Symptomatic Pseudocysts Research Articles

Laparoscopic pancreatic cystgastrostomy.

Internal drainage of acute pancreatic pseudocysts is indicated 6 weeks after the first documentation of pseudocyst. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When pseudocysts are located in close contact with the posterior wall of the stomach, they are best drained by pseudocyst-gastrostomy. This procedure can also be completed making use of intragastric surgical techniques. Under standard laparoscopic observation, three intragastric ports are placed through the abdominal and anterior gastric walls, establishing working channels for a telescope and hand instruments. After the presence of pseudocysts is confirmed, the posterior wall of the stomach and the cyst wall can be incised by electrocautery. After a sufficient drainage orifice is made and the cyst contents are thoroughly debrided, the intragastric ports are removed and defects in the gastric wall are closed with sutures placed via the standard laparoscopic approach. This approach is much less invasive than the conventional approach, which entails a large gastrotomy in the anterior wall of the stomach. This procedure should be the method of choice when interventional radiology or endoscopic intervention fails to effectively drain retrogastric pseudocysts.

Rupture of pseudoaneurysm: a cause of delayed hemorrhage after endoscopic cystoenterostomy; angiographic diagnosis and treatment

Endoscopic cystoenterostomy has become, over the last 15 years, a challenging technique for the treatment of persistent and/or symptomatic pseudocysts adjacent to the upper gastrointestinal tract. The overall results and relapse rate of this technique are similar to those obtained by surgical approaches. Possible complications associated with endoscopic drainage include secondary infection of the pseudocyst and perforation into the abdominal cavity. This latter risk is dramatically reduced if the treatment is reserved for cysts bulging into the digestive tract and/or closely adjacent to the gastric or duodenal wall, as assessed by computed tomography (CT) and/or endosonography.

Endoscopic Treatment of Pancreatic Pseudocysts

Drained surgically or percutaneously, a subset of pancreatic pseudocysts are amenable to transmural or transpapillary endoscopic drainage. Although most series are encouraging, there does appear to be an increased complication rate with the transgastric approach as compared to the transduodenal approach. Moreover, enlarging or symptomatic pseudocysts with considerable necrotic debris are better treated radiographically or with surgical debridement and drainage.

Endoscopic drainage of pancreatic pseudocysts

Pancreatic pseudocysts have traditionally been treated surgically or percutaneously. More recently, endotherapy has been used to decompress enlarging or symptomatic pseudocysts. This manuscript encompasses personal experience and recent literature reports to define the techniques, complications, and short- and long-term results with endoscopic drainage of pancreatic pseudocysts. Three series have reported the transpapillary drainage of pseudocysts. At a mean follow-up of 15–37 months, endotherapy was definitive in 80%, with 0% mortality, 5%–22% morbidity, and a recurrence rate of 6%–9%. Two large series have reported transgastric or transduodenal fistulization. Endoscopic treatment was definitive in 72% and 88%, respectively. Complications approximated 15%, recurrence ranged between 12% and 18%, and there was a single mortality. The majority of published series have used a combination of drainage techniques contingent upon patient anatomy delineated by endoscopic retrograde cholargio pancreatography. These series have reported long-term drainage success in 65%–94%, complications ranging between 4% and 24%, and recurrences that have ranged from 8% to 23%. Endotherapy to drain pancreatic pseudocysts is both technically feasible and effective in a subset of patients with symptomatic pseudocysts.

Management of the later complications of severe acute pancreatitis - pseudocyst, abscess and fistula.

The first-line management of the later complications of severe acute pancreatitis has moved increasingly towards a non-operative approach. Asymptomatic pseudocysts may be safely observed while awaiting spontaneous resolution. Symptomatic, enlarging or complicated pseudocysts, particularly those with an immature wall, should be treated by percutaneous catheter drainage (PCD), reserving surgical drainage for treatment failures. Pancreatic abscesses, if coexisting necrosis can be confidently excluded, should respond to PCD or, if this fails, surgical external drainage. Pancreatic fistulas are rare and often respond to conservative measures. Endoscopically placed pancreatic ductal stents may allow the duct disruption to heal and avoid the need for surgical intervention.

Percutaneous cystogastrostomy with a new catheter for drainage of pancreatic pseudocysts and fluid collections.

We describe a new catheter for the initial percutaneous drainage of large symptomatic pancreatic fluid collections and abscesses using a transgastric approach to allow fluid drainage into the gastric lumen. A double-mushroom stent is placed secondarily for long-term internal drainage to the stomach, avoiding the need for an extended period of external catheter drainage. This technique, termed percutaneous cystogastrostomy (PCG), has been used in 19 consecutive patients with one recurrent symptomatic pseudocyst in the follow-up period fo 9-43 months. There was one death within 30 days of PCG and 1 patient proceeded to surgical necrosectomy. After evidence of resolution of the pseudocysts, the internal stent was retrieved in 17 patients by endoscopic snare.

The clinical challenge of multiple pancreatic pseudocysts

To evaluate the frequency of multiple pancreatic cysts, the likelihood of preoperative diagnosis, and therapeutic outcome, we retrospectively reviewed the records of 157 patients who underwent operation for pancreatic pseudocysts at 2 institutions between 1970 and 1992. Multiple pseudocysts were found in 29 (18.5%). The 8 women and 21 men ranged in age from 21 to 79 years. The etiology was alcohol abuse in 15 (52%), biliary tract disease in 6 (21%), alcohol abuse and biliary tract disease in 3 (10%), and a variety of other causes in the remaining 5 (17%). There was no difference in age, sex, race, etiology, or presenting signs and symptoms between patients with single pseudocysts and those with multiple cysts. Serum amylase levels were significantly higher in patients with multiple cysts compared to those with single cysts (P < 0.05). Computed tomography accurately demonstrated the extent of disease in 20 of 25 patients (80%), while 1 or more cysts were missed in 5 (20%). The mean number of cysts per patient was 2.7, with a range of 2 to 5. Average pseudocyst diameter was 7.8 cm, with a range from 3 to 20 cm. Multiple internal drainage procedures were performed in 19 patients, a combination of internal and external drainage in 6, external drainage in 1, and resection of multiple cysts in the tail in 2. There was no operative mortality. With a mean follow up of 38.5 months, only 1 recurrent pseudocyst has been found. There were six attempts at percutaneous drainage in six patients. Two of these patients were referred to our institution following failure of percutaneous drainage at other hospitals. Three other patients had residual symptomatic pseudocysts following percutaneous drainage at our hospitals and then underwent multiple internal drainage. The sixth patient refused operative drainage despite the persistence of residual symptomatic pseudocysts after attempted percutaneous drainage. The incidence of multiple pseudocysts (18.5%) is higher than previously reported. There is no difference in the clinical features of patients with single versus multiple pseudocysts. Patients with multiple cysts have higher serum amylase levels. Preoperative computed tomography underestimated the number of cysts in 20% of patients. Careful intraoperative exploration is still needed to avoid missing multiple pseudocysts. Internal drainage is the preferred therapy. A thorough search for multiple cysts at the initial operation should eliminate one potential cause for pseudocyst recurrence.

Endoscopic Management of Pancreatic Pseudocysts

Recently, endoscopic interventional procedures were introduced for nonsurgical therapy of symptomatic pancreas pseudocysts. We reported 25 patients treated by endoscopic retrograde pancreas drainage (ERPD), endoscopic cystogastrostomy (ECG), or endosopic cystoduodenostomy (ECD). ERPD was performed in 9 patients by placement of a 5 Fr. or 7 Fr. endoprosthesis transpapillary into the cyst or the main pancreatic duct. ECG was carried out in 10 cases, in 7 of these, a double pigtail catheter was additionally inserted. Three patients suffering from pseudocysts of the pancreas head were treated by ECD. In a further 3 cases, ERPD and ECG were combined. All patients reported a dramatic reduction of pain with a simultaneous increase of appetite and body weight. The drainage tubes were removed after disappearance of symptoms, and abnormal clinical and endoscopic findings within 2 to 12 months. In 4 cases, a recurrence of the cyst was found 10 and 22 months later, in 3 cases the endoprostheses had to be renewed because of catheter occlusion or dislocation. 2 patient underwent surgical treatment after insufficient endoscopic drainage due to haemorrhage or recurrence. Endoscopic treatment of pancreatic pseudocysts yielded good results with low rates of recurrence and complications. According to our experiences we think endoscopic interventional techniques will oust surgery from its present dominant position in the next years.

PERCUTANEOUS CYSTOGASTROSTOMY FOR TREATMENT OF PANCREATIC PSEUDOCYSTS

Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections nad two related to catheter blockage. Percutaneous, cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2-17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.

An endoscopic retrograde cholangiopancreatography (ERCP)-based algorithm for the management of pancreatic pseudocysts

In the treatment of pancreatic pseudocysts, percutaneous and endoscopic drainage have, in certain cases, become alternatives to surgery. However, each treatment modality carries risks of complications and recurrences that may be minimized by the appropriate allocation of therapy. This article proposes the use of an endoscopic retrograde cholangiopancreatography (ERCP)-based algorithm as a means to allocate pseudocyst therapy based on the findings of pancreatic duct obstruction or pseudocyst communication. To evaluate this algorithm, the records of a series of patients with pancreatic pseudocysts seen at Duke University Medical Center from 1984 to 1990 were reviewed. Of 102 patients, 73 had symptomatic pseudocysts that required treatment. Forty of the 69 elective interventions were preceded by ERCPs and retrospectively applied to the algorithm. The number of adverse outcomes (treatment failures + complications) of the group that followed the algorithm was 3 of 26 (12%), while the number of adverse outcomes of the group that did not follow the algorithm was 6 of 14 (43%) (p < 0.04 by Fisher's exact test). These two subgroups were similar in all other characteristics examined. Therefore, this ERCP-based algorithm may be used to allocate pseudocyst treatment; however, a prospective trial is necessary to prove its efficacy.