Percutaneous drainage of pancreatic pseudocysts is associated with a higher failure rate than surgical treatment in unselected patients.
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OBJECTIVE: The primary aim was to compare directly the effectiveness of percutaneous drainage versus surgical treatment of pancreatic pseudocysts in unselected patients. The authors also wished to identify factors that may predict a successful outcome with percutaneous drainage. SUMMARY BACKGROUND DATA: Pancreatic pseudocysts are a common complication of pancreatitis, and recent data suggest that many pseudocysts may be observed or treated successfully by percutaneous drainage. Failures with percutaneous drainage have been recognized increasingly, and a direct comparison of percutaneous and surgical treatment was initiated to identify factors that may affect outcome with these approaches. METHODS: A computerized index search of the medical records of patients with a diagnosis of pancreatic pseudocyst was performed from 1984 to 1995. One hundred seventy-three patients were identified retrospectively and assigned to treatment groups: observation (n = 41), percutaneous drainage (n = 66), or surgical treatment (n = 66). Data on demographics, clinical presentation, pseudocyst etiology and characteristics, diagnostic evaluation, management, and outcome were obtained. Treatment failure was defined as persistence of a symptomatic pseudocyst or the need for additional intervention other than the original treatment. RESULTS: The etiology of pancreatitis, clinical presentation, and diagnostic evaluation did not differ between groups. Twenty-seven percent had documented chronic pancreatitis, and the etiology of pancreatitis was alcohol in 61% of patients. Mean pseudocyst size was 4.2 +/- 1 cm, 8.2 +/- 1.1 cm, and 7.4 +/- 1.3 cm in the observed, percutaneously treated, and surgically treated groups, respectively. Expectant treatment was successful in 93% of patients. Percutaneous drainage was successful in 42% of patients, whereas surgical treatment resulted in a success rate of 88%. Patients treated by percutaneous drainage had a higher mortality rate (16% vs. 0%), a higher incidence of complications (64% vs. 27%), and a longer hospital stay (45 +/- 5 days vs. 18 +/- 2 days) than patients treated by surgery. Eighty-seven percent of patients in whom percutaneous drainage failed required surgical salvage therapy. Multiple logistic regression analysis failed to reveal any factors significantly associated with a successful outcome after percutaneous drainage. CONCLUSIONS: Percutaneous drainage results in higher mortality and morbidity rates and a longer hospital stay than surgical treatment of pancreatic pseudocysts. The clinical benefit of percutaneous drainage of pancreatic pseudocysts in unselected patients has not been realized, and the role of this treatment should be established in a clinical trial. (+info)
Post-traumatic pancreatitis with associated aneurysm of the splenic artery: report of 2 cases and review of the literature.
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In patients with acute pancreatitis, profuse gastrointestinal bleeding is associated with a high death rate. The cause of such bleeding must be evaluated and the bleeding controlled urgently. Aneurysm formation is usually the cause of the bleeding. Angiography is needed to make a definitive diagnosis and the bleeding site should be controlled by angiographic embolization if possible. If this fails, aneurysm resection is necessary. Two patients are described. Both had aneurysms of the splenic artery, presenting as massive gastrointestinal bleeding in one patient and bleeding into an associated pseudocyst in the other. They required surgical repair, which was successful in both cases. (+info)
Pancreatic pseudocysts transpapillary and transmural drainage.
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BACKGROUND: Pancreatic pseudocyst endoscopic drainage has been described as a good treatment option, with morbidity and mortality rates that are lower than surgery. The aim of our study is to describe the efficacy of different forms of endoscopic drainage and estimate pseudocyst recurrence rate after short follow up period. PATIENTS AND METHODS: We studied 30 patients with pancreatic pseudocyst that presented some indication for treatment: persistent abdominal pain, infection or cholestasis. Clinical evaluation was performed with a pain scale, 0 meaning absence of pain and 4 meaning continuous pain. Pseudocysts were first evaluated by abdominal CT scan, and after endoscopic retrograde pancreatography the patients were treated by transpapillary or transmural (cystduodenostomy or cystgastrostomy) drainage. Pseudocyst resolution was documented by serial CT scans. RESULTS: 25/30 patients could be treated. Drainage was successful in 21 (70% in an 'intention to treat' basis). After a mean follow-up of 42 +/- 35.82 weeks, there was only 1 (4.2%) recurrence. A total of 6 complications occurred in 37 procedures (16.2%), and all but 2 were managed clinically and/or endoscopically: there was no mortality related to the procedure. Patients submitted to combined drainage needed more procedures than the other groups. There was no difference in the efficacy when we compared the three different drainage methods. CONCLUSIONS: We concluded that pancreatic pseudocyst endoscopic drainage is possible in most patients, with high success rate and low morbidity. (+info)
Experience of combined endoscopic percutaneous stenting with ultrasound guidance for drainage of pancreatic pseudocycts.
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The therapeutic options for treatment of pancreatic pseudocysts are numerous. We report our experience of combined endoscopic and ultrasound guided percutaneous stenting for pancreatic pseudocysts. Data were prospectively collected for 20 consecutive patients. All patients had undergone a standard technique of combined endoscopic and ultrasound guided percutaneous placement of double J stents, between a pancreatic pseudocyst and the stomach. Patients age ranged between 25 and 84 years. Thirteen of the pseudocysts were due to acute pancreatitis and 7 were due to chronic pancreatitis. The duration of the combined procedure was mean 50 min (range 30-95 min). The length of hospital stay was mean 5 days (range 2-77 days. Only two patients suffered postoperative complications; one was re-admitted 2 weeks following stenting with acute cholecystitis, the other suffering a perforated duodenal ulcer 3 weeks after stenting. There were two failures early in the series, both due to stent migration, these stents were of a small size, (4.7 French). Following this the stent size was increased to at least 7 French, no further failures occurred. There was no operative mortality for the series. Follow-up ranged between 6 months and 5 years. We conclude that a combined percutaneous and endoscopic cyst-gastrostomy stent is a safe and effective treatment for patients with suitably placed pseudocysts. (+info)
Two cases of chronic pancreatitis with pseudocyst complicated by obstructive jaundice.
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We recently treated two cases of chronic pancreatitis with obstructive jaundice due to compression of the common bile duct by pancreatic pseudocyst. The two cases were males admitted with the complaint of icteric skin color. The first, a 46-year-old male, admitted with the complaint of icteric skin color. He was treated by operative cystojejunostomy after percutaneous drainage of the pseudocyst and percutaneous transhepatic biliary drainage. The other case was a 58 year-old male who admitted with the complaint of icteric skin color. He had an infected pseudocyst in the pancreas and was endoscopically treated. Both of them were discharged with favorable clinical course and normal laboratory findings after the treatment. The former patient remained well 11 months after treatment, but the latter patient died from necrotizing pancreatitis and septic shock 6 months after treatment. Most cases of obstructive jaundice associated with pseudocysts appear to be due to fibrotic stricture of the intrapancreatic portion of the common bile duct rather than due to compression of the bile duct by the pseudocyst. In a patient with secondary pancreatic infection or obstructive jaundice following pancreatic disease, differentiating between these two conditions is an important aspect of accurate diagnosis and therapy. Herein we report two unusual cases of chronic pancreatitis with pseudocyst complicated by obstructive jaundice. (+info)
Mucinous tumors of the exocrine pancreas.
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BACKGROUND: Mucin-producing cystic neoplasms of the pancreas account for 1% of all malignant tumors of the pancreas. They include mucinous cystic neoplasms (MCNs) and mucinous ductal ectasia (MDE), also known as intraductal mucin-hypersecreting neoplasms. METHODS: This review focuses on the clinical presentation, the role of diagnostic imaging modalities, and cyst fluid analysis preoperatively in the differentiation between these tumors and other nonneoplastic cysts of the pancreas. RESULTS: MCNs and MDE evolve from pancreatic duct epithelium, produce an abundance of mucin, and are considered premalignant or malignant. While MCNs affect primarily middle-aged women with lesions occurring predominantly in the body and tail of the pancreas, MDE affects primarily men in the sixth or seventh decade with lesions more often located in the head of the pancreas. CONCLUSIONS: All mucin-producing cystic tumors of both types require surgical resection because they are frankly malignant or premalignant. Survival rates of both tumors are better than those reported for ductal cell carcinomas. Future studies are needed to improve the accuracy of diagnosing these tumors preoperatively. (+info)
Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis.
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OBJECTIVE: Erosion of pancreatic pseudocysts into adjacent vessels is a rare but highly lethal cause of intra-abdominal hemorrhage. Percutaneous angiographic embolization (PAE) of the bleeding artery has recently been advocated as the preferred therapy. This study was undertaken to survey the outcome after treatment of this complication and to make recommendations for its management. METHODS: An 11-year retrospective analysis was performed of all patients treated at a large tertiary care referral center for visceral artery pseudoaneurysms associated with pancreatic pseudocysts. RESULTS: From 1988 to 1998, 256 patients were admitted for complications of pancreatic pseudocysts. Sixteen patients (11 men and 5 women) were identified in whom a pseudocyst had eroded into a major blood vessel with hemorrhage or development of a false aneurysm. The mean age was 45 years (range, 23-67 years). Active bleeding was present in 13 patients, whereas three had evidence of recent hemorrhage. Ten of 16 patients initially underwent operative therapy, four elective and six emergency, whereas six stable patients were initially treated with PAE. Technical failures of the initial treatment or secondary complications required both therapeutic modalities in six patients, which resulted in 13 total surgical interventions and 10 PAEs. The surgical morbidity rate was 62% (8 of 13), whereas that of PAE was 50% (5 of 10). Three deaths occurred after emergency operations, two of which failed to stop the bleeding, accounting for all of the deaths in the series (3 [19%] of 16). A trend was noted toward increased death with necrotizing pancreatitis (P =.07) and emergency surgery (P =.06). Ranson's criteria were not found to be predictive of death in this series. Surgical drainage procedures were required in seven (44%) of 16 patients for infections (n = 3) or mass effect of the pseudoaneurysm (n = 3). The mean size of pseudoaneurysms that required operative intervention for secondary complications was 13.9 cm, compared with 7.7 cm for all others in the series (P =.046). Long-term follow-up was available in all 13 survivors at a mean of 44 months (range, 1-108 months). CONCLUSIONS: The management of pancreatic pseudocyst-associated pseudoaneurysms remains a challenging problem with high morbidity and death rates. Operation and PAE play complementary management roles. PAE is recommended as the initial therapy for hemodynamically stable patients. Surgery should be reserved for actively bleeding, hemodynamically unstable patients; for failed embolization; and for other secondary complications such as infection or extrinsic compression. (+info)
Three truncated forms of serum albumin associated with pancreatic pseudocyst.
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Plasma from a patient with chronic pancreatic pseudocyst showed an additional more negative albumin band (18%) on agarose gel electrophoresis. Both components bound (63)Ni(2+), indicating intact N-terminals; however, electrospray ionisation analysis of the intact proteins showed the mass of more negative albumin was 1254 Da less than the control and that the apparently normal band was 112 Da less. Reverse phase mapping and mass analysis of CNBr peptides showed three proteolytically modified forms of the C-terminal peptide indicating that some 81% of the albumin molecules lacked the C-terminal Leu residue, that 18% lacked the C-terminal KKLVAASQAALGL and that approximately 1% lacked the QAALGL sequence. These findings were further verified by tryptic mapping of the aberrant CNBr peptides. The truncations probably result from exposure of the albumin to 'leaking' pancreatic endo and exoproteases. During less acute phases of the disease, the 13 and 6 residue truncated forms together decreased to less than 1%, while the des-Leu(585) form made up the balance; no normal albumin was detected. This suggested that the des-Leu(585) form might be present at low levels in the plasma of normal individuals and CNBr mapping confirmed that it constituted 4-15% of the albumin from normal plasma. (+info)