Pankreas Psödokisti
Özet
Pankreas psödokistleri, genellikle akut veya kronik pankreatit ya da travma sonrasında gelişen, nonepitelyal ve iyi sınırlı duvarla çevrili sıvı koleksiyonlarıdır. En sık klinik semptomu karın ağrısı olan bu hastalıkta tanı, ultrason ve özellikle psödokist ile walled-off nekroz ayrımında yüksek hassasiyet sunan bilgisayarlı tomografi (BT) gibi görüntüleme yöntemleriyle konur. Geçmişte 5 santimetreden büyük asemptomatik kistler için doğrudan müdahale önerilirken, günümüzde semptom göstermeyen vakalarda "bekle ve gör" yaklaşımı ve konservatif takip ön plana çıkmaktadır. Müdahale gerektiren semptomatik, enfekte veya komplikasyonlu kistlerin tedavisinde ise tarihsel olarak standart kabul edilen açık cerrahinin yerini minimal invaziv yöntemler almıştır. Güncel yaklaşımlar arasında yer alan laparoskopik cerrahi ve endoskopik drenaj (transmural veya transpapiller) yöntemleri benzer başarı oranlarına sahiptir. Ancak endoskopik drenaj uygulamaları, özellikle hastanede yatış süresini kısaltması ve maliyet avantajı sağlaması sebebiyle günümüzde birincil tedavi seçeneği olarak öne çıkmaktadır. Altın standart tedavinin belirlenmesi için daha geniş serili çalışmalara ihtiyaç duyulmakla birlikte, mevcut klinik deneyim ve hasta anatomisine göre en uygun invaziv yöntemin seçilmesi başarıyı belirleyen temel unsurdur.
Pancreatic pseudocysts are non-epithelial, well-defined fluid collections encapsulated by a fibrous wall that typically develop secondary to acute or chronic pancreatitis, or pancreatic trauma. Abdominal pain is the most prevalent clinical symptom, and diagnosis is primarily established through imaging modalities like ultrasound and computed tomography (CT), with CT being highly effective in differentiating pseudocysts from walled-off necrosis. Modern management strategies favor a conservative "watch and wait" approach for asymptomatic cases, moving away from past guidelines that recommended immediate intervention for cysts larger than 5 centimeters. When intervention becomes necessary due to symptoms, infection, or serious complications, minimally invasive techniques have largely replaced traditional open surgery. Laparoscopic surgery and endoscopic drainage (either transmural or transpapillary) demonstrate comparable therapeutic success rates. However, endoscopic treatments have progressively become the primary modality of choice due to distinct advantages in reducing both hospital stay durations and overall healthcare costs. While a definitive gold standard therapy remains unestablished pending large-scale randomized controlled trials, selecting the most appropriate intervention based on institutional expertise and specific patient anatomy is essential for optimal clinical outcomes.
Referanslar
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis - 2012: Revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1): 102–111. doi:10.1136/gutjnl-2012-302779
Szakó L, Gede N, Váradi A, et al. Early occurrence of pseudocysts in acute pancreatitis – A multicenter international cohort analysis of 2275 cases. Pancreatology. 2021;21(6): 1161–1172. doi:10.1016/j.pan.2021.05.007
Pan G, Wan MH u., Xie KL, et al. Classification and Management of Pancreatic Pseudocysts. Medicine. 2015;94(24): e960. doi:10.1097/MD.0000000000000960
Pitchumoni CS, Frcp C. When and How Should Drainage. Gastroenterology Clinics Of North America. 1999;28(3): 615–639.
Redwan AA, Hamad MA, Omar MA. Pancreatic Pseudocyst Dilemma: Cumulative Multicenter Experience in Management Using Endoscopy, Laparoscopy, and Open Surgery. Journal of Laparoendoscopic and Advanced Surgical Techniques. 2017;27(10): 1022–1030. doi:10.1089/lap.2017.0006
Xiao N-J, Cui T-T, Liu F, et al. Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis. World Journal of Gastrointestinal Surgery. 2021;13(7): 633–644. doi:10.4240/wjgs.v13.i7.633
Habashi S, Draganov P V. Pancreatic pseudocyst. World Journal of Gastroenterology. 2009;15(1): 38–47. doi:10.3748/wjg.15.38
Cao HST, Kellogg B, Lowy AM, et al. Cystic Neoplasms of the Pancreas. Surg Oncol Clin N Am. 2010;19(2): 267–295. doi:10.1016/j.soc.2009.11.004.Cystic
Tan JH, Chin W, Shaikh AL, et al. Pancreatic pseudocyst: Dilemma of its recent management (Review). Experimental and Therapeutic Medicine. Spandidos Publications; 2020;21(2). doi:10.3892/etm.2020.9590
Agalianos C, Passas I, Sideris I, et al. Review of management options for pancreatic pseudocysts. [Online] Translational Gastroenterology and Hepatology. AME Publishing Company; 2018. doi:10.21037/tgh.2018.03.03
Adrén-Sandberg Å, Dervenis C. Pancreatic pseudocysts in the 21st century. Part I: Classification, pathophysiology, anatomic considerations and treatment. Journal of the Pancreas. 2004;5(1): 8–24.
Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Annals of Surgery. 2002;235(6): 751–758. doi:10.1097/00000658-200206000-00001
Cheruvu CVN, Clarke MG, Prentice M, et al. Conservative treatment as an option in the management of pancreatic pseudocyst. Annals of the Royal College of Surgeons of England. 2003;85(5): 313–316. doi:10.1308/003588403769162413
Aghdassi AA, Mayerle J, Kraft M, et al. Pancreatic pseudocysts - When and how to treat? Hpb. 2006;8(6): 432–441. doi:10.1080/13651820600748012
Tenner S, Baillie J, Dewitt J, et al. American college of gastroenterology guideline: Management of acute pancreatitis. American Journal of Gastroenterology. Nature Publishing Group; 2013;108(9): 1400–1415. doi:10.1038/ajg.2013.218
Rasch S, Nötzel B, Phillip V, et al. Management of pancreatic pseudocysts - A retrospective analysis. PLoS ONE. 2017;12(9): 1–10. doi:10.1371/journal.pone.0184374
Schnelldorfer T. The birth of pancreatic surgery: a tribute to Friedrich Wilhelm Wandesleben. World journal of surgery. 2010;34(1): 190–193. doi:10.1007/s00268-009-0237-6
Michael O, Derick K, Srikant S, et al. Cystocolostomy as an unusual approach to recurrent pancreatic pseudocyst in a Ugandan male with dense hepatogastroduodenal adhesions: A case report. International Journal of Surgery Case Reports. Elsevier Ltd; 2021;88(October): 106546. doi:10.1016/j.ijscr.2021.106546
Ye J, Wang L, Lu S, et al. Clinical study on cystogastrostomy and Roux-en-Y-type cystojejunostomy in the treatment of pancreatic pseudocyst: A single-center experience. Medicine. NLM (Medline); 2021;100(10): e25029. doi:10.1097/MD.0000000000025029
Matsuoka L, Alexopoulos SP. Surgical Management of Pancreatic Pseudocysts. Gastrointestinal Endoscopy Clinics of North America. Elsevier Inc; 2018;28(2): 131–141. doi:10.1016/j.giec.2017.11.002
Guo Y, Hu S, Wang S, et al. Laparoscopic Intervention to Pancreatic Pseudocyst Confers Short-Term Benefits: A Meta-Analysis. Emergency Medicine International. 2021;2021: 1–7. doi:10.1155/2021/7586338
Keane MG, Sze SF, Cieplik N, et al. Endoscopic versus percutaneous drainage of symptomatic pancreatic fluid collections: a 14-year experience from a tertiary hepatobiliary centre. Surgical Endoscopy. Springer US; 2016;30(9): 3730–3740. doi:10.1007/s00464-015-4668-x
Ge PS, Weizmann M, Watson RR. Pancreatic Pseudocysts: Advances in Endoscopic Management. Gastroenterology Clinics of North America. Elsevier Inc; 2016;45(1): 9–27. doi:10.1016/j.gtc.2015.10.003
Amin S, Yang DJ, Lucas AL, et al. There is no advantage to transpapillary pancreatic duct stenting for the transmural endoscopic drainage of pancreatic fluid collections: A meta-analysis. Clinical Endoscopy. 2017;50(4): 388–394. doi:10.5946/ce.2016.091
Garg PK, Meena D, Babu D, et al. Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial. Surgical Endoscopy. Springer US; 2020;34(3): 1157–1166. doi:10.1007/s00464-019-06866-z
Farias GFA, Bernardo WM, De Moura DTH, et al. Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis. Medicine. NLM (Medline); 2019;98(8): e14255. doi:10.1097/MD.0000000000014255
