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.

[Mediastinitis Associated with Mediastinal Pancreatic Pseudocyst Successfully Treated by Thoracoscopic Mediastinal Drainage].

Pancreatic pseudocysts rarely extend to the mediastinum and can be fatal if mediastinitis is complicated. In this report, we describe a case of mediastinitis associated with mediastinal pancreatic pseudocyst successfully treated by the thoracoscopic mediastinal drainage. The patient was a man in his 40s with a history of alcoholic acute pancreatitis. Chest and abdominal computed tomography (CT) scan taken for his complaints of back pain and dyspnea showed a pancreatic pseudocyst extending to the mediastinum. First, an endoscopic nasopancreatic drainage( ENPD) tube was placed, and then thoracoscopic mediastinal drainage was performed through the right thoracic cavity. After the operation, the pseudocyst in the mediastinum rapidly disappeared even though there was no drainage from the ENPD tube. Postoperative recovery of the patient was uneventful, and the patient was discharged on the 17th postoperatively day. This case suggests that the importance of prompt treatment for mediastinitis and the effectiveness of the thoracoscopic surgery.

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.

Analysis of pancreatic pseudocyst drainage procedural outcomes: a population based study.

BACKGROUND: A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts. METHODS: The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann-Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates. RESULTS: Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07-1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23-0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27-0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15-5.82, p = 0.02). CONCLUSIONS: Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database.

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.

Endoscopic ultrasound-guided drainage of peripancreatic fluid collections: What impacts treatment duration?

BACKGROUND: Peripancreatic fluid collections (PFCs) are complications resulting from acute or chronic pancreatitis and require treatment in certain clinical conditions. The present study aimed to identify the factors influencing the duration of endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic pseudocysts (PPCs), walled-off necrosis (WON), and acute necrotic collections (ANCs). METHODS: This was a retrospective cohort study of 68 patients with PFCs who underwent EUS-guided drainage. The timing and duration of EUS-guided drainage of various PFCs (ANC, WON, and PPCs) were compared, and the factors influencing the duration of endoscopic treatment were identified. RESULTS: The mean time to first EUS-guided PFC drainage since the acute pancreatitis episode was 372.0, 505.0, and 18.7 days for WON, PPC, and ANC, respectively, and the mean duration of treatment was 90, 60, and 63 days, respectively. A disconnected pancreatic duct, a history of percutaneous drainage, and an infected PFC were identified as factors influencing the treatment duration. A positive correlation was observed between the treatment duration and patients' age. Patients with a disconnected pancreatic duct had to undergo more procedures. In patients with PPC, clinically successful drainage was more frequently achieved after a single procedure without the need for repeated procedures than in those with WON (90% vs. 59%, P = 0.01). CONCLUSIONS: Patients with a history of percutaneous drainage, disconnected pancreatic duct, or PFC infection may require longer endoscopic treatment.

[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.

Novel 15-mm-long lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections located ≥10 mm from the luminal wall.

BACKGROUND: Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located < 10 mm from the luminal wall. We present outcomes of the use of a novel 15-mm-long cautery-enhanced LAMS for drainage of PFCs located ≥ 10 mm away. METHODS: This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence. RESULTS: 35 patients (median age 57 years; interquartile range [IQR] 47-64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64-117) maximal diameter and located 11.8 mm (IQR 10-12.3; range 10-14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58-236). Three complications occurred (9 %; one mild, two moderate). CONCLUSIONS: The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10-14 mm from the luminal wall.

Gastrointestinal Intramural Pancreatic Pseudocysts in a Dog: A Case Report and Human Literature Review.

A 9.5 yr old Yorkshire terrier presented with chronic intermittent vomiting and lethargy of 1.5 yr duration that progressed to generalized weakness. Insulin:glucose ratio was consistent with an insulinoma. Triple-phase computed tomography revealed a mid-body pancreatic nodule. The mid-body pancreatic nodule was enucleated; histopathology was consistent with an insulinoma. Two weeks after the operation, the dog presented for anorexia and diarrhea. Abdominal ultrasound revealed a thick-walled cystic lesion along the dorsal stomach wall. An intramural gastric pseudocyst was diagnosed via exploratory laparotomy and intraoperative gastroscopy. Comparison of amylase and lipase levels of the cystic fluid with that of concurrent blood serum samples confirmed the lesion was of pancreatic pseudocyst origin. The gastric pseudocyst was omentalized. Two weeks after the operation, the dog re-presented for anorexia, regurgitation, and diarrhea. An intramural duodenal pseudocyst was identified and treated with a duodenal resection and anastomosis. The dog has remained asymptomatic and recurrence free based on serial abdominal ultrasounds 22 mo following insulinoma removal. To our knowledge, this phenomenon of pancreatic pseudocysts forming in organs other than the pancreas has not been reported in dogs. This case report and comprehensive human literature review purpose is to raise awareness of this disease process in dogs.

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 50­year­old 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]. / 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.

Endoscopic cystogastrostomy: Still a viable option in children with symptomatic pancreatic fluid collection.

BACKGROUND/OBJECTIVES: Endoscopic transmural drainage is the preferred method of drainage of pancreatic fluid collections (PFCs) in adults; however, there is scant literature in children. We analyzed our experience of 33 endoscopic cystogastrostomies done in 29 children to find its efficacy and safety. METHODS: We retrospectively analyzed the prospectively collected database of 31 consecutive children (<18 years) who underwent endoscopic cystogastrostomy from June 2013 to December 2017. The procedure was done using the standard technique with an adult duodenoscope. Data related to clinical details, technical success, complications and follow-up were collected. RESULTS: The median age was 14 (3-17) years (22 males). Indications were early satiety in 28 (90%), vomiting in 15 (48%), and duodenal obstruction and infected pseudocyst in 2 children each. Etiology includes acute pancreatitis 22, post-traumatic 4 and chronic pancreatitis 5. The procedure was successful in 29 of 31 (93.5%) children with no mortality. Adverse events happened in four cases (12.9%); two infections, another with bleeding and another with pneumoperitonium, both of which resolved spontaneously. Incidents (minor bleeding) were noted in 6 (19%). Stents were removed in 26 (90%) after 12 (7-20) weeks and got spontaneously migrated out in 3 (10%) cases. Over a median follow-up of 26 (5-48) months, 26 (90%) had no recurrence of pseudocyst and 3 (10%) had recurrence of a small, asymptomatic pseudocyst. CONCLUSIONS: Endoscopic cystogastrostomy is a safe and effective method of draining bulging PFCs in children. The procedure carries acceptable morbidity with minimal recurrence. In younger children it may be the preferred method of drainage of PFCs.

Endoscopic transmural drainage is associated with improved outcomes in disconnected pancreatic duct syndrome: a systematic review and meta-analysis.

BACKGROUND: Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS. METHODS: The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. RESULTS: Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P = 0.389). CONCLUSIONS: Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Endoscopic management of local complications of chronic pancreatitis.

Endoscopic treatment of local complications in patients with chronic pancreatitis has gained ground over the surgical alternative in the last few years. The lower aggressiveness of endoscopic treatment, as well as the possibility to use it repeatedly in high-risk patients, has favored this development. In addition, the incorporation of new, highly accurate endoscopic therapeutic options such as pancreatoscopy-guided lithotripsy and endoscopic ultrasound-guided treatments make endoscopic treatment the first choice in many cases, despite discordant data in the literature. This article reviews the endoscopic treatment of the most common local complications of chronic pancreatitis, such as pancreatolithiasis, pseudocysts, and pancreatic, biliary, and duodenal ductal stenosis.

[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).

[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.

[A case of mediastinal pancreatic pseudocyst diagnosed and treated successfully by endoscopic procedure].

A 60-year-old man was admitted for investigation of a mediastinal cystic lesion. During endoscopic retrograde pancreatography, the contrast medium leaked from the head of the main pancreatic duct, and the cystic fluid collected with endoscopic ultrasonography (EUS) -guided aspiration showed high levels of pancreatic enzymes. Therefore, we diagnosed mediastinal pancreatic pseudocyst. The pseudocyst shrank as a result of EUS-guided drainage, and an endoscopic nasopancreatic drainage tube was then placed to close the fistula of the pancreatic duct. This case suggests that endoscopic procedures could be useful for the diagnosis and treatment of mediastinal pancreatic pseudocyst. We review 48 case reports of mediastinal pancreatic pseudocyst and discuss the usefulness of endoscopic procedures for diagnosis and treatment.

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.

[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.

Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: Meta-analysis.

BACKGROUND: Pancreatic pseudocyst (PP) and walled-off necrosis can be managed endoscopically, percutaneously or surgically, but with diverse efficacy. AIMS & METHODS: A comprehensive literature search was carried out from inception to December 2018, to identify articles which compared at least two of the three kinds of treatment modalities, regarding the mortality, clinical success, recurrence, complications, cost and length of hospitalisation (LOH). RESULTS: The outcomes of endoscopic (ED) and percutaneous drainage (PD) were comparable in six articles. The clinical success of endoscopic intervention was better considering any types of fluid collections (OR = 3.36; 95% confidence interval (CI) 1.48, 7.63; p = 0.004). ED was preferable regarding recurrence of PP (OR = 0.23; 95% CI 0.08, 0.66; p = 0.006). Fifteen articles compared surgical intervention with ED. Significant difference was found in postoperative LOH (WMD (days) = -4.61; 95%CI -7.89, -1.33; p = 0.006) and total LOH (WMD (days) = -3.67; 95%CI -5.00, -2.34; p < 0.001) which favored endoscopy, but ED had lower rate of clinical success (OR = 0.54; 95% CI 0.35, 0.85; p = 0.007) and higher rate of recurrence (OR = 1.80; 95% CI 1.16, 2.79; p = 0.009) in the treatment of PP. Eleven studies compared surgical and percutaneous intervention. PD resulted in higher rate of recurrence (OR = 4.91; 95% CI 1.82, 13.22; p = 0.002) and lower rate of clinical success (OR = 0.13; 95% CI 0.07, 0.22, p < 0.001). CONCLUSION: Both endoscopy and surgery are preferable over percutaneous intervention, furthermore endoscopic treatment is associated with shorter hospitalisation than surgery.