Surgical treatment of pancreatic pseudocysts

Cystocolostomy as an unusual approach to recurrent pancreatic pseudocyst in a Ugandan male with dense hepatogastroduodenal adhesions: A case report

Introduction and importance

Pancreatic pseudocyst is one of the most frequent late complications of acute pancreatitis with increasing prevalence in chronic pancreatitis. Other causes include abdominal trauma, biliary tract disease, and other idiopathic causes. 85% resolve spontaneously within 4–6 weeks. Interventions are required for persistently symptomatic, large and complicated pancreatic pseudocysts. Cystocolostomy is a rarely reported pancreatic pseudocyst drainage option.

Case presentation

20-year-old male with large recurrent pancreatic pseudocyst following trauma underwent 2 exploratory laparotomies from a peripheral hospital, before referral to Lubaga hospital. Ultrasound-guided cyst drainage was performed. He was readmitted two weeks later with features of cyst recurrence. Re-laparotomy was done and the stomach, duodenum and proximal jejunum were inaccessible due to extensive dense non-obstructive adhesions. Therefore, we performed a transverse cystocolostomy. Patient improved and was discharged on 5th post-operative day. Review was unremarkable at 6 weeks and 3 months post-surgery.

Clinical discussion

Current management of pancreatic pseudocyst is percutaneous, endoscopic or laparoscopic drainage. However in cases of large recurrent cysts despite the above interventions, open surgery still has a role. Cystogastrostomy, cystoduodenostomy or cystojejunostomy are the commonly performed drainage options. These 3 options were not possible in this patient due to dense adhesions, hence we performed a transverse cystocolostomy with no post-operative complications. Possible complications from the procedure might include recurrent pancreatitis, pancreatic abscess and stool leak into the pancreatic duct.

Conclusion

In cases of inaccessibility to the stomach, duodenum and jejunum due to non-obstructing dense adhesions, a pancreatic cystocolostomy can be performed with equally good outcomes.

•

A rarely reported alternative surgical option for large recurrent pancreatic pseudocysts.

•

Pancreatic cystocolostomy has equally good outcomes.

•

Challenges of dense adhesions in patients with repeat surgeries in the setting of pancreatitis.

Single-center experience demonstrating low adverse events and high efficacy with self-expandable metal esophageal and biliary stents for pseudocyst and walled off necrosis drainage

Background and study aims  Lumen-apposing metal stents (LAMS) have been designed as proprietary stents for the management of pseudocysts (PC)/walled off necrosis (WON). There has been concern about adverse events (AEs) with LAMS including bleeding, buried stent syndrome and migration. Prior to LAMS becoming available, fully-covered self-expandable metal esophageal and biliary stents (FCSEMSs) were used off-label for management of PC/WON with many centers demonstrating low rates of AEs. The primary aim of this study was to study the safety and efficacy of FCSEMS for the management of pseudocysts/WON. Patients and methods  This was a retrospective review of all endoscopic ultrasound (EUS)-guided placement of FCSEMSs for drainage of PC/WON cases performed at our institution over 4-year period. The primary outcomes studied were technical success, AEs, PC/WON resolution, and salvage surgical/radiologic intervention. Results  Technical success achieved in 65 of 65 (100 %) study patients. An AE occurred 0 of 25 patients (0 %) with PC, and in 10 of 40 patients (25 %) with WON: bleeding (3 %), migration (5 %) and stent dysfunction/infection (18 %). There was resolution in 25 of 25 patients (100 %) with a PC and 31 of 40 patients (78 %) with a WON. Salvage therapy by interventional radiology or surgery was performed in nine of 40 patients (22 %). Conclusions  This single-center 4-year experience in the pre-LAMS era showed that FCSEMS was safe and effective in all patients with PC and over 75 % of patients with WON. Given the large cost differential between LAMS and FCSEMS and the efficacy and safety shown with FCSEMS, we believe that FCSEMS should still be considered a first-line option for patients with pancreatic fluid collections, particularly in patients with PCs.

Endoscopic management of complications of acute pancreatitis: an update on the field

Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances. Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed. Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.

Extracorporeal shock wave lithotripsy is a safe and effective treatment for pancreatic stones coexisting with pancreatic pseudocysts

BACKGROUND AND AIMS

We aimed to investigate outcomes of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for the removal of large pancreatic stones coexisting with pancreatic pseudocysts (PPCs) in chronic pancreatitis (CP).

METHODS

This is a prospective study performed in CP patients with at least 1 stone (≥5 mm). Patients were divided into the PPC group (stones coexisting with PPCs) or the control group (stones alone). Patients were initially subjected to successive P-ESWL treatments, followed by ERCP. Primary outcomes were P-ESWL adverse events, and secondary outcomes were stone clearance, long-term pain relief, improved quality-of-life scores, and PPC regression.

RESULTS

A total of 849 patients (59 in the PPC group and 790 in the control group) was subjected to P-ESWL between March 2011 and October 2013. Occurrences of P-ESWL adverse events were similar between the PPC group and the control group (11.86% vs 12.41%, P = .940). After the treatment of initial P-ESWL combined with ERCP, the complete, partial, and nonclearance of stones occurred in 67.24%, 20.69%, and 12.07%, respectively, of patients in PPC group, with no significant difference from the control group (complete, partial, and nonclearance: 83.17%, 10.40%, and 11.39%, respectively; P = .106). Fifty-five of 59 patients (93.22%) with PPCs were followed for a median period of 21.9 months (range, 12.0-45.1). PPCs disappeared in 56.36% (31/55) and 76.36% (42/55) of patients after 3 months and 1 year of follow-up visits, respectively. Moreover, complete and partial pain relief were achieved in 63.64% (35/55) and 25.45% (14/55) of patients, respectively. The scores for quality of life (P < .001), physical health (P < .001), and weight loss (P < .001) improved.

CONCLUSIONS

In our multispecialty tertiary center, initial P-ESWL followed by ERCP was safe in patients with coexisting pancreatic stones and PPCs and effective for stone clearance, main pancreatic duct drainage, and pain relief.

Endoscopic Ultrasound-Guided Self-Expandable Metal Stent Placement for the Treatment of Infected Pancreatic Pseudocysts

The standard endoscopic ultrasound (EUS) approach of cystogastrostomy involves the use of series of plastic pigtail stents that are placed through the wall of the cyst. The use of a single stent has also been described in the literature. Here we describe five cases of EUS-guided cystogastrostomy with irrigation of infected pancreatic pseudocysts using a single self-expandable metal stent (SEMS). To our knowledge this has not been described in the literature in the United States. This novice approach will have significant implications in the management of infected pseudocysts with a lower morbidity, mortality and overall cost compared to conventional management such as surgery or percutaneous drainage.

Laparoscopic versus open cystgastrostomy for pancreatic pseudocysts: a case-matched comparative study

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.

Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial

BACKGROUND & AIMS

Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage.

METHODS

Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs.

RESULTS

At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003).

CONCLUSIONS

In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00826501.

Multimodality endoscopic treatment of pancreatic duct disruption with stenting and pseudocyst drainage: how efficacious is it?

BACKGROUND

Few studies have described the role of multimodality therapy and the complexity of endoscopic management of pancreatic duct disruption. Our study aim was to analyse and confirm factors associated with the resolution of pancreatic duct disruption.

METHODS

Over 6 years, retrospective data on patients with pancreatic duct disruption managed endoscopically were retrieved. Success was defined as resolution of the pancreatic duct disruption at 12 months. Logistic regression analysis was performed to determine factors associated with resolution.

RESULTS

113 patients (78 male) with a mean age 51.3 year were included. Resolution of the pancreatic duct leak occurred in 80 cases (70.2%). 72 cases received transpapillary pancreatic duct stents, with 51 demonstrating resolution of pancreatic duct leak (71%) cystenterostomy was performed in 68 patients with 51 resolved (75%). In partial duct disruptions, pancreatic duct stenting combined with endoscopic drainage of fluid collections resulted in an increased rate of resolution (80%) compared to complete disruptions treated in a similar manner (57%). In complete pancreatic ductal disruptions, transpapillary pancreatic duct stenting had no additional benefit (9/17, 52.9%) compared to cystenterostomy or percutaneous drainage alone (24/34, 70.6%; P=0.61).

CONCLUSION

Pancreatic duct disruptions require multimodality treatment, addressing not only the integrity of the pancreatic duct but also any fluid collections associated. Partial ductal disruption should be managed by a bridging stent.

Endoscopic transmural drainage of pseudocysts associated with pancreatic resections or pancreatitis: a comparative study

BACKGROUND

Endoscopy has been regarded as an effective modality for draining pancreatic collections, pseudocysts, and abscesses. This study analyzes our experience with endoscopic transmural drainage of pancreatic pseudocysts and compares the outcomes in patients with postsurgical and pancreatitis-associated ones.

METHODS

Patients who underwent endoscopic drainage of a pancreatic pseudocyst from January 1999 through June 2008 were included in this retrospective analysis. The specific indication for attempting the procedure was the presence of direct contact between the pseudocyst and the gastric wall. All the drainages were carried out via a transgastric approach, and one or two straight plastic stents (10 or 11.5 French) were positioned. A comparative analysis of short- and long-term results was made between patients with postoperative pseudocysts (group A) and patients with pancreatitis-associated pseudocysts (group B).

RESULTS

Fifty-five patients were included in the study, 25 in group A and 30 in group B. Overall, a single stent was inserted in 84.0% of patients, while two stents were needed in the remaining 16.0%. The technical success rate was 78.2%, whereas procedure-related complications were 16.4%. Complications included pseudocyst superinfection and major bleeding and were managed mainly by surgery. Mortality rate was 1.8% (1 patient). There were no significant differences in the technical success rate and procedure-related complications between the two groups (p=0.532 and 0.159, respectively) Recurrences were 13.9% and significantly more common in group B (p=0.021). In such cases, a second endoscopic drainage was successfully performed.

CONCLUSION

Transmural endoscopic treatment of pancreatic pseudocysts is feasible and has a technical success rate of 78.2%, without differences related to the pseudocyst etiology. Recurrences, on the other hand, are more common in patients with pancreatitis. Given the severe complications that may occur after the procedure, we recommend that endoscopic drainage be performed in a tertiary-care center with specific expertise in pancreatic surgery.

A unifying concept: pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis

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.

Non-surgical management of a ruptured posttraumatic pancreatic pseudocyst in a child

Generally speaking, isolated pancreatic injuries are rare after abdominal blunt trauma. However, the incidence of pancreatic injuries in children has risen in recent decades. Pancreatic pseudocyst represents a typical complication after acute pancreatitis due to blunt abdominal trauma. Spontaneous rupture of pseudocysts leading to acute abdominal pain has been described, however, it rarely occurs, especially in pediatric patients. We report the successful non-surgical management of a ruptured pancreatic pseudocyst in a 5-year-old girl which occurred 27 days after trauma. The traumatic acute pancreatitis was due to a handlebar injury.

Endoscopic diagnosis and treatment of pancreatic cysts

Pancreatic cystic neoplasms have emerged as an important new opportunity for many disciplines to participate in the diagnosis and management of early pancreatic neoplasia. With an increase in an understanding of these lesions and their potential for malignant transformation, there has been a dramatic increase in the frequency of diagnosis. We critically examined the literature on diagnostic methods for pancreatic cystic lesions over the past 5 years. The methods of endoscopic pancreatic pseudocyst drainage and clinical outcomes are also discussed. Morphologic studies of cystic lesions using cross-sectional imaging or endoscopic ultrasound have a low diagnostic rate. Cyst fluid analysis with the use of tumor markers (eg, carcinoembryonic antigen) increases the accuracy of diagnosis. The management of cystic lesions is heavily dependent on the type of cyst, the neoplastic potential, and the risk of surgery. The traditional therapy is pancreatic resection and not cyst enucleation. In contrast to cystic neoplasms, pseudocysts are localized collections of inflammatory fluid that mimic cystic neoplasms. The fluid collections arise from chronic pancreatitis and ductal leaks. Because pseudocysts have no neoplastic potential, they can be drained rather than resected. Drainage can be safely accomplished with external catheters or endoscopically with internal catheters. As we learn more about the pathophysiology of the various cystic lesions, treatment will be tailored to the specific cyst lesion. Endoscopic ultrasound has an important role in the characterization of pancreatic cystic lesions and helps in selection of the optimal treatment modality.

Percutaneous transgastric snaring for repositioning of a dislocated internal drain from a pancreatic pseudocyst

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.

Combined laparoscopic endoscopic procedures

The combination of laparoscopy and flexible endoscopy has expanded the minimally invasive approaches to both benign and malignant gastrointestinal disease. This article reviews the current applications of combined approaches to gastric, colonic, and pancreatic pathology.

Feasibility of MR imaging-guided percutaneous drainage of pancreatic fluid collections

PURPOSE

To assess the feasibility and safety of magnetic resonance (MR) imaging-guided percutaneous drainage of pancreatic fluid collections in an open configuration low field MR imaging system.

MATERIALS AND METHODS

Ten patients with pancreatic fluid collections were examined prospectively. Five of the fluid collections were symptomatic pseudocysts and five were pancreatic abscesses. All percutaneous drainages were performed solely under MR imaging guidance with a 0.23-T open configuration C-arm shaped MR imaging scanner with interventional optical tracking. Every step of the procedure was monitored using balanced fast field echo sequences. In each case, the drainage of the fluid collection was performed with a MR imaging-compatible drainage kit using the Seldinger technique. The kit included an 18-gauge needle, a 0.035-inch stiff guide wire, 6-F and 8-F dilators, and an 8-F pigtail drainage catheter.

RESULTS

All drainage catheters could successfully be placed into the pancreatic fluid collections under MR imaging guidance. Visualization of the needle, dilator, and drainage catheter was excellent. However, visualization of the guide wire was suboptimal. The mean time needed for the MR-guided drainage procedure was 44 minutes. No immediate complications occurred. The clinical success rate of the percutaneous drainage was 70%; three patients were subsequently treated surgically. There were no deaths. The average duration of catheterization was 40 days.

CONCLUSION

MR imaging-guided percutaneous drainage of pancreatic fluid collections is feasible and safe. The presented technique has limitations--lack of real-time imaging control and small selection of MR imaging-compatible devices--that necessitate further technical developments before the procedure can be recommended for routine clinical use.

Endoscopic Transgastric Drainage of Pancreatic Pseudocyst With the Use of Nd:YAG Laser

Pancreatic pseudocysts have been successfully managed with endoscopic drainage recently. This report describes a case of endoscopic transgastric drainage using endoscopic ultrasonography (EUS) and an Nd:YAG laser. EUS was used to detect an optimal puncture site of the pseudocyst and to reduce the risk of bleeding and perforation. An Nd:YAG laser was used to minimize the risk of bleeding and to penetrate the thick wall of the pseudocyst. After transgastric cystgastrostomy was performed, an internal stent was placed between the pseudocyst and the stomach. There were no complications associated with endoscopic interventions. Complete resolution of the pseudocyst was observed. Endoscopic transgastric drainage of pancreatic pseudocysts is a recommended approach for selected patients with pancreatic pseudocysts that are uncomplicated and are located adjacent to the stomach. Safe and effective drainage can be achieved without hemorrhage and perforation with the use of EUS, an Nd:YAG laser, and a stent. Furthermore, the Nd:YAG laser facilitated passage through a markedly indurated pseudocyst wall and it seemed to be an effective instrument, especially for pseudocysts with a thick wall.

Treatment of pancreatic pseudocysts

According to the Atlanta classification an acute pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of acute pancreatitis or pancreatic trauma, whereas a chronic pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of chronic pancreatitis and lack an antecedent episode of acute pancreatitis. It is generally agreed that acute and chronic pseudocysts have a different natural history, though many reports do not differentiate between pseudocysts that complicate acute pancreatitis and those that complicate chronic disease. Observation--"conservative treatment"--of a patient with a pseudocyst is preponderantly based on the knowledge that spontaneous resolution can occur. It must, however, be admitted that there is substantial risk of complications or even death; first of all due to bleeding. There are no randomized studies for the management protocols for pancreatic pseudocysts. Therefore, today we have to rely on best clinical practice, but still certain advice may be given. First of all it is important to differentiate acute from chronic pseudocysts for management, but at the same time not miss cystic neoplasias. Conservative treatment should always be considered the first option (pseudocysts should not be treated just because they are there). However, if intervention is needed, a procedure that is well known should always be considered first. The results of percutaneous or endoscopic drainage are probably more dependent on the experience of the interventionist than the choice of procedure and if surgery is needed, an intern anastomosis can hold sutures not until several weeks (if possible 6 weeks).

Endoluminal gastric surgery: the modern era of minimally invasive surgery

Laparoendoluminal techniques are the next frontier in modern surgery. They provide a minimally invasive approach to gastric diseases that enables organ preservation while maintaining open surgical principles. Laparoscopic direct access to the stomach provides a magnified, high-resolution image for precise excision using widely available laparoscopic instrumentation. Further improvements in flexible endoscopic equipment, combined with the infusion of robotic instrumentation, will aid in overcoming the technical demands of this procedure and fuel the growth of endo-luminal gastric surgery. Based on the currently available data, inappropriately selected patients, endoluminal gastric surgery affords the patients a definitive surgical procedure with all the advantages of a minimally invasive approach.

[Assessment of the degree of maturity in the wall of pancreatic pseudocysts in relation to choice of surgical procedure]

The aim of this study is to present our experience in the diagnosis and treatment of pancreatic pseudocysts. A pancreatic pseudocyst is an incapsulated collection of pancreatic juice, enclosed by nonepithelial elements, containing a high concentration of pancreatic enzymes, bicarbonates and necrotic detritus. It is a common complication of acute pancreatitis and trauma of the pancreas. In the period between 1996 and 2001, 53 surgical procedures were performed for pancreatic pseudocyst at the Institute for Digestive Diseases (First Surgical University Hospital), 35 male patients (67%) and 17 female patients (33%) underwent surgery. In 39 (75%) patients the method of choice was cystojejunostomy by Roux. In 4 cases distal pancreatectomy for pseudocysts localized within the pancreatic tail was performed, complete pseudocyst excision only was performed in one case and complete pseudocyst excision combined with cystojejunostomy was also performed in one case. Cystogastrostomy and drainage in one case and partial cystectomy and drainage also in one case. Surgical internal drainage is the method of choice for the treatment of pancreatic pseudocysts, involving low morbidity and mortality rates.

Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas

OBJECTIVE

To study the magnitude of complications associated with the nonoperative management of peripancreatic fluid collections and pseudocysts and to assess the surgical management of these complications. These are compared with complications associated with operative management.

SUMMARY BACKGROUND DATA

Pancreatic pseudocysts and peripancreatic fluid collections associated with acute pancreatitis have been managed with success using nonoperative techniques for more than a decade. When successful, these techniques have clear advantages compared with operative management. There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. Our report focuses on these complications and pseudocysts and on the surgical management. We have been struck by the high percentage of patients who sustain significant and at times life-threatening complications related to the nonoperative management of fluid collections. We further define an association between the main pancreatic ductal anatomy and the likelihood of major complications after nonoperative management.

METHODS

Between 1992 and 2003, all patients admitted to our service with peripancreatic fluid collections or pseudocysts were monitored. We evaluated complications patients managed with percutaneous (PD) or endoscopic drainage (E). Data were collected regarding patient characteristics, need for intensive care unit (ICU) stays, hemorrhage, hypotension, renal failure, and ventilator support. We further focused on the duration of fistula drainage from patients who have had a percutaneous drainage, and we assessed the necessity for urgent or emergent operation. By protocol, all patients had pancreatic ductal anatomy evaluated by means of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Patients with complications of E and PD were compared with 100 consecutive patients who underwent operative management of pseudocyst and fluid collections as their sole mode of intervention.

RESULTS

A total of 79 patients with complications of PD, E, or both were studied. There were 41 males and 38 females in the group of patients who sustained complications (mean age 49 years). Sixty-six of the 79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent. The mean elapsed time from diagnosis to nonoperative intervention was 18.1 days. This group of 79 patients had mean 3.1 +/- 0.7 hospitalization (range, 1-7) and length-of-stay 42.7 +/- 4.1 days. ICU stays were required in 36 of the 79 (46%). A defined episode of clinical sepsis was identified in 72 of 79 (91%) and was by far the most common complication. Hemorrhage requiring transfusion was identified in 16 of the 79 (20%), clinical shock 51 of the 79 (65%), renal failure 16 of the 79 (20%), ventilator support for longer than 24 hours 19 of the 79 (24%). A persistent pancreatic fistula occurred in 66 of the 79 patients (84%); mean duration was 61.4 +/- 9.6 days. Sixty-three of the 79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct. Among the 100 operated patients, 69 complications occurred in 6 of the 100 (6%). Operation was initiated electively a mean interval of 42.7 days after diagnosis of pseudocyst. Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients. CT imaging obtained at least 6 months after intervention documented complete resolution after surgery alone in 91 and 9 with cystic structures less than 2 cm. In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions less than 2 cm in diameter.

CONCLUSION

These data support the premise that a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. It is vital to recognize the magnitude and severity of complications of nonoperative measures as one chooses a modality. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.

Mucinous Cystic Neoplasms of the Pancreas

Mucinous cystic neoplasms of the pancreas (MCNP) are rare tumors with presentation and findings that differ in most cases from pancreatic pseudocysts. A simple pancreatic cystic lesion in a younger-aged patient with a history of pancreatitis and endoscopic retrograde cholangiopancreatography (ERCP) demonstration of ductal communication with the cyst strongly suggests the diagnosis of a benign pseudocyst. MCNP may have extensive areas without an epithelial lining, adding histologic sampling error to the potential for confusing these two entities. Pancreatic pseudocysts are benign lesions treated by enteric drainage procedures, while MCNP have significant malignant potential, and resection is advised. Even when clinical presentation and imaging are persuasive for a benign cyst, MCNP of the pancreas should be considered in planning, evaluation, and treatment.

Laparoscopic treatment of pancreatic pseudocysts

BACKGROUND

A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP).

METHODS

We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30-72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5-20).

RESULTS

According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80-300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2-5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4-24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6-36), no recurrence of PP was observed.

CONCLUSIONS

The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage.

Endoscopic drainage of pancreatic pseudocysts in children

BACKGROUND/PURPOSE

Symptomatic pancreatic pseudocysts have traditionally been managed with surgical, percutaneous, and, more recently, endoscopic drainage. Although the role of the latter is well defined in the adult population, its utility in children needs to be clarified. The authors reviewed their experience with endoscopic drainage of pancreatic pseudocyst (EDPP).

METHODS

A retrospective chart review was conducted, and relevant demographic and clinical data were obtained for all patients with pancreatic pseudocysts managed with endoscopic drainage in the period from 1997 through 2001, inclusive.

RESULTS

Three children had successful endoscopic drainage of pancreatic pseudocysts. They were 9, 13, and 14 years old, and were all boys. The etiology of the pancreatitis was idiopathic related to anomalous pancreatic divisum ducts in the first 2 and azathioprine induced in the latter. The first 2 patients had endoscopic transpapillary drainage, whereas the third had an endoscopic cystduodenostomy. All patients had complete resolution of the pseudocyst clinically and radiologically after follow-up periods of 3, 31, and 21 months, respectively. The first needed a subsequent pancreaticojejunostomy for persistent symptoms related to chronic pancreatitis. A successful endoscopic drainage of a posttraumatic pancreatic pseudocyst has previously been reported from our institution.

CONCLUSIONS

This experience would indicate that endoscopic drainage of pancreatic pseudocyst is an effective and relatively safe option of managing this problem in children.

Traitement des pseudokystes du pancréas par kystogastrostomie laparoscopique

AIM

To evaluate the clinical results of laparoscopic cystogastrostomy and to determine the potential advantages of this new therapeutic option.

PATIENTS AND METHODS

This study concerned 12 patients presenting with pancreatic pseudocyst and operated on by laparoscopic cystogastrostomy between 1997 and 2002. There were five men and seven women with a median age of 46 years (range: 30-72). In ten patients, the pseudocyst developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients, the pseudocyst was associated with chronic pancreatitis. All the patients had a single cyst bulging into the posterior wall of the stomach and the median cyst diameter was 9 cm (range: 5-14).

RESULTS

Endoluminal gastric laparoscopy was used in six patients and intraperitoneal transgastric laparoscopy in six patients. Conversion to open surgery was required in one patient because the cyst could not be correctly localised by laparoscopy. The median size of the cystogastrostomy was 3 cm (range: 2-5). In eight patients, necrotic debris were still present within the cyst. The median operative time was 90 min (range: 60-140) and the median postoperative hospital stay was 6 days (range: 4-24). No mortality was recorded and postoperative morbidity was limited to one haematoma of the rectus sheath on a port site. One patient was readmitted on the 20th postoperative day because of cyst infection due to partial closure of the cystogastrostomy and was treated by endoscopic placement of a stent. One patient was lost for follow-up 2 months after surgery. With a median clinical and radiological follow-up of 12 months (range: 6-36), no recurrence of pancreatic pseudocyst was observed.

CONCLUSIONS

In this series, laparoscopic cystogastrostomy is associated with a low postoperative morbidity and an effective permanent result. Laparoscopy has two main advantages: an excellent control of haemostasis and the creation of a wide communication with debridement of the cyst contents thus minimizing the risk of infection or recurrence of the pseudocyst.

Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature

Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross-references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.

Surgical management of pancreaticocutaneous fistula

Although enteric drainage of the fistula tract is a widely accepted treatment for pancreaticocutaneous fistula, few data have been published on the outcome of this procedure. We conducted a retrospective chart review of 30 patients with pancreaticocutaneous fistula who underwent surgical management at a single institution over a 13-year period. The operative morbidity rate was 30%. Overall the incidence of recurrent ductal leaks requiring further intervention was 23%. Six of seven patients who had a recurrence had an ongoing inflammatory pathology, and three of seven had pancreas divisum. Recurrence was most likely when cystenterostomy was used. Enteric drainage of pancreaticocutaneous fistulas is not always curative. Fistulojejunostomy gives a better outcome than cystenterostomy. Recurrence may be expected in patients with continuing inflammatory ductal pathology.

Laparoscopic endogastric pseudocyst gastrostomy: a report of three cases

The transgastric pseudocyst-gastrostomy is the standard approach for internal drainage of persistent and large retrogastric pancreatic pseudocysts that complicate acute necrotizing pancreatitis. We report on the application of a laparoscopic endogastric approach for drainage of pancreatic pseudocysts and discuss the merits of this technique as well as of the other previously described minimally invasive approaches for the management of pancreatic pseudocysts. Between January 2001 and August 2001, three female patients presented with large symptomatic pseudocysts 3-10 months after an episode of acute necrotizing pancreatitis. Internal drainage was effected by a laparoscopic endogastric pseudocyst gastrostomy, and the necrotic pancreas was debrided. There were no conversions and no postoperative complications. The median postoperative hospital stay was 4 days (range, 3-5). All patients remain asymptomatic, and resolution of the pseudocyst was radiologically evident at a median follow-up of 6 months (range, 4-11). The laparoscopic endogastric pseudocyst gastrostomy appears to be a safe and effective minimally invasive approach for internal drainage of large retrogastric pancreatic pseudocysts and facilitates debridement of the necrotic pancreas.

Diagnosis and fine needle aspiration of pancreatic pseudocysts: the role of endoscopic ultrasound

Pseudocysts are localized collections of pancreatic fluid surrounded by nonepithelialized granulation tissue that occur following an insult to the pancreas. High image resolution and the ability sample in real-time by fine needle aspiration permit accurate distinction between various cystic lesions in the pancreas by endoscopic ultrasound (EUS). Other cyst characteristics and background pancreatic changes detectable at EUS assist in the diagnostic process. The use of Doppler flow ultrasound allows diagnosis of important pseudocyst complications such as pseudoaneurysms and varices. Endoscopic approaches to the drainage of symptomatic lesions previously relied on the use of cross-sectional imaging studies such as computed tomography scanning in combination with stent placement using a duodenoscope in the presence of an endoscopically visible cyst bulge. EUS facilitates this process allowing accurate imaging of the lesion prior to stent placement via the echoendoscope and overcomes many of the drawbacks and pitfalls of other endoscopic techniques.

Pancreatic stent placement for duct disruption

BACKGROUND

The aim of this study was to identify predictors of outcome after pancreatic duct stent placement for duct disruption.

METHODS

Patients were identified from endoscopy databases. Disruption was defined by extravasation of contrast from the pancreatic duct during endoscopic retrograde pancreatography. Data collected included demographic information, imaging studies, management before and outcome after stent placement. Success was defined as resolution of the disruption clinically, on radiologic imaging, and/or at endoscopic retrograde pancreatography.

RESULTS

Forty-three patients (23 women, 20 men; mean age 57 years, [SD] 15.2 years) were studied. The etiology of pancreatic duct disruption was acute pancreatitis in 24, chronic pancreatitis in 9, operative injury in 7, and trauma in 3 patients. In 25 patients there was resolution of the disruption, whereas stent therapy was unsuccessful in 16 and the outcome was indeterminate in 2 patients. On univariate analysis, stent positioned to bridge the disruption (p = 0.04) and longer duration of stent therapy (p = 0.002) were associated with a successful outcome. Female gender (p = 0.05) and acute pancreatitis (p = 0.05) were associated with a lack of success. On multivariate analysis, only the bridging stent position remained correlated to outcome. Complications occurred in 4 patients.

CONCLUSIONS

A bridging stent is associated with a successful outcome after pancreatic duct stent placement for duct disruption.

Operative treatment for chronic pancreatitis pain

BACKGROUND

Management of pain is the most frustrating problem associated with chronic pancreatitis. Pain is progressive and difficult to quantify. Uncontrolled, it eventually destroys the patient's quality of life, leading to drug addiction.

STUDY DESIGN

This study reports the results of 258 operations on 239 consecutive patients treated for pain related to chronic pancreatitis between 1969 and 1999. The operations performed were 42 pancreaticoduodenectomies, 48 side-to-side pancreaticojejunostomies, 68 distal pancreatectomies, 21 85% to 95% distal pancreatectomies, 70 cystenterostomies and 9 sphincteroplasties. Efforts were made to choose the operation most appropriate for the pathological conditions encountered in each patient. Results of treatment were satisfactory if patients were entirely relieved of pain and unsatisfactory if there was any residual pain. Presence or absence of pain was based on patient's own evaluation at the time of their last followup examination.

RESULTS

Results were overall satisfactory in 71% of patients after pancreaticoduodenectomy, 68% after side-to-side pancreaticojejunostomy, 69% after distal pancreatectomy; 69% after 85% to 95% distal pancreatectomy, 51% after cystenterostomy, and 44% after sphincteroplasty. The mean followup of patients was 4 y (range 0 to 23 y).

CONCLUSIONS

The cause of chronic pancreatitis is obscure. As a consequence, there have been few advances in the treatment of this condition. There are new techniques to resect the pancreas, but the results are little better than those obtained with older methods. Advances in the treatment of chronic pancreatic pain will come from knowledge concerning its cause. Discovery of mechanisms stimulating the pathways that lead to the perception of pain and methods for interruption of these mechanisms may provide new treatments.

Operative treatment of pseudocysts in patients with chronic pancreatitis

BACKGROUND

Pseudocysts associated with chronic pancreatitis are generally intrapancreatic and associated with parenchymal disease. They tend to persist and cause complications. Minimally invasive methods of treatment challenge the traditional techniques of operative management. Surgical operation allows definitive treatment of the pseudocyst with the option of dealing appropriately with the diseased pancreas and excluding a neoplastic process. The aim of this study was to review the safety and efficacy of a surgical approach to the management of pseudocysts associated with chronic pancreatitis.

METHODS

A personal series of 112 consecutive patients operated for pseudocysts in the setting of chronic pancreatitis was reviewed. Chronic pancreatitis was confirmed by imaging studies in association with exocrine and/or endocrine failure. Cysts were multiple in 31 patients and presented with complications other than pain in 47. Data were collected prospectively regarding the clinical presentation, the nature of the operation and its outcome.

RESULTS

Forty-eight patients (43 per cent) underwent drainage procedures, 56 (50 per cent) had a resection and eight (7 per cent) had a combination. Larger cysts and those located in the head and neck tended to be drained, while smaller and distal cysts were more often resected. The morbidity rate was 28 per cent and the operative mortality rate was 1 per cent. The cyst recurrence rate was 3 per cent and pain was relieved in 74 per cent of patients.

CONCLUSION

Operative management of pseudocysts associated with chronic pancreatitis is effective with low morbidity and mortality rates. The introduction of newer minimally invasive techniques will have to withstand comparison to this traditional approach.

Persistent pancreatocutaneous fistula after percutaneous drainage of pancreatic fluid collections: role of cause and severity of pancreatitis

PURPOSE

To assess the relationship between the cause and severity of pancreatitis and the development of persistent pancreatocutaneous fistula (PPCF) after percutaneous drainage of pancreatic fluid collections.

MATERIALS AND METHODS

Sixty patients (44 male, 16 female; age range, 10-74 years) were included in the study. The cause of pancreatitis was postoperative in 29 patients, alcoholism in 20 patients, biliary in six patients, hyperlipidemia in two patients, unknown in two patients, and trauma in one patient. Patients requiring intensive care unit treatment for their condition at the time of drainage were considered to have severe pancreatitis. Thirty-seven patients had mild pancreatitis, and 23 had severe pancreatitis. PPCF was defined as catheter drainage of pancreatic fluid of more than 10 mL/d for more than 4 weeks after catheter placement.

RESULTS

PPCF developed in 27 of the 60 patients. It occurred in five of the six patients with biliary pancreatitis, 10 of the 20 with alcohol-related pancreatitis, and 10 of the 29 with postoperative pancreatitis (P > .2). The prevalence of PPCF was higher in patients with severe pancreatitis (n = 16 [70%]) than in those with mild pancreatitis (n = 11 [30%]). This difference was statistically significant (P < .002).

CONCLUSION

Development of PPCF correlated with severity of pancreatitis, regardless of the cause of pancreatitis.

Successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a child

The successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a 9-year-old boy is described. This case study suggests that there is a role for endoscopic placement of stents in the treatment of pancreatic pseudocysts in children.

Management of pancreatic pseudocysts

BACKGROUND

Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers.

STUDY DESIGN

A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire.

RESULTS

Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs.

CONCLUSIONS

Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.

Endoscopic management of pancreatic pseudocysts

BACKGROUND

Pancreatic pseudocysts may produce pain, or biliary or duodenal obstruction. Those over 6 cm in diameter or associated with chronic pancreatitis are unlikely to resolve and usually require intervention. There are a number of treatment modalities available and this paper reviews the role of endoscopic drainage.

METHODS

All articles and case reports quoted on Medline (National Library of Medicine, Washington DC, USA) containing the text words 'endoscopy' and 'pseudocyst', and citations from these references were reviewed.

RESULTS

Endoscopic drainage is technically feasible in around 50 per cent of pancreatic pseudocysts associated with chronic pancreatitis. Successful drainage occurred in 82-89 percent. The major complication is bleeding which required surgery for control in 5 per cent of procedures. One death attributable to the procedure has been reported. Recurrence rates range from 6 to 18 per cent with up to 4 years' follow-up. As in open surgery, recurrence is highest with drainage via the stomach.

CONCLUSION

Endoscopic drainage provides a minimally invasive approach to pseudocyst management, with success and recurrence rates similar to those of open surgery but with lower morbidity and mortality rates. It should be considered the treatment of choice for pseudocysts less than 1 cm thick which bulge into the stomach or duodenum, or for those which communicate with the main pancreatic duct.

Percutaneous cystogastrostomy with a new catheter for drainage of pancreatic pseudocysts and fluid collections

We describe a new catheter for the initial percutaneous drainage of large symptomatic pancreatic fluid collections and abscesses using a transgastric approach to allow fluid drainage into the gastric lumen. A double-mushroom stent is placed secondarily for long-term internal drainage to the stomach, avoiding the need for an extended period of external catheter drainage. This technique, termed percutaneous cystogastrostomy (PCG), has been used in 19 consecutive patients with one recurrent symptomatic pseudocyst in the follow-up period fo 9-43 months. There was one death within 30 days of PCG and 1 patient proceeded to surgical necrosectomy. After evidence of resolution of the pseudocysts, the internal stent was retrieved in 17 patients by endoscopic snare.

The efficacy of endoscopic treatment of pancreatic pseudocysts

BACKGROUND

Endoscopic drainage of pancreatic pseudocysts is a new nonsurgical treatment modality. We retrospectively studied the efficacy of endoscopic drainage of pseudocysts in 37 patients with chronic pancreatitis.

METHODS

Endoscopic retrograde pancreatic drainage was performed in 12 patients, endoscopic cystogastrostomy in 10 patients, and endoscopic cystoduodenostomy in 7 patients. In the remaining 8 patients, combinations of drainage routes were used.

RESULTS

ECG failed in 3 patients. Procedure-related complications were seen in 6 patients: bleeding in 3, perforation in 2, and apnea in 1 patient. There was no procedure-related mortality. Seven patients had complications in relation to stents or drains: pseudocyst infection due to stent clogging in 2, stent migration in 4, and kinking of the drain in 1 patient. Twenty-four patients had complete resolution of pseudocysts, 7 had partial resolution, and 6 had no resolution. Three patients had pseudocyst recurrences. Mean follow-up was 32 months. Finally, 10 patients underwent surgery.

CONCLUSIONS

Endoscopic drainage was technically feasible in 92% of the patients. Procedure-related morbidity was 16% and mortality was 0%. Endoscopic drainage was a definitive treatment for two thirds of the patients (65%). Surgery can be reserved for those patients in whom endoscopic therapy fails.

Natural course of operated pseudocysts in chronic pancreatitis

A longterm review (median follow up 11 years) of the postoperative course of pancreatic pseudocysts was undertaken in 55 patients with chronic pancreatitis. While 96% of the patients were free of pain immediately after the operation this figure fell to 53% subsequently. Alcohol abstinence did not significantly reduce pain. Endocrine pancreatic deterioration (60%) was significantly (p = 0.0059) more frequent than exocrine (38%). Unemployment increased from 2 to 41%; retirement rose from 0 to 33%, mainly as a result of pancreatitis. Twenty one (38%) patients died. Chronic pancreatitis related death rate was 14%. Three patients died of extrapancreatic carcinomas.

Percutaneous cystogastrostomy for chronic pancreatic pseudocyst

During the years 1984-1992, 74 patients of mean age 45 (range 6-71) years with chronic pancreatic pseudocyst were treated by percutaneous cystogastrostomy. They comprised 45 men and 29 women. A diagnosis of chronic pancreatitis was verified in 55 patients (74 per cent); pain was the indication for treatment in all cases. The catheter was successfully placed at the first attempt in 68 patients (92 per cent). Immediate complications occurred in four patients (5 per cent); there have been none since 1986. Abscess formation was seen in eight patients (11 per cent). One patient died 4 days after the procedure from myocardial infarction giving a mortality rate of 1 per cent; no death has occurred since 1986. The mean observation time was 27 (range 0-108) months. Pain disappeared or decreased in almost 90 per cent of patients and weight gain was seen in 80 per cent. The method described is less traumatic than operation, and mortality and complication rates compare favourably with those seen after surgery; the results are at least as good.

Percutaneous cystogastrostomy for treatment of pancreatic pseudocysts

Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections nad two related to catheter blockage. Percutaneous, cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2-17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.

Modern management of pancreatic pseudocysts

Pseudocysts may develop as a complication of acute pancreatitis, chronic pancreatitis or pancreatic trauma. As new methods of imaging provide fuller information on their incidence and natural history, important differences are emerging between the pseudocysts of acute and chronic pancreatitis. Traditional surgical approaches to the management of pseudocyst are now being challenged by endoscopic techniques and interventional radiology. In the light of these developments the options available are reviewed and strategies for the modern management of pancreatic pseudocysts are suggested.

[Pancreatic pseudocysts after blunt abdominal trauma]

Pancreatic pseudocyst caused by trauma is rare. Only in 5 of 98 patients on whom we operated between 1977 and 1991 for pancreatic pseudocyst were we able to detect previous blunt abdominal trauma. In a 4-year-old girl just a slight abdominal trauma had given rise to a cyst, while in 2 other patients (aged 9 and 26 years) pancreatitis occurred after trauma that was treated medically. Two patients had to undergo laparotomy immediately after suffering serious abdominal blunt injury. Diagnosis was established sonographically, except in one case, in which a large cyst was determined to originate from the pancreas, but only intraoperatively. The time-span between trauma and treatment of the pseudocyst ranged from 3 months to 1 year. Thus, continuous percutaneous suction, which is basically considered a promising therapy for cysts in their early stages of development, was obviously not feasible in our patients. We therefore carried out cysto-jejunostomy with formation of a Roux-en-Y jejunum loop. At follow up 1-10 years after operation, all patients were asymptomatic and no cyst formation could be detected sonographically.

Pancreatic pseudocysts: a proposed classification and its management implications

Pancreatic pseudocysts in 83 patients were classified according to clinical and radiographic criteria. Group I (45 patients) had acute, 'post-necrotic' pseudocysts with normal pancreatic duct anatomy and rarely duct-pseudocyst communication. Percutaneous drainage was curative in all patients in whom it was used. Group II (26 patients) included 'post-necrotic' pseudocysts developing in patients already suffering from chronic pancreatitis. The pancreatic duct was diseased but not strictured, and duct-pseudocyst communication was often present. Percutaneous drainage is possible for such patients but it may have to be prolonged; surgical internal drainage was usually successful. Group III (12 patients) had chronic 'retention' pseudocysts. The pancreatic duct was grossly diseased and strictured and duct-pseudocyst communication was present in all cases. Percutaneous drainage is contraindicated and surgical internal drainage has a high recurrence rate. Operative procedures in this group should address the specific ductal pathology. An improved classification of pseudocysts could help the surgeon to choose the most appropriate form of treatment.