Clinical manifestations of patients with chronic pancreatitis

BACKGROUND: Recent advances in molecular and genomic technologies and pancreatic imaging techniques provided some insights into genetic, environmental, immunologic, and pathobiological factors for chronic pancreatitis (CP). This study was undertaken to investigate the clinical manifestations of patients with chronic pancreatitis at our hospital. METHODS: The data of the patients with CP who had been treated at our hospital between 1997 and 2004 were analyzed. RESULTS: The major symptoms of the patients with CP were abdominal pain, dyspepsia, loss of weight, diabetes mellitus, pancreatic pseudocyst, steatorrhea, and calcification. Biliary diseases were found to be the first cause of CP in this study; but alcohol abuse was the major cause of CP in men and biliary diseases were the first etiological factors for CP in women. The etiological difference of constituent ratio between men and women was related to alcohol comsumption (P<0.01). CONCLUSIONS: During the past 8 years, biliary diseases have been the major etiological factors for CP, but their constituent ratio is decreasing, and the constituent ratio of alcohol abuse is increasing gradually. Alcohol tends to replace biliary diseases as the primary etiological factor for CP.     

Magnetic resonance cholangiopancreatography study of pancreaticobiliary maljunction and pancreaticobiliary diseases

AIM:To discuss the imaging anatomy about pancreaticobiliary ductal union,occurrence rate of pancreaticobiliary maljunction(PBM)and associated diseases in a Chinese population by using magnetic resonance cholangiopancreatography(MRCP).METHODS:Data were collected from 694 patients who underwent MRCP from January 2010 to December2012.Three hundred and ninety-three patients were male and 301 patients were female.The age range was16-92 years old and the average age was 51.8 years.The recruitment indication of all cases was patients who had clinical symptoms,such as abdominal pain,jaundice,nausea and vomiting,which thus were clinically suspected as relative pancreaticobiliary diseases.All cases were examined by MRCP using single-shot fast spin-echo sequences.In order to obtain MRCP images,the maximum intensity projection was used.RESULTS:According to the anatomy of pancreaticobiliary ductal union based on our analysis of MRCP images,all cases were classified into normal type and abnormal type according to the position of pancreaticobiliary ductal union.The abnormal type could be further divided into P-B type,B-P type and the duodenum type.By analyzing the incidence of biliary stone and inflammation,pancreatitis,biliary duct tumors and pancreatic tumors between normal and abnormal types,significant differences existed.The abnormal group was more likely to suffer from pancreaticobiliary diseases.Comparing three different types of PBM that were associated with pancreaticobiliary diseases by using Fisher’s method,the result showed that there was no significant difference in the incidence of biliary stones,cholecystitis and pancreatic tumors.The incidence of pancreatitis in B-P type and P-B type was higher than that in duodenum type;the incidence of biliary duct tumor in B-P type was higher than that in P-B type;the incidence of biliary duct tumor in duodenum type was lower than that in P-B type.The incidence of congenital choledochus dilatation in normal type and abnormal type was similar,and there was no significant difference between the two types.CONCLUSION:Types of PBM are closely related to the occurrence of pancreaticobiliary diseases.MRCP has important clinical value in the early diagnosis and preventive treatment of pancreaticobiliary diseases.     

Pancreatic pseudocyst

Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications （infection, gastric outlet or biliary obstruction, bleeding）. Three different strategies for pancreatic pseudocysts drainage are available： endoscopic （transpapillary or transmural） drainage, percutaneous catheter drainage, or open surgery. To date, no prospective controlled studies have compared directly these approaches. As a result, the management varies based on local expertise, but in general, endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate. A tailored therapeutic approach taking into consideration patient preferences and involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and pancreatic surgeon should be considered in all cases.     

Optimal biliary drainage for inoperable Klatskin＇s tumor based on Bismuth type

AIM： To investigate differences in the effects of biliary drainage procedures in patients with inoperable Klatskin＇s tumor based on Bismuth type, considering endoscopic retrograde biliary drainage （ERBD）, external percutaneous transhepatic biliary drainage （EPTBD） and internal biliary stenting via the PTBD tract （IPTBD）. METHODS： The initial success rate, cumulative patency rate, and complication rate were compared retrospectively, according to the Bismuth type and ERBD, EPTBD, and IPTBD. Patency was defined as the duration for adequate initial bile drainage or to the point of the patient＇s death associated with inadequate drainage.
RESULTS： One hundred thirty-four patients （93 men, 41 women; 21 Bismuth type Ⅱ, 47Ⅲ, 66 Ⅳ; 34 ERBD, 66 EPTBD, 34 IPTBD） were recruited. There were no differences in demographics among the groups. Adequate initial relief of jaundice was achieved in 91% of patients without a significant difference in the results among different procedures or Bismuth types. The cumulative patency rates for ERBD and IPTBD were better than those for EPTBD with Bismuth type Ⅲ. IPTBD provided an excellent response for Bismuth type IV. However, there was no difference in the patency rate among drainage procedures for Bismuth type Ⅱ. Procedure-related cholangitis occurred less frequently with EPTBD than with ERBD and IPTBD.
CONCLUSION： ERBD is recommended as the firstline drainage procedure for the palliation of jaundice in patients with inoperable Klatskin＇s tumor of Bismuth type Ⅱ or Ⅲ, but IPTBD is the best option for Bismuth type Ⅳ.     

Systematic review comparing endoscopic,percutaneous and surgical pancreatic pseudocyst drainage

AIM: To perform a systematic review comparing the outcomes of endoscopic, percutaneous and surgical pancreatic pseudocyst drainage.METHODS: Comparative studies published between January 1980 and May 2014 were identified on Pub Med, Embase and the Cochrane controlled trials register and assessed for suitability of inclusion. The primary outcome was the treatment success rate. Secondary outcomes included were the recurrence rates, re-interventions, length of hospital stay, adverse events and mortalities.RESULTS: Ten comparative studies were identified and 3 were randomized controlled trials. Four studies reported on the outcomes of percutaneous and surgical drainage. Based on a large-scale national study, surgical drainage appeared to reduce mortality and adverse events rate as compared to the percutaneous approach. Three studies reported on the outcomes of endoscopic ultrasound(EUS) and surgical drainage. Clinical success and adverse events rates appeared to be comparable but the EUS approach reduced hospital stay, cost and improved quality of life. Three other studies comparedEUS and esophagogastroduodenoscopy-guided drainage. Both approaches were feasible for pseudocyst drainage but the success rate of the EUS approach was better for non-bulging cyst and the approach conferred additional safety benefits.CONCLUSION: In patients with unfavorable anatomy, surgical cystojejunostomy or percutaneous drainage could be considered. Large randomized studies with current definitions of pseudocysts and longer-term follow-up are needed to assess the efficacy of the various modalities.     

Differential treatment and early outcome in the interventional endoscopic management of pancreatic pseudocysts in 27 patients

AIM: Pancreatic pseudocysts (PPC) as a complication of pancreatitis are approached only in the case of abdominal pain, infection, bleeding, and compression onto the gastrointestinal tract or biliary tree. METHODS: From 02/01/2002 to 05/31/2004, all con-secutive patients with symptomatic PPC who underwent an interventional endoscopic approach were evaluated in this pilot case-series study: Group (Gr.) I-Primary percutaneous (external), ultrasound-guided drainage. Gr. II-Primary EUS-guided cystogastrostomy. Gr. III-EUS-guid-ed cystogastrostomy including intracystic necrosectomy. RESULTS: (="follow up": n = 27): Gr. I (n = 9; 33.3%): No complaints (n = 3); change of an external into an internal drainage (n = 4); complications: (a) bleeding (n = 1) followed by 3 d at ICU, discharge after 40 d; (b) septic shock (n = 1) followed by ICU and several laparotomies for programmed lavage and necrosectomy, death after 74 d. Gr. II (n = 13; 48.1%): No complaints (n = 11); external drainage (n = 2); complications/problems out of the 13 cases: 2nd separate pseudocyst (n = 1) with external drainage (since no communication with primary internal drainage); infection of the residual cyst (n = 1) following external drainage; spontaneous PPC perforation (n = 1) following closure of the opening of the cystogastrostomy using clips and subsequently ICU for 2 d. Gr. III (n = 5; 18.5%): No complaints in all patients, in average two endoscopic procedures required (range, 2-6). CONCLUSION: Interventional endoscopic management of pancreatic pseudocysts is a reasonable alternative treatment option with low invasiveness compared to sur- gery and an acceptable outcome with regard to the complication rate (11.1%) and mortality (3.7%), as shown by these initial study results.     

Uncomplicated spontaneous rupture of pancreatic pseudocyst into stomach: A case report

Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography(CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.     

Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts： A case report

Pancreatic pseudocysts （PPs） are collections of pancreatic secretions that are lined by fibrous tissues and may contain necrotic debris or blood. The interventions including percutaneous, endoscopic or surgical approaches are based on the size, location, symptoms and complications of a pseudocyst. With the availability of advanced imaging systems and cameras, better hemostatic equipments and excellent laparoscopic techniques, most pseudocysts can be found and managed by laparoscopy. We describe a case of a 30-year-old male patient with a pancreatic pseudocyst amenable to laparoscopic cystogastrostomy. An incision was made through the anterior gastric wall to expose the posterior gastric wall in close contact with the pseudocyst using an ultrasonically activated scalpel. Then, another incision was made for cystogastrostomy to obtain complete and unobstructed drainage. The patient recovered well after operation and was symptom-free during a 6-mo follow-up, suggesting that laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for minimally invasive management of PPs.     

Management of pancreatic fluid collections: A comprehensive review of the literature

Pancreatic fluid collections(PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis(WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct(PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.     

Retrospective study of steroid therapy for patients with autoimmune pancreatitis in a Chinese population

AIM:To explore the optimal steroid therapeutic strategy for autoimmune pancreatitis(AIP).METHODS:This study was conducted retrospectively in two large institutions in China.Patients with clinically,radiologically and biochemically diagnosed AIP were enrolled.The performed radiological investigations and biochemical tests,the regimen of the given steroid treatment,remission and relapse whether with and without steroid therapy were analyzed.RESULTS:Twenty-eight patients with AIP received steroid treatment,while 40 patients were treated surgically by pancreatoduodenectomy,distal pancreatectomy and choledochojejunostomy,radiofrequency ablation for the enlarged pancreatic head,percutaneous transhepatic biliary drainage and endoscopic biliary drainage.The starting oral prednisolone dose was 30 mg/d in 18(64.3%) patients and 40 mg/d in 10(35.7%) patients administered for 3 wk.The remission rate of AIP patients with steroid treatment(96.4%) was significantly higher than in those without steroid treatment(75%).Maintenance therapy(oral prednisolone dose 5 mg/d) was performed after remission for at least 6-12 mo to complete the treatment course.Similarly,the relapse rate was significantly lower in AIP patients with steroid treatment(28.6%) than in those without steroid treatment(42.5%).Steroid re-treatment was effective in all relapsed patients with or without steroid therapy.CONCLUSION:Steroid therapy should be considered in all patients with active inflammatory phase of AIP.However,the optimal regimen still should be trailed in larger numbers of patients with AIP.     

Classification and Management of Pancreatic Pseudocysts

This article aims to elucidate the classification of and optimal treatment for pancreatic pseudocysts.Various approaches, including endoscopic drainage, percutaneous drainage, and open surgery, have been employed for the management of pancreatic pseudocysts. However, no scientific classification of pancreatic pseudocysts has been devised, which could assist in the selection of optimal therapy.We evaluated the treatment modalities used in 893 patients diagnosed with pancreatic pseudocysts according to the revision of the Atlanta classification in our department between 2001 and 2010. All the pancreatic pseudocysts have course of disease >4 weeks and have mature cysts wall detected by computed tomography or transabdominal ultrasonography. Endoscopic drainage, percutaneous drainage, or open surgery was selected on the basis of the pseudocyst characteristics. Clinical data and patient outcomes were reviewed.Among the 893 patients, 13 (1.5%) had percutaneous drainage. Eighty-three (9%) had type I pancreatic pseudocysts and were treated with observation. Ten patients (1%) had type II pseudocysts and underwent the Whipple procedure or resection of the pancreatic body and tail. Forty-six patients (5.2%) had type III pseudocysts: 44 (4.9%) underwent surgical internal drainage and 2 (0.2%) underwent endoscopic drainage. Five hundred six patients (56.7%) had type IV pseudocysts: 297 (33.3%) underwent surgical internal drainage and 209 (23.4%) underwent endoscopic drainage. Finally, 235 patients (26.3%) had type V pseudocysts: 36 (4%) underwent distal pancreatectomy or splenectomy and 199 (22.3%) underwent endoscopic drainage.A new classification system was devised, based on the size, anatomical location, and clinical manifestations of the pancreatic pseudocyst along with the relationship between the pseudocyst and the pancreatic duct. Different therapeutic strategies could be considered based on this classification. When clinically feasible, endoscopic drainage should be considered the optimal management strategy for pancreatic pseudocysts.     

Therapeutic strategies for pancreatic pseudocysts: experience in Taiwan

BACKGROUND/AIMS: A retrospective study of Chinese patients with pancreatic pseudocysts to compare the results between non-conservative and conservative treatments, and the use of serial serum amylase and imaging in monitoring treatment success. METHODOLOGY: One hundred and sixty-two pseudocyst patients, treated between 1974 and 2003, were divided into two groups, conservative treatment and interventions (percutaneous needle drainage, internal drainage, or resection), and treatment results for these groups compared. RESULTS: Ninety-one cases (56%) showed spontaneous pseudocyst resolution (mean duration to resolution, 33.4 days). Pseudocyst size was less than 5cm in 86 of these cases (94.5%). Excellent symptomatic responses after aggressive treatment were noted in 68 of 71 patients (93.1%) with pseudocysts larger than 5 cm. All percutaneous tube drainage patients had pseudocyst resolution when the pseudocyst size was less than 5 cm. Hyperamylasemia was noted in 114 cases (70.4%) at diagnosis and returned to normal range in those patients whose cysts underwent spontaneous resolution or who had successful operations. CONCLUSIONS: Pancreatic pseudocysts smaller than 5 cm should have conservative treatment or percutaneous needle drainage. Larger pseudocysts should be treated aggressively. Serum amylase and ultrasound examinations are important to evaluate the occurrence of spontaneous resolution or the need for surgical intervention.     

Endoscopic treatment of chronic pancreatitis

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.     

内镜超声引导下经胃穿刺覆膜金属支架引流胰腺假性囊肿的初步临床研究

目的评价临床应用胆道覆膜自膨式金属支架引流胰腺假性囊肿的有效性、可行性和安全性。方法回顾分析2013年9月至2014年5月在长海医院接受内镜超声（EUS）引导下经胃胰腺假性囊肿全覆膜自膨式金属支架引流的11例患者病例和随访资料。引流方法采用EUS引导下经胃壁穿刺至囊腔,置入导丝,用囊肿切开刀进行针道扩张,置入金属覆膜支架引流。术后定期随访,囊肿消失后拔除支架。评价操作成功率、治愈成功率、并发症发生率。结果11例患者均完成囊肿穿刺、全覆膜金属支架置入引流术,手术成功率为100％,2例患者并发感染,1例患者发生支架移位,无出血、穿孔、死亡病例。其中7例已完成支架拔除术,囊肿均完全消失。结论EUS引导下经胃穿刺胆道覆膜金属支架引流胰腺假性囊肿手术成功率、治愈率高,并发症发生率较低。     

Pancreatic pseudocysts complicated by splenic parenchymal involvement: results of operative and percutaneous management.

Pancreatic pseudocysts are a common finding in acute and chronic pancreatitis, but most are small and uncomplicated, and do not require treatment. Pseudocysts with splenic parenchymal involvement are uncommon but have the potential for massive hemorrhage. Data on the clinical presentation and optimal treatment of this unusual complication of pseudocysts are lacking. The purpose of this review was to identify the clinical features of pancreatic pseudocysts complicated by splenic parenchymal involvement and to determine the outcome with nonoperative and operative therapy. METHODS: A retrospective review of the medical records of all patients with pancreatic pseudocysts from December 1984 to January 1999 revealed 238 patients, of whom 14 (6%) had splenic parenchymal involvement. These medical records were reviewed in detail and all pertinent radiographs were reviewed by the authors to confirm splenic parenchymal involvement by a pancreatic pseudocyst. RESULTS: Initial treatment included observation (n = 2), percutaneous drainage (n = 8), and surgery (n = 4). Of the eight patients treated by percutaneous drainage, one died, three required repeated percutaneous drainage, and three required surgical intervention. None of the patients treated primarily by surgery required additional therapy for the pseudocyst. Overall, 11 patients had complications of the primary therapy, and 25% of patients treated by surgery had significant hemorrhage. Complications included infection (n = 5), pseudocyst persistence (n = 4), bleeding (n = 2), multisystem organ failure (n = 2), gastric outlet obstruction (n = 1), and splenic rupture (n = 2). CONCLUSIONS: Pancreatic pseudocysts complicated by splenic parenchymal involvement may have life-threatening clinical presentations and respond poorly to percutaneous drainage. Distal pancreatectomy and splenectomy are effective, but the complication rate is high.     

Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone

OBJECTIVE: Endoscopic drainage of a single pseudocyst is a well-known treatment modality. Its role in the management of multiple pseudocysts is not well established. We evaluated the role of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of multiple and large pseudocysts. METHODS: Over 3 yr (2001-2004), endoscopic transpapillary NPD placement was attempted in 11 patients (age range 12-50 yr, 10 men) with symptomatic communicating multiple pseudocysts of pancreas (three in two and two in nine cases). A 5Fr/7Fr NPD was placed across the most distal duct disruption or into one of the pseudocysts. RESULTS: Eight patients had an underlying chronic pancreatitis and three patients had pseudocysts as sequelae of acute pancreatitis. The size of pseudocysts ranged from 2 to 14 cm (mean 7.5 cm). Eight patients (72.7%) had at least one pseudocyst more than 6 cm in size. Nine patients had a partial disruption and two patients had complete disruption of the pancreatic duct. The NPD was successfully placed in 10 of 11 (90.9%) patients. Postprocedure acute febrile illness in one patient was the only complication noted, which responded to intravenous antibiotics. All pseudocysts resolved in 4-8 wk in 7 of 7 patients with successful bridging of the most distal ductal disruption. There was no recurrence of the pseudocysts in a mean follow-up of 19.4 months. Two patients, in whom there was a complete disruption and the NPD could not bridge the disruption, required surgery for the nonresolution of pseudocysts. In one patient with partial ductal disruption that could not be bridged, there was complete resolution of one pseudocyst and a decrease in the size of the other pseudocyst from 12 to 4 cm. The NPD was replaced by a stent and both the pseudocysts resolved in 20 wk. CONCLUSION: Endoscopic transpapillary NPD placement is a safe and effective modality for the treatment of multiple and large pseudocysts, especially when there is partial ductal disruption, and the disruption can be bridged.     

经皮穿刺无水乙醇注入引流治疗胰腺假性囊肿

目的 探讨经皮穿刺无水乙醇注入引流法治疗胰腺假性囊肿(pancreatic pseudocyst,PPC)的临床价值.方法 21例D'Egidio Ⅰ型PPC患者在CT或US引导下经皮穿刺置管外引流,CT或US检查观察引流效果,无明显残腔后,夹管观察3～7 d,无异常即可拔管.经21 d引流不能痊愈者,给予每日无水乙醇20 ml囊腔注入治疗.结果 21例D'EgidioⅠ型PPC患者,经皮穿刺置管外引流后,痊愈15例,治愈率为71.43%.其余6例中,治疗有效3例,无效3例.其中1例为单房PPC并感染,2例为多房PPC无感染,3例为多房PPC合并脓肿,均经无水乙醇注入治疗6～21 d后囊腔消失,治愈率100%,无l例发生并发症,6～12个月随访无1例复发.结论 经皮穿刺无水乙醇注入引流法是治疗PPC合并感染或多房性PPC有效、安全的非手术方法,具有临床应用价值.     

Outcome differences after endoscopic drainage of pancreatic necrosis,acute pancreatic pseudocysts,and chronic pancreatic pseudocysts

BACKGROUND: Comparative outcomes after endoscopic drainage of specific types of symptomatic pancreatic fluid collections, defined by using standardized nomenclature, have not been described. This study sought to determine outcome differences after attempted endoscopic drainage of pancreatic fluid collections classified as pancreatic necrosis, acute pseudocyst, and chronic pseudocyst. METHODS: Outcomes were retrospectively analyzed for consecutive patients with symptoms caused by pancreatic fluid collections referred for endoscopic transmural and/or transpapillary drainage. RESULTS: Complete endoscopic resolution was achieved in 113 of 138 patients (82%). Resolution was significantly more frequent in patients with chronic pseudocysts (59/64, 92%) than acute pseudocysts (23/31, 74%, p = 0.02) or necrosis (31/43, 72%, p = 0.006). Complications were more common in patients with necrosis (16/43, 37%) than chronic (11/64, 17%, p = 0.02) or acute pseudocysts (6/31, 19%, p = NS). At a median follow-up of 2.1 years after successful endoscopic treatment (resolution), pancreatic fluid collections had recurred in 18 of 113 patients (16%). Recurrences developed more commonly in patients with necrosis (9/31, 29%) than acute pseudocysts (2/23, 9%, p = 0.07) or chronic pseudocysts (7/59, 12%, p = 0.047). CONCLUSIONS: Successful resolution of pancreatic fluid collections may be achieved endoscopically by an experienced therapeutic endoscopist. Outcomes differ depending on the type of pancreatic fluid collection drained. Further studies of endoscopic drainage of pancreatic fluid collections must use defined terminology to allow meaningful comparisons.     

十二指肠乳头囊肿引流术治疗胰腺假性囊肿

目的 探讨内镜下经十二指肠乳头囊肿引流术(ETCD)治疗胰腺假性囊肿(PPC)的疗效。方法 26例ETCD治疗患者囊肿大小为1.5-15 cm,23例为直接行ETCD引流,1例因并发黄疸同时行胆管内置管,2例因囊肿外压胃窦及十二指肠而致乳头无法显示,其中1例先行经皮囊肿穿刺术,囊肿缩小后找见乳头,再行ETCD引流。观察术后囊肿消退及临床症状改善情况。结果 治疗后23例患者囊肿消退,腹痛、胃纳、脂肪泻及体重情况均明显改善,1例改善不明显,2例无改善。随访60-850 d,1例囊肿复发,1例并发胰腺脓肿,3例引流术后需行手术治疗。结论 ETCD治疗交通性似性囊肿是安全、有效的首选治疗方法,对于不交通PPC无效。     

Sandostatin for control of catheter drainage of pancreatic pseudocyst

Primary treatment for pancreatic pseudocyst is evolving from surgical intervention to needle aspiration with catheter drainage. The latter treatment results in a similar rate of resolution but has less patient morbidity. This study evaluated the adjuvant role of Sandostatin, which inhibits basal and stimulated pancreatic secretion, in the management of three patients with pancreatic pseudocysts who had prolonged catheter drainage subsequent to percutaneous drainage. Inhibition of secretion occurred in all three patients, as evidenced by decrease in catheter output, which allowed the catheter to be removed. All three patients have remained asymptomatic for 9, 10, and 15 months, respectively. In summary, Sandostatin decreased persistent catheter drainage from chronic pancreatic pseudocysts.