The VIO soft-coagulation system can prevent pancreatic fistula following pancreatectomy

Background/Purpose

The VIO soft-coagulation system (SC) is a new device for tissue coagulation. We hypothesized that this device would be an effective tool for sealing small pancreatic ducts, thus reducing pancreatic fistula following pancreatectomy.

Methods

To confirm whether the SC could be used to seal small pancreatic ducts, we measured the burst pressure in sealed ducts in mongrel dogs. Eight dogs underwent distal pancreatectomy, with the remnant stump coagulated by using the SC. The animals were necropsied on postoperative day 10. In a clinical trial, 11 patients who underwent pancreatoduodenectomy with SC treatment (SC group), and 24 patients who underwent pancreatoduodenectomy without SC treatment (non-SC group) were compared.

Results

In the experimental study, the burst-pressure test revealed that the SC had efficiently sealed the small pancreatic ducts. Histological examination revealed completely obstructed pancreatic ductal structures, ranging from large pancreatic ducts (diameter, 500 μm) to microscopic ducts. No pancreatic leakage was observed following distal pancreatectomy without main pancreatic duct (MPD) suturing in dogs that had an MPD diameter of less than 500 μm. In the clinical trial, pancreatic fistula developed in only one patient (9.1%) in the SC group, but a pancreatic fistula developed in five patients (20.8%) in the non-SC group.

Conclusions

This novel technique using the SC is an effective procedure for preventing the development of pancreatic fistula following pancreatectomy.

     

Choice of the optimal pancreaticojejunal anastomosis technique: how can we improve patient safety in pancreatic surgery?

Background/Purpose

The cause of the morbidity and mortality following pancreaticoduodenectomy (PD) in the surgical treatment of benign and malignant diseases of the periampullary region is leakage from the pancreaticojejunal anastomosis. The size of the main pancreatic duct and the texture of the remnant pancreas are very important factors for a secure pancreaticojejunal anastomosis.

Methods

A new technique was developed for patients having pancreatic ducts smaller than 3 mm and a hard remnant pancreas.

Results

Pylorus-preserving PD was performed for 28 patients who underwent PD at our hospital between January 2004 and January 2007, without mortality. The new technique was used in the 8 patients who had pancreatic ducts smaller than 3 mm and a hard remnant pancreas. With our new technique, different from other previously described techniques, the anastomosis was performed with the sutures passing from the cut-surface of the parenchyma of the pancreas. All patients were operated on by the same surgeon and surgical team. None of the patients developed a fistula.

Conclusions

We believe that this anastomosis technique can be performed securely in patients having a hard remnant pancreas and a main pancreatic duct smaller than 3 mm.

     

Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification

Background

Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention.

Aim

To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature.

Methods

We performed an extensive review of the literature on pancreatic fistulae and leaks.

Results

In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment.

Conclusions

A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.

     

Evaluation of esophageal and airway stent placement for patients with advanced and recurrent esophageal cancer

Background

Patients with advanced esophageal cancer frequently experience dysphagia and dyspnea, and relief of such symptoms is important. We wished to clarify the efficacy of endoscopic stent placement in patients with dysphagia or dyspnea caused by advanced esophageal cancer.

Methods

A database of patients with esophageal cancer who underwent esophageal and airway stent insertion between 2005 and 2012 was analyzed retrospectively. Effects and complications of stent insertion, and survival after stent insertion, were investigated.

Results

Eighteen patients were treated by esophageal (n = 10) and/or airway (n = 9) stent placement. Marked improvements in food intake were recognized in eight patients after esophageal stenting. Marked improvements in breathing were observed in all patients after airway stenting. Dysphagia scores in the esophageal stent group as well as dyspnea grades in Common Terminology Criteria for Adverse Events v4.0 (CTCAE 4.0) in the airway stent group were significantly improved (p = 0.0078). In the esophageal stent group, major complications (CTCAE grade ≥3) occurred in seven of ten patients (70 %). In the airway stent group, major complications occurred in three of nine patients (33 %). Median survival of all 18 patients was 87.5 (range 13–1952) days after esophageal and/or airway stent placement.

Conclusions

Stent placement is effective for the improvement of malignant dysphasia and dyspnea caused by advanced esophageal cancer.

     

Duodenum-preserving total pancreatic head resection for cystic neoplastic lesions in the head of the pancreas

Background/Purpose

Cystic neoplastic lesions of the pancreas are now found with increasing frequency. Duodenumpreserving pancreatic head resection with segmental resection of the duodenum has been introduced for the surgical treatment of inflammatory and neoplastic lesions. We report the following data from 15 patients treated surgically for cystic neoplastic lesions of the pancreas head.

Methods

Duodenum-preserving total pancreatic head resection (DPPHRt) with segmental resection of the duodenum (SD) was performed in eight patients, five with intraductal papillary mucinous neoplasm (IPMN), two with mucinous cystic neoplasm (MCN), and one with cystic endocrine neoplasm (EN). In four patients, a subtotal pancreatic head resection was performed, but recurrence of the IPMN lesion was observed in two patients. Ten patients suffered cystadenoma, three patients had a borderline lesion, and two patients had an in-situ carcinoma.

Results

Eight patients had a DPPHRt with SD resection, two patients had a resection of the uncinate process including segmental resection of the inferior duodenal segment, and one patient had a duodenum-and spleen-preserving total pancreatectomy. In four patients a DPPHR with subtotal pancreatic head resection was carried out. Postoperative local complications occurred in eight patients: there was a recurrence of the IPMN lesion in the remnant pancreatic head in two patients; and there was intraabdominal bleeding in one patient, pancreatic fistula in one patient, and delay of gastric emptying in four patients. Seven patients showed signs of acute pancreatitis. Hospital mortality was 0%, and postoperative length of hospital stay was 10. 4 days (range, 8–18 days).

Conclusions

Duodenum-preserving total pancreatic head resection for IPMN, MCN, serous cystadenoma (SCA), and cystic EN lesions is a safe and beneficial surgical procedure. Segmental resection of the duodenum was applied for an oncologically complete resection. In regard to long-term outcome, the procedure is, additionally, a pancreatic cancer preventive strategy.

     

Risk factors,predictors and prevention of pancreatic fistula formation after pancreatoduodenectomy

Background/Purpose

Although the operative mortality and morbidity associated with pancreatoduodenectomy (PD) has been decreasing, pancreatic fistula remains a potentially fatal complication. The aim of this study was to identify risk factors and predictors of pancreatic fistula formation, and ways to prevent this in a consecutive series of PD patients in a single institution.

Methods

The association between pancreatic fistula formation and various clinical parameters was investigated in 50 patients who underwent PD at Kochi Medical School from January 1991 through February 2006.

Results

The incidence of pancreatic fistula in these patients was 28%. Multivariate analysis identified three independent factors correlated with the occurrence of pancreatic fistula: (1) absence of fibrotic texture of the pancreas examined intraoperatively (relative risk [RR], 1.6; 95% confidence interval [CI], 1.2–2.0; P = 0.01); (2) serum amylase concentration greater than 195?U/l (1.69 times the normal upper limit) on the first postoperative day (RR, 2.4; 95% CI, 1.0–5.7; P = 0.01); and (3) not having early postoperative enteral nutrition (RR, 3.2; 95% CI, 1.2–9.0; P = 0.004).

Conclusions

Soft texture of the pancreas and increased serum amylase the day after PD are both risk factors with predictive value for pancreatic fistula. The incidence of fistula formation is reduced by early postoperative enteral nutrition.

     

Endoscopic management of internally migrated pancreatic duct stents (with video)

Background and Aims

Spontaneous intestinal migration of pancreatic stents is a known phenomenon. However, retrieval of a proximally migrated pancreatic stent (PMPS) poses a therapeutic challenge. The primary aim of this study was to evaluate technical success of endoscopic retrograde of cholangiopancreatography (ERCP) for extraction of PMPS, including number of sessions, need of surgery for failures and intervention-induced adverse events. The secondary outcome was to evaluate long-term effects of PMPS on the ductal morphology.

Methods

Data of patients undergoing pancreatic stenting since January 2007 was reviewed. Fourteen patients were found to have PMPS. The level of stent migration was divided into two categories: level 1: retropapillary migration of the stent, the distal end seen till the genu (n?=?6). Level II: PMPS with distal end seen beyond genu (n?=?8). The stents were placed due to following reasons, prophylactic pancreatic stenting after common bile duct stone extraction (n?=?6), pancreatic endotherapy for chronic pancreatitis (n?=?7), and recurrent acute pancreatitis with incomplete pancreas divisum (n?=?1). ERCP was done using Olympus TJF 160/180 duodenoscope. Stent extraction was initially attempted using rat tooth forceps, snare with or without wire, wire-guided basket, and in case of failures, pancreatoscope was used (Boston Scientific, USA).

Results

PMPS could successfully be retrieved in 13 out of 14 patients (92.8 %). Stents were retrieved using stone extraction balloon in two (14.2 %), modified angiography balloon in one (7 %), rat tooth in three patients (21.4 %), over-the-wire snare in three patients (21.4 %), lasso technique in one (7 %), and under pancreatoscope guidance in three patients (21.4 %). Adverse events encountered were mild pancreatitis (n?=?2, 14 %) and self-limited bleeding (n?=?2, 14 %).

Conclusions

Endotherapy of PMPS could be complex and associated with adverse events. Level II-migrated stents may require specialized methods like pancreatoscopy for stent retrieval.

     

Endoscopic management of pancreatic pseudocysts and walled-off pancreatic necrosis: A two-decade experience

Aim

To determine long-term outcome of endoscopic management of pancreatic pseudocyst/walled-off pancreatic necrosis (WOPN) without necrosectomy.

Methods

One-hundred and sixty-five pancreatic pseudocysts/WOPN managed endoscopically over a period of 22 years were analyzed retrospectively for technical success, complications, and recurrence.

Results

Symptomatic 118 males and 47 females with mean age of 35.8 years were included. Alcohol was the most common etiology (41.2 %). Transmural endoscopic drainage was done in 144 patients, while 21 patients underwent transpapillary drainage. All the patients were subjected to contrast computed tomography (CT) abdomen or routine/Doppler ultrasound. Endoscopic ultrasound was done in last 11 patients. One or two double pigtail 7 Fr stents were placed when clear watery fluid came out from cyst (130 patients, 78.8 %), and nasocystic drainage (NCD) tubes were placed in addition to two 7 Fr stents when there were frank pus, thick dark fluid, or solid components inside the cyst (35 patients). All these patients settled on this treatment. Thirty-three of 35 patients of WOPN could be managed endoscopically without necrosectomy. Complications occurred in 9.2 % of pseudocysts and 40 % of WOPN. Thirty-five patients were followed up for more than 5 years (3 patients more than 10 years), and 130 patients were followed up for up to 5 years. Recurrence occurred in 8.1 % of pseudocysts and 5.7 % of WOPN.

Conclusion

Majority of pancreatic pseudocysts/WOPN can be managed with endoscopic drainage without necrosectomy with high success, low complication, and recurrence rates.

     

Primary pancreatic plasmacytoma: a rare case report

Background

Extramedullary plasmacytoma is a very rare tumor derived from plasma cells and found outside the bone marrow. Most have been identified in patients with the more aggressive anaplastic form of the disease. Only a few cases of primary pancreatic plasmacytoma have been reported.

Case presentation

We present a case of a 56-year-old man in whom a pancreatic mass was found incidentally. The lesion was determined to be a pancreatic plasmacytoma after distal pancreatectomy. There are no indications of clinical, laboratory or imaging findings of multiple myeloma nor any association with plasmacytoma in any other places, so the diagnosis of primary pancreatic plasmacytoma was made.

Conclusion

Primary pancreatic plasmacytoma is rare and the diagnosis is difficult before surgery.

     

Multislice CT study of pancreatic head arterial dominance

Background/Purpose

When a pancreatoduodenectomy is to be conducted, preoperative understanding of the vascular anatomy of the pancreatic head is important in order to reduce intraoperative bleeding. Using multislice computed tomography (MS-CT), we investigated the depiction rate and branching of the inferior pancreaticoduodenal artery (IPDA) and dorsal pancreatic artery (DPA), afferent arteries to the pancreatic head.

Methods

In 109 patients (68 with pancreatic cancer, 21 with biliary tract cancer, 15 with intraductal papillary mucinous tumor of the pancreas, and 5 others), images were taken, using 64-row MS-CT, in the early and late arterial phases.

Results

The depiction rates were 98.2% for the IPDA and 96.3% for the DPA. Branching of the IPDA was categorized into three types: a type in which the IPDA formed a common vessel with the first jejunal branch (72.0%), a type in which the IPDA branched directly from the superior mesenteric artery (18.7%), and a type in which the anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) branched separately (9.3%). DPA branching was categorized into five types, in which the DPA branched from the splenic artery (40.0%), from the common hepatic artery (25.7%), from the superior mesenteric artery (20.0%), and from the celiac artery (8.6%), and a type in which the DPA branching did not follow any of the above patterns (5.7%).

Conclusions

MS-CT images of vascular architecture enable evaluation from any angle, which is not possible with conventional angiography, making MS-CT a useful diagnostic imaging technique for understanding the vascular anatomy of the pancreatic head prior to conducting pancreatoduodenectomy for diseases of the pancreatic head region.

     

Over-the-scope clip placement for closure of gastrointestinal fistula,postoperative leaks and refractory gastrointestinal bleed

Introduction

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application.

Methods

Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy’s lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another.

Results

All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2 months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously.

Conclusion

OTSC provided safe and successful closure in a number of settings.

     

Long-term follow-up in patients treated by stent implantation for post-ablation pulmonary vein stenosis

Purpose

Symptomatic severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a rare but well-recognized complication. Treatment options include pulmonary vein angioplasty with or without drug eluting balloons or angioplasty with stent implantation. The treatment of choice is unclear. In our center, pulmonary vein stenting is the treatment of choice for significantly stenotic veins. We present the long-term clinical outcome of 9 patients treated with stent implantation.

Methods

Between 2001 and 2015, 3048 patients with AF were treated with catheter ablation at our institution, of which 9 developed symptomatic PVS. A total of 11 PVS were treated. Pre-procedural imaging (CT, MR, transesophageal echocardiography, angiography) was performed in all patients.

Results

Mean time from ablation to stenting was 18 months. Three patients had recurrent pneumonia and the remaining reduced functional capacity (NYHA 2). All patients were in functional capacity NYHA 1 (p?<?0.05) after a mean follow-up of 64 (18–132) months. Three patients still had paroxysmal AF, of which two have undergone repeated ablation.

Conclusions

Symptomatic PVS after AF ablation can be successfully treated by stent implantation with durable results and good clinical outcome. AF ablation is still a feasible option after stent deployment.

     

Long-term outcomes of extended radical resection combined with intraoperative radiation therapy for pancreatic cancer

Background/Purpose

Systemic and/or local recurrence often occurs even after curative resection for pancreatic cancer (PC). To prevent local relapse we adopted an extended radical resection combined with intraoperative radiation therapy in patients with PC, and all the patients were followed for more than 5 years.

Methods

We assessed the long-term outcomes of 41 patients who underwent this combined therapy. The cumulative survival curve in this series was depicted using the Kaplan-Meier method. Statistical analyses were performed using the logrank test.

Results

The actual 5-year survival rate was 14.6%, with a median survival time of 17.6 months. Six patients have been 5-year survivors. Local recurrence occurred in only 2 patients (5.0%). Cancer-related death occurred in 32 patients, 18 of whom had liver metastases. The patients with liver metastases had a significantly shorter survival time than those with other cancer-related causes of death. Patients with n3 lymph node involvement, extrapancreatic nerve plexus invasion, and stage IV disease had significantly poorer prognoses than patients without these characteristics.

Conclusions

Our combined therapy for patients with PC contributed to local control; however, it provided no survival benefit, because of liver metastases.

     

Selection of EMR and ESD for Laterally Spreading Lesions of the Colon

Introduction

Colonic laterally spreading lesions (LSL) are increasingly managed using endoscopic methods that comprise two main techniques: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

Purpose of Review

In this review, we aimed to review the most recent literature on selection of the best endoscopic technique in the management of colonic LSL.

Recent Findings

EMR and ESD are complimentary techniques in the management of patients with colonic LSL.

Summary

EMR is safe and effective in most patients with LSL, except for cancers with submucosal invasion in whom R0 resection is favored.

     

Endoscopic Management of Esophagorespiratory Fistulas: A Multicenter Retrospective Study of Techniques and Outcomes

Background and Aims

Esophagorespiratory fistulas (ERF) are a devastating complication of benign and malignant etiologies. ERF are associated with high mortality, short survival, and poor quality of life. We performed a multicenter analysis of patients with ERF undergoing endoscopic treatment.

Methods

Multicentre retrospective study.

Results

We analyzed 25 patients undergoing 35 procedures over an 8-year period. Our data showed high technical success rates (97.1% of procedures) and with good, but not ideal, clinical success rates (60% of procedures, 80% of patients), which were defined as fistula closure confirmed by radiographic or repeat endoscopic evaluation and/or a lack of recurrent episodes of clinical aspiration to focus on durable ERF closure as opposed to only initial success. Proximal ERF were the most difficult to manage with the lowest overall clinical success rates, highest rates of recurrent aspiration despite endoscopic therapy, highest adverse events, and shortest survival times. Adverse events occurred in 40.0% of our patients and were all minor. Treatment allowed for diet advancement in 75% of patients.

Conclusion

This represents the largest recent collection of US data and the first multicenter study evaluating the clinical success of multiple treatment modalities while stratifying data by fistula etiology and esophageal location. The endoscopic approaches detailed in this study offer a minimally invasive and safe choice for intervention with the potential to improve quality of life despite overall suboptimal clinical success and survivorship rates for in with ERF.

     

Bouveret's syndrome complicated by distal gallstone ileus after laser lithotropsy using Holmium: YAG laser

Background

Bouveret's syndrome is an unusual presentation of duodenal obstruction caused by the passage of a large gallstone through a cholecystoduodenal fistula. Endoscopic therapy has been used as first-line treatment, especially in patients with high surgical risk.

Case presentation

We report a 67-year-old woman who underwent an endoscopic attempt to fragment and retrieve a duodenal stone using a Holmium: Yttrium-Aluminum-Garnet Laser (Ho:YAG) which resulted in small bowel obstruction. The patient successfully underwent enterolithotomy without cholecystectomy or closure of the fistula.

Conclusion

We conclude that, distal gallstone obstruction, due to migration of partially fragmented stones, can occur as a possible complication of laser lithotripsy treatment of Bouveret's syndrome and might require urgent enterolithotomy.

     

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals

Background

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals.

Methods

Retrospective analysis of collected database of patients (n=18; age 40.94±8.43 years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals.

Results

Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5 cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3 ± 0.79 and time to resolution was 4.4 ± 1.3 weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2 weeks.

Conclusion

EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

     

Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up

Background

Optimal surgical treatment for anal fistula should result in healing of the fistula track and preserve anal continence. The aim of this study was to evaluate Permacol? collagen paste (Covidien plc, Gosport, Hampshire, UK) injection for the treatment of complex anal fistulas, reporting feasibility, safety, outcome and functional results.

Methods

Between May 2013 and December 2014, 21 consecutive patients underwent Permacol paste injection for complex anal fistula at our institutions. All patients underwent fistulectomy and seton placement 6–8 weeks before Permacol? paste injection. Follow-up duration was 12 months.

Results

Eighteen patients (85.7%) had a high transsphincteric anal fistula, and three female patients (14.3%) had an anterior transsphincteric fistula. Fistulas were recurrent in three patients (14.3%). Seven patients (33%) had a fistula with multiple tracts. After a follow-up of 12 months, ten patients were considered healed (overall success rate 47.6%). The mean preoperative FISI score was 0.33 ± 0.57 and 0.61 ± 1.02 after 12 months.

Conclusions

Permacol? paste injection was safe and effective in some patients with complex anal fistula without compromising continence.

     

Pancreatic fistulae: are we making progress?

Background/Purpose

Pancreatic fistulae constitute a morbid outcome of pancreatic surgery. Yet, a definition of a pancreatic fistula does not exist that can be reliably used to report on and study this outcome. We compare reported fistula, morbidity, and mortality rates with fistula parameters in order to identify high-risk fistulae predictive of morbid outcomes.

Methods

A systematic literature review was performed; of 1426 articles identified, 43 articles ultimately met inclusion and exclusion criteria and were reviewed. Fistula, morbidity, and mortality rates as well as fistula definitions were extracted and then compared and graphically reported.

Results

Thirty-two different definitions of pancreatic fistulae were found in 43 articles; only 24 articles defined fistulae according to all three parameters examined in this study. The data trends suggest that fistula, morbidity, and mortality rates have remained relatively stable since 1980. Further, drainage volumes, amylase levels, and length of drainage do not appear to correlate with reported morbidity or mortality rates.

Conclusions

This study suggests that pancreatic fistulae may not correlate with morbidity and mortality. Further, the parameters historically used to define fistulae do not appear to correlate with morbidity and mortality. A different system is needed to identify this outcome and determine its clinical significance.

     

A new diagnostic approach to pancreatic pseudocyst fine-needle puncture: three-dimensional sonography

Background/Purpose

We evaluated the usefulness of three-dimensional (3D) sonography in percutaneous fine-needle pancreatic pseudocyst puncture.

Methods

We examined 52 patients diagnosed as having pancreatic pseudocysts on the basis of clinical symptoms and two-dimensional (2D) ultrasonography findings. The decision to qualify certain patients for percutaneous fine-needle aspiration guided by ultrasonography was made on the basis of 2D and 3D scan results. Spiral computed tomography was done when the presence of connections between pseudocyst and pancreatic duct was suspected. In these cases diagnosis was confirmed in operative procedures. 3D sonography was used to monitor the tip of the needle making its way to the pancreatic pseudocyst and later inside the fluid collection.

Results

Pancreatic pseudocysts were diagnosed in all 52 cases; 48 patients underwent percutaneous fine-needle biopsies.

Conclusions

3D presentation can better visualize irregular shapes, local thickenings, and calcification of pseudocyst walls than classical 2D ultrasound scans. The use of subtraction in 3D scans of blood vessels increases the safety in performing biopsies. We have shown that 3D sonography collects extremely useful information about the status of the pseudocyst structure, and it should become a complementary method to classical ultrasonography. This technique when used on a routine basis should help us change the inclusion criteria for guided biopsies.