Figure 6. A cyst lying over the neck and body of the pancreas has been excised and found to have continuity with a large pancreatic duct. Because of the duct continuity, an anastomosis should be performed between the duct and the stomach or a loop of jejunum.
of the head of the pancreas is necessary, however, in the management of (1) large cystadenomas, (2) cystadenocarcinomas and (3) often for multiple cysts within the pancreatic head. Total pancreatectomy was performed in one patient with an extremely large cystadenocarcinoma. This patient is still alive ten years later. External Fistulas External drainage of any pancreatic cyst may result in a permanent external pancreatic fistula. This, of course, is most likely to develop when a retention cyst has a connection with a pancreatic duct. The use of the de Pezzer catheter and controlled drainage into a container has diminished greatly the adverse effects of external pancreatic fistula, but nevertheless the loss of fluid and electrolytes may be tremendous, resulting in great debility. Pancreatograms may be obtained by injecting radiopaque material into the catheter leading from the pancreatic cyst. If the dye passes into the duodenum, showing duct continuity, one could then anticipate the eventual closure of the fistula and continue with conservative management. If, however, large amounts of drainage persist and the injection of the dye
608
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
Figure 7. Distal pancreatectomy is shown as it is completed. The pancreas is divided in the body or neck close to the inferior mesenteric and portal veins. Great care is taken in the closure of the cut end of the neck of the pancreas in order to prevent fistula formation. Note the large cyst in the pancreatic tail.
into the duct reveals duct obstruction between the cyst and the duodenum, closure of the fistula is most unlikely. In these instances, the fistulous tract should be dissected down to the pancreas and excised. An anastomosis is then made between the remnant of cystic cavity or pancreatic duct and a loop of jejunum, stomach or duodenum (Fig. 8). If at all possible, a direct anastomosis between the obstructed duct and jejunum should be attempted, since this makes successful resolution of the fistula more certain than if a granulomatous fistulous tract is used for the anastomosis. The anastomosis may be performed in one or two layers, using interrupted fine silk or interrupted catgut sutures. Fistulas arising in the distal portion of the gland are best treated by distal pancreatectomy. SUMMARY
A discussion of the etiology of pancreatic cyst has been given. The nature of the cyst has a most important role in the determination of the type of treatment to be employed. The various types of surgical management for pancreatic cysts have been described. Surgical excision reInains the therapy of choice, but treatment must be individually planned for each patient. Marsupialization is no longer employed because of more satisfactory control by means of catheter drainage of the cyst cavity. We wish to stress that every attempt should be made to exclude the possibility of cystadenoma or cystadenocarcinoma if a cyst is not to be removed. The risk of malignant transformation of cystadenoma is great, and for this reason radical excision is the procedure of choice.
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Fig. 8. An anastomosis is being performed between a fistulous connection to the body of the pancreas and the distal stomach. Note that a two layer closure can be achieved. We prefer to leave a stent of latex or polyethylene within the anastomosis to ensure its patency at least until the edema following surgery has subsided.
REFERENCES 1. Bozeman, N.: Removal of cyst of the pancreas weighing twenty and one-half pounds. Med. Rec. 21: 46 (Feb.) 1882.
2. Fox, N. M., Jr., Ferris, D.O., Moertel, C. G. et al.: Pseudocysts co-existent with pancreatic carcinoma. Ann. Surg. 158: 971-974 (Dec.) 1963. 3. Gussenbauer, C.: Zur operativen Behandlung der Pankreascysten. Arch. f. klin. Coo. 29: 355-364, 1883.
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KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
4. Jedlicka, R.: Eine neue Operationsmethode der Pankreascysten (Pancreatogastrostomie). (Abst.) Zentralbl. f. Chir. 50: 132 (Jan. 27) 1923. 5. Jurasz, A.: Zur Frage der operativen Behandlung der Pankreascysten. Arch. f. klin. Chir. 164: 272-279, 1931. 6. Le Dentu, L.: Rapport sur l'observation precedente, par M. Le Dentu, aide d'anatomie a la Faculte de Medicine. BulL Soc. Anat. de Paris 40: 197-214, 1865. 7. Lucke, A. and Klebs, E.: Beitrag zur ovariotome und zur Kenntniss der Abdominalgeschwulste. Arch. path. Anat. 41: 1-14, 1867.
Two hundred years of evolution underlie our present-day concepts of the management of pancreatic cysts. Morgagni, in 1761, first described pancreatic cysts seen at necropsy, a finding subsequently enlarged upon by Cleason in 1842. The first surgical procedure for a pancreatic cyst was apparently performed by Le Dentu6 in 1862 when he operated on a patient with a presumptive diagnosis of hepatic cyst and found a large pancreatic cyst which he drained directly to the exterior. This patient died of peritonitis. Lucke and Klebs, 7 in 1866, likewise drained a pancreatic cyst to the exterior, with fatal results. The autopsy of Klebs' case revealed that the pancreatic cyst was associated with a pancreatic carcinoma. The first successful surgical treatment of pancreatic cyst was described by Bozemanl in 1882. That cyst was excised. In the same year Gussenbauer3 first applied the principle of marsupialization to the surgical treatment of pancreatic cysts; this was accomplished by suturing the parietal peritoneum to the skin and the wall of the cyst to the peritoneum. The safety of this method made it popular, and for many years the treatment of choice was marsupialization, despite the disadvantages of recurrent cysts and persistent fistulas with their associated skin irritation and the loss of pancreatic enzymes. Internal drainage of pancreatic cysts was first reported by Umberdan in 1911, who described an operation performed by him three years earlier. Umberdan anastomosed a cyst at the pancreatic head to the duodenum. The patient unfortunately did not survive. It was in 1923 that Jedlicka4 reported for the first time the successful elimination of a pancreatic cyst by anastomosing the cyst to the stomach. Hahn was apparently the first to describe an anastomosis between the cyst and the jejunum. The transgastric technique of pancreaticocystogastrostomy was first described in 1931 by Jurasz5 who made a large opening into the pancreatic cyst by 599
600
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
incising the posterior gastric wall through an anterior gastrotomy. Jurasz pointed out the ease with which this procedure could be performed and the safety resulting from the dense adhesions which form between the cyst and the posterior wall of the stomach. Armed with this heritage of successful operations, the present-day surgeon has a choice of techniques, each appropriate in certain circumstances. The choice of treatment and of surgical procedure, however, must depend upon the nature of the individual case. Because of these choices, pancreatic cysts must be classified. The classification which has proved most useful to us follows: 1. Developmental A. Fibrocystic disease B. Simple cysts C. Dermoid cysts D. Cysts associated with polycystic disease of the viscera 2. Acquired A. Inflammatory (1) Pseudocysts (2) Retention cysts B. Traumatic (1) Nonpenetrating (indirect trauma) (2) Penetrating (direct trauma) C. Neoplastic (1) Cystadenoma (2) Cystadenocarcinoma (3) Teratoma (4) Unusual tumors D. Secondary to obstructing carcinomas E. Parasitic
ETIOLOGY
Developmental Cysts A small number of pancreatic cysts are of developmental ongm. Presumably they result from a faulty fusion of the ductal elements. Occasionally, polycystic changes occur in the pancreas in association with polycystic disease of other visceral structures, and cystic teratomas have been found within the pancreas. Acquired Cysts INFLAMMATORY. A vast majority of pancreatic cysts are acquired and most of these are associated with inflammatory pancreatic disease. Pseudocysis. Pseudocysts are cystic collections whose walls are made up of the viscera and abdominal wall adjacent to the pancreas. These cysts lack a true epithelial lining and lie primarily beyond the confines of the pancreatic gland itself. Retention Cysts. Retention cysts result from obstruction of a pancreatic duct and thus have a communication with the duct. The patient
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
601
with chronic pancreatitis may have both retention cysts and pseudocysts in association with his inflamed pancreas. Cystic changes in relationship to the pancreas may be secondary to inflammatory changes in an adjacent organ, and retention cysts are a rare finding in association with a penetrating duodenal ulcer which obstructs the duct of Wirsung. TRAUMATIC. Penetrating wounds of the abdomen or surgical injuries associated with operations in adjacent areas of the abdomen may result in pancreatic cyst formation, usually secondary to division of or damage to one of the major pancreatic ducts. The presence of the rigid and protruding vertebral bodies posterior to the pancreas has resulted in fracture of the pancreas, with division of the pancreatic duct and the development of a pancreatic cyst in association with nonpenetrating abdominal injuries. NEOPLASTIC. Neoplastic changes within the pancreas give rise to cystadenomas, cystadenocarcinomas and, more rarely, teratomas and cystic hemangio-endotheliomas. This neoplastic cyst formation within the pancreas makes proper selection of the surgical procedure important when a pancreatic cyst is treated operatively. A high degree of suspicion will prevent the tragic error of draining a neoplastic lesion. The external appearance of the cystadenoma may not suggest its neoplastic nature, although the multiloculated appearance of many cystadenomas is a useful feature in differentiating this type of lesion and its malignant counterpart, the cystadenocarcinoma, from the benign and non-neoplastic cysts of the pancreas. CYSTS SECONDARY TO OBSTRUCTING CARCINOMAS. 2 Cysts secondary to carcinoma of the pancreas are not very common. The history is usually short, unlike chronic pancreatitis, and suggests a hidden malignant process in association with the benign-appearing cyst. Duct obstruction by a neoplasm must be suspected in the case of the isolated cyst. The treatment is that required for the primary malignant process. PARASITIC. The parasitic cysts of the pancreas are rare and for that reason will not be discussed.
SYMPTOMS
It is obvious from the diversity of etiologic factors associated with pancreatic cyst formation that the symptoms are varied. Approximately one-third of pancreatic cysts present as a palpable mass with no other associated symptoms. Cystic changes associated with chronic pancreatitis are discovered in the course of investigation of the pancreatitis itself; they are associated with attacks of abdominal pain passing through to the back, and occasionally with chills and fever. Large cysts cause symptoms related to the pressure effects they exert upon the adjacent stomach or duodenum and thus may result in nausea and vomiting. It is unusual for a cyst to rupture spontaneously, but this
602
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
unfortunate incident may occur, causing generalized peritoneal irritation. Large cysts pressing upon the diaphragm may result in pleural effusions, and cysts have been known to burrow through the retroperitoneal tissue to the lower portions of the abdomen and pelvis and the upper part of the abdomen even above the diaphragm into the mediastinum. Obstruction of the bile duct by an enlarging cyst results in jaundice. If the cyst occupies a large portion of the pancreas, diabetes may develop. DIAGNOSIS
As with all diseases of the pancreas, an awareness of the constant possibility of pancreatic disease must be shown by the examining physician. A history of trauma or chronic relapsing pancreatitis should lead one to suspect a pancreatic cyst. Tenderness and a palpable mass are found on physical examination. The physician must. remember that the cyst may present in unusual sites sometimes in areas other than the upper portion of the abdomen. Upper gastrointestinal x-ray studies are useful in demonstrating pancreatic enlargement, and large cysts of the head and neck will result in deformity of the duodenum and antrum (Fig. 1). Cysts of the body and
Fig. 1 Fig. 2 Figure 1. Widening of the duodenal loop caused by the presence of a large cyst within the head of the pancreas. Note the flattening of the antral mucosa and the changes on the medial aspect of the duodenum itself. Figure 2. A large cyst of the body of the pancreas has displaced the stomach and flattened the mucosa overlying the cyst.
603
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
Figure 3. A large cyst lying over the neck and body of the pancreas has been entered through a liberal incision and emptied. A de Pezzer catheter is then placed within the cyst. The opening through which the catheter was inserted is closed snugly with interrupted silk sutures to prevent leakage around the catheter. (From Warren, K. W.: Chronic relapsing pancreatitis. In Cooper, P., Ed.: Craft of Surgery. Boston, Little, Brown & Co., 1964, p. 1182.)
tail of the pancreas will cause deviations of the stomach and the region of the ligament of Treitz (Fig. 2). SURGICAL TREATMENT
The diversified nature of pancreatic cysts makes any preconceived plan of surgical treatment potentially dangerous. The selection of treatment must be based upon the findings at operation in that patient and not related to any preoperative decision based upon history or physical examination. Of course, the prime object at the time of surgical treatment is to determine whether the cyst is benign or malignant. Once a cyst has been opened on the operating table, any suspicious protrusions from the lining of the cyst cavity should be examined for malignant degeneration by the frozen section technique.
Drainage The simplest method of managing most cysts
IS
external drainage.
604
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
This is achieved by entering the cystic cavity through a small incision in the cyst itself. The cyst is cleaned of its fluid content and any necrotic pancreas and necrotic inflammatory debris which it might contain. The inner lining of the cyst is carefully inspected to be absolutely certain that there are no papilliferous projections that suggest neoplastic change. The cyst is then drained to the exterior with a de Pezzer catheter (Fig. 3) which may then conduct any future cystic content to the exterior to empty into a bag or other suitable container, thus preventing maceration of the skin about the wound. If the cyst is multilocular, it is important that all locules are emptied by this procedure. This method of treatment is especially useful in the management of cysts that lie in the head of the pancreas or in the uncinate process, for cysts in these sites are not easily treated by internal drainage, and the pancreaticoduodenal resection necessary for their excision is usually not justified. Large cysts and cysts of recent origin with thin walls are better treated by external drainage until such time as the cyst has shrunk to a more manageable size and the walls have become thicker and more easily handled with sutures. Marsupialization Marsupialization has not been used in this clinic for some years because of the disadvantage of skin maceration resulting from the passage of cystic contents onto the anterior abdominal wall. Internal Drainage At this clinic internal drainage has been used in preference to external drainage for many years. Large pseudocysts often occupy the lesser omental sac; in this site the stomach forms part of the anterior wall of the cyst. They are thus ideal for transgastric cystogastrostomy (Fig. 4) which has been used with good effect. Cystogastrostomy has also been employed with good palliative results in patients with inoperable cystadenocarcinoma. A generous anterior gastrotomy is performed, the stomach is cleansed of its contents, and the posterior wall of the stomach is incised, allowing entry into the underlying cystic cavity. The opening between the cyst and stomach should be large in order to allow easy passage of cyst contents and any accumulated food matter from within the cystic cavity back into the stomach. The cystogastrostomy opening is maintained by means of a continuous chromic catgut suture passing around the circumference of the orifice. The anastomosis of the cyst to a defunctionalized loop of jejunum has proved a useful method of treatment in cysts situated away from the stomach and yet not suitable for excisional therapy. For this purpose an anastomosis similar to that described above is performed between the cyst and a loop of jejunum. We prefer to use a loop of jejunum with an accompanying entero-anastomosis sO that the cyst wall may be anastomosed side-to-side with the jejunum, thus allowing a large orifice.
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
605
Figure 4. Through an anterior gastrotomy incision held apart with right angle or Deaver retractors, the posterior wall of the stomach has been opened, allowing thorough inspection and evacuation of the cyst lying in the lesser sac. A continuous suture is passed around this posterior hiatus, maintaining the opening and ensuring continuing drainage (From Warren, K.W.: Chronic relapsing pancreatitis. In Cooper, P., Ed.: Craft of Surgery. Boston, Little, Brown & Co., 1964, p. 1182.)
Some cysts lying within the head of the pancreas can be drained by an incision through the medial wall of the second portion of the duodenum into the cyst as it lies within the head. This has been of considerable value in many of our patients. Other cysts lying in close relationship to the pancreatic duct may be drained directly into the pancreatic duct using a transduodenal sphincterotomy as an approach to the duct and passing probes down the duct and forcibly into the cyst through the cyst wall (Fig. 5). A small polyethylene tube is left within the duct of Wirsung and passing into the cyst to maintain the continuity between the cyst, pancreatic duct and the duodenum, ensuring the complete evacuation of the cyst. Excision
Excision remains the treatment of choice in the management of pancreatic cysts and many cysts of surprisingly large size are suitable for excision. Often the cyst lies surrounded by an area of compressed inflammatory tissue, permitting enucleation. If there is continuity between the cyst cavity and a major pancreatic duct, the excision of the cyst should be
606
KENNETH WARREN, MALCOLM VEIDENHEIMER, SOCRATES ATHANASSIADES
Figure 5. The sphincter has been divided, thus giving access to the common bile duct and the duct of Wirsung through the duodenum. A probe passed up the duct of Wirsung has penetrated into an adjacent cyst, permitting drainage of the cyst contents into the duct of Wirsung and thus into the duodenum. A small polyethylene catheter is placed lying within the duct of Wirsung and entering the cyst at one extremity and the duodenum at the other extremity. The catheter may be anchored at the papilla with a single catgut suture; later it will be passed.
followed by anastomosis between the duct and the stomach, duodenum or a loop of jejunum. Thus, external fistula formation is prevented (Fig. 6). Because of their high incidence of malignant degeneration, cystadenomas should be removed unless they lie in inaccessible portions of the gland. Resection Cysts situated in the distal body and in the tail of the pancreas are resected by distal pancreatectomy and splenectomy. Cysts of traumatic origin, especially those related to fracture of the duct of Wirsung on the vertebral bodies, are satisfactorily dealt with by distal pancreatectomy, since these cysts so often are associated with complete division of the duct and have a great tendency to persist or recur despite drainage procedures (Fig. 7). Pancreaticoduodenal resection has been used in the management of a large number of patients with chronic relapsing pancreatitis with associated cysts. In these instances, however, the operation is performed primarily for the pancreatitis rather than because of the cysts per se. We believe that drainage procedures should be used in preference to pancreaticoduodenal resection for most cysts situated in the head of the gland. Resection
SURGICAL MANAGEMENT OF PANCREATIC CYSTS
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Figure 6. A cyst lying over the neck and body of the pancreas has been excised and found to have continuity with a large pancreatic duct. Because of the duct continuity, an anastomosis should be performed between the duct and the stomach or a loop of jejunum.
of the head of the pancreas is necessary, however, in the management of (1) large cystadenomas, (2) cystadenocarcinomas and (3) often for multiple cysts within the pancreatic head. Total pancreatectomy was performed in one patient with an extremely large cystadenocarcinoma. This patient is still alive ten years later. External Fistulas External drainage of any pancreatic cyst may result in a permanent external pancreatic fistula. This, of course, is most likely to develop when a retention cyst has a connection with a pancreatic duct. The use of the de Pezzer catheter and controlled drainage into a container has diminished greatly the adverse effects of external pancreatic fistula, but nevertheless the loss of fluid and electrolytes may be tremendous, resulting in great debility. Pancreatograms may be obtained by injecting radiopaque material into the catheter leading from the pancreatic cyst. If the dye passes into the duodenum, showing duct continuity, one could then anticipate the eventual closure of the fistula and continue with conservative management. If, however, large amounts of drainage persist and the injection of the dye
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Figure 7. Distal pancreatectomy is shown as it is completed. The pancreas is divided in the body or neck close to the inferior mesenteric and portal veins. Great care is taken in the closure of the cut end of the neck of the pancreas in order to prevent fistula formation. Note the large cyst in the pancreatic tail.
into the duct reveals duct obstruction between the cyst and the duodenum, closure of the fistula is most unlikely. In these instances, the fistulous tract should be dissected down to the pancreas and excised. An anastomosis is then made between the remnant of cystic cavity or pancreatic duct and a loop of jejunum, stomach or duodenum (Fig. 8). If at all possible, a direct anastomosis between the obstructed duct and jejunum should be attempted, since this makes successful resolution of the fistula more certain than if a granulomatous fistulous tract is used for the anastomosis. The anastomosis may be performed in one or two layers, using interrupted fine silk or interrupted catgut sutures. Fistulas arising in the distal portion of the gland are best treated by distal pancreatectomy. SUMMARY
A discussion of the etiology of pancreatic cyst has been given. The nature of the cyst has a most important role in the determination of the type of treatment to be employed. The various types of surgical management for pancreatic cysts have been described. Surgical excision reInains the therapy of choice, but treatment must be individually planned for each patient. Marsupialization is no longer employed because of more satisfactory control by means of catheter drainage of the cyst cavity. We wish to stress that every attempt should be made to exclude the possibility of cystadenoma or cystadenocarcinoma if a cyst is not to be removed. The risk of malignant transformation of cystadenoma is great, and for this reason radical excision is the procedure of choice.
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Fig. 8. An anastomosis is being performed between a fistulous connection to the body of the pancreas and the distal stomach. Note that a two layer closure can be achieved. We prefer to leave a stent of latex or polyethylene within the anastomosis to ensure its patency at least until the edema following surgery has subsided.
REFERENCES 1. Bozeman, N.: Removal of cyst of the pancreas weighing twenty and one-half pounds. Med. Rec. 21: 46 (Feb.) 1882.
2. Fox, N. M., Jr., Ferris, D.O., Moertel, C. G. et al.: Pseudocysts co-existent with pancreatic carcinoma. Ann. Surg. 158: 971-974 (Dec.) 1963. 3. Gussenbauer, C.: Zur operativen Behandlung der Pankreascysten. Arch. f. klin. Coo. 29: 355-364, 1883.
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4. Jedlicka, R.: Eine neue Operationsmethode der Pankreascysten (Pancreatogastrostomie). (Abst.) Zentralbl. f. Chir. 50: 132 (Jan. 27) 1923. 5. Jurasz, A.: Zur Frage der operativen Behandlung der Pankreascysten. Arch. f. klin. Chir. 164: 272-279, 1931. 6. Le Dentu, L.: Rapport sur l'observation precedente, par M. Le Dentu, aide d'anatomie a la Faculte de Medicine. BulL Soc. Anat. de Paris 40: 197-214, 1865. 7. Lucke, A. and Klebs, E.: Beitrag zur ovariotome und zur Kenntniss der Abdominalgeschwulste. Arch. path. Anat. 41: 1-14, 1867.