Laparoscopic treatment of pancreatic pseudocysts in children

Asparaginase-associated Pancreatitis Complicated by Pancreatic Fluid Collection Treated with Endoscopic Cistogastrostomy in Pediatric Acute Lymphoblastic Leukemia: A Case Report and Systematic Review of the Literature

Asparaginase-associated pancreatitis complicates 2-10% of patients treated for acute lymphoblastic leukemia, causing morbidity and discontinuation of asparaginase administration. Among acute complications, pancreatic fluid collections can be managed conservatively, but intervention is indicated when associated with persistent insulin therapy need and recurrent abdominal pain. Endoscopic treatment has become the standard approach in adult patients, with increasing favorable evidence in children. This work compares the characteristics of a pediatric oncology patient treated at our institution with reported literature experiences, showing feasibility, safety and effectiveness of endoscopic approach.

Pancreatic pseudocyst as a cause for gastric outlet obstruction

The pancreatic pseudocyst contains pancreatic enzymes encapsulated by a non-epithelialized wall. They are rare in the pediatric population and are mostly a result of pancreatic trauma: extrinsic, or intrinsic. Management options include conservative or surgical, depending on the clinical signs and symptoms, and the size of the cyst.

Surgical drainage procedures for paediatric chronic pancreatitis: a scoping review

Paediatric chronic pancreatitis (CP) is a relatively rare entity, but it can be accompanied by debilitating complications such as pseudocysts, chronic pain and pancreatic duct obstruction. Surgical drainage procedures, such as pancreaticojejunostomy or cystogastrostomy/jejunostomy to address these complications may be required; however, there is a paucity of evidence as to the efficacy and long-term outcomes of these operations in the paediatric population. A scoping review of contemporary (post-2000) studies detailing surgical pancreatic drainage procedures performed in children (< 18 years) was undertaken. After screening, 24 case series detailing a total of 248 patients met the inclusion criteria. Longitudinal pancreaticojejunostomy and cystogastrostomy were the most common surgical procedures performed in children with CP and pseudocysts, respectively. Overall generally favourable outcomes were reported, but all studies were considered to have a high risk of bias. Operative management for paediatric CP is infrequently required; therefore, large prospective studies or trials focusing on this population are infeasible, limiting the best available evidence on the topic to case series, level IV. Recommendations to improve the quality of surgical care in the paediatric CP population could include centralisation and the formation of registries to allow accurate long-term follow-up.

Laparoscopic cystogastrostomy in children with pancreatic pseudocysts: A preliminary experience of eight cases

Introduction:

Pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) in children following acute pancreatitis are uncommon. The various modalities of therapy possible are conservative treatment, external drainage, endoscopic stenting, and internal surgical drainage procedures. There are no existing guidelines for the management of PPC in children. We evaluate the outcomes of laparoscopic cystogastrostomy (LCG) performed at our center.

Materials and Methods:

Eight children (median age: 10 years) underwent LCG for large PPC (median size: 12.5 cm). There were seven patients with PPC and one with WON. Seven underwent LCG by a transgastric approach and one underwent LCG by a retrogastric approach.

Results:

Seven out of the eight patients had complete resolution of symptoms and the PPC. The median follow-up period was 32 months (interquartile range: 9.5–55.5 months). There were no conversions. There was one patient with a WON who developed a recurrence.

Conclusion:

LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, when indicated, is a safe approach with a comparable outcome.

Intraoperative Endoscopy as an Adjuvant to Minimally Invasive Surgery in Pediatrics

Background: Minimally invasive surgery has a different visual and tactile perception compared with conventional surgery, which could lead to complications, especially in complex procedures. In these cases, flexible endoscopy can facilitate and prevent complications in minimally invasive procedures in children. The study aimed to clarify the utility of intraoperative endoscopy as an adjuvant to minimally invasive surgery in children. Materials and Methods: This retrospective study reviewed the medical records of pediatric patients who had undergone endoscopy during a minimally invasive surgery to treat an upper digestive pathology between January 2000 and December 2020. Results: The study included 83 patients who underwent a laparoscopic procedure with simultaneous endoscopy. The diagnosis was peptic stenosis in 9 patients, achalasia in 23, congenital embryonic tracheobronchial remnants in 4, re-fundoplication in 42, esophageal duplication in 2, superior mesenteric artery syndrome in 2, and giant gastric hemangioma in 1 patient. With adjuvant endoscopy, 7 digestive perforations were noted, 11 cases of short esophagus were diagnosed, and the permeability of the anastomosis was confirmed in 6 cases. No complications were related with the endoscopy procedures. Discussion: Minimally invasive surgery has a few special and tactile limitations that can lead to complications in certain procedures. Simultaneous digestive endoscopy in the upper gastrointestinal tract facilitates organ identification and dissection. Conclusion: Digestive endoscopy is an excellent adjunct to minimally invasive surgery in children because it facilitates and identifies complications and ensures safer minimally invasive surgeries. Future prospective studies are required to assess this conclusion.

Minimally invasive surgery of the pancreas: a narrative review of current practice

Minimally invasive surgery has moved from the fringe of pediatric surgery to the mainstream to address a variety of problems. Pancreatic pathology, though uncommon and complex, is frequently amenable to laparoscopic intervention. Indications for pediatric pancreatic operative intervention includes trauma, congenital hyperinsulinemia and neoplasm. Children may require distal pancreatectomy, subtotal pancreatectomy, enucleation, lateral pancreaticojejunostomy and pancreaticoduodenectomy. Of these operations, all but pancreaticoduodenectomy have been successfully described in children using a minimally invasive approach. Traumatic transection of the main pancreatic duct may require operative intervention if endoscopic techniques are unsuccessful. Distal pancreatectomy has been successfully utilized in this circumstance. Additionally, near total pancreatectomy may also be performed laparoscopically although successful reports are limited. Enucleation, especially with the use of intraoperative ultrasound may avoid a large laparotomy for isolated benign masses. Finally, chronic pancreatitis resulting in a dilated main pancreatic duct may benefit from a lateral pancreaticojejunostomy. This operation has also successfully been performed in children. Included is a review of pediatric pancreatic minimally invasive operations paired with corresponding pathology.

A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients

Objective

To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis.

Summary Background Data

Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods.

Methods

A meta-analysis of 5500 patients.

Results

Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods.

Conclusions

In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.

Management of pancreatic pseudocysts in pediatric oncology patients

BACKGROUND

Management of children with pancreatic pseudocysts has historically been adopted from the adult experience where pancreatic pseudocysts greater than 6 cm are unlikely to resolve without intervention. We reviewed the clinical course of pediatric oncology patients with pancreatic pseudocysts.

METHODS

A retrospective review of patients treated over a 15-year period was performed. Variables evaluated included cancer type, medications administered, clinical and imaging characteristics of the pancreatic pseudocysts, treatment and outcome.

RESULTS

A total of 132 patients with a median age of 13 (IQR, 9-17) years were identified with pancreatitis. Thirty-one (23.5%) patients developed a pancreatic pseudocyst, of which 84% were associated with PEG-asparaginase treatment. The median pseudocyst size was 7.6 (IQR, 4.4-9.9) cm with 59% being greater than 6 cm. Twenty-two (71%) patients with a pancreatic pseudocyst underwent successful conservative management, while only 9 (29%) required procedural intervention including six percutaneous drainage, one of whom recurred and required surgical cyst-enteric drainage. Two other patients had primary surgical cyst-enteric drainage and one patient underwent endoscopic retrograde cholangiopancreatography with stenting. The indication for intervention was worsening pain rather than pseudocyst imaging characteristics, size or serum amylase/lipase.

CONCLUSION

Most medication-induced pancreatic pseudocysts in children being treated for cancer, regardless of pseudocyst size, can be managed non-operatively or with transgastric percutaneous drainage. The need for intervention can be safely dictated by patient symptoms.

LEVEL OF EVIDENCE

III.

Management of acute pancreatitis in children

PURPOSE OF REVIEW

Pediatric acute pancreatitis has been on the rise in the last decades, with an incidence close to adult pancreatitis. In the majority of cases acute pancreatitis resolves spontaneously, but in a subset of children the disease progresses to severe acute pancreatitis with attendant morbidity and mortality.

RECENT FINDINGS

Pediatric acute pancreatitis in this era is recognized as a separate entity from adult acute pancreatitis given that the causes and disease outcomes are different. There are slow but important advances made in understanding the best management for acute pancreatitis in children from medical, interventional, and surgical aspects.

SUMMARY

Supportive care with fluids, pain medications, and nutrition remain the mainstay for acute pancreatitis management. For complicated or severe pancreatitis, specialized interventions may be required with endoscopic or drainage procedures. Surgery has an important but limited role in pediatric acute pancreatitis.

Laparoscopic distal pancreatectomy to treat solid pseudopapillary tumors in children: transition from open to laparoscopic approaches in suitable cases

PURPOSE

The aim of this study was to evaluate the outcomes of open and laparoscopic distal pancreatectomy (LDP) in the treatment of solid pseudopapillary tumors (SPT) in children.

METHODS

This was a retrospective study of 22 patients under 18 years of age who underwent a distal pancreatectomy for SPT between January 1995 and December 2012.

RESULTS

Fourteen patients and eight patients underwent LDP and open distal pancreatectomy (ODP), respectively, and 71.4 % of the LDP and 25.0 % of the ODP procedures were spleen-sparing operations. The median duration of surgery in the LDP group was shorter than that in the ODP group [175 (range 120-540) vs. 257 (range 200-305) min, p = 0.024]. There were no differences in postoperative complications. The LDP patients commenced oral intake earlier than the ODP patients [2.0 (range 1.0-7.0) vs. 4.0 (range 3.0-12.0) days, p = 0.010], and had an earlier discharge from hospital [7.0 (range 5.0-20.0) vs. 13.0 (range 7.0-22.0) days, p = 0.009].

CONCLUSION

LDP treatment for SPT in children is associated with a shorter hospitalization and a shorter time to oral intake compared to ODP. LDP is a safe and feasible option for SPT in select pediatric patients.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections in children

BACKGROUND AND OBJECTIVE

Although endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) has evolved as the standard of care in adults, its role as a single-step drainage modality in children is unclear. The aim of the present study was to evaluate the efficacy and safety of single-step EUS-guided drainage of PFCs in children.

METHODS

This is a retrospective study of all of the children who underwent single-step EUS-guided drainage of PFCs during a 4-year period at 1 institution. An endoscopic retrograde cholangiopancreatography was attempted before EUS-guided drainage to evaluate the pancreatic duct and bridge any ductal disruption.

RESULTS

A total of 7 children (4 boys; mean age 8.4 years [standard deviation 2.1]) underwent EUS-guided drainage of PFCs. The etiology was blunt abdominal trauma in 5, hereditary pancreatitis in 1, and idiopathic pancreatitis in 1. Both technical and treatment success rates were 100% with median procedural duration of 12 minutes (interquartile range 12-20 minutes). Two patients underwent repeat EUS-guided drainage due to lack of adequate resolution of PFC on follow-up computed tomography. There were no immediate or delayed complications. At a median follow-up of 1033 days (interquartile range 193-1167 days), all of the children were doing well with no PFC recurrence.

CONCLUSIONS

Single-step EUS-guided drainage of PFC in children is technically feasible, safe, clinically effective, and when available, should be the first-line treatment modality.

Experience with endoscopy and endoscopy-assisted management of pediatric surgical problems: results and lessons

Minimally invasive surgical techniques are becoming increasingly popular within the pediatric population. Flexible endoscopy may enhance or replace existing techniques in the future. Many of the reported benefits of laparoscopy and thoracoscopy may apply to endoscopy and endoscopy-assisted procedures; however, no reports exist as to the application, results, and outcomes for these procedures in children. It was hypothesized that endoscopy is a useful and safe adjunct for pediatric surgical patients. Retrospective review of medical records for patients who underwent endoscopy or endoscopy-assisted operations at two children's hospitals over 3 years (August 31, 2007-August 31, 2010) was completed. During this time period, 30 procedures were performed on 28 patients. Indications for procedure, age, operative technique, operative times, surgical outcomes, complications, and length of stay for each patient were reviewed. Patient age ranged from 3 days to 20 years. Indications for operation included esophageal pathology (13), gastroduodenal pathology (14), pancreatic pseudocyst (2), and displaced sigmoid Chait® (Cook, Inc., Bloomington, IN, USA) tube. Although endoscopy was intended only as an adjunct in all cases, the planned procedure was satisfactorily completed with a purely endoscopic approach in six cases. There were no intraoperative complications, and minor postoperative complications including one stricture requiring dilation, postoperative stridor, and esophageal leak, were each successfully managed conservatively. Endoscopy offers a promising adjunct to more traditional minimally invasive techniques in children. In some cases, endoscopy may offer an alternative to more invasive procedures or eliminate the need for tube thoracostomy or post-procedural contrast studies in some esophageal cases.

Pancreatic pseudocysts in children: treatment by endoscopic cyst gastrostomy

AIM

The aim of the present study was to review the use of endoscopic cyst gastrostomy (E-CG) as a treatment option for pancreatic pseudocysts referred to a tertiary paediatric surgical centre.

METHODS

Retrospective review during a 10-year period (January 2001-December 2010). Cyst gastrostomies were performed using 1 or 2 double pigtailed Zimmon stents (7-10 Fr) under general anaesthesia. Data are quoted as median (range).

RESULTS

E-CG was performed in 7 (5 males) children (median age at presentation 11.7 [8.2-15.8] years). Pancreatic pseudocysts were caused by acute pancreatitis in 5 (gallstones n = 1, hereditary pancreatitis n = 1, pancreatic divisum n = 1, asparaginase induced n = 1, and idiopathic n = 1) and pancreatic trauma in 2 (motor vehicle accident n = 1, and handlebar injury n = 1). All of the cases were associated with a rise in serum amylase level, median 1028 (276-2077) IU/L at the peak of symptoms. Three children had pancreatic duct stent placement during endoscopic retrograde cholangiopancreatography as the initial therapeutic intervention, but went on to have E-CG later. One who had a huge pseudocyst at presentation had already undergone an open cyst gastrostomy, which had recurred at 1 month. Rescue E-CG was performed 38 days later. All of the stents were removed endoscopically at 8 (6-40) weeks. E-CG was uncomplicated and pseudocysts resolved completely in 5. One required repeat placement at 15 days due to catheter slippage with later full resolution. One child required open cyst gastrostomy due to reaccumulation two months following removal of the stent. Median hospital stay post E-CG was 3 (1-23) days. There has been no recurrence at median follow-up of 18 (5-108) months.

CONCLUSIONS

Endoscopic cyst gastrostomy is a safe and effective alternative for the management of pancreatic pseudocysts in children and should now be considered as treatment of choice.

Acute and chronic pancreatitis: surgical management

Pancreatitis is becoming increasingly prevalent in children, posing new challenges to pediatric health care providers. Although some general adult treatment paradigms are applicable in the pediatric population, diagnostic workup and surgical management of acute and chronic pancreatitis have to be tailored to anatomic and pathophysiological entities peculiar to children. Nonbiliary causes of acute pancreatitis in children are generally managed nonoperatively with hydration, close biochemical and clinical observation, and early initiation of enteral feeds. Surgical intervention including cholecystectomy or endoscopic retrograde cholangiopancreatography is often required in acute biliary pancreatitis, whereas infected pancreatic necrosis remains a rare absolute indication for pancreatic debridement and drainage via open, laparoscopic, or interventional radiologic procedure. Chronic pancreatitis is characterized by painful irreversible changes of the parenchyma and ducts, which may result in or be caused by inadequate ductal drainage. A variety of surgical procedures providing drainage, denervation, resection, or a combination thereof are well established to relieve pain and preserve pancreatic function.