[Mediastinal pancreatobiliary pseudocysts]. / Mediastinal'nye pankreatobiliogennye zhidkostnye obrazovaniya.

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 58-Year-Old Woman with Gallstones, Chronic Pancreatitis, and Pancreatic Pseudocyst Presenting with Pleural Effusion Due to a Pancreaticopleural Fistula.

BACKGROUND Pancreaticopleural fistula (PPF) is a rare complication of acute and chronic pancreatitis. PPF results from the release of pancreatic enzymes, either from a damaged pancreatic duct or pancreatic pseudocyst. This report is of a 58-year-old woman with a history of chronic pancreatitis associated with gallstones who had a known pancreatic pseudocyst that was being managed conservatively and who presented to the Emergency Department with pleural effusion due to a PPF. CASE REPORT A 58-year-old woman with past medical history of gallstone pancreatitis with subsequent development of pancreatic pseudocyst (being managed conservatively) presented with a 2-week history of progressive exertional shortness of breath. Physical examination indicated decreased breath sounds on the right lower lung fields. A chest X-ray revealed possible subphrenic free air. Laboratory test results were unremarkable except for elevated D-dimer levels. Computed tomography angiography revealed a large right-sided pleural effusion, which led to thoracentesis and the results illustrated elevated amylase levels. Magnetic resonance cholangiopancreatography was done, which showed pancreatic pseudocyst and possibly a fistula. Pancreatic enzymes were not checked in pleural fluid, as diagnosis was established with the presence of amylase and imaging findings. The patient felt better clinically after thoracentesis with volume removal and was discharged. She later underwent endoscopic ultrasound, which revealed a pancreatic duct leak requiring stent placement. CONCLUSIONS Pleural effusions rarely occur secondary to PPF. Physicians must be wary of the presentation, especially in patients with a history of a conservatively managed pancreatitis pseudocyst. Early diagnosis and management can lead to prevention of long-term morbidity and mortality.

Chronic pancreatitis for the clinician. Part 1: Etiology and diagnosis. Interdisciplinary position paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees. / Pancreatitis crónica para el clínico. Parte 1: etiología y diagnóstico. Documento de posicionamiento interdisciplinar de la Societat Catalana de Digestologia y la Societat Catalana de Pàncrees.

Chronic pancreatitis is a chronic fibroinflammatory disease of the pancreas with prevalence around 50 cases per 100,000 inhabitants. It appears to originate from diverse and yet mixed etiological factors. It shows highly variable presenting features, complication types and disease progression rates. Treatment options are as wide as the multiple personalized scenarios the disease might exhibit at a given time point. Some medical societies have developed guidelines for diagnosis and treatment based on scientific evidence. Although these efforts are to be acknowledged, the gathered level of evidence for any topic is usually low and, therefore, recommendations tend to be vague or weak. In the present series of position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on interdisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 1 of this paper series discusses topics on aetiology and diagnosis of chronic pancreatitis. Main clinical features are abdominal pain, exocrine and endocrine insufficiency and symptoms derived from complications. Some patients remain symptom-free. Diagnosis (definitive, probable or uncertain) should be based on objective data obtained from imaging, histology, or functional tests.

[Treatment strategy for complicated pancreatic pseudocysts]. / Vybor taktiki lecheniya oslozhnennykh psevdokist podzheludochnoi zhelezy.

OBJECTIVE: To analyze an effectiveness of various surgical approaches for complicated pancreatic pseudocysts. MATERIAL AND METHODS: The results of surgical treatment were analyzed in 188 patients with complicated pancreatic pseudocysts. The study included patients with one of complications of pseudocyst (infection, bleeding, compression of adjacent organs, perforation). Depending on surgical treatment, patients were divided into 2 groups: the 1st group (76 patients) - laparotomy followed by certain open surgery, the 2nd group (112 patients) - various minimally invasive treatments without further open operations. RESULTS: Effectiveness of surgical treatment was analyzed considering incidence of complications (postoperative wound suppuration, pneumonia, sepsis, multiple organ failure) and mortality. In the 1st group, postoperative wound suppuration - 22 (29%) patients, pneumonia - 17 (22.4%), sepsis - 14 (18.4%) patients, multiple organ failure - 14 (18.4%), 15 (19.8%) patients died. In the 2nd group, these values significantly differed: postoperative wound suppuration - 9 (8%), pneumonia - 5 (4.3%), sepsis - 1 (0.9%), multiple organ failure - 4 (3.5%), 1 (0.9%) patient died. CONCLUSION: Minimally invasive measures are the most optimal for any complication of pancreatic pseudocyst. Laparotomy is indicated if minimally invasive intervention is impossible for certain reason. It is advisable to concentrate these patients in specialized centers.

[Conservative or surgical treatment of chronic pancreatitis?] / Konservative oder chirurgische Therapie der chronischen Pankreatitis?

The cardinal symptom of chronic pancreatitis is severe belt-like upper abdominal pain, which requires immediate and adequate treatment. Furthermore, advanced stage chronic pancreatitis is often associated with complications, such as pancreatic pseudocysts, pancreatic duct stones and stenosis as well as biliary stenosis. The various endoscopic and surgical treatment options for chronic pancreatitis patients have been controversially discussed for decades. The new German S3 guidelines on pancreatitis now clearly define the best treatment options depending on the indications for treatment. For the treatment of pain in chronic pancreatitis it has been known for a long time that a surgical intervention is superior to endoscopic intervention concerning long-term pain relief. The recently published ESCAPE study has further underlined this by showing that early surgical intervention was superior to a step-up approach with initial endoscopic treatment. For the treatment of pancreatic pain, an initial endoscopic treatment attempt is therefore justified for short-term pain relief but in the midterm and long term, surgical intervention is the treatment of choice. In contrast, pancreatic pseudocysts, solitary proximally situated pancreatic duct stones and benign biliary strictures (except in calcifying pancreatitis) can nowadays generally be managed endoscopically. For distal pancreatic duct stones and symptomatic pancreatic duct stenosis surgical treatment is again the method of choice. This review article discusses these indication-related procedures in detail and explains them in relation to the recently published S3 guidelines on pancreatitis of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS).

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.

Mediastinal pancreatic pseudocyst masquerading as diffuse alveolar haemorrhage.

Pancreatic pseudocyst formation with extension into the mediastinum is an uncommon complication of pancreatitis that can result in numerous pulmonary and cardiac complications. We present a case of a 56-year-old man with a history of recurrent pancreatitis who presented with haemoptysis. His initial workup was consistent with diffuse alveolar haemorrhage for which he was treated with glucocorticoids. After failure to improve, further imaging demonstrated a complex fluid collection in the mediastinum consistent with extension of his pre-existing pancreatic pseudocyst, leading to erosion into the right lower lobe of the lung. This case highlights a rare pulmonary complication of pancreatitis and underscores the importance of proper identification of this condition to guide successful management.

Surgical Treatment for an Esophageal Carcinoma With a Pancreatic Pseudocyst.

The challenge for surgical management of a pancreatic pseudocyst during esophagectomy is not only to preserve the gastric wall, but also to avoid forming a pancreatic fistula. We report a case of a 54-year-old man with an esophageal squamous cell carcinoma who had a synchronous pancreatic pseudocyst. Roux-en-Y cystojejunostomy was performed during a McKeown esophagectomy to enable drainage of the pancreatic pseudocyst through the jejunum. The patient recovered after the operation, and the formation of a pancreatic fistula was avoided successfully.

Risk Factors Analysis and Nomogram Development for Pancreatic Pseudocyst in Idiopathic Chronic Pancreatitis.

OBJECTIVE: The study concerns identifying risk factors and developing nomogram for pancreatic pseudocyst (PPC) in idiopathic chronic pancreatitis (ICP) to facilitate early diagnosis. METHODS: From January 2000 to December 2013, ICP patients admitted to our center were enrolled. Cumulative incidence of PPC was determined by Kaplan-Meier method. Patients were randomized into training group and validation group in a 2:1 ratio. Risk factors of PPC were determined through Cox proportional hazards regression model based on training cohort. The nomogram was constructed according to risk factors. RESULTS: Totally, 1633 ICP patients were included with a median follow-up duration of 9.8 years. Pancreatic pseudocyst was observed in 14.7% (240/1633) of patients after ICP onset. The cumulative incidences of PPC were 8.2%, 10.4%, and 12.9% at 3, 5, and 10 years after ICP onset, respectively. Male sex, smoking history, history of severe acute pancreatitis, and chronic pain at/before diagnosis of ICP and complex pathologic changes in main pancreatic duct were recognized as risk factors of PPC development. The nomogram constructed with these risk factors achieved good concordance indexes. CONCLUSIONS: Risk for PPC could be estimated through the nomogram. High-risk patients were suggested to be followed up closely to help early diagnosis of PPC.

Seudoquiste mediastinal y fistulización pleural, excepcional complicación de una pancreatitis / Mediastinal pseudocyst and pleural fistulization, exceptional complication of pancreatitis

Resumen Introducción: Las complicaciones torácicas secundarias a pancreatitis aguda son excepcionales y más aún la presencia de un pseudoquiste mediastinal. Caso Clínico: Hombre de 36 años. Consumidor de marihuana y alcohol. Historia de 6 meses de dolor abdominal y adelgazamiento de 20 kilos. Instalando en la evolución sintomatología respiratoria. Discusión: Se discuten las formas de presentación de esta entidad. Sus etiologías más frecuentes. Se hace énfasis en el rol de la imagenología así como en el análisis del líquido pleural. El enfoque terapéutico es conservador al inicio y en algunos pacientes es quirúrgico en la evolución; con diversas opciones.

Introduction: The thoracic complications secondary to acute pancreatitis are exceptional and even more so the presence of a mediastinal pseudocyst. Case report: 36 year old man. Marijuana and alcohol consumer. History of 6 months of abdominal pain and weight loss of 20 kilos. Installing respiratory symptomatology evolution. Discussion: The forms of presentation of this entity are discussed. Its most frequent etiologies. Emphasis is placed on the role of imaging as well as the analysis of pleural fluid. The therapeutic approach is conservative at the beginning and in some patients it is surgical during evolution; with several options.

Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management.

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

Pancreatic abscess within hepato-gastric ligament: case report of an extremely rare disease.

BACKGROUND: Pancreatic pseudocyst is a very common benign cystic lesion of the pancreas. It develops in 5-15% of patients with peri-pancreatic fluid collection following acute pancreatitis. Collection usually occurs within the lesser sac of the omentum (near the pancreatic head and body region). But in 20-22% cases, that may be extra-pancreatic like in the mediastinum, pleura, in the peritoneal cavity including the pelvis. The pancreatic pseudocyst typically contains brownish fluid with necrotic tissue sludge which may get infected giving rise to infected pseudocyst or pancreatic abscess. The present case is an unusual condition of a young alcoholic subject who was finally diagnosed as a case of a pancreatic abscess within hepato-gastric ligament and was managed with operative intervention. To the best of the author's knowledge, it is the first-ever reported case of a pancreatic abscess within the hepato-gastric ligament in the world. Literature was reviewed to explore potential etiopathogenesis and therapeutic strategies of this extremely rare condition. CASE PRESENTATION: A 38 years old gentleman, chronic alcoholic, having a previous history of acute pancreatitis 3 months back, presented with fever (102 degrees Fahrenheit) and a huge [20 cm (horizontal) X 15 cm (vertical)] severely painful swelling in the epigastric region. The swelling was round-shaped, intra-abdominal, fixed to deeper tissue, tense-cystic, poorly trans-illuminant, non-pulsatile and irreducible. Routine blood tests showed leucocytosis (14,500/mm3) with neutrophilia and elevated plasma pancreatic amylase and lipase levels. USG and MDCT scan of the whole abdomen revealed a thick-walled echogenic cystic swelling of size 18 cm × 12 cm in the epigastric region. USG guided aspiration of the cyst revealed mixed purulent brownish fluid. The cyst fluid was negative for mucin stain and contained high amylase level with low CEA level, suggesting infected pancreatic pseudocyst. An open drainage procedure was considered through an upper midline laparotomy. Aspiration of the pus mixed cyst fluid along with tissue debris was done. Through irrigation of the cyst was done with normal saline. The cyst wall was de-roofed leaving a small part adherent to the inferior surface of the left lobe of the liver. Later the cyst fluid culture showed significant growth of Escherichia coli. He was put on IV antibiotics. The patient was discharged in a stable condition after 5 days. The histopathological examination confirmed pancreatic abscess. Six months after the operation, the patient is doing well, remaining asymptomatic and there is no sign of recurrence. CONCLUSIONS: Due to extreme rarity, pancreatic abscess formation within hepato-gastric ligament may be a diagnostic dilemma and requires a high index of suspicion. Surgeons should be aware of this rare clinical entity for prompt management of potential morbidity.

Excellent Accuracy of Glucose Level in Cystic Fluid for Diagnosis of Pancreatic Mucinous Cysts.

BACKGROUND: CEA in pancreatic cystic fluid (PCF) is standard for mucinous cysts diagnosis. Glucose is an alternative, but its accuracy remains poorly described. AIMS: To evaluate PCF glucose using a glucometer and compare its accuracy with CEA for mucinous cysts diagnosis. MATERIALS AND METHODS: In frozen PCF obtained by EUS-FNA, glucose was evaluated using a glucometer. CEA and cytology were available as standard of care. The accuracy of glucose and CEA was calculated using receiver operator (ROC) curves. Definitive diagnoses were surgical or clinicopathological. RESULTS: We evaluated 82 patients with a mean age of 61.3 ± 14.8 years (25-91), predominantly (59%) females. Diagnoses included 17 serous cystadenomas, five pseudocysts, 20 intraductal papillary mucinous neoplasms, three mucinous cystic neoplasms, five adenocarcinomas, four neuroendocrine tumors, two other types, 26 non-defined. The median glucose levels (interquartile range) were 19 mg/dL (19-19) in mucinous and 105 mg/dL (96-127) in non-mucinous cysts (p < 0.0001). The median CEA level was 741 ng/mL (165-28,567) in mucinous and 9 ng/mL (5-19) in non-mucinous cysts (p < 0.0001). For mucinous cyst diagnosis, a CEA > 192 ng/mL had a sensitivity of 72% (95% CI 51-88) and a specificity of 96% (95% CI 82-100), and ROC analysis showed an area under the curve (AUC) of 0.842 (95% CI 0.726-0.959), while glucose < 50 mg/dL had a sensitivity of 89% (95% CI 72-98), a specificity of 86% (95% CI 67-96), and an AUC of 0.86 (95% CI 0.748-0.973). Pseudocysts presented low glucose, identically to mucinous cysts, with CEA allowing differential diagnosis. CONCLUSION: Glucose measured by a glucometer is accurate for mucinous cyst diagnosis, with significantly higher levels in non-mucinous cysts, except pseudocysts.

Disconnected Pancreatic Duct Syndrome: Spectrum of Operative Management.

BACKGROUND: Disconnected pancreatic duct syndrome (DPDS) is common after necrotizing pancreatitis (NP). Surgical management may be by internal drainage or left (distal) pancreatectomy. Therapeutic decision-making must consider sinistral portal hypertension, parenchymal volume of disconnected pancreas, and timing relative to definitive management of pancreatic necrosis. The aim of this study is to evaluate outcomes after operative management for DPDS. METHODS: All patients with NP undergoing an operation for DPDS were included in the study (2005-2017). Perioperative outcomes and long-term durability were evaluated. RESULTS: Among 647 patients with NP, 299 (46%) had DPDS. Operative management was required in 202/299 (68%) patients with DPDS. Median follow-up was 30 mo (2-165). Definitive operative therapy included internal drainage (n = 111) or resection (n = 91). Time from NP diagnosis to operation was 126 d (20 d to 81 mo). Overall morbidity was 46%. Postoperative length of stay was 7 d (2-97). Readmission was required in 39 patients (19%). Mortality was 2%. Repeat pancreatic intervention was required in 23 patients (11%) at a median of 15 mo (1-98). Repeat pancreatectomy was performed in nine patients and the remaining 14 patients were managed with endoscopic therapy. CONCLUSIONS: DPDS is a common and challenging consequence of NP. Appropriate operation is durable in nearly 90% of patients.