Failure of percutaneous drainage in children with traumatic pancreatic pseudocysts

Recent reports have documented the successful use of percutaneous drainage (PD) in the management of traumatic pancreatic pseudocysts in children. This study presents four cases of pancreatic pseudocyst in which percutaneous catheter drainage was performed. In one instance, no operative therapy was required. However, in the other three cases PD failed to resolve the problem and distal pancreatectomy with splenic salvage was performed when contrast studies (endoscopic retrograde cholangiopancreatography or catheter injection) demonstrated disruption of the main pancreatic duct. This report suggests that children with pancreatic pseudocysts unresponsive to PD require prompt investigation of ductal anatomy to rule out transection or other major injury.     

Percutaneous catheter drainage of pancreatic pseudocysts.

Pancreatic pseudocysts represent a complication of severe pancreatic inflammatory disease. Although operative drainage is the cornerstone of therapy for pseudocysts, we have undertaken percutaneous catheter drainage in a selected group of 28 patients over a six-year period (1982-88). This represents 42 per cent of pseudocyst patients managed by the senior author and 1.7 per cent of admissions for pancreatitis at the Medical University Hospitals during that period of time. There were 26 men and two women with an age range of 26-66 years (mean = 42.1). Twenty-six patients had alcohol abuse as the cause of pancreatitis; two were due to surgical trauma. Nondilated pancreatic ducts were demonstrated in 25 patients. Six had pancreatic ascites associated with pseudocysts. Four had previous operative drainage (2 internal and 2 external drainage procedures). Five patients received octreotide acetate, a synthetic peptide which mimics the action of somatostatin, in an attempt to aid closure of external fistulas. The mean length of catheter drainage was 48 days (range 7-210 days). Eight (29%) patients developed procedure-related complications (1 pneumothorax, 1 sheared guidewire, six drain tract infections). There was no mortality. Successful resolution of pseudocysts was achieved in 26 patients (93%). Two patients subsequently had elective caudal pancreaticojejunostomy (CPJ), and one lateral pancreaticojejunostomy (LPJ) to drain obstructed pancreatic ducts. One patient has required repeat external drainage. Percutaneous external drainage is successful in pseudocyst eradication. When underlying pancreatic pathology remains uncorrected, elective surgical decompression of obstructed, dilated ducts may be necessary.     

Endoscopic drainage of pancreatic pseudocysts in children

Background/Purpose

Symptomatic pancreatic pseudocysts have traditionally been managed with surgical, percutaneous, and, more recently, endoscopic drainage. Although the role of the latter is well defined in the adult population, its utility in children needs to be clarified. The authors reviewed their experience with endoscopic drainage of pancreatic pseudocyst (EDPP).

Methods

A retrospective chart review was conducted, and relevant demographic and clinical data were obtained for all patients with pancreatic pseudocysts managed with endoscopic drainage in the period from 1997 through 2001, inclusive.

Results

Three children had successful endoscopic drainage of pancreatic pseudocysts. They were 9, 13, and 14 years old, and were all boys. The etiology of the pancreatitis was idiopathic related to anomalous pancreatic divisum ducts in the first 2 and azathioprine induced in the latter. The first 2 patients had endoscopic transpapillary drainage, whereas the third had an endoscopic cystduodenostomy. All patients had complete resolution of the pseudocyst clinically and radiologically after follow-up periods of 3, 31, and 21 months, respectively. The first needed a subsequent pancreaticojejunostomy for persistent symptoms related to chronic pancreatitis. A successful endoscopic drainage of a posttraumatic pancreatic pseudocyst has previously been reported from our institution.

Conclusions

This experience would indicate that endoscopic drainage of pancreatic pseudocyst is an effective and relatively safe option of managing this problem in children.     

Percutaneous drainage of pancreatic pseudocysts: A prospective study

We classify pancreatic pseudocysts in 3 types: post-necrotic type I, related to acute pancreatitis; post-necrotic type II, related to an acute attack superimposed on chronic pancreatitis; and retention type III, due to chronic pancreatitis with ductal stricture. A prospective study on percutaneous catheter drainage of post-necrotic pseudocysts (type I and II) was undertaken from 1987 to 1990. Twenty-three pseudocysts in 21 patients were drained. Overall recurrence rate was 4%; 2 patients had fistulization of the catheter into bowel; no deaths occurred. The procedure was successful in all type I cysts; in type II cysts it was associated with prolonged drainage and increased risk of complications when cyst-duct communication was present. Percutaneous drainage has no role to play in type III retention cysts. Guidelines regarding indications for treatment and the techniques employed are described.

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Resumen Clasificamos los seudoquistes pancreáticos en tres tipos: Tipo I, post-necrótico, el que está relacionado con pancreatitis aguda; Tipo II, post-necrótico, el que está relacionado con un ataque agudo en un paciente con pancreatitis crónica; tipo III, de retención, el que se debe a pancreatitis crónica con estenosis ductal. Se realizó un estudio prospectivo sobre el drenaje percutáneo con catéter de los quistes post-necróticos (tipos I y II) entre 1987 y 1990. Se drenaron 23 seudoquistes en 21 pacientes. La tasa global de recurrencia fue 4%; dos pacientes desarrollaron fistulización del catéter al intestino; no se presentaron muertes. El procedimiento fue exitoso en todos los quistes tipo I; en los quistes tipo II apareció asociado con drenaje prolongado y con un mayor riesgo de complicaciones cuando había comunicación quiste-canal pancreático. El drenaje percutáneo no está indicado en los quistes de retención tipo III. Se describen las directrices en cuanto a tratamiento y a las técnicas empleadas.

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Résumé Nous avons classé les pseudokystes pancréatiques en trois groupes: type I: postnécrotique, secondaire à une pancréatite aiguë, type II: postnécrotique secondaire à une poussée aiguë sur pancréatite chronique, et type III: rétentionel, en rapport avec une sténose du canal de Wirsung au cours d'une pancréatite chronique. Une étude prospective sur le drainage percutané des pseudokystes nécrotiques: (type I et II) a été entreprise entre 1987 et 1990. Vingt trois pseudokystes chez 21 patients ont été drainés. Le taux de récidive global a été de 4%. Une fistulisation kysto-entérique s'est produite chez deux patients sans entrainer de déces. Le procédé a été couronné de succès dans tous les pseudokystes du type I. Lorsqu'il s'agissait d'un pseudokyste de type II, le drainage a été souvent prolongé, et des complications ont été plus fréquentes lorsqu'une communication kysto-canalaire était présente. Le drainage percutané n'a aucun rôle à jouer dans les pseudokystes du type III. Des recommandations quant aux indications et la technique à employer sont décrities.

     

Percutaneous puncture and drainage under ultrasonic control of pancreatic pseudocysts]

Eighty-seven pancreatic pseudocysts have been treated with a single or repeated puncture, which was or was not followed by percutaneous drainage. When the diameter of the cyst was smaller than 5 cm, it was healed in 83.3% of all cases. When the size of the cysts ranged from 6 to 10 cm, puncture alone allowed curing them in 57.1% of all cases, otherwise it had to be completed by drainage. On the other hand, puncture alone was not sufficient for cysts with a diameter exceeding 10 cm, and an associated suction or surgical drainage was required. In the light of this experience, we can bring out the respective indications of single and multiple puncture and of percutaneous drainage, while taking account both of the size and of the etiological and clinicopathological features of the pseudocysts. In addition, this study allows assessing the incidence of the complications associated to this type of treatment.     

Transcutaneous drainage of pancreatic pseudocysts

The clinical study includes 76 pancreatic pseudocysts localized in the head (24), body (37), and tail (15). The effect of treatment by means of a single or repeated purposeful aspiration in ultrasonic control is discussed. Recovery occurred in 83.3% of cases with cysts measuring up to 5 cm, in 61.3% in those with cysts measuring from 5 to 10 cm, and in 11.1% of cases in which the cysts measured more than 10 cm. As the result of 15 draining manipulations of cysts which were irresponsive to aspiration (9 of them measuring from 5 to 10 cm and 6 larger than 10 cm) complete recovery occurred in 13 cases. The authors discuss the indications for single, two, and many punctures on basis of a complex appraisal of the gland, the size and type of the cyst, and the cytologic results. The indications for percutaneous drainage, the period and techniques of its performance and preliminary and postmanipulation treatment with drugs are determined and the occurring complications are shown.     

Laparoscopic drainage of pancreatic pseudocysts

Background. Laparoscopic drainage of pancreatic pseudocysts (PPs) has been used in selected cases. The aim of this study is to analyze our results with the laparoscopic technique and to compare them with those of a cohort of patients treated by open surgery during the same time period.Patients and methods. Ten patients underwent laparoscopic drainage of PPs during a 7-year period [laparoscopic group (LG)]. The type of drainage was chosen according to the size and location of the PP. Demography, surgical details, results, and complications were analyzed and contrasted with those of 6 patients who underwent open drainage [open group (OG)].Results. All patients presented with mature PPs developed after a documented episode of acute pancreatitis. Mean age of the LG was 42 years (six males and four females). In the OG, mean age was 36 years (five males and one female). Etiology of the pancreatitis was alcoholic in eight patients, biliary in five, toxic in two, and associated with systemic lupus erythematous in one. Laparoscopic procedures included Roux-en-Y cystojejunostomy in four patients, extraluminal cystogastrostomy in four, and intraluminal cystogastrostomy in two. There were no conversions. In the OG, cystogastrostomy was performed in three patients and Roux-en-Y cystojejunostomy in three. One patient in the LG developed upper gastrointestinal bleeding the day after surgery that resolved uneventfully, one patient presented a postoperative abscess that required open drainage, and one patient presented a residual pseudocyst that was treated by endoscopy. Morbidity in the OG included a small bowel obstruction secondary to an internal hernia that required reoperation, pneumonia, and a residual pseudocyst that was treated conservatively in one patient each. At a median follow-up of 22 months (range, 1–72) all patients were asymptomatic with no evidence of recurrent disease by computed tomography scan.Conclusion. Laparoscopic drainage of PPs is feasible, safe, and effective. Results are similar to those obtained using the open technique.     

Endoscopic drainage of pancreatic pseudocysts

Summary Seventeen patients with pancreatic pseudocysts were treated by endoscopic drainage. In nine cases we performed endoscopic retrograde pancreatic drainage (ERPD) by inserting 7-Fr pigtail catheters via the papilla into the cyst or into the main pancreatic duct. In two cases transduodenal cystotomy (ECD) and in eight cases transgastral cystotomy (ECG) are performed by using coagulator and papillotome. In five cases of ECG an endoprosthesis was inserted into the cyst. In two cases combination therapy of ERPD and ECG was performed. All patients reported reduction of continuous pain and postprandial epigastralgia after placement of endoprosthesis. After disappearance of symptoms and abnormal endoscopic findings within a period of 2–12 months the drainage tubes were removed. In one case postoperative dislocation of the prosthesis was observed; no serious complication was not encountered. The period of observation varied from 5 to 40 months. Two patients are presently under treatment with endoprostheses. Endoscopic drainage yielded good results in the treatment of pancreatic pseudocysts.     

Internal drainage surgery in pancreatic pseudocysts

60 pancreatic pseudocysts are reported. 29 cystojejunostomies, 22 cystogastrostomies, 2 cystoduodenostomies and 7 external drainages were performed. Most favourable results could be recorded by cystojejunostomy. The total operative mortality was 8.3%, after cystojejunostomie 3.4%. Most dangerous complications were haemorrhage and peritonitis. In the follow up of internal operative drainage approximately 80% excellent or satisfactory results could be observed. Pancreatic pseudocysts lasting more than 6 weeks should be submit to surgical treatment. Cystojejunostomy is the most favourable procedure. External drainage is indicated in emergency or development of complications.     

超声内镜引导下穿刺引流治疗胰腺假性囊肿

目的探讨超声内镜引导下经胃肠壁穿刺置管引流治疗胰腺假性囊肿的疗效及并发症。方法选择2004年8月至2011年3月胰腺假性囊肿患者28例,首先使用线阵型超声内镜扫查,明确病变部位后选择合适穿刺点,导丝沿穿刺针道进入囊肿,沿导丝放置双猪尾硅胶支架1～3支。术后定期随访,囊肿消失后拔除支架。结果本组28例患者,穿刺引流成功25例,成功率为89．3％,其中经胃19例,经十二指肠6例。发生并发症3例,支架移位、出血、感染各1例。随访8—34个月,19例假性囊肿完全消失,6例腹痛症状消失、囊肿明显缩小、但持续存在2年以上,所有患者均未见假性囊肿复发。结论超声内镜引导下经胃肠壁穿刺置管引流术是治疗胰腺假性囊肿的较好方法之一,其疗效确切,并发症少。     

Percutaneous cystogastrostomy in patients with pancreatic pseudocysts.

OBJECTIVE: To evaluate the results of percutaneous cystogastrostomy for pancreatic pseudocysts secondary to acute or chronic pancreatitis. DESIGN: Retrospective study with prospective follow-up. SETTING: University hospital, Sweden. PATIENTS: 16 patients with symptomatic pseudocysts (10 men and 6 women, mean age 56 (36-78) years) treated during the period 1993-1999. INTERVENTION: Pseudocystogastrostomy was created under local anaesthesia and fluoroscopic control by percutaneous insertion of a double pigtail catheter. RESULTS: The underlying diagnosis was acute pancreatitis in 10 and chronic pancreatitis in 6 patients. 13 patients had one pseudocyst and 4 had 2 or more with a median diameter of 11 (5-20) cm. The procedure was successful in all but 2 patients, who were operated on. 2 patients experienced pain after the intervention that did not require specific treatment, otherwise no complications were noted. Median hospital stay was 2 days (range 1-60). The median follow-up was 45 (1-94) months. All but 2 patients had successful drainage during follow-up with resolution or regression of the pseudocyst and relief of symptoms (pain and abdominal discomfort). CONCLUSION: Pancreatic pseudocysts were treated by percutaneous cystogastrostomy with good results. Percutaneous cystogastrostomy is a safe, minimally invasive procedure that gives good results at long-term follow-up as well as in the short-term.     

Management of pancreatic pseudocysts in children

The management of 25 children with pseudocyst of the pancreas presenting over a 30-year period is reviewed. Nearly a third could be managed nonoperatively, monitoring clinical signs, serum amylase, and in recent years the findings of ultrasound and CT scan. Persistence of symptoms, signs, and hyperamylasemia for more than 4 weeks indicated failed resolution in all but one case. Endoscopic retrograde cholangiopancreatography (ERCP) done in those who did not improve spontaneously facilitated operative strategy. Early operation and internal drainage in selected cases was well tolerated. Individualization of treatment is emphasized.     

Mediastinal pancreatic pseudocysts in children.

Mediastinal pseudocyst is an unusual complication of pancreatitis, with only four cases previously reported in children. The extent of the pseudocyst can be defined by computed tomography or magnetic resonance imaging scan and preoperative aspiration of cyst fluid for amylase level can establish the diagnosis. Endoscopic retrograde cholangiopancreatography to define ductal anatomy can help plan the appropriate drainage procedure. Although exceedingly rare, the diagnosis of pseudocyst should be considered for any cystic mass in the abdomen or thorax, even in the absence of elevated amylase or history suggesting pancreatitis.     

胰腺假性囊肿内引流术式的研究

目的：探讨胰腺假性囊肿内引流术的术式选择。
方法：回顾性分析13余年收治且行囊肿内引流治疗的胰腺假性囊肿62例的临床资料,着重探讨手术方法以及效果。
结果：全组均经B超或/和CT以及术后病理学检查明确胰腺假性囊肿的诊断。行囊肿空肠Roux-en-Y型吻合术的31例,术后囊肿感染发生率为9.7%（3/31）,消化道出血发生率为3.2%（1/31）,无死亡病例。行囊肿胃吻合术的16例,术后囊肿感染发生率为12.5%（2/16）,消化道出血发生率为37.5%（6/16）,病死率为6.25%（1/16）。行序贯式囊肿外、内引流术的15例,术后囊肿感染发生率为6.7%（1/15）,消化道出血发生率为13.3%（2/15）,无死亡者。
结论：囊肿空肠Roux-en-Y型吻合术是安全有效的术式;对适宜行囊肿胃吻合术的囊肿,建议行序贯式囊肿外、内引流术。     

Blunt pancreatic injuries in children: the role of percutaneous external drainage in the treatment of pancreatic pseudocysts

During the past 10 years, 26 cases of blunt pancreatic trauma were diagnosed in our institution. In 42.3% (11/26) the accident was bicycle-related. Seventy-three percent of patients were seen within 48 hours of injury. The most frequent clinical presentations included abdominal pain, tenderness and vomiting. Diagnosis of pancreatic injury was suggested by hypermylasemia in most cases. Associated trauma was seen in seven patients (26.9%) and it was intraabdominal in four (15.3%). Computerized tomography (CT) scan is the single most useful radiologic investigation in evaluating pancreatic trauma. Ultrasound, although less accurate than CT scan in determining the severity of the initial injury, is useful in the evaluation and treatment of pancreatic pseudocysts. Pancreatic pseudocysts developed in ten patients. Spontaneous resolution occurred in five (50%). In three patients, percutaneous external drainage (PED) was successful in treating pancreatic pseudocysts without complications or recurrence at 11, 19, and 31 months. PED is a suitable form of treatment in selected cases of pancreatic pseudocysts. Results in children are better than in the adult population, probably due to the absence of primary pancreatic pathology. We believe that PED should be considered the primary therapeutic procedure for traumatic pancreatic collections prior to more invasive surgical treatment, when there is no evidence of pancreatic duct transection on CT scan.     

Modified ultrasound-guided percutaneous transgastric drainage of pancreatic pseudocysts

Summary We describe a modified ultrasound-guided transgastric drainage technique for pancreatic pseudocysts. Using a water-filled stomach to improve visualization, we have successfully drained pseudocysts in ten patients. This report also describes the use of a stiffening cannula to assist transgastric catheter placement. We emphasize the value of constant real-time tracking of the dilator and guidewire to ensure correct positioning of the drainage catheter.