Place: Hubli Date:
From, DR.VINAYKUMAR TERADAL PG IN GENERAL SURGERY, KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI-580022
To, THE PRINCIPAL KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI-580022
THROUGH PROPER CHANNEL
Respected sir,
Subject: Acceptance of registration and forwarding of dissertation topic,
In accordance with the above cited subject, I the undersigned studying Post Graduate Course in M.S. General Surgery have been allotted the dissertation topic “CLINICAL STUDY AND MANAGEMENT OF PSEUDOCYST OF PANCREAS”, under the guidance of Dr.Shilpa
Huchhannavar M.S D.N.B., Associate Professor, Dept. of General surgery KIMS Hubli.
I request you to kindly forward the dissertation topic in the prescribed form to the University for Approval.
Thanking you,
Yours faithfully,
Dr. Vinaykumar Teradal Signature of the guide PG in Dept. of General surgery Dr.Shilpa HuchhannavarM.S D.N.B KIMS Hubli Associate Professor Dept. of General surgery KIMS Hubli Place: Hubli Date: From, The Professor & Head of the Department, Department of surgery, KIMS Hubli. To, The Registrar, Rajiv Gandhi University of Health Sciences, Bangalore.
THROUGH PROPER CHANNEL
Respected sir,
As per the regulations of the University for registration of Dissertation topic, the following Post Graduate in M.S. in General Surgery has been allotted the dissertation topic as follows, by the Official Registration Committee of all qualified and eligible guides of the Department of surgery.
NAME TOPIC GUIDE
DR.VINAYKUMAR Dr.SHILPA “CLINICAL STUDY AND TERADAL HUCHHANNAVAR M.S D.N.B Post Graduate in Department MANAGEMENT OF Associate Professor of General Surgery, Dept. of General surgery PSEUDOCYST OF KIMS Hubli. KIMS Hubli PANCREAS”.
Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the PG student at an early date.
Thanking you,
Yours faithfully
Signature of the guide DR. B. S. MADAKATTIM.S.(Gen.Surgery) Dr.SHILPA.HUCHHANNAVARM.S D.N.B Professor and Head of the Department Associate Professor Dept. of General surgery Dept. of General surgery KIMS Hubli KIMS Hubli RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE
ANNEXURE—II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. NAME OF THE CANDIDATE AND DR.VINAYKUMAR TERADAL ADDRESS (in block letters) Post Graduate in Department of General Surgery, KIMS Hubli
2. NAME OF THE INSTITUTION KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI
3. COURSE OF STUDY AND MS in GENERAL SURGERY SUBJECT
4. DATE OF ADMISSION TO THE 18-06-2012 COURSE
5. TITLE OF THE TOPIC “CLINICAL STUDY AND MANAGEMENT OF PSEUDOCYST OF PANCREAS”.
6. BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY: Pancreatic pseudocysts are encapsulated collections of necrotic tissue, old blood and secretions from the pancreas. The prefix “pseudo” is used to emphasize the fact that these collections frequently have no true capsule and that the cyst wall is made up of adjacent viscera such as the stomach and / or colon. The pseudocysts are the most common complications following pancreatic inflammation both acute and chronic. They also constitute the most frequently encountered cystic lesions of the pancreas others being the cystic neoplasms. The pseudocysts present clinically as epigastric pain, abdominal masses to jaundice. The laboratory findings are not much of use in the diagnosis of these pseudocysts. It is radiology which helps in the diagnosis of the pseudocysts with the help of USG, CT scan, MRI, etc. These investigations govern the therapeutic procedures to be carried out. The treatment team for pseudocysts includes radiologists, endoscopists and surgeons. The radiologists by way of guided per-cutaneous techniques for aspiration/drainage to the therapeutic embolization of bleeding aneurysms and the endoscopists by way of various endoscopic drainage procedures contribute to the team. The various diagnostic and therapeutic procedures available for intervention are also studied and effectiveness of USG guided aspiration as the primary modality of treatment as compared to conventional surgeries is also studied.
6.2 REVIEW OF LITERATURE:
1)Pancreatic pseudocyst Samir Habashi, Peter V Draganov
Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications (infection, gastric outlet or biliary obstruction, bleeding).
2) Pancreatic Pseudocyst: Therapeutic Dilemma A. K. Khanna, Satyendra K. Tiwary, and Puneet Kumar
Pancreatic pseudocysts are the most common cystic lesions of the pancreas, accounting for 75%–80% of such lesions. The most common symptoms are abdominal pain, nausea, and vomiting, although they can be asymptomatic. Abdominal CT is an excellent choice for initial imaging. EUS plays an important role in differentiating pseudocyst from other cystic lesions of the pancreas and can greatly assist in transmural endoscopic drainage. Initial management consists of supportive care. Persistent symptoms and the development of complications warrant invasive intervention. The endoscopic and minimally invasive therapeutic procedures for the drainage of pancreatic pseudocysts are superior to open surgical techniques with respect to theirsuccess, morbidity, and mortality rates, but they cannot always be performed. 50% of pancreatic pseudocysts do not require any intervention and can be successfully managed by a wait-and-watch approach. Laparoscopic and endoscopic drainages have comparable success rates, while that of transcutaneous drainage are somewhat worse. 3) Pancreatic pseudocysts :when and how to treat? ALEXANDER A. AGHDASSI1 et al
There are different therapeutic strategies: Endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention.
4) Role of endosocopic ultrasound in the diagnosis of cystic tumours of the pancreas M.C. Petrone ∗, P.G. Arcidiacono EUS provides the highest resolution of the pancreas and can distinguish structures as small as <2–3 mm, as well as the surrounding parenchyma and ductal system. In addition EUS-FNA provides further informations that may help in differentiating mucinous and non-mucinous cystic lesions. If the cytology of cyst fluid is non-diagnostic the findings of a cystic lesion containing viscous fluid rich in CEA are supportive of a diagnosis of a mucinous lesion.The diagnosis of pancreatic cystic lesions is a common problem. EUS allows high resolution imaging of the pancreas and EUS-guided FNA plays an important role in the differential diagnosis between mucinous (premalignant) and non-mucinous cystic lesions.
5) Pancreatic Pseudocyst -Operative Strategy CHARLES F. FREY, M.D.
The operative mortality was highest in patients undergoing incision and drainage and cystoduodenostomy. Other factors influencing mortality unfavourably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or fistulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pseudoaneurysms associated with their Pseudocysts. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. 6) Surgical Management of Complications Associated With Percutaneous and/or Endoscopic Management of Pseudocyst of the Pancreas William H. Nealon, MD and Eric Walser, MD
There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. A total of 79 patients with complications of PD, E, or both were studied. a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.
7) Blunt pancreatic trauma and pseudocyst: Management of major pancreatic duct injury B.-C. Lin, J.-F. Fang, Y.-C. Wong , N.-J. Liu
Based on this study. When there is no major pancreatic duct injury (AAST grade I or II), or the injury involves the distal major pancreatic duct, percutaneous drainage should be considered first. If the pseudocyst does not resolve, ERP(endoscopic retrograde pancreatography) should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but without obstruction, pancreatic duct stenting may avoid surgical resection. If the major duct is disrupted and obstructed, surgical resection is required.
8) Acute Pancreatic Pseudocysts: Incidence and Implications EDWARD L. BRADLEY, 111, M.D., A.C. GONZALEZ, M.D., J. L. CLEMENTS, JR., M.D.
92 patients with moderately severe acute pancreatitis initially studied within three weeks of onset by ultrasonic tomography, 52 developed an acute fluid collection in the lesser sac. Documentation of the ultrasound prediction of pseudocyst was achieved by surgery or autopsy in 26 cases. Spontaneous resolution of the acute pseudocyst was demonstrated by serial ultrasonography and radiography in another 10 patients. Exploration exposed 3 false positive predictions of pseudocyst. Eleven other patients with a cystic configuration either refused surgery or were lost to follow up. Acute pseudocyst formation is a relatively common phenomenon in the early phases of moderately severe pancreatitis. While spontaneous resolution of acute pseudocysts is frequent, in approximately 50% of cases acute pseudocysts progress to chronic pseudocysts. When a pseudocyst has achieved chronic status, spontaneous resolution is rare. Persistent conservative management under these conditions invites the excessive mortality and morbidity of spontaneous rupture.
. 6.3 OBJECTIVES OF THE STUDY:
1. To find out the relative frequency of pseudo cyst of pancreas in relation to age and sex 2. To establish accurate diagnosis by various investigative procedure USG abdomen and CT abdomen. 3. To study various modes of management like conservative, percutaneous drainage and surgery
7. MATERIALS AND METHODS This is a prospective study conducted in the department of General surgery, KIMS HUBLI, from November 2012 to june 2014
7.1 SOURCE OF DATA:
The patients admitted in our hospital wards with symptomatic pancreatic pseudocyst from November 2012 to june 2014 will be taken up for the study.
7.2 METHOD OF COLLECTION OF DATA (including sampling procedure, if any):
The selected patients, after explaining the options of treatment and taking their consent appropriately will be subjected to a detailed history elicitation followed by thorough evaluation of risk factors and clinical features. They will then be subjected with baseline investigations (Biochemistry, microbiology, Haemogram, and Chest Skiagram). This will then be followed up by specific investigations like serum amylase, serum lipase, liver function tests, USG – Abdomen, CT – Abdomen, Barium swallow and if possible MRI scan. Each patient will be individualized and treated accordingly. The outcomes will be documented using proforma.
INCLUSION CRITERIA FOR THE STUDY:
a) Patients diagnosed as pseudo pancreatic cyst with the help of clinical examination, diagnostic procedures like USG Abdomen, CT Abdomen, Barium Meal..
b) Admitted patients of both sex and all age groups.
EXCLUSION CRITERIA :
a) All the true cysts of Pancreas.
b) Neoplastic cystic swellings of Pancreas.
c) Hydatid cyst of Pancreas.
d) Congenital cysts of Pancreas.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO DESCRIBE BRIEFLY.
The investigative profile available and accessible at KIMS Hubli are Routine Investigations: Hemoglobin Total leucocyte count Differential count ESR Random blood sugar Blood urea Serum creatinine Urine routine Serum amylase and lipase Bleeding time and clotting time Liver function tests
Ultra sound abdomen Barium swallow CT abdomen If possible MRI scan No animals will be used in the study The management will be on the basis of current standards for each specific condition.
DESIGN OF THE STUDY
Prospective study
8. REFERENCES
1)Samir Habashi, Peter V Draganov, “Pancreatic pseudocyst”, World J Gastroenterology 2009 January 7; 15(1): page no-38-47
2) A. K. Khanna, Satyendra K. Tiwary, and Puneet Kumar, “Pancreatic Pseudocyst: Therapeutic Dilemma” Hindawi Publishing Corporation ,International Journal of Inflammation,Volume 2012, Article ID 279476, 7 pages
3) Alexandar A. Aghdassi1 et al, “Pancreatic pseudocysts :when and how to treat?” HPB, 2006; 8:page no- 432-441
4) M.C. Petrone ∗, P.G. Arcidiacono, “Role of endosocopic ultrasound in the diagnosis of cystic tumours of the pancreas” Digestive and Liver Disease 40 (2008) page no: 847–853
5) Charles F. Frey, M.D,. “Pancreatic Pseudocyst -Operative Strategy” Ann. Surg. * November 1978, Vol. 188 o No. S, page no: 652-662
6) William H. Nealon, MD and Eric Walser, MD, “Surgical Management of Complications Associated With Percutaneous and/or Endoscopic Management of Pseudocyst of the Pancreas” Annals of Surgery • Volume 241, Number 6, June 2005,page no: 948-960,
7) B.-C. Lin a,*, J.-F. Fang a, Y.-C. Wong b, N.-J. Liu c, “Blunt pancreatic trauma and pseudocyst: Management of major pancreatic duct injury” Injury, Int. J. Care Injured (2007) 38, page no: 588—593
8) Edward L. Bradley, 111, M.D., A.C. Gonzalez, M.D., J. L. Clements, JR., M.D..”Acute Pancreatic Pseudocysts: Incidence and Implications” Annals of Surg. o December 1976, Vol. 184 . NO. 6,page no: 734-737
9. SIGNATURE OF THE CANDIDATE: (Dr. VINAYKUMAR TERADAL)
10. REMARKS OF THE GUIDE:
11. NAME AND DR. SHILPA
DESIGNATION OF HUCHHANNAVAR M.S 11.1 GUIDE D.N.B ASSOCIATE PROFESSOR DEPARTMENT OF GENERAL SURGERY KIMS HUBLI
11.2 SIGNATURE
11.3 CO.GUIDE (if any)
11.4 SIGNATURE
11.5 HEAD OF THE DR. B. S. MADAKATTI
DEPARTMENT: M.S.(Gen.Surgery) PROF. & HEAD OF THE DEPARTMENT, DEPARTMENT OF SURGERY, KIMS HUBLI
11.6 SIGNATURE 12. REMARKS OF THE CHAIRMAN & PRINCIPAL
13. SIGNATURE