The clinical challenge of multiple pancreatic pseudocysts

Multiple pancreatic pseudocysts treated with endoscopic transpapillary drainage

Management of a solitary pancreatic pseudocyst with endoscopic transpapillary stent drainage is a well recognized treatment modality. Endoscopic options are however limited in the presence of multiple pancreatic pseudocysts. Conventionally surgery has been the mainstay of treatment in this situation. In this case report, we present a patient with multiple pancreatic pseudocysts who was successfully treated via transpapillary placement of pancreatic duct stent.

Graded dilation technique for EUS-guided drainage of peripancreatic fluid collections: an assessment of outcomes and complications and technical proficiency (with video)

BACKGROUND

Although the utility and safety of EUS and EUS-guided FNA is well known, there is a need for more data on outcomes and complications of EUS-guided drainage procedures.

OBJECTIVE

To evaluate the rates of technical success, treatment success, and complications of the graded dilation technique for performing EUS-guided drainage of peripancreatic fluid collections (PFCs) in a large cohort of patients. Also, the technical proficiency for performing EUS-guided drainage of PFCs was evaluated.

DESIGN

A prospective study of all patients undergoing EUS-guided drainage of PFC.

SETTING

A tertiary-referral center.

INTERVENTIONS

After passage of a 0.035-inch guidewire into the PFC by using a 19-gauge needle, graded dilation of the tract was sequentially performed by using a 4.5F ERCP cannula, a 10F ERCP inner guiding catheter, and an 8-mm balloon dilator. A transmural stent and/or drainage catheter was then deployed.

MAIN OUTCOME MEASUREMENTS

To evaluate the technical success, treatment success, and complications of the graded dilation technique. Technical proficiency was evaluated by comparing the procedural duration between the first 25 cases (group A), with a later cohort of patients (group B, n = 29) who underwent EUS-guided drainage of a single PFC.

RESULTS

Sixty patients (41 men; mean age 51 years [range 20-79 years], 6 multiple PFCs) underwent EUS-guided drainage of a PFC (types included 36 pseudocyst, 15 abscess, and 9 necrosis) over a 42-month period. The rates of technical and treatment success were 95% and 93%, respectively. A minor complication of stent migration was encountered in 1 of 60 patients (1.7%). There was no significant difference in patient or clinical characteristics between group A and B patients who were undergoing drainage of a single PFC. Although there was no significant difference in technical or treatment outcome, median procedural duration was significantly shorter for group B than for group A patients (25 vs 70 minutes; P < .001). Procedural duration for performing EUS-guided drainage of a single PFC was more likely to be <30 minutes in group B than in group A patients (crude odds ratio [OR] 18.8; P < .001), which remained significant (adjusted OR 11.8; P = .01), even after adjusting for patient age; serum albumin; type, location, and size of PFCs; drainage modality (stent vs stent plus drainage catheter); and site of endoscopic access for establishing drainage.

CONCLUSIONS

In this study, EUS-guided drainage of a PFC could be performed safely by using the graded dilation technique, with a successful outcome in a majority of patients. Technical proficiency, with regard to procedural duration, improved significantly after the first 25 cases.

Minilaparoscopic transgastric cystgastrostomy

BACKGROUND

A technique combining upper endoscopy with percutaneous transgastric minilaparoscopic instrumentation for the formation of pancreatic cystgastrostomy is safe and effective for the internal drainage of pancreatic pseudocysts.

METHODS

At a tertiary-care academic medical center, 6 patients with pancreatic pseudocysts with a mean size of 19 cm (range, 16-23 cm) were selected for combined endoscopic and percutaneous transgastric minilaparoscopic (1.7-2 mm) pancreatic cystgastrostomy. All pseudocysts had been followed-up for a minimum of 5 weeks (range, 5-22 wk) and were noted to significantly displace the stomach anteriorly.

RESULTS

The mean surgical time was 98 minutes (range, 45-150 min). The mean amount of fluid removed from the pseudocysts was 2167 mL (range, 1600-2600 mL). All ports were removed from the stomach without the need to suture the gastric wall or skin except for 2 gastric serosal sites that were closed with a single intracorporeal stitch. The length of hospital stay averaged 2.2 days (range, 0-6 d). All patients were discharged in good condition, tolerating a regular diet. With a mean follow-up period of 13.4 months (range, 1-30 mo), all patients remain asymptomatic from their pancreatic pseudocysts.

CONCLUSIONS

The technique of combining upper endoscopy with percutaneous transgastric minilaparoscopic instruments to create a pancreatic cystgastrostomy can be used to apply well-established surgical principals for internal drainage and has the potential to be used for the management of other gastric pathology.

Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone

OBJECTIVE

Endoscopic drainage of a single pseudocyst is a well-known treatment modality. Its role in the management of multiple pseudocysts is not well established. We evaluated the role of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of multiple and large pseudocysts.

METHODS

Over 3 yr (2001-2004), endoscopic transpapillary NPD placement was attempted in 11 patients (age range 12-50 yr, 10 men) with symptomatic communicating multiple pseudocysts of pancreas (three in two and two in nine cases). A 5Fr/7Fr NPD was placed across the most distal duct disruption or into one of the pseudocysts.

RESULTS

Eight patients had an underlying chronic pancreatitis and three patients had pseudocysts as sequelae of acute pancreatitis. The size of pseudocysts ranged from 2 to 14 cm (mean 7.5 cm). Eight patients (72.7%) had at least one pseudocyst more than 6 cm in size. Nine patients had a partial disruption and two patients had complete disruption of the pancreatic duct. The NPD was successfully placed in 10 of 11 (90.9%) patients. Postprocedure acute febrile illness in one patient was the only complication noted, which responded to intravenous antibiotics. All pseudocysts resolved in 4-8 wk in 7 of 7 patients with successful bridging of the most distal ductal disruption. There was no recurrence of the pseudocysts in a mean follow-up of 19.4 months. Two patients, in whom there was a complete disruption and the NPD could not bridge the disruption, required surgery for the nonresolution of pseudocysts. In one patient with partial ductal disruption that could not be bridged, there was complete resolution of one pseudocyst and a decrease in the size of the other pseudocyst from 12 to 4 cm. The NPD was replaced by a stent and both the pseudocysts resolved in 20 wk.

CONCLUSION

Endoscopic transpapillary NPD placement is a safe and effective modality for the treatment of multiple and large pseudocysts, especially when there is partial ductal disruption, and the disruption can be bridged.

Therapeutic laparoscopy of the pancreas

OBJECTIVE

To communicate results of laparoscopic treatment of pancreatic pseudocyst (PP) and resection of benign lesions of the pancreas. Perioperative data, surgical outcomes, techniques and insights from 54 cases are presented.

SUMMARY BACKGROUND DATA

Although laparoscopic therapy for other solid organs has been widely adopted, reports of therapeutic laparoscopy of the pancreas have been few and of limited numbers, and its role in pancreatic disease is still unclear.

METHODS

Eighteen men and 11 women were selected for laparoscopic PP surgery. Four distinct laparoscopic approaches were used. An additional 9 men and 16 women underwent laparoscopic distal pancreatectomy (LDP) using a technique similar to the lesser sac approach.

RESULTS

Laparoscopic PP surgery was completed successfully in 28 of 29 patients. The overall mean operative time was 2.8 hours and the mean postoperative length of stay was 4.4 days. Of the techniques described, the authors prefer cyst gastrostomy by the lesser sac approach or the minilaparoscopic cystic gastrostomy. LDP was attempted in 25 patients and completed successfully in 23. One underwent a successful hand-assisted enucleation of an insulinoma. In 12 cases the spleen was preserved. Mean operative time was 3.7 hours, and mean postoperative length of stay was 4.1 days.

CONCLUSIONS

In the authors' experience, minimally invasive treatment of PP produces good results and avoids difficulties linked with percutaneous drainage or endoscopic internal procedures. However, combining upper endoscopy with intragastric laparoscopic surgery offers advantages of both. LDP compares well to open procedures and often allows preservation of the spleen.

Therapeutic laparoscopy of the pancreas

OBJECTIVE

To communicate results of laparoscopic treatment of pancreatic pseudocyst (PP) and resection of benign lesions of the pancreas. Perioperative data, surgical outcomes, techniques and insights from 54 cases are presented.

SUMMARY BACKGROUND DATA

Although laparoscopic therapy for other solid organs has been widely adopted, reports of therapeutic laparoscopy of the pancreas have been few and of limited numbers, and its role in pancreatic disease is still unclear.

METHODS

Eighteen men and 11 women were selected for laparoscopic PP surgery. Four distinct laparoscopic approaches were used. An additional 9 men and 16 women underwent laparoscopic distal pancreatectomy (LDP) using a technique similar to the lesser sac approach.

RESULTS

Laparoscopic PP surgery was completed successfully in 28 of 29 patients. The overall mean operative time was 2.8 hours and the mean postoperative length of stay was 4.4 days. Of the techniques described, the authors prefer cyst gastrostomy by the lesser sac approach or the minilaparoscopic cystic gastrostomy. LDP was attempted in 25 patients and completed successfully in 23. One underwent a successful hand-assisted enucleation of an insulinoma. In 12 cases the spleen was preserved. Mean operative time was 3.7 hours, and mean postoperative length of stay was 4.1 days.

CONCLUSIONS

In the authors' experience, minimally invasive treatment of PP produces good results and avoids difficulties linked with percutaneous drainage or endoscopic internal procedures. However, combining upper endoscopy with intragastric laparoscopic surgery offers advantages of both. LDP compares well to open procedures and often allows preservation of the spleen.