The CT-guided percutaneous drainage of pancreatic pseudocyst accompanied by pseudoaneurysm: A case report

RATIONALE

This case report discusses the CT-guided percutaneous drainage of a pancreatic pseudocyst accompanied by a pseudoaneurysm. Pancreatic pseudocysts can erode the peripancreatic artery and produce pseudoaneurysms. This is rare, but it can be life-threatening.

PATIENT CONCERNS

The case presented involves a 58-year-old female who was diagnosed with pancreatic cancer and underwent surgical treatment. She presented with hematochezia, dizziness, and hypodynamic findings with no obvious cause. Imaging revealed a pancreatic pseudocyst and small arterial aneurysms. To reduce the risk of aneurysm rupture, the patient underwent transcatheter arterial coil embolization. Three days later, CT-guided catheter drainage was performed to reduce the erosion of the arterial wall caused by pancreatic fluid.

DIAGNOSES

The contrast-enhanced-CT imaging showed a round, slightly high-density lesion in the cyst, suggesting the presence of a pseudoaneurysm.

INTERVENTIONS

The patient was sent for another transcatheter arterial embolization with coils and n-butyl-2-cyanoacrylate.

OUTCOMES

After receiving the transcatheter arterial embolization, the patient had no serious bleeding or other complications.

LESSONS

Early detection and accurate assessment of pseudoaneurysms are essential for appropriate management. This case shows that contrast-enhanced CT is necessary before CT-guided percutaneous drainage of pancreatic pseudocysts. It also shows that, due to the many complications that pancreatic pseudocysts may cause, appropriate treatment of pseudocysts complicated with pseudoaneurysm has important clinical significance.

Successful Endoscopic Treatment of a Pancreatic Pseudocyst in a Patient with Situs Inversus Totalis and Upper GI Duplication

BACKGROUND Duplication of the gastrointestinal tract is a rare congenital malformation that can develop in any part of the digestive tract. These duplications may be asymptomatic into adult age. Situs inversus totalis is a rare congenital anomaly characterized by a mirror transposition of thoracic and abdominal organs. We present a case of a pancreatic pseudocyst in a patient with a combination of situs inversus totalis and doubling of the esophagus, stomach, and first part of the duodenum. CASE REPORT A 64-year-old woman presented with epigastric pain. Abdominal computed tomography revealed a pancreatic pseudocyst and a previously identified duplication of the esophagus, stomach, and duodenum with situs inversus totalis. The patient underwent esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography for pseudocyst drainage. During EGD, a bifurcation of the esophagus was found. Duplication of the esophagus, stomach, and first part of the duodenum was evident on further advancement. A week later, there was repeated filling of the pseudocyst with a liquid component, and the patient underwent cystogastrostomy with stenting. Five months after discharge, the stent was removed without complications. CONCLUSIONS Duplication of the gastrointestinal tract and situs inversus totalis are very rare congenital malformations that require early diagnosis. While situs inversus totalis does not represent any medical disadvantage, physicians should be aware of abnormal anatomy before procedures to prepare specialists for this in case of the need for special techniques. Endoscopic treatment of pancreatic pseudocysts is safe and effective even in such rare cases. The use of endoscopic methods also minimizes intervention and decreases the length of the patients' stays in the hospital.

Endoscopic intramural cystogastrostomy for treatment of peripancreatic fluid collection: A viewpoint from a surgeon

Percutaneous or endoscopic drainage is the initial choice for the treatment of peripancreatic fluid collection in symptomatic patients. Endoscopic transgastric fenestration (ETGF) was first reported for the management of pancreatic pseudocysts of 20 patients in 2008. From a surgeon's viewpoint, ETGF is a similar procedure to cystogastrostomy in that they both produce a wide outlet orifice for the drainage of fluid and necrotic debris. ETGF can be performed at least 4 wk after the initial onset of acute pancreatitis and it has a high priority over the surgical approach. However, the surgical approach usually has a better success rate because surgical cystogastrostomy has a wider outlet (> 6 cm vs 2 cm) than ETGF. However, percutaneous or endoscopic drainage, ETGF, and surgical approach offer various treatment options for peripancreatic fluid collection patients based on their conditions.

Sinistral Portal Hypertension Due to a Pancreatic Pseudocyst: A Rare Cause of Upper Gastrointestinal Bleeding

Sinistral portal hypertension (SPH), also known as segmental portal hypertension, is a complication of pancreatic disorders and an extremely rare cause of upper gastrointestinal (GI) bleeding. SPH is observed in patients without cirrhosis and arises from splenic vein thrombosis. Unmitigated backflow of blood may cause gastric venous congestion and ultimately GI hemorrhage. Herein, we report a rare case of massive hematemesis due to SPH in a male patient with a history of chronic pancreatitis and pancreatic pseudocyst. Our patient was successfully treated with endoscopic necrosectomy followed by open splenectomy, distal pancreatectomy, and partial gastric resection.

Comparative outcome of single versus two double-pigtail stents for endoscopic drainage of pancreatic fluid collections with minimal necrosis: a retrospective analysis

Background

Endoscopic ultrasound (EUS)-guided cystogastrostomy is the treatment of choice for managing symptomatic pancreatic fluid collections (PFC). However, studies on the number of stents for optimal drainage of PFCs are limited. Hence, the present study was conducted to compare the outcome of single versus two double-pigtail stents for endoscopic drainage of PFCs.

Methods

This is a single-center, retrospective analysis of patients undergoing endoscopic drainage of PFCs with minimal necrosis (pseudocyst or walled-off necrosis with <30% solid content) at a tertiary center in South India from October 2020 to October 2022. Post-procedure, patients were followed up for clinical improvement, and stents were removed after documentation of cyst size reduction on imaging.

Results

Sixty-three patients (82.5% males, median age: 34 years) fulfilling the selection criteria were included. For single stent placement (n = 47), stents of size 8.5 Fr or 10 Fr were used, while for placement of two stents (n = 16), 7 Fr stents were used. The technical success rate was 100%. Intraprocedural and early postprocedural adverse events (all mild to moderate) were comparable between the groups (17.0% with single stent vs. 25.0% with two stents, p = NS). Clinical success was achieved in 93.6% of patients, with no difference between both groups. Three patients in the single stent group required additional procedures. All patients underwent successful stent removal after a median follow-up of 14 weeks.

Conclusion

A single pigtail stent of 8.5 Fr or 10 Fr size for EUSguided cystogastrostomy provides efficacy and safety similar to that of two stents.

Early (<4 weeks) versus standard (≥4 weeks) endoscopic drainage of pancreatic walled-off fluid collections: a systematic review and meta-analysis

BACKGROUND AND AIMS

Previous studies have demonstrated that the ideal time for drainage of walled-off pancreatic fluid collections is 4 to 6 weeks after their development. However, some pancreatic collections, notably infected pancreatic fluid collections, require earlier drainage. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. The aim of this study was to evaluate the clinical efficacy and safety of EUS-guided drainage of pancreatic fluid collections <4 weeks after development compared with ≥4 weeks after development.

METHODS

Search strategies were developed for PubMed, Embase, and Cochrane Library databases from inception. Outcomes of interest were technical success, defined as successful endoscopic placement of a lumen-apposing metal stent; clinical success, defined as a reduction in cystic collection size; and procedure-related adverse events. A random-effects model was used for analysis, and results are expressed as odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Six studies (630 patients) were included in our final analysis, in which 182 patients (28.9%) were enrolled in the early drainage cohort and 448 patients (71.1%) in the standard drainage cohort. The mean fluid collection size was 143.4 ± 18.8 mm for the early cohort versus 128 ± 19.7 mm for the standard cohort. Overall, technical success was equal in both cohorts. Clinical success did not favor either standard drainage or early drainage (OR, .39; 95% CI, .13-1.22; P = .11). No statistically significant differences were found in overall adverse events (OR, 1.67; 95% CI, .63-4.45; P = .31) or mortality (OR, 1.14; 95% CI, .29-4.48; P = .85). Hospital stay was longer for patients undergoing early drainage compared with standard drainage (23.7 vs 16.0 days, respectively).

CONCLUSIONS

Both early (<4 weeks) and standard (≥4 weeks) drainage of walled-off pancreatic fluid collections offer similar technical and clinical outcomes. Patients requiring endoscopic drainage should not be delayed for 4 weeks.

[Pancreatic mucinous cystadenoma with atypical clinical presentation]

We present a 33-year-old patient with atypical clinical course of pancreatic mucinous cystadenoma. The tumor had connection with pancreatic ductal system and led to bleeding into cystic cavity. This contributed to incorrect preoperative diagnosis of post-necrotic cyst. The final diagnosis of mucinous cystadenoma was established after histological examination. Distal pancreatectomy excluded incorrect treatment.

Efficacy and safety of endoscopic ultrasound guided drainage of pseudocysts and walled-off necrosis after failure of percutaneous drainage

BACKGROUND

Endoscopic Ultrasound (EUS) represents the gold standard for initial drainage of pancreatic fluid collections (PFC) due to various etiologies. However, data concerning salvage EUS drainage after initial percutaneous drainage are limited. The purpose of our study was to evaluate the clinical outcomes and safety of EUS-guided drainage of pancreatic collections after failure of percutaneous drainage.

METHODS

This retrospective study was conducted in a single, tertiary university center from August 2013 to January 2020. Indication was pancreatic collection after acute pancreatitis with PFC requiring EUS-guided drainage after failure of percutaneous drainage.

RESULTS

Twenty-two patients with PFC after acute pancreatitis were included (mean age 64.1 ± 11.3 years) of which 4/22 (18.2%) had pancreatic pseudocyst and 18/22 (81.8%) presented with a walled-off necrosis. Seventy-six interventions were performed among the 22 patients. Lumen-Apposing Metal Stent (LAMS) were used in 5/22 (22.7%) and double pigtail plastic stents in 17/22 (77.3%) of interventions with a median number intervention of 3 per patient (range 1 to 7). Technical success rate was 98.7% (75/76) with an overall clinical success of 81.8% (18/22). Procedure related adverse events rate was 9.1% (2/22) including one bleeding and one pancreatic fistula. Two non-procedure related deaths were observed.

CONCLUSION

EUS-guided pancreatic collection drainage is clinically effective and safe after clinical/technical failure of radiological percutaneous management.

Coincidence of splenic vein aneurysm and haemorrhagic cyst of the pancreas

Pseudoaneurysm of the splenic vein is a rare entity which is associated with pancreatitis in 52 % cases. Pseudocysts of the pancreas create approximately 70 % of all cystic lesions of the pancreas. One of the most dangerous complications of pancreatic pseudocysts is bleeding into the cystic lumen. This is caused by perforation of the pseudoaneurysm of the splenic vein. Enzymatic damage of the splenic vein´s wall is the cause of pseudoaneurysm. The clinical condition varies. It can be asymptomatic or bring about haemodynamic instability. The diagnostic process of pseudoaneurysm of the splenic vein is difficult. This case study introduces a case of a 50‑year‑old man with the anamnesis of recurrent pancreatitis caused by alcoholism. He had abdominal pain and was diagnosed with a pseudocyst of the pancreas. Abdominal CT showed an extensive capsulated collection in the left subphrenic space, 23cm in diameter, with serosanguineous content and coagulations. The CT visualised the mass effect on the surrounding tissues and a complete deformation of the spleen. Between the collection and partially oppressed tail of the pancreas there was a venous pseudoaneurysm, 3.5cm in diameter. Considering its localization, it most probably originated from the splenic vein. Surgery was done. We did distal resection of the pancreas with a complete removal of the pseudocyst and spleen (Fig. 7, Ref. 11). Keywords: splenic vein, pseudoaneurysm, pancreatitis, pancreatic pseudocysts.

[Mediastinal pancreatobiliary pseudocysts]

OBJECTIVE

To select the optimal treatment for uninfected and suppurative rare mediastinal pancreatobiliary pseudocysts.

MATERIAL AND METHODS

There were 10 patients with mediastinal pancreatogenic (n=9) and biliogenic (n=1) pseudocysts formed through esophageal (n=9) and aortic (n=1) hiatus of the diaphragm. All patients were divided into groups: group A - uninfected pancreatic pseudocysts (n=5) formed through esophageal hiatus; group B - 5 patients with suppurative pancreatogenic (n=4) and biliogenic (n=1) mediastinitis complicated by biliopleuroesophageal (n=1), pancreatoesophageal (n=1) and pancreatopleural (n=2) fistulas.

RESULTS

In the group A, simultaneous procedures (n=5) were performed depending on pancreatic parenchyma and pancreatic duct destruction. Distal ductal obstruction required Frey procedure (n=3). If distal duct was patent, we resected cyst-containing pancreatic tail (n=2). Early and long-term results were favorable. In the group B, mediastinitis persisted for a long time with normal temperature as a rule. In our opinion, mild course is associated with gradual introduction of purulent tissues into mediastinum and development of a tissue barrier. Two-stage surgeries were performed in patients with pancreatopleural empyema. Mediastinitis lasting 6-8 weeks caused perforation of the lower third of esophagus (n=2) and death of 1 patient. Risk factors of mediastinal pseudocysts: hypertension in pancreatic duct and pseudocysts, immobile cicatricial tissues of omental bursa, proximity of subdiaphragmatic structures to esophageal and aortic hiatus of the diaphragm. Pressure in aortic canal (mmHg) is 10 times higher than in esophageal canal that increases migration through the esophageal hiatus. It is advisable to distinguish pancreatoesophageal and biliopleuroesophageal fistulas.

CONCLUSION

Uninfected mediastinal pseudocysts require simultaneous procedures, pancreatopleural empyema - two-stage interventions. Therapy is recommended in patients with esophageal fistula and no severe symptoms and intoxication.

[A Case of Pancreatic Pseudocyst Recurrence after Surgery for Remnant Pancreatic Cancer]

The patient was a 72-year-old man with a history of pancreatic cancer and IPMA treated with distal pancreatectomy. He had recurrence-free period after adjuvant chemotherapy with S-1. But 6 years after the surgery, a diameter of 1 cm mass was noted in the remnant pancreas on MRI examination after hepatocellular carcinoma treatment. The mass was diagnosed as remnant pancreatic cancer, and he had undergone partial pancreatectomy of remnant pancreas. The pathological diagnosis was pancreatic ductal carcinoma with negative margin. However, 6 months after the reoperation, epigastric pain appeared, and CT scan showed a pseudocyst of 10 cm in size. The diagnosis was local recurrence with positive cytology, and then puncture drainage was performed. After repeated drainages, adhesion of the cystic lesion, and chemotherapy, the cytology became negative and the cystic lesion disappeared, but peritoneal dissemination metastasis also appeared. The patient died of the primary disease 7 years and 8 months after the first surgery and 1 year and 11 months after the second surgery. There has been no report of local recurrence in the form of pancreatic pseudocyst after pancreatic cancer surgery, and we report this case with literature discussion.

Calcified pseudocyst: an uncommon presentation of chronic pancreatitis

Pseudocysts are localised fluid collections, usually developing as a complication of acute or chronic pancreatitis. Pancreatic ductal or parenchymal calcifications are commonly seen in routine radiological imaging, but calcification of pseudocyst is extremely rare. Calcified pseudocysts have been reported in literature as case reports, but a calcified pseudocyst in the lesser sac, without underlying pancreatic calcification, has not been reported. We report a case of a pancreatic pseudocyst with a calcified wall, requiring surgical excision and histological examination confirming the diagnosis.

Safety and Feasibility of Robotic-Assisted Drainage of Symptomatic Pancreatic Pseudocysts: A Case-Series Analysis (with video)

Background: The surgical treatment of pancreatic pseudocysts (PPs) in patients who fail nonoperative management has evolved from aggressive open to a minimally invasive approach. The application of robotic surgery in this setting is scarcely reported. The aim of this study is to analyze the safety and feasibility of the robotic approach to pancreatic pseudocyst drainage. Methods: A single centre retrospective review of consecutive patients undergoing robotic-assisted pancreatic pseudocyst surgeries in an academic tertiary institution was performed. Results: There were 14 patients studied, of whom 10 underwent cystogastrostomy and 4 Roux-En- Y cystojejunostomy. Eight patients had gallstone pancreatitis and 3 patients alcoholic pancreatitis. The mean size of cyst was 8.9 +-1cm and 57.1% located at the pancreatic body. The overall operative time of the procedure was 135 +-34 minutes. There were no open conversions. The overall success rate was 92.8%, while the primary success rate 85.7%. The major morbidity rate was 14.3% and there was no 30-day mortality. The mean post-operative hospital stay was 7 +-3 days with one recurrence of the pancreatic pseudocyst on follow-up requiring endoscopic drainage without further recurrence. Conclusions: The robotic approach for the drainage of symptomatic pancreatic pseudocyst is safe and feasible and can be considered as a viable modality for operative intervention in well-selected patients.

Endoscopic Versus Laparoscopic Treatment for Pancreatic Pseudocysts: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to evaluate the efficacy and safety of endoscopic treatment for pancreatic pseudocysts (PPCs) compared with laparoscopic treatment.

METHODS

The Embase, Medline, Cochrane Library, Web of Science databases, China National Knowledge Infrastructure Chinese citation database, and WANFANG database were systematically searched to identify all comparative trials investigating endoscopic versus laparoscopic treatment for PPC. The main outcome measures included treatment success rate, adverse events, recurrence rate, operation time, intraoperative blood loss, and hospital stay.

RESULTS

Six studies with 301 participants were included. The results suggested that there was no difference in rates of treatment success (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.40-2.01; P = 0.79), adverse events (OR, 0.80, 95% CI, 0.38-1.70; P = 0.57), or recurrence (OR, 0.55, 95% CI, 0.22-1.40; P = 0.21) between endoscopic and laparoscopic treatments. However, the endoscopic group exhibited reduced operation time (weighted mean difference [WMD], -67.11; 95% CI, -77.27 to -56.96; P < 0.001), intraoperative blood loss (WMD, -65.23; 95% CI, -103.38 to -27.08; P < 0.001), and hospital stay (WMD, -2.45; 95% CI, -4.74 to -0.16; P = 0.04).

CONCLUSIONS

Endoscopic treatment might be suitable for PPC patients.

Radiological and surgical management of bleeding pancreatic pseudocyst in a pediatric patient

INTRODUCTION

The pancreas is the fourth most frequently involved solid organ in pediatric abdominal trauma. We present the case of a giant pancreatic pseudocyst secondary to trauma and how it was radiologically and surgically managed.

CLINICAL CASE

This is the case of a 13-year-old male patient admitted as a result of a grade IV pancreatic lesion, which turned into a 170x86x180 mm pancreatic pseudocyst. Intracystic bleeding required radiological embolization of the proximal gastroduodenal artery. Subsequent abdominal compartment syndrome, biliary leak, and chemical peritonitis required laparotomy and collection drainage. Pancreatitis and duct fistula had a slow but favorable progression.

DISCUSSION

The presence of duct damage is a failure predictor in the conservative treatment of pancreatic trauma. Surgical management could be indicated in recurrent, multiple, or giant (> 200 mm) pseudocysts. Intracystic bleeding is rare but potentially fatal. Selective angiogram could be a useful tool for improved prognosis.

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.

Clinical study on cystogastrostomy and Roux-en-Y-type cystojejunostomy in the treatment of pancreatic pseudocyst: A single-center experience

ABSTRACT

The main purpose is to compare the efficacy of cystogastrostomy (CG) and Roux-en-Y-type cystojejunostomy (RCJ) in the treatment of pancreatic pseudocyst (PPC), and to explore the risk factors of recurrence and complications after internal drainage.Two hundred eight patients undergoing either CG or RCJ for PPC Between January 1, 2013and February 1, 2019, at West China Hospital of Sichuan University were retrospectively analyzed. The cure rate, complication rate and related factors were compared between the 2 groups.Two hundred eight patients with PPC underwent either a CG (n = 119) or RCJ (n = 89). The median follow-up time was 42.7 months. Between the 2 cohorts, there were no significant differences in cure rate, reoperation rate, and mortality (all P > .05). The operative time, estimated intraoperative blood loss, install the number of drainage tubes and total expenses in CG group were lower than those in RCJ group (all P < .05). The Logistic regression analysis showed that over twice of pancreatitis' occurrence was were independent risk factor for recurrence after internal drainage of PPC (OR 2.760, 95% CI 1.006∼7.571, P = .049). Short course of pancreatitis (OR 0.922, 95% CI 0.855∼0.994, P = .035), and RCJ (OR 2.319, 95% CI 1.033∼5.204, P = .041) were independent risk factors for complications after internal drainage of PPC.Both CG and RCJ are safe and effective surgical methods for treating PPC. There were no significant differences in cure rate, reoperation rate, and mortality between the 2 groups, while the CG group had a short operation time, less intraoperative bleeding and less cost.

Massive left upper abdominal cyst: how to diagnose and what to do

We present a case of a large splenic pseudocyst in a 16-year-old female, who presented with a left upper quadrant mass and features of gastric outlet obstruction. We discuss the difficulties in diagnosis, the management options and why the definitive treatment of distal pancreatectomy and splenectomy was necessary.

Diagnostic accuracy of EUS-guided through-the-needle-biopsies and simultaneously obtained fine needle aspiration for cytology from pancreatic cysts: A systematic review and meta-analysis

OBJECTIVES

To address the diagnostic accuracy of endoscopic ultrasound guided through-the-needle-biopsies (TTNBs) and simultaneously obtained cytology samples from pancreatic cysts compared to the final histopathological diagnosis of the surgical specimen, and to give an overview of ancillary tests performed on TTNBs.

METHODS

A literature search was conducted in MEDLINE, Embase and Scopus. Studies were included in the meta-analysis, if they had data for TTNB, cytology and a surgical specimen of pancreatic cysts as reference standard. The assessment of the risk of bias and quality of the included studies was conducted using the modified QUADAS-2 tool.

RESULTS

Ten studies with 99 patients were included in the meta-analysis. Data regarding study design and clinicopathological features were extracted systematically. For TTNB, pooled sensitivity was 0.86 (95 % CI 0.62-0.96), specificity 0.95 (95 % CI 0.79-0.99) and area under the curve (AUC) 0.86 for the diagnosis of a mucinous cyst and pooled sensitivity was 0.78 (95 % CI 0.61-0.89), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.92 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.69 (95 % CI 0.50-0.83), specificity 0.47 (95 % CI 0.28-0.68) and AUC 0.49. For cytology performed simultaneously, pooled sensitivity was 0.46 (95 % CI 0.35-0.57), specificity 0.90 (95 % CI 0.46-0.99) and AUC 0.64 for the diagnosis of mucinous cysts, and pooled sensitivity was 0.38 (95 % CI 0.23-0.55), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.84 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.29 (95 % CI 0.21-0.39), specificity 0.45 (95 % CI 0.25-0.66) and AUC 0.30. Furthermore, immunohistochemical stains can be useful to establish the specific cyst subtype.

CONCLUSIONS

TTNBs have a higher sensitivity and specificity than cytology for the diagnosis of mucinous cyst and high- risk cysts of the pancreas.

Efficacy and safety of endoscopic ultrasound-guided drainage of pancreatic pseudocysts using double-pigtail plastic stents: A single tertiary center experience

OBJECTIVES

Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital.

METHODS

Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence.

RESULTS

Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution.

CONCLUSION

EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification

Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated. Within the last decade, endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage. Proper understanding of anatomic landmarks, including assessment of the main pancreatic duct and any associated lesions – such as disruptions and strictures – are key to achieving clinical success, reducing the need for reintervention or recurrence, especially in cases with suspected disconnected pancreatic duct syndrome. Additionally, proper review of imaging and anatomic landmarks, including collection location, are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents. Pancreatography to adequately assess the main pancreatic duct may be performed by two methods: Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopan-creatography. Despite the critical need to understand anatomy via pancrea-tography and assess the main pancreatic duct, a standardized approach or uniform assessment strategy has not been described in the literature. Therefore, the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.

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.

Pancreatic pseudocyst-portal vein fistula: a case treated with EUS-guided cyst-drainage and a review of the literature

Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula (PPVF) is a rare and life-threatening complication. In PPVF patients, drainage or operative therapy is necessary under certain conditions, including communication between the pseudocyst and pancreatic duct, pancreatic duct stricture, pancreatic duct stone, and infection that is difficult to control with antibiotics. We describe the case of a 78-year-old woman who presented with an infected pancreatic pseudocyst invading the portal venous system with obstruction due to thromboembolization. Conservative therapy with antibiotics was insufficient. We, therefore, performed endoscopic ultrasound-guided cyst-drainage (EUS-CD). During EUS-CD, PPVF and pseudocyst-pancreatic duct fistula were confirmed by contrast medium injection. Despite the presence of the pseudocyst-pancreatic duct fistula, the pancreatic duct was not visualized in the pancreatic head, suggesting stricture in the main pancreatic duct. We, therefore, performed endoscopic retrograde pancreatography, which revealed pancreatic stone in the main pancreatic duct. Then, we added a 7-Fr pancreatic stent. She was discharged after 89 days of hospitalization. We reviewed the literature on the management of PPVF formation, and EUS-CD is considered to be a good treatment option for PPVF patients without portal vein patency.

Endoscopy-assisted, single trans-gastric trocar, laparoscopic pseudocysto-gastrostomy A minimally invasive alternative for drainage of large pseudocysts

INTRODUCTION

Pancreatic pseudocyst is a complication of acute and chronic pancreatitis, which requires treatment in correlation with its size, symptomatology and mass effect on adjacent structures. Currently, pseudocyst drainage can be done within the stomach or small intestine through endoscopic, laparoscopic or open surgery approach.

AIMS

In this paper we present a hybrid surgical technique applied by our team on 3 consecutive patients with pancreatic pseudocyst.

METHOD

The pseudocysts were in all cases internally drained by endoscopic assisted laparoscopic approach, this article highlighting the technical aspects of this procedures. The patients were known with repeated episodes of acute pancreatitis. Imaging examinations indicated the presence of large pancreatic pseudocysts in all cases, for which we decided to perform a mechanical pseudo-cysto-gastro-anastomosis done laparoscopically-trans-gastric through a single trocar under endoscopic guidance.

RESULTS

The length of surgery was from 60 to 90 min with no intraoperative blood loss recorded. The laparoscopic ultrasound was used in all cases to facilitate the safe localization of the future anastomotic site. The laparoscopic examination of the pseudocyst cavity was done systematically and in 2 cases revealed necrotic areas requiring debridement. The patients had no postoperative complications and were discharged 4-6 days after surgery.

CONCLUSIONS

Internal drainage of pancreatic pseudocyst inside the stomach, by the technique described above, is facile, giving the patient the advantages of endoscopy and minimally invasive surgery. In these circumstances, we consider it superior to endoscopic drainage, by providing a broad communication between the pseudocyst and stomach cavity, reducing the risk of relapse and abscess formation. Moreover, it offers the possibility of exploring the pseudocyst cavity and of removing any necrotic tissues. The endoscopic assistance makes possible the single trans-gastric trocar approach, limiting the injury of the gastric wall.

KEY WORDS

Endoscopic assisted laparoscopic procedure, Hybrid technique, Pancreatic pseudocyst, Pseudo-cystogastro- anastomosis technique.

Duodenal obstruction due to chronic pancreatitis of the pancreas tail treated by surgical intervention: A case report

RATIONALE

Duodenal obstruction (DO) sometimes induces the groove pancreatitis. However, the case of DO due to chronic pancreatitis in pancreas tail (CPPT) is extremely rare. Therefore, the managements of DO caused by CPPT have not been established yet.

PATIENT CONCERNS

A 68-year-old man, who was under the treatment of chronic pancreatitis, presented to our hospital with nausea and abdominal pain. He was diagnosed as DO caused by CPPT. The Conservative treatment, including the nasogastric aspiration and intravenous infusion under the absence of food, was performed. The drainage fluid from naso-gastric tube had been more than 2000 ml per a day although continuing treatment for 14 days. Hence, we decided that the conservative therapy was failed and the surgical intervention was required.

DIAGNOSIS

Computed tomography showed gastroduodenal expansion due to stenosis at the horizontal portion of the duodenum with increasing pancreatic pseudocyst. The contrast radiography of the duodenum showed severe stenosis around Treitz ligament. His pre-surgical diagnosis was DO due to CPPT through exclusion of other etiologies for DO such as annular pancreas, SMA syndrome, duodenal diaphragm and Crohn disease.

INTERVENTION

Spleen preserving distal pancreatectomy (Warshaw operation) was performed with gastrojejunostomy. During surgery, marked redness and thickness of the mesenteric serosa around Treiz ligament were observed. His surgical findings were supported our preoperative prediction.

OUTCOMES

The patient was successfully treated and discharged uneventfully after postoperative day 14. At the 9 months follow-up visit, the patient is still doing well without any symptoms.

CONCLUSION

Combination of gastrojejunostomy and Warshaw operation is one of the ideal surgical procedures for patients of DO due to CPPT.

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial

BACKGROUND

Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP.

PATIENTS AND METHODS

Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications.

RESULTS

Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention.

CONCLUSIONS

Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.

Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP).

METHODS

The researchers did a search in Medline, EMBASE, Scielo/Lilacs, and Cochrane electronic databases for studies comparing surgical and endoscopic drainage of PP s in adult patients. Then, the extracted data were used to perform a meta-analysis. The outcomes were therapeutic success, drainage-related adverse events, general adverse events, recurrence rate, cost, and time of hospitalization.

RESULTS

There was no significant difference between treatment success rate (risk difference [RD] -0.09; 95% confidence interval [CI] [0.20,0.01]; P = .07), drainage-related adverse events (RD -0.02; 95% CI [-0.04,0.08]; P = .48), general adverse events (RD -0.05; 95% CI [-0.12, 0.02]; P = .13) and recurrence (RD: 0.02; 95% CI [-0.04,0.07]; P = .58) between surgical and endoscopic treatment.Regarding time of hospitalization, the endoscopic group had better results (RD: -4.23; 95% CI [-5.18, -3.29]; P < .00001). When it comes to treatment cost, the endoscopic arm also had better outcomes (RD: -4.68; 95% CI [-5.43,-3.94]; P < .00001).

CONCLUSION

There is no significant difference between surgical and endoscopic treatment success rates, adverse events and recurrence for PP. However, time of hospitalization and treatment costs were lower in the endoscopic group.

A novel self-expanding biflanged metal stent vs tubular metal stent for EUS-guided transmural drainage of pancreatic pseudocyst: A retrospective, cohort study

Although endoscopic ultrasound (EUS)-guided transmural drainage of pancreatic fluid collections with metal stents is generally preferred over plastic stents, its superiority among different types of metal stents has not yet been well studied. We conducted this study to compare clinical outcomes and complications of a novel self-expanding biflanged metal stent (BFMS) and a traditional-shaped tubular metal stent (TMS) in treating pancreatic pseudocyst (PPC).This was a retrospective analysis on consecutive patients with PPC underwent EUS-guided transmural drainage with either TMS or BFMS in a single tertiary center with expertise in management of complex biliary and pancreatic problems. The technical and functional success rate, reintervention, complications, and recurrence rate were evaluated.From September 2013 to January 2018, 125 patients (66.4% male, median age 47 years) underwent EUS-guided transmural drainage for PPC. Among them, 49 used TMS and 76 used BFMS. All patients met the inclusion criteria that cyst diameter was >6 cm or the distance between cyst and stomach wall was shorter than 1 cm. There was no difference in technical success (98% vs 97.4%, P = 1.0) or functional success rate (87.8% vs 92.1%, P = .54) using 2 types of metal stents. However, more procedure related complications occurred in TMS than in BFMS group. TMS group had a much higher migration rate than BFMS group (14.6% vs 0, P = .001), even though there was no significant difference in bleeding, infection, or death rate between 2 groups. With similar clinical outcomes, TMS group required more additional plastic stent placement than BFMS group for better drainage.TMS and BFMS placement can both be considered as methods of endoscopic transmural PPC drainage with equal efficacy, whereas BFMS could be preferred for fewer complications or less need of additional plastic stent placement.

Laparoscopic Transgastric Sutured Cystogastrostomy for Post-traumatic Pancreatic Pseudocyst in a Low Resource Setting: Case Report and Literature Review

Pancreatic pseudocyst (PPC) complicating blunt and penetrating abdominal injury is well documented in paediatric age groups. In adults, PPC is often one of the sequelae of acute pancreatitis rather than trauma. Blunt abdominal trauma accounts for most documented cases of post-traumatic PPC. To the best of our knowledge, PPC following penetrating abdominal gunshot injury is a rare event. Laparoscopic drainage of PPC is fast gaining acceptance as the procedure of choice amongst experts as it offers many advantages and benefits of minimal access surgery to the patient. We report our experience and challenges with our first case of laparoscopic cystogastrostomy for a large post-traumatic PPC in a 24-yearold man who was diagnosed 8 months after laparotomy for a penetrating thoraco-abdominal gunshot wound. We also conduct a review of the literature on laparoscopic management of Pancreatic pseudocyst.

Increased Incidence of Pseudoaneurysm Bleeding With Lumen-Apposing Metal Stents Compared to Double-Pigtail Plastic Stents in Patients With Peripancreatic Fluid Collections

BACKGROUND & AIMS

There have been few studies that compared the effects of lumen-apposing metal stents (LAMS) and double-pigtail plastic stents (DPS) in patients with peripancreatic fluid collections from pancreatitis. We aimed to compare technical and clinical success and adverse events in patients who received LAMS vs DPS for pancreatic pseudocysts and walled-off necrosis.

METHODS

We performed a retrospective study of endoscopic ultrasound-mediated drainage in 149 patients (65% male; mean age, 47 y) with pancreatic pseudocysts or walled-off necrosis (97 received LAMS and 152 received DPS), from January 2011 through September 2016 at a single center. We collected data on patient characteristics, outcomes, hospitalizations, and imaging findings. Technical success was defined as LAMS insertion or a minimum of 2 DPS. Clinical success was defined as resolution of pancreatic pseudocysts or walled-off necrosis based on imaging results. The primary outcome was resolution of peripancreatic fluid collection with reduced abdominal pain or obstructive signs or symptoms. Secondary outcomes included the identification and management of adverse events, number of additional procedures required to resolve fluid collection, and the recurrence of fluid collection.

RESULTS

Patients who received LAMS had larger peripancreatic fluid collections than patients who received DPS prior to intervention (P = .001), and underwent an average 1.7 interventions vs 1.9 interventions for patients who received DPS (P = .93). Technical success was achieved for 90 patients with LAMS (92.8%) vs 137 patients with DPS (90.1%) (odds ratio [OR] for success with DPS, 0.82; 95% CI, 0.33-2.0; P = .67). Despite larger fluid collections in the LAMS group, there was no significant difference in proportions of patients with clinical success following placement of LAMS (82 of 84 patients, 97.6%) vs DPS (118 of 122 patients, 96.7%) (OR for clinical success with DPS, 0.73; 95% CI, 0.13-4.0; P = .71). Adverse events developed in 24 patients who received LAMS (24.7%) vs 27 patients who received DPS (17.8%) (OR for an adverse event in a patient receiving a DPS, 0.82; 95% CI, 0.33-2.0; P = .67). However, patients with LAMS had a higher risk of pseudoaneurysm bleeding than patients with DPS (OR, 10.0; 95% CI, 1.19-84.6; P = .009).

CONCLUSIONS

In a retrospective study of patients undergoing drainage of pancreatic pseudocysts or walled-off necrosis, we found LAMS and DPS to have comparable rates of technical and clinical success and adverse events. Drainage of walled-off necrosis or pancreatic pseudocysts using DPS was associated with fewer bleeding events overall, including pseudoaneurysm bleeding, but bleeding risk with LAMS should be weighed against the trend of higher actionable perforation and infection rates with DPS.

Pancreatic pseudocyst with spontaneous cutaneous fistulization: Case report

RATIONALE

Pancreatic fistula occurs as a result of pancreatic duct disruption during acute pancreatitis. An external or pancreatico-cutaneous fistula is defined as a leakage of pancreatic secretion through an abdominal wound or previously inserted drain. If the extravasated pancreatic juice is walled-off by the fibrous or granulation tissue, a pseudocyst is formed. Fistulization of the pancreatic pseudocyst into the different surrounding hollow viscera is reported. However, we present a patient with spontaneous cutaneous fistulization of the pancreatic pseudocyst into the lumbar region successfully treated conservatively. Such an extremely rare presentation is only reported twice and thus highly unexpected during the follow-up of patients after recovery from acute pancreatitis.

PATIENT CONCERNS

The patient presented with 5-days intermittent fever and a tender, fluctuant, and erythematous swelling of the left lumbar paravertebral region with black necrotic skin spot on the top of it.

DIAGNOSES

Abdominal computed tomography scan revealed retroperitoneal pseudocyst originating from the pancreatic body and tail and extending to the left flank.

INTERVENTIONS

Incision of the swelling evacuated dark amylase rich fluid. Colostomy disc and bag were applied to collect further spontaneous outflow of pseudocyst content.

OUTCOMES

Symptoms instantly resolved and the patient was managed conservatively with ambulatory follow-up of the daily volume of fistula discharge. Over the next 37 days daily fistula output gradually reduced to nil with the spontaneous closure of the external skin fistula opening.

LESSONS

Frequent follow-ups of patients after severe acute pancreatitis are necessary for early detection and timely successful treatment of pancreatic pseudocysts with such unusual and rare presentation.

[Mucous pseudocysts-when and how to treat?]

The treatment of mucous pseudocysts must consider their tendency for recurrence. There are numerous established treatment options available. The decision on the optimal therapy, however, depends on the clinical presentation and symptoms as well as on possible side effects. This review presents surgical as well as nonsurgical treatment options for digital mucous pseudocysts and an algorithm is suggested. For recurrent and symptomatic lesions with pain or deformation of the nail plate, surgical excision of the pseudocyst and closure with a flap can be considered.

Therapeutical Aspects Regarding Pancreatic Pseudocysts

Frequently appearing as a complication of pancreatitis, pancreatic pseudocysts are rare appearances in current medical practice. Multiple therapeutical options are available, from minimum invasive methods to complex open surgical techniques. The indications of drainage include symptomatic pseudocysts, large pseudocysts along with the development of complications such as hemorrhage, secondary infection, and rupture. Choosing the best drainage technique is often a challenge. Multiple factors need to be considered in managing a pseudoocyst, including its location, dimension and the patient's general state and comorbidities. Thus, a therapeutical algorithm may be of great use in choosing the most feasible technique for the diagnosed lesion that is also patient-adapted.

A case report of autoimmune pancreatitis associated with a pancreatic pseudocyst

RATIONALE

Autoimmune pancreatitis (AIP) is a special type of chronic pancreatitis, which is rarely associated with pseudocyst.

PATIENT CONCERNS

A 48-year-old man complained of a recurrent upper abdominal pain in our hospital.

DIAGNOSES

A cystic mass of size 4 × 3 cm in his pancreatic tail was found by computed tomography. The concentrations of serum carbohydrate antigen19-9 (81 U/mL) and serum immunoglobulin G4 (181 mg/dL) were elevated.

INTERVENTIONS

The patient received partial pancreatectomy with splenectomy and partial esophagectomy.

OUTCOMES

Further histopathological examination revealed a pseudocyst, significant lymphoplasmatic infiltration, and fibrosis in the pancreas and esophagus. We report a rare case of AIP complicated with a pancreatic pseudocyst and invasion of lower esophagus.

LESSONS

Our study demonstrated that surgical therapy should be considered for the refractory AIP complicated with a pancreatic pseudocyst and invasion of lower esophagus.

Black pleural effusion due to pancreatic pseudocyst: A case report

RATIONALE

Black pleural effusion (BPE) is an extremely uncommon type of pleural fluid, which can be due to infection, primary or metastatic malignancy, and hemorrhage. As reported in previous studies, BPE is also observed in some patients with pancreatic pseudocyst.

PATIENT CONCERNS

We herein reported a case of a 14-year-old female patient who was admitted to our center with a history of cough for 1 and a half months and right chest pain for 1 month. Before this, she was consecutively hospitalized in 3 different hospitals due to the same symptoms. However, the previous treatments were ineffective due to the lack of a definitive diagnosis. Laboratory examination of the pleural effusion showed BPE with a high amylase concentration. Chest x-ray and computed tomography (CT) showed massive pleural effusion, more prominent in the right chest. CT and MRCP of the abdomen showed a cystic lesion located in the tail of the pancreas, which entered the chest cavity via an esophageal hiatal hernia. DIAGNOSES:: pancreatic pseudocyst.

INTERVENTIONS

After confirming that the tumor was a pancreatic pseudocyst by intraoperative biopsy, internal drainage to the jejunum was performed.

OUTCOMES

The postoperative recovery was rapid and without complications, and the final discharge diagnosis was idiopathic pancreatic pseudocyst (without history of pancreatitis or pancreatic injuries) with BPE of the right chest.

LESSONS

This case demonstrates that massive BPE could present as a rare complication of pancreatic pseudocyst, and surgery is a potential treatment for such patients.

Surgical Treatment of Splenic Artery Pseudoaneurysm with Digestive Tract Communication - Presentation of Two Cases

Splenopancreatectomy performed for pancreatic pseudo-cyst with splenic artery pseudo-aneurysm and communication with the digestive tract (stomach or colon) is a very rare indication and a small number of these procedures are described in literature. Managing peri-pancreatic pseudo-aneurysm is complex and can be challenging. Surgical treatment is of curative intent and can involve multiple visceral resections. Surgery can be performed in an emergency setting, if the patient presents cataclysmic bleeding, or in a planned manner if the pseudo-aneurysm is discovered incidentally or if the patient manages to overcome the initial bleeding. In this paper we present two cases of pancreatic pseudo-cysts with splenic artery pseudo-aneurysms and communication with the digestive tract (one with pseudo-cystic-colonic communication and the other one with gastric communication). Both patients were males, suffered from chronic pancreatitis and were known to have pancreatic pseudo-cysts. For the treatment of the first patient, surgery was performed in an elective setting, after intensive investigations. The other patient presented with cataclysmic bleeding and emergency surgery was performed in order to control the bleeding. We conclude that surgery remains the main option of treatment for these patients. It can be used as a first line of treatment or secondary to endovascular procedures.