85 year old gentleman, previous CABG (current cardiac status deemed satisfactory by cardiologist), cholecystolithiasis on USG, 2 episodes of abdominal pain in the last month - first episode was with normal LFTs, settled with conservative management, second episode was with deranged LFTs (obstructive pattern), again settled with conservative management. MRCP done after the second episode showed normal CBD (probably a passed stone), but an incidental note of 1.5 cm cystic lesion in head of pancreas - ? IPMN.
What would be your treatment approach?
Normally needs CA19-9 and EUS assessment and aspiration cytology and proceed with Lap chole.Repeat LFT after one week.However in this case as the cyst is small,elderly age group with coronary artery disease and post CABG,you should go ahead with Lap chole.
Laparoscopic cholecystectomy must be performed. A 1.5cm cyst ("suspicious" of IPMN) at 85 years can be followed-up if CA 29-9 and CEA are normal. After cholecystectomy, you can do more explorations if the patient accepts (EUS with cyst analysis), or wait and do this if the cyst is enlarged at next visit.
Assessment of cyst nature by EUS and aspiration of the cyst and doing tumor markers(CA19-9, CEA) in the contents and the serum, if benign proceed with LC, if malignant, prepare for whipple after good patient preparation
Should probably have an EUS at some point provided the managemebt of the patiet would be changed by the results (ie they would he fit enought for surgery). Given likely passed cbd stone should he considered for lap chole if fit.
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