Non-operative treatment versus percutaneous drainage of pancreatic pseudocysts in children

Endoscopic cystogastrostomy: Still a viable option in children with symptomatic pancreatic fluid collection

BACKGROUND/OBJECTIVES

Endoscopic transmural drainage is the preferred method of drainage of pancreatic fluid collections (PFCs) in adults; however, there is scant literature in children. We analyzed our experience of 33 endoscopic cystogastrostomies done in 29 children to find its efficacy and safety.

METHODS

We retrospectively analyzed the prospectively collected database of 31 consecutive children (<18 years) who underwent endoscopic cystogastrostomy from June 2013 to December 2017. The procedure was done using the standard technique with an adult duodenoscope. Data related to clinical details, technical success, complications and follow-up were collected.

RESULTS

The median age was 14 (3-17) years (22 males). Indications were early satiety in 28 (90%), vomiting in 15 (48%), and duodenal obstruction and infected pseudocyst in 2 children each. Etiology includes acute pancreatitis 22, post-traumatic 4 and chronic pancreatitis 5. The procedure was successful in 29 of 31 (93.5%) children with no mortality. Adverse events happened in four cases (12.9%); two infections, another with bleeding and another with pneumoperitonium, both of which resolved spontaneously. Incidents (minor bleeding) were noted in 6 (19%). Stents were removed in 26 (90%) after 12 (7-20) weeks and got spontaneously migrated out in 3 (10%) cases. Over a median follow-up of 26 (5-48) months, 26 (90%) had no recurrence of pseudocyst and 3 (10%) had recurrence of a small, asymptomatic pseudocyst.

CONCLUSIONS

Endoscopic cystogastrostomy is a safe and effective method of draining bulging PFCs in children. The procedure carries acceptable morbidity with minimal recurrence. In younger children it may be the preferred method of drainage of PFCs.

Management of pancreatic pseudocysts in pediatric oncology patients

BACKGROUND

Management of children with pancreatic pseudocysts has historically been adopted from the adult experience where pancreatic pseudocysts greater than 6 cm are unlikely to resolve without intervention. We reviewed the clinical course of pediatric oncology patients with pancreatic pseudocysts.

METHODS

A retrospective review of patients treated over a 15-year period was performed. Variables evaluated included cancer type, medications administered, clinical and imaging characteristics of the pancreatic pseudocysts, treatment and outcome.

RESULTS

A total of 132 patients with a median age of 13 (IQR, 9-17) years were identified with pancreatitis. Thirty-one (23.5%) patients developed a pancreatic pseudocyst, of which 84% were associated with PEG-asparaginase treatment. The median pseudocyst size was 7.6 (IQR, 4.4-9.9) cm with 59% being greater than 6 cm. Twenty-two (71%) patients with a pancreatic pseudocyst underwent successful conservative management, while only 9 (29%) required procedural intervention including six percutaneous drainage, one of whom recurred and required surgical cyst-enteric drainage. Two other patients had primary surgical cyst-enteric drainage and one patient underwent endoscopic retrograde cholangiopancreatography with stenting. The indication for intervention was worsening pain rather than pseudocyst imaging characteristics, size or serum amylase/lipase.

CONCLUSION

Most medication-induced pancreatic pseudocysts in children being treated for cancer, regardless of pseudocyst size, can be managed non-operatively or with transgastric percutaneous drainage. The need for intervention can be safely dictated by patient symptoms.

LEVEL OF EVIDENCE

III.

Paediatric acute pancreatitis: Clinical profile and natural history of collections

BACKGROUND & AIMS

Acute Pancreatitis (AP) tends to have a benign course in children. However there is a paucity of information with respect to severity of AP in children, the categorization of collections viz., walled off necrosis (WON)& pseudocyst and their natural history & outcomes.

METHODS

A retrospective medical record review of 187 children with pancreatitis diagnosed and managed at our centre was performed.

RESULTS

101 children (59% boys, Median age 9yrs) had AP of which 37.6%, 60.4% and 2% had mild, moderately severe and severe AP. 61.4%(62) had PFC at diagnosis; 34%(21) acute pancreatic fluid collections (APFC) and 66%(41) acute necrotic collections (ANC). 52.3%(11of21) of APFC evolved into pseudocysts & 68.2%(28of41) of ANC into WON's. Drainage was required in 31%(12of39) of persisting collections, more frequently in children with traumatic AP. Percutaneous catheter drainage (PCD) was done in 6 children and endoscopic ultrasound (EUS) guided cystogastrostomy with placement of plastic or self expanding metal stents (SEMS) in 6 children.

CONCLUSIONS

Moderately severe AP is common in hospitalized children with AP with PFC developing in 61.4%, majority being APFC. 48% of APFC and 32% of ANC will resolve and the rest evolve into pseudocyst or WON. Spontaneous resolution is more likely in children with non -traumatic AP having pseudocysts rather than WON's.

Pancreatitis and Pancreatic Pseudocyst

Pancreatitis which is characterized by inflammation of the pancreas is an uncommon condition in the pediatric age group. Pancreatitis in children represents a diagnostic challenge for clinicians and a high index of suspicion is important for early diagnosis of pancreatitis which is known to be associated with significant morbidity and mortality. The etiology, diagnosis and aspects of management are discussed.

[Pancreatic pseudocyst in children: about 7 cases]

Le pseudokyste du pancréas est une affection bénigne, rare, en particulier chez l'enfant. Ce sont des collections de suc pancréatique, dépourvues de revêtement épithélial, et dont la localisation peut être intra ou extra pancréatique. Nous rapportons une étude rétrospective de 7 enfants colligés au service de chirurgie pédiatrique du centre hospitalier universitaire Hassan II de Fès, durant une période de 11 ans, allant du 1^erjanvier 2005 au 31 décembre 2016. Tous les enfants étaient de sexe masculin, l'âge moyen était de 6,6 ans (15 mois-12 ans). Un antécédent de traumatisme abdominal était retrouvé dans 4 cas, le ballonnement abdominal, la douleur, les vomissements et les troubles du transit étaient les principaux motifs de consultation. L'examen clinique retrouvait chez tous les enfants une sensibilité épigastrique et une altération de l'état général, l'échographie abdominale et le scanner abdominal réalisés respectivement ont permis de poser le diagnostic de pseudo kyste du pancréas avant l'intervention chirurgicale. Six malades sur sept ont été opérés ; Nous avons opté pour la dérivation interne (anastomose gastro-kystique) dans 4 cas, une dérivation externe dans 2 cas, et l'abstention thérapeutique dans le dernier cas. Les Pseudo kystes du pancréas sont des affections rares, néanmoins, ils sont de loin les plus fréquents (80% des lésions kystiques du pancréas étant des pseudo kystes, et sont la conséquence d'une pancréatite aigüe et/ou chronique, d'un traumatisme pancréatique, ou d'une obstruction canalaire pancréatique.

Outcome of radiological interventions in pediatric gastrointestinal diseases: A large tertiary center experience

Background

Interventional radiology (IR) is an indispensable component of multidisciplinary care in various gastrointestinal (GI) diseases. The literature on safety and utility of IR is limited in children.

Objectives

In this study, we aim to analyze the outcomes of IR in various pediatric GI diseases.

Methods

The data of children (≤18 years) who underwent radiological interventions for GI disorders (2009-2017) were analyzed, retrospectively. The indications for interventions included vascular (Budd Chiari syndrome [BCS], pseudoaneurysm) and nonvascular (pancreatic fluid collections [PFCs], cholangitis and anastomotic biliary strictures). The outcomes of radiological interventions, including success and adverse events, were assessed.

Results

A total of 93 children (mean age 13.45 ± 4.09 years) underwent radiological interventions for vascular (chronic BCS = 14, pseudoaneurysm = 28) or nonvascular (PFCs = 33, hepaticojejunostomy strictures or leaks = 12, cholangitis = 6) indications. Of 33 children who underwent drainage of PFCs, clinical success was noticed in 32 children during a mean follow-up of 32.4 ± 21.66 months; 11 children with persistent external pancreatic fistula were managed with endoscopic pancreatic ductal stenting (8 children) and internalization of transgastric drain (3 children). In children who underwent hepatic vein or inferior vena cava stenting for BCS, mean stent patency was 78.57% during a follow-up of 24.1 ± 13.78 months. In children with pseudoaneurysms, angioembolization was successfully performed in 92.8% patients. Re-bleeding was noticed in two children, one of whom required reintervention. In children who underwent percutaneous transhepatic biliary drainage, resolution of anastomotic strictures was noticed in all during a follow-up of 36.1 ± 13.73 months.

Conclusion

Interventional radiology is safe and effective in the management of various pediatric GI diseases.

Identification of risk factors for pancreatic pseudocysts formation, intervention and recurrence: a 15-year retrospective analysis in a tertiary hospital in China

BACKGROUND

Pancreatic pseudocyst (PPC) is a common complication of acute and chronic pancreatitis. To our knowledge no study has systematically reported the risk factors for the formation, intervention and recurrence of PPC. Therefore, the present study aimed to investigate the potential risk factors for PPC, with regards to its formation, intervention and recurrence.

METHODS

A database containing 5106 pancreatitis patients was retrospectively analyzed. As a result, a total of 4379 eligible patients were identified and divided into 2 groups: PPC group (group A, n = 759) and non-PPC group (group B, n = 3620). The PPC group was subdivided into 2 groups: intervention PPC (group C, n = 347) and resolution PPC (group D, n = 412). The differences in surgical complication and recurrence rates were compared among 347 PPC patients receiving different interventions, including surgical, endoscopic and percutaneous drainages. Furthermore, group C was subdivided into 2 groups: recurrent PPC (group E, n = 34) and non-recurrent PPC (group F, n = 313). All possible risk factors for PPC formation, intervention and recurrence were determined by multivariate regression analysis.

RESULTS

In this study, PPC was developed in 17.3% (759/4379) of pancreatitis patients. The significant risk factors for PPC formation included alcoholic pancreatitis (OR, 6.332; 95% CI, 2.164-11.628; p = 0.031), chronic pancreatitis (CP) (OR, 5.822; 95% CI, 1.921-10.723; p = 0.006) and infected pancreatic necrosis (OR, 4.253; 95% CI, 3.574-7.339; p = 0.021). Meanwhile, the significant risk factors of PPC patients who received intervention were alcoholic pancreatitis (OR, 7.634; 95% CI, 2.125-13.558; p = 0.016), size over 6 cm (OR, 8.834; 95% CI, 2.017-16.649; p = 0.002) and CP (OR, 4.782; 95% CI, 1.897-10.173; p = 0.038). In addition, the recurrence rate in PPC patients treated with percutaneous drainage was found to be the highest (16.3%) among the three intervention groups. Furthermore, percutaneous drainage was the only risk factor of PPC recurrence (OR, 7.812; 95% CI, 3.109-23.072; p = 0.013) identified from this retrospective cohort study.

CONCLUSIONS

Alcoholic pancreatitis and CP are the main risk factors for PPC formation and intervention, but not PPC recurrence. A higher recurrence rate is found in PPC patients treated with percutaneous drainage, as compared to endoscopic and surgical interventions.

EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis

BACKGROUND

Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has increased, it is now 3.6-13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population.

METHODS

Pediatric Pancreatitis was divided into three main clinical categories: acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Fifteen relevant topics (acute pancreatitis: diagnosis; etiology; prognosis; imaging; complications; therapy; biliary tract management; acute recurrent pancreatitis: diagnosis; chronic pancreatitis: diagnosis, etiology, treatment, imaging, intervention, pain, complications; enzyme replacement) were defined. Ten experts from the USA and Europe reviewed and summarized the available literature. Evidence was classified according to the GRADE classification system.

RESULTS

Within fifteen topics, forty-seven relevant clinical questions were defined. The draft of the updated guideline was presented and discussed at the consensus meeting held during the 49th Meeting of European Pancreatic Club, in Budapest, on July 1, 2017.

CONCLUSIONS

These evidence-based guidelines provides the current state of the art of the diagnosis and management of pediatric pancreatitis.

Operative Versus Nonoperative Management of Blunt Pancreatic Trauma in Children: A Systematic Review

The aim of this study was to compare operative versus nonoperative management of blunt pancreatic trauma in children. A systematic literature search was performed. Studies including children with blunt pancreatic injuries classified according to the American Association for the Surgery of Trauma classification were included. The primary outcome was pseudocyst formation. After screening 526 studies, 23 studies with 928 patients were included. Sufficient data were available for 674 patients (73%). Of 309 patients with grade I or II injuries, 258 (83%) were initially managed nonoperatively with a 96% success rate. Of 365 patients with grade III, IV, or V injuries, nonoperative management was initially chosen for 167 patients (46%) with an 89% success rate. Pseudocysts occurred in 18% of patients managed nonoperatively versus 4% of patients managed operatively (P < 0.01), of whom 65% were treated nonoperatively. Hospitalization was 20.5 days after nonoperative versus 15.1 days after operative management (nonparametric t test, P = 0.41). Blunt pancreatic trauma in children can be managed nonoperatively in the majority of patients with grade I or II injuries and in about half of the patients with grade III to V injuries. Although pseudocysts are more common after nonoperative management, two thirds can be managed nonoperatively.