Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series

The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents

Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

Endoscopic Versus Laparoscopic Drainage of Pancreatic Pseudocysts: a Cost-effectiveness Analysis

BACKGROUND

Both endoscopic and laparoscopic interventions have a high therapeutic success rate in the management of symptomatic pancreatic pseudocysts; however, neither has been established as the gold standard.

METHODS

A decision tree analysis was performed to examine the costs and outcomes of intervening on pancreatic pseudocysts endoscopically versus laparoscopically. Within the model, a theoretical patient cohort was separated into two treatment arms: endoscopic drainage and laparoscopic drainage. Variables within the model were selected from the published literature. Medicare reimbursements rates (US$) were used to represent costs accumulated during a 3-month perioperative period. Effectiveness was characterized by quality-adjusted life-years (QALYs). A willingness-to-pay of $100,000 per 1 year of perfect health (1 QALY) gained was used as the cost-effectiveness threshold. The model was validated using one-way, two-way, and probabilistic sensitivity analysis.

RESULTS

Endoscopic management of symptomatic pancreatic pseudocysts was the dominant strategy, producing 0.22 QALYs more while saving $23,976.37 in comparison to laparoscopic management. This result was further validated by one-way, two-way, and probabilistic sensitivity analysis.

CONCLUSIONS

For patients presenting with symptomatic pancreatic pseudocysts amenable to either endoscopic or laparoscopic management, endoscopic drainage should be considered first-line therapy.

Laparoscopic cystogastrostomy in children with pancreatic pseudocysts: A preliminary experience of eight cases

Introduction:

Pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) in children following acute pancreatitis are uncommon. The various modalities of therapy possible are conservative treatment, external drainage, endoscopic stenting, and internal surgical drainage procedures. There are no existing guidelines for the management of PPC in children. We evaluate the outcomes of laparoscopic cystogastrostomy (LCG) performed at our center.

Materials and Methods:

Eight children (median age: 10 years) underwent LCG for large PPC (median size: 12.5 cm). There were seven patients with PPC and one with WON. Seven underwent LCG by a transgastric approach and one underwent LCG by a retrogastric approach.

Results:

Seven out of the eight patients had complete resolution of symptoms and the PPC. The median follow-up period was 32 months (interquartile range: 9.5–55.5 months). There were no conversions. There was one patient with a WON who developed a recurrence.

Conclusion:

LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, when indicated, is a safe approach with a comparable outcome.

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.

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

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Pancreatic cystocolostomy has equally good outcomes.

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

Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: Meta-analysis

BACKGROUND

Pancreatic pseudocyst (PP) and walled-off necrosis can be managed endoscopically, percutaneously or surgically, but with diverse efficacy.

AIMS & METHODS

A comprehensive literature search was carried out from inception to December 2018, to identify articles which compared at least two of the three kinds of treatment modalities, regarding the mortality, clinical success, recurrence, complications, cost and length of hospitalisation (LOH).

RESULTS

The outcomes of endoscopic (ED) and percutaneous drainage (PD) were comparable in six articles. The clinical success of endoscopic intervention was better considering any types of fluid collections (OR = 3.36; 95% confidence interval (CI) 1.48, 7.63; p = 0.004). ED was preferable regarding recurrence of PP (OR = 0.23; 95% CI 0.08, 0.66; p = 0.006). Fifteen articles compared surgical intervention with ED. Significant difference was found in postoperative LOH (WMD (days) = -4.61; 95%CI -7.89, -1.33; p = 0.006) and total LOH (WMD (days) = -3.67; 95%CI -5.00, -2.34; p < 0.001) which favored endoscopy, but ED had lower rate of clinical success (OR = 0.54; 95% CI 0.35, 0.85; p = 0.007) and higher rate of recurrence (OR = 1.80; 95% CI 1.16, 2.79; p = 0.009) in the treatment of PP. Eleven studies compared surgical and percutaneous intervention. PD resulted in higher rate of recurrence (OR = 4.91; 95% CI 1.82, 13.22; p = 0.002) and lower rate of clinical success (OR = 0.13; 95% CI 0.07, 0.22, p < 0.001).

CONCLUSION

Both endoscopy and surgery are preferable over percutaneous intervention, furthermore endoscopic treatment is associated with shorter hospitalisation than surgery.

Outcomes following laparoscopic internal drainage of walled off necrosis of pancreas: experience of 134 cases from a tertiary care centre

INTRODUCTION

Internal drainage of walled of necrosis of pancreas has been considered as the standard of care. For symptomatic walled off necrosis (WON) of pancreas with the advent of laparoscopy and refinement of techniques and instrumentation, laparoscopic internal drainage is becoming the standard surgical drainage procedure for these patients. However, there is a dearth of literature regarding outcomes following laparoscopic drainage. Most of the studies have small number of patients with limited follow-up. We in this study describe our experience of laparoscopic internal drainage of walled off necrosis over the last 13 years.

MATERIALS AND METHODS

This is a retrospective analysis of a prospectively maintained database. All patients with WON undergoing laparoscopic internal drainage between January 2005 and December 2018 were included. Primary outcome measure was successful drainage. Secondary outcome measures included morbidity, hospital stay, re-intervention rate and mortality. Patients were followed up post-operatively at 1 week, 4 weeks, 3 months and then annually thereafter. Ultrasonography was done periodically for the assessment of cyst resolution.

RESULTS

Between 2005 and 2018, 154 surgical drainage procedures were performed for symptomatic pseudocyst/walled off necrosis. Out of these, 134 underwent laparoscopic drainage; 129 patients (96.3%) underwent laparoscopic cystogastrostomy and 5 (3.7%) underwent laparoscopic cystojejunostomy. Majority of the patients were male (male:female = 6:1) with a mean age of 36 ± 12.9 years (range 15-58 years). The mean operative time was 94 min (range 64-144 min). There were three conversions because of intra-operative bleeding. The overall post-operative morbidity was 8.9%. The average hospital stay was 4.4 days (2-19 days). The mean duration of follow-up was 5.5 years (range 6 months-13 years). Complete cyst resolution was achieved in 95.5% (n = 128) patients. There has been no mortality till date.

CONCLUSION

In conclusion, laparoscopic internal drainage is a very effective technique for drainage of WON with an excellent success rate.

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial

BACKGROUND

Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP.

PATIENTS AND METHODS

Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications.

RESULTS

Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention.

CONCLUSIONS

Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.

Surgical Management of Pancreatic Pseudocysts

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.

Review of management options for pancreatic pseudocysts

Pancreatic pseudocysts (PPs) present a challenging problem for physicians dealing with pancreatic disorders. Their management demands the co-operation of surgeons, radiologists and gastroenterologists. Historically, they have been treated either conservatively or surgically, with acceptable rates of complications and recurrence. However, recent advances in radiology and endoscopy, have leaded physicians to implement percutaneous and endoscopic drainage (ED) into their treatment algorithms. Moreover, laparoscopic surgery, with its advantages, has become an attractive alternative choice when surgical drainage (SD) is required. The aim of this review is to summarize the main diagnostic and therapeutic tools in the management of pseudocysts and to present the main studies that compare the three different types of pseudocyst drainage.

Effect of endoscopic failure on the results of internal surgical drainage in pancreatic pseudocyst

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.

Treatment of retrogastric pancreatic pseudocysts by laparoscopic transgastric cystogastrostomy

This paper discusses variations of laparoscopic transgastric cystogastrostomy in management of retrogastric pancreatic pseudocysts for 8 patients with symptom or pseudocysts (larger than 6 cm) companied with clinical manifestations. Using a Harmonic scalpel, two 3-5-cm incisions were made in the anterior and posterior gastric wall respectively. In the last step, the anterior gastrotomy was closed with an Endo-GIA stapler. All cases were successfully treated without large blood loss and without conversion to open surgery. The mean operative time was 114.29±19.24 min, blood loss was 157.14±78.70 mL, and mean hospital stay was 8.29±2.98 days. Gastric fistula occurred in one case on the postoperative day 7, and closed 1 month later. No bleeding was seen in all patients during the perioperative follow-up period. CT scans, given one month after the surgeries, displayed that the pancreatic pseudocysts disappeared or decreased in size, and ultrasounds showed no fluid or food residue in stomas at the third and fifth month following surgery. No patient experienced a recurrence during the follow-up period. Transgastric laparoscopic cystogastrostomy is a minimally invasive surgical procedure with a high rate of success and a low rate of recurrence, accompanied by rapid recovery. It is easy to master, safe to perform and may be the preferred option to treat retrogastric pancreatic pseudocysts.

Novel and supplementary management of pancreatic fluid collections: Endoscopic ultrasound-guided drainage

AIM

To compare efficacy and safety of endoscopic ultrasound (EUS)-guided and surgical drainage in pancreatic fluid collection management.

METHODS

Data were obtained retrospectively from January 2012 to December 2016. Patients with pancreatic fluid collection were performed EUS-guided or surgical procedure. Main outcome measures including clinical efficiency, complication, duration of procedures, hospital stay and cost were analyzed.

RESULTS

Thirty-six patients were enrolled into the study, including 14 in endoscopic group while 22 in the surgical group. Twelve (86%) patients were treated successfully by endoscopic approach while 21 (95%) patients benefited through surgical procedure. Endoscopic treatment had higher recurrence and complication rates than surgery, resulting in more re-interventions. Meanwhile, duration of procedure, hospital stay and cost were significantly lower in endoscopic group.

CONCLUSION

Both approaches were effective and safe. EUS-guided approach should be the first-line treatment in mild and simple cases, while surgical approach should be considered as priority in severe and complex cases.

Pancreatic Pseudocyst Dilemma: Cumulative Multicenter Experience in Management Using Endoscopy, Laparoscopy, and Open Surgery

BACKGROUND

Pancreatic pseudocyst (PP) is the commonest cystic lesion of the pancreas. Internal drainage of PPs can be accomplished by traditional open or recently by minimally invasive laparoscopic or endoscopic approaches. We aimed to evaluate and compare the clinical outcomes after endoscopic, laparoscopic, and open drainage.

METHODS

Seventy-one patients with PP underwent endoscopic (n = 35), laparoscopic (n = 4), and open surgical drainage (n = 32). The primary outcome was the success rate. The secondary outcomes were the estimated blood loss, operative time, opioid requirement, morbidity and mortality, length of hospital stay, and recurrence rate.

RESULTS

The primary success rate was significantly higher for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups. There were no significant differences in the morbidity, mortality, requirement of blood transfusion, reinterventions, and recurrence rate between the groups. Endoscopic drainage revealed significantly lower blood loss, operative time, opioid requirement, and hospital stay in comparison to open and laparoscopic drainage.

CONCLUSION

Minimally invasive therapeutic techniques, whether endoscopic or laparoscopic for treatment of PP could be considered valuable, competitive, and promising alternatives for open surgery. Moreover, it is less invasive with less hospitalization and rapid return to work.

Pancreatic pseudocyst: combined single incision laparoscopic cystogastrostomy and cholecystectomy in a resource poor setting

Laparoscopic cystogastrostomy is a well-accepted minimally invasive modality to treat pancreatic pseudocysts. There has been one prior report of cystogastrostomy via single incision laparoscopic surgery (SILS) in which specialized instrumentation and access platforms were used.

We report the challenges encountered in a low resource setting with the SILS approach to drainage using only standard laparoscopic instruments. To the best of our knowledge this is the second report of SILS cystogastrostomy and the first to be performed in a resource poor setting without specialized instruments or platforms.

Robotic transgastric cystgastrostomy and pancreatic debridement in the management of pancreatic fluid collections following acute pancreatitis

Pancreatic and peripancreatic fluid collections may develop after severe acute pancreatitis. Organized fluid collections such as pancreatic pseudocyst and walled-off pancreatic necrosis (WOPN) that mature over time may require intervention to treat obstructive or constitutional symptoms related to the size and location of the collection as well as possible infection. Endoscopic, open surgical and minimally invasive techniques are described to treat post-inflammatory pancreatic fluid collections. Surgical intervention may be required to treat collections containing necrotic pancreatic parenchyma or in locations not immediately apposed to the stomach or duodenum. Comprising a blend of the surgical approach and the clinical benefits of minimally invasive surgery, the robot-assisted technique of pancreatic cystgastrostomy with pancreatic debridement is described.

RESECTION OPERATIONS IN SURGICAL TREATMENT OF PATIENTS WITH CHRONIC PANCREATITIS COMPLICATED BY BILIARY HYPERTENSION

Surgical treatment was applied in 145 patients with complicated forms of chronic pancreatitis (CP) at the department of surgery of the Ivano-Frankivsk Regional Clinical Hospital in 2009–2016. Fourty-nine (33.7 %) patients had symptoms of biliary hypertension (BH); in five (3.4 %) of them BH was combined with chronic duodenal obstruction (CDO), the other 5 (3.4 %) patients had a combination of BH+CDP and local venous hypertension of pancreaticobiliary area vessels. Resection-type surgeries were applied in 28 (57.1 %) patients with CP complicated by BH. Intraoperative monitoring of biliary pressure was used in 17 patients in the process of duodenum-preserving resections of the pancreas. Frey’s procedure was applied to 20 (71.4 %) patients, in whom BH persisted after the resection stage of the surgery; Frey’s procedure was supplemented by interventions on bile ducts: hepaticoenteroanastomosis was applied in 12 patients, excision of pancreas lingula was applied in one patient, internal biliopancreatic anastomosis was applied in one patient. Berne modification was used in 2 (7.2 %) patients, and pancreaticoduodenal resection (PDR) according to Whipple – in 6 (21.4 %) patients. Remote results were studied in 19 (67.8 %) patients. Patients after duodenum-preserving resections had the best quality of life indicators, for BH signs were absent.

Systematic review comparing endoscopic, percutaneous and surgical pancreatic pseudocyst drainage

AIM: To perform a systematic review comparing the outcomes of endoscopic, percutaneous and surgical pancreatic pseudocyst drainage.

METHODS: Comparative studies published between January 1980 and May 2014 were identified on PubMed, Embase and the Cochrane controlled trials register and assessed for suitability of inclusion. The primary outcome was the treatment success rate. Secondary outcomes included were the recurrence rates, re-interventions, length of hospital stay, adverse events and mortalities.

RESULTS: Ten comparative studies were identified and 3 were randomized controlled trials. Four studies reported on the outcomes of percutaneous and surgical drainage. Based on a large-scale national study, surgical drainage appeared to reduce mortality and adverse events rate as compared to the percutaneous approach. Three studies reported on the outcomes of endoscopic ultrasound (EUS) and surgical drainage. Clinical success and adverse events rates appeared to be comparable but the EUS approach reduced hospital stay, cost and improved quality of life. Three other studies compared EUS and esophagogastroduodenoscopy-guided drainage. Both approaches were feasible for pseudocyst drainage but the success rate of the EUS approach was better for non-bulging cyst and the approach conferred additional safety benefits.

CONCLUSION: EUS-guided drainage appeared to be advantageous in drainage of pancreatic pseudocysts located adjacent to the stomach or duodenum. In patients with unfavorable anatomy, surgical cystojejunostomy or percutaneous drainage could be considered. Large randomized studies with current definitions of pseudocysts and longer-term follow-up are needed to assess the efficacy of the various modalities.

Endoscopic versus surgical treatment for pancreatic pseudocyst

BACKGROUND AND AIM

To evaluate the effectiveness and safety of endoscopic treatment for pancreatic pseudocyst compared with surgical treatment.

METHODS

PubMed and The Cochrane Library were systematically searched to identify all comparative trials investigating endoscopic versus surgical treatment for pancreatic pseudocyst. Main outcome measures included treatment success rate, adverse events, recurrence rate, length of hospital stay and hospital cost.

RESULTS

Five comparative studies with 255 participants were included in this meta-analysis. The surgical group exhibited a higher treatment success rate than the endoscopic group (OR, 0.43; 95% CI, 0.20-0.95; P = 0.04). However, there was no difference in the rates of adverse events (OR, 0.67; 95% CI, 0.33-1.36; P = 0.27) or recurrence (OR, 1.53; 95% CI, 0.37-6.39; P = 0.56) between the endoscopic and the surgical groups. Evidence from included studies demonstrated that the endoscopic group was associated with shorter length of hospital stay and lower hospital cost compared to the surgical group.

CONCLUSION

Endoscopic treatment may be the first-line treatment approach for patients with pancreatic pseudocyst.

Laparoscopic management of pancreatic pseudocysts: experience at a general hospital in Mexico City

BACKGROUND

Invasive management of pancreatic pseudocysts (PP) is currently indicated in those patients with symptoms or complications. Treatment options are classified as surgical (open and laparoscopic) and non-surgical (endoscopic and radiologic).

AIM

To describe the morbidity, mortality, and efficacy in terms of technical and clinical success of the laparoscopic surgical approach in the treatment of patients with PP in the last 3 years at our hospital center.

METHODS

We included patients with PP treated with laparoscopic surgery within the time frame of January 2012 and December 2014. The morbidity and mortality associated with the procedure were determined, together with the postoperative results in terms of effectiveness and recurrence.

RESULTS

A total of 38 patients were diagnosed with PP within the last 3 years, but only 20 of them had invasive treatment. Laparoscopic surgery was performed on 17 of those patients (mean pseudocyst diameter of 15.3, primary drainage success rate of 94.1%, complication rate of 5.9%, and a 40-month follow-up).

CONCLUSIONS

The results obtained with the laparoscopic technique used at our hospital center showed that this approach is feasible, efficacious, and safe. Thus, performed by skilled surgeons, it should be considered a treatment option for patients with PP.

Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center

INTRODUCTION

Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center.

METHOD

This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared.

RESULTS

Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups.

CONCLUSION

Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.

Minimally invasive treatment of pancreatic pseudocysts

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.

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.

Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement

BACKGROUND

Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach.

METHODS

We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed.

RESULTS

From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m(2), 77 % had an ASA score ≥ 3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections.

CONCLUSION

This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.

'Step-port' laparoscopic cystgastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis

BACKGROUND

Post-acute pancreatic collections (PAPCs) may require intervention when persistent, large or symptomatic. An open cystgastrostomy is an effective treatment option particularly for larger, solid predominant collections. A laparoscopic cystgastrostomy (LCG) as initially described, could be technically challenging. This report describes the evolution of the operative technique and the results from LCG in a tertiary referral centre.

METHODS

Retrospective analysis of the unit's prospectively populated database was conducted. All patients who underwent a surgical cystgastrostomy (SCG) were identified. Patient demographics, outcome and complications were collected and analysed.

RESULTS

Forty-four patients underwent SCG: 8 open and 36 laparoscopic. Of the 36 LCG, 6 required open conversion, although with evolution of the technique all of the last 17 cases were completed laparoscopically. The median interquartile range (IQR) length of stay in patients completed laparoscopically was 6 (2-10) compared with 15.5 days (8-19) in those patients who were converted (P = 0.0351). The only peri-operative complication after a LCG was a self-limiting upper gastrointestinal bleed. With a median (IQR) follow-up of 891 days (527-1495) one patient required re-intervention for a residual collection with no recurrent collections identified.

CONCLUSION

LCG is a safe and effective procedure in patients with large, solid predominant PAPCs. With increased experience and technical expertise conversion rates can be lowered and outcome optimized.

Pancreatic cysts: etiology, diagnosis and management

Pancreatic cysts involve a wide spectrum of pathologies from post-inflammatory cysts to malignant neoplasms. Pancreatic pseudocysts, serous cystadenomas, mucinous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary tumors occur most frequently. Differential diagnosis involves the following imaging investigations: transabdominal ultrasonography (TUS), contrast enhanced ultrasonography (CEUS) and endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance (MR) and magnetic resonance cholangiopancretography (MRCP), endoscopic retrograde cholangiopancretography (ERCP). The cyst fluid cytology is performed in difficult differential diagnosis between pseudocysts and benign and potentially malignant or malignant tumors. Most frequently, viscosity, amylase, CEA and CA 19-9 levels are determined. Imaging findings should be correlated with cytology. The management depends on the cyst type and size. Small asymptomatic pseudocysts, serous cystadenomas and branchduct IPMNs should be carefully observed, whereas symptomatic large or uncertain serous cystadenomas and cystadenocarcinomas, mucinous cystadenomas and cystadenocarcinomas, main-duct IPMNs and large branch-duct IPMNs with malignant features, serous and mucinous cystadenocarcinomas, and solid pseudopapillary tumors require surgery. Pseudocysts are usually drained. Percutaneous / EUS-guided or surgical cyst drainage can be performed. Complicated and uncertain pseudocysts and cystic tumors need surgical resection. The type of surgery depends on cyst location and size and includes proximal, central, distal, total pancreatectomies and enucleation.

Endoscopic transmural drainage of pancreatic pseudocysts: technical challenges in the resource poor setting

Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options, the requirement for specialized equipment, technical expertise, and consumables limits the options available in low resource settings. We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers. Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware. Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

Robotic-assisted cystogastrostomy for a patient with a pancreatic pseudocyst

Pancreatic pseudocysts are generally treated by endoscopic cystogastrostomy. However, difficult cases involving abscess, necrosis, or risk of hemorrhage often require surgical intervention. Here, we report a case of a robotically assisted cystogastrostomy. The patient presented with an infected pseudocyst with adjacent varices. Use of the da Vinci Surgical System allowed us to create a widely patent anastomosis between the pseudocyst and the stomach. The patient tolerated the procedure well without any complications. This report demonstrates the feasibility of robotic cystogastrostomy.

Minimally invasive management of pancreatic pseudocysts

INTRODUCTION

The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PP) are the current minimally invasive management options. Indications, and early and late results of endoscopic and laparoscopic approaches are being discussed.

AIM

To present experience in treatment of PP by laparoscopic pseudocystogastrostomy (LPGS) and endoscopic pseudocystogastrostomy (EPGS) and to compare results, feasibility and safety.

MATERIAL AND METHODS

THIRTY PATIENTS UNDERWENT SURGICAL INTERVENTION: 18 patients - LPGS (group I), 12 - EPGS (group II). Groups were compared by age, gender, pancreatic pseudocysts's age, diameter and localization, as well as intraoperative, early and late postoperative complications.

RESULTS

GENDER DISTRIBUTION, GROUP I: 14 (77.8%) men and 4 (22.2%) women, group II: 4 (33.3%) men and 8 (66.7%) women, p = 0.02. Average cyst diameter: group I - 149.9 ±52.1 mm, group II - 119 ±37.9 mm, p = 0.07. Average time between diagnosis and operation performance: group I - 12 (3-60) months, group II - 8 (2-36) months, p = 0.19. Neither in group I nor in group II did intraoperative complications occur. Early postoperative complications were divided into minor and major. Early minor complications: group I - 2 (11.1%), group II - 0, p = 0.5. Early major complications: group I - 0, group II - 2 (16.7%), p = 0.15. Late postoperative complications: group I - 0, group II - 1 (8.3%), p = 0.4. In group I there was no case, whereas in II group there was 1 (8.3%) case of recidivation, p = 0.4.

CONCLUSIONS

For selected patients both minimally invasive methods are equally safe an effective. For comprehensive evaluation of methods prospective trials are needed.

Endoscopic management of acute pancreatitis

Patients presenting with acute pancreatitis can be complex on different levels. Having a multifaceted approach to these patients is often necessary with radiographic, endoscopic, and surgical modalities all working to benefit the patient. Major surgical intervention can often be avoided or augmented by therapeutic and diagnostic endoscopic maneuvers. The diagnostic role of endoscopy in patients presenting with acute idiopathic pancreatitis can help define specific causative factors and ameliorate symptoms by endoscopic maneuvers. Etiologies of an acute pancreatitis episode, such as choledocholithiasis with or without concomitant cholangitis, microlithiasis or biliary sludge, and anatomic anomalies, such as pancreas divisum and pancreatobiliary ductal anomalies, often improve after endoscopic therapy.

[Therapy of pancreatic pseudocysts: endoscopy versus surgery]

Pancreatic pseudocysts are frequent complications following acute and chronic pancreatitis as well as abdominal trauma. They originate from enzymatic and/or necrotizing processes within the organ involving the surrounding tissues through inflammatory processes following pancreatic ductal lesion(s). Pseudocysts require definitive treatment if they become symptomatic, progressive, larger than 5 cm after a period of more than 6 weeks and/or have complications. Cystic neoplasms must be excluded before treatment. Endoscopic interventions are commonly accepted first line approaches. Should these fail or not be feasible surgical procedures have been well established and show comparable results. In summary, pancreatic pseudocysts require a reliable diagnostic approach with a multidisciplinary professional management involving gastroenterologists and surgeons.

[Laparoscopic drainage of a pancreatic pseudocyst: a case report]

Pancreatic pseudocysts are defined as homogeneous pancreatic or peripancreatic collections that are not associated with necrotic tissue and are surrounded by granulated or fibrous tissue with no epithelium. Management has been classified as surgical (conventional and laparoscopic) and nonsurgical (endoscopic and radiologic). The aim of this report is to describe our initial experience in the management of a pancreatic pseudocyst by means of laparoscopic posterior cyst-gastrostomy anastomosis, performed at the Pancreas Clinic of the Hospital General "Dr. Manuel Gea González" in Mexico City. New techniques and instrumentation have contributed to the relatively recent development of laparoscopic pancreatic surgery. Our technique has practical advantages that have been confirmed by other authors, such as simple hemostasis, a wide viewing angle enabling adequate necrosectomy, anastomosis that does not require the use of staples, and the possibility of resolving other associated intra-abdominal pathologies, as in this case.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diagnostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.

Pseudocyst management: endoscopic drainage and other emerging techniques

Pseudocyst formation is a well known complication of pancreatitis. Not all pancreatic pseudocysts require intervention. Selected patients who are asymptomatic can be subject to expectant management. Spontaneous resolution has been shown to occur in 40% to 50% of patients with no serious complications occurring during the observation period. Intervention is warranted if the patient is symptomatic, there is a progressive increase in size or if the pseudocyst is infected. Surgery was the only available treatment for pseudocysts for a long time. Of late other modalities like percutaneous, endoscopic, and laparoscopic drainage have come to be seen as viable alternatives.

Pancreatic pseudocyst with pancreatolithiasis and intracystic hemorrhage treated with distal pancreatectomy: a case report

Introduction

Hemorrhage from pancreatic pseudocyst is one of the serious complications of chronic pancreatitis. We experienced intracystic hemorrhage from a huge pancreatic pseudocyst and successfully treated it with distal pancreatectomy.

Case presentation

A 65-year-old-man with a history of alcohol abuse was admitted to our hospital for abdominal pain and was diagnosed as having chronic pancreatitis with pancreatolithiasis and pseudocyst in the pancreatic tail. The pancreatic pseudocyst increased in size gradually for 4 month observation period. For intracystic hemorrhage we performed an urgent distal pancreatectomy with splenectomy. Postoperative course was good and the elevated serum amylase level decreased to the normal range.

Conclusion

Prolonged observation resulted in intracystic hemorrhage. Drainage or surgery in adequate time is important for the management of pancreatic pseudocysts to prevent complications.

Endoscopy and laparoscopy co-therapies for pancreatic pseudocyst: an analysis of 38 cases

AIM: To investigate essentiality of laparoscopy and endoscopy co-therapies for pancreatic pseudocyst and to propose a reasonable algorithm.

METHODS: The clinical data of patients with pancreatic pseudocyst who underwent endoscopy and laparoscopy treatment in department of Tianjin Mini-invasive Surgery, from March 2000 to April 2008, were analyzed retrospectively, including general information, success rate, recurrence rate and incidence of complication, etc.

RESULTS: Compared with abdominal surgery group, no significant difference was observed in success rate, incidence of complications either in laparoscopy therapy or endoscopy therapy group, but shorter treatment sessions, less bleeding during operation and shorter hospital stay were noted. (110 ± 30 , 47.1 ± 15 vs 150 ± 24; 100 ± 30, 20 ± 8 vs 380 ± 40; 10 ± 3, 6.7 ± 3 vs 16 ± 4, all P < 0.05). Success rates for the three treatment groups were < 90%. However, 3 cases who received endoscopy and laparoscopy co-therapies had minimal invasive injury, and 2 cases whom open abdominal surgery failed obtained desired results following endoscopy therapy.

CONCLUSION: The endoscopy and laparoscopy co-therapies are safe, effective and minimally invasive for pancreatic pseudocyst.

[Invasive endoscopy or surgery for pancreatic disorders?]

Endoscopic double papillotomy occupied the place of surgical transduodenal double sphincteroplasty for disorders of papilla of Vater or chronic pancreatitis several years ago. Endoscopic cystoenterostomy and cystogastrostomy can also replace surgery in the treatment of pseudocysts and walled-of necrosis even in cases of severe acute pancreatitis with/or without sepsis. In chronic pancreatitis endotherapy may be the treatment of choice at first, although surgical techniques give somewhat better long-term results for pain relief. Extracorporeal shock wave lithotripsy, stone resolution or extraction and multiple pancreatic stents without aggressive balloon dilatation can progressively calibrate dominant stricture of the main pancreatic duct without further damage, ischemia or obstruction of side branches. Relapse-free period becomes longer (also after stents removal) if alcohol consumption and smoking are stopped definitively. Well-controlled, randomised studies are still needed to demonstrate clinical advantage of multiple endoscopic stent placement in comparison to surgery.

[Minimally invasive interventions in the treatment of pancreatic diseases]

We have used minimal invasive therapy in the treatment of pancreatic diseases for a long time. CT and/or ultrasound guided techniques have been used for the treatment of pancreatic pseudocysts for more than 20 years. The development of technology has also made an opportunity for the extensive use of laparoscopic surgery at patients suffering from pancreatic diseases. Currently, almost every type of open operation has a laparoscopic version, too. By now we can take part in the combined use of the CT/US and laparoscopic techniques. Recently the new NOTES procedures have appeared. Based on the literary items, the author summarizes the possibilities of minimal invasive treatments in pancreatic diseases.

Primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts

BACKGROUND

Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts.

METHODS

Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis.

RESULTS

There were no significant differences (p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m(2)), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1-40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher (p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy (n = 13), percutaneous drainage (n = 3), and repeat endoscopic drainage (n = 6).

CONCLUSIONS

Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.

Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts: A case report

Pancreatic pseudocysts (PPs) are collections of pancreatic secretions that are lined by fibrous tissues and may contain necrotic debris or blood. The interventions including percutaneous, endoscopic or surgical approaches are based on the size, location, symptoms and complications of a pseudocyst. With the availability of advanced imaging systems and cameras, better hemostatic equipments and excellent laparoscopic techniques, most pseudocysts can be found and managed by laparoscopy. We describe a case of a 30-year-old male patient with a pancreatic pseudocyst amenable to laparoscopic cystogastrostomy. An incision was made through the anterior gastric wall to expose the posterior gastric wall in close contact with the pseudocyst using an ultrasonically activated scalpel. Then, another incision was made for cystogastrostomy to obtain complete and unobstructed drainage. The patient recovered well after operation and was symptom-free during a 6-mo follow-up, suggesting that laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for minimally invasive management of PPs.

Cystic lesions of the pancreas. A diagnostic and management dilemma

BACKGROUND/AIMS

Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management.

METHODS

A search was undertaken with a Pubmed database to identify all English articles using the keywords 'pancreatic cysts', 'serous cystadenoma', 'intraductal papillary mucinous tumour', 'pseudocysts', 'mucinous cystic neoplasm' and 'solid pseudopapillary tumour'.

RESULTS

The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones.

CONCLUSION

In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. and IAP.