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.     

Case report. Laparoscopic pancreatic cystogastrostomy

Summary

Definitive management of pancreatic pseudocysts has traditionally involved surgical drainage via laparotomy. Minimally invasive percutaneous and endoscopic techniques for pseudocyst treatment have recently been described. The advantages of minimally invasive surgical techniques have led to the identification of new therapeutic applications of laparoscopy. We describe the technique we used to perform laparoscopic pancreatic cystogastrostomy. Although long-term predictions of morbidity, mortality and recurrence rates cannot be made based on a single case report, a laparoscopic approach to pancreatic pseudocyst is possible and may become an attractive treatment option.     

A case of laparoscopic cystogastrostomy for the pancreatic abscess

BACKGROUND: Pancreatic abscess are serious clinical conditions that develop during the course of severe pancreatitis. A variety of treatments in pancreatic abscess have been reported, such as conventional open surgery, percutaneous drainage, and endoscopic cystogastrostomy. However, these forms of intervention are associated with considerable morbidity and adverse effects. A less invasive and more effective method is likely to be desired. METHOD: With the clinical application of laparoscopic ultrasound and the development of laparoscopic skills has made laparoscopic cystogastrostomy as a preferred treatment for pancreatic abscess. We report a 49-year-old male patient suffering from pancreatic abscess was managed successfully by laparoscopic cystogastrostomy. RESULTS: The patient recovered well after operation and was asymptomatic on a follow-up of six months with no recurrence on ultrasonography. CONCLUSIONS: Due to the vicinity with the stomach, laparoscopic cystogastrostomy is an acceptable procedure for the treatment of pancreatic abscess. On the one hand, this approach is sufficient to eradicate infection; on the other hand, this minimally invasive technique reduces hospital stay and the patient recovery rapidly.     

Surgical Management of Life Threatening Bleeding after Endoscopic Cystogastrostomy

ABSTRACT

Postprocedural bleeding is a rare but life threatening complication of endoscopic cystogastrostomy which may require surgical management in some patients. The presence of adhesions and inflammation due to antecedent acute pancreatitis, difficult location of the bleeding site and breach in the posterior wall of stomach pose significant challenges during the surgical management. Here we have described the surgical approach and technique that we used to manage three patients who required surgery for life threatening bleeding after endoscopic cystogastrostomy.     

PERCUTANEOUS CYSTOGASTROSTOMY FOR TREATMENT OF PANCREATIC PSEUDOCYSTS

Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections and two related to catheter blockage. Percutaneous cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2–17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.     

胰腺巨大假性囊肿超声内镜引导下胃内支架引流1例报告——附文献复习

为探讨胰腺假性囊肿内镜治疗的操作技术和临床疗效，在超声内镜引导下对1例巨大胰腺假性囊肿行超声内镜引导下经胃壁穿刺置管引流。术后当天患者症状缓解，1周后囊肿缩小50%，随访6个月，囊肿消失无复发，未发生出血、穿孔等并发症。超声内镜引导下囊肿胃置管引流术安全、可靠，并发症少，是一种有效的微创介入治疗方法。     

Endoscopic-ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts and abscesses

Objective. Surgery is the traditional treatment for symptomatic pancreatic pseudocysts and abscesses, but morbidity and mortality are still too high. Minimally invasive approaches have been encouraged. The aim of this study was to evaluate the results of the endoscopic-ultrasound-guided (EUS) endoscopic transmural drainage of these pancreatic collections. Material and methods. In this retrospective review of consecutive cases from a single referral centre, cystogastrostomy and cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control by the endoscopic insertion of straight or double pigtail stents. Results. Fifty-one symptomatic patients (33 men; mean age 58 years) were submitted to 62 procedures from January 2003 to December 2005. EUS-guided drainage was successful in 48 (94%) patients. Only three patients needed surgery. There were two procedure-related complications managed clinically. During a mean follow-up of 39 weeks, recurrence due to migration or obstruction of the stent was 17.7%. All these cases were submitted to a new session of endoscopic drainage. There was no mortality. Complications were more frequent in patients with a recent episode of acute pancreatitis (38.5% versus 10%; p=0.083). The endoscopic approach was not more hazardous for abscesses in regard to complications rate (19% versus 16.6%; p>0.05). In abscesses, a nasocystic drain did not decrease the complications rate (27% versus 13%; p=0.619), but the placement of 2 stents did decrease this rate (18% versus 20%; p>0.05), although increased it in pseudocysts (40% versus 13%; p=0.185). Conclusions. Endoscopic transmural drainage is a minimally invasive, effective and safe approach in the management of pancreatic pseudocysts and abscesses.     

Late massive hemorrhage following cystogastrostomy for pancreatic pseudocyst: Report of a case

We report the case of a man who developed life-threatening massive gastric hemorrhage 3 months after undergoing cystogastrostomy for a pancreatic pseudocyst. After cystogastrostomy, the pancreatic pseudocyst became remarkably reduced in size, having the appearance of a shallow ulcer by barium study. However, tarry stools and hematemesis developed 3 months later, 6 days after which sudden massive hematemesis and melena occurred with severe hypotension. At emergency operation, a large artery at the bottom of the reduced cyst wall was found to have ruptured and hemostasis was achieved by suture ligation. The splenic artery was suspected as the bleeding point because a 95% abrupt stenosis was seen on angiography-performed the next day. Thus, the risk of hemorrhage occurring after internal drainage of a pancreatic pseudocyst even in the late postoperative period should always be borne in mind.