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Fujiwara M. Diagnosis of Hereditary Pancreatitis Following the Initial Acute Episode With Multiple Pseudocyst Complications. Cureus 2024; 16:e73653. [PMID: 39677196 PMCID: PMC11645519 DOI: 10.7759/cureus.73653] [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] [Accepted: 11/08/2024] [Indexed: 12/17/2024] Open
Abstract
Hereditary pancreatitis (HP) is an unusual form of pancreatitis inherited as an autosomal dominant disorder. Patients typically present with recurrent acute pancreatitis-like symptoms that eventually progress to chronic pancreatitis, resulting in pancreatic exocrine insufficiency or diabetes mellitus, and a high risk of developing pancreatic cancer. As such, early diagnosis is crucial. Herein, we present the case of an 11-year-old boy with no significant medical history, but a family history of type 1 diabetes and pancreatic cancer, who presented with intermittent epigastric pain and nausea. Imaging revealed multiple pancreatic pseudocysts, pancreatic stones, and pancreatic duct dilation, resulting in the diagnosis of acute-on-chronic pancreatitis. Genetic testing confirmed the presence of a mutation in the PRSS1 gene, ultimately resulting in the diagnosis of HP. The patient remained symptom-free for five years during follow-up post-treatment. This case highlights the importance of considering HP in young patients presenting with pseudocysts and other signs of chronic pancreatitis even during the initial acute episode.
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Affiliation(s)
- Michimasa Fujiwara
- Pediatrics, National Hospital Organization Fukuyama Medical Center, Fukuyama, JPN
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Koo JGA, Liau MYQ, Kryvoruchko IA, Habeeb TAAM, Chia C, Shelat VG. Pancreatic pseudocyst: The past, the present, and the future. World J Gastrointest Surg 2024; 16:1986-2002. [PMID: 39087130 PMCID: PMC11287700 DOI: 10.4240/wjgs.v16.i7.1986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/19/2024] [Accepted: 06/17/2024] [Indexed: 07/22/2024] Open
Abstract
A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.
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Affiliation(s)
- Jonathan GA Koo
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Matthias Yi Quan Liau
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Igor A Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv 61022, Ukraine
| | - Tamer AAM Habeeb
- Department of General Surgery, Faculty of Medicine Zagazig University, Sharkia 44511, Egypt
| | - Christopher Chia
- Department of Gastroenterology, Woodlands General Hospital, Singapore 737628, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Umapathy C, Gajendran M, Mann R, Boregowda U, Theethira T, Elhanafi S, Perisetti A, Goyal H, Saligram S. Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management. Dis Mon 2020; 66:100986. [PMID: 32312558 DOI: 10.1016/j.disamonth.2020.100986] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.
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Affiliation(s)
- Chandraprakash Umapathy
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, TX 79905, USA.
| | - Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, 1303 E Herndon Ave, Fresno, CA 93730, USA
| | - Umesha Boregowda
- Department of Internal Medicine, Bassett Healthcare Network, Columbia Bassett Medical School, 1 Atwell Road, Cooperstown, NY 13326, USA
| | - Thimmaiah Theethira
- Department of Gastroenterology and Hepatology, University of California San Francisco, Fresno, CA 93721, USA
| | - Sherif Elhanafi
- Department of Internal Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, TX 79905, USA
| | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hemant Goyal
- The Wright Center of Graduate Medical Education, Scranton, PA, USA
| | - Shreyas Saligram
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Xu MM, Andalib I, Novikov A, Dawod E, Gabr M, Gaidhane M, Tyberg A, Kahaleh M. Endoscopic Therapy for Pancreatic Fluid Collections: A Definitive Management Using a Dedicated Algorithm. Clin Endosc 2019; 53:355-360. [PMID: 31794655 PMCID: PMC7280836 DOI: 10.5946/ce.2019.113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic ultrasonography (EUS)-guided drainage is the preferred approach for infected or symptomatic pancreatic fluid collections (PFCs). Here, we developed an algorithm for the management of pancreatitis complicated by PFCs and report on its effcacy and safety. METHODS Between September 2011 and October 2017, patients were prospectively managed according to the algorithm. PFCs were classified as poorly organized fluid collections (POFCs), pancreatic pseudocysts (PPs), or walled-off pancreatic necrosis (WOPN). Clinical success was defined as a decrease in PFC size by ≥50% of the maximal diameter or to ≤2 cm. RESULTS A total of 108 patients (62% male; mean age, 53 years) were included: 13 had POFCs, 43 had PPs, and 52 had WOPN. Seventytwo patients (66%) required a pancreatic duct (PD) stent, whereas 65 (60%) received enteral feeding. A total of 103 (95%) patients achieved clinical success. Eight patients experienced complications including bleeding (n=6) and surgical intervention (n=2). Patients with enteral feeding were 3.4 times more likely to achieve resolution within 60 days (p=0.0421), whereas those with PD stenting was five times more likely to achieve resolution within 90 days (p=0.0069). CONCLUSION A high PFC resolution rate can be achieved when a dedicated algorithm encompassing EUS-guided drainage, PD stenting, and early enteral feeding is adopted.
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Affiliation(s)
- Ming Ming Xu
- Division of Gastroenterology, Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Iman Andalib
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Aleksey Novikov
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Enad Dawod
- Division of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Moamen Gabr
- Division of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Monica Gaidhane
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Amy Tyberg
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Michel Kahaleh
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Rerknimitr R. Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods. Clin Endosc 2019; 53:49-53. [PMID: 31530792 PMCID: PMC7003012 DOI: 10.5946/ce.2019.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/22/2019] [Indexed: 12/31/2022] Open
Abstract
Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.
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Affiliation(s)
- Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand
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Abstract
The last decade has seen dramatic shift in paradigm in the management of pancreatic fluid collections with the rise of endoscopic therapy over radiologic or surgical management. Endosonographic drainage is now considered the gold standard therapy for pancreatic pseudocyst. Infected pancreatic necroses are being offered endoscopic necrosectomy that has been facilitated by the arrival on the market of large diameter lumen-apposing metal stent. Severe pancreatitis or failure to thrive should receive enteral nutrition while pancreatic ductal disruption or strictures are best treated by pancreatic stenting.
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Affiliation(s)
- Iman Andalib
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
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Majidi S, Golembioski A, Wilson SL, Thompson EC. Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment. South Med J 2017; 110:727-732. [PMID: 29100225 DOI: 10.14423/smj.0000000000000727] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute pancreatitis is a fascinating disease. In the United States, the two most common etiologies of acute pancreatitis are gallstones and excessive alcohol consumption. The diagnosis of acute pancreatitis is made with a combination of history, physical examination, computed tomography scan, and laboratory evaluation. Differentiating patients who will have a benign course of their pancreatitis from patients who will have severe pancreatitis is challenging to the clinician. C-reactive protein, pro-calcitonin, and the Bedside Index for Severity of Acute Pancreatitis appeared to be the best tools for the early and accurate diagnosis of severe pancreatitis. Early laparoscopic cholecystectomy is indicated for patients with mild gallstone pancreatitis. For patients who are going to have a prolonged hospitalization, enteral nutrition is preferred. Total parenteral nutrition should be reserved for patients who cannot tolerate enteral nutrition. Prophylactic antibiotics are not indicated for patients with pancreatic necrosis. Surgical intervention for infected pancreatic necrosis should be delayed as long as possible to improve patient outcomes.
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Affiliation(s)
- Shirin Majidi
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Adam Golembioski
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Stephen L Wilson
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Errington C Thompson
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
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Abstract
The pancreatic pseudocyst is a pancreatic fluid collection which classically develops due to acute or chronic pancreatitis. A 68-year-old male with the remote history of alcohol abuse presented with abdominal pain secondary to acute pancreatitis. The first computed tomography (CT) of the abdomen showed acute necrotizing pancreatitis. He was initially treated conservatively. Repeat CT of the abdomen after two weeks revealed a peripancreatic fluid collection of 20x12x10 cm. One month later, he became septic following biliary stent placement. Repeat CT of the abdomen showed an enlarging pseudocyst of 25x20x14 cm (estimated 7000 mL of fluid). Percutaneous CT-guided cyst drainage was performed and only three liters of infected fluid could be drained which eventually grew Enterococcus faecalis. Due to lack of improvement, he underwent laparotomy with pancreatic necrosectomy, pseudocyst debridement, and cholecystectomy. The patient did well postoperatively and until one-year follow-up visit. The largest pancreatic pseudocyst in the literature (about 9500 mL) was reported in 1882. To our knowledge, this case is the second largest pseudocyst in the literature which was successfully managed by surgical resection.
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Affiliation(s)
- Sulaiman Alhassan
- Division of Pulmonary and Critical Care Medicine, Allegheny General Hospital, Pittsburgh, USA
| | - Shifa Umar
- Department of Medicine, Allegheny General Hospital, Pittsburgh, USA
| | - Mark Lega
- Division of Pulmonary and Critical Care Medicine, Allegheny General Hospital, Pittsburgh, USA
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Abstract
Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.
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Kirks RC, Sola R, Iannitti DA, Martinie JB, Vrochides D. Robotic transgastric cystgastrostomy and pancreatic debridement in the management of pancreatic fluid collections following acute pancreatitis. J Vis Surg 2016; 2:127. [PMID: 29078515 DOI: 10.21037/jovs.2016.07.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/29/2016] [Indexed: 12/17/2022]
Abstract
Pancreatic and peripancreatic fluid collections may develop after severe acute pancreatitis. Organized fluid collections such as pancreatic pseudocyst and walled-off pancreatic necrosis (WOPN) that mature over time may require intervention to treat obstructive or constitutional symptoms related to the size and location of the collection as well as possible infection. Endoscopic, open surgical and minimally invasive techniques are described to treat post-inflammatory pancreatic fluid collections. Surgical intervention may be required to treat collections containing necrotic pancreatic parenchyma or in locations not immediately apposed to the stomach or duodenum. Comprising a blend of the surgical approach and the clinical benefits of minimally invasive surgery, the robot-assisted technique of pancreatic cystgastrostomy with pancreatic debridement is described.
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Affiliation(s)
- Russell C Kirks
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Richard Sola
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Aydogdu B, Arslan S, Zeytun H, Arslan MS, Basuguy E, İçer M, Goya C, Okur MH, Uygun I, Cıgdem MK, Onen A, Otcu S. Predicting pseudocyst formation following pancreatic trauma in pediatric patients. Pediatr Surg Int 2016; 32:559-563. [PMID: 26857478 DOI: 10.1007/s00383-016-3872-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are insufficient data on pre-screening for pancreatic pseudocysts (PC) following pancreatic trauma. This study investigated the use of radiological and laboratory testing for predicting the development of pancreatic pseudocysts after trauma. MATERIALS AND METHODS The clinical records of all pediatric patients presenting with pancreatic trauma between January 2003 and December 2014 were reviewed retrospectively. Patients with American Association for the Surgery of Trauma (AAST) scores of Grade 3-5 were enrolled. The patients were divided into groups that developed [Group 1 (n = 20)] and did not develop [Group 2 (n = 18)] PC. The patients were evaluated in terms of their baseline characteristics, additional injuries, Injury Severity Score (ISS), pancreatic injury site, blood amylase levels 2 h and 10-15 days after the trauma, clinical presentation, and duration of intensive care unit (ICU) stay. FINDINGS We followed 38 patients. Of the patients in Group 1, 70 % had an injury to the tail of the pancreas. The ISS trauma scores and durations of hospitalization and ICU stay were significantly greater in Group 2 (p < 0.05). The mean blood amylase level on Day 1 was 607 U/L (range 183-801 U/L) in Group 1 and 314 U/L (range 25-631 U/L) in Group 2; the respective levels on Day 10 were 838 U/L (range 123-2951 U/L) and 83.2 U/L (range 35-164 U/L). The serum amylase levels were significantly higher (p < 0.001) in Group 1 than in Group 2 on Days 1 and 10. Four patients developed complications and two patients died. CONCLUSION Pancreatic pseudocyst formation is more likely in patients with AAST Grade 3 pancreatic injury, also serum amylase levels ten times greater than normal 2 h after the trauma, and persistently elevated serum amylase levels 10-15 days following the trauma.
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Affiliation(s)
- Bahattin Aydogdu
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey.
| | - Serkan Arslan
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Hikmet Zeytun
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Mehmet Serif Arslan
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Erol Basuguy
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Mustafa İçer
- Department of Trauma and Emergency, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Cemil Goya
- Department of Radiology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Mehmet Hanifi Okur
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Ibrahim Uygun
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Murat Kemal Cıgdem
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Abdurrahman Onen
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
| | - Selcuk Otcu
- Department of Pediatric Surgery and Pediatric Urology, Medical Faculty of Dicle University, 21280, Diyarbakir, Turkey
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Prevalence, Natural History, and Outcome of Acute Fluid Collection and Pseudocyst in Children With Acute Pancreatitis. J Pediatr Gastroenterol Nutr 2015; 61:451-5. [PMID: 26029866 DOI: 10.1097/mpg.0000000000000800] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Recent years have witnessed an increase in acute pancreatitis (AP) in children; however, the natural history of acute fluid collection (AFC) and pseudocyst is largely unknown. We evaluated the frequency, clinical characteristics, and natural history of pseudocysts in children with AP. METHODS Children with AP admitted at Sanjay Gandhi Postgraduate Institute of Medical Sciences from 2001 to 2011 were enrolled and studied until complete resolution. Subjects with inadequate follow-up, recurrent AP, and chronic pancreatitis were excluded. RESULTS Of the 58 children (43 boys, median age 14 [1-18] years) with AP, 34 (58.6%) and 22 (38%) developed AFC and pseudocyst, respectively. No difference in age (12 [4-18] vs 13 [1-16] years), etiology (idiopathic 64% vs 47% and traumatic 27.2% vs 22.2%), and systemic complications (pulmonary [18% vs 11%], renal [22.7% vs 11%], and shock [13.6% vs 10%]) was observed between children with and without pseudocyst. A total of 11 of the 22 subjects with pseudocyst underwent drainage, the commonest symptom requiring drainage being gastric outlet obstruction [n = 5] and infection [n = 2]. The 11 of the 22 children with AP and pseudocyst (size 6.4 [3-14.4] cm) showed spontaneous resolution (disappearance [n = 9] and significant reduction in size [n = 2]) during 110 (25-425) days. Symptomatic pseudocysts requiring drainage were more often secondary to traumatic AP (6/6 vs 2/14 [idiopathic], P = 0.0007) than asymptomatic pseudocysts resolving spontaneously. Overall, only 26.4% (9/34) children with AFC required drainage because of symptomatic pseudocyst. CONCLUSIONS Among children with AP, 58.6% developed AFC and 38% developed pseudocysts. Only patients with symptomatic pseudocyst need drainage, and asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection.
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Zamolodchikov RD, Solodinina EN, Starkov YG. [Internal drainage of pancreatic pseudocysts]. Khirurgiia (Mosk) 2015:68-75. [PMID: 26103647 DOI: 10.17116/hirurgia2015468-75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R D Zamolodchikov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - E N Solodinina
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - Yu G Starkov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
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14
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Abstract
This article aims to elucidate the classification of and optimal treatment for pancreatic pseudocysts. Various approaches, including endoscopic drainage, percutaneous drainage, and open surgery, have been employed for the management of pancreatic pseudocysts. However, no scientific classification of pancreatic pseudocysts has been devised, which could assist in the selection of optimal therapy. We evaluated the treatment modalities used in 893 patients diagnosed with pancreatic pseudocysts according to the revision of the Atlanta classification in our department between 2001 and 2010. All the pancreatic pseudocysts have course of disease >4 weeks and have mature cysts wall detected by computed tomography or transabdominal ultrasonography. Endoscopic drainage, percutaneous drainage, or open surgery was selected on the basis of the pseudocyst characteristics. Clinical data and patient outcomes were reviewed. Among the 893 patients, 13 (1.5%) had percutaneous drainage. Eighty-three (9%) had type I pancreatic pseudocysts and were treated with observation. Ten patients (1%) had type II pseudocysts and underwent the Whipple procedure or resection of the pancreatic body and tail. Forty-six patients (5.2%) had type III pseudocysts: 44 (4.9%) underwent surgical internal drainage and 2 (0.2%) underwent endoscopic drainage. Five hundred six patients (56.7%) had type IV pseudocysts: 297 (33.3%) underwent surgical internal drainage and 209 (23.4%) underwent endoscopic drainage. Finally, 235 patients (26.3%) had type V pseudocysts: 36 (4%) underwent distal pancreatectomy or splenectomy and 199 (22.3%) underwent endoscopic drainage. A new classification system was devised, based on the size, anatomical location, and clinical manifestations of the pancreatic pseudocyst along with the relationship between the pseudocyst and the pancreatic duct. Different therapeutic strategies could be considered based on this classification. When clinically feasible, endoscopic drainage should be considered the optimal management strategy for pancreatic pseudocysts.
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Affiliation(s)
- Gang Pan
- From the Department of Liver Surgery (GP, K-LX, WL, HW); Department of Pancreatic Surgery (MHW, W-FT); Department of Integrated Traditional and Western Medicine (W-MH, X-BL), West China Hospital, Sichuan University, Chengdu, Sichuan, China
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15
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Pediatric laparoscopic transgastric cystgastrostomy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2014.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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16
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Abstract
Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6-8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.
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Affiliation(s)
- Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Simona Vultur
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
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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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Rotman SR, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: new perspectives. Endosc Ultrasound 2014; 1:61-8. [PMID: 24949339 PMCID: PMC4062209 DOI: 10.7178/eus.02.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 04/26/2012] [Indexed: 12/13/2022] Open
Abstract
Since the introduction of endoscopic ultrasonography (EUS), many centers have utilized this imaging modality for transmural pancreatic fluid collection (PFC) drainage. The expanded use of EUS has resulted in increased safety and efficacy of endoscopic PFC drainage. The major procedural steps include EUS-guided transgastric or transduodenal fistula creation into the PFC, and stent placement or nasocystic drain deployment to decompress the collection. In this and other applications, EUS has become a major therapeutic advancement in the field of endoscopy and has figured in myriad diagnostic applications. Recent research indicates a number of situations in which EUS-guided PFC drainage is appropriate. These include unusual location of the collection, small window of entry, non-bulging collections, coagulopathy, intervening varices, or failed conventional transmural drainage. In this study, we discuss the EUS-guided technique and review current literatures.
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Affiliation(s)
- Stephen R Rotman
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Presbyterian Hospital, New York, NY 10021, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Presbyterian Hospital, New York, NY 10021, USA
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Abstract
BACKGROUND Endoscopic necrosectomy for necrotizing pancreatitis has been increasingly used as an alternative to surgical or percutaneous interventions. The use of fully covered esophageal self-expandable metallic stents may provide a safer and more efficient route for internal drainage. The aim of this study was to evaluate the safety and efficacy of endoscopic treatment of pancreatic necrosis with these stents. METHODS A retrospective study at 2 US academic hospitals included patients with infected pancreatic necrosis from July 2009 to November 2012. These patients underwent transgastric placement of fully covered esophageal metallic stents draining the necrosis. After necrosectomy, patients underwent regular sessions of endoscopic irrigation and debridement of cystic contents. The efficacy endpoint was successful resolution of infected pancreatic necrosis without the need for surgical or percutaneous interventions. RESULTS Seventeen patients were included with the mean age of 41±12 years. A mean of 5.3±3.4 sessions were required for complete drainage and the follow-up period was 237.6±165 days. Etiology included gallstone pancreatitis (6), alcohol abuse (6), s/p distal pancreatectomy (2), postendoscopic retrograde cholangiopancreatography pancreatitis (1), medication-induced pancreatitis (1), and hyperlipidemia (1). Mean size of the necrosis was 14.8 cm (SD 5.6 cm), ranging from 8 to 19 cm. Two patients failed endoscopic intervention and required surgery. The only complication was a perforation during tract dilation, which was managed conservatively. Fifteen patients (88%) achieved complete resolution. CONCLUSIONS Endoscopic necrosectomy with covered esophageal metal stents is a safe and successful treatment option for infected pancreatic necrosis.
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Haemorrhagic pseudocyst of the pancreatic tail causing acute abdominal pain in a 12-year-old girl. ANNALS OF PEDIATRIC SURGERY 2014. [DOI: 10.1097/01.xps.0000434486.86253.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Singhal S, Rotman SR, Gaidhane M, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: an update. Clin Endosc 2013; 46:506-14. [PMID: 24143313 PMCID: PMC3797936 DOI: 10.5946/ce.2013.46.5.506] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 07/25/2013] [Accepted: 08/01/2013] [Indexed: 12/14/2022] Open
Abstract
Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage.
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Affiliation(s)
- Shashideep Singhal
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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22
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L-Asparginase Induced Pseudopancreatic Cyst: A Rare Case Report. Indian J Surg Oncol 2013; 4:313-5. [DOI: 10.1007/s13193-013-0250-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 05/31/2013] [Indexed: 11/26/2022] Open
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Self-expandable metal stents for endoscopic ultrasound-guided drainage of peripancreatic fluid collections. GASTROINTESTINAL INTERVENTION 2013. [DOI: 10.1016/j.gii.2013.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Non-operative treatment versus percutaneous drainage of pancreatic pseudocysts in children. Pediatr Surg Int 2013; 29:305-10. [PMID: 23274700 DOI: 10.1007/s00383-012-3236-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The objective of this study was to characterize the clinical course and outcomes of children with pancreatic pseudocysts that were initially treated non-operatively or with percutaneous drainage. METHODS A retrospective review of children with pancreatic pseudocysts over a 12-year period was completed. Categorical variables were compared using Fischer's exact method and the Student's t test was used to compare continuous variables. Analysis was done using logistic and linear regression models. RESULTS Thirty-six children met the criteria for pancreatic pseudocyst and 33 children were treated either non-operatively or with percutaneous drainage. Of the 22 children managed non-operatively, 17 required no additional intervention (77 %) and five required surgery. Operative procedures were: Frey procedure (3), distal pancreatectomy (1), and cystgastrostomy (1). Eight of the 11 children treated with initial percutaneous drainage required no additional treatment (72 %). The other three children underwent distal pancreatectomy. Success of non-operative management or percutaneous drainage was not dependent on size or complexity of the pseudocyst Logistic regression did not identify any patient demographic (gender, age, and weight), etiologic (trauma, non-traumatic pancreatitis) or pseudocyst characteristic (size, septations) that predicted failure of non-operative therapy. CONCLUSIONS In children, pancreatic pseudocysts can frequently be managed without surgery regardless of size or complexity of the pseudocyst. When an intervention is needed, percutaneous drainage can be performed successfully, avoiding the need for major surgical intervention in the majority of patients.
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Patrzyk M, Maier S, Busemann A, Glitsch A, Heidecke CD. [Therapy of pancreatic pseudocysts: endoscopy versus surgery]. Chirurg 2013; 84:117-24. [PMID: 23371027 DOI: 10.1007/s00104-012-2376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pancreatic pseudocysts are frequent complications following acute and chronic pancreatitis as well as abdominal trauma. They originate from enzymatic and/or necrotizing processes within the organ involving the surrounding tissues through inflammatory processes following pancreatic ductal lesion(s). Pseudocysts require definitive treatment if they become symptomatic, progressive, larger than 5 cm after a period of more than 6 weeks and/or have complications. Cystic neoplasms must be excluded before treatment. Endoscopic interventions are commonly accepted first line approaches. Should these fail or not be feasible surgical procedures have been well established and show comparable results. In summary, pancreatic pseudocysts require a reliable diagnostic approach with a multidisciplinary professional management involving gastroenterologists and surgeons.
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Affiliation(s)
- M Patrzyk
- Abteilung für Allgemeine Chirurgie, Viszeral-, Thorax- und Gefäßchirurgie, Klinik und Poliklinik für Chirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Deutschland.
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Kahaleh M. Endoscopic necrosectomy for walled-off pancreatic necrosis. Clin Endosc 2012; 45:313-5. [PMID: 22977825 PMCID: PMC3429759 DOI: 10.5946/ce.2012.45.3.313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 07/20/2012] [Accepted: 07/20/2012] [Indexed: 12/27/2022] Open
Abstract
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.
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Affiliation(s)
- Michel Kahaleh
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Nici AJ, Hussain SA, Kim SH, Mehta P. Unique usage of a partially covered metal stent for drainage of a pancreatic pseudocyst via endosonography-guided transcystgastrostomy. Dig Endosc 2012; 24:185-7. [PMID: 22507094 DOI: 10.1111/j.1443-1661.2011.01202.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pancreatic pseudocysts are frequent complications of pancreatitis episodes. The current therapeutic modalities for drainage of pancreatic pseudocysts include surgical, percutaneous, and endoscopic drainage modalities. Endosonography-assisted endoscopic drainage of these pseudocysts with the placement of multiple plastic or fully covered self-expanding biliary metal stents is becoming more commonly carried out. The present case report discusses the unique and successful drainage of a pancreatic pseudocyst with the placement of a partially covered self-expanding metal stent.
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Affiliation(s)
- Anthony J Nici
- New York Hospital Queens-Weill Medical College of Cornell University, 56-45 Main Street, Flushing, NY 11355, USA.
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Abstract
OBJECTIVES The aim of this study was to analyze the incidence, risk factors, and clinical outcomes of pancreatic pseudocyst after acute or acute-on-chronic pancreatitis. METHODS We retrospectively reviewed the medical records of 350 patients with acute pancreatitis and 55 patients with acute-on-chronic pancreatitis. RESULTS Pancreatic pseudocyst developed in 14.6% of acute pancreatitis and in 41.8% of acute-on-chronic pancreatitis (P = 0.00). In the acute-on-chronic pancreatitis group, interval from symptom onset to hospital visit was longer, and the incidence of recurrent pancreatitis and alcoholic etiology was higher than that of the acute pancreatitis group (P < 0.01). There was no significant difference in the spontaneous resolution rate between both groups. Of the total 68 conservatively treated patients with pseudocyst, the pseudocyst decreased in size or disappeared in 77.9% and showed no change in 1.5%. The risk factors of pseudocyst were the presence of underlying chronic pancreatitis, the interval from symptom onset to visiting the hospital, and an alcoholic etiology. The factor-predicted spontaneous resolution was a single lesion. CONCLUSIONS Pseudocyst developed more frequently in patients with acute-on-chronic pancreatitis, and most pseudocysts improved spontaneously irrespective of underlying chronic pancreatitis. A longer period of a "wait-and-see" policy for more than 6 weeks is suggested for asymptomatic pseudocyst, especially for a single lesion.
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Rodríguez-D'Jesús A, Fernández-Esparrach G, Saperas E. [Endoscopic treatment of pancreatic pseudocyst. Practical features]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:711-6. [PMID: 22112632 DOI: 10.1016/j.gastrohep.2011.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 10/09/2011] [Indexed: 11/24/2022]
Abstract
The initial treatment of most cases of pancreatic pseudocyst is endoscopic while surgery has been relegated to patients who cannot undergo this procedure for technical reasons, such as roux-en-Y roux reconstruction, or to those in whom other procedures have been unsuccessful. This change in the management of this entity is due to advances in therapeutic endoscopy (as a result of the development of guidelines, dilatation balloons, prostheses, safer techniques) as well as to better knowledge of the pathogenesis of pancreatic pseudocyst. The present study aims to describe endoscopic procedures for the drainage of pancreatic pseudocysts, particularly key technical features to ensure the maximum safety and effectiveness of this therapeutic technique.
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Dai QL, Qin MF, Wang ZY, Wang Q, Gou CY, Li N, Zhao HZ, Zheng MW. Endoscopic ultrasound-guided transgastric drainage of pancreatic pseudocysts: An analysis of 36 cases. Shijie Huaren Xiaohua Zazhi 2011; 19:2583-2586. [DOI: 10.11569/wcjd.v19.i24.2583] [Citation(s) in RCA: 2] [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 assess the clinical value of endoscopic ultrasound (EUS)-guided transgastric drainage of pancreatic pseudocysts (PPs).
METHODS: The clinical data for 36 patients who underwent EUS-guided transgastric drainage of PPs at our center between February 2005 and May 2010 were retrospectively analyzed.
RESULTS: EUS-guided puncture of PPs and stent placement were successful in 34 patients, and the success rate was 94.4% (34/36). The rate of complications (infection and stent clogging or migration) was 17.6%. The mean operative time was 50 minutes (range, 40-65 min) and mean postoperative hospital stay was 4.7 d (range, 2-9 d). The mean time between stent implantation and removal was 6.9 mo (range, 4-11 mo). The mean follow-up period was 30 mo (range, 10-60 mo). Endoscopic cure rate was 97.1% (33/34). No recurrences occurred.
CONCLUSION: EUS-guided transgastric drainage is a safe, effective and minimally invasive therapeutic method for PPs.
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Heinzow HS, Meister T, Pfromm B, Lenze F, Domschke W, Ullerich H. Single-step versus multi-step transmural drainage of pancreatic pseudocysts: the use of cystostome is effective and timesaving. Scand J Gastroenterol 2011; 46:1004-13. [PMID: 21492051 DOI: 10.3109/00365521.2011.571709] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Pancreatic pseudocysts are a major complication of chronic and acute pancreatitis and often require endoscopic intervention. Endoscopic single-step and multi-step transmural drainage techniques have been reported in the literature. The aim of this study was to evaluate and compare technical results and clinical outcome rates of the single-step versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts of >4 cm size. DESIGN Retrospective study at an academic tertiary referral center. PATIENTS AND METHODS A total of 38 consecutive patients comprising 42 interventions were studied: 16 patients with pancreatic pseudocysts (18 interventions) had undergone single-step EUS-guided transmural cystostome drainage between 2007 and 2010. Results were compared with a cohort of 22 patients who had submitted to multi-step EUS-guided transmural drainage of pancreatic pseudocysts in 24 cases between 2005 and 2007. RESULTS The technical success rate for using the single-step procedure was 94% compared with multi-step procedure with 83% (n.s.). Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the single-step group compared with 62 ± 12 min for the multi-step access (p < 0.001). CONCLUSIONS The use of single-step cystostome appears useful in managing selected patients with symptomatic pancreatic pseudocysts as it is effective and timesaving.
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Chronic pancreatitis: modern surgical management. Langenbecks Arch Surg 2010; 396:139-49. [PMID: 21174215 DOI: 10.1007/s00423-010-0732-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 12/01/2010] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency. CONCLUSIONS The only success parameter of any treatment is the effective long-lasting pain relief and improvement in the quality of life. The surgical armamentarium includes simple drainage procedures, resections of different extents or a combination of both. Duodenum-preserving resection of the pancreas offers the best short-term outcome according to trials conducted so far. It has the benefit of combining the highest safety with the highest efficiency. Additionally, the extent of the operation can be adapted to the morphology of the individual patient.
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Roux-en-Y gastric bypass after Roux-en-Y pancreaticojejunostomy. Surg Obes Relat Dis 2010; 7:e1-2. [PMID: 20869328 DOI: 10.1016/j.soard.2010.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 07/13/2010] [Accepted: 07/13/2010] [Indexed: 11/23/2022]
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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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Boutros C, Somasundar P, Espat NJ. Open cystogastrostomy, retroperitoneal drainage, and G-J enteral tube for complex pancreatitis-associated pseudocyst: 19 patients with no recurrence. J Gastrointest Surg 2010; 14:1298-303. [PMID: 20535579 DOI: 10.1007/s11605-010-1242-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 05/25/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Various techniques have been described to achieve definitive resolution of complex acute pancreatitis associated pseudocysts (PACs). Many of these strategies, inclusive of open, minimally invasive, and radiological procedures, are hampered by high recurrence or failed resolution, particularly for PAC near the pancreatic head. The present series describes a multimodal strategy combining a minilaparotomy for anterior gastrostomy for the creation of a stapled posterior cystogastrostomy, placement of an 8F secured silastic tube for intentional formation of a cystogastric fistula tract in combination with gastric drainage, and postduodenal enteral alimentation. MATERIALS AND METHODS Using a prospectively maintained hepatobiliary database, patients with complex PAC undergoing the above procedures were identified. PAC location, postoperative length of stay (LOS), and time to start enteral feeding were identified. PAC were assessed by computed tomography (CT) scan prior to operation, 1 month after drainage, and patients with PAC resolution were started on oral diet, with the fistula silastic tube kept in place for an additional month. RESULTS Over the interval 2003 to 2008, 19 patients were managed with the stated strategy. PACs were located at the pancreatic body/tail in 12 patients, and 7 patients had PAC at the level of the pancreatic head/neck area. In this cohort, prior to surgical drainage, 17/19 patients had undergone failed endoscopic retrograde cholangiopancreatography (ERCP) with decompressive stent placement and 13/19 had a failed percutaneous PAC drainage. There was no perioperative mortality after open surgical drainage. All patients started on jejunal tube feeding 24 h after surgical procedure. Median postoperative LOS was 7 days (4-13). At 1 month, 16/19 (84%) of patients showed complete resolution of the PAC on CT scan and were started on oral diet; 3/19 required additional month for complete resolution. After a mean follow-up of 31 months, there was no PAC recurrences in any of these patients demonstrated on follow-up. CONCLUSION The described strategy is safe, efficient, and allows early restoration of enteral feeding with early hospital discharge. High resolution rates and absence of PAC recurrences in this series supports this approach for complex PAC.
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Affiliation(s)
- Cherif Boutros
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, RI, USA
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Surgical treatment in chronic pancreatitis timing and type of procedure. Best Pract Res Clin Gastroenterol 2010; 24:299-310. [PMID: 20510830 DOI: 10.1016/j.bpg.2010.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 03/01/2010] [Accepted: 03/07/2010] [Indexed: 01/31/2023]
Abstract
Pain relief and improvement in the quality of life are of paramount importance for any intervention in chronic pancreatitis. In several trial good results have been published after different drainage procedures and resections. An optimal surgical intervention should manage mainly the intractable pain, resolve the complications of the adjacent organs and achieve the drainage of the main pancreatic duct. An optimal procedure should guarantee a low relapse rate, preserve a maximum of endocrine and exocrine function, and most importantly, restore quality of life. Thus an ideal operation should representing a one-stop-shopping. According to the trials conducted so far, Duodenum-preserving resection of the pancreatic head offers the best short-term outcome. It combines the highest safety of all surgical procedures with the highest efficacy. By varying the extent of the cephalic resection, it offers the possibility of customizing surgery according to the individual patient's morphology.
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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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Yadav SK, Gupta V, Khan AA. Spontaneous duodenal fistulization of pseudocyst of pancreas: A rare entity in children. J Indian Assoc Pediatr Surg 2010; 15:32-3. [PMID: 21180504 PMCID: PMC2998668 DOI: 10.4103/0971-9261.69141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The spontaneous resolution of pseudopancreatic cyst due to internal fistulization into the duodenum in a 4-year-old male child is described here. This is rare and the child presented initially with features of duodenal obstruction. Upper gastrointestinal endoscopy and computed tomography scan confirmed the diagnosis and the unusual mode of resolution of this entity.
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Affiliation(s)
- Sunil Kumar Yadav
- Department of Pediatric and Neonatal Surgery, IBN Sina Hospital, Kuwait
| | - Vipul Gupta
- Department of Pediatric and Neonatal Surgery, IBN Sina Hospital, Kuwait
| | - Ashhad Ali Khan
- Department of Pediatric and Neonatal Surgery, IBN Sina Hospital, Kuwait
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Abstract
Treatment with asparaginase for acute lymphoblastic leukemia can cause acute pancreatitis. Complication of pancreatitis by pancreatic pseudocyst formation can prolong the hospital stay, delay chemotherapy, and necessitate long-term parenteral nutrition. We report 5 children with acute lymphoblastic leukemia who developed acute pancreatitis complicated by pancreatic pseudocysts. They required modifications to their chemotherapy regimen and prolonged parenteral nutrition but no surgical intervention. All 5 patients survive in first remission and their pseudocysts resolved after 3 to 37 months or continued to decrease in size at last follow-up. These cases illustrate that nonsurgical management of pancreatic pseudocyst is safe, though pseudocyst resolution may require many months. In addition, these patients demonstrate that oral feeding can be initiated after the acute episode of pancreatitis resolves even if a pseudocyst is present.
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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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Diagnosis and management of pancreatic pseudocysts: what is the evidence? J Am Coll Surg 2009; 209:385-93. [PMID: 19717045 DOI: 10.1016/j.jamcollsurg.2009.04.017] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Revised: 02/17/2009] [Accepted: 04/13/2009] [Indexed: 12/13/2022]
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A unifying concept: pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis. J Am Coll Surg 2009; 208:790-9; discussion 799-801. [PMID: 19476839 DOI: 10.1016/j.jamcollsurg.2008.12.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 12/19/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Precepts about acute pancreatitis, necrotizing pancreatitis, and pancreatic fluid collections or pseudocyst rarely include the impact of pancreatic ductal injuries on their natural course and outcomes. We previously examined and established a system to categorize ductal changes. We sought a unifying concept that may predict course and direct therapies in these complex patients. STUDY DESIGN We use our system categorizing ductal changes in pseudocyst of the pancreas and severe necrotizing pancreatitis (type I, normal duct; type II, duct stricture; type III, duct occlusion or "disconnected duct"; and type IV, chronic pancreatitis). From 1985 to 2006, a policy was implemented of routine imaging (cross-sectional, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography). Clinical outcomes were measured. RESULTS Among 563 patients with pseudocyst, 142 resolved spontaneously (87% of type I, 5% of type II, and no type III, and 3% of type IV). Percutaneous drainage was successful in 83% of type I, 49% of type II, and no type III or type IV. Among 174 patients with severe acute pancreatitis percutaneous drainage was successful in 64% of type I, 38% of type II, and no type III. Operative debridement was required in 39% of type I and 83% and 85% of types II and III, respectively. Persistent fistula after debridement occurred in 27%, 54%, and 85% of types I, II, and III ducts, respectively. Late complications correlated with duct injury. CONCLUSIONS Pancreatic ductal changes predict spontaneous resolution, success of nonoperative measures, and direct therapies in pseudocyst. Ductal changes also predict patients with necrotizing pancreatitis who are most likely to have immediate and delayed complications.
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Prochazka V, Al-Eryani S, Herman M. Endoscopic treatment of multiple pancreatic abscesses case report and review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2009; 153:27-30. [PMID: 19365522 DOI: 10.5507/bp.2009.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIMS Pancreatic abscesses are treated surgically and the role of endotherapy is still to be established. We describe the case of successful endoscopic management of two pancreatic abscesses in a critically ill patient. METHODS A patient was admitted to the hospital for severe acute pancreatitis. One month later the patient developed pancreatic sepsis. CT scan showed two large abscesses. The first was bulging to the posterior wall of the stomach and another at the tail of the pancreas. Parenteral antibiotic therapy was administered. The clinical status of the patient rapidly deteriorated and the patient was unfit for surgical intervention. The endoscopic retrograde cholangiopancreatography was performed. The pancreatic duct communicated with the abscess at the tail of the pancreas. The drainage of this abscess was done transpapillarily. Endoscopic cystogastrostomy was performed to treat the pancreatic abscess that bulged to the posterior gastric wall. A double nasocystic tube was placed for continuous lavage of the abscess. Pseudomonas aeruginosa was cultured and antibiotics were administered according to sensitivity tests. The clinical status returned gradually to normal. A follow-up CT scan 4 months later showed complete resolution of abscesses. RESULT The drainage of the abscesses was done by the means of endoscopic cystogastrostomy and transpapillary stent insertion. This was a minimally invasive intervention, by which we avoided surgical intervention that bears significant mortality and morbidity. CONCLUSION Endoscopic drainge of pancreatic abscesses may be the therapy of choice in such patients mainly because it does not prevent the chance of subsequent surgical intervention if needed.
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Affiliation(s)
- Vlastimil Prochazka
- Department of Internal Medicine II, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic.
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Voermans RP, Fockens P. Endoscopic treatment of pancreatic fluid collections in 2008 and beyond. Gastrointest Endosc 2009; 69:S186-91. [PMID: 19179154 DOI: 10.1016/j.gie.2008.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Talreja JP, Shami VM, Ku J, Morris TD, Ellen K, Kahaleh M. Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video). Gastrointest Endosc 2008; 68:1199-203. [PMID: 19028232 DOI: 10.1016/j.gie.2008.06.015] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 06/15/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Drainage of pancreatic-fluid collections (PFCs) by using fully covered self-expanding metallic stents (CSEMSs) offers the option of providing a larger-diameter access fistula for drainage when compared with plastic stents. OBJECTIVE To evaluate the efficacy and safety of transenteric drainage of PFCs by using CSEMSs. DESIGN A prospective case series. SETTING A tertiary-referral center. PATIENTS Between January 2007 and September 2007, 18 patients underwent drainage of PFCs by using CSEMSs. Follow-up and final results were prospectively recorded until May 2008. INTERVENTIONS Placement of CSEMSs with a double-pigtail stent placed alongside (4 cases) or into the CSEMS (14 cases) to prevent migration. MAIN OUTCOME MEASUREMENTS The number of sessions and time to resolution of the PFCs. RESULTS A median of 1 session was required to achieve drainage (range 1-4) when using CSEMSs. Complications included superinfection (5), bleeding (2), and inner migration (1). A total of 17 of 18 patients (95%) responded successfully, with 14 patients (78%) achieving complete resolution of their PFC. The mean (+/- SD) time of follow-up until final resolution was 77 +/- 80 days (range 15-310 days). CONCLUSIONS Placement of CSEMSs seems to offer an effective and safe alternative for the drainage of PFCs. A randomized controlled trial should be performed to compare this technique with plastic-stent drainage.
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Affiliation(s)
- Jayant P Talreja
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, Virginia 22908-0708, USA
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Gachago C, Draganov PV. Pain management in chronic pancreatitis. World J Gastroenterol 2008; 14:3137-48. [PMID: 18506917 PMCID: PMC2712844 DOI: 10.3748/wjg.14.3137] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2007] [Revised: 01/30/2008] [Accepted: 02/06/2008] [Indexed: 02/06/2023] Open
Abstract
Abdominal pain is a major clinical problem in patients with chronic pancreatitis. The cause of pain is usually multifactorial with a complex interplay of factors contributing to a varying degree to the pain in an individual patient and, therefore, a rigid standardized approach for pain control tends to lead to suboptimal results. Pain management usually proceeds in a stepwise approach beginning with general lifestyle recommendations. Low fat diet, alcohol and smoking cessation are encouraged. Analgesics alone are needed in almost all patients. Maneuvers aimed at suppression of pancreatic secretion are routinely tried. Patients with ongoing symptoms may be candidates for more invasive options such as endoscopic therapy, and resective or drainage surgery. The role of pain modifying agents (antidepressants, gabapentin, peregabalin), celiac plexus block, antioxidants, octreotide and total pancreatectomy with islet cell auto transplantation remains to be determined.
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Abstract
Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Diagnosis is accomplished most often by computed tomographic scanning, by endoscopic retrograde cholangiopancreatography, or by ultrasound, and a rapid progress in the improvement of diagnostic tools enables detection with high sensitivity and specificity. Different strategies contribute to the treatment of pancreatic pseudocysts: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means. This review entails publications referring to the classification of pancreatic pseudocysts, epidemiology, diagnostic tools, and therapeutic options for pancreatic pseudocysts. Only full articles were considered for the review. Based on a search in PubMed, the MeSH terms "pancreatic pseudocysts and classification," "diagnosis," and "endoscopic, percutaneous, and surgical treatment" were used either alone or in combination.
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Krishna RP, Lal R, Sikora SS, Yachha SK, Pal L. Unusual causes of extrahepatic biliary obstruction in children: a case series with review of literature. Pediatr Surg Int 2008; 24:183-90. [PMID: 18071716 DOI: 10.1007/s00383-007-2087-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2007] [Indexed: 11/25/2022]
Abstract
This paper highlights the etiology, diagnosis, management and outcome in nine unusual cases of extrahepatic biliary obstruction in children. Extrahepatic biliary atresia and choledochal cyst constituted 127 out of 136 (93%) cases of all pediatric surgical biliary disorders managed between March 2000 and February 2007 at the reporting centre. However, nine children (aged 1.5-15 years) presented with uncommon causes like (1) idiopathic benign non-traumatic inflammatory stricture (n = 3), (2) idiopathic fibrosing chronic pancreatitis (n = 2), (3) post-cholecystectomy type 4 benign biliary stricture (n = 1), (4) post-acute pancreatitis pseudo-cyst of pancreas (n = 1), (5) non-Hodgkin's lymphoma (NHL) with extramural common bile duct compression and gall bladder perforation (n = 1), and (6) Langerhan cell histiocytosis (LCH, n = 1). The clinical features and the diagnostic work up of each group are discussed. A preoperative endoscopic/percutaneous biliary drainage was required in four children because of cholangitis at presentation. A biliary-enteric anastomosis was performed for all seven children in groups (1)-(4). The patients with NHL and LCH were referred for chemotherapy after establishing tissue diagnosis at laparotomy. With a follow-up period of 3 months to 7 years, seven children (with the exception of patients with NHL and LCH) are currently anicteric. This paper draws attention to some infrequently discussed causes of extrahepatic biliary obstruction in children. The management entails a carefully planned combination of endoscopic interventions, interventional radiology and surgery. The outcome in benign cases is usually satisfactory.
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Affiliation(s)
- R Phani Krishna
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
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Pancreas. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Palanivelu C, Senthilkumar K, Madhankumar MV, Rajan PS, Shetty AR, Jani K, Rangarajan M, Maheshkumaar GS. Management of pancreatic pseudocyst in the era of laparoscopic surgery--experience from a tertiary centre. Surg Endosc 2007; 21:2262-2267. [PMID: 17516116 DOI: 10.1007/s00464-007-9365-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Revised: 01/26/2007] [Accepted: 02/27/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND In the era of minimally invasive surgery, laparoscopy has a great role to play in the management of pseudocyst of pancreas. We present our surgical experience over the past 12 years (May 1994 to April 2006) in the management of pancreatic pseudocysts. MATERIALS AND METHODS The total number of cases was 108, with 76 male and 32 female patients. Age ranged from 18 to 70 years. Duration of symptoms ranged from 45 days to 7 months. Fifty-nine patients presented with pain abdomen. Sixty-one patients had co-morbid illness. Ten patients had abdominal mass on clinical examination. Predisposing factors were gallstones in 58 cases, alcohol in 20 cases, trauma in eight cases and post-pancreatectomy in one case. In 21 cases there are no predisposing factors. RESULTS All the cases were successfully operated without any significant intraoperative complication. Laparoscopic cystogastrostomy was done in 90 cases (83.4%), laparoscopic cystojejunostomy in eight cases (7.4%), open cystogastrostomy in two cases (1.8%), and laparoscopic external drainage in eight cases (7.4%). Laparoscopic cholecystectomy was done in 47 cases along with the drainage procedure. The mean operating time was 95 minutes. Mean blood loss was 69 ml. Mean hospital stay was 5.6 days. Percutaneous tube drain to assist decompression of the cyst was kept in all the laparoscopic cystojejunostomy (LCJ) group. Two patients were re-operated for bleeding and gastric outlet obstruction. We had no mortality in the postoperative period. With mean follow up of 54 months (range 3-145 months); only one patient who underwent laparoscopic cystogastrostomy (LCG) earlier in this series had recurrence due to inadequate stoma size. This patient later underwent OCG CONCLUSION: Laparoscopy has a significant role to play in the surgical management of pseudocysts with excellent outcome. It offers all the benefits of minimally invasive surgery to the patients.
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