Cholestasis due to compression of the common bile duct by pancreatic pseudocysts

We studied 10 patients with pancreatitis who had persistent cholestasis secondary to compression of the common bile duct by a pancreatic pseudocyst. Elevation of the serum bilirubin or alkaline phosphatase levels, or both, (sensitive indicators of cholestasis) was present in each of our patients. The diagnosis of a pancreatic pseudocyst is best made by CAT scan and ultrasonography. These techniques will delineate the small intrapancreatic pseudocyst that otherwise may be difficult to recognize on inspection at operation. Endoscopic retrograde cholangiography and pancreatography are desirable because they delineate the anatomic alterations of the pancreatic and common bile ducts and may contribute information pertaining to the possibility of common duct obstruction by pancreatic fibrosis. In our opinion, cholestasis secondary to bile duct compression by a pseudocyst is an indication for operation. Each of our 10 patients had drainage of their pseudocysts. Cystoduodenostomy, performed in seven patients, was the method most commonly used. If there is concern regarding the patency of the common duct after drainage of the cyst, intraoperative cholangiography should be performed. This was carried out in three patients. In each patient, the preoperative elevations of serum alkaline phosphatase and serum bilirubin levels returned to normal limits after operative decompression of a pancreatic pseudocyst alone without an accompanying or subsequent bilioenteric bypass being required.     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated. Methods After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct. Results ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far. Conclusions ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

Pancreatic pseudo-pseudocysts

The records of nine patients referred for evaluation of pancreatic pseudocysts were reviewed. Nearly all presented with the triad of epigastric pain, palpable abdominal mass, and distortion or displacement of the upper gastrointestinal tract on barium study. All nine patients either failed to reveal a pancreatic pseudocyst at laparotomy or had disappearance of the mass at clinical follow-up study. In the last three patients, duodenal endoscopy with retrograde pancreatography was performed. In two of the three patients, normal anatomic structures were identified, which should have alerted clinicians to postpone surgery. In the third patient, abnormalities of the pancreatic duct and gland were sufficient to suggest a mass which later disappeared. We interpreted this to represent the appearance of edematous pancreatitis which resolved with supportive management.The term pseudo-pseudocyst is offered for this group of findings in an attempt to alert the clinician to the importance of diagnosis, the potential reversibility of the transient edema associated with acute pancreatitis which may mimic pseudocyst, and the need to avoid exploratory laparotomy when newer endoscopic technics suggest that surgery may not be indicated.     

Multicentric pancreatic intraepithelial neoplasias (PanINs) presenting with the clinical features of chronic pancreatitis

A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas.     

Surgical Management of Failed Endoscopic Treatment of Pancreatic Disease

Introduction  Endoscopic therapy of acute and chronic pancreatitis has decreased the need for operative intervention. However, a significant proportion of patients treated endoscopically require definitive surgical management for persistent symptoms. Objective  Our aim was to determine which patients are likely to fail with endoscopic therapy, and to assess the clinical outcome of surgical management. Patients were identified using ICD-9 codes for pancreatic disease as well as CPT codes for endoscopic therapy followed by surgery. Material and Methods  Patients with documented acute or chronic pancreatitis treated endoscopically prior to surgical therapy were included (N = 88). The majority of patients (65%) exhibited chronic pancreatitis due to alcohol abuse. Common indicators for surgery were: persistent symptoms, anatomy not amenable to endoscopic treatment and unresolved common bile duct or pancreatic duct strictures. Surgical salvage procedures included internal drainage of a pseudocyst or an obstructed pancreatic duct (46%), debridement of peripancreatic fluid collections (25%), and pancreatic resection (31%). Results  Death occurred in 3% of patients. The most common complications were hemorrhage (16%), wound infection (13%), and pulmonary complications (11%). Chronic pancreatitis with persistent symptoms is the most common reason for pancreatic surgery following endoscopic therapy. Surgical salvage therapy can largely be accomplished by drainage procedures, but pancreatic resection is common. Conclusion  These complex procedures can be performed with acceptable mortality but also with significant risk for morbidity. Presented at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, CA, May 21, 2008.     

Pancreatic ascites: recognition and management.

In a patient with chronic ascites, an abnormally raised ascitic fluid amylase concentration and a protein content above 2.5 gm/100 ml is diagnostic of pancreatic ascites. Thirty-one episodes in 26 patients treated between 1958 and 1975 have been analyzed. Twenty patients (65%) experienced abdominal pain and ten (32%) had concomitant pleural effusions roentgenographically. Although a leaking pancreatic pseudocyst was the cause of ascites in at least 21 episodes (70%), an abdominal mass could only be palpated in two of 26 patients. Roentgenographic series of the upper part of the gastrointestinal tract failed to demonstrate pancreatic pseudocyst in 7 of 21 episodes (33%). Endoscopic retrograde pancreatography is invaluable in delineating the pancreatic ductal system and, in conjunction with intraoperative pancreatography, makes a vital contribution to rational surgical therapy. Medical treatment or external drainage during 18 episodes resulted in death in four (22%) and recurrences of ascites or pancreatic pseudocyst in nine (64%). Since routine pancreatography followed by pancreatic resection or internal drainage has been instituted, mortality and recurrence have been reduced to zero.     

Endoscopic retrograde cholangiopancreatography for surgeons

Endoscopic retrograde cholangiopancreatography remains an important tool for the management of biliary and pancreatic disease. Endoscopic removal of common bile duct stones is the procedure of choice for retained stones and is a common option preoperatively with the gallbladder in place. Cholangitis is best treated by endoscopic sphincterotomy and stenting along with intravenous antibiotics initially with the possibility of definitive treatment with endoscopic stone removal and/or dilatation and stenting for strictures. Endoscopic sphincterotomy is also recommended in severe or rapidly worsening gallstone pancreatitis or in those with combined pancreatitis and rising bilirubin or cholangitis. Palliation with internal stents for malignant strictures has been possible with good outcome and very little difference in efficacy, complications, mortality, and long-term survival compared to surgical treatment. Biliary fistulae are easily treated by endoscopic stenting, particularly when the source is the cystic or an accessory duct. Benign biliary strictures can be dilated and stented for prolonged periods with good long-term success in selected cases. Pancreatic stenting is useful to treat pancreatic duct strictures and duct hypertension with considerable improvement of pain. Endoscopic drainage of pancreatic pseudocyst appears to be a safe, effective, and definitive treatment for patients in whom anatomic considerations allow its use. In summary, therapeutic uses of ERCP are of broad interest to the general surgeon and should be understood and utilized appropriately by the surgical community.     

Pancreatitis After a Primary and Secondary Excision of Congenital Choledochal Cysts

Purpose Pancreatitis has been reported long after total choledochal cyst excision. The aim of this study was to determine if the disease process of postoperative pancreatitis differs between a primary and secondary cyst excision in a long-term follow-up. Methods Among 53 postoperative patients who underwent a total cyst excision and were followed up, 44 patients underwent a primary cyst excision (primary excision group), while 9 patients underwent a secondary cyst excision after a previous cyst-duodenostomy for internal drainage (secondary excision group). The long-term clinical course, including the pancreatographic findings after a total cyst excision, was compared. Results In the primary excision group, six patients had mild pancreatitis. Endoscopic retrograde pancreatography demonstrated ductal dilatation that was limited to the common channel in two patients, concurrent with the ventral duct in three, and extended the duct of Santorini in three. Conservative treatments were carried out in three patients, and endoscopic irrigation in one patient with protein plugs in the ventral duct. A resection of the choledochal remnant in the pancreas was performed in two patients with choledochal remnant-associated pancreatitis. From the secondary excision group, 5 of the 9 patients had chronic pancreatitis. Endoscopic retrograde pancreatography showed entire pancreatic ductal dilatation. Two of these patients underwent duodenal papilloplasty at the same time as secondary surgery; however, the disease progressively worsened. Conclusion In patients undergoing a secondary total excision after internal drainage, it is difficult to half the ongoing aggravating process in pancreatitis.     

Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature

Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross-references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.     

The endoscopic approach to pancreatic duct stones

Pancreatic duct stones may complicate the course of chronic pancreatitis and be responsible for recurrent episodes of pancreatitis and/or exacerbations of abdominal pain. Endoscopic management of pancreatic duct stones with or without extracorporeal shock-wave lithotripsy (ESWL) is a relatively safe and effective method to treat main pancreatic duct stones in symptomatic patients. Selection of candidates most likely to respond to endoscopic therapy needs further evaluation. Studies comparing medical, surgical, and endoscopic treatment of pancreatic duct stones are still awaited.     

Symposium on pancreatitis: 3. Diagnostic tools in the management of chronic pancreatitis

The chief diagnostic tools used in planning the management of chronic pancreatitis require close collaboration of the surgeon and radiologist. Barium meal, endoscopic retrograde cholangiopancreatography (ERCP), ultrasonography and angiography are the most useful procedures. The barium meal is the initial screening procedure. Uultrasonography should follow if there is suspicion of a pseudocyst or pancreatic abscess. It is also may be of value in demonstrating localized chronic pancreatitis. The most useful of all the tests is ERCP. This shows the pancreatic duct, the common bile duct, or both ducts, so that the surgeon may avoid operation where there is no defect to correct, or it may guide him in selecting an operation that is designed to correct the anatomical abnormalities of either duct. Angiography is occasionally of use when the foregoing procedures have not provided enough information. In over 80% of patients it is possible for the surgeon to undertake an operation with foreknowledge of the pancreas that will help him select the correct procedure to alleviate the patient's symptoms.     

Endoscopic placement of pancreatic stents and drains in the management of pancreatitis.

Although widely used in the biliary tree, little data is available on endoscopic placement of stents or drains within the pancreas. This report describes 17 patients, nine with acute relapsing pancreatitis and eight with chronic pancreatitis, who had drain or stent placement for hypertensive pancreatic duct (PD) sphincter, dominant ductal stenosis, duct disruption, or pseudocyst. Two patients have subsequently undergone surgery, and six other patients continue long-term stent placement with marked reduction of chronic pain or attacks of recurrent pancreatitis. All six pseudocysts resolved, although one recurred and required surgery. It is concluded that pancreatic drains or stents may obviate the need for surgery, temporize before definitive therapy, or direct a subsequent surgical procedure.     

Carcinoma masquerading as a pancreatic pseudocyst on ultrasound

Ultrasound has proven invaluable in detecting and evaluating pancreatic pseudocysts, and it is now a standard test to rule out complications of pancreatitis. In reviewing the authors' experience with 122 patients treated surgically for a pancreatic pseudocyst, five patients were identified in whom an ultrasound demonstrated a pseudocyst that was associated with an unexpected cancer at the time of operation. A sixth patient, with a pseudocyst documented by ultrasound, died prior to surgery and was found at autopsy to have metastatic common bile duct carcinoma. There was little difference in presenting symptoms, age, frequency of alcoholism, or physical findings compared with patients with pseudocysts secondary to pancreatitis. In two patients, pseudocysts were found in the tail of the pancreas at operation, in addition to carcinoma. In the other three patients, no pseudocyst was found; however, a subcapsular splenic hematoma was present in one. Five patients had metastatic disease, three from pancreatic adenocarcinoma, one from islet cell carcinoma, and one from a common bile duct carcinoma. One patient with a pancreatic adenocarcinoma confined to the head underwent a Whipple procedure and has no evidence of disease 6 months later. Malignancy may cause or coexist with pancreatic pseudocysts. Ultrasound is often not helpful in distinguishing pseudocysts associated with malignancy from those associated with pancreatitis. Biopsy should be performed to rule out malignancy when operating for pancreatic pseudocysts.     

慢性胰腺炎39例外科治疗体会

目的　探讨慢性胰腺炎病人的外科治疗方法。方法　对本院 1980年 1月～ 2 0 0 0年 12月间 39例接受手术治疗的慢性胰腺炎病人的病史进行回顾性分析。结果　本组病例的病因最多为胆源性 ,其次为胰石性和酒精性。其诊断多依赖于临床表现和影像学改变。手术适应证主要是肿块性胰腺炎、胰管结石、胰腺假性囊肿、顽固性腹痛和无法排除恶性疾病者。手术方式则根据不同的分类来选择 ,不外乎胰管引流或 (和 )胰腺切除术。结论　部分严重的病人通过手术治疗可以缓解腹痛 ,提高生活质量 ,并控制胰腺内、外分泌功能的恶化     

Mucinous cystic neoplasm of the pancreas presenting with hemosuccus pancreaticus: Report of a case

Hemosuccus pancreaticus (HP) is mostly induced by a ruptured pseudoaneurysm or hemorrhage from a pseudocyst in chronic pancreatitis. We herein report a rare case with HP induced by tumor hemorrhage. The present patient is a 71-year-old woman referred to us with a diagnosis of severe progressive anemia. Endoscopy revealed hemorrhage from the papilla of Vater. Computed tomography showed a multilocular cystic tumor in the tail of the pancreas. The patient underwent a distal pancreatectomy. The histopathological diagnosis was carcinoma in mucinous cystadenoma. No cancer infiltration into the pancreatic duct was detected. Pancreatography of the resected specimen demonstrated an overt communication between the main pancreatic duct and the cystic cavity of the tumor, which was not demonstrated preoperatively by endoscopic retrograde pancreatography. Although the cause of HP is mainly acute or chronic pancreatitis, we should bear in mind that a pancreatic tumor may be a possible cause of HP and that, as such, prompt and proper treatment is mandatory.     

Pancreatic pseudocyst

In 74 patients treated for pancreatic pseudocyst, the underlying disease of acute or chronic pancreatitis was found to influence the clinical course. Even in the era of computed tomographic scans and ultrasonography, selective contrast studies of the pancreatic duct and common bile duct can improve results, particularly when the cause is chronic pancreatitis.     

Evaluation of therapeutic options for pancreatic pseudocysts

A review of 81 patients with pancreatic pseudocyst was conducted to assess the value of different treatment modalities. Resection was associated with 18% mortality (two of 11 patients) and 36% morbidity. In three of nine patients undergoing external drainage a recurrent pseudocyst developed, and in one additional patient, a pancreatic fistula persisted. Internal drainage by cystogastrostomy (21 patients) resulted in 9.5% mortality and 9.5% morbidity, whereas cystojejunostomy (33 patients) was associated with a 6% mortality and 6% morbidity. Endoscopic drainage through the posterior wall of the stomach was unsuccessful in the two patients in which it was used. Internal drainage into the stomach, duodenum, or jejunum is a safe and effective approach for most pseudocysts. Persistent symptoms following surgical treatment were primarily related to failure to recognize multiple cysts and/or pancreatic duct obstruction and dilation characteristic or chronic pancreatitis.     

Endoscopic therapy for chronic pancreatitis.

When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality. The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases. In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.     

Pancreas divisum--a rare cause of chronic pancreatitis

Pancreas divisum (P.D.) is a congenital anatomic variant, characterized by the nonunion of dorsal and ventral pancreatic ducts. A 20 years old man followed for 8 years with reccurent abdominal pain and relapsing acute pancreatitis develope chronic calcific pancreatitis. He was diagnosed with P.D. on endoscopic retrograde pancreatography and operative pancreatography. The patient was treated with longitudinal pancreatico-jejunostomy (PUESTOW-GILLESBY procedure). His pain resolved following surgical drainage of the pancreatic duct. Evaluation of the clinical course of this patient and critical review of other such cases in the literature support the role of compromised ductal drainage of the pancreas in the pathogenesis of chronic pancreatitis in P.D.     

PANCREATIC STENTS IN THE MANAGEMENT OF CHRONIC PANCREATITIS

Background: Elevated pancreatic duct pressure is a potential source of pain in patients with chronic pancreatitis. Endoscopic pancreatic duct stenting is a minimally invasive way of reducing this pressure and may be a useful adjunct to surgery in these patients. Methods: We prospectively reviewed a series of nine symptomatic patients with obstructive chronic pancreatitis and relative contraindications to open surgery, who were managed by attempted endoscopic placement of a pancreatic stent. Results: Stents were successfully inserted endoscopically into the main or accessory duct in six patients and into a pseudocyst, transduodenally, in one patient. Of the two unsuccessful insertions, one proceeded to longitudinal pancreato-jejunostomy and in the other a stent was inserted at distal pancreatic cyst-jejunostomy. Median follow up was 21 months (range 14–43). In all eight cases with stent insertion there was rapid pain resolution, pain scores falling from 9/10 (8–10) to 2 (1–5) after 2 days (1–7). Associated symptoms of weight loss, nausea and vomiting settled in all eight cases. In one patient with a persistent pancreatic fistula, the fistula resolved. In the three with pseudocysts, the cysts resolved on computed tomography (CT) (one recurred). Five patients subsequently proceeded to stent removal after 6 months (5–23). In three of these, the stent was removed endoscopically, and replaced endoscopically in two cases, with pain resolution. Two patients underwent transduodenal pancreatic duct septectomy (one had stent change prior) and one proceeded to pseudocyst-gastrostomy, with pain resolution. The remaining three patients with stents in situ remain symptom-free. No patient suffered acute pancreatitis. Conclusions: In selected patients with obstructive chronic pancreatitis, insertion of a pancreatic stent is a safe procedure, which can lead to rapid symptomatic control over the intermediate period. A significant proportion will need further intervention.