Objective:Endoscopic ultrasound (EUS)-guided drainage is a widely used treatment modality for pancreatic pseudocysts (PPC). However, data on the clinical outcome and complication rates are conflicting. Our study aims to evaluate the rates of technical success, treatment success and complications of EUS-guided PPC drainage in a medium-term follow-up of 45 weeks.Materials and Methods:A retrospective review was conducted for 55 patients with symptomatic PPC from December 2005 to August 2010 drained by EUS. Medium-term follow-up data were obtained by searching their medical history or by telephonic interview.Results:A total of 61 procedures were performed. The symptoms that indicated drainage were abdominal pain (n = 43), vomiting (n = 7) and jaundice (n = 5). The procedure was technically successful in 57 of the 61 procedures (93%). The immediate complication rate was 5%. At a mean follow-up of 45 weeks, the treatment success was 75%. The medium term complications appeared in 25% of cases, which included three cases each of stent clogging, stent migration, infection and six cases of recurrence. There was no mortality.Conclusion:EUS-guided drainage is an effective treatment for PPC with a successful outcome in most of patients. Most of the complications require minimal invasive surgical treatment or repeated EUS-guided drainage procedures.

Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis (ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct (CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography (US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography (TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography (EUS) seems to be a more effective tool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography (ERCP), which should be performed only for therapeutic purposes. As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography (MRCP) or EUS, especially for small stones and small diameter of CBD, the later techniques are nowadays preferred for the evaluation of ABP patients. ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies, especially after sphincterotomy and balloon extraction of CBD stones. Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis. Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful. A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge. In conclusion, the general algorithm for CBD stone detection starts with anamnesis, serum biochemistry and then TUS, followed by EUS or MRCP. In the end, bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.

There remains debate as to how recurrent inguinal hernias should be managed. This study aimed to establish a management plan for recurrent hernias. From 1991-2000, 163 patients were operated on for recurrent inguinal hernias. The average interval from the initial surgery to recurrence was 46 months (range 10 days-13 years). The initial surgery prior to recurrence was Shouldice and other techniques without mesh in 142 cases, a Stoppa or a Lichtenstein procedure in ten and three cases, respectively, and laparoscopic repair in eight cases. The recurrent hernias were treated with a Shouldice repair in 52 cases (31.9%), the Lichtenstein technique in 48 cases (29.4%), a totally extraperitoneal laparoscopic repair in 40 cases (24.5%), and a Stoppa procedure in 23 (14.1%). The approaches to management evolved with time: the use of prostheses for recurrent hernia repair increased from 10% in 1991 (2/10) to 100% in 2000 (22/22). In contrast, the Shouldice repair decreased from 90% (18/20) in 1991 to 0% (0/22) in 2000. The Lichtenstein technique was first employed in 1993, in patients with a history of a conventional, laparoscopic, or Stoppa repair and has increased to represent 77% of cases (17/22) in 2000. The Stoppa technique has not been used since 1998. The use of a totally extraperitoneal laparoscopic approach went from 11% (2/18) in 1992 (introduction of the technique) to 23% (5/22) in 2000 and is reserved for recurrence after a Lichtenstein procedure or after conventional repair in working and/or physically active patients without any contraindications to general anesthesia. Prosthetic reinforcement has become the norm in the treatment of recurrent hernias. Given a previous conventional repair, the prosthesis can be placed by either an anterior or posterior approach. The approach is dependent on the level of activity and operability of the patient. If the recurrence follows a totally extraperitoneal or a Stoppa procedure, then the Lichtenstein intervention is recommended. A recurrence after a Lichtenstein procedure should be treated by a totally extraperitoneal approach.

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