Endoscopic management of pancreatic pseudocyst in children

Pancreatic pseudocyst as a cause for gastric outlet obstruction

The pancreatic pseudocyst contains pancreatic enzymes encapsulated by a non-epithelialized wall. They are rare in the pediatric population and are mostly a result of pancreatic trauma: extrinsic, or intrinsic. Management options include conservative or surgical, depending on the clinical signs and symptoms, and the size of the cyst.

Endoscopic Management of Pancreatic Fluid Collections in Children

The incidence of acute pancreatitis in children has increased over the last few decades. The development of pancreatic fluid collection is not uncommon after severe acute pancreatitis, although its natural course in children and adolescents is poorly understood. Asymptomatic fluid collections can be safely observed without any intervention. However, the presence of clinically significant symptoms warrants the drainage of these fluid collections. Endoscopic management of pancreatic fluid collection is safe and effective in adults. The use of endoscopic ultrasound (EUS)-guided procedure has improved the efficacy and safety of drainage of pancreatic fluid collections, which have not been well studied in pediatric populations, barring a scant volume of small case series. Excellent results of EUS-guided drainage in adult patients also need to be verified in children and adolescents. Endo-prostheses used to drain pancreatic fluid collections include plastic and metal stents. Metal stents have wider lumens and become clogged less often than plastic stents. Fully covered metal stents specifically designed for pancreatic fluid collection are available, and initial studies have shown encouraging results in adult patients. The future of endoscopic management of pancreatic fluid collection in children appears promising. Prospective studies with larger sample sizes are required to establish their definitive role in the pediatric age group.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

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.

Endoscopic management of pancreatic pseudocysts and walled-off pancreatic necrosis: A two-decade experience

AIM

To determine long-term outcome of endoscopic management of pancreatic pseudocyst/walled-off pancreatic necrosis (WOPN) without necrosectomy.

METHODS

One-hundred and sixty-five pancreatic pseudocysts/WOPN managed endoscopically over a period of 22 years were analyzed retrospectively for technical success, complications, and recurrence.

RESULTS

Symptomatic 118 males and 47 females with mean age of 35.8 years were included. Alcohol was the most common etiology (41.2%). Transmural endoscopic drainage was done in 144 patients, while 21 patients underwent transpapillary drainage. All the patients were subjected to contrast computed tomography (CT) abdomen or routine/Doppler ultrasound. Endoscopic ultrasound was done in last 11 patients. One or two double pigtail 7 Fr stents were placed when clear watery fluid came out from cyst (130 patients, 78.8%), and nasocystic drainage (NCD) tubes were placed in addition to two 7 Fr stents when there were frank pus, thick dark fluid, or solid components inside the cyst (35 patients). All these patients settled on this treatment. Thirty-three of 35 patients of WOPN could be managed endoscopically without necrosectomy. Complications occurred in 9.2% of pseudocysts and 40% of WOPN. Thirty-five patients were followed up for more than 5 years (3 patients more than 10 years), and 130 patients were followed up for up to 5 years. Recurrence occurred in 8.1% of pseudocysts and 5.7% of WOPN.

CONCLUSION

Majority of pancreatic pseudocysts/WOPN can be managed with endoscopic drainage without necrosectomy with high success, low complication, and recurrence rates.

Hybrid notes: incisionless intragastric stapled cystgastrostomy of a pancreatic pseudocyst

PURPOSE

We present a case report of a novel hybrid natural orifice transluminal endoscopic surgery (NOTES). The operation performed was a transgastric cystgastrostomy with endoscopic guidance for a pancreatic pseudocyst. This operation was completed entirely through an existing gastrostomy site with no incisions, thus avoiding the peritoneal cavity.

METHODS

This is a case of a 7-year-old boy with neurologic impairment from congenital herpes simplex virus encephalitis who is tube fed. He had acute pancreatitis and developed a 9 cm pancreatic pseudocyst. The pseudocyst failed to resolve after 6 weeks and developed a mature wall. Due to a history of multiple abdominal surgeries and known abdominal adhesions, a minimally invasive approach that would avoid entering the peritoneal cavity was the desired approach. The technique involved a trans-oral endoscope for visualization and the use of the gastrostomy as access to the gastric lumen and pseudocyst. The pancreatic pseudocyst was stabilized with two T-fasteners and confirmed with needle aspiration under endoscopic visualization. The pseudocyst was then opened with the LigaSure (Valleylab, Boulder, CO). The cystgastrostomy anastomosis was completed with an Endopath ETS-Flex Articulating Linear Stapler/Cutter (Ethicon Endo-Surgery, Inc, Cincinnati, OH). The operation took less than 2 hours and was completed without an incision. Under the policies of the Human Research Protection Program, review of a single case is outside the scope of the definition of human subjects research and does not require institutional review board review and approval.

RESULTS

The patient did well postoperatively and had a dramatic reduction in size of the pancreatic pseudocyst to 3.5 cm by 2 weeks.

CONCLUSIONS

Hybrid NOTES cystgastrostomy performed through an existing gastrocutaneous fistula is an excellent approach for minimally invasive drainage of pancreatic pseudocysts.

Endoscopic management of pancreatic pseudocyst in children-a long-term follow-up

BACKGROUND

Literature on long-term outcome after endoscopic management of pediatric pancreatic pseudocyst is not available. The aim of the present study is to report long-term outcome after endoscopic drainage of pancreatic pseudocyst in children.

METHODS

Nine patients younger than 15 years, subjected to endoscopic pseudocyst drainage, were included in this study (between 1994 and 2004). Eight patients were subjected to endoscopic cystogastrostomy and stenting, whereas 1 patient was subjected to cystoduodenostomy and stenting. A follow-up of patients was done at 1 month and at 2 to 10 years after drainage. Endoscopic retrograde cholangiopancreatography (ERCP) was done in 2 patients at the time of drainage, and it was repeated in both the patients at the time of final follow-up.

RESULTS

Mean age of the patients was 9.6 years. Trauma was the most common cause (n = 8). Mean follow-up of these patients was 5.7 years (2-10 years). No recurrence was seen in any patient. Endoscopic retrograde cholangiopancreatography revealed complete pancreatic duct block in prevertebral region in 2 posttraumatic patients, and it was persisting on repeat ERCP at final follow-up.

CONCLUSIONS

Endoscopic drainage of pancreatic pseudocyst is safe in children with a very good long-term outcome. Pancreatic duct block seen on ERCP may not be clinically important on long-term follow-up.

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.

Endoscopic cystogastrostomy

Endoscopic cystoenterostomy for drainage of pancreatic pseudocyst is a new emerging modality which has rarely been reported in pediatric patients. Only ten successfully performed cases of pediatric endoscopic cystoenterostomy have been reported previously. We report a case of 9 year old male child with post traumatic pseudocyst of pancreas, successfully managed by endoscopic cystogastrostomy. To best of our knowledge, this is the first pediatric case report in Indian literature.

Cystogastrostomy: a valid option for treating pancreatic pseudocysts of children in developing countries

Twelve children with pancreatic pseudocysts were managed for over 10 years at our institute that is a tertiary referral center of our country. A majority of them had posttraumatic pancreatic pseudocysts. Six of them were early referrals and presented within 1-2 weeks of pancreatic injury while the remaining six were referred later than 6 weeks with thick cyst walls. An initial conservative management and observation (with serial ultrasounds) led to a resolution of the pseudocysts in three patients (25% resolution rate). All the remaining subjects were treated using surgical modality (cystogastrostomy). In all the subjects where cystogastrostomy was done, the pseudocysts resolved completely, except in one child, who required the procedure to be repeated. The authors encountered no complications of the pancreatic pseudocyst disease in children i.e. infection, rupture, etc, that have been frequently described for adults. The authors conclude that pancreatic pseudocyst is a comparatively benign entity in children with a better outcome than in adults. Though various sophisticated treatment modalities are in vogue in the developed countries for managing pancreatic pseudocysts in children, cystogastrostomy is still a valid option for this purpose in the developing countries with suboptimal infrastructure and gives good results.

Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts in children

Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The management is based upon the pseudocyst size and presence of symptoms. Those requiring intervention are often drained using several available options. The use of laparoscopic cystogastrostomy for large and recurrent PPSs has been described in adult patients as a less morbid alternative to open drainage procedures. This technique is considered a novel approach in children. We describe 2 children who had PPSs amenable to laparoscopic cystogastrostomy. The first was an 11-year-old girl who had blunt abdominal trauma from a bicycle handlebar. The second patient was a 7-year-old girl who developed idiopathic pancreatitis. Briefly, 2 ports were placed through the anterior abdominal and gastric walls, and into the lumen of the stomach. This intraluminal placement provided access to the posterior gastric wall. Using electrocautery diathermy, an incision was made through the posterior gastric wall and into the adjacent pseudocyst to obtain complete and unobstructed drainage. Both children tolerated the procedures well with resolution of their PPSs. The patients were each discharged on the fourth postoperative day and have been asymptomatic on 2 years follow-up. Laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for the minimally invasive management of PPSs in the pediatric population.

Chronic pancreatitis with pancreaticolithiasis and pseudocyst in a 5-year-old boy with homozygous SPINK1 mutation

We report a 5-year-old boy with a 5-month history of symptoms owing to chronic pancreatitis. Abdominal imaging revealed a large pseudocyst in the pancreatic tail and concretions in the main pancreatic duct. Successful endoscopic papillotomy and stent implantation were performed. Genetic testing showed homozygous SPINK1-N34S mutation, which is an established risk factor for chronic pancreatitis.