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 pseudocyst in children: about 7 cases]. / Le pseudokyste du pancréas chez l'enfant: à propos de 7 cas.

Pancreatic pseudocyst is a rare benign condition, in particular among children. It is an intra or extra pancreatic juice collection lacking of an epithelial lining. We conducted a retrospective study of 7 children whose medical record data were collected in the Department of Paediatric Surgery at the University Hospital Hassan II in Fez, over a period of 11 years, from 1 January 2005 to 31 December 2016. All children were male, their average age was 6.6 years (15 months - 12 years). An history of abdominal trauma was found in 4 cases, abdominal bloating, pain, vomiting and transit disorders were the primary reason for consultation. Clinical examination showed epigastric tenderness and an alteration of the general state in all cases. Abdominal ultrasound as well as abdominal CT scan helped to diagnose pancreatic pseudocyst before surgery. Six patients, out of a total of seven, underwent surgery; we opted for internal bypass (gastro-cystic anastomosis) in 4 cases, external bypass in 2 cases and therapeutic abstention in one case. Pancreatic pseudocysts are rare. Nevertheless, they are the most frequent (80% of pancreatic cystic lesions are pseudocysts and due to acute and/or chronic pancreatitis, pancreatic trauma or pancreatic ductal obstruction).

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.

The emerging role of endoscopic ultrasound for pancreaticobiliary diseases in the pediatric population.

BACKGROUND: Endoscopic ultrasound (EUS) is a useful diagnostic and therapeutic tool in the pediatric population. Given the high accuracy and sensitivity of EUS, it is particularly effective in evaluating pancreaticobiliary disease. Published literature in the use of pediatric EUS is limited. Therefore we aimed to review the current literature for EUS indications, safety, and effectiveness for the pediatric population. DATA SOURCES: English language articles on the use of pediatric endoscopic ultrasound in evaluating pancreaticobiliary diseases were retrieved from PubMed/ MEDLINE. RESULTS: We analyzed various retrospective studies and case series publications. Data were extrapolated for pediatric patients with pancreaticobiliary diseases. CONCLUSIONS: EUS offers superior imaging. It is comparible to magnetic resonance imaging and/or pancreatic-protocol computed tomography. In the current literature, there are a variety of pancreaticobiliary conditions where EUS was utilized to make a diagnosis. These include recurrent pancreatitis, congenital anomalies, microlithiasis, pancreatic pseudocysts, and pancreatic mass lesions. EUS was shown to be a safe and cost-effective modality with both diagnostic and therapeutic capabilities in the pediatric population. EUS is now increasingly being recognized as a standard of care when evaluating pancreaticobiliary conditions in children.

Chronic Pancreatitis.

Chronic pancreatitis is a debilitating condition often associated with severe abdominal pain and exocrine and endocrine dysfunction. The underlying cause is multifactorial and involves complex interaction of environmental, genetic, and/or other risk factors. The pathology is dependent on the underlying pathogenesis of the disease. This review describes the clinical, gross, and microscopic findings of the main subtypes of chronic pancreatitis: alcoholic chronic pancreatitis, obstructive chronic pancreatitis, paraduodenal ("groove") pancreatitis, pancreatic divisum, autoimmune pancreatitis, and genetic factors associated with chronic pancreatitis. As pancreatic ductal adenocarcinoma may be confused with chronic pancreatitis, the main distinguishing features between these 2 diseases are discussed.

Management of pancreatic fluid collections: A comprehensive review of the literature.

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.

Prevalence, Natural History, and Outcome of Acute Fluid Collection and Pseudocyst in Children With Acute Pancreatitis.

OBJECTIVE: Recent years have witnessed an increase in acute pancreatitis (AP) in children; however, the natural history of acute fluid collection (AFC) and pseudocyst is largely unknown. We evaluated the frequency, clinical characteristics, and natural history of pseudocysts in children with AP. METHODS: Children with AP admitted at Sanjay Gandhi Postgraduate Institute of Medical Sciences from 2001 to 2011 were enrolled and studied until complete resolution. Subjects with inadequate follow-up, recurrent AP, and chronic pancreatitis were excluded. RESULTS: Of the 58 children (43 boys, median age 14 [1-18] years) with AP, 34 (58.6%) and 22 (38%) developed AFC and pseudocyst, respectively. No difference in age (12 [4-18] vs 13 [1-16] years), etiology (idiopathic 64% vs 47% and traumatic 27.2% vs 22.2%), and systemic complications (pulmonary [18% vs 11%], renal [22.7% vs 11%], and shock [13.6% vs 10%]) was observed between children with and without pseudocyst. A total of 11 of the 22 subjects with pseudocyst underwent drainage, the commonest symptom requiring drainage being gastric outlet obstruction [n = 5] and infection [n = 2]. The 11 of the 22 children with AP and pseudocyst (size 6.4 [3-14.4] cm) showed spontaneous resolution (disappearance [n = 9] and significant reduction in size [n = 2]) during 110 (25-425) days. Symptomatic pseudocysts requiring drainage were more often secondary to traumatic AP (6/6 vs 2/14 [idiopathic], P = 0.0007) than asymptomatic pseudocysts resolving spontaneously. Overall, only 26.4% (9/34) children with AFC required drainage because of symptomatic pseudocyst. CONCLUSIONS: Among children with AP, 58.6% developed AFC and 38% developed pseudocysts. Only patients with symptomatic pseudocyst need drainage, and asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection.

[Surgical approach to chronic pancreatitis: draining and resection procedure]. / Chirurgisches Vorgehen bei chronischer Pankreatitis : Drainierende und resezierende Verfahren.

The major aims of surgical therapy in chronic pancreatitis (CP) are pain relief and good long-term quality of life with preservation of endocrine and exocrine organ function. The surgical approach is therefore focused on drainage of the congested pancreatic (and bile) duct as well as resection of fibrotic and calcified tissue. Draining procedures alone are adequate for drainage of pseudocysts (cystojejunostomy) and the pancreatic duct (Partington) if no inflammatory tumor is present in the organ. Most CP patients present with unclear head mass and subsequent duct dilation. In these patients the different modifications of duodenum-preserving pancreatic head resections (e.g. Beger, Bern) offer a preferable option. Partial duodenopancreatectomy is an alternative but may be difficult to perform due to inflammatory changes around the portal vein and venous collaterals. Segmental resection and V-shaped excision may be appropriate in special situations (segmental fibrosis, small duct disease) and are performed less frequently (approximately 5 %) in the entire surgical CP population. In cases of suspected CP-related malignancy, formal resections (partial, distal or total pancreaticoduodenectomy) must be the surgical procedures of choice and be performed according to oncological principles.

[Diagnosis of cysts in the pancreas in the mediastinum: what has changed over the past 25 years].

The paper describes a case of pancreatic pseudocyst atypically located in the mediastinum. The objective and subjective reasons for the untimely diagnosis were analyzed.

[Postnecrotic cysts of the pancreas: possible ways of minimally invasive external and internal drainage].

The authors have shown a possibility of minimally invasive interventional surgery in treatment of postnecrotic cysts of the pancreas and their complications. The most optimal accesses for drainage of the cavities located inside the body and the pancreas head are determined. The use of the methods of internal drainage of the cyst cavity connected with the main pancreatic duct allowed avoidance of open operations. The results of antegrade percutaneous or transcavital as well as retrograde endoscopic restoration of the patency of the main pancreatic duct in treatment of the pancreatic cysts connected with the duct system are shown.

The management of pancreatic injuries in children: operate or observe.

PURPOSE: The critical management decision in pediatric pancreatic injuries involves whether or not to operate on patients with grade II or III injuries. Because of the rarity of these injuries, no one hospital cares for enough patients to determine the outcome of this decision. Given this, the American Pediatric Surgical Association accrued a series of patients with pancreatic injuries from the members of its Trauma Committee. METHODS: A retrospective review of concurrent pancreatic injuries from 9 level 1 pediatric trauma centers was performed. RESULTS: Data on 131 children were submitted. Forty-three patients suffered grade II or grade III injuries. Twenty patients underwent an operation, and 23 were observed. Patients who underwent an operation had an average length of stay of 16.1 days compared with 14.2 days. Two in the operative group received total parenteral nutrition compared with 12 in the nonoperative group. Eight in the nonoperative group developed a pseudocyst compared with 3 in the operative group. CONCLUSIONS: Children with grade II or grade III pancreatic injuries managed nonoperatively had a higher rate of pseudocyst, lower rate of reoperation, and a comparable length of stay compared with those who underwent surgery. These data will be used to help design a prospective study of pancreatic injury management.

Clinical, biochemical, and radiologic parameters at admission predicting formation of a pseudocyst in acute pancreatitis.

GOALS: To evaluate clinical, biochemical, and radiologic parameters at admission, which predict the development of acute pseudocyst (AP) after acute pancreatitis. BACKGROUND: There is limited data on factors that predict the development of AP. STUDY: Seventy-five consecutive patients with AP were prospectively enrolled and subjected to clinical, laboratory, and radiologic investigation. The patients were followed up for a period of 4 weeks and then investigated radiologically for the development of AP. RESULTS: After exclusion, 65 patients (44 males) were studied. The median age was 37 years (40.9±15.5 y). Etiology of acute pancreatitis was alcohol in 24 patients, gallstones in 18, both in 4, drugs in 4, pancreas divisum in 2, postendoscopic retrograde cholangiopancreatography in 1, trauma in 1, and idiopathic in 11 patients. On admission, acute fluid collections were observed in 34 (52.31%) patients. Necrosis was noted in 38 (58.46%) patients (<30% necrosis, 30% to 50% necrosis, and >50% necrosis was observed in 36.8%, 26.3%, and 36.8% patients, respectively). On follow-up, 34 (52.3%) patients developed a pseudocyst. On univariate analysis, the factors significantly associated with pseudocyst formation were male sex, palpable mass, blood sugar greater than 150 mg/dL, necrosis, sepsis, acute fluid collections, presence of ascites, pleural effusion, a high grade of pancreatitis, and a high computed tomography severity index (CTSI) score. Multivariate regression analysis showed that male sex, presence of a palpable abdominal mass, ascites, and a high CTSI score were associated with the development of AP. CONCLUSIONS: Male sex, palpable mass, ascites, and a high CTSI score at admission can predict the development of a pseudocyst after an attack of acute pancreatitis. Acute pancreatitis patients with these parameters at admission should be closely followed for the development of a pseudocyst.

Intra-abdominal pressure alterations after large pancreatic pseudocyst transcutaneous drainage.

BACKGROUND: Acute pancreatitis leads to abdominal hypertension and compartment syndrome. Weeks after the episodes pancreatic fluids sometimes organize to pseudocysts, fluid collections by or in the gland. Aims of the present study were to evaluate the intra-abdominal pressure (IAP) induced by large pancreatic pseudocysts and to examine the effect of their transcutaneous drainage on IAP. METHODS: Twenty seven patients with a pancreatic pseudocyst were included. Nine patients with pseudocysts greater than 1l (group A) had CT drainage and eighteen (volume less than 1l) were the control group. The measurements of group A were taken 6 hours before and every morning after the drainage, while for group B, two measurements were performed, one at the day of the initial CT and one 7 days after. Abdominal compliance (Cabd) was calculated. Data were analyzed using student's t-test. RESULTS: Baseline IAP for group A was 9.3 mmHg (S.D. 1.7 mmHg), while the first post-drainage day (PDD) IAP was 5.1 mmHg (S.D. 0.7 mmHg). The second PDD IAP was 5.6 mmHg (S.D. 0.8 mmHg), the third 6.4 mmH (S.D. 1.2 mmHg)g, the fourth 6.9 mmHg (S.D. 1.6 mmHg), the fifth 7.9 mmHg (S.D. 1.5 mmHg), the sixth 8.2 mmHg (S.D. 1.4 mmHg), and the seventh 8.2 mmHg (S.D. 1.5 mmHg). Group B had baseline IAP 8.0 mmHg (S.D. 1.2 mmHg) and final 8.2 mmHg (S.D. 1.4 mmHg). Cabd after drainage was 185.6 ml/mmHg (SD 47.5 ml/mmHg). IAP values were reduced between the baseline and all the post-drainage measurements in group A. IAPs seem to stabilize after the 5th post-drainage day. Baseline IAP was higher in group A than in group B, while the two values, at day 7, were equivalent. CONCLUSION: The drainage of large pancreatic pseudocyst reduces IAP. Moreover, the IAP seems to rise shortly after the drainage again, but in a way that it remains inferior to the initial value. More chronic changes to the IAP are related to abdominal cavity's properties and have to be further studied.

A safe, effective, and cheap method of achieving pancreatic rest in patients with chronic pancreatitis with refractory symptoms and malnutrition.

OBJECTIVES: Chronic pancreatitis (CP) is common. It is associated with a substantial morbidity, including malnutrition, malabsorption, pseudocysts, metabolic disturbances, and intractable abdominal pain. Approximately 5% of patients with CP are refractory to nutritional support and opiate analgesia, making management challenging.Pancreatic rest can provide symptomatic relief. However, achieving simultaneous pancreatic rest and adequate nutritional support in these patients is difficult. We describe a technique for providing nutritional support and pancreatic rest in patients with intractable symptomatic CP. METHODS: Three patients with symptomatic CP refractory to standard treatment were included in the study. All 3 patients had masses associated with the pancreas. Symptom relief and adequate nutritional support were achieved by inserting a long-term nasojejunal (NJ) tube (Flocare Bengmark, Nutricia Clinical Care, United Kingdom) under ambulatory endoscopic guidance. Data were recorded prospectively. RESULTS: Long-term NJ tube feeding achieved pancreatic rest and significant symptomatic relief while delivering adequate nutritional support. Pseudocyst size decreased substantially in 2 patients. The third patient was found to have pancreatic carcinoma after pancreaticoduodenectomy. CONCLUSIONS: In patients with symptomatic CP refractory to standard nutritional support and opiate analgesia, long-term NJ tube feeding can be a cheap, well-tolerated, safe, and effective method of providing adequate nutritional support and substantially relieving intractable symptoms.

Pancreatic pseudocyst causing celiac artery trunk thrombosis.

CONTEXT: Vascular complications of pancreatitis are more common in alcohol- rather than gallstone-induced pancreatitis. Such complications are an important cause of mortality and morbidity, although peripancreatic vessel obstruction is a rare consequence. Patients with peripancreatic arterial obstruction can present with sudden and unexplained clinical deterioration requiring prompt diagnosis and intervention. CASE REPORT: A 42-year-old woman with a proven pancreatic pseudocyst presented with acute abdominal pain. Initial investigations were non-diagnostic. A gastroscopy revealed patchy necrosis of the proximal stomach. Following sudden clinical deterioration, a contrast-enhanced CT scan was performed. The CT scan demonstrated a thickened gastric wall with intramural gas. The decision was taken to proceed to laparotomy, which revealed both gastric and splenic infarction. A total gastrectomy with Roux-en-Y reconstruction and splenectomy was performed. She made a successful recovery. CONCLUSION: Arterial thrombosis should be considered in any patient with chronic pancreatitis who presents with an acute clinical deterioration. Successful outcomes can be achieved with prompt diagnosis using contrast-enhanced CT scanning and early surgical intervention.