Pancreatic pseudocyst treated by laparoscopic Roux-en-Y cystojejunostomy. Report of a case and review of the literature

Inpatient Management and Treatment of a Giant Pancreatic Pseudocyst: A Case Report

Pancreatic pseudocyst formation is a common sequela of pancreatitis caused by alcohol use or gallstones. Giant pancreatic pseudocyst is an infrequently reported but serious complication of pancreatitis. Due to the large volume of pancreatic fluid containing active enzymes, giant pancreatic pseudocysts may require surgical intervention. We report a case of a giant pancreatic pseudocyst in a 56-year-old-female with a history of heavy alcohol use presenting with shortness of breath, general malaise, and dyspnea on exertion. Initial computed tomography (CT) scan demonstrated a giant pancreatic pseudocyst measuring up to 22 cm in the largest diameter. The patient was hospitalized, and an endoscopic cystogastrostomy was performed. Once the patient was stabilized, the cystogastrostomy stent was removed and replaced with a pigtail catheter. CT scan at three-month follow-up demonstrated no evidence of fluid re-accumulation. Due to the large size of giant pancreatic pseudocysts, drainage of the pseudocyst is the most appropriate treatment. There are different treatment modalities to achieve the goal of draining pseudocysts. One of the most commonly used treatments is an endoscopic ultrasound-guided cystogastrostomy, which this case highlights as an acceptable treatment option for giant pancreatic pseudocyst.

18F-FDG PET/CT of Hepatosplenic Actinomycosis After Laparoscopic Cystojejunostomy for Pancreatic Pseudocyst

ABSTRACT

We report the 18F-FDG PET/CT appearance of abdominal actinomycosis in a 48-year-old immunocompetent woman with a history of laparoscopic cystojejunostomy for pancreatic pseudocyst previously. 18F-FDG PET/CT demonstrated multiple hypermetabolism in the liver, spleen, cystojejunostomy anastomosis, greater omentum, and umbilical region. Actinomycosis was verified by biopsy. Hepatosplenic actinomycosis secondary to cystojejunostomy is extremely rare and easily to be misdiagnosed. PET/CT is helpful for auxiliary diagnosis, guiding biopsy, and exploring the extent of the disease.

Giant pseudocyst of the pancreas: A report of three cases

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Giant pseudocysts of pancreas may not be as rare as they were thought to be.

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They can be effectively managed by cysto-gastrostomy.

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Gastroscopy is a useful tool for follow up.

Background

A Pancreatic pseudocyst is usually a complication of pancreatitis but may follow abdominal trauma in children. Giant pseudocysts are rare and usually complicate chronic pancreatitis.

Aim

To report 3 cases of giant pseudocysts of the pancreas managed in our Centre within a three-month-period.

Case reports

Two female patients aged 22 years and 65 years respectively, and an 11-year-old boy presented with giant pancreatic pseudocysts (>10 cm in diameter each) to our unit and were successfully managed.

They all underwent exploratory laparotomy and cysto-gastrostomy with good outcome.

Conclusion

Giant pseudocysts of pancreas may not be as rare as they were thought to be. They can be effectively managed by cysto-gastrostomy

A giant pancreatic pseudocyst treated by cystogastrostomy

We report a case of a giant pancreatic pseudocyst in a 65-year-old man presenting with abdominal pain, loss of appetite and abdominal distension. CT scans demonstrated a giant pancreatic pseudocyst measuring 25.7 cm×15.3 cm×10.9 cm anteroposteriorly, with significant compression of surrounding organs. An open cystogastrostomy was performed through a midline incision, and 3 L of fluid was drained from the giant pseudocyst. Recovery has been uneventful.

Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series

BACKGROUND

The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PPs) are the current minimally invasive management options. This article reviews the evidence available on their effectiveness.

METHODS

A computerized search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from 1974 to 2005.

RESULTS

A total of 118 and 569 patients featured, respectively, in 19 and 25 reports underwent 118 and 583 laparoscopic and endoscopic drainage procedures, respectively. Pancreatic pseudocysts were considerably larger in the laparoscopic series (mean, 13 vs. 7 cm; p < 0.0001). The success rates for achieving resolution of the PPs in the laparoscopic and endoscopic series were 98.3% and 80.8% respectively, with morbidity rates of 4.2% and 12% and mortality rates of 0% and 0.4%, respectively. During follow-up period (mean, 13 vs 24 months; p < 0.0001), PPs recurred for 2.5% of the patients in the laparoscopic series and 14.4% of the patients in the endoscopic series, and the reintervention rates were 0.9% and 11.8%, respectively.

CONCLUSIONS

The laparoscopic and endoscopic approaches to internal drainage of PPs are safe. Although laparoscopic drainage appears to carry a higher success rate and lower rates of morbidity and recurrence, the heterogeneity of the published reports and the varied follow-up periods limit direct comparisons. Data from longer follow-up periods and randomized comparative trials are needed.

Laparoscopic pancreatic surgery

In the past, in the pancreas, a minimally invasive technique was only used for diagnostic laparoscopy in evaluating periampullary malignancy. Recent advances in operative techniques and instrumentation have empowered surgeons to perform virtually all procedures in the pancreas, including the Whipple procedure. Some of these procedures represent the most sophisticated application of minimally invasive surgery, and their outcomes are reportedly better than those of conventional open approaches. In addition to the evaluation of resectability in periampullary malignancy, palliative procedures, including biliary bypasses and gastrojejunostomy, can be performed laparoscopically. Although it is reportedly feasible to perform a Whipple procedure laparescopically, no benefit of the laparoscopic approach over the conventional open approach has been documented. Laparoscopic distal pancreatectomy, with or without preserving the spleen, is technically easier than the Whipple procedure, and is more widely accepted. Indications for laparoscopic distal pancreatectomy include cystic neoplasms and islet-cell tumors located in the pancreatic body or tail. Complications of acute and chronic pancreatitis may be treated with the use of surgical laparoscopy. When infected necrotizing pancreatitis is identified, surgical intervention for drainage and debridement is required. According to the type and location of infected necrotizing pancreatitis, three laparoscopic operative approaches have been reported: infracolic debridement, retroperitoneal debridement, and laparoscopic transgastric pancreatic necrosectomy. When internal drainage is indicated for a pseudocyst, a minimally invasive technique is a promising option. Laparoscopic pseudocyst gastrostomy, cyst jejunostomy, or cyst duodenostomy can be performed, depending on the size and location of the pseudocyst. Especially when a pseudocyst is located in close contact with the posterior wall of the stomach, it is best drained by a pseudocyst gastrostomy, which can also be done with the use of an intragastric operative technique.

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).

Laparoscopic treatment of pancreatic pseudocysts

BACKGROUND

A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP).

METHODS

We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30-72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5-20).

RESULTS

According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80-300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2-5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4-24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6-36), no recurrence of PP was observed.

CONCLUSIONS

The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage.

Traitement des pseudokystes du pancréas par kystogastrostomie laparoscopique

AIM

To evaluate the clinical results of laparoscopic cystogastrostomy and to determine the potential advantages of this new therapeutic option.

PATIENTS AND METHODS

This study concerned 12 patients presenting with pancreatic pseudocyst and operated on by laparoscopic cystogastrostomy between 1997 and 2002. There were five men and seven women with a median age of 46 years (range: 30-72). In ten patients, the pseudocyst developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients, the pseudocyst was associated with chronic pancreatitis. All the patients had a single cyst bulging into the posterior wall of the stomach and the median cyst diameter was 9 cm (range: 5-14).

RESULTS

Endoluminal gastric laparoscopy was used in six patients and intraperitoneal transgastric laparoscopy in six patients. Conversion to open surgery was required in one patient because the cyst could not be correctly localised by laparoscopy. The median size of the cystogastrostomy was 3 cm (range: 2-5). In eight patients, necrotic debris were still present within the cyst. The median operative time was 90 min (range: 60-140) and the median postoperative hospital stay was 6 days (range: 4-24). No mortality was recorded and postoperative morbidity was limited to one haematoma of the rectus sheath on a port site. One patient was readmitted on the 20th postoperative day because of cyst infection due to partial closure of the cystogastrostomy and was treated by endoscopic placement of a stent. One patient was lost for follow-up 2 months after surgery. With a median clinical and radiological follow-up of 12 months (range: 6-36), no recurrence of pancreatic pseudocyst was observed.

CONCLUSIONS

In this series, laparoscopic cystogastrostomy is associated with a low postoperative morbidity and an effective permanent result. Laparoscopy has two main advantages: an excellent control of haemostasis and the creation of a wide communication with debridement of the cyst contents thus minimizing the risk of infection or recurrence of the pseudocyst.

Laparoscopic Roux-en-Y pancreatic cyst-jejunostomy

BACKGROUND

The surgical management of pancreatic pseudocysts can be established through a variety of techniques. Internal drainage has consistently proven to be the treatment of choice for both acute and chronic pancreatic pseudocysts. With the growing popularity of minimally invasive surgery and improvements in surgical technique, laparoscopic internal drainage procedures for pancreatic pseudocysts are being attempted. While most authors have focused on laparoscopic cyst-gastrostomies, few have written about laparoscopic cyst-jejunostomies.

METHODS

In this article, we report our experience with eight laparoscopic Roux-en-Y cyst-jejunostomies. Of the eight patients, six had alcoholic pancreatitis, and two had gallstone pancreatitis. There were five men and three women with a mean age of 48 (range 35-71 years).

RESULTS

The mean operative time was 150 min, with a range of 100-215 min. We report a mean EBL of 78 cc, a minor complication rate of 20%, and no major complications or mortalities.

CONCLUSIONS

These data compare favorably with both open and laparoscopic internal drainage procedures. Laparoscopic cyst-jejunostomy offers a feasible alternative in the minimally invasive management of pancreatic pseudocyst.

Laparoscopic management of severe acute pancreatitis

INTRODUCTION

Severe acute pancreatitis (SAP) remains a serious disease state difficult to manage. Laparoscopic surgery represents a relatively new solution to this problem. This study was aimed to investigate the feasibility of laparoscopic treatment of SAP and the selection of laparoscopic procedures in various stages of SAP according to different pathologic alterations.

METHODS

Thirteen patients, 9 men and 4 women with an average age of 46 years old, were diagnosed with SAP. Laparoscopic necrosectomy followed by external drainage were performed on 7 patients with massive fluid collections and/or infected necrosis in acute reaction phase of SAP. For 2 cases in subacute phase characterized by fresh-formed adhesions and encapsulation, laparoscopic intracavitary debridement experienced difficulty. For the other 4 patients in late phase with well-defined pancreatic or peripancreatic pseudocyst/abscess, ultrasound-guided, directly visualized laparoscopic intracavitary debridement, and external drainage were carried out with ease and efficiency.

RESULTS

Laparoscopic procedures were accomplished successfully on 12 patients (92.3%), except for 1 conversion (7.7%) to open laparotomy owing to poor exposure and hard maneuvers in subacute phase. There was no mortality in this group. Patients were witnessed to have accelerated recovery following laparoscopic surgery.

CONCLUSION

Laparoscopic technique offers new hope for the treatment of SAP. It is recommended as a feasible, effective, and less traumatic therapeutic means on condition that the strategy of individualization is followed.

Minimally invasive pancreatic surgery

Robotic surgery remains in its infancy, and little experience has been reported, as surgeons carefully explore the application of this type of technology to diseases of the pancreas. While challenging and controversial, Dr. Zollinger would most likely support the ongoing research in the techniques of pancreatic surgery that can lead only to an improvement in the outcomes of our patients.

Acute biliary pancreatitis, endoscopy, and laparoscopy

Current practices for diagnosis and treatment of common bile duct stones are not evidence-based. Acute biliary pancreatitis (ABP) is a specific situation in which endoscopic procedures are either overused or misused. Pancreatitis is a poor marker for choledocholithiasis. Prognostic systems are accurate to discern those patients with ABP who do not need aggressive procedures. Patients with a benign ABP do not need an endoscopic approach. Laparoscopic common bile duct exploration is an underrated treatment for patients with choledocholithiasis. Laparoscopic approach to infected necrotic collections and pseudocysts warrant further investigations.

Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature

Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross-references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.