假性胰腺囊肿55例治疗对策分析

假性胰腺囊肿是一种胰外的胰液集聚,通常由于胰管系统破裂和损伤造成,常发生于急、慢性胰腺炎和胰腺外伤后,对假性胰腺囊肿的转归、手术和非手术方案的选择,目前尚无统一认识。本文总结我院15年间55例假性胰腺囊肿的治疗经验,并结合文献探讨其治疗对策。临床资料一、一般资料19     

超声内镜引导下经胃内置管行胰腺假性囊肿引流术的护理配合

对16例胰腺炎后形成假性囊肿患者在超声内镜引导下经胃内置管行胰腺假性囊肿引流术,术前做好患者和器械准备;术中严密观察病情变化,熟悉操作流程,做好手术配合;术后加强病情监测,积极预防和处理并发症。结果16例中1例置管后囊肿内出血不止,转外科手术治疗后痊愈出院;13例术后1周至8个月经腹部B超、上腹部CT复查显示胰腺假性囊肿消失;2例囊肿并发感染,再放置鼻囊肿引流管反复冲洗,5～6个月后囊肿消失,拔除支架。提出精良的护理配合是手术成功和避免并发症的重要保证。     

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.     

Detection of cryptic vascular malformations by computerized tomography. Report of two cases.

Two cases of cryptic vascular malformation that were not demonstrated by cerebral angiography were detected by computerized tomography. One of these patients had a cavernous angioma in the fourth ventricle with recurrent subarachnoid hemorrhages, and the other harbored a small arteriovenous malformation and intracerebral hematoma. The usefulness and limitations of computerized tomography in the identification of cryptic vascular malformations are discussed.     

Surgical treatment of pancreatic pseudocysts. A review of 42 cases

21 years' experience of operated pancreatic pseudocysts is reviewed. The number of patients was 42, with mean age of 50 +/- 5 years. Thirteen patients (31%) were alcoholic. In 6/42 cases (14%) pancreatic carcinoma was considered the reason for pseudocyst formation. In 30 patients an internal and in 11 an external drainage was created. Operative mortality occurred in 3 patients (7%). External drainage was effected in patients with complicated pseudocyst. The complication rate in this group was 6/11 (55%) and in the internal drainage group 7/30 (23%). Internal drainage is a safe and effective procedure in patients with a mature pseudocyst wall. External drainage should be used in patients critically ill or with an immature pseudocyst wall.     

Oversized pseudocysts of the spleen: Report of two cases: Optimal management of oversized pseudocysts of the spleen

INTRODUCTION

Pseudocysts of the spleen are usually asymptomatic and associated with a history of trauma, infection or infarction. In this report, we present two uncommon cases of solitary, oversized pseudocysts of the spleen.

PRESENTATION OF CASE

Two patients (cases A and B), with symptoms of abdominal pain, were investigated. The laboratory and ultrasound examination confirmed the diagnosis of a large, non-parasitic splenic cyst in both cases. Computed tomography described an oversized pseudocyst occupying almost the entire splenic parenchyma in both cases and in patient A, the cyst was located in the splenic hilum. The medical history revealed a previous abdominal injury only in case A. The two patients underwent an open total splenectomy. The pathology examination verified the diagnosis of a non-parasitic splenic pseudocyst.

DISCUSSION

Both patients presented with symptoms, in contrast to the majority of patients with splenic cysts. The medical history of patients with splenic pseudocysts does not always reveal the cause of the pseudocyst formation. Any type of spleen-sparing procedure is not easy to perform in cases of surgical and anatomical difficulty, because of recurrence and the risk of intractable bleeding from the spleen.

CONCLUSION

Partial splenectomy is the recommended method for parenchymal preservation, but total splenectomy is preferred when the splenic cyst is oversized or cannot be excised with safety.     

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).     

Unresolved problems of pancreatic pseudocysts.

The treatment of 54 patients with pancreatic pseudocysts was reviewed. The operative mortality was 11% and after an average followup of 3 years the recurrence rate was 3.8%. Hemorrhage was the most significant complication of pseudocysts and occurred in 4 patients preoperatively and three patients postoperatively. The patients who developed recurrence or died had been operated within one day after the diagnoses of pseudocysts were made. The deaths were due to the conditions that necessitated the emergency operations rather than to the fact that the cyst wall had not adequately matured. Ideally, operation should be performed when the patient has reached an optimal clinical condition and the walls of the cyst are sufficiently thick. Currently there is no guide for estimation of the state of cyst maturation, although this may develop with the use of ultrasound. Since complications can develop during a prolonged observation period it was our policy to proceed with surgery as soon after diagnosis as the patient was in satisfactory clinical condition. It is evident from this study that internal drainage can be performed safely in less time than the 6 weeks frequently recommended. Morbidity and mortality were not adversely affected by a short interval between diagnosis and operation if the timing was a matter of election rather than a condition of emergency.     

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.     

Role of laparoscopic ultrasonography in intraoperative localization of pancreatic insulinoma

Background: A combination of digital palpation and ultrasonography plays an important role in locating insulinomas intraoperatively. Laparoscopic resection of insulinomas has been described recently, but experience in locating insulinomas during laparoscopy is lacking. Methods: From January 1998 to January 1999, three patients with pancreatic insulinomas underwent laparoscopy and laparoscopic ultrasonography aimed at intraoperative localization and potential resection. The role of laparoscopy and laparoscopic ultrasonography in locating insulinomas is evaluated. Results: Preoperative localization studies were routinely performed, and two patients had an occult tumor before laparoscopy. None of the tumors was detected by laparoscopic examination, but laparoscopic ultrasonography identified solitary tumors located at the body and tail of the pancreas. Conversion to laparotomy was performed in one patient as a planned procedure. One patient underwent laparoscopic enucleation, whereas the other had a laparoscopic distal pancreatectomy. Conclusions: Laparoscopic ultrasonography seems to be sensitive in locating insulinomas at the body and tail of the pancreas. It optimizes and facilitates resection of insulinomas through a minimally invasive approach. Received: 8 March 1999/Accepted: 10 August 1999/Online publication: 7 September 2000     

Simultaneous multiple brain tumors of different histological nature. Report of two cases

Two cases of patients harbouring simultaneously multiple brain tumors of different histological nature are here reported. Clinical presentation, site of growth and neuroradiological findings are illustrated and discussed in light of the data previously reported by the literature.     

Treatment of pancreatic pseudocysts by laparoscopic cystogastrostomy

AIM: To evaluate the clinical results of laparoscopic cystogastrostomy and to determine the potential advantages of this new therapeutic option. PATIENTS AND METHODS: This study concerned 12 patients presenting with pancreatic pseudocyst and operated on by laparoscopic cystogastrostomy between 1997 and 2002. There were five men and seven women with a median age of 46 years (range: 30-72). In ten patients, the pseudocyst developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients, the pseudocyst was associated with chronic pancreatitis. All the patients had a single cyst bulging into the posterior wall of the stomach and the median cyst diameter was 9 cm (range: 5-14). RESULTS: Endoluminal gastric laparoscopy was used in six patients and intraperitoneal transgastric laparoscopy in six patients. Conversion to open surgery was required in one patient because the cyst could not be correctly localised by laparoscopy. The median size of the cystogastrostomy was 3 cm (range: 2-5). In eight patients, necrotic debris were still present within the cyst. The median operative time was 90 min (range: 60-140) and the median postoperative hospital stay was 6 days (range: 4-24). No mortality was recorded and postoperative morbidity was limited to one haematoma of the rectus sheath on a port site. One patient was readmitted on the 20th postoperative day because of cyst infection due to partial closure of the cystogastrostomy and was treated by endoscopic placement of a stent. One patient was lost for follow-up 2 months after surgery. With a median clinical and radiological follow-up of 12 months (range: 6-36), no recurrence of pancreatic pseudocyst was observed. CONCLUSIONS: In this series, laparoscopic cystogastrostomy is associated with a low postoperative morbidity and an effective permanent result. Laparoscopy has two main advantages: an excellent control of haemostasis and the creation of a wide communication with debridement of the cyst contents thus minimizing the risk of infection or recurrence of the pseudocyst.     

Percutaneous catheter drainage of pancreatic pseudocysts.

Pancreatic pseudocysts represent a complication of severe pancreatic inflammatory disease. Although operative drainage is the cornerstone of therapy for pseudocysts, we have undertaken percutaneous catheter drainage in a selected group of 28 patients over a six-year period (1982-88). This represents 42 per cent of pseudocyst patients managed by the senior author and 1.7 per cent of admissions for pancreatitis at the Medical University Hospitals during that period of time. There were 26 men and two women with an age range of 26-66 years (mean = 42.1). Twenty-six patients had alcohol abuse as the cause of pancreatitis; two were due to surgical trauma. Nondilated pancreatic ducts were demonstrated in 25 patients. Six had pancreatic ascites associated with pseudocysts. Four had previous operative drainage (2 internal and 2 external drainage procedures). Five patients received octreotide acetate, a synthetic peptide which mimics the action of somatostatin, in an attempt to aid closure of external fistulas. The mean length of catheter drainage was 48 days (range 7-210 days). Eight (29%) patients developed procedure-related complications (1 pneumothorax, 1 sheared guidewire, six drain tract infections). There was no mortality. Successful resolution of pseudocysts was achieved in 26 patients (93%). Two patients subsequently had elective caudal pancreaticojejunostomy (CPJ), and one lateral pancreaticojejunostomy (LPJ) to drain obstructed pancreatic ducts. One patient has required repeat external drainage. Percutaneous external drainage is successful in pseudocyst eradication. When underlying pancreatic pathology remains uncorrected, elective surgical decompression of obstructed, dilated ducts may be necessary.     

Combining the selective arterial calcium injection test and intraoperative blood glucose monitoring for multiple insulinomas: Report of two cases

(Received for publication on Mar. 29, 1999; accepted on Jan. 7, 2000)