Yavuz ÖZDEN, Göksel BENGİ, Funda BARLIK OBUZ, Canan ALTAY, Özgül SAĞOL, Anıl AYSAL AĞALAR, Tarkan ÜNEK, Müjde SOYTÜRK

Pankreatik psödokistlerde tanısal yöntemlerin performansı

Giriş ve Amaç: Pankreas kistik lezyonlarının tedavisini yönetmek çoğu zaman klinisyen için zordur. Bu nedenle ayırıcı tanı yapılması için öykü, klinik, laboratuvar, radyolojik görüntüleme, endoskopik ultrasonografi, endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi ile alınan kist sıvı analizi ve sitopatoloji verilerinin değerlendirilmesi önemlidir. Endoskopik ultrasonografi ile saptanan pankreatik psödokistlerin yönetiminde görüntüleme yöntemlerinin performansını ve endoskopik ultrasonografi eşliğinde endoskopik drenaj işlemi yaptığımız hastaların klinik özelliklerini çalışmamızda inceledik. Gereç ve Yöntem: Çalışmamızda Temmuz 2009-Ocak 2018 tarihleri arasında Dokuz Eylül Üniversitesi Tıp Fakültesi Hastanesi İç Hastalıkları Anabilim Dalı Gastroenteroloji Kliniği Endoskopi Ünitesinde pankreas kisti nedeniyle endoskopik ultrasonografi yapılan 18 yaş üstü hastalar retrospektif olarak değerlendirilmiştir. Endoskopik ultrasonografi ve/veya endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi değerlendirilmesi sonucu Atlanta klasifikasyonuna göre pankreatik psödokist tanısı alan 102 hasta çalışmaya dahil edilmiştir. Hastaların demografik verileri, klinik özellikleri, laboratuvar verileri, radyolojik/endoskopik ultrasonografi görüntü raporları ve patolojik inceleme sonuçları retrospektif olarak değerlendirilmiştir. Bulgular: Radyolojik açıdan pankreas kistlerini, psödokist olarak ayırma yüzdesi bilgisayarlı tomografi için %58.3, magnetik rezonans için %70.5, endoskopik ultrasonografi için %84.3, endoskopik ultrasonografi + ince iğne aspirasyon biyopsisi için ise %100 olarak saptanmıştır. Tanısal performans olarak bilgisayarlı tomografi %47.5, magnetik rezonans %63.1, endoskopik ultrasonografi %78.4, endoskopik ultrasonografi + ince iğne aspirasyon biyopsisi %95 olarak saptanmıştır. Pankreatik psödokist tanılı 102 hastadan, 36’sına drenaj işlemi uygulanmıştır. Drenaj işlemi uygulanan 36 hastanın, 35’inde tam rezolüsyon, 1 hastada kısmi rezolüsyon sağlanmıştır. Drenaj işlemi uygulanan ve uygulanmayan hastalar arasında yaş, cinsiyet, kistin lokalizasyonu, serum C reaktif protein, serum amilaz, kist amilaz, kist karsinoembriyonik antijeni, kist karbonhidrat antijen 19-9 düzeyleri kıyaslandığında anlamlı farklılık elde edilememiştir. Sonuç: Pankreatik psödokistlerin tanısında ve izleminde bilgisayarlı tomografi ve magnetik rezonansa kıyasla endoskopik ultrasonografi ve endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi daha yüksek tanısal duyarlılığa sahiptir. Buna rağmen %15’e varan oranda endoskopik ultrasonografi ve endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi neoplastik/benign kist ayrımını yapmada yeterli olamamaktadır. Günümüzde pankreatik psödokistlerde endoskopik drenaj zamanlaması ile ilgili bir fikir birliği bulunmamaktadır. Bizim uyguladığımız endoskopik ultrasonografi eşliğinde drenaj işlemlerindeki yüksek başarı ve düşük komplikasyon oranları bize hastaların büyük bir kısmı için bu yöntemin uygun olduğunu ve kabul edilebilir oranda risk taşıdığını göstermektedir

Anahtar Kelimeler:

Pankreatik kistik lezyon, pankreas psödokisti, endoskopik ultrasonografi, endoskopik drenaj

Performance of diagnostic methods in pancreatic pseudocyst

Background and Aims: Managing the treatment of pancreatic cystic lesions is often difficult for the clinician. Therefore, history, clinical, laboratory, radiological imaging, endoscopic ultrasound, cyst fluid analysis obtained by endoscopic ultrasound guided fine needle aspiration biopsy and cytopathology data are important for differential diagnosis. In our study, we examined the performance of imaging methods in the management of pancreatic pseudocysts detected by endoscopic ultrasound and the clinical characteristics of patients who underwent endoscopic drainage by endoscopic ultrasound. Materials and Method: In our study, patients over 18 years of age who underwent endoscopic ultrasound for pancreatic cysts in the Endoscopy Unit of Dokuz Eylül University Faculty of Medicine, Department of Internal Medicine/Gastroenterology Clinic between July 2009 and January 2018 were evaluated retrospectively. 102 patients with pre-diagnosis of pancreatic pseudocyst according to Atlanta Classification as a result of endoscopic ultrasound and/or endoscopic ultrasound guided fine needle aspiration biopsy evaluation, and 36 patients who underwent cystogastrostomy/cystoduodenostomy were included in the study. Demographic data, clinical characteristics, laboratory data, radiological/endoscopic ultrasound image reports and pathological examination results of the patients were evaluated retrospectively. Results: Radiologically, the percentage of separating pancreatic cysts as pseudocyst was 58.3% for computed tomography, 70.5% for magnetic resonance imaging, 84.3% for endoscopic ultrasound, and 100% for endoscopic ultrasound guided fine needle aspiration biopsy. Diagnostic performance was found to be 47.5% in computed tomography, 63.1% in magnetic resonance imaging, 78.4% in endoscopic ultrasound, and 95% in endoscopic ultrasound guided fine needle aspiration biopsy. Drainage procedure was applied to 36 of 102 patients with pancreatic pseudocyst. Complete resolution was achieved in 35 of 36 patients who underwent drainage procedure, and partial resolution was achieved in 1 patient. When the age, gender, localization of the cyst, serum C-reactive protein, serum amylase, cyst amylase, cyst carcinoembryonic antigen, cyst arbohydrate antigen 19-9 levels were compared, no significant difference was found between patients who underwent and did not undergo drainage. Conclusion: Compared to computed tomography and magnetic resonance imaging, endoscopic ultrasound and endoscopic ultrasound guided fine needle aspiration biopsy have higher diagnostic sensitivity in the diagnosis and follow-up of pancreatic pseudocysts. Despite this, up to 15% of endoscopic ultrasound and endoscopic ultrasound guided fine needle aspiration biopsy are not sufficient to differentiate between neoplastic/benign cysts. Today, there is no consensus on the timing of endoscopic drainage in pancreatic pseudocyst. The high success and low complication rates in our endoscopic ultrasound - guided drainage procedures show us that this method is suitable for most of the patients and carries an acceptable risk.

Keywords:

Pancreatic cystic lesion, pancreatic pseudocyst, endoscopic ultrasonography, endoscopic drainage,

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