Pancreatic pseudocyst or a cystic tumor of the pancreas?

Mucinous cystadenoma of the pancreas associated with pancreatic pseudocyst

Mucinous cystadenoma of the pancreas is considered as a premalignant lesion, and resection is recommended. The majority of pancreatic cystic lesions are pancreatic pseudocysts, so differentiation between mucinous cystadenoma and pseudocyst is frequently required. We report a rare case of mucinous cystadenoma of the pancreas coexisting with pseudocyst. A 43-year-old woman presented with abdominal pain. Imaging examinations showed a large cystic lesion in the tail of the pancreas, and distal pancreatectomy and splenectomy were performed. Pathological examination revealed that the majority of the cystic wall comprised thick collagen fibrous connective tissue, while part of the cystic wall represented a single layer of columnar, mucin-producing epithelium without atypia. Those findings suggested mucinous cystadenoma with an inflammatory pseudocyst. The mixture of mucinous cystadenoma and pseudocyst within the same cystic lesion appears to be very rare. Complete resection of the cystic lesion seems to allow an excellent prognosis.

Controversies in EUS-guided treatment of walled-off necrosis

This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.

Idiopathic giant pancreatic pseudocyst presenting in emergency with abdominal compartment syndrome and intestinal occlusion: Case report and review of the literature

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Idiopathic giant pancreatic pseudocyst (IGPP) is a rare pancreatic disease.

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Diagnosis of IGPP in emergency [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]] is a challenge because of its rarity, the absence of history of pancreatitis and specific symptoms and signs.

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IGPP may cause intestinal obstruction, intra-abdominal hypertension and abdominal compartment syndrome requiring a decompressive laparotomy.

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Distal pancreaticosplenectomy may be the correct treatment of undiagnosed IGPP if there is suspicion or inability to exclude a malignant cystic pancreatic neoplasm.

Introduction and importance

This is the first case of idiopathic giant pancreatic pseudocyst (IGPP) causing intestinal occlusion, intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) reported in the literature. Diagnosis of IGPP in emergency is a challenge because of its rarity and the absence of a history of pancreatitis or pancreatic trauma and specific clinical presentation. Abdominal contrast-enhanced computed tomography (CECT) represents the gold standard in diagnosing of pancreatic cyst (PP). Different types of treatment of PP are reported in the literature.

Case presentation

A 52-year-old Caucasian female was admitted to the Emergency Department with a three-day history of abdominal pain, inability to pass gas or stool, nausea and vomiting, oliguria and a seven-day history of abdominal swelling and swollen legs. Physical examination revealed abdominal distention, abdominal pain, swelling in the legs. CECT showed a voluminous cystic pancreatic mass suspected of neoplasm. Laboratory tests reported high serum levels of BUN, creatinine and C-reactive protein and neutrophilic leukocytosis. After preoperative diagnosis of ACS, the patient was taken to the operating room for pancreatic resection. The postoperative course was uneventful. Diagnosis of IGPP was made by histopathological examination.

Clinical discussion

IGPP is difficult to diagnose in emergency. Although different types of drainage of IGPP are described in the literature, pancreatic resection represents the treatment of choice when a cystic pancreatic neoplasm cannot be excluded.

Conclusion

IGPP is a rare disease that may cause intestinal occlusion, IAH and ACS. Pancreatic resection if necessary is safe and therapeutic with acceptable morbidity and mortality.

Pancreatic pseudocyst: Dilemma of its recent management (Review)

Advances in radiological techniques have led to an increase in the number of diagnoses of pancreatic pseudocyst, which is the most common pancreatic cyst lesion disease, accounting for two-thirds of all pancreatic cyst lesions. Historically, the management of pancreatic pseudocyst has been achieved through the use of conservative treatments and surgery; however, due to the complications and recurrence rate associated with these techniques, the management of pancreatic pseudocyst is challenging. Surgeons and gastroenterologists have attempted to determine the optimal management technique to treat pancreatic pseudocyst to reduce complications and the recurrence rate. From these investigations, percutaneous catheter, surgical and endoscopic drainage with ultrasonography guidance have become promising management techniques. The present review aimed to summarize the diagnostic and therapeutic methods used for the management of pancreatic pseudocyst and to compare percutaneous catheter, surgical and endoscopic drainage.

Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives

Purpose of review

Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management.

Recent findings

The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk.

Summary

International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).

Prevalence and outcomes of cystic lesions of the transplant pancreas: The University of Wisconsin Experience

Literature on the behavior of cystic lesions in pancreas transplants is scarce, and hence a better understanding is warranted. Data on recipients and their respective donors that underwent simultaneous kidney and pancreas, pancreas transplant alone, and pancreas after kidney between 1994 and 2015 were reviewed (n = 1185). Cystic lesions of the transplant pancreas developed in 22 patients (1.8%): 12 pseudocysts, 2 cysts/remnants, 4 intraductal papillary mucinous neoplasms (IPMN), 2 adenocarcinomas, 1 low-grade intraepithelial pancreatic neoplasia, and 1 case of polycystic kidney disease. The median size was 3.6 cm (1.6-5.5 cm), and occurred at a median time of 65.5 months (2-183 months) posttransplant. The median age of the graft at time of diagnosis was 42 years (25.7-54.5), with 17 of 22 grafts (77%) functioning at time of diagnosis. Triggers for investigation were elevations in pancreatic enzymes, re-admissions for abdominal pain, and incidentalomas. High-resolution imaging and diagnostic biopsy/aspiration with ancillary tests were the main diagnostic tests. Most pseudocysts were managed by percutaneous drainage, and although no firm inference can be made from such a small series, we have observed that the behavior and management of IPMN and adenocarcinoma in the pancreas graft appears congruent to that of the native pancreas.

Pancreatic pseudocyst or mucinous cystadenocarcinoma of pancreas? A diagnostic dilemma

Pancreatic cystic neoplasm is difficult to distinguish from pseudocyst as clinical and radiological evidences may not be sufficient to make an accurate diagnosis. This may result in misdiagnosis with inappropriate management. Hence, every effort should be made for their distinction to avoid internal drainage procedures for neoplasms instead of extirpation.