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Jivani A, Shinde RK, Nagtode T, Vaidya K, Goel S. The Surgical Management of Pancreatic Pseudocysts: A Narrative Review. Cureus 2024; 16:e69055. [PMID: 39391462 PMCID: PMC11465202 DOI: 10.7759/cureus.69055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 09/10/2024] [Indexed: 10/12/2024] Open
Abstract
Pancreatic pseudocysts, commonly arising as a complication of acute or chronic pancreatitis, present a significant clinical challenge. This narrative review explores the surgical management of pancreatic pseudocysts, emphasizing advancements, techniques, and outcomes. We examine the indications for surgical intervention, including symptomatic pseudocysts, complications such as infection or hemorrhage, and pseudocysts resistant to conservative treatment. Various surgical approaches are discussed, including open surgery, laparoscopic techniques, and endoscopic interventions. The review highlights the evolution of surgical strategies, from traditional cystogastrostomy to minimally invasive methods, and assesses their efficacy and safety. Additionally, we address patient selection criteria, preoperative assessment, and postoperative care. By synthesizing current evidence and clinical experiences, this review aims to provide a comprehensive overview of the best practices in the surgical management of pancreatic pseudocysts, offering valuable insights for clinicians in optimizing patient outcomes.
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Affiliation(s)
- Ashish Jivani
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Raju K Shinde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tushar Nagtode
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Khushbu Vaidya
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Somya Goel
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Latif J, Creedon L, Mistry P, Thurley P, Bhatti I, Awan A. Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach. J Gastrointest Surg 2022; 26:1686-1696. [PMID: 35581460 DOI: 10.1007/s11605-022-05350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP. MATERIALS AND METHODS A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution. RESULTS Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years. CONCLUSION Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.
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Affiliation(s)
- Javed Latif
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - Lee Creedon
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Pritesh Mistry
- Department of Upper Gastro-Intestinal Surgery, Countess of Chester Hospital, Liverpool Road, Liverpool Road, Chester, CH2 1UL, UK
| | - Peter Thurley
- Department of Interventional & Clinical Radiology, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Imran Bhatti
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Altaf Awan
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
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Laparoscopic Intervention to Pancreatic Pseudocyst Confers Short-Term Benefits: A Meta-Analysis. Emerg Med Int 2021; 2021:7586338. [PMID: 34840827 PMCID: PMC8612789 DOI: 10.1155/2021/7586338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background Surgical interventions for pancreatic pseudocyst (PP) are traditionally managed by an open surgical approach. With the development of minimally invasive surgical techniques, a laparoscopic surgical approach for PPs has been conducted increasingly with comparable outcomes. The present study was conducted to compare the efficacy and safety of surgical intervention for PPs between the laparoscopic approach and the open approach. Methods Databases including Cochrane Library, PubMed, and EMBASE were searched to identify studies that compared the safety and efficacy of surgical intervention for PPs between the laparoscopic approach and the open approach (until Aug 1st 2020). Results A total of 6 studies were eligible in qualitative synthesis. The laparoscopic approach was associated with less intraoperative blood loss (MD = -69.97; 95% CI: -95.14 to -44.70, P < 0.00001; P=0.86 for heterogeneity) and shorter operating time (MD = -33.12; 95% CI: -62.24 to -4.00, P=0.03; P < 0.00001 for heterogeneity). There was no significant difference found between the two approaches regarding the success rate and the recurrence rate. The postoperative complications and mortality rates were comparable between the two approaches. Conclusions The laparoscopic approach for the surgical intervention of PPs is safe and efficacious with shorter-term benefits.
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Hao W, Chen Y, Jiang Y, Yang A. Endoscopic Versus Laparoscopic Treatment for Pancreatic Pseudocysts: A Systematic Review and Meta-analysis. Pancreas 2021; 50:788-795. [PMID: 34347721 PMCID: PMC8376268 DOI: 10.1097/mpa.0000000000001863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/21/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate the efficacy and safety of endoscopic treatment for pancreatic pseudocysts (PPCs) compared with laparoscopic treatment. METHODS The Embase, Medline, Cochrane Library, Web of Science databases, China National Knowledge Infrastructure Chinese citation database, and WANFANG database were systematically searched to identify all comparative trials investigating endoscopic versus laparoscopic treatment for PPC. The main outcome measures included treatment success rate, adverse events, recurrence rate, operation time, intraoperative blood loss, and hospital stay. RESULTS Six studies with 301 participants were included. The results suggested that there was no difference in rates of treatment success (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.40-2.01; P = 0.79), adverse events (OR, 0.80, 95% CI, 0.38-1.70; P = 0.57), or recurrence (OR, 0.55, 95% CI, 0.22-1.40; P = 0.21) between endoscopic and laparoscopic treatments. However, the endoscopic group exhibited reduced operation time (weighted mean difference [WMD], -67.11; 95% CI, -77.27 to -56.96; P < 0.001), intraoperative blood loss (WMD, -65.23; 95% CI, -103.38 to -27.08; P < 0.001), and hospital stay (WMD, -2.45; 95% CI, -4.74 to -0.16; P = 0.04). CONCLUSIONS Endoscopic treatment might be suitable for PPC patients.
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Affiliation(s)
| | - Yunli Chen
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yu Jiang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Aiming Yang
- From the Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
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Badgurjar MK, Mandovra P, Mathur SK, Patankar R. Laparoscopic loop cystojejunostomy: An alternative to Roux-en-Y cystojejunostomy for pancreatic pseudocyst. J Minim Access Surg 2021; 17:221-225. [PMID: 32964880 PMCID: PMC8083751 DOI: 10.4103/jmas.jmas_73_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Surgical internal drainage of pancreatic pseudocyst can be done into the stomach, duodenum or jejunum depending on the anatomic relation of pseudocyst with hollow viscera. For cystojejunostomy, a Roux-en-Y loop is preferred over loop cystojejunostomy as former is thought to avoid the reflux of jejunal contents into the cyst cavity. This study presents our experience with laparoscopic loop cystojejunostomy showing loop cystojejunostomy for the pseudocyst of the pancreas can be safely performed laparoscopically with simpler technique with no complications including reflux.
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Affiliation(s)
- Mohit K Badgurjar
- Department of Digestive Diseases, Zen Multispecialty Hospital, Mumbai, Maharashtra, India
| | - Pranav Mandovra
- Department of Digestive Diseases, Zen Multispecialty Hospital, Mumbai, Maharashtra, India
| | - Surendra K Mathur
- Department of Digestive Diseases, Zen Multispecialty Hospital, Mumbai, Maharashtra, India
| | - Roy Patankar
- Department of Digestive Diseases, Zen Multispecialty Hospital, Mumbai, Maharashtra, India
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Suggs P, NeCamp T, Carr JA. A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients. ANNALS OF SURGERY OPEN 2020; 1:e024. [PMID: 37637446 PMCID: PMC10455460 DOI: 10.1097/as9.0000000000000024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
Objective To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis. Summary Background Data Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods. Methods A meta-analysis of 5500 patients. Results Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods. Conclusions In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.
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Affiliation(s)
- Patrick Suggs
- From the The Department of General Surgery, St. Joseph Mercy Medical Center, Ann Arbor, MI
| | - Timothy NeCamp
- The Department of Statistics, University of Michigan, Ann Arbor, MI
| | - John Alfred Carr
- The Department of Trauma Surgery, Mid-Michigan Medical Center, Midland, MI
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Gupta R, Singh AK, Verma P. Acute Small Bowel Obstruction Secondary to a Pancreatic Pseudocyst. Indian J Surg 2019; 81:391-393. [DOI: 10.1007/s12262-018-1845-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022] Open
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Garg PK, Meena D, Babu D, Padhan RK, Dhingra R, Krishna A, Kumar S, Misra MC, Bansal VK. Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial. Surg Endosc 2019; 34:1157-1166. [PMID: 31140002 DOI: 10.1007/s00464-019-06866-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP. PATIENTS AND METHODS Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications. RESULTS Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention. CONCLUSIONS Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.
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Affiliation(s)
- Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Danishwar Meena
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Divya Babu
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Kumar Padhan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajan Dhingra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Asuri Krishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Mahesh Chandra Misra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
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Kaushal-Deep SM, Singh V, Mani R, Gupta P, Lodi M. Negotiating the Curve of Laparoscopic Hepatopancreaticobiliary Procedures (Basic to Advanced) at a Tertiary Rural Teaching Institute. Int J Appl Basic Med Res 2019; 8:237-243. [PMID: 30598911 PMCID: PMC6259292 DOI: 10.4103/ijabmr.ijabmr_399_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: We present here our experience of laparoscopic hepatopancreaticobiliary (HPB) surgeries at our rural institute and the hurdles we faced overcoming the various challenges. Aims and Objectives: The objectives of this study were to assess the feasibility, successful completion, operative time, conversions/requirement of assistance, duration of hospital stay, and postoperative complications on the HPB procedures performed laparoscopically in our surgical unit; and to help young surgeons for smooth navigation through their laparoscopic career. Materials and Methods: All the patients admitted under our unit over the past 9 years for elective HPB surgeries operated by a single surgeon were included in this study. Results: Total 1304 basic laparoscopic biliary procedures were successfully completed laparoscopically. After getting well versed with the standard procedure, we switched over to difficult cases involving densely adhered gallbladder, frozen Calot's, Mirizzi's syndrome, use of intraoperative cholangiogram, and take down of cholecystoduodenal fistulas. Next step in evolution was doing laparoscopic common bile duct exploration and biliary procedures with decreased number of ports. Five hundred and sixty-eight procedures were advanced HPB surgeries. With time, we also started performing a variety of complex advanced laparoscopic procedures such as cystogastrostomy, hepaticojejunostomy, choledochoduodenostomy, and pancreaticojejunostomy. All these procedures have been discussed with respect to operative duration, conversion rates, blood loss, hospital stay, and complication rates in the initial and later parts of the learning curves and further compared with previous standard large case studies on specific surgeries. Conclusion: Several hurdles are met in a new institute, that too, a rural one. The present discussion will help the budding surgeons to identify their deficiencies and chart a way forward in a systematic scientific manner.
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Affiliation(s)
| | - Vikas Singh
- Department of Surgery, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India
| | - Rudra Mani
- Department of Surgery, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India
| | - Poonam Gupta
- Department of Surgery, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India
| | - Mehershree Lodi
- Department of Anesthesia, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Costi R, Zarzavadjian Le Bian A, Mita MT, Brou Fulgence Kassi A, Sarli L, Violi V. Delayed, diffuse acute peritonitis secondary to misplacement of a cystogastrostomic "pigtail" drain in an outpatient after discharge. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:254-259. [PMID: 29957760 PMCID: PMC6179022 DOI: 10.23750/abm.v89i2.6721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 08/31/2017] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: Pancreatic pseudocyst endoscopic drainage by pancreatogastrostomy “pigtail” drain placement is spreading worldwide, with high success-rate and low morbidity, and is increasingly performed as outpatient procedure. The paper reports an unusual very early complication of this procedure and discusses the peculiar aspects of this event in an outpatient setting. Methods: The first case of a 56-year-old outpatient developing a postoperative diffused acute peritonitis by gastric juice spilling caused by the misplacement of the distal end of two transgastric drains not reaching the pseudocyst is reported. As the case was programmed as outpatient and acute peritonitis symptoms occurred eight hours postoperatively, the patient was discharged and rehospitalized. A review of the literature of rare perforative complications of pancreatogastrostomy is performed. Results: CT scan allowed the prompt diagnosis, as it showed massive pneumoperitoneum, free fluid collection, and pigtail drain misplacement. Emergency laparoscopy allowed the removal of the two misplaced drains and gastric reparation. The procedure lasted 65 minutes, mostly needed for lavage. The patient was discharged 5 days later and outcomes are unremarkable 7 months after the procedure. Conclusion: The indication to endoscopic pancreatogastrostomy and its outpatient management should be carefully pondered. Pancreogastrostomy drain misplacement may cause a life-threatening acute peritonitis associated with early aspecific symptoms, resulting in a challenging situation, especially in an outpatient setting. CT-scan may allow prompt diagnosis and effective management by minimally invasive surgery. (www.actabiomedica.it)
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Affiliation(s)
- Renato Costi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, Italia; and Service de Chirurgie Digestive, Hôpital "Simone Veil", Eaubonne, France..
| | | | - Maria Teresa Mita
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, Italia.
| | | | - Leopoldo Sarli
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, Italia.
| | - Vincenzo Violi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, Italia.
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Abstract
Open surgical intervention for treatment of simple pancreatic pseuodocyst (PP) has a high success rate and has been the historical gold standard. Open surgical intervention, however, confers significant morbidity and mortality, which has spurred the development of less invasive techniques. Laparoscopic approaches are feasible with the potential for lower complication rates and length of stay. The endoscopic approach has the appeal of potentially shorter hospitalization length of stays and does not require general anesthesia. Complicated PPs or those that arise in the setting of chronic pancreatitis warrant additional workup and special consideration.
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Affiliation(s)
- Lea Matsuoka
- Department of Surgery, Vanderbilt University, 801 Oxford House, 1313 21st Avenue South, Nashville, TN 37232, USA.
| | - Sophoclis P Alexopoulos
- Department of Surgery, Vanderbilt University, 801 Oxford House, 1313 21st Avenue South, Nashville, TN 37232, USA
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Effect of endoscopic failure on the results of internal surgical drainage in pancreatic pseudocyst. J Surg Res 2018; 223:1-7. [PMID: 29433859 DOI: 10.1016/j.jss.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of pancreatic pseudocysts has evolved during the past two decades. Endoscopic treatment (ET) has gradually become used as a first-line management even though it showed no significant superiority to surgical internal drainages (SIDs) in a recent randomized trial. The objective of the present work was to analyze the effect of ET failure on the results of SID in the global management of pancreatic pseudocysts. METHODS A multicenter retrospective study (Clichy, Bordeaux, Nantes, and Rennes) was conducted between January 2000 and December 2012. The main criteria were as follows: (i) major postoperative complications (MPCs) (Clavien ≥ 3) and (ii) treatment failure in the first 12 mo. All factors that may affect these two parameters were tested in univariate and multivariate analyses, when necessary. RESULTS One hundred nineteen patients, with a median age of 52 y (22-83) underwent SID, including 45 procedures (37.8%) performed after ET failure. Mortality and overall morbidity rates were 1.7% and 30.2%, respectively. Eighteen patients (15.1%) presented an MPC. Multivariate analysis revealed that failure of ET (odds ratio 3.04, confidence interval [1.04 to 9.5], P = 0.046) and BMI ≤20 (odds ratio 4.5, confidence interval [1.50; 15.5], P = 0.010) were independent risk factors of MPCs. The success of SID was 92.5% in the first year. In univariate analysis, the occurrence of an MPC was the only factor linked to the failure of SID (P = 0.029). CONCLUSIONS Performing an SID after ET failure is associated with an increased risk of MPC. Close postoperative monitoring is recommended for these patients.
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Treatment of retrogastric pancreatic pseudocysts by laparoscopic transgastric cystogastrostomy. Curr Med Sci 2017; 37:726-731. [PMID: 29058286 DOI: 10.1007/s11596-017-1795-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 07/31/2017] [Indexed: 01/03/2023]
Abstract
This paper discusses variations of laparoscopic transgastric cystogastrostomy in management of retrogastric pancreatic pseudocysts for 8 patients with symptom or pseudocysts (larger than 6 cm) companied with clinical manifestations. Using a Harmonic scalpel, two 3-5-cm incisions were made in the anterior and posterior gastric wall respectively. In the last step, the anterior gastrotomy was closed with an Endo-GIA stapler. All cases were successfully treated without large blood loss and without conversion to open surgery. The mean operative time was 114.29±19.24 min, blood loss was 157.14±78.70 mL, and mean hospital stay was 8.29±2.98 days. Gastric fistula occurred in one case on the postoperative day 7, and closed 1 month later. No bleeding was seen in all patients during the perioperative follow-up period. CT scans, given one month after the surgeries, displayed that the pancreatic pseudocysts disappeared or decreased in size, and ultrasounds showed no fluid or food residue in stomas at the third and fifth month following surgery. No patient experienced a recurrence during the follow-up period. Transgastric laparoscopic cystogastrostomy is a minimally invasive surgical procedure with a high rate of success and a low rate of recurrence, accompanied by rapid recovery. It is easy to master, safe to perform and may be the preferred option to treat retrogastric pancreatic pseudocysts.
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Abstract
The aim of this study was to compare operative versus nonoperative management of blunt pancreatic trauma in children. A systematic literature search was performed. Studies including children with blunt pancreatic injuries classified according to the American Association for the Surgery of Trauma classification were included. The primary outcome was pseudocyst formation. After screening 526 studies, 23 studies with 928 patients were included. Sufficient data were available for 674 patients (73%). Of 309 patients with grade I or II injuries, 258 (83%) were initially managed nonoperatively with a 96% success rate. Of 365 patients with grade III, IV, or V injuries, nonoperative management was initially chosen for 167 patients (46%) with an 89% success rate. Pseudocysts occurred in 18% of patients managed nonoperatively versus 4% of patients managed operatively (P < 0.01), of whom 65% were treated nonoperatively. Hospitalization was 20.5 days after nonoperative versus 15.1 days after operative management (nonparametric t test, P = 0.41). Blunt pancreatic trauma in children can be managed nonoperatively in the majority of patients with grade I or II injuries and in about half of the patients with grade III to V injuries. Although pseudocysts are more common after nonoperative management, two thirds can be managed nonoperatively.
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Redwan AA, Hamad MA, Omar MA. Pancreatic Pseudocyst Dilemma: Cumulative Multicenter Experience in Management Using Endoscopy, Laparoscopy, and Open Surgery. J Laparoendosc Adv Surg Tech A 2017; 27:1022-1030. [PMID: 28459653 DOI: 10.1089/lap.2017.0006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pancreatic pseudocyst (PP) is the commonest cystic lesion of the pancreas. Internal drainage of PPs can be accomplished by traditional open or recently by minimally invasive laparoscopic or endoscopic approaches. We aimed to evaluate and compare the clinical outcomes after endoscopic, laparoscopic, and open drainage. METHODS Seventy-one patients with PP underwent endoscopic (n = 35), laparoscopic (n = 4), and open surgical drainage (n = 32). The primary outcome was the success rate. The secondary outcomes were the estimated blood loss, operative time, opioid requirement, morbidity and mortality, length of hospital stay, and recurrence rate. RESULTS The primary success rate was significantly higher for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups. There were no significant differences in the morbidity, mortality, requirement of blood transfusion, reinterventions, and recurrence rate between the groups. Endoscopic drainage revealed significantly lower blood loss, operative time, opioid requirement, and hospital stay in comparison to open and laparoscopic drainage. CONCLUSION Minimally invasive therapeutic techniques, whether endoscopic or laparoscopic for treatment of PP could be considered valuable, competitive, and promising alternatives for open surgery. Moreover, it is less invasive with less hospitalization and rapid return to work.
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Affiliation(s)
- Alaa A Redwan
- 1 Department of General Surgery, Sohag University , Sohag, Egypt
| | - Mostafa A Hamad
- 2 Department of General Surgery, Assiut University , Assiut, Egypt
| | - Mohammed A Omar
- 3 Department of General Surgery, Qena Faculty of Medicine, South Valley University , Qena, Egypt
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Doussot A, Perrin T, Rat P, Facy O. Robotic-assisted Roux-en-Y cystojejunostomy for pancreatic pseudocyst (with video). J Visc Surg 2016; 153:385-386. [PMID: 27618700 DOI: 10.1016/j.jviscsurg.2016.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- A Doussot
- Service de chirurgie digestive et cancérologique, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon cedex, France
| | - T Perrin
- Service de chirurgie digestive et cancérologique, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon cedex, France
| | - P Rat
- Service de chirurgie digestive et cancérologique, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon cedex, France
| | - O Facy
- Service de chirurgie digestive et cancérologique, CHU de Dijon, 14, rue Gaffarel, 21079 Dijon cedex, France.
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Dedemadi G, Nikolopoulos M, Kalaitzopoulos I, Sgourakis G. Management of patients after recovering from acute severe biliary pancreatitis. World J Gastroenterol 2016; 22:7708-7717. [PMID: 27678352 PMCID: PMC5016369 DOI: 10.3748/wjg.v22.i34.7708] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Cholelithiasis is the most common cause of acute pancreatitis, accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned, the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management, including cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process, usually not earlier than 6 wk after onset of acute pancreatitis, seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed, but if used for definitive treatment, they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques, if not therapeutic, can be used as a bridge to definitive operative treatment, which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.
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Fernandes E, Giulianotti PC. Robotic-assisted pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 20:583-9. [PMID: 23588851 DOI: 10.1007/s00534-013-0615-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Pancreatic surgery is a challenging application of minimally invasive surgery. Due to the complexity of the surgical technique, requiring dissection along major abdominal vessels as well as delicate reconstruction involving biliary, pancreatic and enteric anastomoses, reports on laparoscopic pancreatic surgery have been scanty. With the advent of robotic-assisted surgery, however, the increased dexterity granted by endo-wristed instruments, the improved three-dimensional vision and the computer filtration of the surgeon's movements have brought minimally invasive pancreatic surgery into a new era. METHODS As the surgical group which has performed the highest number of robotic-assisted pancreatic procedures worldwide, we review the state of the art of minimally invasive robotic-assisted pancreatic surgery. Clinical results from all major robotic-assisted pancreatic surgery series are considered. RESULTS Preliminary reports from the published major pancreatic surgery series show encouraging results, with morbidity and mortality comparable to open surgery. Preliminary data on cancer survival rates also appear to be similar to open series. CONCLUSION Robotic-assisted pancreatic surgery is safe and feasible for all pancreatic diseases. The complexity of pancreatic procedures warrant them to be carried out in specialised centres, where short- and long-term outcomes seem to be similar to the ones achieved in open surgery.
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Affiliation(s)
- E Fernandes
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 South Wood Street, Chicago, IL, 60612, USA.
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Crisanto-Campos BA, Arce-Liévano E, Cárdenas-Lailson LE, Romero-Loera LS, Rojano-Rodríguez ME, Gallardo-Ramírez MA, Cabral-Oliver J, Moreno-Portillo M. Laparoscopic management of pancreatic pseudocysts: experience at a general hospital in Mexico City. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 80:198-204. [PMID: 26249139 DOI: 10.1016/j.rgmx.2015.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/21/2015] [Accepted: 05/28/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Invasive management of pancreatic pseudocysts (PP) is currently indicated in those patients with symptoms or complications. Treatment options are classified as surgical (open and laparoscopic) and non-surgical (endoscopic and radiologic). AIM To describe the morbidity, mortality, and efficacy in terms of technical and clinical success of the laparoscopic surgical approach in the treatment of patients with PP in the last 3 years at our hospital center. METHODS We included patients with PP treated with laparoscopic surgery within the time frame of January 2012 and December 2014. The morbidity and mortality associated with the procedure were determined, together with the postoperative results in terms of effectiveness and recurrence. RESULTS A total of 38 patients were diagnosed with PP within the last 3 years, but only 20 of them had invasive treatment. Laparoscopic surgery was performed on 17 of those patients (mean pseudocyst diameter of 15.3, primary drainage success rate of 94.1%, complication rate of 5.9%, and a 40-month follow-up). CONCLUSIONS The results obtained with the laparoscopic technique used at our hospital center showed that this approach is feasible, efficacious, and safe. Thus, performed by skilled surgeons, it should be considered a treatment option for patients with PP.
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Affiliation(s)
- B A Crisanto-Campos
- Clínica de Cirugía Hepatobiliar y Pancreática del Departamento de Cirugía General, Cirugía Endoscópica y Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México.
| | - E Arce-Liévano
- Departamento de Cirugía Endoscópica, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
| | - L E Cárdenas-Lailson
- Clínica de Cirugía Hepatobiliar y Pancreática del Departamento de Cirugía General, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
| | - L S Romero-Loera
- Departamento de Cirugía General, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
| | - M E Rojano-Rodríguez
- Departamento de Cirugía Endoscópica y Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
| | - M A Gallardo-Ramírez
- Departamento de Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
| | - J Cabral-Oliver
- Departamento de Cirugía Bariátrica, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
| | - M Moreno-Portillo
- Departamento de Cirugía Endoscópica y Endoscopia Gastrointestinal, Hospital General Dr. Manuel Gea González, Secretaría de Salud, México, D.F., México
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Urgent laparoscopic gastrocystostomy after iatrogenic perforation of pancreatic cyst - case report and literature review. Wideochir Inne Tech Maloinwazyjne 2015; 10:328-31. [PMID: 26240638 PMCID: PMC4520832 DOI: 10.5114/wiitm.2015.49248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 12/18/2014] [Accepted: 12/23/2014] [Indexed: 11/18/2022] Open
Abstract
Pancreatic cysts, a common complication of pancreatitis, often require invasive treatment. When possible, endoscopic technique tends to be the procedure of choice. Despite its advantages, most of its complications may require immediate surgical assistance. Experienced surgeons tend to choose a laparoscopic approach bearing in mind its advantages. We present a case of a 71-year-old patient with an idiopathic pancreatic cyst, causing chronic epigastric pain. The attempt of endoscopic drainage led to iatrogenic perforation, which was successfully managed by laparoscopic posterior gastrocystostomy. The postoperative course was uneventful. In our opinion, laparoscopy should always be considered to manage complications caused by endoscopic drainage of a pancreatic pseudocyst.
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Khreiss M, Zenati M, Clifford A, Lee KK, Hogg ME, Slivka A, Chennat J, Gelrud A, Zeh HJ, Papachristou GI, Zureikat AH. Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center. J Gastrointest Surg 2015; 19:1441-8. [PMID: 26033038 DOI: 10.1007/s11605-015-2864-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center. METHOD This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared. RESULTS Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups. CONCLUSION Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.
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Affiliation(s)
- Mohammad Khreiss
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Laparoscopic management of pancreatic pseudocysts: experience at a general hospital in Mexico City. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2015. [DOI: 10.1016/j.rgmxen.2015.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Lu QW, Qin MF, Sun XY. A case of endoscopic ultrasound guided transgastric and transpapillary pancreatic pseudocyst drainage. Shijie Huaren Xiaohua Zazhi 2015; 23:2839-2842. [DOI: 10.11569/wcjd.v23.i17.2839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) guided transgastric or transpapillary pancreatic pseudocyst (PPC) drainage is safe and effective in treating PPC and can therefore be a preferred therapeutic approach, which is now replacing other conventional therapies. However, pseudocysts existing simultaneously in the head and the body and tail of the pancreas are uncommon, and this paper presents such a case to improve the awareness of the approach in treating PPC.
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Zerem E, Hauser G, Loga-Zec S, Kunosić S, Jovanović P, Crnkić D. Minimally invasive treatment of pancreatic pseudocysts. World J Gastroenterol 2015; 21:6850-6860. [PMID: 26078561 PMCID: PMC4462725 DOI: 10.3748/wjg.v21.i22.6850] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/29/2015] [Accepted: 04/28/2015] [Indexed: 02/07/2023] Open
Abstract
A pancreatic pseudocyst (PPC) is typically a complication of acute and chronic pancreatitis, trauma or pancreatic duct obstruction. The diagnosis of PPC can be made if an acute fluid collection persists for 4 to 6 wk and is enveloped by a distinct wall. Most PPCs regress spontaneously and require no treatment, whereas some may persist and progress until complications occur. The decision whether to treat a patient who has a PPC, as well as when and with what treatment modalities, is a difficult one. PPCs can be treated with a variety of methods: percutaneous catheter drainage (PCD), endoscopic transpapillary or transmural drainage, laparoscopic surgery, or open pseudocystoenterostomy. The recent trend in the management of symptomatic PPC has moved toward less invasive approaches such as endoscopic- and image-guided PCD. The endoscopic approach is suitable because most PPCs lie adjacent to the stomach. The major advantage of the endoscopic approach is that it creates a permanent pseudocysto-gastric track with no spillage of pancreatic enzymes. However, given the drainage problems, the monitoring, catheter manipulation and the analysis of cystic content are very difficult or impossible to perform endoscopically, unlike in the PCD approach. Several conditions must be met to achieve the complete obliteration of the cyst cavity. Pancreatic duct anatomy is an important factor in the prognosis of the treatment outcome, and the recovery of disrupted pancreatic ducts is the main prognostic factor for successful treatment of PPC, regardless of the treatment method used. In this article, we review and evaluate the minimally invasive approaches in the management of PPCs.
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25
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Menon P, Rao KLN. Novel use of gelatine sponge as primary dressing in Hypospadias surgery. J Indian Assoc Pediatr Surg 2015; 20:54. [PMID: 25552839 PMCID: PMC4268764 DOI: 10.4103/0971-9261.145568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Prema Menon
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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26
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Hollemans RA, van Brunschot S, Bakker OJ, Bollen TL, Timmer R, Besselink MGH, van Santvoort HC. Minimally invasive intervention for infected necrosis in acute pancreatitis. Expert Rev Med Devices 2014; 11:637-48. [DOI: 10.1586/17434440.2014.947271] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Khaled YS, Malde DJ, Packer J, Fox T, Laftsidis P, Ajala-Agbo T, De Liguori Carino N, Deshpande R, O'Reilly DA, Sherlock DJ, Ammori BJ. Laparoscopic versus open cystgastrostomy for pancreatic pseudocysts: a case-matched comparative study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:818-23. [PMID: 25082571 DOI: 10.1002/jhbp.138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cystgastrostomy is the commonest method of internal drainage of pancreatic pseudocysts (PPs). While large and persistent retrogastric pancreatic pseudocysts are amenable to laparoscopic cystgastrostomy, the potential benefits of this minimally invasive laparoscopic approach over open surgery remain to be demonstrated. The aim of this study was to compare the outcomes of the laparoscopic and open approaches for cystgastrostomy. METHODS Patients who underwent laparoscopic cystgastrostomy (LCG) were matched on a 3:1 basis to those who underwent open cystgastrostomy (OCG) according to age, sex distribution, and size of pseudocyst. The outcomes of the two approaches were compared on an intention-to-treat basis. Data shown represent medians. RESULTS A total of 54 patients underwent cystgastrostomy (35 LCG, 19 OCG) between 1997 and 2011. The final case matched cohort consisted of 40 patients (12 female and 28 male) of which 30 underwent LCG (two converted to open surgery) and 10 underwent OCG. The laparoscopic and open groups were comparable for age (55 vs. 59 years, P = 0.80), sex distribution, and size of pseudocyst (10 vs. 13 cm, P = 0.51). The laparoscopic approach had a significantly shorter operating time (62 vs. 95 min, P = 0.035) and carried a significantly lower risk of postoperative morbidity (10% vs. 60%, P = 0.024) and shorter postoperative hospital stay (6.2 vs. 11 days, P = 0.038). There was one operative death after OCG (10%). CONCLUSION The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a shorter operating time, smoother and more rapid recovery, and a shorter hospital stay compared with open surgery. The laparoscopic approach should be considered the preferable approach where expertise is available.
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Affiliation(s)
- Yazan S Khaled
- Hepato-Pancreato-Biliary Unit, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester, M8 5RB, UK; The University of Manchester, Manchester, UK
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Surgical transgastric debridement of walled off pancreatic necrosis: an option for patients with necrotizing pancreatitis. Surg Endosc 2014; 29:575-82. [DOI: 10.1007/s00464-014-3700-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/22/2014] [Indexed: 12/15/2022]
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Gibson SC, Robertson BF, Dickson EJ, McKay CJ, Carter CR. 'Step-port' laparoscopic cystgastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis. HPB (Oxford) 2014; 16:170-6. [PMID: 23551864 PMCID: PMC3921013 DOI: 10.1111/hpb.12099] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/11/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-acute pancreatic collections (PAPCs) may require intervention when persistent, large or symptomatic. An open cystgastrostomy is an effective treatment option particularly for larger, solid predominant collections. A laparoscopic cystgastrostomy (LCG) as initially described, could be technically challenging. This report describes the evolution of the operative technique and the results from LCG in a tertiary referral centre. METHODS Retrospective analysis of the unit's prospectively populated database was conducted. All patients who underwent a surgical cystgastrostomy (SCG) were identified. Patient demographics, outcome and complications were collected and analysed. RESULTS Forty-four patients underwent SCG: 8 open and 36 laparoscopic. Of the 36 LCG, 6 required open conversion, although with evolution of the technique all of the last 17 cases were completed laparoscopically. The median interquartile range (IQR) length of stay in patients completed laparoscopically was 6 (2-10) compared with 15.5 days (8-19) in those patients who were converted (P = 0.0351). The only peri-operative complication after a LCG was a self-limiting upper gastrointestinal bleed. With a median (IQR) follow-up of 891 days (527-1495) one patient required re-intervention for a residual collection with no recurrent collections identified. CONCLUSION LCG is a safe and effective procedure in patients with large, solid predominant PAPCs. With increased experience and technical expertise conversion rates can be lowered and outcome optimized.
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Affiliation(s)
- Simon C Gibson
- Correspondence Simon C Gibson, Crosshouse Hospital, Kilmarnock Road, Kilmarnock, UK. Tel: +44 1563 5211 133. Fax: +44 141 232 0701. E-mail:
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Boot C. A review of pancreatic cyst fluid analysis in the differential diagnosis of pancreatic cyst lesions. Ann Clin Biochem 2013; 51:151-66. [PMID: 24097809 DOI: 10.1177/0004563213503819] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing.
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Affiliation(s)
- Christopher Boot
- Clinical Laboratory Services, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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31
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Gurusamy KS, Nagendran M, Davidson BR, Cochrane Upper GI and Pancreatic Diseases Group. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013; 2013:CD010326. [PMID: 23996398 PMCID: PMC11452085 DOI: 10.1002/14651858.cd010326.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gallstones and alcohol account for more than 80% of acute pancreatitis. Cholecystectomy is the definitive treatment for gallstones. Laparoscopic cholecystectomy is the preferred route for performing cholecystectomy. The timing of laparoscopic cholecystectomy after an attack of acute biliary pancreatitis is controversial. OBJECTIVES To compare the benefits and harms of early versus delayed laparoscopic cholecystectomy in people with acute biliary pancreatitis. For mild acute pancreatitis, we considered 'early' laparoscopic cholecystectomy to be laparoscopic cholecystectomy performed within three days of onset of symptoms. We considered all laparoscopic cholecystectomies performed beyond three days of onset of symptoms as 'delayed'. For severe acute pancreatitis, we considered 'early' laparoscopic cholecystectomy as laparoscopic cholecystectomy performed within the index admission. We considered all laparoscopic cholecystectomies performed in a later admission as 'delayed'. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, issue 12), MEDLINE, EMBASE, Science Citation Index Expanded, and trial registers until January 2013. SELECTION CRITERIA We included randomised controlled trials, irrespective of language or publication status, comparing early versus delayed laparoscopic cholecystectomy for people with acute biliary pancreatitis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion and independently extracted data. We planned to analyse data with both the fixed-effect and the random-effects models using Review Manager 5 (RevMan 2011). We calculated the risk ratio (RR), or mean difference (MD) with 95% confidence intervals (CI) based on an intention-to-treat analysis. MAIN RESULTS We identified one trial comparing early versus delayed laparoscopic cholecystectomy for people with mild acute pancreatitis. Fifty participants with mild acute gallstone pancreatitis were randomised either to early laparoscopic cholecystectomy (within 48 hours of admission irrespective of whether the abdominal symptoms were resolved or the laboratory values had returned to normal) (n = 25), or to delayed laparoscopic cholecystectomy (surgery after resolution of abdominal pain and after the laboratory values had returned to normal) (n = 25). This trial is at high risk of bias. There was no short-term mortality in either group. There was no significant difference between the groups in the proportion of participants who developed serious adverse events (RR 0.33; 95% CI 0.01 to 7.81). Health-related quality of life was not reported in this trial. There were no conversions to open cholecystectomy in either group. The total hospital stay was significantly shorter in the early laparoscopic cholecystectomy group than in the delayed laparoscopic cholecystectomy group (MD -2.30 days; 95% CI -4.40 to -0.20). This trial reported neither the number of work-days lost nor the costs. We did not identify any trials comparing early versus delayed laparoscopic cholecystectomy after severe acute pancreatitis. AUTHORS' CONCLUSIONS There is no evidence of increased risk of complications after early laparoscopic cholecystectomy. Early laparoscopic cholecystectomy may shorten the total hospital stay in people with mild acute pancreatitis. If appropriate facilities and expertise are available, early laparoscopic cholecystectomy appears preferable to delayed laparoscopic cholecystectomy in those with mild acute pancreatitis. There is currently no evidence to support or refute early laparoscopic cholecystectomy for people with severe acute pancreatitis. Further randomised controlled trials at low risk of bias are necessary in people with mild acute pancreatitis and severe acute pancreatitis.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Myura Nagendran
- Department of SurgeryUCL Division of Surgery and Interventional Science9th Floor, Royal Free HospitalPond StreetLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
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Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145:583-90.e1. [PMID: 23732774 DOI: 10.1053/j.gastro.2013.05.046] [Citation(s) in RCA: 325] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 05/24/2013] [Accepted: 05/28/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage. METHODS Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs. RESULTS At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003). CONCLUSIONS In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost. TRIAL REGISTRATION ClinicalTrials.gov: NCT00826501.
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Qian D, Qin MF. Diagnosis and treatment of pancreatic pseudocysts by endoscopy and laparoscopy: Our experience with 56 cases. Shijie Huaren Xiaohua Zazhi 2013; 21:1992-1995. [DOI: 10.11569/wcjd.v21.i20.1992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the choice of minimally invasive treatments for pancreatic pseudocysts (PPC).
METHODS: Clinical data for 56 patients with PPC were retrospectively analyzed. The method of treatment was selected based on etiology, cyst formation time, adjacent organ position, and presence of intracystic infection or not.
RESULTS: Of 34 cases treated by endoscopic ultrasonography (EUS)-guided gastric or duodenal drainage, 33 were successful and 1 developed stent migration and underwent laparoscopic cyst drainage. Four cases were confirmed to have communication between cyst and the main pancreatic duct by ERCP, and two of them underwent pancreatic duct stent placement (ERPD). Of 9 cases undergoing laparoscopic cyst-jejunum Roux-en-Y anastomosis, 7 were successful and 2 were converted to open surgery. Four cases underwent laparoscopic cyst excision because cyst was too small and could not be distinguished from pancreatic cystadenoma preoperatively, and one patient developed postoperative pancreatic leakage. Four patients underwent CT-guided puncture and external drainage of cyst.
CONCLUSION: Treatments for PPC are diverse, and selection of appropriate treatment based on the patient's situation is key to the treatment of PPC. With the development of endoscopic and laparoscopic technologies, traditional treatment methods will be gradually replaced by minimally invasive treatments.
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Patel AD, Lytle NW, Sarmiento JM. Laparoscopic Roux-en-Y Drainage of a Pancreatic Pseudocyst. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0013-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Minimally invasive management of pancreatic pseudocysts. Wideochir Inne Tech Maloinwazyjne 2013; 8:211-5. [PMID: 24130634 PMCID: PMC3796721 DOI: 10.5114/wiitm.2011.33809] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 01/18/2013] [Accepted: 02/08/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PP) are the current minimally invasive management options. Indications, and early and late results of endoscopic and laparoscopic approaches are being discussed. AIM To present experience in treatment of PP by laparoscopic pseudocystogastrostomy (LPGS) and endoscopic pseudocystogastrostomy (EPGS) and to compare results, feasibility and safety. MATERIAL AND METHODS THIRTY PATIENTS UNDERWENT SURGICAL INTERVENTION: 18 patients - LPGS (group I), 12 - EPGS (group II). Groups were compared by age, gender, pancreatic pseudocysts's age, diameter and localization, as well as intraoperative, early and late postoperative complications. RESULTS GENDER DISTRIBUTION, GROUP I: 14 (77.8%) men and 4 (22.2%) women, group II: 4 (33.3%) men and 8 (66.7%) women, p = 0.02. Average cyst diameter: group I - 149.9 ±52.1 mm, group II - 119 ±37.9 mm, p = 0.07. Average time between diagnosis and operation performance: group I - 12 (3-60) months, group II - 8 (2-36) months, p = 0.19. Neither in group I nor in group II did intraoperative complications occur. Early postoperative complications were divided into minor and major. Early minor complications: group I - 2 (11.1%), group II - 0, p = 0.5. Early major complications: group I - 0, group II - 2 (16.7%), p = 0.15. Late postoperative complications: group I - 0, group II - 1 (8.3%), p = 0.4. In group I there was no case, whereas in II group there was 1 (8.3%) case of recidivation, p = 0.4. CONCLUSIONS For selected patients both minimally invasive methods are equally safe an effective. For comprehensive evaluation of methods prospective trials are needed.
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Abstract
Laparoscopic cystogastrostomy is an established procedure for the drainage of pancreatic pseudocysts. Cysts are mainly present in the lesser sac (retro-gastric), which is completely amenable to cystogastrostomy. We discuss the problems faced and simple solutions to the problems in managing a huge pancreatic pseudocyst of 22 cm×18 cm in a young boy 18 y of age.
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Affiliation(s)
- Deborshi Sharma
- Department of Surgery, Lady Hardinge Medical College, New Delhi, India.
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Crisanto-Campos BA, Rojano-Rodríguez ME, Cárdenas-Lailson LE, Gallardo-Ramírez MA, Arrieta-Joffe P, Márquez-Ugalde MA, Moreno-Portillo M. [Laparoscopic drainage of a pancreatic pseudocyst: a case report]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2012; 77:148-52. [PMID: 22951042 DOI: 10.1016/j.rgmx.2012.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 03/25/2012] [Accepted: 04/30/2012] [Indexed: 11/24/2022]
Abstract
Pancreatic pseudocysts are defined as homogeneous pancreatic or peripancreatic collections that are not associated with necrotic tissue and are surrounded by granulated or fibrous tissue with no epithelium. Management has been classified as surgical (conventional and laparoscopic) and nonsurgical (endoscopic and radiologic). The aim of this report is to describe our initial experience in the management of a pancreatic pseudocyst by means of laparoscopic posterior cyst-gastrostomy anastomosis, performed at the Pancreas Clinic of the Hospital General "Dr. Manuel Gea González" in Mexico City. New techniques and instrumentation have contributed to the relatively recent development of laparoscopic pancreatic surgery. Our technique has practical advantages that have been confirmed by other authors, such as simple hemostasis, a wide viewing angle enabling adequate necrosectomy, anastomosis that does not require the use of staples, and the possibility of resolving other associated intra-abdominal pathologies, as in this case.
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Affiliation(s)
- B A Crisanto-Campos
- Clínica de Páncreas, Departamento de Cirugía General, Departamento de Cirugía Endoscópica y Endoscopia Gastrointestinal, Hospital General Dr Manuel Gea González, México DF, México.
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The minimally invasive approach to surgical management of pancreatic diseases. Gastroenterol Clin North Am 2012; 41:77-101. [PMID: 22341251 DOI: 10.1016/j.gtc.2011.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.
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Splenic artery pseudoaneurysm as a complication of pancreatic pseudocyst. VOJNOSANIT PREGL 2011; 68:602-6. [PMID: 21899182 DOI: 10.2298/vsp1107602m] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Pancreatic pseudocyst presented as pseudoaneurysm of the splenic artery is a potential serious complication in patients with chronic pancreatitis. CASE REPORT A 42-year-old male patient with a long-standing evolution of chronic pancreatitis and 8-year long evolution of pancreas pseudocyst was referred to the Military Medical Academy, Belgrade due to worsening of the general condition. At admission, the patient was cachectic, febrile, and had the increased values of amylases in urine and sedimentation (SE). After clinical and diagnostic examination: laboratory assessment, esophagogastroduodenoscopy (EGDS), ultrasonography (US), endoscopic ultrasonography (EUS), multislice computed scanner (MSCT) angiography, pseudoaneurysm was found caused by the conversion of pseudocyst on the basis of chronic pancreatitis. The patient was operated on after founding pancreatic pseudocyst, which caused erosion of the splenic artery and their mutual communication. Postoperative course was duly preceded without complications with one year follow-up. CONCLUSION Angiography is the most reliable and the safest method for diagnosing hemorrhagic pseudocysts when they clinically present as pseudoaneurysms. A potentially dangerous complication in the presented case was treated surgically with excellent postoperative results.
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Cavallini A, Butturini G, Malleo G, Bertuzzo F, Angelini G, Abu Hilal M, Pederzoli P, Bassi C. Endoscopic transmural drainage of pseudocysts associated with pancreatic resections or pancreatitis: a comparative study. Surg Endosc 2010; 25:1518-25. [PMID: 20976483 DOI: 10.1007/s00464-010-1428-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Accepted: 09/30/2010] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopy has been regarded as an effective modality for draining pancreatic collections, pseudocysts, and abscesses. This study analyzes our experience with endoscopic transmural drainage of pancreatic pseudocysts and compares the outcomes in patients with postsurgical and pancreatitis-associated ones. METHODS Patients who underwent endoscopic drainage of a pancreatic pseudocyst from January 1999 through June 2008 were included in this retrospective analysis. The specific indication for attempting the procedure was the presence of direct contact between the pseudocyst and the gastric wall. All the drainages were carried out via a transgastric approach, and one or two straight plastic stents (10 or 11.5 French) were positioned. A comparative analysis of short- and long-term results was made between patients with postoperative pseudocysts (group A) and patients with pancreatitis-associated pseudocysts (group B). RESULTS Fifty-five patients were included in the study, 25 in group A and 30 in group B. Overall, a single stent was inserted in 84.0% of patients, while two stents were needed in the remaining 16.0%. The technical success rate was 78.2%, whereas procedure-related complications were 16.4%. Complications included pseudocyst superinfection and major bleeding and were managed mainly by surgery. Mortality rate was 1.8% (1 patient). There were no significant differences in the technical success rate and procedure-related complications between the two groups (p=0.532 and 0.159, respectively) Recurrences were 13.9% and significantly more common in group B (p=0.021). In such cases, a second endoscopic drainage was successfully performed. CONCLUSION Transmural endoscopic treatment of pancreatic pseudocysts is feasible and has a technical success rate of 78.2%, without differences related to the pseudocyst etiology. Recurrences, on the other hand, are more common in patients with pancreatitis. Given the severe complications that may occur after the procedure, we recommend that endoscopic drainage be performed in a tertiary-care center with specific expertise in pancreatic surgery.
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Affiliation(s)
- Alvise Cavallini
- Department of Surgery-General Surgery B, G.B. Rossi Hospital, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
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Zerem E, Imamović G, Omerović S, Ljuca F, Haracić B. Percutaneous treatment for symptomatic pancreatic pseudocysts: Long-term results in a single center. Eur J Intern Med 2010; 21:393-397. [PMID: 20816592 DOI: 10.1016/j.ejim.2010.06.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 06/26/2010] [Accepted: 06/29/2010] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of the study was to present and evaluate the long-term results of percutaneous catheter drainage (PCD) in the treatment of symptomatic pancreatic pseudocysts (PPC). METHODS We performed a retrospective analysis of 128 patients with 140 PPC treated by PCD from 01/01/1989 to 12/31/2008. All procedures were performed under ultrasound control. Surgical treatment was planned only in patients with failed PCD. The patients were followed up monthly with sonography for 12 months. The primary outcome was conversion rate to surgery. Secondary outcomes were disappearance of PPC, requirement for additional treatment, length of hospital stay, and catheter dwell time. RESULTS During the follow-up, 42 of the 140 cysts (30%) recurred. 19/42 cysts were small and they were followed up without intervention and 23/42 cysts required further intervention. These patients were offered a second attempt but 5 patients declined it and they chose to undergo surgery. The remaining 18 patients underwent second PCD and 10 of them developed recurrence. All of them underwent third PCD and 6 of the 10 patients developed recurrences. Four and 2 of them necessitated surgery and follow-up, respectively. In total, 9 of the 128 patients (7%) underwent surgery during the study period. Medians (interquartile ranges) of hospital stay and catheter dwell time were 19 (14-23) and 23 (15-43) days, respectively. There were no complications related to the procedure. CONCLUSION PCD is a safe and effective management for PPC, with low recurrence rates and complication rate and it can eliminate the need for surgery in majority of patients with PPC.
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Affiliation(s)
- Enver Zerem
- University Clinical Center Tuzla, Trnovac bb, Tuzla, Bosnia and Herzegovina.
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Thomasset SC, Berry DP, Garcea G, Ong SL, Hall T, Rees Y, Sutton CD, Dennison AR. A simple, safe technique for the drainage of pancreatic pseudocysts. ANZ J Surg 2010; 80:609-14. [PMID: 20840403 DOI: 10.1111/j.1445-2197.2010.05402.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND A number of methods are available for the drainage of pancreatic pseudocysts, including percutaneous, endoscopic and open approaches. In Leicester, we developed a combined radiological and endoscopic technique (predating the use of endoscopic/ultrasound) to allow drainage of pancreatic pseudocysts into the stomach. The aim of the study was to evaluate the long-term results of this approach. METHODS This is a retrospective study of patients undergoing combined endoscopic/ultrasound-guided percutaneous stenting between 1994 and 2007. Data were extracted from case records and our computerised radiology database. RESULTS Thirty-seven combined endoscopic/ultrasound-guided procedures were undertaken. Median patient age was 52 years (range 26-84 years). Nineteen pseudocysts were secondary to acute pancreatitis and 18 were in patients with chronic pancreatitis. The diameter of pseudocysts on pre-procedure imaging ranged from 4 to 21 cm (median 11 cm). Median duration of hospital stay was 7 days (range 1-44 days) and 30-day mortality was 0%. Stents were inserted in 70.3% of patients (n= 26). Of those patients stented during the combined procedure, three developed infection of the pseudocyst, necessitating open cystgastrostomy within the first month. During a mean follow-up period of 41 months, two patients developed recurrent pseudocysts which were successfully drained with a further combined procedure (16 and 43 months). Repeat imaging in the remainder of patients failed to show any evidence of a persistent or recurrent pseudocyst beyond 2 months. CONCLUSION Combined radiological and endoscopic drainage is safe, cost-effective and highly efficient in preventing recurrent pseudocyst formation.
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Affiliation(s)
- Sarah C Thomasset
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK.
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Abstract
This video, Supplemental Digital Content 1, http://links.lww.com/SLE/A10, shows the steps necessary to carry out a stapled laparoscopic cystogastrostomy through an anterior gastrotomy. As with open surgery, at least a 3-cm anastamosis should be created to reduce the risk of early closure and recurrent pseudocyst formation. Although the initial minimally invasive cystogastrostomies reported were carried out by placing the laparoscopic trocars directly into the stomach, the anterior approach uses only 1 gastrostomy procedure and may have a decreased risk of gastric leak. A posterior approach has been described here; however, it may be more technically demanding. Only when the pseudocyst does not clearly communicate with the posterior stomach wall should cystojejunostomy be attempted. This can be done with a loop of jejunum or through a Roux-en Y.
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Hamza N, Ammori BJ. Laparoscopic drainage of pancreatic pseudocysts: a methodological approach. J Gastrointest Surg 2010; 14:148-55. [PMID: 19789929 DOI: 10.1007/s11605-009-1048-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 09/11/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND This paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts (PPs) based on an anatomical classification. METHODS We adopted the laparoscopic approach in "all comers" who had PPs requiring surgical drainage. The recipient organ for drainage (e.g., cystgastrostomy, cystjejunostomy, or cystduodenostomy) and method of access (e.g., transgastric, endogastric, exogastric or lesser sac, and infracolic) were decided based on preoperative computed tomography (CT) and intraoperative findings. The results shown represent median (range). RESULTS Between 2001 and 2009, 30 laparoscopic drainage procedures for PPs were performed in 28 consecutive patients. The surgical approach included transgastric (n = 17) or endogastric (n = 3) cystgastrostomy for large retrogastric PPs (n = 20), exogastric cystgastrostomy for small perigastric PPs (n = 4), cystduodenostomy (n = 1) under ultrasound guidance, cystjejunostomy for infracolic PPs (n = 4), and one external drainage. The operative time was 118 (25-300) min. There was one conversion to laparotomy (3.3%), low morbidity (3.3%), and no mortality. The postoperative hospital stay was 2 (1-7) days. At a follow-up of 15 (1-48) months, PPs recurred in two patients (7.1%) and were drained by laparoscopic cystgastrostomy. CONCLUSION CT findings and laparoscopic exploration demonstrate the anatomical characteristics of PPs and enable successful planning and execution of their laparoscopic drainage.
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Affiliation(s)
- Numan Hamza
- The Manchester Hepato-Pancreato-Biliary Centre, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8 5RB, UK
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Amano H, Takada T, Isaji S, Takeyama Y, Hirata K, Yoshida M, Mayumi T, Yamanouchi E, Gabata T, Kadoya M, Hattori T, Hirota M, Kimura Y, Takeda K, Wada K, Sekimoto M, Kiriyama S, Yokoe M, Hirota M, Arata S. Therapeutic intervention and surgery of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:53-59. [PMID: 20012651 DOI: 10.1007/s00534-009-0211-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 02/08/2023]
Abstract
The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.
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Affiliation(s)
- Hodaka Amano
- Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga-cho, Itabashi, Tokyo, 173-8605, Japan.
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EUS-guided transesophageal drainage of peripancreatic fluid collections. Gastrointest Endosc 2009; 70:793-7. [PMID: 19647247 DOI: 10.1016/j.gie.2009.05.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/11/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although several large series have reported on EUS-guided transgastric and transduodenal drainage of peripancreatic fluid collections (PFCs), only commentary on individual cases has been presented on EUS-guided transesophageal drainage of PFCs. OBJECTIVE To evaluate the technical success and safety of EUS-guided transesophageal drainage of PFCs. DESIGN Observational study. SETTING Tertiary academic referral center. PATIENTS This study involved 3 consecutive patients referred for EUS-guided transesophageal drainage of PFCs over a 3-year period. INTERVENTIONS The PFCs were accessed via the transesophageal route under EUS-guidance by using a 19-gauge needle. After a 0.035-inch guidewire was passed into the PFC, and the transmural tract was dilated to 6 mm, a transmural stent and/or drainage catheter was deployed. MAIN OUTCOME MEASUREMENTS Evaluation of the technical and treatment success and safety profile of EUS-guided transesophageal drainage of PFCs. RESULTS Three male patients (mean age 57.8 years [range 49-75 years]) underwent EUS-guided transesophageal drainage of PFCs (2 pseudocyst, 1 abscess) over a 3-year period. The etiology of the PFC was alcohol abuse in 2 patients and postsurgical in 1. The mean size of the PFCs was 7 cm (range 6-8 cm) in its largest dimension. The procedures were technically successful in all 3 patients, and no complications were encountered. All 3 patients had a successful treatment outcome. At a mean follow-up period of 24 months (range 12-36 months), all patients were doing well, without any evidence of PFC recurrence. LIMITATION Small number of patients. CONCLUSIONS In experienced hands, EUS-guided transesophageal drainage of PFCs is technically feasible and safe and is associated with favorable clinical outcomes. A long-term follow-up with larger numbers of patients is required to determine whether the procedure could be an effective alternative to surgical cyst-enterostomy or percutaneous drainage techniques.
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Lerch MM, Stier A, Wahnschaffe U, Mayerle J. Pancreatic pseudocysts: observation, endoscopic drainage, or resection? DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:614-21. [PMID: 19890418 DOI: 10.3238/arztebl.2009.0614] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 01/12/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis. They are diagnosed with imaging studies and can be treated successfully with a variety of methods: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, laparoscopic surgery, or open pseudocystoenterostomy. METHODS Relevant publications that appeared from 1975 to 2008 were retrieved from the MEDLINE, PubMed and EMBASE databases for this review. RESULTS Endoscopic pseudocyst drainage has a high success rate (79.2%) and a low complication rate (12.9%). Percutaneous drainage is mainly used for the emergency treatment of infected pancreatic pseudocysts. Open internal drainage and pseudocyst resection are surgical techniques with high success rates (>92%), but also higher morbidity (16%) and mortality (2.5%) than endoscopic treatment (mortality 0.7%). Laparoscopic pseudocystoenterostomy, a recently introduced procedure, is probably similar to the endoscopic techniques with regard to morbidity and mortality. CONCLUSIONS An interdisciplinary approach is best suited for the safe and effective stage-specific treatment of pancreatic pseudocysts. The different interventional techniques that are currently available have yet to be compared directly in randomized trials.
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Affiliation(s)
- Markus M Lerch
- Klinik und Poliklinik für Innere Medizin A, Universitätsklinikum der Ernst-Moritz-Arndt-Universität, Greifswald, Germany.
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Yoder SM, Rothenberg S, Tsao K, Wulkan ML, Ponsky TA, St Peter SD, Ostlie DJ, Kane TD. Laparoscopic treatment of pancreatic pseudocysts in children. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S37-40. [PMID: 19281422 PMCID: PMC3097026 DOI: 10.1089/lap.2008.0124.supp] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pancreatic pseudocysts are problematic sequelae of pancreatitis or pancreatic trauma causing persistent abdominal pain, nausea, and gastric outlet obstruction. Due to the low volume of disease in children, there is scant information in the literature on the operative management of pseudocysts with minimally invasive techniques. We conducted a multi-institutional review to illustrate several technical variations utilized in achieving laparoscopic cystgastrostomy in the pediatric population. METHODS A retrospective review was conducted of all patients who underwent laparoscopic cystgastrostomy in five institutions. Patient data, operative techniques, and postoperative course were analyzed. RESULTS There were 13 patients with a mean age of 10.4 years and mean weight of 52.1 kg. The etiologies of pancreatitis included: trauma (4), gallstones (3), chemotherapy (2), hereditary (1), and idiopathic (3). Preoperative radiographic measurements of the maximal cyst diameter averaged 11.7 cm. Cystgastrostomy was approached by using transgastric exposure in 5 cases and intragastric ports in 8 cases. An average of four ports were used to complete these operations. Mean operative time was 113 minutes. There were no conversions in this series. Cystgastrostomy was performed by using an endoscopic stapler (average 3.8 loads) in 6 cases, sutures in 6 cases, and 1 was formed solely with the Harmonic Scalpel (Johnson and Johnson). Gastrotomy sites were closed by using a stapler in 4 cases and suture techniques in 9. Mean time to initial and goal feeds was 3 and 4 days, respectively. Postoperative imaging revealed persistent pseudocyst in 1 patient, who was treated with a distal pancreatectomy. Therefore, 92% required no further operative intervention and remained asymptomatic upon recovery from their pancreatitis. CONCLUSION A laparoscopic approach to pancreatic cystgastrostomy for chronic pseudocyst proved to be safe and effective in this five-institution survey. Techniques varied, but 92% had complete resolution with minimal morbidity and rapid recovery. Laparoscopic cystgastrostomy should be considered as an appropriate first-line treatment for chronic pseudocysts in children.
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Affiliation(s)
- Suzanne M Yoder
- Department of Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado 80218, USA.
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Winternitz T. [Minimally invasive interventions in the treatment of pancreatic diseases]. Orv Hetil 2008; 149:2277-81. [PMID: 19028650 DOI: 10.1556/oh.2008.28484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We have used minimal invasive therapy in the treatment of pancreatic diseases for a long time. CT and/or ultrasound guided techniques have been used for the treatment of pancreatic pseudocysts for more than 20 years. The development of technology has also made an opportunity for the extensive use of laparoscopic surgery at patients suffering from pancreatic diseases. Currently, almost every type of open operation has a laparoscopic version, too. By now we can take part in the combined use of the CT/US and laparoscopic techniques. Recently the new NOTES procedures have appeared. Based on the literary items, the author summarizes the possibilities of minimal invasive treatments in pancreatic diseases.
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Affiliation(s)
- Tamás Winternitz
- Semmelweis Egyetem, Altalános Orvostudományi Kar I. Sebészeti Klinika Budapest Ullôi út 78. 1082.
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Melman L, Matthews BD. Current Trends in Laparoscopic Solid Organ Surgery: Spleen, Adrenal, Pancreas, and Liver. Surg Clin North Am 2008; 88:1033-46, vii. [PMID: 18790153 DOI: 10.1016/j.suc.2008.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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