Pancreas pseudocyst associated with L-asparaginase treatment: a case report

A major complication of L-asparaginase used in the treatment of paediatric malignancies in children is pancreatitis (2%-16%). However, only seven paediatric cases of pancreatic pseudocyst caused by the utilization of the agent have been reported in literature. We present the case of a 5-year old girl who had abdominal pain and epigastric dullness after the third course of BMF-95 protocol with a diagnosis of ALL. A pancreatic pseudocyst of 10 x 10 cm size was found by abdominal tomography. The cyst was treated by percutaneous external drainage, total parenteral nutrition (TPN), administration of octreotide and antibiotherapy for one month. Percutaneous external drainage has proven to be an effective, noninvasive method in this special case with a systemic disorder and the high risk of mortality should a surgical intervention have been performed.     

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??EUS-guided internal drainage through the stomach in the treatment of postoperative infection of huge pancreatic pseudocyst: A report of 5 cases YUAN Hai-cheng, QIN Ming-fang, WU Yu, et al. Minimally Invasive Surgery Center, Tianjin Nankai Hospital, Tianjin 300070, China
Corresponding author: YUAN Hai-cheng, E-mail: ironyhc2002@163.com
Abstract Objective To explore treatment experience of EUS-guided internal drainage through the stomach in the treatment of infection after surgery of huge pancreatic pseudocyst. Methods The clinical data of 7 cases of huge pancreatic pseudocyst treated by EUS-guided internal drainage through the stomach between March 2010 and October 2013 in Minimally Invasive Surgery Center of Tianjin Nankai Hospital were analyzed retrospectively. Results Seven cases were drainaged successfully. Five cases were with postoperative infection. Among them, 2 cases were performed BD duct cyst external drainage; 2 cases were performed counterpart drainage with BD duct cyst drainage and CT guided cyst puncture; 1 case performed BD duct cyst external drainage was still unable to control, then cured by cyst infection tissue removal and abdominal drainage. The mean follow-up period was 21 (3-30) months without recurrence. Conclusion Huge pancreatic pseudocyst cured by EUS-guided internal drainage through the stomach is feasible, but postoperative infection is common. The preferred treatment is EUS-guided through the stomach cyst double stent drainage combined BD duct cyst external drainage .     

Percutaneous retropleural drainage of a posttraumatic pancreatic mediastinal pseudocyst in a child

Pancreatic mediastinal pseudocyst is a rare complication of pancreatitis in children. These children usually present with abdominal pain, anorexia, vomiting, and dysphagia. Computed tomography not only is essential in defining the extent of the pseudocyst but also can guide percutaneous external drainage. We present the case of a 4-year-old child with a mediastinal pseudocyst secondary to pancreatic trauma, which was successfully treated with computed tomography-guided percutaneous drainage via a posterior, extrapleural approach.     

胰腺假性囊肿的诊治体会

目的 总结胰腺假性囊肿的诊治体会。方法 回顾性分析46例胰腺假性囊肿患者的临床资料，7例保守治疗，行内引流术12例，外引流术9例，序贯式内外引流术5例，胰腺部分切除术13例。结果 保守治疗者均痊愈，无复发；行内引流术者中有1例发生肠瘘，其余11例恢复良好无复发；行外引流术1例出现胰瘘，2例复发；行胰腺部分切除术者有1例出现胰瘘，其余恢复良好。结论 根据病情和病程选择合适的术式是治疗胰腺假性囊肿的关键。     

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.     

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.     

Towards a non-operative strategy for severe blunt pancreatic injury—Case report

BackgroundPancreatic injury remains uncommon and the majority occurs in association with injury of other organs. For years, surgery has been advised for those with evidence of pancreatic duct damage. However, a lot of changes were seen in the management of blunt abdominal trauma, with strong support for non-operative management of solid organ injuries. There is strong evidence from paediatric patients that those with severe pancreatic contusion and ductal injury can be managed conservatively.Patients and methodWe present our cases of severe blunt pancreatic injury with ductal damage that were successfully managed non-operatively. We reviewed the literature to find evidence to support this management strategy.ResultOur case report and the literature showed that majority of pancreatic ductal injury have been successfully managed non-operatively without increased morbidity or mortality.ConclusionNon-operative management of blunt pancreatic injury with ductal damage allows the formation of a pseudocyst for delayed drainage safely. This strategy of “induced pseudocyst” is particularly applicable to cases that present late and those with concomitant injuries of other organs. The majority of pseudocysts will subside by themselves. The use of embolization may decrease the need for urgent operation and timely percutaneous drainage may help relieve early symptoms.     

Pseudocysts of the pancreas in children in Morocco.

BACKGROUND/PURPOSE: Five children with pancreatic pseudocyst were treated from 1986 to 1998, 4 of these pseudocysts have a traumatic origin. Medical therapy reduces the pancreatic stimulation and favors the resolution or the maturation of the pseudocyst. METHODS: First, all the children were treated with ultrasound-guided drainage. The duration of this drainage varied from 1 to 10 days with successful results in 3 cases. The internal drainage by cystogastrostomy was used in 2 cases. RESULTS: The first showed a cystogastric fistula in the fifth day of the external drainage, the second was drained 2 times without success. There were no pseudocyst recurrences, and children treated surgically were discharged home within 7 to 10 days after operation.     

Operative strategies in the management of mediastinal pancreatic pseudocyst

Thirty-four cases of mediastinal pancreatic pseudocyst have been previously reported. Among the 32 previous reports with operative or autopsy analysis, communication has been identified in 30. Even when this communication has been quite small between the mediastinal fluid collection and the pancreas, the recommended operative strategy has been enteric drainage directly to this communicating tract. We report the case of a patient with a mediastinal pancreatic pseudocyst in whom the communication between the pancreas and the pseudocyst was not located. The condition was managed by drainage of the mediastinal pseudocyst with decompression of the main pancreatic duct by means of a longitudinal pancreaticojejunostomy in a patient with chronic pancreatitis.     

胰腺假性囊肿内引流术式的研究

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

Internal drainage of infected pancreatic pseudocysts: safe or sorry?

BACKGROUND: External drainage is the traditional surgical therapy for infected pancreatic pseudocyst, although associated with high morbidity and mortality rates. In this study it was determined whether internal drainage is feasible with acceptable postoperative morbidity and recurrence rates. METHODS: A retrospective comparison was made of the outcome of internal versus external drainage of infected pseudocysts in 15 patients. All patients were known to have a (sterile) pseudocyst and presented with symptoms suggestive of infection of the cyst, proven by positive cultures and Gram staining. RESULTS: Internal drainage was performed in 8 and external drainage in 7 patients. Patient characteristics appeared comparable, as was the time of sterile cyst presence before infection occurred (6 and 9 weeks, respectively). No major complications occurred, although hospital stay was prolonged after external drainage due to development of pancreaticocutaneous fistulas along the drain tract in 4 patients. Enteric microorganisms were cultured in 11 patients, of whom 10 had undergone ERCP just prior to infection. During follow-up no pseudocyst recurred. CONCLUSION: Surgical internal drainage of an infected pseudocyst is safe and effective and, in selected patients, is first-choice treatment. ERCP seems to play an important role in the secondary infection of pseudocysts.     

Surgical treatment of pancreatic pseudocysts. Analysis of 119 cases.

A review was made of the hospital records of 119 patients with pancreatic pseudocysts. Alcoholism, biliary disease and abdominal trauma were the most common antecedent conditions. Abdominal pain was the most frequent symptom, and abdominal tenderness or mass were the most common physical findings. Abdominal echography and contrast study of the upper gastrointestinal tract were diagnostic in 90% of the patients examined. X-rays of the chest, colon, and biliary tract revealed pathology in 30--40% of the patients. Compared to patients with uncomplicated pseudocyst, patients who were acutely ill at the time of external drainage had twice the incidence of postoperative complications. Each subgroup experienced similar, high rates of postoperative death and pseudocyst recurrence. Both groups of patients treated by internal drainage had lower rates of postoperative morbidity, mortality, and pseudocyst recurrence than patients with uncomplicated pseudocysts undergoing external drainage. External drainage should be used in all patients with immature pseudocysts and in critically ill patients with mature pseudocysts not juxtaposed to a portion of the upper gastrointestinal tract. Internal drainage is a safer and more effective procedure in most other patients with mature pseudocysts, irrespective of the clinical status of the patient.     

Evaluation of somatostatin or octreotide efficacy in the treatment of external pancreatic fistulas

AIM OF THE STUDY: To evaluate the prevalence of pancreatic pseudocyst after persistent fistula closure with somatostatin or octreotide. To compare the patient characteristics according to the subsequent presence or absence of pseudocyst. PATIENTS AND METHODS: This retrospective study from January 1994 to August 1999 included 15 patients with an external pancreatic fistula. Fistula closure was observed for all patients with somatostatin or octreotide. CT scan was performed 66 +/- 34 days after the end of this treatment. RESULTS: CT scan was normal in 9 patients (favorable group) and showed pancreatic pseudocyst (failure group) in 6 patients. Pancreatic fistula etiologies were different between the two groups. The 5 patients presenting pancreatic fistula after duodenopancreatectomy belonged to the favorable group. Six of the 10 patients presenting pancreatic fistula after pseudocyst drainage belonged to the failure group. There were no other differences between the two groups. CONCLUSION: Persistent pancreatic fistula can be cured with somatostatin or octreotide. However, fistulas occurring after duodenopancreatectomy are more easily cured with somatostatin or octreotide than fistulas occurring after external pseudocyst drainage. Somatostatin or octreotide cannot be considered to be an effective treatment for pancreatic fistula occurring after pseudocyst drainage, despite the fact that 40% of them were permanently cured.     

非胰腺手术后胰腺假性囊肿的治疗

目的探讨非胰腺手术后胰腺假性囊肿的治疗方法。方法对近11年来治疗的28例非胰腺手术后胰腺假性囊肿进行回顾性临床分析。结果保守治疗4例。B超引导下经皮多次穿刺10例(其中穿刺后置管外引流3例)。手术行外引流6例,内引流8例。1例外引流无效后,改行内引流。28例均痊愈出院。结论手术后胰腺假性囊肿应采用个体化的治疗原则,早期应采取保守治疗、穿刺抽液或外引流,内引流可作为治疗的最后选择。     

Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis

OBJECTIVE: To test a hypothesis that definitive management of pseudocyst associated with chronic pancreatitis is predicated on addressing pancreatic ductal anatomy. SUMMARY BACKGROUND DATA: The authors have previously confirmed the impact of pancreatic ductal anatomic abnormalities on the success of percutaneous drainage of pancreatic pseudocyst. The authors have further defined a system to categorize the pancreatic ductal abnormalities that can be seen with pancreatic pseudocyst. The authors have published, as have others, the usefulness of defining ductal anatomy when managing pancreatic pseudocysts associated with chronic pancreatitis. METHODS: Beginning in 1985, all patients with pseudocyst who were candidates for intervention (operative, percutaneous, or endoscopic) have undergone endoscopic retrograde cholangiopancreatography (ERCP). An associated diagnosis of chronic pancreatitis was established by means of ERCP findings. Patients were candidates for longitudinal pancreaticojejunostomy (LPJ) if they had a pancreatic ductal diameter greater than 7 mm. In a nonrandomized fashion, patients were managed with either combined simultaneous LPJ and pseudocyst drainage or with LPJ alone. RESULTS: Two hundred fifty-three patients with pseudocyst have been evaluated. Among these there have been 103 patients with chronic pancreatitis and main pancreatic duct (MPD) dilatation (>7 mm). Among these 103 patients, 56 underwent combined LPJ/pseudocyst drainage and 47 had LPJ alone. Compared to combined LPJ/pseudocyst drainage, the patients undergoing LPJ alone had a shorter operative time, slightly less transfusion requirement, slightly reduced length of hospital stay, and slightly reduced complication rate. Long-term pain relief was achieved in 90%, and pseudocyst recurrence was less than 1%. Rates of each of these long-term outcomes were nearly incidental among the two groups. CONCLUSIONS: Ductal drainage alone (LPJ) is sufficient in patients with chronic pancreatitis (MPD > 7 mm) and an associated pseudocyst. Simultaneous drainage of pseudocyst is not necessary.     

Analysis of 29 cases of pancreatic pseudocyst treated surgically

Twenty-nine cases of pancreatic pseudocyst requiring operative management were reviewed to determine the method of diagnosis and to analyse the results of internal and external drainage. Pain and the presence of an intra-abdominal mass were the two most common clinical features in the 29 patients. Serum amylase values were elevated in 50%. Diagnosis was confirmed by barium contrast roentgenography and abdominal ultrasonography in 60% of cases. Endoscopic retrograde cholangiopancreatography was a valuable diagnotic technique in four problem cases. The most common form of surgical treatment was internal drainage of the pseudocyst (18 patients). Th mortality resulting from internal drainage was 6% and there was an overall complication rate of 44%. External drainage was carried out in seven patients (six required emergency operation). The mortality associated with external drainage was 43% and the overall complication rate 86%.     

Assessment of the degree of maturity in the wall of pancreatic pseudocysts in relation to choice of surgical procedure

The aim of this study is to present our experience in the diagnosis and treatment of pancreatic pseudocysts. A pancreatic pseudocyst is an incapsulated collection of pancreatic juice, enclosed by nonepithelial elements, containing a high concentration of pancreatic enzymes, bicarbonates and necrotic detritus. It is a common complication of acute pancreatitis and trauma of the pancreas. In the period between 1996 and 2001, 53 surgical procedures were performed for pancreatic pseudocyst at the Institute for Digestive Diseases (First Surgical University Hospital), 35 male patients (67%) and 17 female patients (33%) underwent surgery. In 39 (75%) patients the method of choice was cystojejunostomy by Roux. In 4 cases distal pancreatectomy for pseudocysts localized within the pancreatic tail was performed, complete pseudocyst excision only was performed in one case and complete pseudocyst excision combined with cystojejunostomy was also performed in one case. Cystogastrostomy and drainage in one case and partial cystectomy and drainage also in one case. Surgical internal drainage is the method of choice for the treatment of pancreatic pseudocysts, involving low morbidity and mortality rates.     

Gastric outlet and duodenal obstruction from inflammatory pancreatic disease

During a ten-year period, 16 patients with gastric outlet and duodenal obstruction due to inflammatory pancreatic disease were seen. The cause of obstruction was chronic pancreatitis in ten patients, pseudocysts with associated pancreatitis in five patients, and pancreatic abscess in one patient. All patients had nausea and vomiting, 14 had abdominal pain, and five had weight loss greater than 4.5 kg. Diagnosis was made by plain abdominal film in one case, upper gastrointestinal tract roentgenographic series in 15 cases, and endoscopy in 11 cases. Mobilization of the duodenum relieved the obstruction in two patients. Fixed obstruction remained in 14 patients. This was relieved by gastrojejunostomy in 12 patients. Gastrojejunostomy was combined with drainage of a pseudocyst in three patients, a dilated pancreatic duct in three patients, and a dilated common bile duct in four patients. Obstruction was relieved by pseudocyst drainage in two patients. Associated common duct and pancreatic duct obstruction must be identified preoperatively.     

Surgical management of pancreatic pseudocysts.

Pancreatic pseudocyst is a complication of pancreatitis or pancreatic trauma. A review of the experience with surgical treatment of pseudocyst of the pancreas at the University of Iowa was carried out. Pancreatitis associated with alcoholism accounted for a smaller percentage of the pseudocysts than is usually reported and reflects the nature of the population. Internal drainage of the pseudocyst obviates the development of pancreatic fistula which is often associated with external drainage; however, the mortality for each method of drainage was comparable.     

胰头部囊性病变的处理：附33例分析

目的探讨胰头部囊性病变的诊治特点。方法33例胰头部囊性病变（假性囊肿24例，慢性胰腺炎合并胰管囊性扩张5例，囊性肿瘤4例），外引流6例，胰十二指肠切除2例，内引流23例，剖腹探查1例，未手术1例。结果全组康复出院，外引流4例再次手术内引流，26例获6月～9年随诊：12例有糖尿病、脂肪泻，9例有餐后消化不良，5例情况良好；7例仅获2～3月随诊，情况良好；剖腹探查及未手术各1例分别于5月、2月后死亡。结论影像学结合针吸囊液检查可作为诊断胰头部囊性病变的常规；无论前、后入路内引流对胰头部囊性病变均可取得良好效果，“夹心饼”式胰腺前、后方双胰肠吻合术可用于特殊病例。