The natural and unnatural history of pancreatic pseudocysts

Pancreatic pseudocyst: The past, the present, and the future

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.

Pancreatic pseudocyst with fistula to the dilated common bile duct: Mimmicking choledocal cyst?

We present a rare case of a fistula between a pancreatic pseudocyst and the bile duct with saccular dilatation that appeared to be a type I choledocal cyst. There are only 19 described cases in the consulted bibliography. The patient was studied with an ultrasound, CT and MRCP and later surgically intervened. A resection was performed of the extrahepatic biliary and hepaticojejunostomy. There was a subsequent good evolution.

Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management

Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.

Treatment strategies for bleeding from gastroduodenal artery pseudoaneurysms complicating the course of chronic pancreatitis-A case series of 10 patients

We analyzed our experience with management of gastroduodenal artery (GDA) pseudoaneurysms associated with chronic pancreatitis using a multidisciplinary approach. We treated 10 patients with GDA pseudoaneurysms (all men, aged 24-62 year) who underwent treatment during April 1998 to December 2016. All had presented with recent hematemesis and/or melena. Hemodynamically, stable patients were initially subjected to transcatheter embolization or radiologically guided thrombin injection. Recurrence of bleeding within 48 h was taken as failure. Emergency surgery was done for hemodynamic instability and recurrent bleeding, and elective surgery was carried out as per specific indications. Ten interventional procedures were performed in nine patients, while one was directly subjected to surgery. Angioembolization was done in five patients (with success in four) and thrombin injection in five patients (including one with embolization failure; with success in three). Six patients underwent surgery, two on emergency basis, for hemodynamic instability and recurrent bleeding in one each, and four for definitive treatment of pancreatitis/associated complication. One patient died while the other nine survived and well with no recurrence of bleeding during follow up (6 months to 10 years). Management of GDA pseudoaneurysms requires a multidisciplinary approach. Pseudoaneurysms with narrow neck are suitable for thrombin injection while those with wide neck should be subjected to angioembolization. Emergency surgical treatment is reserved for non-surgical failures, and choice between trans-ductal or trans-cystic approach is based on the location of the aneurysm.

Effect of endoscopic failure on the results of internal surgical drainage in pancreatic pseudocyst

BACKGROUND

The treatment of pancreatic pseudocysts has evolved during the past two decades. Endoscopic treatment (ET) has gradually become used as a first-line management even though it showed no significant superiority to surgical internal drainages (SIDs) in a recent randomized trial. The objective of the present work was to analyze the effect of ET failure on the results of SID in the global management of pancreatic pseudocysts.

METHODS

A multicenter retrospective study (Clichy, Bordeaux, Nantes, and Rennes) was conducted between January 2000 and December 2012. The main criteria were as follows: (i) major postoperative complications (MPCs) (Clavien ≥ 3) and (ii) treatment failure in the first 12 mo. All factors that may affect these two parameters were tested in univariate and multivariate analyses, when necessary.

RESULTS

One hundred nineteen patients, with a median age of 52 y (22-83) underwent SID, including 45 procedures (37.8%) performed after ET failure. Mortality and overall morbidity rates were 1.7% and 30.2%, respectively. Eighteen patients (15.1%) presented an MPC. Multivariate analysis revealed that failure of ET (odds ratio 3.04, confidence interval [1.04 to 9.5], P = 0.046) and BMI ≤20 (odds ratio 4.5, confidence interval [1.50; 15.5], P = 0.010) were independent risk factors of MPCs. The success of SID was 92.5% in the first year. In univariate analysis, the occurrence of an MPC was the only factor linked to the failure of SID (P = 0.029).

CONCLUSIONS

Performing an SID after ET failure is associated with an increased risk of MPC. Close postoperative monitoring is recommended for these patients.

Prevalence and outcomes of cystic lesions of the transplant pancreas: The University of Wisconsin Experience

Literature on the behavior of cystic lesions in pancreas transplants is scarce, and hence a better understanding is warranted. Data on recipients and their respective donors that underwent simultaneous kidney and pancreas, pancreas transplant alone, and pancreas after kidney between 1994 and 2015 were reviewed (n = 1185). Cystic lesions of the transplant pancreas developed in 22 patients (1.8%): 12 pseudocysts, 2 cysts/remnants, 4 intraductal papillary mucinous neoplasms (IPMN), 2 adenocarcinomas, 1 low-grade intraepithelial pancreatic neoplasia, and 1 case of polycystic kidney disease. The median size was 3.6 cm (1.6-5.5 cm), and occurred at a median time of 65.5 months (2-183 months) posttransplant. The median age of the graft at time of diagnosis was 42 years (25.7-54.5), with 17 of 22 grafts (77%) functioning at time of diagnosis. Triggers for investigation were elevations in pancreatic enzymes, re-admissions for abdominal pain, and incidentalomas. High-resolution imaging and diagnostic biopsy/aspiration with ancillary tests were the main diagnostic tests. Most pseudocysts were managed by percutaneous drainage, and although no firm inference can be made from such a small series, we have observed that the behavior and management of IPMN and adenocarcinoma in the pancreas graft appears congruent to that of the native pancreas.

Percutaneous Puncture and Drainage of Pancreatic Pseudocysts; a Retrospective Study

Experience with 19 consecutive patients who had 20 pancreatic pseudocysts treated by percutaneous puncture and/or drainage was reviewed. Ten pseudocysts (5 infected, 5 non-infected), underwent complete resolution after percutaneous treatment only and there was a considerable regression in 6 (5 infected, 1 non-infected), which means an overall cure rate of 80 per cent. Only one small pseudocyst remained unchanged. Complementary surgery was necessary in 3 cases. Fine needle evacuation was the method in 13 cases (11 cured) and catheter drainage in 7 (5 cured). We conclude that percutaneous drainage is a safe method for the treatment of pancreatic pseudocysts, that will cure the patient in most cases.

Classification and Management of Pancreatic Pseudocysts

This article aims to elucidate the classification of and optimal treatment for pancreatic pseudocysts. Various approaches, including endoscopic drainage, percutaneous drainage, and open surgery, have been employed for the management of pancreatic pseudocysts. However, no scientific classification of pancreatic pseudocysts has been devised, which could assist in the selection of optimal therapy. We evaluated the treatment modalities used in 893 patients diagnosed with pancreatic pseudocysts according to the revision of the Atlanta classification in our department between 2001 and 2010. All the pancreatic pseudocysts have course of disease >4 weeks and have mature cysts wall detected by computed tomography or transabdominal ultrasonography. Endoscopic drainage, percutaneous drainage, or open surgery was selected on the basis of the pseudocyst characteristics. Clinical data and patient outcomes were reviewed. Among the 893 patients, 13 (1.5%) had percutaneous drainage. Eighty-three (9%) had type I pancreatic pseudocysts and were treated with observation. Ten patients (1%) had type II pseudocysts and underwent the Whipple procedure or resection of the pancreatic body and tail. Forty-six patients (5.2%) had type III pseudocysts: 44 (4.9%) underwent surgical internal drainage and 2 (0.2%) underwent endoscopic drainage. Five hundred six patients (56.7%) had type IV pseudocysts: 297 (33.3%) underwent surgical internal drainage and 209 (23.4%) underwent endoscopic drainage. Finally, 235 patients (26.3%) had type V pseudocysts: 36 (4%) underwent distal pancreatectomy or splenectomy and 199 (22.3%) underwent endoscopic drainage. A new classification system was devised, based on the size, anatomical location, and clinical manifestations of the pancreatic pseudocyst along with the relationship between the pseudocyst and the pancreatic duct. Different therapeutic strategies could be considered based on this classification. When clinically feasible, endoscopic drainage should be considered the optimal management strategy for pancreatic pseudocysts.

Black pleural effusion

BACKGROUND

Black pleural effusions are extremely rare and have been reported in patients with infection, malignancy, and hemorrhage. However, no review articles appear to have focused on this rare clinical presentation.

PURPOSE

To classify and characterize diseases causing "black pleural effusion" based on the pathophysiological mechanisms involved.

METHODS

We searched the medical literature to find reports of "black pleural effusion" using the PubMed database.

RESULTS

We identified 8 cases and classified the underlying diseases into the following 4 entities based on pathophysiological conditions: 1) infection (Aspergillus niger and Rhizopus oryzae); 2) malignant melanoma, in which cells contain melanin pigment; 3) hemorrhage and hemolysis associated with non-small cell lung cancer or rupture of a pancreatic pseudocyst; and 4) other causes (charcoal-containing empyema). Discrimination between biliopleural fistula and pancreatico-pleural fistula, which also mimicking in color, was easily achieved by focusing on pleural amylase levels, elevation of pleural indirect bilirubin, presence of pleural glycoholic acid, and the predominant site of pleural effusion.

CONCLUSION

Black pleural effusions can be divided into 4 major categories based on the underlying pathophysiological conditions.

Acute pancreatic pseudocyst: incidence, risk factors, and clinical outcomes

OBJECTIVES

The aim of this study was to analyze the incidence, risk factors, and clinical outcomes of pancreatic pseudocyst after acute or acute-on-chronic pancreatitis.

METHODS

We retrospectively reviewed the medical records of 350 patients with acute pancreatitis and 55 patients with acute-on-chronic pancreatitis.

RESULTS

Pancreatic pseudocyst developed in 14.6% of acute pancreatitis and in 41.8% of acute-on-chronic pancreatitis (P = 0.00). In the acute-on-chronic pancreatitis group, interval from symptom onset to hospital visit was longer, and the incidence of recurrent pancreatitis and alcoholic etiology was higher than that of the acute pancreatitis group (P < 0.01). There was no significant difference in the spontaneous resolution rate between both groups. Of the total 68 conservatively treated patients with pseudocyst, the pseudocyst decreased in size or disappeared in 77.9% and showed no change in 1.5%. The risk factors of pseudocyst were the presence of underlying chronic pancreatitis, the interval from symptom onset to visiting the hospital, and an alcoholic etiology. The factor-predicted spontaneous resolution was a single lesion.

CONCLUSIONS

Pseudocyst developed more frequently in patients with acute-on-chronic pancreatitis, and most pseudocysts improved spontaneously irrespective of underlying chronic pancreatitis. A longer period of a "wait-and-see" policy for more than 6 weeks is suggested for asymptomatic pseudocyst, especially for a single lesion.

Splenic artery pseudoaneurysm as a complication of pancreatic pseudocyst

INTRODUCTION

Pancreatic pseudocyst presented as pseudoaneurysm of the splenic artery is a potential serious complication in patients with chronic pancreatitis.

CASE REPORT

A 42-year-old male patient with a long-standing evolution of chronic pancreatitis and 8-year long evolution of pancreas pseudocyst was referred to the Military Medical Academy, Belgrade due to worsening of the general condition. At admission, the patient was cachectic, febrile, and had the increased values of amylases in urine and sedimentation (SE). After clinical and diagnostic examination: laboratory assessment, esophagogastroduodenoscopy (EGDS), ultrasonography (US), endoscopic ultrasonography (EUS), multislice computed scanner (MSCT) angiography, pseudoaneurysm was found caused by the conversion of pseudocyst on the basis of chronic pancreatitis. The patient was operated on after founding pancreatic pseudocyst, which caused erosion of the splenic artery and their mutual communication. Postoperative course was duly preceded without complications with one year follow-up.

CONCLUSION

Angiography is the most reliable and the safest method for diagnosing hemorrhagic pseudocysts when they clinically present as pseudoaneurysms. A potentially dangerous complication in the presented case was treated surgically with excellent postoperative results.

Pancreatic pseudocyst with pancreatolithiasis and intracystic hemorrhage treated with distal pancreatectomy: a case report

Introduction

Hemorrhage from pancreatic pseudocyst is one of the serious complications of chronic pancreatitis. We experienced intracystic hemorrhage from a huge pancreatic pseudocyst and successfully treated it with distal pancreatectomy.

Case presentation

A 65-year-old-man with a history of alcohol abuse was admitted to our hospital for abdominal pain and was diagnosed as having chronic pancreatitis with pancreatolithiasis and pseudocyst in the pancreatic tail. The pancreatic pseudocyst increased in size gradually for 4 month observation period. For intracystic hemorrhage we performed an urgent distal pancreatectomy with splenectomy. Postoperative course was good and the elevated serum amylase level decreased to the normal range.

Conclusion

Prolonged observation resulted in intracystic hemorrhage. Drainage or surgery in adequate time is important for the management of pancreatic pseudocysts to prevent complications.

Pancreatic pseudocyst with fistula to the common bile duct resolved by combined biliary and pancreatic stenting--a case report and literature review

Pancreatic pseudocysts develop in 10% to 20% of patients with chronic pancreatitis, and can cause a variety of complications such as infection, bleeding or development of fistulae. However, fistulous communication with the common bile duct is very rare. The present report describes an unusual case of a patient with a large, symptomatic pancreatic pseudocyst with a fistula to the common bile duct that was treated successfully by combined biliary and pancreatic stenting.

Pancreaticobiliary fistula evident after ESWL treatment of pancreatolithiasis

Here we report a patient with a pancreaticobiliary fistula that was possibly associated with pancreatolithiasis. He was admitted due to mild pancreatitis. Pancreatolithiasis was revealed in the parenchyma of the head region and in the main pancreatic duct of the pancreas body with distal dilatation. Extracorporeal shock wave lithotripsy (ESWL) effectively eliminated the pancreatic stones; however, an apparent internal fistula from the middle portion of the common bile duct (CBD) to the main pancreatic duct was revealed where the parenchymal stones had been located. The patient was considered to be in the same condition as pancreato-biliary malunion without CBD dilatation, and was treated with laparoscopic cholecystectomy.

Biliopancreatic fistula with portal vein thrombosis caused by a pancreatic pseudocyst

We encountered a very rare case of biliopancreatic fistula with portal vein thrombosis caused by pancreatic pseudocyst. A 57-year-old man was referred to our hospital because of abdominal pain, obstructive jaundice, and portal vein thrombosis due to acute pancreatitis. Computed tomography showed a 7-cm-diameter pseudocyst around the superior mesenteric vein extending towards the pancreatic head, dilatation of the intrahepatic bile duct, and portal vein thrombosis. Endoscopic retrograde pancreatography revealed a main pancreatic duct with a pseudocyst communicating with the common bile duct. After pancreatic sphincterotomy, a 7-F tube stent was endoscopically placed into the pseudocyst. However, a 6-F nasobiliary tube could not be inserted into the bile duct because the fistula had a tight stenosis. Subsequently, the patient's abdominal pain improved, the pancreatic cyst disappeared, and the serum amylase level normalized. Two months after the endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage was required because the patient's jaundice became aggravated. Two weeks after the choledochojejunostomy, the patient left the hospital in good condition. A follow-up computed tomography showed cavernous transformation of the portal vein and no pancreatic pseudocyst. The patient remains asymptomatic for 2 years and 7 months after surgery. Biliary drainage may be necessary for biliopancreatic fistula with obstructive jaundice in addition to pancreatic cyst drainage. Biliopancreatic fistula can be treated by endoscopic procedure in some cases; however, surgical treatment should be required in cases that are impossible to insert a biliary stent because of hard stricture.

MDCT of acute mild (nonnecrotizing) pancreatitis: abdominal complications and fate of fluid collections

OBJECTIVE

The objective of our study was to describe the occurrence of local complications and the fate of fluid collections in milder forms of acute nonnecrotizing pancreatitis.

MATERIALS AND METHODS

Initial MDCT studies of 169 consecutive patients with mild acute pancreatitis and 203 follow-up CT examinations were reviewed. The fate of peripancreatic fluid collections was investigated, and the incidence and type of local complications were recorded and correlated to the CT grading system (A-E).

RESULTS

Complications developed in nine of 169 patients, for an incidence of 5.3%. All morbidity occurred in the subgroup of 73 patients with initial fluid collections, for an incidence of 12.3%. Follow-up CT examinations available in 51 of these 73 patients documented rapid fluid resolution in 35 cases (68.6%) and persistence of fluid more than 2 weeks from onset in seven asymptomatic patients (13.7%). Acute, life-threatening complications (hemorrhage, infection, perforation) occurred in five patients, for an incidence of 6.8% among the 73 patients with initial fluid collections, or 3.0% in the entire group of 169 patients. Five patients developed acute pseudocysts. Long-term follow-up studies discovered two patients with chronic pancreatitis and one with groove pancreatitis.

CONCLUSION

A small number of acute, life-threatening abdominal complications and chronic complications are expected to occur in patients with milder forms of acute nonnecrotizing pancreatitis presenting with fluid collections. In these patients, clinical monitoring and repeated imaging studies are recommended to document the resolution of fluid or the development of complications.

Diagnosis and treatment of pancreatic pseudocysts in chronic pancreatitis

Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Diagnosis is accomplished most often by computed tomographic scanning, by endoscopic retrograde cholangiopancreatography, or by ultrasound, and a rapid progress in the improvement of diagnostic tools enables detection with high sensitivity and specificity. Different strategies contribute to the treatment of pancreatic pseudocysts: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means. This review entails publications referring to the classification of pancreatic pseudocysts, epidemiology, diagnostic tools, and therapeutic options for pancreatic pseudocysts. Only full articles were considered for the review. Based on a search in PubMed, the MeSH terms "pancreatic pseudocysts and classification," "diagnosis," and "endoscopic, percutaneous, and surgical treatment" were used either alone or in combination.

Two cases of pancreatic abscess associated with penetration to the gastrointestinal tract during treatment using endoscopic ultrasound-guided drainage

Of pancreatic pseudocysts, approximately 30% are complicated by abscess formation, perforation into the abdominal cavity, penetration to the gastrointestinal tract, or bleeding. We report two cases of pancreatic abscess complicating severe acute pancreatitis in which the abscess penetrated to the gastrointestinal tract during the course of treatment with endoscopic ultrasound (EUS)-guided pseudocyst drainage. In these cases, neither aggravation nor recurrence of the pancreatic abscess has been identified since the event occurred. The EUS-guided treatment was effective for improvement of severe inflammation of the pseudocyst as an initial treatment. However, drainage tube placement limitations pertained because the pseudocyst was present with multilocular infection. Penetrations eventually contributed to their resolution because the fistulas were used as wide drainage routes. It is important to understand the courses of these cases for preparation of therapeutic strategies to treat pancreatic pseudocyst/abscess.

Endovascular treatment of arterial bleeding in patients with pancreatitis

PURPOSE

To assess the technical and clinical success of endovascular treatment of arterial bleeding in pancreatitis.

MATERIALS AND METHODS

From 1992 to 2005, 28 patients with pancreatitis underwent endovascular treatment of associated arterial lesions. Fifteen patients were affected by acute pancreatitis and 13 by chronic pancreatitis. The diagnosis was obtained according to medical history and clinical and laboratory evidence of disease. Arterial involvement was diagnosed by non-invasive imaging and angiography. After treatment, all patients underwent CT scanning at a minimum of 15, 30 and 90 days. We evaluated the feasibility of embolization and patients' survival at 90 days.

RESULTS

Transcatheter embolization was feasible in 26/28 patients (93%). In 2 patients with acute pancreatitis, selective catheterization failed so we could not proceed with the angiographic approach. After treatment, there were 3/26 rebleeds (11.5%), all of whom died within the first week. At 90 days' follow-up, 21/26 patients (81%) were alive. Two of 26 patients (8%) suffered splenic complications. Among the 13 patients with acute pancreatitis, 8 (61.5%) were alive after 90 days. All 13 patients with chronic pancreatitis were alive after 90 days.

CONCLUSIONS

Comparing our results with the surgical literature, we found that embolization is less invasive and, at least, as successful as surgery. Thus, it should be considered the first choice in pancreatitis arterial complications.

Endoscopic ultrasonography-guided cystogastrostomy for large pancreatic pseudocyst with obstructive jaundice--a case report

The patient was a 45-year-old man with a history of heavy drinking. A pseudocyst about 30 mm in diameter was found in the head of his pancreas. About four weeks later an upper abdominal mass, abdominal pain and obstructive jaundice were confirmed. Abdominal CT revealed that the cyst had increased in size to about 60 mm, compressing the lower common bile duct and the surrounding digestive tract. Therefore endoscopic ultrasonography-guided cystogastrostomy following percutaneous transhepatic biliary drainage (PTBD) was performed. Postoperatively, the cyst quickly decreased in size and jaundice improved. Because of persistent common bile duct stenosis, an endoscopic retrograde biliary stent was implanted. There has been no recurrence at ten months after the endoscopic therapy. While invasive surgery is generally employed in the treatment of pancreatic pseudocyst complicated by obstructive jaundice, EUS-guided cystogastrostomy appears to be a useful procedure, particularly when considering the relatively minor degree of surgical invasion.

Combined percutaneous thrombin injection and endovascular treatment of gastroduodenal artery pseudoaneurysm (PAGD): case report

A 69-year-old man with a history of acute pancreatitis developed a huge pseudoaneurysm of the gastroduodenal artery (PAGD), as diagnosed by CT scan. The PAGD was treated by percutaneous thrombin injection (2,000 IU) under ultrasound guidance and selective embolization of gastroduodenal artery with microcoils with its complete exclusion. The 6-month follow-up confirmed the complete exclusion of the PAGD sac.

Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications

PURPOSE

To describe a 10-year experience of endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis, and to analyze this experience and propose a classification based on computed tomography (CT) and angiographic findings that has therapeutic implications. This may reduce the rate of recurrent bleeding after surgery or endovascular treatment.

MATERIALS AND METHODS

Twenty-three patients with aneurysms or pseudoaneurysms associated with acute pancreatitis were treated by endovascular or percutaneous methods. All underwent CT and angiography. The early development of a simple classification based on the CT and angiographic findings was used to guide treatment decisions. In accordance with this classification, 19 patients were treated by primary coil embolization and four were treated by primary percutaneous thrombin injection.

RESULTS

Among the 19 patients treated by primary coil embolization, there were two early recurrences of the pseudoaneurysm. All four patients treated by percutaneous thrombin injection exhibited late recurrences and were successfully treated by percutaneous thrombin injections. Twenty-one patients (91.3%) were alive at 6 months.

CONCLUSIONS

Endovascular and percutaneous treatment of aneurysms and pseudoaneurysms complicating pancreatitis is safe and effective and is associated with good outcomes, but careful follow-up is necessary. The decision of which treatment option is most appropriate can be made in accordance with a classification based on CT and angiographic appearance.

Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone

OBJECTIVE

Endoscopic drainage of a single pseudocyst is a well-known treatment modality. Its role in the management of multiple pseudocysts is not well established. We evaluated the role of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of multiple and large pseudocysts.

METHODS

Over 3 yr (2001-2004), endoscopic transpapillary NPD placement was attempted in 11 patients (age range 12-50 yr, 10 men) with symptomatic communicating multiple pseudocysts of pancreas (three in two and two in nine cases). A 5Fr/7Fr NPD was placed across the most distal duct disruption or into one of the pseudocysts.

RESULTS

Eight patients had an underlying chronic pancreatitis and three patients had pseudocysts as sequelae of acute pancreatitis. The size of pseudocysts ranged from 2 to 14 cm (mean 7.5 cm). Eight patients (72.7%) had at least one pseudocyst more than 6 cm in size. Nine patients had a partial disruption and two patients had complete disruption of the pancreatic duct. The NPD was successfully placed in 10 of 11 (90.9%) patients. Postprocedure acute febrile illness in one patient was the only complication noted, which responded to intravenous antibiotics. All pseudocysts resolved in 4-8 wk in 7 of 7 patients with successful bridging of the most distal ductal disruption. There was no recurrence of the pseudocysts in a mean follow-up of 19.4 months. Two patients, in whom there was a complete disruption and the NPD could not bridge the disruption, required surgery for the nonresolution of pseudocysts. In one patient with partial ductal disruption that could not be bridged, there was complete resolution of one pseudocyst and a decrease in the size of the other pseudocyst from 12 to 4 cm. The NPD was replaced by a stent and both the pseudocysts resolved in 20 wk.

CONCLUSION

Endoscopic transpapillary NPD placement is a safe and effective modality for the treatment of multiple and large pseudocysts, especially when there is partial ductal disruption, and the disruption can be bridged.

Sonographic diagnosis and endoscopic therapy of a biliopancreatic fistula complicating a pancreatic pseudocyst

This is the first report of a case of biliopancreatic fistula complicating a pancreatic pseudocyst diagnosed correctly by transabdominal ultrasound. The diagnosis was confirmed by magnetic resonance and endoscopic retrograde cholangiopancreatography. The fistula was treated successfully with biliary stenting. The clinical and imaging features of this exceptional complication are presented along with a brief review of the topic.

Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage

BACKGROUND

Pancreatic pseudocyst bleeding is an unusual entity of acute abdomen, usually occurring among alcoholics. A high mortality developed in patients with conservative treatment of hemorrhagic pancreatic pseudocyst. We report a 37-year-old male with a pseudoaneurysm in the tail of the pancreas presenting with sudden onset of abdominal pain and swelling. Emergency laparotomy after blood transfusion and fluid resuscitation was successfully performed.

METHODS

An abdominal radiography showed multiple calcifications in the epigastric area. Computed tomography of the abdomen showed a cystic lesion with a calcified wall in the tail of the pancreas and a large amount of ascites. After contrast enhancement, there was hemorrhage into the pancreatic pseudocyst with extravasation of contrast into the peritoneal cavity.

RESULTS

At operation, active bleeding was noted from a ruptured pseudocyst in the tail of the pancreas and ligation of the bleeding vessel was done.

CONCLUSIONS

Hemorrhage into the pancreatic pseudocyst associated with intraperitoneal bleeding is a potentially life threatening condition. Emergency surgical treatment should be carried out as soon as possible.

Pancreatic pseudocysts--when and how to treat?

Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Currently several classification systems are in use that are based on the origin of the pseudocyst, their relation to pancreatic duct anatomy and a possible pseudocyst-duct communication. Diagnosis is accomplished most often by CT scanning, by endoscopic retrograde cholangiopancreaticography (ERCP) or by ultrasound, and rapid progress in the improvement of diagnostic tools has enabled detection with high sensitivity and specificity. There are different therapeutic strategies: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means.

Biliary pancreatic portal fistula as a complication of chronic pancreatitis: a case report with review of the literature

In this study we describe an unusual complication in a patient suffering from chronic calcifying pancreatitis. The patient had a fistula between the common bile duct, the pancreatic duct, and the portal vein. He received supportive medical treatment and achieved long-term survival. A review of the literature including diagnosis, treatment and outcome of this rare complication is presented.

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).

Surgical treatment of pancreatic pseudocysts in the 2000's--laparoscopic approach

A pseudocyst presents as a cystic cavity bound to the pancreas by inflammatory tissue. Typically the wall of a pancreatic pseudocyst lacks an epithelial lining, and the cyst contains pancreatic juice or amylase-rich fluid. Today the mostly used definitions make a difference between peripancreatic fluid collections, pseudocysts after acute and chronic pancreatitis and pancreatic abscess as in the Atlanta classification system for acute pancreatitis. Distinction between pseudocyst and acute fluid collection leads to a better understanding of the natural history of peripancreatic fluid collections and facilitates the progress of the treatment of these two separate entities even though they are a part of a continuous pathological process. The presence of a well-defined wall composed of granulation or fibrous tissue is what distinguishes a pseudocyst from an acute fluid collection. A pseudocyst is usually rich in pancreatic enzymes and is most often sterile. Formation of a pseudocyst requires usually 4 or more weeks (many clinicians state six) from the onset of acute pancreatitis. The differentiation in the Atlanta classification between acute and chronic pseudocyst is important, but it invite to confusion. It is important to note that in the classification the terms "acute" and "chronic" refers to the pancreatitis behind the pseudocyst and not to the mode of symptomatology of the pseudocyst itself. This means that an acute pseudocyst may have be known for months, whereas a chronic pseudocyst in the next patient has been documented only a week or two.

Pancreatic Pseudocyst Observed on F-18 FDG PET Imaging

A 72-year-old man with right lower lobe squamous cell carcinoma of the lung-status, post resection-and prostate carcinoma was referred for restaging with whole-body PET using F-18 FDG. PET images, in addition to the presence of moderate hypermetabolic activity seen in the left lower paratracheal and bilateral hilar regions, revealed a large hypometabolic space-occupying lesion in the abdomen. The appearance of this lesion was highly suggestive of a pancreatic pseudocyst. Further review of a CT scan performed 3 years ago confirmed the presence of a pancreatic pseudocyst. However, this information was not available to the nuclear medicine physician at the time of the PET examination.

Complications of acute pancreatitis: clinical and CT evaluation

Mortality of acute pancreatitis is dependent on the development of potentially lethal complications that can coexist and occur at any time following an acute attack. The nature and clinical relevance of these complications differ, contingent on the time of occurrence following a severe episode of pancreatitis. They can be divided into (1), early complications that manifest at the onset or within the first 2 to 3 days, (2) intermediate complications that occur predominantly during the second to fifth week, and (3) late complications that usually manifest months or years following the resolution of an acute attack. Early complications are systemic in nature with diverse clinical manifestations of the cardiovascular, pulmonary, renal, and/or metabolic systems. Intermediate complications are abdominal, pancreatic, and retroperitoneal, and are mostly septic in nature, associated with pancreatic or peripancreatic fat necrosis and pseudocysts. Late, life-threatening complications are mainly vascular or hemorrhagic in nature or involve the development of chronic pancreatic ascites. The early detection and objective evaluation of these complications by clinical and imaging methods leads to specific treatment options in the continuous attempt to decrease mortality rates in acute pancreatitis.

Diagnosis and fine needle aspiration of pancreatic pseudocysts: the role of endoscopic ultrasound

Pseudocysts are localized collections of pancreatic fluid surrounded by nonepithelialized granulation tissue that occur following an insult to the pancreas. High image resolution and the ability sample in real-time by fine needle aspiration permit accurate distinction between various cystic lesions in the pancreas by endoscopic ultrasound (EUS). Other cyst characteristics and background pancreatic changes detectable at EUS assist in the diagnostic process. The use of Doppler flow ultrasound allows diagnosis of important pseudocyst complications such as pseudoaneurysms and varices. Endoscopic approaches to the drainage of symptomatic lesions previously relied on the use of cross-sectional imaging studies such as computed tomography scanning in combination with stent placement using a duodenoscope in the presence of an endoscopically visible cyst bulge. EUS facilitates this process allowing accurate imaging of the lesion prior to stent placement via the echoendoscope and overcomes many of the drawbacks and pitfalls of other endoscopic techniques.

Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging

OBJECTIVE

To analyze and describe the incidence, pathophysiology, radiographic diagnosis and the initial management of hemorrhagic complications associated with pancreatitis.

MATERIAL AND METHODS

Among 1,910 patients diagnosed of having pancreatitis in the last 10 years, 26 developed hemorrhagic complications (1.3%). These complications were detected from 2 months to 8 years after one or several episodes of pancreatitis with a mean of 2.3 years. Radiographic studies were reviewed and clinical management and outcome were recorded.

RESULTS

Ten patients had CT evidence of pancreatic necrosis, 12 patients chronic pancreatitis, and 17 patients pancreatic pseudocysts. The cause of hemorrhage was bleeding pseudoaneurysm in 16 patients (61%), diffuse bleeding with pancreatic necrosis in 5 patients (19.5%) and hemorrhagic pseudocysts in 5 patients (19.5%). Intra-abdominal hemorrhage developed in 21 patients and gastro-intestinal bleeding in 5 patients. Arterial embolization was attempted in 12 patients and was successful in 9 patients (75%). Surgery was used in 16 patients and the overall mortality rate was 11%.

CONCLUSIONS

Hemorrhagic complications are rarely seen and are usually late sequelae of pancreatitis. They develop because of leaking or ruptured pseudoaneurysms, diffuse bleeding in pancreatic necrosis, and hemorrhagic pseudocysts. Early detection followed by angiography, embolization and/or surgery has decreased mortality rates.

Massive pancreatico-pleural effusion--an often unrecognised entity

Massive haemorrhagic pleural effusion secondary to pancreatitis in a five year old girl is described. The diagnosis was established on the basis of an exudative pleural effusion with an amylase level above 4,000 IU/l. Management of effusion was by intercostal tube drainage and antibiotics.

Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis

OBJECTIVE

Erosion of pancreatic pseudocysts into adjacent vessels is a rare but highly lethal cause of intra-abdominal hemorrhage. Percutaneous angiographic embolization (PAE) of the bleeding artery has recently been advocated as the preferred therapy. This study was undertaken to survey the outcome after treatment of this complication and to make recommendations for its management.

METHODS

An 11-year retrospective analysis was performed of all patients treated at a large tertiary care referral center for visceral artery pseudoaneurysms associated with pancreatic pseudocysts.

RESULTS

From 1988 to 1998, 256 patients were admitted for complications of pancreatic pseudocysts. Sixteen patients (11 men and 5 women) were identified in whom a pseudocyst had eroded into a major blood vessel with hemorrhage or development of a false aneurysm. The mean age was 45 years (range, 23-67 years). Active bleeding was present in 13 patients, whereas three had evidence of recent hemorrhage. Ten of 16 patients initially underwent operative therapy, four elective and six emergency, whereas six stable patients were initially treated with PAE. Technical failures of the initial treatment or secondary complications required both therapeutic modalities in six patients, which resulted in 13 total surgical interventions and 10 PAEs. The surgical morbidity rate was 62% (8 of 13), whereas that of PAE was 50% (5 of 10). Three deaths occurred after emergency operations, two of which failed to stop the bleeding, accounting for all of the deaths in the series (3 [19%] of 16). A trend was noted toward increased death with necrotizing pancreatitis (P =.07) and emergency surgery (P =.06). Ranson's criteria were not found to be predictive of death in this series. Surgical drainage procedures were required in seven (44%) of 16 patients for infections (n = 3) or mass effect of the pseudoaneurysm (n = 3). The mean size of pseudoaneurysms that required operative intervention for secondary complications was 13.9 cm, compared with 7.7 cm for all others in the series (P =.046). Long-term follow-up was available in all 13 survivors at a mean of 44 months (range, 1-108 months).

CONCLUSIONS

The management of pancreatic pseudocyst-associated pseudoaneurysms remains a challenging problem with high morbidity and death rates. Operation and PAE play complementary management roles. PAE is recommended as the initial therapy for hemodynamically stable patients. Surgery should be reserved for actively bleeding, hemodynamically unstable patients; for failed embolization; and for other secondary complications such as infection or extrinsic compression.

Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery

Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.

Chronic pancreatitis: complications and management

Chronic pancreatitis is characterized by progressive and irreversible loss of pancreatic exocrine and endocrine function. In the majority of cases, particularly in Western populations, the disease is associated with alcohol abuse. The major complications of chronic pancreatitis include abdominal pain, malabsorption, and diabetes. Of these, pain is the most difficult to treat and is therefore the most frustrating symptom for both the patient and the physician. While analgesics form the cornerstone of pain therapy, a number of other treatment modalities (inhibition of pancreatic secretion, antioxidants, and surgery) have also been described. Unfortunately, the efficacy of these modalities is difficult to assess, principally because of the lack of properly controlled clinical trials. Replacement of pancreatic enzymes (particularly lipase) in the gut is the mainstay of treatment for malabsorption; the recent discovery of a bacterial lipase (with high lipolytic activity and resistance to degradation in gastric and duodenal juice) represents an important advance that may significantly increase the efficacy of enzyme replacement therapy by replacing the easily degradable porcine lipase found in existing enzyme preparations. Diabetes secondary to chronic pancreatitis is difficult to control and its course is often complicated by hypoglycaemic attacks. Therefore, it is essential that caution is exercised when treating this condition with insulin. This paper reviews recent research and prevailing concepts regarding the three major complications of chronic pancreatitis noted above. A comprehensive discussion of current opinion on clinical issues relating to the other known complications of chronic pancreatitis such as pseudocysts, venous thromboses, biliary and duodenal obstruction, biliary cirrhosis, and pancreatic cancer is also presented.