INTERESTING CASE PRESENTATION

Lyceum-Northwestern University
Dr. Francisco Q. Duque Medical Foundation
College of Medicine
Department of Surgery

A Tale of Two Cysts:

Exploring the Fine Line
Between Pancreatic
Cysts and Cancer
GROUP 6
 GENERAL DATA
PATIENT AM 45 YEAR OLD

MALE MARRIED

ROMAN
FILIPINO
CATHOLIC
Chief complaint:
ABDOMINAL PAIN BORN BORN
ON AUGUST
ON PREVIOUS
CONSTRUCTION
25,
AUGUST
1977: 25, 1977 WORKRR

FROM NAVATAT, BASISTA, PANGASINAN

 HISTORY OF PRESENT ILLNESS
4 months PTA
● (+) LUQ pain, sharp, stabbing and
non radiating (PS=3/10)
● Palpable mass (One peso–coin size)
● No meds taken, no consultation
3 months PTA
● Enlarging mass – whole (L) quadrant
● Increasing pain intensity (7/10)
● Worsens during activity
● Improves when lying down
● With episodes of black tarry stools
● Meds: KINGS herbal food
supplement, TID
● No consultation
 2 months
PTA

● Went to a district hospital due to

persistent signs and symptoms
● Abdominal UTZ done → referred
to R1MC
○ Work ups done
○ No meds and no procedure
done
● No follow up check ups done
Few hours PTA
● Signs and symptoms persisted
● Worsening pain (10/10)
● Additional symptoms: pallor,
weight loss, generalized
weakness

ADMISSION
 PATIENT’S HISTORY

MEDICAL SURGICAL SOCIAL FAMILY

HISTORY HISTORY HISTORY HISTORY
● No previous hx of ● Previous construction
worker (approx 10 ● (+) HTN - Father (88 y/
● No known history trauma
years) o)
● No previous
of DM, HPN, PTB, hospitalizations ● 4.25 pack-year ● (-) Other
and CA smoking history heredofamilial
● No previous surgical
● Previous alcoholic diseases
interventions or
blood transfusions. drinker (approx 17
● No allergies to food, years, 1-2 bottles per
drugs, , and animals week)

UNREMARKABLE UNREMARKABLE CONTRIBUTORY NON-

CONTRIBUTORY
 REVIEW OF SYSTEMS
(+) ANOREXIA (+) BLOATEDNESS (+) BACK PAIN
(+) EARLY SATIETY (+) LOSS OF APPETITE (-) JAUNDICE
OTHERS:
(-) HEMATEMESIS CONTRIBUTORY
(-) FEVER
UNREMARKABLE
(-) HEADACHE
(-) EASY FATIGABILITY (-) DYSPNEA (-) N/V
(-) HEMATURIA (-) HEMOPTYSIS
 PHYSICAL EXAMINATION
GENERAL SURVEY: awake, coherent, ANTHROPOMETRIC
alert, oriented to time, place and
person, not in cardiopulmonary MEASUREMENTS
distress, appeared weak and ill
looking Height: 168 cm
SKIN: Pale Weight: 58 kg
T: 37.2 via axilla
PR: 88 bpm BMI: 20.5 kg/m2

OTHER FINDINGS:
RR: 20 cpm
BP: 100/60
VITAL SIGNS
SPO2: 98% at room ABDOMEN: Globular and distended,
air normoactive bowel sounds, with
EYES: Pale conjunctiva,
dirty sclera
UNREMARKABLE palpable mass on the epigastric
area (3cmx5cm),firm palpable
mass on the left quadrant
RESPIRATORY: Symmetrical chest (7cmx7cm), soft non tender on the
expansion, with decreased breath right quadrant area
sounds on left lower field, clear
breath sound on the remaining fields, ● Dull on the left quadrant and
no adventitious sounds heard epigastric area, tympanitic on
DRE: No lesions, masses, tags or the R quadrant
discoloration, patent anus, no ● (-) CVA tenderness, (+) fluid
masses, tenderness and wave test
bleeding, good sphincter tone ● Abdominal girth: 100cm
 DIAGNOSTICS
LABORATORY STUDIES
FINDINGSIMAGING
ABDOMINAL UTZ STUDY
CBC
●● ● Mild WITH BT lobulated
hydronephrosis, Left
There is a large
Hgb:
○internal
● Abdominal 57 (R: as
mass,
septation
● CXR
described.
within
PA
cystic mass exhibiting
Suggest
the pancreatic bodyCT scan
and tail
135-170 g/L
measuring
correlation. (25.4 x 15.4 x 12.1 cm)
●
●● Other
Mass
S. ELEC,is BUN,
intimately
organ
be compressing
CREA
L
findingsE
related to the left kidney, appears to
unremarkable.
its anterior aspect and ipsilateral
● AMYLASE,
ureter
CA19-9
CEA,
within
AB
K
Resultant
● ABDOMINAL dilatation
CT SCAN of theWITH
ipsilateral calyces, renal
CONTRAST
normal limits
R
● pelvis and proximal ureter
Large left upper quadrant mass.
●
● ● ALP
Large,
A
Its superior margin displaces the liver and enlarged
lobulated cystic mass exhibiting internal
○spleen
M
(splenic
737.74 ( R:index:
64- 973) superolaterally while its
septations
mass E
in thedisplaces
inferior border
306)
toward
R
the right
effects
pancreatic bodyinferiorly
the bowel and tail and
with

UN
● ● PTEnlarged
INR lymph is seen in the perinephric region
●● Considerations
TPAG include
(1,1cm in short axis pancreatic cystic
dimension)
● ● neoplasm,
12LMinimal stromal
ECG ascites, tumor, hemorrhagic
degenerative changes, lumbar spine
Minimal left
● pancreatic pleural
pseudocyst. effusion, with adjacent atelectasis
●
○ Right bundle
Pleural thickening and subsegmental atelectasis in
branch
the right lowerblock
lobe
● RAT CONTRIBUTORY
 SALIENT FEATURES
SUBJECTIVE DATA OBJECTIVE DATA

● 49 years old, Male ● (+) Pallor, pale conjunctiva

● CC: abdominal pain
● 4 months history of enlarging mass (L
quadrant and epigastric area of the
abdomen)
● Previous smoker (4.25 pack years)
● Chronic alcohol drinker (1-2 bottles of gin/
wk)
● (+) weight loss, loss of appetite, early
satiety, bloatedness, generalized body
weakness and back pain
● Distended abdomen, normal bowel sound
● Firm palpable mass on the epigastric area
(3 x 5 cm) and on the left quadrant area (7
x 7 cm), direct tenderness, dull upon
percussion
● (+) Fluid wave Test, abdominal girth:
100cm
● CT FINDINGS: large lobulated cystic mass
exhibiting internal septations in the
pancreatic body and tail with mass effects
(25.4x15.4x12.1cm)
● LABS: Amylase within normal values, ALP:
737.74 U/L (elevated), normal CA19-9 and
CEA, Hgb: 57 (decreased)
PRIMARY IMPRESSION
PANCREATIC PSEUDOCYST,
T/C PANCREATIC CYSTIC
NEOPLASM,
SECONDARY ANEMIA
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
 PLAN
Diagnostic Treatment

Laboratory Workups: ● Admit to surgical ward

● CBC typing, S. elec, Crea,
Amylase, PT-INR, TPAG, CXR,
ECG, RAT
Serum tests:
● Amylase and lipase levels
● Bilirubin and liver function
test
● Secure consent for admission
and management
● Diet as tolerated
● Hydration with PNSS
● Pain management
● Monitor the patient
● Surgical Treatment
Considerations
○ Drainage (Percutaneous
vs Surgical)
○ Excision
 INDICATION FOR SURGERY
● Diagnostics → to classify if it is neoplastic or non neoplastic
● Complicated pseudocyst → compression of major organs
● Symptomatic pseudocyst → (+) early satiety, weight loss, severe abdominal
pain, back pain

OPERATIVE PLAN
Exploratory Laparotomy, RFS, possible Cystogastrostomy or
Cystojejunostomy vs En bloc resection
(Distal Pancreatectomy + Splenectomy + possible Nephrectomy, Left)
 PREOPERATIVE ASSESSMENT
LABORATORY WORK-UPS AIRWAY ASSESSMENT
COMPLETE BLOOD COUNT Neck
Hgb: 103
Hct: 0.32 Free range of motion
Plt: 443
Mouth opening
SERUM ELECTROLYTES
Na: 134.7
UNREMARKABLE
>3 fingerbreadths
K: 3.55
Teeth/Oral
PROTEIN PROFILE
Total: 73 Edentulous
Albumin: 35
Globulin: 38
Mallampati
A protruding mass located in the epigastric and left quadrant score
area of the abdomen,
OTHER LABS Mallampati 1
being prepped in a sterile manner in preparation for a procedure conducted under
Crea: 64 Thyromental Distance
ALP: 502 general endotracheal anesthesia.
Amylase: 80 >6cms
●
INTRAOPERATIVE
INTRAOPERATIVE ASSESSMENT
Titrated Sevo upon increase in BP during
ASSESSMENT
cutting (150/90)
PRE-INDUCTION VITALS
● Upon resection of mass and dissection,
● No initial subjective complaints Increase BP – 185/100mmHg
noted bloody field.
● Claims to be comfortable despite tachycardia decrease after giving
● Episodes of hypotension prompted start of
● Preloaded with 100ml PNSS Midazolam 1mg (135/90)
Norepinephrine drip started at 0.05mcg/
HR – 128
kg/min and maxed at 0.3mcg/kg/min
SpO2 – 99%
● Persistent hypotension prompted start of
Dopamine drip INDUCTION
started at 0.5mcg/kg/min
Induced
● and maxedusing RA-GA (Epidural + GETA
to 20mcg/kg/min
RSI)
● Epinephrine drip was also started 0.05mcg/ VITALS
Epidural inserted at L4-5, negative test,
● kg/min Elevated BP – 130/90mmHg;
+Trajanowski
● Prolonged episode of hypotension was decreased after giving
GETA-RSI
● noted intraop(Midazolam, Fentanyl, Propofol, Midazolam 1mg IV
Succinylcholine) HR – 121
SpO2 – 99-100%
POST-OPERATIVE ASSESSMENT
ANESTHESIA CARE
● BP maintained at 90/60 mmHg but still tachycardic at 120
to 130 beats per minute
● Pupils were fixed dilated
● Patient was on triple pressors
● Noted that there was still active bleeding
● Total operative duration was 5 hours
● Prolonged hypotension was > 2 hours
● Transferred to PACU
The photograph displays the patient after the surgery, with
appropriate wound dressing applied, and currently undergoing
stabilization
 SURGICAL COURSE SUMMARY
EXPLORATORY LAPAROTOMY, GASTROSTOMY, CYSTOGASTROSTOMY RFS;
EN BLOC RESECTION (DISTAL PANCREATECTOMY, SPLENECTOMY)

CONTENTS OF THE MASS SUGGEST A HIGHER LIKELIHOOD OF CYSTIC

NEOPLASM RATHER THAN PANCREATIC PSEUDOCYST
 POST-OPERATIVE DIAGNOSIS

PANCREATIC CYSTIC NEOPLASM, S/P

EXPLORATORY LAPAROTOMY, GASTROSTOMY,
CYSTOGASTROSTOMY RFS; EN BLOC RESECTION
(DISTAL PANCREATECTOMY, SPLENECTOMY),
GASTRORRHAPHY, JP DRAIN #1
CASE DISCUSSION
SYSTEMATIC APPROACH

CLASSIFICATIONS
● Pseudocysts
● Common cystic neoplasms:
● Intraductal papillary
mucinous neoplasm
● Serous cystic neoplasm
● Mucinous cystic neoplasm
● Uncommon cystic neoplasms:
● Solid pseudopapillary
epithelial neoplasm
● Tumors with cystic
degeneration:
■ adenocarcinoma
■ neuroendocrine
tumor
 KEY FINDINGS
● Unilocular cyst without solid
components, central scar or wall
calcification.
● Collection of pancreatic enzymes,
blood and necrotic tissue.
● Debris within a cystic lesion is a
specific MR finding.
● History of pancreatitis or
abdominal trauma.
● Cysts develop in 4-6 weeks
PANCREATIC PSEUDOCYST
● Premalignant tumor - may transform
into a mucinous cystadenocarcinoma
○ Exclusively seen in women -
Typically in 'Mother'
○ Median age: 40-50 years
● Macrocystic with thick wall
septations.
● Peripheral calcifications seen in 25%.
● Location in the tail and body of the
pancreas (95%).
● Most are symptomatic, presenting
with nondescript abdominal pain
MUCINOUS CYSTIC NEOPLASM
JOURNALS
 SUMMARIZATION
Pancreatic Pseudocysts
Etiology ● Pancreatitis (most common cause)
● Trauma
● Pancreatic duct obstruction
● Infection (rarely)
Incidence ● Acute pancreatitis: Approximately
10-20% of cases
● Chronic Pancreatitis: 20-40% of cases
Management ● Conservative management
● image-guided drainage
● surgical intervention
Cystic Neoplasms
● Serous Cystic Neoplasms
● Mucinous cystic neoplasms
● Intraductal papillary mucinous
neoplasms.
● Serous cystadenomas:1-2% of pancreatic
tumors
● MCN and IPMNs: ~0.5-2 per 100,000
individuals/year.
● Observation (for small, asymptomatic,
low-risk cystic neoplasms)
● Resection (for larger or high-risk cystic
neoplasms)
● Endoscopic intervention (for tissue
sampling or cyst ablation)
● Surveillance (regular imaging and
clinical follow-up)
 REFERENCES
● Brunicardi, F. C. (2023). Schwartz's principles of surgery. McGraw Hill.
● Cannon, J. W., Callery, M. P., & Vollmer Jr, C. M. (2009). Diagnosis and management of pancreatic
pseudocysts: what is the evidence?. Journal of the American College of Surgeons, 209(3), 385-393.
● Dhir, V., Itoi, T., Khashab, M. A., & Park, D. H. (2015). Pancreatic pseudocysts: an update. Digestive
endoscopy: official journal of the Japan Gastroenterological Endoscopy Society, 27(4), 375-383.
● Karki, B., Thapa, B. B., & Shrestha, R. (2018). Treatment of pancreatic pseudocyst in a developing
country: A case report. Journal of Kathmandu Medical College, 7(3), 174-177.
● Misra D, Sood T. Pancreatic Pseudocyst. [Updated 2023 Feb 27]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-.
● Pal, A., Mukherjee, S., & Pal, S. (2021). Endoscopic ultrasound-guided transmural drainage of
pancreatic pseudocysts with a novel lumen-apposing self-expandable metal stent: A tertiary care
center experience. Endoscopic Ultrasound, 10(6), 436-441.
● Schwartz, S. I., Brunicardi, F. C., & Dunn, D. L. (2020). Pancreatic Pseudocysts. In Schwartz's Principles
of Surgery (11th ed., pp. 1125-1126). McGraw-Hill Education.
● Wang, Q., Zhao, Y., Wang, Q., Jiang, S., & Wu, W. (2019). Laparoscopic internal drainage for
pancreatic pseudocyst: A retrospective analysis of 59 cases. Journal of Minimal Access Surgery, 15(4),
321-326
“Surgery is the ultimate test of skill,
knowledge, and dedication.
Embrace the challenge and strive for
excellence.”

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GROUP 6