Endoscopic management of pancreatic pseudocyst in children-a long-term follow-up

Background

Literature on long-term outcome after endoscopic management of pediatric pancreatic pseudocyst is not available. The aim of the present study is to report long-term outcome after endoscopic drainage of pancreatic pseudocyst in children.

Methods

Nine patients younger than 15 years, subjected to endoscopic pseudocyst drainage, were included in this study (between 1994 and 2004). Eight patients were subjected to endoscopic cystogastrostomy and stenting, whereas 1 patient was subjected to cystoduodenostomy and stenting. A follow-up of patients was done at 1 month and at 2 to 10 years after drainage. Endoscopic retrograde cholangiopancreatography (ERCP) was done in 2 patients at the time of drainage, and it was repeated in both the patients at the time of final follow-up.

Results

Mean age of the patients was 9.6 years. Trauma was the most common cause (n = 8). Mean follow-up of these patients was 5.7 years (2-10 years). No recurrence was seen in any patient. Endoscopic retrograde cholangiopancreatography revealed complete pancreatic duct block in prevertebral region in 2 posttraumatic patients, and it was persisting on repeat ERCP at final follow-up.

Conclusions

Endoscopic drainage of pancreatic pseudocyst is safe in children with a very good long-term outcome. Pancreatic duct block seen on ERCP may not be clinically important on long-term follow-up.     

Hybrid notes: incisionless intragastric stapled cystgastrostomy of a pancreatic pseudocyst

Purpose

We present a case report of a novel hybrid natural orifice transluminal endoscopic surgery (NOTES). The operation performed was a transgastric cystgastrostomy with endoscopic guidance for a pancreatic pseudocyst. This operation was completed entirely through an existing gastrostomy site with no incisions, thus avoiding the peritoneal cavity.

Methods

This is a case of a 7-year-old boy with neurologic impairment from congenital herpes simplex virus encephalitis who is tube fed. He had acute pancreatitis and developed a 9 cm pancreatic pseudocyst. The pseudocyst failed to resolve after 6 weeks and developed a mature wall. Due to a history of multiple abdominal surgeries and known abdominal adhesions, a minimally invasive approach that would avoid entering the peritoneal cavity was the desired approach. The technique involved a trans-oral endoscope for visualization and the use of the gastrostomy as access to the gastric lumen and pseudocyst. The pancreatic pseudocyst was stabilized with two T-fasteners and confirmed with needle aspiration under endoscopic visualization. The pseudocyst was then opened with the LigaSure (Valleylab, Boulder, CO). The cystgastrostomy anastomosis was completed with an Endopath ETS-Flex Articulating Linear Stapler/Cutter (Ethicon Endo-Surgery, Inc, Cincinnati, OH). The operation took less than 2 hours and was completed without an incision. Under the policies of the Human Research Protection Program, review of a single case is outside the scope of the definition of human subjects research and does not require institutional review board review and approval.

Results

The patient did well postoperatively and had a dramatic reduction in size of the pancreatic pseudocyst to 3.5 cm by 2 weeks.

Conclusions

Hybrid NOTES cystgastrostomy performed through an existing gastrocutaneous fistula is an excellent approach for minimally invasive drainage of pancreatic pseudocysts.     

Traumatic pancreatic duct injury in children: minimally invasive approach to management

Background

The management of children with main pancreatic duct injuries is controversial. We report a series of patients with pancreatic trauma who were treated using minimally invasive techniques.

Methods

Retrospective review of children with pancreatic trauma treated at a UK tertiary referral institution between 1999 and 2004.

Results

Fifteen children (11 boys) were admitted with pancreatic trauma. Twelve (80%) were less than 50th centile for body weight. Contrast-enhanced computed tomography (CT) scans were used to define organ injury, supplemented by magnetic resonance cholangiopancreatography (MRCP) in 7. Twelve (80%) underwent diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with a median time after injury of 11 (range, 6-29) days. The degree of pancreatic injury was defined by ERCP and CT/MRCP as grade II (n = 2), grade III (n = 4), grade IV (n = 9) (American Association for the Surgery of Trauma grades). Nine children had a transductal pancreatic stent inserted endoscopically. Computed tomography/ultrasound-guided drainage was performed in 4 children for acute fluid collections. Two children later underwent endoscopic cyst-gastrostomy, one of whom later required conversion to an open cyst-gastrostomy.

Conclusion

Body habitus may predispose to pancreatic duct trauma. Contrast-enhanced CT scan (and MRCP) should dictate the need for ERCP. Transductal pancreatic stenting allows internal drainage of peripancreatic collections and may reestablish duct continuity, although a proportion still requires percutaneous or endoscopic cyst-gastrostomy drainage. Open surgery for pancreatic trauma should now be an exception.     

The management of pancreatic injuries in children: operate or observe

Purpose

The critical management decision in pediatric pancreatic injuries involves whether or not to operate on patients with grade II or III injuries. Because of the rarity of these injuries, no one hospital cares for enough patients to determine the outcome of this decision. Given this, the American Pediatric Surgical Association accrued a series of patients with pancreatic injuries from the members of its Trauma Committee.

Methods

A retrospective review of concurrent pancreatic injuries from 9 level 1 pediatric trauma centers was performed.

Results

Data on 131 children were submitted. Forty-three patients suffered grade II or grade III injuries. Twenty patients underwent an operation, and 23 were observed. Patients who underwent an operation had an average length of stay of 16.1 days compared with 14.2 days. Two in the operative group received total parenteral nutrition compared with 12 in the nonoperative group. Eight in the nonoperative group developed a pseudocyst compared with 3 in the operative group.

Conclusions

Children with grade II or grade III pancreatic injuries managed nonoperatively had a higher rate of pseudocyst, lower rate of reoperation, and a comparable length of stay compared with those who underwent surgery. These data will be used to help design a prospective study of pancreatic injury management.     

Longitudinal pancreaticojejunostomy and selective biliary diversion for chronic pancreatitis in children

Background

Chronic pancreatitis requiring surgery is rare in children. We review our experience in treating pediatric chronic pancreatitis with longitudinal pancreaticojejunostomy (LPJ).

Methods

Records of children with chronic pancreatitis treated with LPJ between 1997 and 2003 were reviewed. Demographic data, associated conditions, endoscopic interventions, operative procedures, postoperative complications, length and costs of hospitalization, and long-term outcome were recorded.

Results

Four patients (one girl), 3 to 16 years old, underwent LPJ. Associated conditions included bile duct obstruction (2), single (1) or multiple (1) pancreatic duct strictures, recurrent familial pancreatitis (1), pseudocyst (1), Down's syndrome (1), and duodenal web (1). Preoperative endoscopic stenting was performed in two patients. All were on restricted diets, one on parenteral nutrition. Pre-LPJ, each child had 3 to 6 admissions for pancreatitis with mean total cost of $39,000, excluding diet charges. At surgery, two patients required biliary diversion for persistent biliary obstruction in addition to LPJ. Postoperatively, no patient developed fistulas or anastomotic leaks. There were no deaths. The median length of hospitalization post-LPJ was 8 days with mean cost of US$37,000. All patients resumed a normal diet post-LPJ. There were no recurrences of pancreatitis with follow-ups between 2 and 6 years.

Conclusion

Longitudinal pancreaticojejunostomy is safe and cost-effective for treating pediatric chronic pancreatitis. It has minimal complications and frees patients from pancreatitis-related hospitalizations.     

Pancreatic injury in children: good outcome of nonoperative treatment

Purpose

Treatment of blunt injury of the pancreas in children remains controversial. Some prefer nonoperative treatment, whereas others prefer operative management in selected cases. This report reviews the treatment of patients with blunt pancreatic trauma admitted to a level I pediatric trauma center in The Netherlands.

Methods

Medical records of all children less than 15 years with blunt pancreatic trauma admitted to the University Medical Center St Radboud in the period 1975 to 2003 were retrospectively analyzed.

Results

Thirty-four children were included, age 3 to 14 years. Most injuries were because of bicycle accidents (58%). On admission, amylase was raised in 90% of the patients. Five patients had pancreatic duct injuries identified by imaging (endoscopic retrograde cholangiopancreaticography was used once, magnetic resonance cholangiopancreaticography twice) or at surgery. Thirty-one children were initially managed nonoperatively. Pancreatic surgery was performed in 3 children (1 Roux-Y, 2 drainage only). Mean hospital stay was 29 days in the operative group and 24 days in the nonoperative group. Fluid collections developed in 2 operated patients. Both resolved spontaneously. In 14 of the 31 nonoperated patients, a pseudocyst developed. Only 6 of these needed secondary intervention. Of these, 3 were drained percutaneously. There was no mortality and no long-term morbidity in both groups.

Conclusions

Nonoperative management of pancreatic injury in children has good clinical outcome. Only 10% need secondary surgery. In 50%, pseudocysts develop of which half can be managed nonoperatively. The reliability of computed tomographic scan grading is of limited value to decide whether to operate primarily. There is little to gain with ERCP and stenting. The place of MRCP as a noninvasive diagnostic tool remains to be determined.     

Pancreatic pseudocyst in children: the impact of management strategies on outcome

Introduction

Persistent pancreatic pseudocysts (PPs) are rare in childhood and management tends to be individualized. The purpose of this review is to determine the impact of different management strategies and to analyze their effects on patient outcomes.

Methods

An institutional review board-approved retrospective chart review was performed on children younger than 18 years who had PP diagnosed between January 1976 and December 2003.

Results

There were 24 patients, 13 male and 11 female, with a mean age 10.7 years (range, 2-17 years). The mean PP size was 5.8 cm (range, 1.7-20 cm). Posttraumatic pseudocysts were identified in 11 children. The etiologies of 13 nontraumatic PP were idiopathic (6), familial pancreatitis (4), drug-induced (1), cholelithiasis (1), and bifid duct (1). All patients were symptomatic at diagnosis. Resolution of pseudocysts without operative intervention occurred in 7 (29%) of 24 patients. The mean time to operation for the remaining 17 children (71%) was 13.1 weeks (range, 6-36 weeks), with indications for intervention including persistent/recurrent abdominal pain (17), failure to thrive (9), infected PP (1), and ruptured PP (1). Surgical therapies for 13 of 17 patients consisted of cystogastrostomy (8), cystojejunostomy (2), longitudinal pancreaticojejunostomy (2), and Frey's procedure (1). Four patients underwent pancreatic sphincterotomy and stenting, 2 of whom also had image-guided pseudocyst drainage. The intervention-related mortality and morbidity rates were 0% and 11%, respectively, for children undergoing surgical therapies. The morbidities included pancreatic leak (1) and wound infection (1). Etiology of the PP had a significant influence on the need for intervention (traumatic, 45%; nontraumatic, 92%; P = .02); however, patient age, size, and location of the PP had no significant effect. All 24 patients continued to do well at mean follow-up of 73.3 months (range, 6 weeks-25 years). One patient with idiopathic pancreatitis has since developed insulin-dependent diabetes. All 4 patients with familial pancreatitis had their chronic pain improved without long-term narcotic therapy.

Conclusion

The treatment of PPs in children is dependent on etiology, where pseudocysts from nontraumatic etiologies are more likely to require and benefit from surgical interventions, whereas pseudocysts from traumatic etiology are more amenable to conservative management. For children with persistent symptoms or interval complication, surgical therapy is safe and effective.     

Idiopathic fibrosing pancreatitis in children--a single-center experience

Purpose

The experience of a single institution on idiopathic fibrosing pancreatitis (IFP) is presented.

Methodology

This is a retrospective review of medical records of affected patients.

Results

There were 7 cases with a mean age of 7 years. Upper abdominal pain followed by jaundice was the most common presentation. One child had varicella and 1 developed Crohn's disease 3 years later. In 5 cases, diagnosis was established intraoperatively, whereas 2 cases were diagnosed preoperatively. Ultrasonography suggested the diagnosis in 2 of the 7 cases, contrast computed tomography scan in 1 of the 3 cases, and magnetic resonance cholangiopancreatography in 1 of the 4 cases. Six patients were treated by biliary enteric bypass surgery. Treatment by endoscopic biliary stenting was successful in one. There were no postoperative complications. Pancreatic biopsies showed fibrosis of exocrine elements with preservation of islets. Three patients have pancreatic atrophy, and none has diabetes at follow-up (mean, 62 months).

Discussion

Idiopathic fibrosing pancreatitis presents as biliary obstruction in children. Precise preoperative diagnosis of IFP is difficult. Noninvasive imaging has limited sensitivity. Surgery offers satisfactory long-term relief of biliary obstruction. Treatment using temporary endoscopic biliary drainage appears promising in treatment of IFP. Patients should be followed up for pancreatic insufficiency, long-term biliary obstruction, and inflammatory bowel disease.     

Laparoscopic distal pancreatectomy using radiofrequency energy

Introduction

The pancreatic remnant remains a significant source of morbidity during laparoscopic pancreatectomy. Previous series have relied heavily on the endoscopic stapler for transection. Our study is the first to report use of a laparoscopic radiofrequency device for pancreatic transection.

Methods

The laparoscopic Habib 4x delivers high-energy radio waves through a hand-held device consisting of 4 electrodes and allows for bloodless tissue transection. We retrospectively evaluated prospectively collected data. Fourteen patients were identified and used in our analysis.

Results

There were no conversions, blood transfusions, reoperations, or mortalities. Average length of stay was 4.6 days. There was 1 readmission. Clinically significant fistula occurred in 2 patients (14%), only one of which required an intervention.

Conclusion

Radiofrequency energy is safe and feasible for use during laparoscopic pancreatic transection. Moreover, it is technically simple to use.     

Typical carcinoids and neuroendocrine carcinomas of the stomach: differing clinical courses and prognoses

Background

Gastric endocrine tumors are usually classified as 3 types of well-differentiated endocrine tumors (typical carcinoids or carcinoids) and poorly differentiated carcinomas (neuroendocrine carcinomas [NECs]).

Methods

From 1993 to 2008, 97 patients (73 men and 24 women) were diagnosed with gastric neuroendocrine tumors at the Asan Medical Center.

Results

Of the 45 patients with typical carcinoids, 37 underwent surgery (eg, endoscopic resection). Of the 52 patients with NECs, 43 underwent surgery (eg, radical gastrectomy). One patient died of recurrence of the typical carcinoids, whereas 26 patients with NECs died of related diseases (P < .05). The rates of survival and recurrence did not significantly differ by type of typical carcinoid (P > .05).

Conclusions

Regardless of the type, carcinoids that are not yet advanced can be effectively treated with minimal endoscopic or laparoscopic surgery. However, all NECs and advanced carcinoids should be treated with radical gastrectomy.     

Endoscopic Management of Urologic Complications Following Renal Transplantation: Impact of Ureteral Anastomosis

Objective

To evaluate the success of ureteral stent placement to treat or prepare for surgical treatment of urologic complications after renal transplantation, according to a type of ureteral anastomosis.

Patient and methods

From May 1989 to December 2006, we performed 703 kidney transplantations including 412 extravesical ureteroneocystostomy (according to Lich-Gregoire technique) and 265 transvesical ureteroneocystostomy (according to Politano-Leadbetter technique). We retrospectively analyzed our endoscopic management of urinary leaks and ureteral strictures. The criteria of success were the feasibility to place a ureteral stent, permitting good drainage of the upper renal graft tract before further endoscopic or surgical treatment.

Results

Forty-three urinary leaks or ureteral strictures occurred after extravesical ureteroneocystostomy (n = 21) or after Politano-Leadbetter anastomosis (n = 22). The success rate of endoscopic management was 75% (n = 16) for Politano-Leadbetter anastomosis versus 53% (n = 11) for the Lich-Gregoire anastomosis. There was no statistical difference (P = .1).

Conclusion

Ureteroneocystostomy according to Lich-Gregoire procedure were twice less complicated than those according to the Politano-Leadbetter technique, but were associated with a rate of failure of ureteral stent placement in urgency higher to 25%.     

Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma

Introduction

Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma.

Methods

This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes.

Results

One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst.

Conclusion

There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Thoracoscopic versus open resection of congenital lung lesions: a case-matched study

Purpose

The purpose of the study was to compare the outcomes in children undergoing thoracoscopic versus open resection of congenital lung lesions.

Methods

Retrospective review of 12 consecutive children (<3 years of age) undergoing thoracoscopic resection of a congenital lung lesion between 2004 and 2005 was performed. Intraoperative and early postoperative results were compared with randomly selected age- and sex-matched (2:1) patients undergoing thoracotomy between 2000 and 2005.

Results

Twelve children underwent thoracoscopic resection and were compared with 24 that underwent thoracotomy. Seventy five percent of the lesions in both groups were congenital cystic adenomatoid malformations. There were no major intraoperative complications. Two thoracoscopic procedures were converted to a thoracotomy. Perioperative outcomes including operative time, length of stay, duration and volume of chest tube drainage, and dose and duration of intravenous opioids were similar for the procedures. However, children undergoing thoracoscopic procedures were less likely (odds ratio = 0.07) to have received adjunctive regional anesthesia. Overall morbidity was 33% thoracoscopic and 25% open (P = .70).

Conclusion

Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions. Examination of long-term advantages of the thoracoscopic approach such as decreased risk of chest wall deformity and scoliosis and improved cosmesis will require longer follow-up.     

Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes

Background

Nonoperative management (NOM) is an accepted treatment of pediatric solid organ injuries and is typically successful. Blunt pancreatic trauma tends to require operative intervention more frequently. We sought to identify predictors of failure of NOM and compare the outcome of operative management against NOM.

Methods

A retrospective analysis was performed from January 1993 to December 2002 of all children with blunt pancreatic injuries from the trauma registries of 7 designated level 1 pediatric trauma centers. Failure of NOM was defined as the need for intraabdominal operative intervention. Injuries were graded I to V, and ductal injury was defined as grades III to V. Parameters included mechanism of injury, injury severity score (ISS), organ grade, Glasgow Coma Scale score, and outcome. Data were analyzed by Fisher exact test and Mann-Whitney U test, with mean values ± SD and significance of P < .05.

Results

Pancreatic injuries were present in 173 (9.2%) of 1823 patients. Of these, 43 (26.0% [43/173]) required an operation. Valid morbidity data was obtained in 118 of 173 patients. ISS was significantly higher in all patients treated operatively. Patients with an injury of grade III to V failed NOM more frequently than all patients with pancreatic injury (P =.0169). Length of stay was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in NOM patients, although not significant.

Conclusions

Patients with pancreatic injuries had a NOM failure rate of 26.0%. ISS and injury grades III to V were predictors of NOM failure. Patients with pancreatic ductal injury require more aggressive management.     

A prospective observational study examining quality of life in patients with malignant gastric outlet obstruction

Background

Gastric outlet obstruction (GOO) often complicates advanced malignancy. Palliative options include surgical bypass, endoscopic stent, percutaneous gastrostomy (PEG), or percutaneous jejunostomy (PEJ).

Methods

We enrolled 50 patients with GOO secondary to unresectable primary or metastatic cancer in a study examining palliative interventions. Validated instruments assessed quality of life (QOL) at baseline, 1 month, and 3 months following intervention.

Results

Median overall survival was 64 days. A shorter hospital stay and trend to lower mortality were observed after stent placement; solid food intake and rates of secondary intervention were comparable. Both stent and surgical bypass were associated with acceptable QOL outcomes. Fifteen patients refused participation at 1 month and 28 died of disease before 3 months, so 10 patients completed all surveys.

Conclusions

Although malignant GOO is associated with poor survival, there are reasonable alternatives for palliation. QOL studies are difficult to complete in this population due to severity of illness and short life expectancy.     

Laparoscopic Cystogastrotomy by Ultrasonic Dissection after Pylorus-Preserving Pancreaticoduodectomy

Background and Objectives:

Symptomatic pancreatic pseudocysts can be drained using open, endoscopic, and laparoscopic techniques. Little is written on the role of laparoscopic drainage techniques after major abdominal operations. We describe a case of laparoscopic cystgastrotomy after pancreaticoduodenecomy.

Case Report:

A 55-year-old female with a prior history of open pylorus-preserving pancreaticoduodenectomy presented with multiple symptomatic pancreatic pseudocysts in the setting of alcohol-induced chronic pancreatitis.

Methods:

After preoperative planning with contrast-enhanced computed tomography, the patient successfully underwent laparoscopic cystgastrotomy with ultrasonic dissection.

Conclusion:

This case report illustrates that laparoscopic cystenteric drainage of pancreatic pseudocysts can be performed safely after major open abdominal operations. Further investigation is needed.     

Intussusception after pancreatic surgery in children: a case series

Background

Postoperative intussusception (POI) has been described after a wide variety of pediatric surgical procedures, but it has not been reported as a complication after pediatric pancreatic resections.

Methods

We performed a retrospective review of 5 cases of pancreatectomy-related POI observed between October 1998 and July 2009 within a series of 234 pancreatic resections in children.

Results

The incidence of pancreatectomy-related POI was 2.1%. Postoperative intussusception was observed after either partial or near-total pancreatic resections. There was no sex predisposition. All cases occurred within the first 2 postoperative weeks and involved the small bowel exclusively. The outcome after surgery was uneventful in all cases. The overall clinical course in our cases was similar to that described in the literature for POI associated with other surgical procedures.

Conclusions

The incidence of POI after pancreatic resections in children is significantly higher than the general incidence reported in the literature (2.1% vs 0.08%-0.25%).