Diagnosis and treatment of pancreatic pseudocysts in chronic pancreatitis

The minimally invasive approach to surgical management of pancreatic diseases

Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Pancreatic Cystic Lesions of Nonmucinous Type

Cystic lesions of nonmucinous type can arise within the pancreas or can develop from adjacent structures and appear to involve the pancreas. In addition, some typically solid masses can become cystic or can present as cystic lesions. Nonmucinous cysts can be neoplastic, inflammatory, reactive, or congenital. The vast majority of neoplastic nonmucinous cysts are benign. Because of the difficulty in determining the neoplastic potential of a pancreatic cyst preoperatively, many non-neoplastic cysts are resected. This article reviews the surgical pathology of nonmucinous cysts.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

Endoscopic transmural drainage of pseudocysts associated with pancreatic resections or pancreatitis: a comparative study

BACKGROUND

Endoscopy has been regarded as an effective modality for draining pancreatic collections, pseudocysts, and abscesses. This study analyzes our experience with endoscopic transmural drainage of pancreatic pseudocysts and compares the outcomes in patients with postsurgical and pancreatitis-associated ones.

METHODS

Patients who underwent endoscopic drainage of a pancreatic pseudocyst from January 1999 through June 2008 were included in this retrospective analysis. The specific indication for attempting the procedure was the presence of direct contact between the pseudocyst and the gastric wall. All the drainages were carried out via a transgastric approach, and one or two straight plastic stents (10 or 11.5 French) were positioned. A comparative analysis of short- and long-term results was made between patients with postoperative pseudocysts (group A) and patients with pancreatitis-associated pseudocysts (group B).

RESULTS

Fifty-five patients were included in the study, 25 in group A and 30 in group B. Overall, a single stent was inserted in 84.0% of patients, while two stents were needed in the remaining 16.0%. The technical success rate was 78.2%, whereas procedure-related complications were 16.4%. Complications included pseudocyst superinfection and major bleeding and were managed mainly by surgery. Mortality rate was 1.8% (1 patient). There were no significant differences in the technical success rate and procedure-related complications between the two groups (p=0.532 and 0.159, respectively) Recurrences were 13.9% and significantly more common in group B (p=0.021). In such cases, a second endoscopic drainage was successfully performed.

CONCLUSION

Transmural endoscopic treatment of pancreatic pseudocysts is feasible and has a technical success rate of 78.2%, without differences related to the pseudocyst etiology. Recurrences, on the other hand, are more common in patients with pancreatitis. Given the severe complications that may occur after the procedure, we recommend that endoscopic drainage be performed in a tertiary-care center with specific expertise in pancreatic surgery.

Endoscopic ultrasound in chronic pancreatitis: where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.

Pseudocyst management: endoscopic drainage and other emerging techniques

Pseudocyst formation is a well known complication of pancreatitis. Not all pancreatic pseudocysts require intervention. Selected patients who are asymptomatic can be subject to expectant management. Spontaneous resolution has been shown to occur in 40% to 50% of patients with no serious complications occurring during the observation period. Intervention is warranted if the patient is symptomatic, there is a progressive increase in size or if the pseudocyst is infected. Surgery was the only available treatment for pseudocysts for a long time. Of late other modalities like percutaneous, endoscopic, and laparoscopic drainage have come to be seen as viable alternatives.

Chronic pancreatitis in Chinese children: etiology, clinical presentation and imaging diagnosis

BACKGROUND AND AIMS

There is a paucity of literature regarding the clinical profile of chronic pancreatitis (CP) in children. The aims of this retrospective study were to determine the etiology and clinical presentation, and to present our experience in diagnosing CP in children in China.

METHODS

Clinical data of children who were treated for CP at Changhai Hospital from January 1997 to August 2006 were reviewed.

RESULTS

A total of 427 CP patients presented to our center. There were 42 (9.8%) children with CP, including 21 males and 21 females, with a mean age of 11.7 years at the first onset. The main etiological factor was idiopathic (73.8%). Of the patients, 78.5% had episodes of mild to moderate abdominal pain and 54.8% had multiple (> or = 4) episodes. The mean duration of symptoms prior to the diagnosis was 41.6 months and a definite diagnosis was not made until 2 years later in 57.1% of these patients. The positive rates of ultrasound (US), computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) (or magnetic resonance imaging [MRI]) for detecting ductal changes and intraductal stones or pancreatic calcification were 51.4% and 45.4%, 71.4% and 87.5%, 80.0% and 61.5%, respectively.

CONCLUSION

The main etiological factor of Chinese children with CP is idiopathic. The main symptom in these patients is multiple episodes of mild to moderate abdominal pain, which often lead to a delay in the definite diagnosis. CT and MRCP (or MRI) should be used as the first investigation in the evaluation of these cases.

Interventional endoscopic ultrasound: the next frontier in gastrointestinal endoscopy

Endoscopic ultrasound (EUS) has become well established as a diagnostic modality in gastrointestinal cancer staging. It offers high-resolution imaging and fine-needle biopsy, which is essential in tumor and nodal staging of gastrointestinal cancers. In the recent decade, however, many therapeutic applications of EUS have become possible. Currently, interventional EUS endoscopy involves celiac plexus neurolysis, pseudocyst drainage, and intratumoral fine-needle injection therapy for inoperable pancreatic malignancy. Emerging techniques include the accurate endoscopic delivery of radioactive beads to localize tumor therapy as well as other therapies, such as radiofrequency ablation or cryotherapy. Diagnostic and therapeutic access to the biliary tree and pancreatic duct is increasingly being used successfully in failed endoscopic retrograde cholangiopancreatography (ERCP) procedures. This review discusses these procedures and several evolving future applications, including vascular access and EUS-guided enteral anastomosis.

An Unusual Case of Colon Perforation Complicating Acute Pancreatitis

Colonic complications of severe acute pancreatitis occur rarely. Although there have been several theories on how pancreatic pseudocysts rupture into the colon, the exact pathogenesis remains unknown. We report an unusual case of pseudocysts complicating severe acute pancreatitis presenting with colonic perforation in a 71-year-old man with a history of chronic mesenteric ischemia. Pressure effects from a giant pseudocyst and intravascular volume depletion with acute insult on chronic mesenteric ischemia are highlighted as possible etiologic factors.