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Alizai Q, Anand T, Bhogadi SK, Nelson A, Hosseinpour H, Stewart C, Spencer AL, Colosimo C, Ditillo M, Joseph B. From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries. Am J Surg 2023; 226:682-687. [PMID: 37543483 DOI: 10.1016/j.amjsurg.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries. METHODS We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed. RESULTS We identified 1553 patients (NOP = 1092; OP = 461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9-25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR = 1.47; p = 0.03), intraabdominal abscesses (aOR = 2.7; p < 0.01), pancreatic pseudocyst (aOR = 2.4; p = 0.04), and need for percutaneous or endoscopic management (aOR = 5.8; p < 0.001). CONCLUSION Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.
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Affiliation(s)
- Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Collin Stewart
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
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Harish C S, Dixit R, Singh S, Prakash A. Cervical extension of pancreatic pseudocyst: An unusual cause of neck stiffness and dysphagia. SA J Radiol 2022; 26:2385. [PMID: 35747785 PMCID: PMC9210193 DOI: 10.4102/sajr.v26i1.2385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/01/2022] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sneha Harish C
- Department of Radiodiagnosis, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Rashmi Dixit
- Department of Radiodiagnosis, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Sapna Singh
- Department of Radiodiagnosis, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Anjali Prakash
- Department of Radiodiagnosis, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
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Bhakta D, de Latour R, Khanna L. Management of pancreatic fluid collections. Transl Gastroenterol Hepatol 2022; 7:17. [PMID: 35548474 PMCID: PMC9081921 DOI: 10.21037/tgh-2020-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/10/2021] [Indexed: 12/28/2023] Open
Abstract
Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).
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Affiliation(s)
- Dimpal Bhakta
- New York University School of Medicine, New York, USA
| | | | - Lauren Khanna
- New York University School of Medicine, New York, USA
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4
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Abstract
Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.
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Farias GF, Bernardo WM, De Moura DT, Guedes HG, Brunaldi VO, Visconti TADC, Gonçalves CV, Sakai CM, Matuguma SE, dos Santos ME, Sakai P, De Moura EG. Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14255. [PMID: 30813129 PMCID: PMC6407966 DOI: 10.1097/md.0000000000014255] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP). METHODS The researchers did a search in Medline, EMBASE, Scielo/Lilacs, and Cochrane electronic databases for studies comparing surgical and endoscopic drainage of PP s in adult patients. Then, the extracted data were used to perform a meta-analysis. The outcomes were therapeutic success, drainage-related adverse events, general adverse events, recurrence rate, cost, and time of hospitalization. RESULTS There was no significant difference between treatment success rate (risk difference [RD] -0.09; 95% confidence interval [CI] [0.20,0.01]; P = .07), drainage-related adverse events (RD -0.02; 95% CI [-0.04,0.08]; P = .48), general adverse events (RD -0.05; 95% CI [-0.12, 0.02]; P = .13) and recurrence (RD: 0.02; 95% CI [-0.04,0.07]; P = .58) between surgical and endoscopic treatment.Regarding time of hospitalization, the endoscopic group had better results (RD: -4.23; 95% CI [-5.18, -3.29]; P < .00001). When it comes to treatment cost, the endoscopic arm also had better outcomes (RD: -4.68; 95% CI [-5.43,-3.94]; P < .00001). CONCLUSION There is no significant difference between surgical and endoscopic treatment success rates, adverse events and recurrence for PP. However, time of hospitalization and treatment costs were lower in the endoscopic group.
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Affiliation(s)
- Galileu F.A. Farias
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Wanderley M. Bernardo
- Thoracic Surgery Department, Instituto do Coração (InCor, Heart Institute), University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Diogo T.H. De Moura
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | | | - Vitor O. Brunaldi
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Thiago A. de C. Visconti
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Caio V.T. Gonçalves
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Christiano M. Sakai
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Sergio E. Matuguma
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Marcos E.L. dos Santos
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Paulo Sakai
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Eduardo G.H. De Moura
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
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Rana SS, Sharma R, Chhabra P, Sharma V, Gupta R, Bhasin DK. Endoscopic management of splenic pseudocysts associated with acute and chronic pancreatitis. Ann Gastroenterol 2016; 29:373-7. [PMID: 27366041 PMCID: PMC4923826 DOI: 10.20524/aog.2016.0038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 03/30/2016] [Indexed: 12/02/2022] Open
Abstract
Background Splenic pseudocysts (SP) are a rare consequence of both acute and chronic pancreatitis. Surgery has been conventional treatment for SP and literature on role of endoscopic treatment is scant. In this study, we retrospectively evaluated SP clinical and radiological characteristics as well as the outcome following endoscopic drainage. Methods Retrospective analysis of SP patients seen at our unit from January 2002 to June 2015. All patients were treated with attempted endoscopic transpapillary drainage with a nasopancreatic drain or stent. Patients not responding underwent endoscopic ultrasound-guided transmural or percutaneous radiological drainage. Results Eleven patients with SP (all male; mean age: 40.5±8.8 years) were studied. Seven patients had chronic pancreatitis and 4 patients had SP following acute pancreatitis. The majority (10/11; 91%) had alcohol-related acute or chronic pancreatitis with one patient having coexistent pancreas divisum. Seven (64%) patients were treated successfully with transpapillary drainage only; one (9%) patient needed combined transpapillary and transmural drainage; and 3 (27%) patients needed surgery. Conclusion Endoscopic transpapillary drainage is an effective treatment for SP especially when it is not infected and with clear contents, and is associated with partial ductal disruption that can be bridged by an endoprosthesis.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Puneet Chhabra, Vishal Sharma, Deepak Kumar Bhasin), India
| | - Ravi Sharma
- Department of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Puneet Chhabra, Vishal Sharma, Deepak Kumar Bhasin), India
| | - Puneet Chhabra
- Department of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Puneet Chhabra, Vishal Sharma, Deepak Kumar Bhasin), India; Department of Gastroenterology and Hepatology, Fortis Hospital, Mohali, Punjab (Puneet Chhabra, Deepak Kumar Bhasin), India
| | - Vishal Sharma
- Department of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Puneet Chhabra, Vishal Sharma, Deepak Kumar Bhasin), India
| | - Rajesh Gupta
- Department of Surgery (Rajesh Gupta), Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Puneet Chhabra, Vishal Sharma, Deepak Kumar Bhasin), India; Department of Gastroenterology and Hepatology, Fortis Hospital, Mohali, Punjab (Puneet Chhabra, Deepak Kumar Bhasin), India
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7
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Nitsche U, Siveke J, Friess H, Kleeff J. [Delayed complications after pancreatic surgery: Pancreatic insufficiency, malabsorption syndrome, pancreoprivic diabetes mellitus and pseudocysts]. Chirurg 2015; 86:533-9. [PMID: 25997699 DOI: 10.1007/s00104-015-0006-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Benign and malignant pathologies of the pancreas can result in a relevant chronic disease burden. This is aggravated by morbidities resulting from surgical resections as well as from progression of the underlying condition. OBJECTIVE The aim was to summarize the current evidence regarding epidemiology, pathophysiology, diagnosis and treatment of endocrine and exocrine pancreatic insufficiency, as well as of pancreatic pseudocysts. MATERIAL AND METHODS A selective literature search was performed and a summary of the currently available data on the surgical sequelae after pancreatic resection is given. RESULTS Reduction of healthy pancreatic parenchyma down to 10-15 % leads to exocrine insufficiency with malabsorption and gastrointestinal complaints. Orally substituted pancreatic enzymes are the therapy of choice. Loss of pancreatic islets and/or islet function leads to endocrine insufficiency and pancreoprivic diabetes mellitus. Inflammatory, traumatic and iatrogenic injuries of the pancreas can lead to pancreatic pseudocysts, which require endoscopic, interventional or surgical drainage if symptomatic. Finally, pancreatic surgery harbors the long-term risk of gastrointestinal anastomotic ulcers, bile duct stenosis, portal vein thrombosis and chronic pain syndrome. CONCLUSION As the evidence is limited, an interdisciplinary and individually tailored approach for delayed pancreatic morbidity is recommended.
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Affiliation(s)
- U Nitsche
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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8
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Patrzyk M, Maier S, Busemann A, Glitsch A, Heidecke CD. [Therapy of pancreatic pseudocysts: endoscopy versus surgery]. Chirurg 2013; 84:117-24. [PMID: 23371027 DOI: 10.1007/s00104-012-2376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- M Patrzyk
- Abteilung für Allgemeine Chirurgie, Viszeral-, Thorax- und Gefäßchirurgie, Klinik und Poliklinik für Chirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Deutschland.
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Bhasin DK, Rana SS, Rao C, Gupta R, Kang M, Sinha SK, Nagi B, Singh K. Clinical presentation, radiological features, and endoscopic management of mediastinal pseudocysts: experience of a decade. Gastrointest Endosc 2012; 76:1056-60. [PMID: 22867447 DOI: 10.1016/j.gie.2012.06.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 06/18/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, India
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Mangiavillano B, Arcidiacono PG, Masci E, Mariani A, Petrone MC, Carrara S, Testoni S, Testoni PA. Single-step versus two-step endo-ultrasonography-guided drainage of pancreatic pseudocyst. J Dig Dis 2012; 13:47-53. [PMID: 22188916 DOI: 10.1111/j.1751-2980.2011.00547.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this prospective study was to compare the feasibility, technical success rate and complication between single-step endo-ultrasonography (EUS)-guided and two-step EUS-guided drainage technique for symptomatic pancreatic pseudocyst (PP). METHODS Twenty-one PP patients with clear intra-cystic fluid that needed to be drained were divided into two groups, depending on the availability of the therapeutic echoendoscope at the time of the procedure: Group 1 (13 patients) underwent a single-step EUS-guided endoscopic drainage and Group 2 (8 patients) underwent a two-step EUS-guided drainage technique. RESULTS In Group 1 immediate technical success was achieved in 92.3% (12/13); two patients had recurrent PP and both were successfully treated by a second EUS-guided drainage. Clinical success was achieved in all cases. In Group 2 technical success was achieved in 75.0% of the patients (6/8). One patient (12.5%) bled 36 h after the procedure. Five out of 6 patients had long-term success. Clinical success was significantly greater in Group 1 (P < 0.05). CONCLUSION The technique of single-step EUS-guided drainage was superior to the technique of a two-step EUS-guided drainage technique for PP drainage.
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Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc 2011; 26:1710-7. [PMID: 22179480 DOI: 10.1007/s00464-011-2097-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/26/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is widely used to manage pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after pancreatic resection. METHODS At the authors' hospital, 262 patients underwent surgery involving pancreatic resection from April 2005 to March 2010. In 90 of these patients (34%), a grade B or C postoperative pancreatic fistula developed that required additional treatment. The authors performed EUS-guided transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilation of the main pancreatic duct visible by EUS. Percutaneous drainage was provided for 18 patients (6.8%). The success rates for EUS-TD and percutaneous drainage were compared in a retrospective analysis. RESULTS In all six cases, EUS-TD was performed successfully without complications. Five of the six patients were successfully treated with only one trial of EUS-TD. The final technical success rate was 100% for both EUS-TD and percutaneous drainage. Both the short- and long-term clinical success rates for EUS-TD were 100% and those for percutaneous drainage were 61.1 and 83%, respectively. The differences in these rates were not significant (short-term success, P = 0.091 vs. long-term success, P = 0.403). However, the time to clinical success was significantly shorter with EUS-TD (5.8 days) than with percutaneous drainage (30.4 days; P = 0.0013) in the current series. CONCLUSIONS The EUS-TD approach appears to be a safe and technically feasible alternative to percutaneous drainage and may be considered as first-line therapy for pancreatic fistulas visible by EUS.
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Comparative evaluation of transpapillary drainage with nasopancreatic drain and stent in patients with large pseudocysts located near tail of pancreas. J Gastrointest Surg 2011; 15:772-6. [PMID: 21359595 DOI: 10.1007/s11605-011-1466-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 02/08/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic transpapillary drainage is usually not advocated for large pseudocysts for fear of infection. We compared efficacy of transpapillary drainage with nasopancreatic drain (NPD) or stent alone in large pseudocysts (>6 cm) located near tail of pancreas. METHODS In a prospective study, a 5-Fr stent/NPD was placed across/near pancreatic duct disruption in 11 patients (nine chronic and two acute pancreatitis) with large pseudocysts located near tail of pancreas. The patients were followed up for resolution of pseudocyst, need for surgery, and complications. RESULTS Pseudocysts diameter ranged from 7 to 15 cm. An attempt to place NPD was made in five patients and a stent in six patients. In NPD group, deep cannulation could not be achieved in one patient; it was treated successfully with percutaneous drainage. In four patients with partial duct disruption, NPD was successfully placed bridging disruption and all had resolution within 6 weeks. In stent group, five had partial and one had complete duct disruption, who later recovered by placement of a stent. Of five patients with partial disruption, one recovered uneventfully at 6 weeks with stent bridging disruption. Other four patients (bridging stent in three) developed febrile illness and infection of pseudocyst. They required additional percutaneous drainage and antibiotics. There was no recurrence of pseudocysts over follow-up of 16.4 months. CONCLUSION Endoscopic transpapillary drainage with NPD bridging disruption is associated with good outcome in patients with large pseudocysts at tail end of pancreas. However, there was increased frequency of infection when stent was used for drainage.
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Bhasin DK, Rana SS, Nanda M, Chandail VS, Masoodi I, Kang M, Kalra N, Sinha SK, Nagi B, Singh K. Endoscopic management of pancreatic pseudocysts at atypical locations. Surg Endosc 2009; 24:1085-91. [PMID: 19915913 DOI: 10.1007/s00464-009-0732-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 10/12/2009] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS There is paucity of data on endoscopic management of pseudocysts at atypical locations. We evaluated the efficacy of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of pseudocysts of pancreas at atypical locations. PATIENTS AND METHODS Eleven patients with pseudocysts at atypical locations were treated with attempted endoscopic transpapillary nasopancreatic drainage. On endoscopic retrograde pancreatography (ERP), a 5-F NPD was placed across/near the site of duct disruption. RESULTS Three patients each had mediastinal, intrahepatic, and intra/perisplenic pseudocysts and one patient each had renal and pelvic pseudocyst. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. The size of the pseudocysts ranged from 2 to 15 cm. On ERP, the site of ductal disruption was in the body of pancreas in five patients (45.4%), and tail of pancreas in six patients (54.6%). All the patients had partial disruption of pancreatic duct. The NPD was successfully placed across the disruption in 10 of the 11 patients (90.9%) and pseudocysts resolved in 4-8 weeks. One of the patients developed fever, 5 days after the procedure, which was successfully treated by intravenous antibiotics. In another patient, NPD became blocked 12 days after the procedure and was successfully opened by aspiration. The NPD slipped out in one of the patient with splenic pseudocyst and was replaced with a stent. There was no recurrence of symptoms or pseudocysts during follow-up of 3-70 months. CONCLUSION Pancreatic pseudocysts at atypical locations with ductal communication and partial ductal disruption that is bridged by NPD can also be effectively treated with endoscopic transpapillary NPD placement.
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Affiliation(s)
- Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
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Lerch MM, Stier A, Wahnschaffe U, Mayerle J. Pancreatic pseudocysts: observation, endoscopic drainage, or resection? DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:614-21. [PMID: 19890418 DOI: 10.3238/arztebl.2009.0614] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 01/12/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis. They are diagnosed with imaging studies and can be treated successfully with a variety of methods: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, laparoscopic surgery, or open pseudocystoenterostomy. METHODS Relevant publications that appeared from 1975 to 2008 were retrieved from the MEDLINE, PubMed and EMBASE databases for this review. RESULTS Endoscopic pseudocyst drainage has a high success rate (79.2%) and a low complication rate (12.9%). Percutaneous drainage is mainly used for the emergency treatment of infected pancreatic pseudocysts. Open internal drainage and pseudocyst resection are surgical techniques with high success rates (>92%), but also higher morbidity (16%) and mortality (2.5%) than endoscopic treatment (mortality 0.7%). Laparoscopic pseudocystoenterostomy, a recently introduced procedure, is probably similar to the endoscopic techniques with regard to morbidity and mortality. CONCLUSIONS An interdisciplinary approach is best suited for the safe and effective stage-specific treatment of pancreatic pseudocysts. The different interventional techniques that are currently available have yet to be compared directly in randomized trials.
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Affiliation(s)
- Markus M Lerch
- Klinik und Poliklinik für Innere Medizin A, Universitätsklinikum der Ernst-Moritz-Arndt-Universität, Greifswald, Germany.
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15
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EUS-guided diagnosis and successful endoscopic transpapillary management of an intrahepatic pancreatic pseudocyst masquerading as a metastatic pancreatic adenocarcinoma (with videos). Gastrointest Endosc 2009; 70:393-6. [PMID: 19394005 DOI: 10.1016/j.gie.2008.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Accepted: 10/13/2008] [Indexed: 01/10/2023]
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Debridement and drainage of walled-off pancreatic necrosis by a novel laparoendoscopic rendezvous maneuver: experience with 6 cases. Gastrointest Endosc 2008; 67:871-8. [PMID: 18367186 DOI: 10.1016/j.gie.2007.10.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Accepted: 10/30/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is a known complication of acute and chronic pancreatitis. Indications for treatment of WOPN are infection, a rapid increase in size, pain, or biliary or duodenal obstruction. Endoscopic transgastric treatment of pseudocysts with liquid content is successful in approximately 90% of patients; however, the treatment of WOPN is less satisfactory. OBJECTIVE A demonstration of a novel minimally invasive approach to adequately remove and drain pancreatic necrosis. DESIGN Between June 2004 and June 2006, a nonrandomized observational study was conducted with 6 consecutive patients. WOPN was treated by a minimally invasive laparoendoscopic rendezvous technique. SETTING All patients were examined at the university hospital in Freiburg, Germany. PATIENTS Six patients were treated for WOPN of an average diameter of 13 cm (range 9-20 cm). In 5 cases, the WOPN was a consequence of acute pancreatitis; there was 1 case of chronic pancreatitis. The average interval between diagnosis and initial treatment was 14 weeks (range 6-20 weeks). RESULTS Conventional surgery was avoided in 5 patients (83%) over a median follow-up of 14 months (range 1.5-27 months). Six endoscopic sessions (range 4-11) were performed during the entire treatment period. One patient needed emergency surgery on day 4 after the intervention for a perforation because of gastric-wall separation from the necrotic cavity. There was 1 lethal gastric variceal bleeding, which occurred when a gastrostomy tube was removed 46 days after the initial treatment. LIMITATION The small number of patients. CONCLUSIONS In selected cases, minimally invasive laparoendoscopic treatment of WOPN is possible without the need of laparotomy or laparoscopy.
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Abstract
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.
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Abstract
Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Diagnosis is accomplished most often by computed tomographic scanning, by endoscopic retrograde cholangiopancreatography, or by ultrasound, and a rapid progress in the improvement of diagnostic tools enables detection with high sensitivity and specificity. Different strategies contribute to the treatment of pancreatic pseudocysts: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means. This review entails publications referring to the classification of pancreatic pseudocysts, epidemiology, diagnostic tools, and therapeutic options for pancreatic pseudocysts. Only full articles were considered for the review. Based on a search in PubMed, the MeSH terms "pancreatic pseudocysts and classification," "diagnosis," and "endoscopic, percutaneous, and surgical treatment" were used either alone or in combination.
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Perfusion computerized tomography can predict pancreatic necrosis in early stages of severe acute pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1484-92. [PMID: 17950676 DOI: 10.1016/j.cgh.2007.07.014] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The mortality rate associated with severe acute pancreatitis (SAP) with necrosis remains high because early prediction of pancreatic necrosis is difficult. We evaluated whether perfusion computerized tomography (CT), which is used to identify early stage ischemia in the brain, could detect ischemic changes in the pancreas in the early stages of SAP and predict development of necrosis. PATIENTS AND METHODS Thirty consecutive patients with a diagnosis of SAP according to the Atlanta criteria and whose score was greater than 6 were enrolled in this study. All patients were hospitalized within 3 days after onset of symptoms indicative of acute pancreatitis and underwent perfusion CT. Three weeks later, all patients underwent conventional contrast-enhanced CT to detect progression of their disease. RESULTS Perfusion CT showed that 10 of the 30 patients had pancreatic ischemia at the time of diagnosis. Contrast-enhanced CT disclosed that pancreatic necrosis developed in 9 of these 10 patients, but not in the 20 patients who did not have pancreatic ischemia. The sensitivity and specificity of perfusion CT for predicting pancreatic necrosis was calculated to be 100% and 95.3%, respectively. CONCLUSIONS Perfusion CT is a useful tool for early detection of ischemic changes in the pancreas that lead to pancreatic necrosis.
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Lee TH, Park DH, Lee SH, Park JH, Park JY, Kim HS, Park SH, Chung IK, Kim SJ. Simultaneous multitransgastric drainage for large and noncontagious pancreatic pseudocysts (with video). Gastrointest Endosc 2007; 66:1237-8. [PMID: 18061726 DOI: 10.1016/j.gie.2007.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 08/27/2007] [Indexed: 12/10/2022]
Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
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Jansen JM, Hanrath A, Rauws EA, Bruno MJ, Fockens P. Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 2007; 66:157-61. [PMID: 17591491 DOI: 10.1016/j.gie.2007.02.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Accepted: 02/01/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic drainage of pancreatic pseudocysts and abscesses has been shown to be an effective treatment modality. A major determinant for successful cyst resolution is the insertion of multiple endoprostheses and/or placement of a nasocystic drain, which require repeated entries of a catheter into the pseudocyst to reintroduce the guidewire. OBJECTIVE We describe a novel and easy technique to prevent the need for repeated access into the pseudocyst, thereby facilitating the placement of multiple endoprostheses by using a commercially available guiding system for stent introduction. DESIGN Case series. SETTING Academic Medical Center, The Netherlands. PATIENTS Eight consecutive patients with symptomatic pancreatic pseudocysts after acute pancreatitis. INTERVENTIONS Intracystic wire exchange for the insertion of multiple stents in endoscopic treatment of pancreatic pseudocysts by using an echoendoscope. MAIN OUTCOME MEASUREMENTS Feasibility of intracystic wire exchange and complications. RESULTS No guidewire access to the pseudocyst was lost. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established in all patients. CONCLUSIONS The endoscopic appliance of multiple stents becomes easier when using intracystic wire exchange for transgastric pancreatic pseudocyst drainage.
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Affiliation(s)
- Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Arvanitakis M, Delhaye M, Bali MA, Matos C, De Maertelaer V, Le Moine O, Devière J. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65:609-19. [PMID: 17324413 DOI: 10.1016/j.gie.2006.06.083] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 06/20/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic transmural drainage is obtained by creating a communication between the intestinal tract and the pancreatic-fluid collection, and then inserting 1 or more stents. Collection recurrence after therapy is noted in 10% to 30% of cases. It is not known whether leaving the stents in position reduces recurrence rates. OBJECTIVE To test the hypothesis that patients who have undergone previous successful pancreatic-collection drainage and whose stents are retrieved have higher recurrence rates. DESIGN Randomized controlled trial. SETTING Tertiary referral center. PATIENTS During a period of 27 months, 46 of 77 patients who had undergone endoscopic transmural drainage for pancreatic collections met inclusion or exclusion criteria, and 28 of these patients were randomized. INTERVENTIONS Fifteen patients were assigned to group A, whose stents were left in place, and 13 were assigned to group B, whose stents were removed after collection resolution. The remaining 18 patients, who were not randomized, also had their stents left in place. All 46 patients were similarly followed. MAIN OUTCOME MEASUREMENT Recurrence of the same pancreatic collection that required therapy. RESULTS All patients were followed for a median period of 14 months (interquartile range, 8.2-22 months) after treatment. The primary end point was reached in 5 patients in group B (stent retrieval), as opposed to none in group A (P = .013). Moreover, no recurrence was observed in the remaining 18 nonrandomized patients. LIMITATIONS Small sample size. CONCLUSIONS In patients who underwent successful transmural drainage of pancreatic collections, stent retrieval was associated with higher recurrence rates.
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Chahal P, Papachristou GI, Baron TH. Endoscopic transmural entry into pancreatic fluid collections using a dedicated aspiration needle without endoscopic ultrasound guidance: success and complication rates. Surg Endosc 2007; 21:1726-32. [PMID: 17332952 DOI: 10.1007/s00464-007-9236-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 01/18/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endoscopic drainage of pancreatic fluid collections (PFC) is performed with increasing frequency. A variety of techniques for performing transmural entry have been described. However, data are lacking on the technical success and safety of transmural entry using a single technique. The authors describe the largest experience in transmural entry of PFCs without endoscopic ultrasound (EUS) guidance using a dedicated aspiration needle. METHODS All patients who underwent endoscopic transmural drainage of PFC from October 1998 to May 2006 were identified from the endoscopy database. Data were abstracted from the endoscopic procedure report and the patient records then placed in a JMP drive. All drainages were performed without EUS guidance after visualization of an obvious intraluminal bulge using a dedicated large-bore aspiration needle. The transmural tract into the PFC was dilated using a balloon with a diameter of 6 to 20 mm followed by subsequent placement of one or two 10-Fr double pigtail stents with or without nasocystic irrigation tubes. Successful entry was defined as entry allowing for the placement of stents. RESULTS No significant difference in the complication rates was observed when they were analyzed for the following variables: age, gender, balloon diameter, presence of endoscopic impression, drainage approach, and size and type of fluid collection. CONCLUSION Endoscopic transmural drainage of pancreatic fluid collections can be performed safely and effectively via the Seldinger technique without endoscopic ultrasound guidance. The study data will allow sample size calculations to be made if direct comparisons with this technique and others are undertaken.
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Affiliation(s)
- P Chahal
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Bhasin DK, Rana SS, Udawat HP, Thapa BR, Sinha SK, Nagi B. Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone. Am J Gastroenterol 2006; 101:1780-6. [PMID: 16780558 DOI: 10.1111/j.1572-0241.2006.00644.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Deepak K Bhasin
- Department of Gastroenterology, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Ahmed SA, Wray C, Rilo HLR, Choe KA, Gelrud A, Howington JA, Lowy AM, Matthews JB. Chronic pancreatitis: recent advances and ongoing challenges. Curr Probl Surg 2006; 43:127-238. [PMID: 16530053 DOI: 10.1067/j.cpsurg.2005.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Syed A Ahmed
- University of Cincinnati Medical Center, Ohio, USA
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Aghdassi AA, Mayerle J, Kraft M, Sielenkämper AW, Heidecke CD, Lerch MM. Pancreatic pseudocysts--when and how to treat? HPB (Oxford) 2006; 8:432-41. [PMID: 18333098 PMCID: PMC2020756 DOI: 10.1080/13651820600748012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Currently several classification systems are in use that are based on the origin of the pseudocyst, their relation to pancreatic duct anatomy and a possible pseudocyst-duct communication. Diagnosis is accomplished most often by CT scanning, by endoscopic retrograde cholangiopancreaticography (ERCP) or by ultrasound, and rapid progress in the improvement of diagnostic tools has enabled detection with high sensitivity and specificity. There are different therapeutic strategies: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means.
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Affiliation(s)
- Alexander A. Aghdassi
- Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt Universität GreifswaldGermany
| | - Julia Mayerle
- Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt Universität GreifswaldGermany
| | - Matthias Kraft
- Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt Universität GreifswaldGermany
| | - Andreas W. Sielenkämper
- Department of Anesthesiology and Intensive Care Medicine, Westfälische Wilhelms-Universität MünsterGermany
| | | | - Markus M. Lerch
- Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt Universität GreifswaldGermany
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Roeder BE, Pfau PR. Endoscopic Pancreatic Pseudocyst Drainage. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2005. [DOI: 10.1016/j.tgie.2005.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
AIM: To explore the implications of underlying diseases in treatment of pancreatic pseudocysts (PPC).
METHODS: Clinical data of 73 cases of pancreatic pseudocyst treated in a 12-year period were reviewed comprehensively. Pancreatic pseudocysts were classified according to the etiological criteria proposed by D’Egidio. The correlation between the etiological classification, measure of treatment and clinical outcome of the patients was analyzed.
RESULTS: According to the etiological criteria proposed by D’Egidio, 73 patients were divided into three groups. Group I was comprised of 37 patients with type I pseudocyst, percutaneous drainage was successful in the majority (9/11, 82%) while external or internal drainage was not satisfactory with a low success rate (8/16, 50%). Group II was comprised of 24 patients with type II pseudocyst, and internal drainage was curative for most of the cases (11/12, 92%), but the success rate of percutaneous or external drainage was unacceptably low (4/9, 44%). Group III consisted of 12 patients with type III pseudocyst. Internal drainage or pancreatic resection performed in 10 of these patients produced a curative rate of 80% (8/10) with the correction of the ductal pathology as a prerequisite.
CONCLUSION: The classification of pancreatic pseudocyst based on its underlying diseases is meaningful for its management. Awareness of the underlying diseases of pancreatic pseudocyst and detection of the ductal pathology in type II and III pancreatic pseudocysts with endoscopic retrograde cholangiopancreatography may help make better decisions of treatment to reduce the rate of complications and recurrence.
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Affiliation(s)
- Ai-Bin Zhang
- Department of Hepatobiliary Pancreatic Surgery, First Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China.
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Affiliation(s)
- John Baillie
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Soliani P, Ziegler S, Franzini C, Dell'Abate P, Del Rio P, Di Mario F, Cavestro M, Sianesi M. The size of pancreatic pseudocyst does not influence the outcome of invasive treatments. Dig Liver Dis 2004; 36:135-40. [PMID: 15002822 DOI: 10.1016/j.dld.2003.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Authors generally agree that Giant Pancreatic Pseudocysts (> 10 cm) have a lower spontaneous resolution and are more difficult to treat than smaller pancreatic pseudocysts. This study was carried out on two groups of patients with larger and smaller pancreatic pseudocysts (pancreatic pseudocysts > 10 cm versus pancreatic pseudocysts < 10 cm), and aims to establish whether the size of pancreatic pseudocysts is a factor influencing treatment outcomes. PATIENTS AND METHODS In a retrospective study, we examined 71 patients with pancreatic pseudocysts following an episode of acute pancreatitis, which were treated in our hospital from 1980 to 2000. Forty-one (57.5%) patients had a large pancreatic pseudocyst. Most patients underwent invasive treatments: 9 (12.6%) had percutaneous drainage, 37 (52.1%) open surgery and 13 (18.3%) endoscopic cyst gastrostomy. 12 patients (16.9%) of the 71 were cured with medical therapy alone. RESULTS As far as the aetiology of the pancreatitis, location and number of the cysts were concerned, no major differences emerged between the two groups, although large pancreatic pseudocysts followed more severe pancreatitis (P = 0.0005). All giant pancreatic pseudocysts required invasive treatments; 40% of the pancreatic pseudocysts < 10 cm were successfully treated with medical therapy alone. No statistical differences were found regarding hospital mortality, morbidity, recurrence rate and hospital stay among the patients treated invasively. CONCLUSIONS Giant pancreatic pseudocysts more often require invasive therapy due to persistent symptoms or complications. Treatment outcomes do not seem to be influenced by the size of the pancreatic pseudocysts.
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Affiliation(s)
- P Soliani
- Department of General Surgery and Organ Transplantation, University of Parma, Via Gramsci, 14, 43100 Parma, Italy.
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Rebouissoux L, Llanas B, Jouvencel P, Dobremez E, Brun M, Fayon M, Lamireau T. Pancreatic pseudocyst complicating hemolytic-uremic syndrome. J Pediatr Gastroenterol Nutr 2004; 38:102-4. [PMID: 14676604 DOI: 10.1097/00005176-200401000-00022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Nealon WH, Walser E. Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis. Ann Surg 2003; 237:614-20; discussion 620-2. [PMID: 12724627 PMCID: PMC1514521 DOI: 10.1097/01.sla.0000064360.14269.ef] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To test a hypothesis that definitive management of pseudocyst associated with chronic pancreatitis is predicated on addressing pancreatic ductal anatomy. SUMMARY BACKGROUND DATA The authors have previously confirmed the impact of pancreatic ductal anatomic abnormalities on the success of percutaneous drainage of pancreatic pseudocyst. The authors have further defined a system to categorize the pancreatic ductal abnormalities that can be seen with pancreatic pseudocyst. The authors have published, as have others, the usefulness of defining ductal anatomy when managing pancreatic pseudocysts associated with chronic pancreatitis. METHODS Beginning in 1985, all patients with pseudocyst who were candidates for intervention (operative, percutaneous, or endoscopic) have undergone endoscopic retrograde cholangiopancreatography (ERCP). An associated diagnosis of chronic pancreatitis was established by means of ERCP findings. Patients were candidates for longitudinal pancreaticojejunostomy (LPJ) if they had a pancreatic ductal diameter greater than 7 mm. In a nonrandomized fashion, patients were managed with either combined simultaneous LPJ and pseudocyst drainage or with LPJ alone. RESULTS Two hundred fifty-three patients with pseudocyst have been evaluated. Among these there have been 103 patients with chronic pancreatitis and main pancreatic duct (MPD) dilatation (>7 mm). Among these 103 patients, 56 underwent combined LPJ/pseudocyst drainage and 47 had LPJ alone. Compared to combined LPJ/pseudocyst drainage, the patients undergoing LPJ alone had a shorter operative time, slightly less transfusion requirement, slightly reduced length of hospital stay, and slightly reduced complication rate. Long-term pain relief was achieved in 90%, and pseudocyst recurrence was less than 1%. Rates of each of these long-term outcomes were nearly incidental among the two groups. CONCLUSIONS Ductal drainage alone (LPJ) is sufficient in patients with chronic pancreatitis (MPD > 7 mm) and an associated pseudocyst. Simultaneous drainage of pseudocyst is not necessary.
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Affiliation(s)
- William H Nealon
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0544, USA.
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Abstract
In the past decade, our understanding of the genetic basis, pathogenesis, and natural history of pancreatitis has grown strikingly. In severe acute pancreatitis, intensive medical support and non-surgical intervention for complications keeps patients alive; surgical drainage (necrosectomy) is reserved for patients with infected necrosis for whom supportive measures have failed. Enteral feeding has largely replaced the parenteral route; controversy remains with respect to use of prophylactic antibiotics. Although gene therapy for chronic pancreatitis is years away, our understanding of the roles of gene mutations in hereditary and sporadic pancreatitis offers tantalising clues about the disorder's pathogenesis. The division between acute and chronic pancreatitis has always been blurred: now, genetics of the disorder suggest a continuous range of disease rather than two separate entities. With recognition of pancreatic intraepithelial neoplasia, we see that chronic pancreatitis is a premalignant disorder in some patients. Magnetic resonance cholangiopancreatography and endoscopic ultrasound are destined to replace endoscopic retrograde cholangiopancreatography for many diagnostic indications in pancreatic disease.
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Affiliation(s)
- R M S Mitchell
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, USA
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Byrne MF, Mitchell RM, Baillie J. Pancreatic Pseudocysts. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:331-338. [PMID: 12207856 DOI: 10.1007/s11938-002-0021-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pseudocysts complicate acute pancreatitis in less than 5% of cases and chronic pancreatitis in 20% to 40% of cases. A pseudocyst is a localized collection of pancreatic fluid surrounded by a wall of granulation tissue and collagen. It takes 4 to 6 weeks for a fluid collection to mature and become a true pseudocyst. Unlike other cystic lesions of the pancreas from which they should be differentiated, pseudocysts lack an epithelial layer. Patients with pseudocysts present with a range of symptoms and signs. Pseudocysts are imaged using transabdominal ultrasound, CT, endoscopic ultrasound (EUS), and MRI. EUS confers an advantage over other imaging modalities in that certain EUS features are suggestive of pseudocysts over other cystic lesions. The diagnostic accuracy of EUS has improved further with the use of EUS-guided fine-needle aspiration. Therapeutic options include watchful observation or intervention. In our opinion, if acute pseudocysts are uncomplicated, asymptomatic, and do not appear to be enlarging on serial imaging, it is preferable to withhold intervention because many of these cysts resolve spontaneously. However, one needs to beware of the possibility of complications such as infection in unresolved pseudocysts. Pseudocysts associated with chronic pancreatitis are less likely to resolve spontaneously and are drained by intervention more frequently. Of the three interventional options, namely endoscopic, percutaneous, and surgical drainage, endoscopic drainage should be the treatment of choice if certain criteria are met. Preinterventional endoscopic retrograde cholangiopancreatography is mandatory to define ductal anatomy. If there is communication between the pseudocyst and the pancreatic duct, a transpapillary approach is preferred. Use of EUS should increase the number of cases in which pseudocysts can be drained endoscopically. Surgery should be reserved for cases in which there is a concern about malignancy or when there is glandular disruption.
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Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002; 235:751-8. [PMID: 12035030 PMCID: PMC1422503 DOI: 10.1097/00000658-200206000-00001] [Citation(s) in RCA: 142] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To test the hypothesis that pancreatic ductal anatomy may predict the likely success of percutaneous drainage of pseudocysts of the pancreas. SUMMARY BACKGROUND DATA Various modalities are currently applied to pseudocysts, with little or no data to aid in the choice of management strategy. Pancreatic ductal anatomy was assessed and a system to categorize ductal changes was established. METHODS Patients with a diagnosis of pancreatic pseudocyst were evaluated from 1985 to 2000. Two hundred fifty-three patients have been included in this series. Pancreatic ductal anatomy was defined using endoscopic retrograde cholangiopancreatography and categorized as a normal duct, a stricture, or complete cut-off of the pancreatic duct. Communication between the duct and cyst was noted. RESULTS Among the 253 patients, 68 (27%) had spontaneous resolution. Fifty of the remaining 185 had percutaneous drainage and 148 (13 of whom failed to respond to percutaneous drainage) had surgery. There were no deaths in either group. Mean length of time with catheter drainage among all percutaneous drainage patients was 79.2 +/- 19.6 days. Patients with normal pancreatic ducts and those with strictures but no communication between the duct and the cyst who had percutaneous drainage had a much shorter length of hospital stay (6.1 +/- 4.6 days) than patients with strictures and duct-cyst communication and patients with complete cut-off of the duct (33.5 +/- 5.2 days and 39.1 +/- 7.9 days, respectively). Length of drainage also correlated with ductal anatomy. All patients with chronic pancreatitis failed to respond to percutaneous drainage. CONCLUSIONS Pancreatic ductal anatomy provides a clear correlation with the failure and successes of pseudocysts managed by percutaneous drainage as well as predicting the total length of drainage. Percutaneous drainage is best applied to patients with normal ducts and is acceptably applied to patients with stricture but no cyst-duct communication.
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Affiliation(s)
- William H Nealon
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0544, USA.
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Patty I, Kalaoui M, Al-Shamali M, Al-Hassan F, Al-Naqeeb B. Endoscopic drainage for pancreatic pseudocyst in children. J Pediatr Surg 2001; 36:503-5. [PMID: 11227007 DOI: 10.1053/jpsu.2001.21620] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The authors report here the results of endoscopic cystogastrostomy performed on 3 children aged 11, 3, and 2.5 years with nonresolving pancreatic pseudocyst (PP) of 12, 9.5, and 7 cm in diameter. The etiology of PP was abdominal trauma in 2 and idiopathic acute pancreatitis in 1 case. Ultrasound and computed tomography scans confirmed the diagnosis and suitability for gastric drainage. After the puncture of cyst, a double pig-tail stent was placed for the permanent drainage of cystogastrostomy. Complete regression was confirmed by follow-up ultrasonography at 8, 6, and 7 weeks, respectively. There were no procedure-related complications, nor was there a recurrence of cyst during the 2 years of follow-up. This report suggests that children with nonresolving PP, that are anatomically accessible, can be treated successfully and safely by endoscopic drainage.
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Affiliation(s)
- I Patty
- Gastroenterology Center, Amiri Hospital, Kuwait
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Reed DN, Vitale GC. Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery. Surg Clin North Am 2000; 80:1171-201. [PMID: 10987030 DOI: 10.1016/s0039-6109(05)70219-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.
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Affiliation(s)
- D N Reed
- Department of Surgery, University of Louisville School of Medicine, Kentucky, USA
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