Pancreatic pseudocyst: therapeutic dilemma. Int J Inflam. 2012;2012:279476. [PMID: 22577595 DOI: 10.1155/2012/279476]

Interventional management and diagnostic follow-up of a large pancreatic pseudocyst: A case report

We present a case of a large pancreatic pseudocyst in a 69-year-old man following post biopsy pancreatitis. Radiological findings revealed a thick-walled, fluid filled mass in proximity to the pancreas. Although pancreatic pseudocysts generally self-resolve, extensive or complicated cysts may require surgical or interventional management. Pseudocyst size >6 cm, compression of the inferior vena cava or biliary duct, and severe symptoms often prognosticate the need for intervention.

Effect of Early Continuous Veno-Venous Haemofiltration in Severe Acute Pancreatitis for the Prevention of Local Pancreatic Complications

Objective

To compare the conventional treatment and continuous veno-venous haemofiltration (CVVH) in severe acute pancreatitis (SAP) for the prevention of pseudocyst and walled-off necrosis. Patients and Methods. Forty-two patients were divided into two treatment groups: conventional treatment group contained 24 patients and CVVH had 18. Conventional treatment group patients were treated symptomatically and according to the causes. CVVH group patients were treated symptomatically, and CVVH was done within 2 hours of admission.

Results

In both groups, there was a decrease in amylase, lipase, CRP, IL-6, IL-10, TNF-alpha, Ranson score, Balthazar score, and APACHE-II score after 72 hours, but the decrease was significantly greater in CVVH patients. There were no any local pancreatic complications in CVVH patients, but 1 patient had an acute peripancreatic fluid collection, 2 patients had pseudocyst, and 2 patients had walled-off necrosis (WON), and a mortality one was seen in the conventional treatment group.

Conclusion

The present study shows that early CVVH may be able to prevent the formation of pseudocyst and win in SAP patients.

Bedside Percutaneous Approach in a Critically Ill ICU Patient with Complex Pancreatobiliary Disorder Followed by Endoscopic Approach: Lessons Learnt from a Tertiary Referral Center

Pancreatobiliary disorder is a challenging clinical condition, especially when this condition is causing severe infection or biliary sepsis, and sometimes it requires intensive care unit (ICU) treatment. Biliary drainage is the mainstay of therapy; however, the choice of the drainage method is dependent on the patient's clinical condition and the disease itself. A 79-year-old female was transferred on a ventilator to our ICU from another hospital due to biliary sepsis, a large common bile duct stone, and an infected pancreatic pseudocyst. The patient also has other comorbidities such as heart problems, hypothyroidism, and diabetes mellitus. Bedside percutaneous transhepatic biliary drainage without fluoroscopy and percutaneous cyst aspiration was successfully performed, which improved the patient's condition; this was followed by an endoscopic approach, i.e., endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided pancreatic pseudocyst drainage. The clinical improvement showed itself in the change of the patient's respiratory status and ventilator mode. In conclusion, the percutaneous approach has a big role in managing critically ill patients in the ICU setting. However, expertise, training experience, and a multidisciplinary team approach are very important for successful management and patient outcome.

Laparoscopic loop cystojejunostomy: An alternative to Roux-en-Y cystojejunostomy for pancreatic pseudocyst

Surgical internal drainage of pancreatic pseudocyst can be done into the stomach, duodenum or jejunum depending on the anatomic relation of pseudocyst with hollow viscera. For cystojejunostomy, a Roux-en-Y loop is preferred over loop cystojejunostomy as former is thought to avoid the reflux of jejunal contents into the cyst cavity. This study presents our experience with laparoscopic loop cystojejunostomy showing loop cystojejunostomy for the pseudocyst of the pancreas can be safely performed laparoscopically with simpler technique with no complications including reflux.

Unusual Locations of Pancreatic Pseudocysts in Lumbar Triangle, Psoas Muscle and Intercostal Space, and Obturator Externus

Pancreatic pseudocyst develops as a complication of both acute and chronic pancreatitis. Although the common location of pseudocyst is lesser sac, extension of pseudocyst can occur into mesentery, retroperitoneum, inguinal region, scrotum, liver, spleen, mediastinum, pleura, and lung. Extension of pseudocyst into psoas muscle and lumbar triangle is extremely rare. The development of pseudocyst in lumbar triangle is radiologically equivalent and further extension of Grey Turner's sign seen clinically in acute pancreatitis. This extension occurs due to the destructive nature of pancreatic enzymes. The lumbar triangle is the site of anatomic weakness in the lateral abdominal wall in the lumbar region. We report the case of a 35-year-old alcoholic male patient who presented with abdominal pain followed by distension and swelling in the right lumbar region for 1 week. On computed tomography scan of the abdomen, acute-on-chronic pancreatitis with multiple pseudocysts in the right posterior pararenal space, extending through the right lumbar triangle in the right lateral abdominal wall, right posterior paraspinal muscles, right iliopsoas, right obturator externus, and medial aspect of the right upper thigh, beneath anterior abdominal wall in the upper abdomen and in the right lateral thoracic wall through the right 11^th intercostal space, was detected.

Review of management options for pancreatic pseudocysts

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

Successful surgical internal drainage of postoperative pancreatic pseudocyst through pancreaticojejunostomy with distal pancreatectomy: a case report

Pancreatic pseudocyst is usually treated by percutaneous external drainage, endoscopic internal or external drainage, or surgical internal drainage such as cystogastrostomy. Surgical external drainage is an option if these procedures fail. We describe a case of a 70-year-old man with a pancreatic body pseudocyst that developed postoperatively. It was improved by endoscopic external drainage, and the stent was changed to an internal stent. However, surgery was required as the pseudocyst grew again. A direct approach to the pseudocyst was not possible because of severe adhesion. A distal pancreatectomy with pancreaticojejunostomy was performed, and an external pancreatic stent tube was inserted from the cut end into the duodenum to drain the pseudocyst. One month later, the pseudocyst disappeared, and the stent was removed.

Extension of pancreatic pseudocyst into psoas muscle in a setting of acute pancreatitis

Pancreatic pseudocysts are known to extend beyond the confines of the pancreatic bed due to the digestive nature of enzyme rich pancreatic fluid. Extension of a pseudocyst beyond the retroperitoneum, along the retrofascial plane within the psoas muscle is, however, unusual, with only a handful of cases described in the literature. We report a case of a 28-year-old man who presented with right lumbar pain and painful ipsilateral hip extension. Imaging findings revealed extension of the pseudocyst into psoas along with features of acute pancreatitis. The pseudocyst was drained percutaneously under image guidance, which led to resolution of symptoms.

Endoscopic ultrasound for treatment of infected pancreatic pseudocysts

AIM: To explore the clinical effect of endoscopic ultrasound (EUS) in the treatment of infected pancreatic pseudocysts (PPs).

METHODS: Between January 2008 and December 2013, 25 patients were admitted to our center for infected PPs and underwent EUS. The clinical data about therapies and recovery of the patients were analyzed.

RESULTS: All patients underwent EUS with transgastric stenting and BD drainage. One patient required laparoscopic surgery because therapeutic EUS was unsuccessful. Mean operative time was 48.3 min ± 27.6 min. Mean postoperative hospital stay was 8.4 d ± 3.7 d. The median follow-up period was 19.6 mo. No recurrence or other complications occurred.

CONCLUSION: Endoscopic ultrasound is a safe, effective and minimally invasive therapeutic method for infected PPs.

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

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

Diagnosis and treatment of pancreatic pseudocysts by endoscopy and laparoscopy: Our experience with 56 cases

AIM: To investigate the choice of minimally invasive treatments for pancreatic pseudocysts (PPC).

METHODS: Clinical data for 56 patients with PPC were retrospectively analyzed. The method of treatment was selected based on etiology, cyst formation time, adjacent organ position, and presence of intracystic infection or not.

RESULTS: Of 34 cases treated by endoscopic ultrasonography (EUS)-guided gastric or duodenal drainage, 33 were successful and 1 developed stent migration and underwent laparoscopic cyst drainage. Four cases were confirmed to have communication between cyst and the main pancreatic duct by ERCP, and two of them underwent pancreatic duct stent placement (ERPD). Of 9 cases undergoing laparoscopic cyst-jejunum Roux-en-Y anastomosis, 7 were successful and 2 were converted to open surgery. Four cases underwent laparoscopic cyst excision because cyst was too small and could not be distinguished from pancreatic cystadenoma preoperatively, and one patient developed postoperative pancreatic leakage. Four patients underwent CT-guided puncture and external drainage of cyst.

CONCLUSION: Treatments for PPC are diverse, and selection of appropriate treatment based on the patient's situation is key to the treatment of PPC. With the development of endoscopic and laparoscopic technologies, traditional treatment methods will be gradually replaced by minimally invasive treatments.