Acute haemorrhage associated with pancreatic pseudocyst and chronic pancreatitis

The present study reports 18 patients operated on for chronic pancreatitis complicated by bleeding in the upper gastrointestinal tract, the peritoneal cavity or the retroperitoneal space. Damage to the splenic artery by a pancreatic pseudocyst was the most common reason for the bleeding (10 patients, 56%) and the most common site was the duodenum (10 patients, 56%). Eleven patients were treated by transcystic multiple suture ligations combined with external drainage of the pseudocyst, and seven by pancreatic resection or total pancreatectomy. Hospital mortality was 33% (6 patients); two patients had undergone transcystic suture ligation, and four pancreatic resection. Five patients needed a reoperation because of further bleeding, four of them having been treated initially by transcystic suture ligation. Our results suggest that haemostasis by suture ligation is a method to be recommended if the patient's condition has been exacerbated by severe haemorrhage.     

Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst.

The records of 92 patients with symptomatic pancreatic pseudocysts referred for surgical management over a 27-year period were retrospectively reviewed to compare outcome in 42 patients managed with operative internal drainage procedures (group I) with that in 52 patients managed with computed tomography-directed percutaneous catheter drainage (PCD) (group II). The two groups were similar for patient age, sex, pseudocyst location, and cause. The frequency of antecedent pseudocyst-associated complications was less in group I (16.7 versus 38.5%, p less than 0.05). Seven group I patients and four group II patients had major complications (16.7 versus 7.7%, not significant). Group II mean duration of catheter drainage was 42.1 days, and the drain track infection rate was 48.1%. The frequency of antecedent operative cyst drainage was similar (14.2 versus 13.5%), as was the frequency of subsequent operations for complications related to chronic pancreatitis (9.5 versus 19.2%, not significant). Mortality rate was greater in group I (7.1% versus 0%, p less than 0.05). Pseudocysts can be effectively managed either by open operation with internal drainage or by PCD. Drawbacks of PCD include the controlled external pancreatic fistula and the risk of drain track infection. Percutaneous catheter drainage has the following advantages: (1) low mortality rate, (2) does not require a major operation, (3) does not violate the operative field in cases when subsequent retrograde duct drainage procedures are required. Neither PCD nor internal drainage is definitive, and with either technique subsequent correction of underlying pancreatic pathology may be necessary.     

Simultaneous treatment of chronic pancreatitis and pancreatic pseudocyst

Records from 87 consecutive patients undergoing lateral pancreaticojejunostomy (LPJ) for chronic pancreatitis were reviewed to determine the incidence of pseudocyst and the safety of combined pancreatic duct and pseudocyst drainage. Twelve patients had undergone previous pancreatic pseudocyst drainage; four of them also had pancreatic pseudocysts present at the time of LPJ. In addition, 22 patients had pseudocysts identified preoperatively and/or confirmed at operation. The overall incidence of pseudocyst was 39%. Twenty-six patients (group 1) underwent pancreaticojejunostomy combined with pseudocyst drainage. Sixty-one patients (group 2) underwent pancreaticojejunostomy only. Operative morbidity and mortality results (19% and 8%, respectively, in group 1; 18% and 2%, respectively, in group 2) were similar. Patient outcome was also similar in the two groups (81% and 84% of patients obtained pain relief in groups 1 and 2, respectively). There were no pseudocyst recurrences in either group. Thus, there is a high incidence (39%) of pancreatic pseudocyst in patients undergoing LPJ for chronic pancreatitis. Combined drainage of the pancreatic duct and pseudocyst is safe and effective.     

Surgical treatment of chronic pancreatitis with ductal hypertension complicated by posterior pancreatic pseudocyst

The experience was summarized concerning the treatment of 5 patients with chronic pancreatitis and ductal hypertension, complicated by retropancreatic pseudocyst. One-stage internal draining of pseudocyst and the pancreatic duct, using the method elaborated in the clinic, was performed. There were no postoperative complications. Late follow-up result is good.     

Laparoscopic pancreatic surgery in patients with chronic pancreatitis

BACKGROUND: In recent years, technological advances and technical refinements to laparoscopic instruments have encouraged some surgeons to explore the application of laparoscopic methods to benign disorders of the pancreas. The aim of this report was to evaluate the feasibility and outcome of laparoscopic pancreatic surgery in patients with chronic pancreatitis. METHODS: One group of five patients with disease of nonalcoholic origin localized in the body-tail of the pancreas underwent distal pancreatectomy with preservation of the splenic vessels; a second group of six patients with symptomatic pancreatic pseudocysts (alcoholic origin in four cases and idiopathic in two cases) underwent laparoscopic transgastric drainage. For distal pancreatectomy and spleen salvage, the patient's positioning was half-lateral decubitus with the left side up. Four ports were used. A comparison was made with 41 patients with chronic, pancreatitis who underwent conventional open distal pancreatectomy. For the patients with laparoscopic distal pancreatectomy, the mean operative time was 4 h (range 3-5). RESULTS: There were no pancreatic-related complications, but one patient was reoperated for perforation of duodenal ulcer. The mean hospital stay was 6 days and the mean time to resume normal daily activities was 3 weeks. Laparoscopic pseudocyst drainage was performed in four patients via laparoscopic anterior gastrostomy and two patients via laparoscopic intraluminal cystogastrostomy. The mean operative time was 100 min (range 60-160). There was no morbidity. The mean hospital stay was 5 days, and the mean time to resume normal daily activities was 2 weeks. CONCLUSION: This study provides information about the possibilities of performing laparoscopic surgery in patients with chronic pancreatitis. Laparoscopic distal pancreatectomy with preservation of the splenic vessels and laparoscopic transgastric drainage are feasible and safe techniques. They offer obvious advantages, such as reduction of the parietal damage to the abdomen, a shorter hospital stay, and an earlier postoperative recovery than can be obtained with conventional open pancreatic resection.     

Endoscopic drainage for pancreatic pseudocyst in children

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.     

Percutaneous drainage of pancreatic pseudocyst into the stomach

Background: We present our experience with percutaneous ultrasonographically guided internal cystogastric drainage of pancreatic pseudocysts using a double pigtail catheter. Methods: In nine patients, the pancreatic pseudocysts following acute pancreatitis were drained percutaneously into the stomach with the double pigtail catheter under ultrasonographical (US) control. The needle insertion through both gastric walls and the final position of the proximal curve of the catheter were monitored with a gastroscope. The position of the distal curve of the catheter was checked by US. There were no procedure-related complications. The patients were followed up monthly by clinical and US examination. Results: At first follow-up 1 month after the intervention, none of the patients had evidence of the pseudocyst. The patients were not aware of the catheter and functioned normally throughout the procedure and catheter removal. The catheter was removed endoscopically after 5–8 months. Conclusions: The method is minimally invasive and also feasible in high-risk surgical patients. It requires a team consisting of an interventional radiologist, an ultrasonographer, and an endoscopist. In properly selected patients, the results are excellent.     

A new method for pseudocysto-duodenostomy as therapy in pancreatic pseudocyst in chronic pancreatitis

Reference in the surgical literature to the use of pseudocysto-duodenostomy whether laterolateral by Ombredanne [6] or transduodenal by Kerschner [4], is uncommon. The author with the aid of specially designed three-jaw prong, now, prefer to use pseudocysto-duodenostomy. From 1970, 411 patients underwent surgery for complicated chronic pancreatitis. 67 of the 93 patients requiring an internal cysto-intestinal procedure were treated by pseudocysto-duodenostomy; 11 additional patients were treated by derivation in the first retroperitoneal transposed jejunal loop. Postoperative mortality for the first month was 0%. The actuarial survival rate at 5 years was 86.9%. These satisfactory results have encouraged us to compare this new operative method with cystojejunostomy. It allows pancreatic secretions to drain into their natural anatomical site. Compared with external drainage it avoids the often prolonged and costly complications.     

A modern review of the operative management of chronic pancreatitis

Chronic pancreatitis is a debilitating disease resulting in pain, intestinal malabsorption, endocrine dysfunction, and poor quality of life (QoL). Our aim was to analyze surgical outcomes for patients with chronic pancreatitis. Data for patients undergoing operations for chronic pancreatitis between 1990 and 2009 were reviewed. Demographics, operative and perioperative data, and survival were catalogued. QoL was determined (Short Form 36 and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire + PAN-26) and compared with historical controls. The mean age was 51 +/- 2 years, 38 patients were male (53%), the most common indication was pain (71%), the etiology of pancreatitis often was alcohol, and most patients underwent a Whipple procedure (56%). Operative time was 316 +/- 17 minutes and blood loss was 363 +/- 75 mL. There were 34 complications in 30 patients (42%) and one death. QoL surveys were administered for 25 of 55 (45%) surviving patients at a mean follow-up of 72 +/- 16 months. Mean survival was 99 +/- 9 months, whereas 5- and 10-year survival were 86 and 75 per cent. QoL scores were uniformly better than historical controls. Our data demonstrate that operations for chronic pancreatitis can be performed with acceptable morbidity and mortality. Patients have excellent survival and improved QoL compared with historical controls. Surgery is an effective and durable treatment option for patients with chronic pancreatitis.     

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with pancreatic pseudocyst associated with resolving acute and chronic pancreatitis.

Experience with patients with pancreatic pseudocysts has led the authors to the hypothesis that preoperative evaluation of the pancreatic and bile ducts by ERCP will define those patients who may be inadequately treated by pseudocyst drainage alone without attention to associated pancreatic and biliary ductal abnormalities. In patients with certain ductal abnormalities, the pseudocyst operation was combined with a definitive operative drainage of the pancreatic duct and/or of the biliary tree where appropriate. A prospective evaluation of routine preoperative ERCP was undertaken over a 36-month period in all patients scheduled for operative treatment of pseudocyst of the pancreas. From an initial group of 44 patients with pseudocysts, three patients who had spontaneous regression of the pseudocyst were excluded. ERCP was successful in 39 of the remaining 41 patients. Among 41 operated patients, 24 were admitted with a diagnosis of pseudocyst that arose after an episode of acute pancreatitis, and 17 had chronic pancreatitis with pseudocyst. Nine patients, initially assumed to have acute pancreatitis, were recognized to have chronic pancreatitis on the basis of ERCP findings. Communication with the main pancreatic duct (MPD) was demonstrated in 18 of 41 pseudocysts, and the rate of communication was similar in patients with acute and chronic pancreatitis. Dilatation of the MPD was seen in 23 of 41 patients and was associated with chronic pancreatitis in 21. Dilatation of the common bile duct was found in 12 patients with chronic pancreatitis. The operative plan was altered by ERCP findings in 24 of 41 patients; 22 of the 24 patients had chronic pancreatitis. There were no complications of ERCP. These data suggest that ERCP should be performed in all patients with pseudocysts to establish correct diagnosis and to allow optimal choice of operation.     

Jaundice and chronic pancreatitis: common bile duct compression by pancreatic pseudocyst

In chronic pancreatitis, obstructive jaundice solely due to common bile duct compression by a pancreatic pseudocyst is highly unusual. In most of these cases, the jaundice is due to fibrotic stricture of the intrapancreatic portion of the common bile duct. We report two cases of obstructive jaundice in chronic pancreatitis with pseudocyst. Operative findings and follow-up during the postoperative period demonstrated compression by the pseudocyst over the common bile duct as the only etiologic factor of the jaundice. We believe that intraoperative cholangiography should be performed after drainage of a pseudocyst to correctly assess the etiology of obstruction.     

Pancreatic duct drainage in 100 patients with chronic pancreatitis.

Although the development of islet cell autotransplantation has focused attention on extended resections of the pancreas, drainage of a dilated pancreatic duct remains an effective means of relieving intractable pain of chronic pancreatitis. Between 1954 and 1980, 98 men and two women with chronic pancreatitis were treated for pain with ductal drainage. All patients had a history of chronic alcoholism. Pancreatic calculi were found in 68 patients. Operative procedures include: seven caudal pancreaticojejunostomies, 42 longitudinal pancreaticojejunostomies, and 54 side-to-side pancreaticojejunostomies. Two caudal pancreaticojejunostomies were converted to longitudinal pancreaticojejunostomies, and one longitudinal pancreaticojejunostomy required revision. The operative mortality rate was 4%. Follow-up studies, lasting up to 24 years, were conducted for all but seven patients. Eighty per cent of these patients have had substantial improvement or complete resolution of their pain. Diabetes, as evidence by an elevated fasting blood sugar level, was present prior to operation in 30% of the patients, and developed after operation in 14%. Only nine of 21 insulin-dependent diabetics in this series did not require insulin prior to pancreaticojejunostomy. Pancreatic enzyme replacement was needed for control of steatorrhea in 18 patients. Four patients with continued pain underwent total or near total pancreatectomies. Three of these patients died of uncontrolled diabetes. Only one patient with a drainage procedure alone has died of uncontrolled diabetes. In patients with dilated pancreatic ducts, pancreaticojejunostomy is a safe, reliable means of providing pain relief, with minimal loss of endocrine and exocrine function.