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.     

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.     

Stent displacement in endoscopic pancreatic pseudocyst drainage and endoscopic management

A pancreatic pseudocyst(PPC)is a collection of pancreatic fluid enclosed by a non-epithelialized,fibrous or granulomatous wall.Endoscopic pancreatic pseudocyst drainage(PPD)has been widely used clinically to treat PPCs.The success and complications of endoscopic PPD are comparable with surgical interventions.Stent displacement is a rare complication after endoscopic PPD.Almost all the complications of endoscopic PPD have been managed surgically,and there is rare report involving the endoscopic treatment of intraperitoneal stent displacement.We report here a case of stent displacementafter endoscopic ultrasound-and fluoroscopy-guided PPD in a 41-year-old female patient with a PPC in the tail of the pancreas.The endoscopic treatment was successfully performed to remove the displaced stent.The clinical course of the patient was unremarkable.The cyst had significantly reduced and disappeared by 12 wk.We found that both endoscopic ultrasound and fluoroscopy should be used during endoscopic PPD to avoid stent displacement.The displaced stent can be successfully treated by endoscopic removal.     

Treatment of pancreatic pseudocysts in line with D＇Egidio＇s classification

AIM: To explore the implications of underlying diseases in treatment of pancreatic pseudocysts (PPC). METHODS: Clinical data of 73 cases of pancreatic pseudocyst treated in a 12-year period were reviewed comprehensively. Pancreatic pseudocysts were classified according to the etiological criteria proposed by D'Egidio. The correlation between the etiological classification, measure of treatment and clinical outcome of the patients was analyzed. RESULTS: According to the etiological criteria proposed by D'Egidio, 73 patients were divided into three groups. Group I was comprised of 37 patients with type I pseudocyst, percutaneous drainage was successful in the majority (9/11, 82%) while external or internal drainage was not satisfactory with a low success rate (8/16, 50%). Group II was comprised of 24 patients with type II pseudocyst, and internal drainage was curative for most of the cases (11/12, 92%), but the success rate of percutaneous or external drainage was unacceptably low (4/9, 44%). Group III consisted of 12 patients with type III pseudocyst. Internal drainage or pancreatic resection performed in 10 of these patients produced a curative rate of 80% (8/10) with the correction of the ductal pathology as a prerequisite. CONCLUSION: The classification of pancreatic pseudocyst based on its underlying diseases is meaningful for its management. Awareness of the underlying diseases of pancreatic pseudocyst and detection of the ductal pathology in type II and III pancreatic pseudocysts with endoscopic retrograde cholangiopancreatography may help make better decisions of treatment to reduce the rate of complications and recurrence.     

Laparoscopic resection of an adrenal pseudocyst mimicking a retroperitoneal mucinous cystic neoplasm

Adrenal pseudocysts are rare cystic masses that arise within the adrenal gland and are usually non-functional and asymptomatic. Adrenal pseudocysts consist of a fibrous wall without a cellular lining. We report a patient with a 9 cm, left-sided suprarenal cystic mass who presented with abdominal discomfort of 2 years＇ duration. A 38-year-old woman was referred to our service for evaluation of abdominal discomfort and gastrointestinal symptoms. Routine laboratory tests were within normal limits. An abdominal computed tomography scan showed a 9 cm × 8 cm × 8 cm well-defined cystic lesion displacing the left kidney. Magnetic resonance imaging showed a cystic lesion with low signal intensity on the Tl-weighted image and high signal intensity on the T2-weighted image. A laparoscopic left adrenalectomy was performed to diagnose the lesion. The final pathology showed an adrenal pseudocyst without a cellular lining. The patient had no postoperative complications and she was discharged four days after surgery.     

Echo-enhanced ultrasound with pulse inversion imaging： A new imaging modality for the differentiation of cystic pancreatic tumours

AIM: To describe and discuss echo-enhanced sonography in the differential diagnosis of cystic pancreatic lesions. METHODS: The pulse inversion technique (with intravenous injection of 2.4 mL SonoVue(?)) or the power-Doppler mode under the conditions of the 2nd harmonic imaging (with intravenous injection of 4 g Levovist(?)) was used for echo-enhanced sonography. RESULTS: Cystadenomas frequently showed many vessels along fibrotic strands. On the other hand, cystadenocarcinomas were poorly and chaotically vascularized. "Young pseudocysts" were frequently found to have a highly vascularised wall. However, the wall of the "old pseudocysts" was poorly vascularized. Data from prospective studies demonstrated that based on these imaging criteria the sensitivities and specificities of echo-enhanced sonography in the differentiation of cystic pancreatic masses were > 90%. CONCLUSION: Cystic pancreatic masses have a different vascularization pattern at echo-enhanced sonography. These characteristics are useful for their differential diagnosis, but histology is still the gold standard.     

Isolated gastric variceal bleeding caused by splenic lymphoma-associated splenic vein occlusion

Isolated gastric varices(IGV) can occur in patients with left-sided portal hypertension resulting from splenic vein occlusion caused by thrombosis or stenosis. In left-sided portal hypertension,blood flows retrogradely through the short and posterior gastric veins and the gastroepiploic veins,leading to the formation of an IGV. The most common causes of splenic vein occlusion are pancreatic diseases,such as pancreatic cancer,pancreatitis,or a pseudocyst. However,various other cancers,such as colon,gastric,or renal cancers,have also been known to cause splenic vein occlusion. Our patient presented with a rare case of IGV bleeding induced by splenic lymphoma-associated splenic vein occlusion. Splenectomy,splenic artery embolization,and stenting of the splenic vein are the current treatment choices. Chemotherapy,however,is an alternative effective treatment for splenic vein occlusion caused by chemotherapy-sensitive tumors. Our patient responded well to chemotherapy with a cyclophosphamide,hydroxydaunorubicin,oncovin,and prednisolone regimen,and the splenic vein occlusion resolved after the lymphoma regressed.     

Gastrointestinal stromal tumor of the stomach with a giant abscess penetrating the gastric lumen

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. In large GISTs, cystic degeneration, necrosis and focal hemorrhage that occur inside the tumor can result in gastrointestinal bleeding. We describe a case of a 74-year old male with GIST of the stomach accompanied with a giant abscess that penetrated the gastric lumen. The patient experienced undiagnosed fever for two months prior to hospitalization. Gastrointestinal endoscopy, X-ray series and computed tomography of the patient’s abdomen revealed a gastric submucosal tumor in the fornix, with a fistula to the gastric lumen that was inundated with a great deal of pus. The mass was diagnosed as a GIST from biopsy specimens. The patient was treated by endoscopic drainage of the abscess and intravenous administration of antibiotics. Eventually, a partial gastrectomy was performed. He was also administered Imanitib mesylate as adjuvant therapy. He was followed up for 2 years and no metastasis or recurrence was recognized at the follow- up examinations. This is the first report of a patient with clearly diagnosed GIST with endoscopic evidence of an abscess penetrating into the gastric lumen.     

Isolated splenic metastases from gastric carcinoma:A case report and literature review

Isolated metastases to the spleen from gastric carcinoma is very rare.Only a few cases have been reported in the literature.We herein present a case of isolated splenic metastases in a 62-year-old man,occurring 12 mo after total gastrectomy for gastric carcinoma.The patient underwent a laparoscopic exploration,during which two lesions were found at the upper pole of the spleen,without involvement of other organs.A laparoscopic splenectomy was performed.Histological examination confirmed that the splenic tumor was a poorly differentiated adenocarcinoma similar to the primary gastric lesion.The postoperative course was uneventful and the patient has been well for 9 mo,with no tumor recurrence.The clinical data of 18 cases of isolated splenic metastases from gastric carcinoma treated by splenectomy were summarized after a literature review.To our knowledge,this is the first reported case of isolated splenic metastases undergoing laparoscopic splenectomy.     

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.     

The Retrogastric Transventricular Approach for Drainage of the "Supragastric" Pancreatic Pseudocyst

The majority of pancreatic pseudocysts develop in a retrogastric situation and are amenable to transgastric cystogastrostomy through the anterior gastric wall. We have encountered two pseudocysts in an unusual situation, in which adherence of the anterior gastric wall to the anterior parietal peritoneum precluded this approach. A retrogastric exposure through the lesser sac allowed for the creation of a cystogastrostomy through the superior aspects of the anterior and posterior gastric walls, adjacent to the lesser curvature of the stomach. This type of drainage is successful despite the theoretical failure to satisfy the dictum of dependent drainage.     

A Case of Postsurgical Pancreatic Pseudocyst Treated by Endoscopic Cystogastrostomy

Pancreatic pseudocyst after pancreatic surgery is a relatively rare condition and conservative therapy is the common treatment of choice. When symptoms persist or complications follow, however, surgical treatment is considered. There have been reports on endoscopic cystoenterostomy since the early 1980s. We herein describe a case of postsurgical pancreatic pseudocyst treated successfully by endoscopic cystogastrostomy. A nineteen-year-old female showing left hypochondralgia and back pain with elevation of her serum amylase level, who had undergone enucleation of a solid cystic tumor in the body of the pancreas, was referred to our department. She was diagnosed as having a pseudocyst of the pancreas 5.8×4.5 cm in size at the site of enucleation by US and CT. Endoscopic retrograde pancreatography and endoscopic ultrasonography performed simultaneously revealed obstruction of the main pancreatic duct and a cystic change in the body-tail of the pancreas just behind the gastric wall of the upper body. An extrinsic compression was seen in the posterior wall of the upper body of the stomach endoscopically. An incision was made using a sphincterotome. A pigtail stent, 7.2 Fr in size, was placed to keep the patency of the fistula, which was removed one and a half months later. Her symptoms showed great improvement immediately after the procedure. Follow-up CT demonstrated no recurrence of the pseudocyst.     

Prognostic Factors for Successful Endoscopic Transpapillary Drainage of Pancreatic Pseudocysts

Background and Aims

The transpapillary approach can be used for draining pancreatic pseudocysts (PPs) with pancreatic-duct abnormalities. The purpose of this study was to analyze prognostic factors for clinical success of transpapillary drainage.

Patients and Methods

Data for all patients who underwent transpapillary drainage between November 2000 and September 2009 were obtained by retrospective review and entered into a computerized database. Patient data were prospectively followed up to determine long-term outcomes.

Results

Seventy interventional ERCP procedures were performed for 43 patients. Technical success was 90.7 % (39/43). Overall clinical success was 79.5 % (31/39). Clinical success for pancreatic head pseudocyst was significantly different from that for body or tail pseudocyst (62.5 vs. 91.3 %, P = 0.043). Logistic regression analysis showed that location of the PPs predicted the success of endoscopic transpapillary pseudocyst drainage (P = 0.025).

Conclusion

Transpapillary drainage is the least traumatic approach for drainage of PPs, and is also effective for patients with no communicating pseudocysts. Clinical success for pancreatic body or tail pseudocyst drainage was higher than that for pancreatic head pseudocyst drainage. It was found that the location of PPs predicted the success of transpapillary pseudocyst drainage. None of the other factors tested was a significant predictor of clinical success.     

超声内镜引导下经胃壁电穿孔造瘘术内引流胰腺假性囊肿

[目的]评价超声内镜引导下经胃壁造瘘置入双猪尾支架内引流胰腺假性囊肿的疗效及安全性。[方法]回顾性分析行超声内镜引导下经胃壁造瘘置入双猪尾支架内引流胰腺假性囊肿患者5例的临床资料。[结果]5例胰腺假性囊肿患者,囊肿最大15cm×10cm、最小7cm×5cm,分别位于胰腺头体尾部、体尾部和尾部,巨大囊肿患者胃体窦小弯侧有明显压迹。5例患者均一次性电穿孔造瘘内引流成功,成功率100%,随访6~12个月无复发,治愈率100%。[结论]超声内镜引导下经胃壁电穿孔造瘘置管内引流术治疗胰腺假性囊肿疗效确切,并发症少。     

Palliative endoscopic ultrasound-guided drainage of a malignant pancreatic cyst causing gastric outlet obstruction.

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has been well described but it is not an established therapy for malignant pancreatic cystic neoplasms. We report the first EUS-guided cystogastrostomy for the palliative treatment of a cystic pancreatic adenocarcinoma. CASE REPORT: We describe a 70-year-old male with a nonresectable cystic pancreatic adenocarcinoma causing partial gastric outlet obstruction treated successfully with palliative EUS-guided cystogastrostomy stent placement. The diagnosis was confirmed by EUS-guided fine needle aspiration. Computerized tomography (CT) and EUS staging revealed vascular invasion precluding the patient from surgical resection. Cystogastrostomy was performed entirely under EUS guidance utilizing a 10-Fr double pigtail stent. After cystogastrostomy stent placement, the patient developed dramatic symptomatic improvement of gastric outlet obstructive symptoms, although subsequent imaging did not reveal complete collapse of the cystic structure. CONCLUSION: EUS-guided cystogastrostomy can be considered in the palliative treatment of nonresectable pancreatic cystic neoplasms. Cyst decompression may result in significant symptomatic improvement, although the architecture of malignant cysts may prevent complete resolution.     

Treatment of pseudocysts in acute pancreatitis. Retrospective study of 45 patients]

A total of 55 pancreatic pseudocysts in 45 patients with acute pancreatitis were managed between 1980 and 1990. Six patients were managed conservatively with resolution of pseudocysts in 5 patients. All pancreatic pseudocysts that disappeared were smaller than 35 mm. CT or ultrasound-guided aspiration were performed in 26 patients with a morbidity rate of 5%. Nine among 21 patients (42%) who were initially treated by percutaneous puncture were definitively cured: all pseudocysts were smaller than 55 mm. Nine patients were managed by long-term percutaneous drainage: 3 minor complications occurred and in 7 patients, no other treatment was necessary even for large pseudocysts. Endoscopic cystoenterostomy was performed in 12 patients. Only 15 pseudocysts (27%) bulged into the digestive wall, mainly of the stomach. Three complications (following 2 cystogastrostomies) occurred and one patient died after endoscopic cystogastrostomy. In 7 patients (58%), no other treatment was necessary even for large pancreatic pseudocysts. Surgery was required in 13 patients but only 4 patients underwent surgery as primary treatment. One major complication occurred and one patient died. Percutaneous drainage and endoscopic cystoenterostomy when technically feasible, are effective treatments of pancreatic pseudocysts complicating acute pancreatitis.     

Transmural endoscopy drainage of pancreatic pseudocyst: long-term outcome

BACKGROUND: Pancreatic pseudocysts are relatively common complications of pancreatitis in adults. OBJECTIVE: To evaluate the long-term results from transmural endoscopic drainage and thus to establish its role in managing pancreatic pseudocyst. METHODS: Fourteen patients with pancreatic pseudocyst were studied. Their main complaint was pain in the upper levels of the abdomen. They presented palpable abdominal mass and underwent cystogastrostomy (n = 12) and cystoduodenostomy (n = 2), with clinical follow-up using abdominal computed tomography for up to 51 months. Retrograde endoscopic cholangiopancreatography was attempted in all cases to study the pancreatic duct and classify the cysts. RESULTS: There were 10 cases (71.5%) of chronic pancreatitis that had become acute through alcohol abuse and 4 (28.5%) that had become acute through biliary disorders. Both types of endoscopic drainage (cystogastrostomy and cystoduodenostomy) were effective. There was no change in the therapeutic management proposed. Migration of the orthesis into the pseudocyst at the time of insertion (two cases) was the principal complication, and these could be removed during the same operation, by means of a Dormia basket, with the aid of fluoroscopy. There has so far not been any mortality or relapse. The mean hospital stay was 3 days. CONCLUSION: Transmural endoscopic drainage was an efficacious form of therapy, presenting a low complication rate and no mortality, and only requiring a short stay in hospital.     

Outcome and complications of endoscopic ultrasound guided pancreatic pseudocyst drainage using combined endoprosthesis and naso-cystic drain

Background and Aim: Endoscopic ultrasound guided pancreatic pseudocyst drainage (EUS‐PPD) is increasingly being used for management of pancreatic pseudocysts. We evaluated the outcome and complications of EUS‐PPD with modified combined technique by inserting both endoprosthesis and naso‐cystic drain. Methods: Forty patients referred between August 2007 and January 2010 for EUS‐PPD were prospectively studied. EUS‐PPD was attempted for symptomatic pancreatic pseudocysts which were; (i) resistant to conservative treatment, (ii) in contact with the gastric or duodenal wall on EUS and (iii) having no bulge seen on endoscopy. Controlled radial expansion wire guided balloon dilation of the puncture tract was performed followed by insertion of a 10 French double pigtail stent and 7‐Fr naso‐biliary drain. The early and late outcome and complications of EUS‐PPD were analyzed. Results: Thirty‐two patients had non‐infected and eight had infected pseudocysts. EUS‐PPD was technically successful in all. Pseudocysts resolved completely in 39 patients, while one with infected pseudocyst underwent surgical resection for bleeding in the cyst. Naso‐cystic drain was removed in 39 patients after median duration of 13 days. Thereafter, the double pigtail stent was removed in all cases after median duration of 10 weeks. Pseudocyst recurred in one patient requiring a second session of EUS‐PPD. All 32 patients without cystic infection were successfully treated by EUS‐PPD. Seven out of eight patients (87%) with cystic infection were successfully treated by EUS‐PPD. Conclusion: Endoscopic ultrasound guided pancreatic pseudocyst drainage with modified combined technique is safe and is associated with high success rate.