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Pancreatic Cysts

Dr Thng Yongxian

Hepatopancreatobiliary & General Surgeon
MBBS • MMed • MRCS (IRE) • FRCSED • FAMS

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What Are Pancreatic Cysts?

Pancreatic cysts are fluid-filled sacs in the pancreas, a vital organ behind the stomach. The pancreas plays a crucial role in digestion and blood sugar regulation, producing enzymes that break down food and hormones such as insulin.

 

Pancreatic cysts can vary in size and type, ranging from benign cysts requiring minimal to no treatment to malignant cysts needing more aggressive management.

Types of Pancreatic Cysts

Pancreatic cysts are classified into several types based on their pathology and the potential for malignancy.

Pseudocysts

Pseudocysts are the most common type of pancreatic cysts, typically forming as a result of pancreatitis. These cysts are non-cancerous and are filled with fluid and debris from pancreatic enzymes. Pseudocysts do not contain an epithelial lining, distinguishing them from true cysts.

Serous Cystadenomas

Serous cystadenomas are benign cysts filled with a thin, watery fluid. They are usually not cancerous and tend to grow slowly. These cysts can occur anywhere in the pancreas and are more common in women than men.

Intraductal Papillary Mucinous Neoplasms (IPMNs)

IPMNs are a type of cyst that forms in the pancreatic ducts. They can either be main duct IPMNs, which have a higher risk of becoming cancerous, or branch duct IPMNs, which have a lower risk. These cysts produce mucin and can lead to blockage of the pancreatic duct.

Mucinous Cystadenomas

Mucinous cystadenomas are precancerous cysts that can potentially become cancerous if not appropriately managed. They are filled with thick, mucinous fluid and are more likely to occur in women.

Solid Pseudopapillary Neoplasms

Solid pseudopapillary neoplasms are rare pancreatic tumours that can become cancerous. They typically affect younger women and have a better prognosis than other pancreatic cancers when surgically removed early.

Causes and Risk Factors

  • Pancreatitis
    Pancreatitis, or pancreas inflammation, is a significant risk factor for developing pancreatic cysts, particularly pseudocysts. Both acute and chronic forms of pancreatitis can lead to cyst formation.
  • Genetic Predisposition
    Certain genetic mutations and hereditary conditions can increase the risk of developing pancreatic cysts, such as mutations in the PRSS1, SPINK1, or CFTR genes associated with pancreatitis.
  • Age and Gender
    The incidence of pancreatic cysts tends to increase with age, with most cases diagnosed in people over the age of 60. Some types of cysts are also more prevalent in women.
  • Smoking
    Smoking is a known risk factor for pancreatitis and pancreatic cancer. This highlights the importance of smoking cessation in reducing the risk of pancreatic disorders.
  • Alcohol Consumption Both long-standing type 2 diabetes and new-onset diabetes may be associated with pancreatic cancer.
  • Obesity
    Obesity is associated with an increased risk of pancreatitis and may indirectly influence the risk of developing pancreatic cysts through its impact on pancreatic health.
  • History of Abdominal Injury
    A history of abdominal trauma can lead to the development of pseudocysts as a result of pancreatic damage.

Symptoms

Pancreatic cysts often remain asymptomatic, especially in their early stages. However, when symptoms do occur, they can vary depending on the size, location, and type of the cyst.

  • Abdominal Pain
    Pain in the abdomen, particularly in the upper middle or upper left side, can occur if a cyst grows large enough to press on other structures in the abdomen.
  • Nausea and Vomiting
    Large cysts or cysts that obstruct the stomach or duodenum may cause nausea and vomiting, often exacerbated by eating.
  • Jaundice
    If a cyst compresses the common bile duct, obstructing bile flow, the skin and eyes may be yellowed.
  • Weight Loss
    Unintended weight loss can occur if a cyst interferes with digestion or appetite or as a general response to the body’s stress from the cyst.
  • Changes in Stool
    A cyst obstructing the digestive tract can lead to changes in stool, such as steatorrhea, where stools become oily or greasy due to fat malabsorption.
  • Palpable Mass
    Upon physical examination, a large cyst may be felt as a mass in the abdomen.
  • Diabetes
    Cysts that affect the endocrine function of the pancreas may contribute to the development of diabetes by impairing insulin production.

Diagnose

Imaging Studies

  • Computed Tomography (CT) Scan: A CT scan provides detailed cross-sectional images of the pancreas, helping to identify cysts, their size, and location.
  • Magnetic Resonance Imaging (MRI): MRI offers detailed images of the pancreas and surrounding structures, including the pancreatic ducts. This is useful for identifying types of cysts and their potential for malignancy.
  • Endoscopic Ultrasound (EUS): EUS involves using an endoscope equipped with an ultrasound device inserted through the mouth and into the stomach to obtain close-up images of the pancreas.

Cyst Fluid Analysis

Fluid obtained from a cyst during an EUS can be analysed for its chemical composition, cytology, and tumour markers. This analysis can help differentiate between benign and malignant cysts and identify specific types of cystic lesions.

Blood Tests

While blood tests alone cannot diagnose pancreatic cysts, they can provide information on the pancreas’s overall health and detect markers associated with inflammation or malignancy.

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Treatment Options

The treatment of pancreatic cysts is highly individualised, based on the type of cyst, its size, location, and whether it shows signs of cancer.

  • Observation and Monitoring
    For small, asymptomatic cysts with a low risk of malignancy, a conservative approach involving regular monitoring with MRI or CT scans is often recommended. This strategy helps to track any changes in the cyst’s size or appearance over time.
  • Endoscopic Treatment
    Certain types of cysts can be treated endoscopically. This may involve endoscopic ultrasound-guided drainage, where a needle is used to drain the cyst fluid, or the insertion of a stent to allow cysts to drain into the digestive tract.
  • Surgical Removal
    Surgery is considered for symptomatic cysts, growing or having a high risk of turning cancerous. The type of surgery depends on the cyst’s location and the condition of the surrounding pancreatic tissue.
  • Distal Pancreatectomy: This procedure involves removing the body and tail of the pancreas and is typically performed for cysts located in these areas. The spleen may also be removed if necessary.
  • Pancreaticoduodenectomy (Whipple Procedure): For cysts located in the head of the pancreas, a Whipple procedure may be performed. This involves removing the head of the pancreas, the first part of the small intestine, the gallbladder, and part of the bile duct, with reconnection of the remaining organs to allow digestion.
  • Enucleation: For smaller cysts that are well-defined and not deeply integrated into the pancreatic tissue, enucleation allows for the removal of the cyst while preserving the majority of the pancreatic tissue.

Complications Associated with Pancreatic Cysts

While many pancreatic cysts are benign and may not cause significant issues, some can lead to complications, such as:

Infection

Cysts can become infected, leading to pancreatitis or abscess formation. This requires prompt medical treatment, often including antibiotics and possibly surgical drainage.

Rupture

A cyst rupture is a serious condition that can lead to leakage of cyst contents into the abdominal cavity, potentially causing peritonitis (inflammation of the abdominal lining) and internal bleeding.

Pancreatitis

Cysts, especially those obstructing the pancreatic duct, can contribute to pancreatitis. This condition can be acute or chronic and may necessitate hospitalisation and intensive treatment.

Biliary Obstruction

Large cysts located near the bile duct can compress it, leading to obstructive jaundice. This may require surgical or endoscopic intervention to relieve the obstruction.

Dr Thng Yongxian

Senior Consultant

HEPATOPANCREATOBILIARY & GENERAL SURGEON

MBBS (SG) • MMed (Surg) • MRCS (Ire) • FRCSEd (Gen) • FAMS (Surg)

Dr Thng Yongxian is a dual fellowship-trained Hepatopancreatobiliary & General Surgeon who has performed over 6000 surgical procedures.

  • Bachelor of Medicine & Bachelor of Surgery
  • National University of Singapore
  • Membership of the Royal College of Surgeons, Ireland
  • Master of Medicine, General Surgery, Singapore
  • Fellow of the Royal College of Surgeons, Edinburgh
  • Fellow of the Academy of Medicine, Singapore

He pursued his subspecialty training in Hepatopancreatobiliary surgery first in the Department of Hepatopancreatobiliary Surgery, Singapore General Hospital. Following this, he completed a clinical fellowship in Minimally Invasive Hepatopancreatobiliary Surgery at Seoul National University Hospital in Bundang, South Korea.


Dr Thng set up and pioneered the Minimally invasive surgery program for his hospital in complex liver and pancreas cases. His surgeries were featured on live national television. His surgical videos have also been presented at international surgical conferences. He also pioneered the use of capsule colonoscopy for colorectal screening.


Dr Thng has served on various committees at hospital, cluster and ministry level. Dr Thng served as a member of the Ministry of Health (MOH) Laparoscopic cholecystectomy Clinician workgroup for value-driven care (VDC).

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Nexus Surgical @ Mt. Alvernia

Nexus Surgical @ Mt. Elizabeth Orchard

Nexus Surgical @ Mt. Elizabeth Novena

Nexus Surgical @ Parkway East

Nexus Surgical @ Gleneagles Medical Centre

Nexus Surgical @ Mt. Alvernia

Nexus Surgical @ Mt. Elizabeth Orchard

Nexus Surgical @ Mt. Elizabeth Novena

Nexus Surgical @ Parkway East

Nexus Surgical @ Gleneagles Medical Centre

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