Hemorrhagic Cysts in the Pancreas: Risk Factors, Treatment, and Outcomes - Insights from a Single-Center Study.

BACKGROUND Hemorrhagic cysts are rarely discussed subtypes of pancreatic pseudocysts that occur in about 10% of these cases. They are caused by erosion of the walls of neighboring vessels by extravasated proteolytic pancreatic enzymes. A retrospective analysis was performed to clinically characterize risk factors, treatment, and outcome in patients with hemorrhagic cysts of the pancreas. MATERIAL AND METHODS The retrospective study included patients from the Department of Digestive Tract Surgery in Katowice, Poland, who were treated surgically for a pancreatic hemorrhagic cyst from January 2016 to November 2022. We gathered and assessed data on cyst etiology, symptoms, imaging examinations, risk factors, time, type, and complications of surgery. RESULTS The main symptom was abdominal pain, noted in 5 (62.5%) patients. The most common etiology of cyst was acute pancreatitis, which occurred in 5 patients (62.5%). The most common localization was the tail of pancreas, found in 3 patients (36.5%). The largest dimension of the cyst was 98±68 (30-200) mm. Every patient needed surgical intervention. Patients underwent distal pancreatectomy (n=3) or marsupialization (n=5). One (12.5%) postoperative complication was observed, while mortality was 0%. CONCLUSIONS Hemorrhagic cyst is a life-threatening complication of pancreatitis requiring immediate treatment. In most cases, open surgery is the treatment of choice. Despite the continuous development of minimally invasive techniques, surgical treatment remains the only effective treatment method. Depending on the cyst localization and technical possibilities, pancreatectomy or marsupialization can be applied, and both of them have low complication and mortality rates.

Surgical cystogastrostomy: Is it still worthwhile?

The article by Ker et al explores the treatment of peripancreatic fluid collection (PFC). The use of percutaneous drainage, endoscopy, and surgery for managing PFC are discussed. Percutaneous drainage is noted for its low risk profile, while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent. Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention, especially for cases with extensive collections and significant necrosis. The choice of treatment modality should be tailored to individual patient characteristics and disease factors, considering the expertise available.

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis.

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Endoscopic Drainage of Pancreatic Fluid Collections.

Pancreatic fluid collections (PFCs) are commonly encountered complications of acute and chronic pancreatitis. With the advancement of endoscopic ultrasound (EUS) techniques and devices, EUS-directed transmural drainage of symptomatic or infected PFCs has become the standard of care. Traditionally, plastic stents have been used for drainage, although lumen-apposing metal stents (LAMSs) are now favored by most endoscopists due to ease of use and reduced procedure time. While safety has been repeatedly demonstrated, follow-up care for these patients is critical as delayed adverse events of indwelling drains are known to occur.

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.

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.

[Pancreatic mucinous cystadenoma with atypical clinical presentation]. / Mutsinoznaya tsistadenoma podzheludochnoi zhelezy ­ netipichnyi variant techeniya zabolevaniya.

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.

New model for predicting the development of pancreatic pseudocyst secondary to acute pancreatitis.

Pancreatic pseudocyst (PPC) increases the risk of a poor prognosis in in patients with acute pancreatitis (AP). Currently, an efficient tool is not available for predicting the risk of PPC in patients with AP. Therefore, this research aimed to explore the risk factors associated with PPC secondary to AP and to develop a model based on clinical information for predicting PPC secondary to AP. This study included 400 patients with acute pancreatitis and pancreatic pseudocyst secondary to acute pancreatitis admitted to the emergency department and gastroenterology department of The First Affiliated Hospital of the University of Science and Technology of China from January 2019 to June 2022. Participants were divided into no PPCs (321 cases) and PPCs (79 cases). Independent factors of PPC secondary to AP were analyzed using univariate and multivariate logistic regression. The nomogram model was constructed based on multivariate logistic regression analyses, which included all risk factors, and evaluated using R. We enrolled 400 eligible patients and allocated 280 and 120 to the training and test sets, respectively. Clinical features, including severe pancreatitis history [odds ratio (OR) = 4.757; 95% confidence interval (CI): 1.758-12.871], diabetes mellitus (OR = 6.919; 95% CI: 2.084-22.967), history of biliary surgery (OR = 9.232; 95% CI: 3.022-28.203), hemoglobin (OR = 0.974; 95% CI: 0.955-0.994), albumin (OR = 0.888; 95% CI: 0.825-0.957), and body mass index (OR = 0.851; 95% CI: 0.753-0.962), were significantly associated with the incidence of PPC after AP in the training sets. Additionally, the individualized nomogram demonstrated good discrimination in the training and validation samples with good calibration, The area under the curve and 95% CI of the nomogram were 0.883 (0.839-0.927) in the training dataset and 0.839 (0.752-0.925) in the validation set. We developed a nomogram model of PPC secondary to AP using R Studio. This model has a good predictive value for PPC in patients with AP and can help improve clinical decision-making.

Left renal vein thrombosis due to pancreatic pseudocyst compression.

letter to editor.