Pancreas divisum: analysis and therapeutic alternatives with a case report.

INTRODUCTION: Pancreas divisum is a relatively common pancreatic duct anatomic variant, firstly described in the 17th century. CASE REPORT: We reported a 2-year-old child admitted to the Pediatric Clinic with breathing difficulties and abdominal pains. Examination and X-ray image, showed a vast right hydrothorax containing rusty coloured solution with a high degree of amylase. Ultrasound and computed tomography examination revealed pancreatic polycyclic pseudocysts; following magnetic resonance cholangiopancreatography (MRCP), the diagnosis of pancreas divisum was confirmed. The general condition of the patient worsened, requiring an urgent operation. External drainage of the perforated pancreatic pseudocyst was performed. Following external fistula maturation, a change from external to internal drainage was performed using Roux-en-Y fistulojejunostomy. A 3-year postoperative period was uneventful. CONCLUSION: Pancreas divisum cases are unique requiring clinical experience, rational approach, and complex multimodal management. MRCP is a valuable diagnostic method. Amongst therapeutic options, outer and internal drainage can be seen as reliable methods. Further investigations are absolutely required to determine practical and appropriate conclusions.

The microbiology of secondary and postoperative pancreatic infections: implications for antimicrobial management.

HYPOTHESIS: We reviewed our experience with secondary pancreatic infections with a focus on preemptive intervention and the potential alteration of the recovered microbial flora. The pathogens associated with postoperative pancreatic infections were analyzed with respect to nonenteric organisms, if any, that were recovered. We hypothesized that our findings might alter the antimicrobial management of these patients. DESIGN: Retrospective review. SETTING: Hospitals affiliated with the University of Tennessee Health Science Center, Memphis. PATIENTS: Patients developing secondary and postoperative pancreatic infections following severe acute pancreatitis. METHODS: Factors examined relative to secondary pancreatitis included preoperative antibiotic use and antecedent extrapancreatic infections potentially implicated in seeding the pancreatic bed. Patients who had elective resection received 24 to 48 hours of antibiotic prophylaxis. RESULTS: Twenty-two patients required surgery for secondary infections following severe acute pancreatitis, with 29 pathogenic isolates being recovered. Of these 22 patients, 14 received vancomycin hydrochloride prior to surgical intervention. Of those 14 patients, 6 had isolates recovered at the time of surgery that were positive for Enterococcus faecalis and 5 of these isolates were vancomycin resistant. Eight of the 22 patients received antifungal prophylaxis with no fungi recovered from intraoperative culture. However, 2 of the 14 patients who did not receive empiric therapy had isolates that were positive for fungi. Five patients who required an urgent operation for sepsis had pathogenic isolates that were similar to those recovered from central lines. Postoperative infections occurred in 40 of 225 patients (17.8%) who had an elective pancreatic resection, with 72 pathogenic isolates being recovered. Of these 40 patients, 22 (55.0%) had polymicrobial infections. Of the 72 pathogenic isolates recovered from patients, 34 (47.2%) were gram-positive organisms, 15 (20.8%) were fungal organisms, and 17 (23.6%) were drug-resistant bacteria. CONCLUSIONS: Prolonged vancomycin use in patients with severe acute pancreatitis is associated with the acquisition of vancomycin-resistant enterococci. Empiric antifungal therapy may reduce the incidence of secondary fungal pancreatic infections. Systemic bloodstream infections at extrapancreatic sites can lead to seeding of pancreatic pseudocysts. Postoperative infections frequently include gram-positive, fungal, and drug-resistant organisms, and empiric therapy directed at these pathogens should be utilized until definitive culture results are obtained.

[Estimation of efficacy of the ozone-quant therapy in prophylaxis and treatment of the purulent-necrotic complications of pancreatic pseudocysts].

There were analyzed the tactics and the results of 132 patients complex surgical treatment , suffering pancreatic gland pseudocysts (PGP). The original method of the ozone-quant therapy (OQTH), using biophysical factors, such as the ozonized solution of sodium chloride and low-intensity laser irradiation, was applied for prophylaxis and treatment of PGP purulent-necrotic complications (PNC). The data obtained, witness about efficacy of the proposed OQTH method in prophylaxis and treatment of PGP PNC.

[Intestinal occlusion due to pancreatitis mimicking stenosing neoplasm of the splenic angle of the colon]. / Oclusión intestinal secundaria a pancreatitis que mimetiza una neoplasia estenosante del ángulo esplénico del colon.

Colonic involvement in patients with severe acute pancreatitis or chronic pancreatitis is common and complications such as paralytic ileus, segmental necrosis and pancreatic-colonic fistulae have been described. However, mechanical occlusion of the colon due to pancreatitis is infrequent. We present the case of a 45-year-old man with occlusion of the colon secondary to asymptomatic pancreatitis mimicking a locally advanced stenosing neoplasm of the splenic angle. Ten years prior to the present episode the patient had presented acute alcoholic pancreatitis complicated by a pseudocyst requiring surgery. The current reason for admission was abdominal colic pain and constipation with onset 5 days previously. Contrast enema was administered showing colonic occlusion caused by stenosis at the splenic flexure, suggesting the presence of a neoplasm. Urgent laparotomy showed the presence of a tumor originating in the colon that infiltrated the splenic hilum. Subtotal colectomy and en-bloc splenectomy were performed. Histopathological analysis showed pericolonic inflammation and fibrosis secondary to pancreatitis; the colonic mucosa showed no tumoral infiltration. To date, fewer than 30 cases of this infrequent complication have been published.

Oclusión intestinal secundaria a pancreatitis que mimetiza una neoplasia estenosante del ángulo esplénico del colon / Intestinal occlusion due to pancreatitis mimicking stenosing neoplasm of the splenic angle of the colon

La afectación del colon en pacientes con pancreatitis aguda grave o pancreatitis crónica es frecuente y se han descrito complicaciones como el íleo paralítico, la necrosis segmentaria y la fístulas pancreatocolónicas. Sin embargo, la oclusión mecánica del colon debida a la pancreatitis es infrecuente. Presentamos el caso de un paciente de 45 años con una oclusión de colon secundaria a una pancreatitis asintomática que mimetizaba una neoplasia estenosante y localmente avanzada del ángulo esplénico. El paciente había presentado una pancreatitis aguda alcohólica complicada con un seudoquiste que requirió cirugía 10 años antes del presente episodio. El motivo del ingreso actual fue dolor abdominal cólico y estreñimiento de 5 días de evolución. Se realizó un enema con contraste que mostraba una oclusión de colon causada por una estenosis en la flexura esplénica muy indicativa de neoplasia. La laparotomía de urgencia mostró la presencia de una tumoración originada en el colon que infiltraba el hilio esplénico. Se realizaron una colectomía subtotal y una esplenectomía en bloque. El examen histopatológico mostró una inflamación pericólica y fibrosis secundaria a una pancreatitis; la mucosa del colon no mostraba infiltración tumoral. Hasta ahora se han publicado menos de 30 casos de esta infrecuente complicación

Colonic involvement in patients with severe acute pancreatitis or chronic pancreatitis is common and complications such as paralytic ileus, segmental necrosis and pancreatic-colonic fistulae have been described. However, mechanical occlusion of the colon due to pancreatitis is infrequent. We present the case of a 45-year-old man with occlusion of the colon secondary to asymptomatic pancreatitis mimicking a locally advanced stenosing neoplasm of the splenic angle. Ten years prior to the present episode the patient had presented acute alcoholic pancreatitis complicated by a pseudocyst requiring surgery. The current reason for admission was abdominal colic pain and constipation with onset 5 days previously. Contrast enema was administered showing colonic occlusion caused by stenosis at the splenic flexure, suggesting the presence of a neoplasm. Urgent laparotomy showed the presence of a tumor originating in the colon that infiltrated the splenic hilum. Subtotal colectomy and en-bloc splenectomy were performed. Histopathological analysis showed pericolonic inflammation and fibrosis secondary to pancreatitis; the colonic mucosa showed no tumoral infiltration. To date, fewer than 30 cases of this infrequent complication have been published

Surgical decisions in the treatment of pancreatic pseudocysts

Durante os anos de 1969 a 1979 foram operados 35 pacientes com pseudocistos pancreáticos no Departamento de Cirurgia do Hospital Universitário de Göttingen, República Federal da Alemanha. Utilizaram-se como meios diagnósticos exames de laboratório, em especial amilase sérica e urinária seriada e creatinina, ecografia abdominal, estudo contrastado do trato digestivo superior, Rx de tórax, enema opaco e colangiografia. Apesar do alto número de acidentes de trânsito, os pseudocistos de origem traumática foram raros e a maioria foi operada como resultado de uma pancreatite crônica. O mesmo ocorreu com os que sucederam pancreatite aguda ou recidivante. Uma única operaçäo foi necessária em 31 casos, enquanto um dos casos de ressecçäo pancreática, de um total de quatro, constituiu a única ocasiäo em que se teve que recorrer a re-intervençöes. Drenagem externa exclusiva foi realizada em três casos, utilizando-se drenagem interna 28 vezes, dentre as quais 21 derivaçöes em Y de Roux. Este método demonstrou-se o mais apropriado do ponto de vista cirúrgico e funcional. Näo houve mortalidade na série, sendo que apenas três pacientes tiveram curso pós-operatório complicado. O tempo médio de hospitalizaçäo foi de 25 dias. Recomenda-se a cistojejunostomia em Y de Roux como tratamento cirúrgico de escolha para drenagem de pseudocisto pancreático

[Surgical aspect in the management of pancreatic pseudocyst]. / Aspecto quirúrgico en el manejo de los pseudoquistes pancreáticos.

During the years from 1969 to 1979, 35 patients were operated 36 occasioned by pancreatic pseudocysts in the Department of Surgery of the University Hospital of Göettingen, West Germany. They were utilized as diagnostic methods laboratory exams, especially serial seric and urinary amylase as creatinine and at the same time abdominal echography, upper gastrointestinal tract X-rays, thorax X-rays, Barium Enema and Biliary tract X-rays. Although the great number of transit accidents, the traumatic pancreatic pseudocysts were seldom found and most of them were operated as a result of a chronic pancreatitis. Contrarily the pancreatic pseudocysts as result of an acute pancreatitis and recurrent acute pancreatitis were in a limited number. We observed only 2 cases of acute pancreatitis with biliary etiology. We realized one operation in 31 cases and in one resection, four of the series, was the only occasion that we recurred for a second and a third operation. The external drainage was realized exclusively in 3 cases while internal drainage was performed 28 times. The surgical technic frequently used as internal drainage was the Roux en-Y Cystojejunostomy and was perfomed in 21 patients. This method demonstrated to be the most fit by morphologic as functional reasons. We observed that our mortality was null and our post-operative morbility was minimal, so, we have only 3 patients with complicated post-operative course. The mean hospitalization time was 25 days. We surgical treatment of choice for the drainage of the pancreatic pseudocysts.