超声内镜引导下经胃引流治疗早期胰腺假性囊肿23例

目的 探讨超声内镜引导下经胃引流治疗早期胰腺假性囊肿的疗效.方法 回顾性分析2003至2008年在超声内镜引导下早期经胃穿刺置管引流进行治疗的23例巨大胰腺假性囊肿患者的临床资料.结果 假性囊肿位于胰头部3例,胰体部11例,胰尾部9例,囊肿平均直径11 cm(8～18 cm),均为单发囊性,所有病例在超声内镜引导下经胃引流治疗胰腺假性囊肿,假性囊肿发现至穿刺手术间隔17～65d,平均31 d.2例术后发生囊肿感染,1例改用外引流,另1例改用手术内引流治疗治愈;3例出现消化道出血,保守治疗后治愈.2～3个月后CT复查,6例患者假性囊肿完全消失,余15例患者囊肿明显缩小,所有患者腹胀、腹痛症状缓解.随访1年,无溃疡、出血、囊腔感染等并发症发生.结论 超声引导下早期经胃穿刺置管引流治疗胰腺假性囊肿是安全、有效的.     

A case report on the usefulness of early endoscopic ultrasound (EUS)-guided transgastric internal stenting for severe blunt pancreatic trauma

IntroductionTherapeutic strategies for pancreatic trauma vary greatly depending on its severity. Surgical intervention is recommended in cases of severe pancreatic injuries for which standard therapy is not advised. We present a two-step treatment method for severe pancreatic injury using an endoscopic ultrasound (EUS)-guided transgastric internal stent.Clinical caseA 50 year-old male with blunt abdominal trauma sustained in a traffic accident was transported with vital signs indicating shock and CT findings of complete transection of the proximal pancreas and a huge haematoma. A life-saving primary emergency damage control operation was performed. A secondary EUS-guided transgastric internal stent was placed into the pancreatic fluid collection on post-operative day 8 (POD 8). The pancreatic juice secreted from the transected pancreatic tail eventually flowed along the internal stent and emptied completely into the stomach. The patient did not display prognostic symptoms at discharge.DiscussionEUS-guided transgastric internal stenting is currently considered the first line of therapy for pancreatic pseudocysts. It is recommended that pseudocyst drainage occur at least four weeks or more after its formation. In this severe case of blunt pancreatic trauma, the primary damage control operation saved the patient's life. Following primary surgery, a secondary early operation involved insertion of an EUS-guided transgastric internal stent into the collection of pancreatic juice secreted from the transected pancreatic tail, which allowed complete recovery without surgical extraction or reconstruction of the pancreatic tail.ConclusionIn cases of severe pancreatic trauma, practitioners should consider the value of early EUS-guided transgastric internal stenting.     

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??Endoscopic??laparoscopic individualized treatment for pancreatic pseudocysts: An analysis of 68 cases YUAN Hai-cheng??QIN Ming-fang??WU Yu??et al. Minimally Invasive Surgery Center, Tianjin Nankai Hospital??Tianjin 300100??China
Corresponding author??YUAN Hai-cheng??E-mail??ironyhc2002@Gmail.com
Abstract Objective To investigate endoscopic??laparoscopic individualized treatment strategies for pancreatic pseudocysts based on the guidance of endoscopic??laparoscopic treatment program of pancreatic pseudocysts. Methods The clinical data of 68 cases of pancreatic pseudocysts treated in accordance with endoscopic??laparoscopic treatment program of pancreatic pseudocysts between March 2000 and December 2010 in Tanjin Minimally Invasive Surgery Center were analyzed retrospectively. The data included the general information??treatment methods, success rate??recurrence rate and complications. Results There were 28 cases of EUS-guided through the stomach cyst drainage??12 cases of laparoscopic cyst-gastric anastomosis??5 cases of laparoscopic cyst-jejunal Roux-en-Y anastomosis??23 cases of ERPD (5Fr pancreatic duct stent placed by endoscopy). Three cases had fever after EUS internal drainage. One case had peritonitis. There was no complication in other forms of treatment. Follow-up was last from six months to nine years in 82% (56/68) of cases without recurrence. Conclusion The endoscopic??laparoscopic treatment for pancreatic pseudocyst is more minimally invasive??can become individualized treatment strategies.     

Minilaparoscopic transgastric cystgastrostomy

BACKGROUND: A technique combining upper endoscopy with percutaneous transgastric minilaparoscopic instrumentation for the formation of pancreatic cystgastrostomy is safe and effective for the internal drainage of pancreatic pseudocysts. METHODS: At a tertiary-care academic medical center, 6 patients with pancreatic pseudocysts with a mean size of 19 cm (range, 16-23 cm) were selected for combined endoscopic and percutaneous transgastric minilaparoscopic (1.7-2 mm) pancreatic cystgastrostomy. All pseudocysts had been followed-up for a minimum of 5 weeks (range, 5-22 wk) and were noted to significantly displace the stomach anteriorly. RESULTS: The mean surgical time was 98 minutes (range, 45-150 min). The mean amount of fluid removed from the pseudocysts was 2167 mL (range, 1600-2600 mL). All ports were removed from the stomach without the need to suture the gastric wall or skin except for 2 gastric serosal sites that were closed with a single intracorporeal stitch. The length of hospital stay averaged 2.2 days (range, 0-6 d). All patients were discharged in good condition, tolerating a regular diet. With a mean follow-up period of 13.4 months (range, 1-30 mo), all patients remain asymptomatic from their pancreatic pseudocysts. CONCLUSIONS: The technique of combining upper endoscopy with percutaneous transgastric minilaparoscopic instruments to create a pancreatic cystgastrostomy can be used to apply well-established surgical principals for internal drainage and has the potential to be used for the management of other gastric pathology.     

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。     

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.     

Personal experience with the endoscopic treatment of pancreatic pseudocysts. Long-term results and analysis of prognostic factors

BACKGROUND: The aim of this study was to assess the safety and utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome of endoscopic drainage were assessed in a prospective analysis. METHODS: Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients. RESULTS: Successful drainage was achieved in 27/30 (90%) of patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications; 2 patients had bleeding, 2 had mild pancreatitis, 8 had cyst infection, in relation to the presence of necrosis (5 patients) or stent clogging (3 patients). Nine patients (20.9%) had recurrence of pseudocyst. Endoscopic drainage was a definitive treatment in 37 out of 49 (75.5%) patients (median follow-up: 25.9 months). Presence of necrosis was the only significant prognostic factor for infectious complication. CONCLUSIONS: Endoscopic drainage provides a successful and safe minimally invasive approach to the management of pancreatic pseudocysts.     

Endoscopic computerized tomography guided percutaneous trans-gastric drainage: A case report on this hybrid approach

Percutaneous drainage, percutaneous transgastric drainage, and endoscopic ultrasound (EUS)-guided transgastric drainage are primarily utilized for drainage of fluid collections dorsal to the stomach. Percutaneous transgastric drainage is performed with computed tomography (CT) guidance, but it requires inflation of a balloon in the stomach, and gastric peristalsis makes it difficult to ensure a reliable puncture route via the stomach. Using endoscopy-assisted CT-guidance, we were able to safely and effectively perform percutaneous transgastric drainage.A 69-year-old man underwent a pancreaticoduodenectomy for cancer of the inferior section of the common bile duct. Postoperative day 5, the amylase value of the drainage fluid was 1,232 IU/L, we diagnosed a pancreatic fistula developed as a result of pancreaticojejunal anastomotic failure and we performed drainage at the drain which was placed in the foramen of Winslow intraoperatively, however fluid collection dorsal to the stomach was detected on a follow-up abdominal CT scan, and the fluid was a high value of amylase, we judged the drain was not working well and the pancreatic fistula occured. Endoscopy-assisted, CT-guided percutaneous transgastric drainage was therefore performed, and the pancreatic fistula was successfully closed the fistula.     

Laparoscopic endogastric pseudocyst gastrostomy: a report of three cases

The transgastric pseudocyst-gastrostomy is the standard approach for internal drainage of persistent and large retrogastric pancreatic pseudocysts that complicate acute necrotizing pancreatitis. We report on the application of a laparoscopic endogastric approach for drainage of pancreatic pseudocysts and discuss the merits of this technique as well as of the other previously described minimally invasive approaches for the management of pancreatic pseudocysts. Between January 2001 and August 2001, three female patients presented with large symptomatic pseudocysts 3-10 months after an episode of acute necrotizing pancreatitis. Internal drainage was effected by a laparoscopic endogastric pseudocyst gastrostomy, and the necrotic pancreas was debrided. There were no conversions and no postoperative complications. The median postoperative hospital stay was 4 days (range, 3-5). All patients remain asymptomatic, and resolution of the pseudocyst was radiologically evident at a median follow-up of 6 months (range, 4-11). The laparoscopic endogastric pseudocyst gastrostomy appears to be a safe and effective minimally invasive approach for internal drainage of large retrogastric pancreatic pseudocysts and facilitates debridement of the necrotic pancreas.     

Pseudocysts in chronic pancreatitis. Surgical results in 102 consecutive patients

Preoperative symptoms, diagnoses, and postoperative outcomes in 102 consecutive patients with pancreatic pseudocysts were analyzed. Upper epigastric pain, loss of weight, obstructive jaundice, and sudden arterial bleeding from the pseudocyst were the most common preoperative symptoms. Ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography were the most useful diagnostic tools in the evaluation of the presence, size, location, and possible pancreatic ductal communications of the pseudocyst. In a single thick-walled pseudocyst, the best long-term results were achieved by internal drainage. Pancreatic resection is justified if the patient already has diabetes or multiple pseudocysts or if the pseudocyst is not amenable to internal drainage. The most fatal preoperative complication was a sudden arterial bleeding from a pseudocyst. In treating this complication, hemostasis with transcystic arterial ligation and external drainage of the pseudocyst gave the best results.     

PERCUTANEOUS CYSTOGASTROSTOMY FOR TREATMENT OF PANCREATIC PSEUDOCYSTS

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

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??Endoscopic retrograde cholangiopancreatography (ERCP)-based operation in treating blunt pancreatic trauma??A report of 10 cases ZHAO Ming-ning?? WU Wen-guang, TAO Yi-jing, et al. Department of General Surgery??Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine??Institute of Biliary Tract Disease??Shanghai Jiao Tong University School of Medicine??Shanghai 200092, China
Corresponding author??WANG Xue-feng??E-mail??wxxfd@live.cn
Abstract Objective To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in treating blunt pancreatic trauma??BPT??. Methods The clinical data of 10 cases of BPT underwent ERCP-based management between August 2006 and December 2011 in Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. The pancreatic injuries were assessed with the American Association for the Surgery of Trauma (ASST) grading system. Pancreatic injuries in 10 cases were graded including 1 case of grade I??3 of grade ??4 of grade ?? and 2 of grade ??. Results Ten cases of BPT all survived after ERCP-based treatment. Four cases of grade??/?? injury were cured after endoscopic naso-pancreatic drainage. Four with grade ?? injury were placed with pancreatic stent??in which one underwent endoscopic ultrasound (EUS)-guided transgastric drainage of peripancreatic fluid detected by contrast-enhanced CT??and two developed pancreatic pseudocyst identified by postoperative CT and cured by EUS-guided transgastric puncture. Two cases of grade ?? injury were treated by concurrent placement of pancreatic stent and biliary stent??including one cured by EUS-guided puncture and drainage of peripancreatic fluid. All the stents were dislodged 3 months after implantation. Conclusion ERCP-based treatment for BPT depends on strict control of indications. Therapeutic strategy of ERCP should be established on the grade of pancreatic injury which is determined by clinical assessment, CT and ERCP imaging comprehensively.     

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.     

A simple,safe technique for the drainage of pancreatic pseudocysts

Background: A number of methods are available for the drainage of pancreatic pseudocysts, including percutaneous, endoscopic and open approaches. In Leicester, we developed a combined radiological and endoscopic technique (predating the use of endoscopic/ultrasound) to allow drainage of pancreatic pseudocysts into the stomach. The aim of the study was to evaluate the long‐term results of this approach. Methods: This is a retrospective study of patients undergoing combined endoscopic/ultrasound‐guided percutaneous stenting between 1994 and 2007. Data were extracted from case records and our computerised radiology database. Results: Thirty‐seven combined endoscopic/ultrasound‐guided procedures were undertaken. Median patient age was 52 years (range 26–84 years). Nineteen pseudocysts were secondary to acute pancreatitis and 18 were in patients with chronic pancreatitis. The diameter of pseudocysts on pre‐procedure imaging ranged from 4 to 21 cm (median 11 cm). Median duration of hospital stay was 7 days (range 1–44 days) and 30‐day mortality was 0%. Stents were inserted in 70.3% of patients (n= 26). Of those patients stented during the combined procedure, three developed infection of the pseudocyst, necessitating open cystgastrostomy within the first month. During a mean follow‐up period of 41 months, two patients developed recurrent pseudocysts which were successfully drained with a further combined procedure (16 and 43 months). Repeat imaging in the remainder of patients failed to show any evidence of a persistent or recurrent pseudocyst beyond 2 months. Conclusion: Combined radiological and endoscopic drainage is safe, cost‐effective and highly efficient in preventing recurrent pseudocyst formation.     

Endoscopic ultrasound (EUS)-guided pseudocyst drainage as a one-step procedure using a novel multiple-wire insertion technique (with video)

Background

The EUS 2008 working group considered the development of equipment and methods to minimize the need for exchanging accessories and to facilitate insertion of multiple transmural stents during endoscopic ultrasound (EUS)-guided pseudocyst drainage as an important advance for therapeutic EUS. The authors aimed to describe their experience with EUS-guided pseudocyst drainage using a novel multiple-wire insertion technique facilitated by the double-lumen biliary cytology brush catheter.

Methods

The study enrolled 10 symptomatic patients undergoing EUS-guided pseudocyst drainage. The EUS-guided pseudocyst drainage was performed as a one-step procedure using graded catheter and balloon dilation of the cystgastrostomy tract and a novel multiple-wire insertion technique facilitated by a modified double-lumen biliary cytology brush catheter. The main outcome measured was technical success.

Results

In this study, 10 patients with 11 pseudocysts underwent a EUS-guided pseudocyst using the novel multiple-wire insertion technique. Technical success, defined as successful achievement of access and drainage of pseudocysts, was achieved in all cases (100?%) with no procedural complications. Clinical success was achieved in all cases with complete resolution of pseudocysts.

Conclusions

The novel method of using a modified double-lumen biliary cytology brush catheter allows for a simple and safe one-step EUS-guided drainage of pseudocysts.     

Laparoscopic pancreatic cystgastrostomy

Internal drainage of acute pancreatic pseudocysts is indicated 6 weeks after the first documentation of pseudocyst. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When pseudocysts are located in close contact with the posterior wall of the stomach, they are best drained by pseudocyst-gastrostomy. This procedure can also be completed making use of intragastric surgical techniques. Under standard laparoscopic observation, three intragastric ports are placed through the abdominal and anterior gastric walls, establishing working channels for a telescope and hand instruments. After the presence of pseudocysts is confirmed, the posterior wall of the stomach and the cyst wall can be incised by electrocautery. After a sufficient drainage orifice is made and the cyst contents are thoroughly debrided, the intragastric ports are removed and defects in the gastric wall are closed with sutures placed via the standard laparoscopic approach. This approach is much less invasive than the conventional approach, which entails a large gastrotomy in the anterior wall of the stomach. This procedure should be the method of choice when interventional radiology or endoscopic intervention fails to effectively drain retrogastric pseudocysts. Received for publication on April 21, 1999; Accepted on Sept. 1, 1999     

超声内镜检查与胰腺疾病内镜治疗

超声内镜检查原理与腹部超声相似,其区别只是将微型高频超声探头安装在内镜顶端,进行实时超声扫描.胰腺是腹膜后器官,由于EUS插入胃和十二指肠肠腔内扫查,可清晰显示胰腺结构.随着EUS的广泛应用和内镜附件发展,EUS在胰腺疾病微创治疗中的地位越来越高.EUS-FNA与注射技术、EUS-CPN、EUS介导放射粒子植入术和内镜超声引导下胰腺假性囊肿穿刺引流等治疗技术会逐步推广应用,成为继ERCP内镜治疗后胰腺疾病微创治疗的重要方法.     

Treatment of pancreatic pseudocysts.

According to the Atlanta classification an acute pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of acute pancreatitis or pancreatic trauma, whereas a chronic pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of chronic pancreatitis and lack an antecedent episode of acute pancreatitis. It is generally agreed that acute and chronic pseudocysts have a different natural history, though many reports do not differentiate between pseudocysts that complicate acute pancreatitis and those that complicate chronic disease. Observation--"conservative treatment"--of a patient with a pseudocyst is preponderantly based on the knowledge that spontaneous resolution can occur. It must, however, be admitted that there is substantial risk of complications or even death; first of all due to bleeding. There are no randomized studies for the management protocols for pancreatic pseudocysts. Therefore, today we have to rely on best clinical practice, but still certain advice may be given. First of all it is important to differentiate acute from chronic pseudocysts for management, but at the same time not miss cystic neoplasias. Conservative treatment should always be considered the first option (pseudocysts should not be treated just because they are there). However, if intervention is needed, a procedure that is well known should always be considered first. The results of percutaneous or endoscopic drainage are probably more dependent on the experience of the interventionist than the choice of procedure and if surgery is needed, an intern anastomosis can hold sutures not until several weeks (if possible 6 weeks).     

Transpapillary stenting for pancreaticocutaneous fistulas

Because transpapillary stents have been successfully placed to treat the ductal disruptions associated with pseudocysts, pancreatic ascites and pleural effusions, and pancreaticoenteric fistulas, we reviewed our experience with endoscopically placed prostheses in patients who had persistent pancreaticocutaneous fistulas but an otherwise intact duct. Nine patients who underwent endoscopic transpapillary stent placement for ongoing pancreaticocutaneous fistulas at our institution were retrospectively reviewed. Fistulas were present for a mean (±SEM) of 35 ±11 days and averaged 225±55 ml of output daily. Etiology of the fistulas included percutaneous pseudocyst drainage in four patients, pancreatic necrosis in two, complications of pancreatic surgery in two, and perforation of the duct of Santorini at the time of minor aphincterotomy in one. All patients had an otherwise intact duct at the time of endoscopic retrograde cholangiopancreatography. Six patients had transpapillary stents placed that did not bridge the area of leakage and three had prostheses placed across the ductal disruption. Eight of nine fistulas were successfully closed by means of this technique including five within 48 hours. There was one instance of stent migration and one patient developed prosthesis occlusion and an infected pseudocyst, which was treated with stent exchange. Stents were retrieved 10 to 14 days after fistula closure and no patient has had a recurrence at a median follow-up of 3 years. Transpapillary stents appear to effect closure of pancreaticocutaneous fistulas that fail to respond to conventional therapy.     

Unusual manifestations of pancreatic pseudocysts and their surgical management

Six cases representing selected complications of pancreatic pseudocyst are reported and their surgical management is discussed. Patients with mediastinal extension of a pseudocyst frequently present with symptoms in the chest rather than in the abdomen. Chronic recurrent pleural effusion, rich in protein and amylase, often accompanies mediastinal extension of a pancreatic pseudocyst. It is important to recognize that such an effusion almost certainly represents disruption of the pancreatic duct with formation of a pancreatic pseudocyst or a pancreaticopleural fistula. Internal drainage from below the diaphragm is the treatment of choice for pancreatic pseudocysts extending into the mediastinum.To be certain that obstructive jaundice is due to a pancreatic pseudocyst, there must be operative demonstration of compression of the common bile duct by the pseudocyst, relief of the obstruction by surgical drainage of the cyst, and subsequent disappearance of jaundice. Cysts that cause jaundice are located in the head of the pancreas, and cystoduodenostomy is the treatment of choice.Intraperitoneal rupture has been associated with a high mortality, but with adequate fluid replacement, prompt evacuation of the cyst contents from the peritoneal cavity, and adequate drainage, mortality can be lowered.Pancreatic ascites is much more common than is generally supposed and may result from a leaking pancreatic pseudocyst. In contrast to cirrhotic ascites, pancreatic ascites produces elevation of both the serum amylase level and protein concentration.Massive hemorrhage from pancreatic pseudocysts is usually due to the development of a false aneurysm in a branch of the celiac axis in the wall of the pseudocyst, with subsequent rupture of the aneurysm into the gut or peritoneal cavity. Any patient with a pancreatic pseudocyst who shows signs of bleeding should have prompt arteriography for determination of the bleeding site and appropriate surgical control.Pancreaticobronchial fistula is a rare complication. Treatment should be directed toward adequate drainage of the pseudocyst in the abdomen.