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Soltani A, Salimi M, Nemati M, Mirshamsi A. Recurrent gastric intramural pseudocyst: A case report and comprehensive literature review of reported cases. Radiol Case Rep 2024; 19:5429-5441. [PMID: 39285981 PMCID: PMC11403908 DOI: 10.1016/j.radcr.2024.08.041] [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: 08/04/2024] [Revised: 08/07/2024] [Accepted: 08/10/2024] [Indexed: 09/19/2024] Open
Abstract
Intramural gastric pseudocysts are extremely rare and are often associated with pancreatitis and pancreatic pseudocysts; they can lead to complex clinical presentations requiring careful diagnosis and management. We present a case of a 57-year-old man with a history of pancreatitis and pancreatic pseudocysts who was diagnosed with intramural gastric pseudocysts. The patient was diagnosed with multiple gastric intramural pseudocysts at different locations during separate admissions and imaging studies. This indicates a recurrence of gastric intramural pseudocysts. In these cases, studies rarely discuss recurrence and its underlying causes. This highlights a significant gap in the existing literature. To provide a broader understanding, we reviewed the literature by searching major databases (PubMed, Scopus, and Web of Science) and then extracted and analyzed data from 18 articles, reaching 24 similar cases. Of the 25 patients studied (including our case), 92% were male and 8% were female. Cases had a mean age of 47.68 ± 14.82 years. Additionally, 84% of the patients had a history of alcohol consumption, and 88% had a positive history of pancreatitis. Common symptoms were abdominal pain (especially in the epigastric region), vomiting, nausea, and weight loss. In conclusion, results showed that intramural gastric pseudocysts generally occur in middle-aged men with a history of chronic or heavy alcohol consumption and pancreatitis.
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Affiliation(s)
- Amirhossein Soltani
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
- Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohsen Salimi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Nemati
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Mirshamsi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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2
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Skedros JG, Montgomery JA, Cronin JT, Moesinger RC, Kaushal SD, Johnson PJ. Elective Lumbar Spine Surgery Leads to the Development of Chronic Pancreatitis and Pancreatic Pseudocyst: A Case Report and Literature Review. Cureus 2024; 16:e70272. [PMID: 39463520 PMCID: PMC11513181 DOI: 10.7759/cureus.70272] [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: 08/01/2024] [Indexed: 10/29/2024] Open
Abstract
The occurrence of pancreatitis shortly after elective lumbar spine surgery in an adult is rare. We report a case of a 63-year-old female who developed, for the first time, acute pancreatitis within three days of elective lumbar (L) spine surgery that was performed for degenerative disk disease without significant deformity (i.e., no scoliosis or spondylolisthesis). The surgery was conducted using a lateral transpsoas approach and included interbody fusions at L3-L4 and L4-L5 levels and posterior instrumentation with pedicle screws and rods. Ten years prior, she had a cholecystectomy, and she was not diabetic or obese. She began experiencing significant nausea and malaise two days after that lumbar spine surgery, requiring hospitalization on the third postoperative day. Her pancreatitis became chronic, and a large pancreatic pseudocyst developed and persisted despite using an external drainage catheter for 52 days. At 126 days after the spinal surgery, an open Roux-en-Y pancreatic cystojejunostomy was performed to internally drain the cyst, which had enlarged to 19 cm. Significant pre-surgical risk factors for this first-time case of pancreatitis were not identified. The spine surgeon denied iatrogenic causes such as instrument plunging or complications associated with the use of a "lateral access retraction system," and surgical blood loss was only 50 ml during the elective lumbar spine surgery. However, during the lumbar spine surgery, hypotension occurred for 20 minutes (mean arterial pressure: 63-73 mmHg), which was associated with transient acute kidney injury. This might have contributed to the development of her pancreatitis because the pancreas is more sensitive to ischemia than the kidney. During the initial week after the onset of pancreatitis, her symptoms were mainly believed to be due to an acute postoperative infection. However, there was no growth in cultures from aspirations of the pleural effusion, retroperitoneal effusion, and deeper incision area. Despite extensive workup, the cause of the patient's pancreatitis was not determined. We report this case not only because of its rarity but also to help surgeons and other healthcare providers in the workup and management of similar situations.
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Affiliation(s)
- John G Skedros
- Shoulder and Elbow Surgery, Utah Orthopaedic Specialists, Salt Lake City, USA
- Orthopaedics, University of Utah, Salt Lake City, USA
| | | | - John T Cronin
- Shoulder and Elbow Surgery, Utah Orthopaedic Specialists, Salt Lake City, USA
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3
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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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Duggal S, Nagineni L, Trivedi BS, Zuckerman M, Badillo R. Evolving Endoscopic Approaches to Pancreatic Pseudocysts and Walled-Off Necrosis: Case Series and Review of Evidence. J Investig Med High Impact Case Rep 2024; 12:23247096241304521. [PMID: 39660888 PMCID: PMC11635886 DOI: 10.1177/23247096241304521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 11/04/2024] [Accepted: 11/14/2024] [Indexed: 12/12/2024] Open
Abstract
Imaging followed by endoscopic ultrasound (EUS)-guided therapy has become the preferred modality for treating pancreatic pseudocysts over surgical or radiological interventions. However, there continues to be a lack of consensus regarding the utility of endoscopic retrograde cholangiopancreatography (ERCP) before and after cyst drainage. We describe 4 cases of large pancreatic pseudocyst causing extrinsic biliary obstruction treated successfully with endoscopic cystogastrostomy decompression using a lumen-apposing self-expandable metal stent (LAMS) without ERCP. Endoscopic cystogastrostomy with LAMS was successful in all cases; none required ERCP. As endoscopic therapeutic systems continue to evolve, ERCP is becoming less essential to improve outcomes in patients with extrinsic biliary obstruction by pseudocysts and walled-off necrosis.
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Affiliation(s)
| | | | | | - Marc Zuckerman
- Texas Tech University Health Sciences Center El Paso, USA
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5
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Zerem E, Kurtcehajic A, Kunosić S, Zerem Malkočević D, Zerem O. Current trends in acute pancreatitis: Diagnostic and therapeutic challenges. World J Gastroenterol 2023; 29:2747-2763. [PMID: 37274068 PMCID: PMC10237108 DOI: 10.3748/wjg.v29.i18.2747] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/07/2023] [Accepted: 04/18/2023] [Indexed: 05/11/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.
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Affiliation(s)
- Enver Zerem
- Department of Medical Sciences, The Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo 71000, Bosnia and Herzegovina
| | - Admir Kurtcehajic
- Department of Gastroenterology and Hepatology, Plava Medical Group, Tuzla 75000, Bosnia and Herzegovina
| | - Suad Kunosić
- Department of Physics, Faculty of Natural Sciences and Mathematics, University of Tuzla, Tuzla 75000, Bosnia and Herzegovina
| | - Dina Zerem Malkočević
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
| | - Omar Zerem
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
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Yan J, Yu W, Yan J, Guo X, Hou L, Ren L, Fan H. Spontaneous Rupture and Hemorrhage of WON: A Case Report. Front Surg 2022; 9:906520. [PMID: 35846954 PMCID: PMC9276918 DOI: 10.3389/fsurg.2022.906520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pancreatic pseudocysts are characterized by the leakage of pancreatic juice caused by various reasons, which leads to pancreatic juice accumulates around the pancreas, and stimulates the greater omentum and other tissues to form an area of fibrotic loculated effusion with an integrated capsule. Approximately, one-third of patients experienced recurrent pancreatic juice leakage, compression symptoms, infection, and bleeding, which requires surgical intervention, but spontaneous rupture cases are extremely rare. CASE PRESENTATION We here present the case of 40-year-old male who presented with abdominal pain and vomiting for two days and 10 h, respectively. He had a history of chronic pancreatitis and pseudocysts. The symptoms of abdominal pain worsened in the second day. Laboratory tests showed a progressive decrease in hemoglobin. Then, emergency pancreatoduodenectomy was performed. Intraoperative exploration found a small blood clot in the abdominal cavity and a hematoma that had formed in the intestinal cavity and retroperitoneum. CONCLUSION This case showed that pseudocysts of the pancreas can rupture under certain circumstances, leading to intraperitoneal bleeding and hematoma formation, which can endanger the life of the patient. And surgical treatment can be the first choice for hemorrhagic pseudocysts.
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Affiliation(s)
- Jican Yan
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Xining, China
- Department of Postgraduate, Qinghai University, Xining, China
| | - Wenhao Yu
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Xining, China
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Qinghai Key Laboratory of Hydatid Research, Xining, China
| | - Jingxin Yan
- Department of Postgraduate, Qinghai University, Xining, China
- Department of Interventional Therapy, Qinghai University, Xining, China
| | - Xinjian Guo
- Department of Pathology, Affiliated Hospital of Qinghai University, Xining, China
| | - Lizhao Hou
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Xining, China
| | - Li Ren
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Xining, China
| | - Haining Fan
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Xining, China
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Qinghai Key Laboratory of Hydatid Research, Xining, China
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Copelin E, Widmer J. Management of severe acute pancreatitis in 2019. Transl Gastroenterol Hepatol 2022; 7:16. [PMID: 35548476 PMCID: PMC9081916 DOI: 10.21037/tgh-2020-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 05/25/2020] [Indexed: 09/17/2023] Open
Abstract
Pancreatic fluid collections (PFCs) are frequent complications in severe acute pancreatitis that are the result of damage to the pancreas to include but not limited to trauma, surgery, autoimmune diseases, alcohol abuse, infections, medications, gallstones, metabolic disorders, and premalignant or malignant conditions. The majority of these collections resolve spontaneously; however, if the collection is infected or causes symptoms to include abdominal pain, nausea, vomiting, diarrhea, fevers, and tachycardia, drainage is indicated. Drainage of PFCs can be accomplished surgically, percutaneously, or endoscopically and should be approached in a multidisciplinary fashion for best overall patient care and outcomes. Before the introduction of endoscopic procedures, surgical and percutaneous drainage was the preferred modality. Today a minimally-invasive "step-up" approach is generally accepted depending upon the specific characteristics of the PFC and clinical presentation. Endoscopic ultrasound-guided PFC drainage is favored due to high success rates, shorter hospital stays, and lower cost. Direct debridement of walled-off pancreatitis can now be performed endoscopically with higher success rates with larger caliber fully covered metal stents. At large, the field of endoscopic techniques has evolved, and more specifically, the management of PFCs continues to evolve with increasing experience and with the advent of new stents and accessories, leading to increased efficacy with less adverse events.
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Endoscopic Drainage of Giant Pancreatic Pseudocysts Using Both Lumen-Apposing Metal Stent and Plastic Stent: A Report of Two Cases and Review of the Current Literature. Case Rep Gastrointest Med 2021; 2021:6610610. [PMID: 33868735 PMCID: PMC8035029 DOI: 10.1155/2021/6610610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/22/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction A pancreatic pseudocyst (PP) with major diameter equal to 10 cm or more is called a giant pseudocyst. The ideal management for giant PPs is controversial. Endoscopic drainage is an alternative nonsurgical approach for PP management. Only a few cases of giant PPs were reported to be managed by endoscopic drainage. Case Presentation. We reported two cases of giant PPs following an episode of acute pancreatitis. Both were resolved following endoscopic cystogastrostomy using metallic and double-pigtail stents with excellent outcomes. There was no history of recurrence or complications on follow-up. In addition, we extensively reviewed all available literature studies of giant pancreatic pseudocyst presentation, management, and complications. We summarized all reported cases and presented them in a comprehensive table. Conclusion The endoscopic cystogastrostomy approach is cost saving, can avoid surgical complications, and offers an early hospital discharge.
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Renelus BD, Jamorabo DS, Gurm HK, Dave N, Briggs WM, Arya M. Comparative outcomes of endoscopic ultrasound-guided cystogastrostomy for peripancreatic fluid collections: a systematic review and meta-analysis. Ther Adv Gastrointest Endosc 2019; 12:2631774519843400. [PMID: 31192314 PMCID: PMC6537502 DOI: 10.1177/2631774519843400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/20/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Endoscopic ultrasound–guided cystogastrostomy has become the first-line treatment for symptomatic peripancreatic fluid collections. The aim of this study is to analyze the efficacy and safety of cystogastrostomy via a meta-analysis of the literature. Methods: We performed a systematic search of PubMed and Medline databases for studies published from January 2005 to May 2018. We included randomized controlled trials along with retrospective and prospective observational studies reporting endoscopic ultrasound–guided cystogastrostomy stent placement for peripancreatic fluid collections. The primary outcome for our meta-analysis was complete peripancreatic fluid collection resolution on imaging. Our secondary outcomes included comparative efficacy and safety of the procedure for pseudocysts and walled-off pancreatic necrosis using metal and plastic stents. Results: Seventeen articles involving 1708 patients met our inclusion criteria for meta-analysis. Based upon the random effects model, the pooled technical success rate of cystogastrostomy was 88% (95% confidence interval = 83–92 with I2 = 85%). There was no difference in the technical success rate between pancreatic pseudocysts and walled-off pancreatic necrosis (91% and 86%, respectively p = nonsignificant). The adverse event rates for metal and plastic stents were equivalent (14% and 18%, respectively, p = nonsignificant). Conclusion: Endoscopic ultrasound–guided cystogastrostomy stents are effective in the treatment of pancreatic pseudocysts and walled-off pancreatic necrosis. We found no difference in technical success or adverse event rates of drainage based on peripancreatic fluid collection type or stent used.
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Affiliation(s)
- Benjamin D Renelus
- Division of Gastroenterology and Hepatobiliary Disease, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Daniel S Jamorabo
- Division of Gastroenterology and Hepatobiliary Disease, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Hashroop K Gurm
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Niel Dave
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - William M Briggs
- Division of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, NY, USA
| | - Mukul Arya
- Division of Gastroenterology and Hepatobiliary Disease, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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Biliary Stenosis and Gastric Outlet Obstruction: Late Complications After Acute Pancreatitis With Pancreatic Duct Disruption. Pancreas 2018; 47:772-777. [PMID: 29771770 DOI: 10.1097/mpa.0000000000001064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Pancreatic duct disruption (PDD) after acute pancreatitis can cause pancreatic collections in the early phase and biliary stenosis (BS) or gastric outlet obstruction (GOO) in the late phase. We aimed to document those late complications after moderate or severe acute pancreatitis. METHODS Between September 2010 and August 2014, 141 patients showed pancreatic collections on computed tomography. Percutaneous drainage was primarily performed for patients with signs or symptoms of uncontrolled pancreatic juice leakage. Pancreatic duct disruption was defined as persistent amylase-rich drain fluid or a pancreatic duct cut-off on imaging. Clinical course of the patients who developed BS or GOO was investigated. RESULTS Among the 141 patients with collections, 33 patients showed PDD in the pancreatic head/neck area. Among them, 9 patients (27%) developed BS 65 days after onset and required stenting for 150 days, and 5 patients (15%) developed GOO 92 days after onset and required gastric decompression and jejunal tube feeding for 147 days (days shown in median). All 33 patients recovered successfully without requiring surgical intervention. CONCLUSIONS Anatomic proximity of the bile duct or duodenum to the site of PDD and severe inflammation seemed to contribute to the late onset of BS or GOO. Conservative management successfully reversed these complications.
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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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12
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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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Kamal A, Singh VK, Akshintala VS, Kawamoto S, Tsai S, Haider M, Fishman EK, Kamel IR, Zaheer A. CT and MRI assessment of symptomatic organized pancreatic fluid collections and pancreatic duct disruption: an interreader variability study using the revised Atlanta classification 2012. ACTA ACUST UNITED AC 2016; 40:1608-16. [PMID: 25425489 DOI: 10.1007/s00261-014-0303-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Compare CT and MRI for fluid/debris component estimate and pancreatic duct (PD) communication with organized pancreatic fluid collections in acute pancreatitis. Evaluate fat density globules on CT as marker for debris. METHODS 29 Patients with 46 collections with CECT and MRI performed ≥4 weeks of symptom onset assessed for necrotizing pancreatitis, estimated percentage of fluid volume and PD involvement by two radiologists on separate occasions. T2WI used as standard for estimated percentage of fluid volume. Presence of fat globules and fluid attenuation on CT was recorded. Spearman rank correlation and kappa statistics were used to assess the correlation between imaging techniques and interreader agreement, respectively. RESULTS Necrotizing pancreatitis seen on CT in 27 (93%, κ 0.119) vs. 20 (69%, κ 0.748) patients on MRI. CT identified 42 WON and 4 pseudocysts vs. 34 WON, and 12 pseudocysts on MRI. Higher interreader agreement for percentage fluid volume on MRI (κ = 0.55) vs. CT (κ = 0.196). Accuracy of CT in evaluation of percentage fluid volume was 65% using T2WI MRI used as standard. Fat globules identified on CT in 13(65%) out of 20 collections containing <75% fluid vs. 4(15%) out of 26 collections containing >75% fluid (p = 0.0001). PD involvement confidently excluded on CT in 68% collections vs. 93% on MRI. CONCLUSION MRI demonstrates higher reproducibility for fluid to debris component estimation. Fat globules on CT were frequently seen in organized pancreatic fluid collections with large amount of debris. PD disruption more confidently excluded on MRI. This information may be helpful for pre-procedure planning.
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Affiliation(s)
- Ayesha Kamal
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N. Caroline Street, JHOC 3235 A, Baltimore, MD, 21231, USA,
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Abstract
BACKGROUND A pancreatic pseudocyst is the collection of pancreatic secretions surrounded by fibrous tissue caused by pancreatic disease that affects the pancreatic duct. Clinical presentation is variable. Management includes percutaneous, endoscopic or surgical drainage and resection. MATERIAL AND METHODS Review of a cohort of patients with pancreatic pseudocyst in a third level hospital. An analysis was performed on the demographic data, aetiology, clinical presentation, radiological and laboratory findings, type of surgical procedure, complications, recurrence and mortality. The statistical analysis was performed using Chi squared and Student t tests, with a p<0.05. RESULTS A total of 139 patients were included, of whom 58% were men and 42% were women, with median age of 44.5 years. Chronic pancreatitis was the most common aetiology, present in 74 patients (53%). The main complaint was abdominal pain in 73% of patients. Median size was 18cm (range 7-29) and the most frequent location was body and tail of the pancreas. Internal surgical drainage was selected in 111 (80%) patients, of whom 96 were cystojejunostomy, 20 (14%) had external surgical drainage, and 8 (6%) resection. Complications were, pancreatic fistula (12%), haemorrhage (4%), infection (4%), and other non-surgical complications (4%). Complication rate was higher if the cause was chronic pancreatitis or if the management was external surgical drainage. Recurrence rate was 6%, and a mortality rate of 1%. CONCLUSION Surgical management is a viable option for the management of pancreatic pseudocyst with a low complication and recurrence rate.
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Patel BN, Gupta RT, Zani S, Jeffrey RB, Paulson EK, Nelson RC. How the radiologist can add value in the evaluation of the pre- and post-surgical pancreas. ABDOMINAL IMAGING 2015; 40:2932-44. [PMID: 26482048 DOI: 10.1007/s00261-015-0549-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Disease involving the pancreas can be a significant diagnostic challenge to the interpreting radiologist. Moreover, the majority of disease processes involving the pancreas carry high significant morbidity and mortality either due to their natural process or related to their treatment options. As such, it is critical for radiologists to not only provide accurate information from imaging to guide patient management, but also deliver that information in a clear manner so as to aid the referring physician. This is no better exemplified than in the case of pre-operative staging for pancreatic adenocarcinoma. Furthermore, with the changing healthcare landscape, it is now more important than ever to ensure that the value of radiology service to other providers is high. In this review, we will discuss how the radiologist can add value to the referring physician by employing novel imaging techniques in the pre-operative evaluation as well as how the information can be conveyed in the most meaningful manner through the use of structured reporting. We will also familiarize the radiologist with the imaging appearance of common complications that occur after pancreatic surgery.
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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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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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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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Zerem E. Treatment of severe acute pancreatitis and its complications. World J Gastroenterol 2014; 20:13879-13892. [PMID: 25320523 PMCID: PMC4194569 DOI: 10.3748/wjg.v20.i38.13879] [Citation(s) in RCA: 226] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/08/2014] [Accepted: 06/02/2014] [Indexed: 02/06/2023] Open
Abstract
Severe acute pancreatitis (SAP), which is the most serious type of this disorder, is associated with high morbidity and mortality. SAP runs a biphasic course. During the first 1-2 wk, a pro-inflammatory response results in systemic inflammatory response syndrome (SIRS). If the SIRS is severe, it can lead to early multisystem organ failure (MOF). After the first 1-2 wk, a transition from a pro-inflammatory response to an anti-inflammatory response occurs; during this transition, the patient is at risk for intestinal flora translocation and the development of secondary infection of the necrotic tissue, which can result in sepsis and late MOF. Many recommendations have been made regarding SAP management and its complications. However, despite the reduction in overall mortality in the last decade, SAP is still associated with high mortality. In the majority of cases, sterile necrosis should be managed conservatively, whereas in infected necrotizing pancreatitis, the infected non-vital solid tissue should be removed to control the sepsis. Intervention should be delayed for as long as possible to allow better demarcation and liquefaction of the necrosis. Currently, the step-up approach (delay, drain, and debride) may be considered as the reference standard intervention for this disorder.
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The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines. ACTA ACUST UNITED AC 2013; 38:125-36. [PMID: 22584543 DOI: 10.1007/s00261-012-9908-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Imaging of acute pancreatitis requires not only an understanding of the disease subtypes and the myriad of associated complications but also familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, by the Acute Pancreatitis Classification Working Group in 2008. The accurate description of the radiological findings plays a critical role in the evaluation and management of patients with acute pancreatitis, particularly those with severe disease. There have been increasing efforts to develop uniformity in the use of terminology used to define the radiologic findings in acute pancreatitis, in particular, the terminology for fluid collections, a common area of inconsistency and confusion. Terms such as "acute peripancreatic fluid collections," "acute post- necrotic fluid collections," "pseudocyst," and "walled-off pancreatic necrosis" are now recommended as they describe the evolution of fluid collections in patients with both interstitial and necrotizing pancreatitis and nonspecific terms such as "pancreatic abscess" and "phlegmon" are being abandoned. In this review we illustrate, with case examples, the standardized terminology used in the radiological and clinical description of acute pancreatitis, its severity, and complications with an emphasis on the role of ultrasound, computed tomography and magnetic resonance imaging. Different management options of the associated complications are also discussed. The use of standardized terminology will hopefully improve the communication between radiologists, gastroenterologists, and surgeons to facilitate treatment planning and will lead to enhanced outcomes for patients with acute pancreatitis as well as create uniformity for enrollment into research studies.
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Laparoscopic Transgastric Pancreatic Débridement. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0020-3] [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]
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Gupta T, Lemmers A, Tan D, Ibrahim M, Le Moine O, Devière J. EUS-guided transmural drainage of postoperative collections. Gastrointest Endosc 2012; 76:1259-1265. [PMID: 23021161 DOI: 10.1016/j.gie.2012.07.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 07/18/2012] [Indexed: 12/14/2022]
Affiliation(s)
- Tarun Gupta
- Department of Gastroenterology, Hepato-Pancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 2012; 262:751-64. [PMID: 22357880 DOI: 10.1148/radiol.11110947] [Citation(s) in RCA: 263] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.
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Affiliation(s)
- Ruedi F Thoeni
- University of California San Francisco Medical School, Department of Radiology and Biomedical Imaging, PO Box 1325, San Francisco, CA 94143-1325, USA.
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25
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Kocher HM, Kadaba R. Chronic pancreatitis. BMJ CLINICAL EVIDENCE 2011; 2011:0417. [PMID: 22189345 PMCID: PMC3635586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Chronic pancreatitis affects 3-9 people in 100,000; 70% of cases are alcohol-induced. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of lifestyle interventions in people with chronic pancreatitis? What are the effects of dietary supplements in people with chronic pancreatitis? What are the effects of drug interventions in people with chronic pancreatitis? What are the effects of nerve blocks for pain relief in people with chronic pancreatitis? What are the effects of different invasive treatments for specific complications of chronic pancreatitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 27 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: avoiding alcohol consumption, biliary decompression, calcium supplements, ductal decompression (endoscopic or surgical), low-fat diet, nerve blocks, opioid analgesics, pancreatic enzyme supplements, pseudocyst decompression (endoscopic or surgical), resection using distal pancreatectomy, resection using pancreaticoduodenectomy (Kausch-Whipple or pylorus-preserving), and vitamin/antioxidant supplements.
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Abstract
Percutaneous abscess drainage is one of the most common and rewarding procedures performed by interventional radiologists. Technical success is immediately apparent by aspiration of purulent contents and is nearly always achieved, with rates exceeding 90% in most literature studies. Clinical success is typical even for many abscesses colonized with multidrug-resistant organisms. In patients presenting with sepsis, this procedure offers an immediate and minimally invasive solution to a life-threatening condition, often resulting in defervescence and restoration of hemodynamic stability within 1 to 2 days. Although complications of abscess drainage are uncommon, radiologists should be able to recognize and treat all adverse sequelae discussed in this article.
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Affiliation(s)
- Jonathan Lorenz
- Section of Interventional Radiology, University of Chicago Hospitals, Chicago, Illinois
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Frulloni L, Falconi M, Gabbrielli A, Gaia E, Graziani R, Pezzilli R, Uomo G, Andriulli A, Balzano G, Benini L, Calculli L, Campra D, Capurso G, Cavestro GM, De Angelis C, Ghezzo L, Manfredi R, Malesci A, Mariani A, Mutignani M, Ventrucci M, Zamboni G, Amodio A, Vantini I, Bassi C, Delle Fave G, Frulloni L, Vantini I, Falconi M, Frulloni L, Gabbrielli A, Graziani R, Pezzilli R, Capurso IV, Cavestro GM, De Angelis C, Falconi M, Gaia E, Ghezzo L, Gabbrielli A, Graziani R, Manfredi R, Malesci A, Mariani A, Mutignani M, Pezzilli R, Uomo G, Ventrucci M, Zamboni G, Vantini I, Magarini F, Albarello L, Alfieri S, Amodio A, Andriulli A, Anti M, Arcidiacono P, Baiocchi L, Balzano G, Benini L, Berretti D, Boraschi P, Buscarini E, Calculli L, Carroccio A, Campra D, Celebrano MR, Capurso G, Casadei R, Cavestro GM, Chilovi F, Conigliaro R, Dall'Oglio L, De Angelis C, De Boni M, De Pretis G, Di Priolo S, Di Sebastiano PL, Doglietto GB, Falconi M, Filauro M, Frieri G, Frulloni L, Fuini A, Gaia E, Ghezzo L, Gabbrielli A, Graziani R, Loriga P, Macarri G, Manes G, Manfredi R, Malesci A, Mariani A, Massucco P, Milani S, Mutignani M, Pasquali C, Pederzoli P, Pezzilli R, et alFrulloni L, Falconi M, Gabbrielli A, Gaia E, Graziani R, Pezzilli R, Uomo G, Andriulli A, Balzano G, Benini L, Calculli L, Campra D, Capurso G, Cavestro GM, De Angelis C, Ghezzo L, Manfredi R, Malesci A, Mariani A, Mutignani M, Ventrucci M, Zamboni G, Amodio A, Vantini I, Bassi C, Delle Fave G, Frulloni L, Vantini I, Falconi M, Frulloni L, Gabbrielli A, Graziani R, Pezzilli R, Capurso IV, Cavestro GM, De Angelis C, Falconi M, Gaia E, Ghezzo L, Gabbrielli A, Graziani R, Manfredi R, Malesci A, Mariani A, Mutignani M, Pezzilli R, Uomo G, Ventrucci M, Zamboni G, Vantini I, Magarini F, Albarello L, Alfieri S, Amodio A, Andriulli A, Anti M, Arcidiacono P, Baiocchi L, Balzano G, Benini L, Berretti D, Boraschi P, Buscarini E, Calculli L, Carroccio A, Campra D, Celebrano MR, Capurso G, Casadei R, Cavestro GM, Chilovi F, Conigliaro R, Dall'Oglio L, De Angelis C, De Boni M, De Pretis G, Di Priolo S, Di Sebastiano PL, Doglietto GB, Falconi M, Filauro M, Frieri G, Frulloni L, Fuini A, Gaia E, Ghezzo L, Gabbrielli A, Graziani R, Loriga P, Macarri G, Manes G, Manfredi R, Malesci A, Mariani A, Massucco P, Milani S, Mutignani M, Pasquali C, Pederzoli P, Pezzilli R, Pietrangeli M, Rocca R, Russello D, Siquini W, Traina M, Uomo G, Veneroni L, Ventrucci M, Zilli M, Zamboni G. Italian consensus guidelines for chronic pancreatitis. Dig Liver Dis 2010; 42 Suppl 6:S381-S406. [PMID: 21078490 DOI: 10.1016/s1590-8658(10)60682-2] [Show More Authors] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.
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Affiliation(s)
- Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy.
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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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Seewald S, Ang TL, Kida M, Teng KYK, Soehendra N. EUS 2008 Working Group document: evaluation of EUS-guided drainage of pancreatic-fluid collections (with video). Gastrointest Endosc 2009; 69:S13-21. [PMID: 19179137 DOI: 10.1016/j.gie.2008.10.061] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 10/28/2008] [Indexed: 12/13/2022]
Affiliation(s)
- Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications (infection, gastric outlet or biliary obstruction, bleeding). Three different strategies for pancreatic pseudocysts drainage are available: endoscopic (transpapillary or transmural) drainage, percutaneous catheter drainage, or open surgery. To date, no prospective controlled studies have compared directly these approaches. As a result, the management varies based on local expertise, but in general, endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate. A tailored therapeutic approach taking into consideration patient preferences and involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and pancreatic surgeon should be considered in all cases.
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Andersson B, Andrén-Sandberg A, Andersson R. Survey of the management of pancreatic pseudocysts in Sweden. Scand J Gastroenterol 2009; 44:1252-1258. [PMID: 19658018 DOI: 10.1080/00365520903132005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The management of pancreatic pseudocysts varies, based mainly on local traditions, resources and expertise. No prospective, randomized study has been done comparing different approaches to treatment. The aim of the present study was to identify current treatment strategies in Sweden. MATERIAL AND METHODS A questionnaire comprising 12 questions was e-mailed to the surgical departments of all hospitals (n=58) treating patients with pancreatitis. Comparisons were made between university and non-university hospitals and between hospitals with 150,000 or more persons versus less in the primary catchment area. RESULTS Fifty-one hospitals responded (88%). In median, 4 (0-25) patients were treated yearly due to pancreatic pseudocysts at each hospital. Five hospitals had written guidelines. Multidisciplinary team conferences were held at 36/48 centres. Treatment strategies for acute compared to chronic pancreatitis associated pseudocysts differed significantly depending on the underlying diagnosis in the major hospitals (p=0.005). Overall, 21/49 hospitals refer some of these patients and 15/50 of the departments state that they regularly assist in taking care of patients with pancreatic pseudocysts from other hospitals. The chosen treatment modalities vary widely, above all concerning endoscopic drainage, which is more common for symptomatic non-infected pseudocysts (p=0.005) as well as infected pseudocysts (p=0.004) in university hospitals. CONCLUSIONS The lack of protocols and management strategies for pancreatic pseudocysts is reflected by the heterogeneity in treatment strategies, as seen in the present survey. Therefore patients may be at risk of receiving suboptimal treatment. A tailored therapeutic approach that takes into consideration patient preferences and involves a multidisciplinary team should be considered in all cases.
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Affiliation(s)
- Bodil Andersson
- Department of Surgery, Lund University Hospital, Lund, Sweden.
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33
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Kocher HM, Froeling FE. Chronic pancreatitis. BMJ CLINICAL EVIDENCE 2008; 2008:0417. [PMID: 19445788 PMCID: PMC2907985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Chronic pancreatitis affects 3-9 people in 100,000; 70% of cases are alcohol-induced. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of lifestyle interventions in people with chronic pancreatitis? What are the effects of dietary supplements in people with chronic pancreatitis? What are the effects of drug interventions in people with chronic pancreatitis? What are the effects of nerve blocks for pain relief in people with chronic pancreatitis? What are the effects of different invasive treatments for specific complications of chronic pancreatitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2008 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 23 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: avoiding alcohol consumption, biliary decompression, calcium supplements, ductal decompression (endoscopic or surgical), low-fat diet, nerve blocks, opioid analgesics, pancreatic enzyme supplements, pseudocyst decompression (endoscopic or surgical), resection using distal pancreatectomy, resection using pancreaticoduodenectomy (Kausch-Whipple or pylorus-preserving), and vitamin/antioxidant supplements.
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Affiliation(s)
- Hemant M Kocher
- Department of Health National Clinician Scientist, London, UK
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Behrns KE, Ben-David K. Surgical therapy of pancreatic pseudocysts. J Gastrointest Surg 2008; 12:2231-9. [PMID: 18461418 DOI: 10.1007/s11605-008-0525-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 03/26/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic pseudocysts are a common complication associated with acute and chronic pancreatitis. Fifteen percent and 40% of patients diagnosed with either acute or chronic pancreatitis, respectively, develop pseudocysts (Grace and Williamson, Br J Surg, 80:573-581, 1993). The treatment of pancreatic pseudocysts has evolved since the early 1980s, and changes in management have lead to an improved understanding of the pathophysiology of pseudocysts as well as necessary treatment paradigms. CONCLUSIONS It has become evident that not all pseudocysts are equal. Pseudocysts arising in the setting of acute pancreatitis have a different pathophysiologic basis than those arising from chronic pancreatitis. Moreover, even those pseudocysts that arise in acute pancreatitis exhibit unique features. Pseudocysts that develop from a mild episode of pancreatitis, complicated by pancreatic duct disruption, differ significantly from those developed as a consequence of severe acute necrotizing pancreatitis with severe distortion of the pancreatic parenchyma or pancreatic duct. This review will focus on the surgical therapy of pancreatic pseudocysts in the context of the underlying pathophysiology and alternative nonoperative therapies.
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Affiliation(s)
- Kevin E Behrns
- Department of Surgery, Division of General and GI Surgery, University of Florida, P.O. Box 100286, 1600 SW Archer Rd, Gainesville, FL 32610, USA.
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35
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van Santvoort HC, Bollen TL, Besselink MG, Banks PA, Boermeester MA, van Eijck CH, Evans J, Freeny PC, Grenacher L, Hermans JJ, Horvath KD, Hough DM, Laméris JS, van Leeuwen MS, Mortele KJ, Neoptolemos JP, Sarr MG, Vege SS, Werner J, Gooszen HG. Describing peripancreatic collections in severe acute pancreatitis using morphologic terms: an international interobserver agreement study. Pancreatology 2008; 8:593-9. [PMID: 18849641 DOI: 10.1159/000161010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 07/16/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS The current terminology for describing peripancreatic collections in acute pancreatitis (AP) derived from the Atlanta Symposium (e.g. pseudocyst, pancreatic abscess) has shown a very poor interobserver agreement, creating the potential for patient mismanagement. A study was undertaken to determine the interobserver agreement for a new set of morphologic terms to describe peripancreatic collections in AP. METHODS An international, interobserver agreement study was performed: 7 gastrointestinal surgeons, 2 gastroenterologists and 8 radiologists in 3 US and 5 European tertiary referral hospitals independently evaluated 55 computed tomography (CT) scans of patients with predicted severe AP. The percentage agreement [median, interquartile range (IQR)] for 9 clinically relevant morphologic terms was calculated among all reviewers, and separately among radiologists and clinicians. The percentage agreement was defined as poor (<0.50), moderate (0.51-0.70), good (0.71-0.90), and excellent (0.91-1.00). RESULTS Overall agreement was good to excellent for the terms collection (percentage agreement = 1; IQR 0.68-1), relation with pancreas (1; 0.68-1), content (0.88; 0.87-1), shape (1; 0.78-1), mass effect (0.78; 0.62-1), loculated gas bubbles (1; 1-1), and air-fluid levels (1; 1-1). Overall agreement was moderate for extent of pancreatic nonenhancement (0.60; 0.46-0.88) and encapsulation (0.56; 0.48-0.69). The percentage agreement was greater among radiologists than clinicians for extent of pancreatic nonenhancement (0.75 vs. 0.57, p = 0.008), encapsulation (0.67 vs. 0.46, p = 0.001), and content (1 vs. 0.78, p = 0.008). CONCLUSION Interobserver agreement for the new set of morphologic terms to describe peripancreatic collections in AP is good to excellent. Therefore, we recommend that current clinically based definitions for CT findings in AP (e.g. pancreatic abscess) should no longer be used.
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36
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Jury RP, Tariq N. Minimally invasive and standard surgical therapy for complications of pancreatitis and for benign tumors of the pancreas and duodenal papilla. Med Clin North Am 2008; 92:961-82, x. [PMID: 18570949 DOI: 10.1016/j.mcna.2008.03.004] [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: 01/04/2023]
Abstract
The treatment of severe pancreatitis and its complications is rapidly evolving because of increasing clinical application of effective, minimally invasive techniques. With ongoing innovations in therapeutic endoscopy, image-guided percutaneous techniques, and minimally invasive surgery, the long-standing traditional management algorithms have recently changed. A multidisciplinary approach is necessary for the treatment of complicated inflammatory diseases of the pancreas and benign periampullary tumors. Surgeons, gastroenterologists, and therapeutic radiologists combine expertise as members of a team to offer their patients improved outcomes and faster recovery.
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Affiliation(s)
- Robert P Jury
- Division of Gastrointestinal, Pancreatic and Hepatobiliary Surgery, William Beaumont Hospital, 3601 W. Thirteen Mile Road, Royal Oak, MI 48073, USA.
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37
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Bergman S, Melvin WS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2008; 87:1447-60, ix. [PMID: 18053841 DOI: 10.1016/j.suc.2007.09.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The management of pancreatic pseudocysts has changed greatly over the last decade. As laparoscopic and endoscopic techniques continue to evolve, their use in the treatment of pseudocysts has gained acceptance, whereas the role of percutaneous drainage has become more limited. The literature on laparoscopic, endoscopic, and percutaneous management of pancreatic pseudocyst is reviewed here and, based on these data, a treatment algorithm is suggested.
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Affiliation(s)
- Simon Bergman
- Department of Surgery, Center for Minimally Invasive Surgery, The Ohio State University, 558 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA
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38
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Abstract
Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis, pancreatic trauma, or after surgery. Endoscopic treatment of pancreatic pseudocysts can be achieved using transpapillary and/or transmural (transgastric or transduodenal) approaches with acceptable success rates, complication rates, and recurrence rates. Advantages of endoscopic drainage is the avoidance of external pancreatic fistula.
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Affiliation(s)
- Todd H Baron
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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39
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Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, Gooszen HG. The Atlanta Classification of acute pancreatitis revisited. Br J Surg 2008; 95:6-21. [PMID: 17985333 DOI: 10.1002/bjs.6010] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed. METHODS A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used. RESULTS A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections. CONCLUSION The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.
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Affiliation(s)
- T L Bollen
- Department of Radiology, St Antonius Hospital Nieuwegein, The Netherlands
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40
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Bollen TL, van Santvoort HC, Besselink MGH, van Es WH, Gooszen HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR 2008; 28:371-83. [PMID: 17970553 DOI: 10.1053/j.sult.2007.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Imaging of patients with acute pancreatitis requires an understanding of the subtypes and complications that were defined at the Atlanta symposium in 1992. In the last decade, several new entities have been recognized with important clinical implications. In this article, the radiological aspects of the terminology and classification of acute pancreatitis are reviewed and new entities are clarified. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed and the limitations of each imaging technique, when interpreting pancreatic and peripancreatic inflammatory disease, are addressed.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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41
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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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Sandrasegaran K, Tann M, Jennings SG, Maglinte DD, Peter SD, Sherman S, Howard TJ. Disconnection of the pancreatic duct: an important but overlooked complication of severe acute pancreatitis. Radiographics 2007; 27:1389-400. [PMID: 17848698 DOI: 10.1148/rg.275065163] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In patients with severe acute pancreatitis, the percentage of necrosis of pancreatic glandular parenchyma is an important predictor of prognosis. However, little attention has been paid to necrosis of ductal epithelium, which may result in disconnection of the main pancreatic duct. In pancreatic duct disconnection, a viable segment of the pancreatic body or tail is isolated from the gastrointestinal tract; the result is a persistent end fistula, that is, an uncontrolled leak of pancreatic secretions into peripancreatic spaces without communication to the gastrointestinal tract. The authors present their experience with clinical and radiologic follow-up of 85 patients with necrotic pancreatitis who either did (n = 46) or did not (n = 39) have pancreatic duct disconnection at surgery. Confident preoperative diagnosis of a disconnected duct requires both imaging tests (computed tomography or magnetic resonance imaging) and pancreatography. However, not all peripancreatic collections signify ductal disconnection, and imaging has poor accuracy in differentiation between pancreatic and peripancreatic necrosis. Early recognition of disconnected pancreatic duct obviates unnecessary and potentially harmful drainage procedures.
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Affiliation(s)
- Kumaresan Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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43
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Anderson MA. Diagnostic and Therapeutic Applications of EUS in Pancreatic Disease. Gastroenterol Hepatol (N Y) 2007; 3:768-771. [PMID: 21960784 PMCID: PMC3104156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle A Anderson
- Assistant Professor of Medicine Division of Gastroenterology University of Michigan Health System
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Ito K, Perez A, Ito H, Whang EE. Pancreatic pseudocysts: is delayed surgical intervention associated with adverse outcomes? J Gastrointest Surg 2007; 11:1317-21. [PMID: 17674114 DOI: 10.1007/s11605-007-0237-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 06/30/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nonsurgical interventions are increasingly applied for pancreatic pseudocysts. We hypothesized that surgical therapy applied after failure of percutaneous or endoscopic therapies for pseudocysts is associated with poorer outcomes than cases in which surgery is the initial intervention. MATERIALS AND METHODS Medical records of all 284 patients admitted with pancreatic pseudocysts at our institution (1/1990-9/2005) were analyzed. Forty-six patients underwent surgery as the initial intervention (group A). Among 162 patients who underwent percutaneous or endoscopic drainage as the initial intervention, 75 patients required subsequent surgery after failure of nonsurgical intervention (group B). RESULTS Groups were comparable in demographic variables and in location, number, and size of pseudocysts. Forty-two percent of group B patients developed infection within their pseudocysts after their nonsurgical interventions. Compared to group A patients, group B patients had higher rates of overall perioperative morbidity (47.8% vs 73.3%, p = 0.01) and postoperative readmission (24.0% vs 44.7%, p = 0.04). Five (6.7%) group B patients died in the perioperative period; there were no perioperative deaths among group A patients. CONCLUSION Delayed surgical intervention for pancreatic pseudocysts is associated with higher incidences of postoperative complications, readmission, morbidity, and mortality. The increasing application of nonsurgical interventions needs to be reevaluated.
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Affiliation(s)
- Kaori Ito
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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45
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Mahnken AH, Günther RW, Winograd R. Percutaneous transgastric snaring for repositioning of a dislocated internal drain from a pancreatic pseudocyst. Cardiovasc Intervent Radiol 2007; 31 Suppl 2:S217-20. [PMID: 17763902 DOI: 10.1007/s00270-007-9152-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 07/18/2007] [Indexed: 12/15/2022]
Abstract
Pancreatic pseudocysts may occur in up to 10% of patients with acute or chronic pancreatitis. Symptomatic, persistent, and infected pancreatic pseudocysts require interventional therapy. We present the case of a patient with complete dislocation of a double pigtail catheter into an infected pseudocyst and the repositioning of the drainage catheter using a transgastric snaring technique. The combination of CT-guided percutaneous puncture and fluoroscopic snaring permitted minimally invasive management of this rare complication.
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Affiliation(s)
- Andreas H Mahnken
- Department of Diagnostic Radiology, University Hospital, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany.
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46
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Bollen TL, Besselink MGH, van Santvoort HC, Gooszen HG, van Leeuwen MS. Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms. Pancreas 2007; 35:107-13. [PMID: 17632315 DOI: 10.1097/mpa.0b013e31804fa189] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium. METHODS We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis." RESULTS A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis." CONCLUSIONS This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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47
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Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007; 245:943-51. [PMID: 17522520 PMCID: PMC1876949 DOI: 10.1097/01.sla.0000254366.19366.69] [Citation(s) in RCA: 201] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Experience with minimal access, transoral/transmural endoscopic drainage/debridement of walled-off pancreatic necrosis (WOPN) after necrotizing pancreatitis is limited. We sought to determine outcome using this technique. METHODS Retrospective analysis. RESULTS From 1998 to 2006, 53 patients underwent transoral/transmural endoscopic drainage/debridement of sterile (27, 51%) and infected (26, 49%) WOPN. Intervention was performed a median of 49 days (range, 20-300 days) after onset of acute necrotizing pancreatitis. A median of 3 endoscopic procedures/patient (range, 1-12) were performed. Twenty-one patients (40%) required concurrent radiologic-guided catheter drainage of associated or subsequent areas of peripancreatic fluid and/or WOPN. Twelve patients (23%) required open operative intervention a median of 47 days (range, 5-540) after initial endoscopic drainage/debridement, due to persistence of WOPN (n = 3), recurrence of a fluid collection (n = 2), cutaneous fistula formation (n = 2), or technical failure, persistence of pancreatic pain, colonic obstruction, perforation, and flank abscess (n = 1 each). Final outcome after initial endoscopic intervention (median, 178 days) revealed successful endoscopic therapy in 43 (81%) and persistence of WOPN in 10 (19%). Preexistent diabetes mellitus, size of WOPN, and extension of WOPN into paracolic gutter were significant predictive factors for need of subsequent open operative therapy. CONCLUSIONS Successful resolution of symptomatic, sterile, and infected WOPN can be achieved using a minimal access endoscopic approach. Adjuvant percutaneous drainage is necessary in up to 40% of patients, especially when WOPN extends to paracolic gutters or pelvis. Operative intervention for failed endoscopic treatment is required in about 20% of patients.
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Affiliation(s)
- Georgios I Papachristou
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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48
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Baron TH. Treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks. Gastrointest Endosc Clin N Am 2007; 17:559-79, vii. [PMID: 17640583 DOI: 10.1016/j.giec.2007.05.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.
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Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Charlton 8A, Rochester, MN 55905, USA.
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49
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Piraka C, Chen YK. Pseudocyst Drainage: ERCP and EUS Approaches. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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50
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Erickson RA. EUS-guided pancreaticogastrostomy: invasive endosonography coming of age. Gastrointest Endosc 2007; 65:231-2. [PMID: 17141773 DOI: 10.1016/j.gie.2006.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 07/12/2006] [Indexed: 02/08/2023]
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