Endoscopic versus surgical treatment for pancreatic pseudocyst

Zhao, Xin; Feng, Tao; Ji, Wu

doi:10.1111/den.12542

Cited by 41 publications

(32 citation statements)

References 26 publications

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“…Evidence-based multidisciplinary guidelines issued by the European Society of Gastrointestinal Endoscopy (ESGE) currently stipulate that in the absence of clinical improvement, endoscopic drainage is now the first-line procedure for symptomatic WON, with endoscopic necrosectomy or minimally invasive methods (rather than open surgery) constituting the next therapeutic step[ 2 ]. Although previous studies have shown that endoscopic and surgical remedies are comparable in instances of pancreatic pseudocyst[ 3 - 7 ], endoscopic treatment of symptomatic WON (especially infected lesions) is more of a challenge. The ESGE recommends either plastic or lumen-apposing metal stent (LAMS) placement for initial endoscopic transmural drainage[ 2 ].…”

Section: Introductionmentioning

confidence: 99%

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

Liu¹,

Wang

et al. 2020

WJG

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BACKGROUND Endoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention. AIM To assess the feasibility, efficacy and safety of EGF for WON. METHODS Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy. RESULTS EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients. CONCLUSION EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

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Section: Introductionmentioning

confidence: 99%

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

Liu¹,

Wang

et al. 2020

WJG

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“…Furthermore a Cochrane review comparing surgical and endoscopic treatment modalities concluded that further studies are required on this topic [ 27 ]. A recent analysis concluded that the optimal treatment for pancreatic pseudocyst is still controversial, in the absence of meta-analysis comparing the two approaches [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Wirsung atraumatic rupture in patient with pancreatic pseudocysts: a case presentation

et al. 2018

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BackgroundPancreatic duct disruption is a challenging condition leading to pancreatic juice leakage and consequently to pancreatic fluid collections. The manifestations of pancreatic main duct leak include pseudocysts, walled-off necrosis, pancreatic fistulas, ascites, pleural and pericardial effusions. Pseudocyst formation is the most frequent outcome of a pancreatic duct leak.Case presentationWe describe a case of a 64-year old man with large multiple pancreatic cysts discovered for progressive jaundice and significant weight loss in the absence of a previous episode of acute pancreatitis. Computed tomography scan showed lesion with thick enhancing walls. The main cyst dislocated the stomach and the duodenum inducing intra and extrahepatic bile ducts enlargement. Magnetic resonance cholangiopancreatography revealed a communication between the main pancreatic duct and the cystic lesions due to Wirsung duct rupture. Endoscopic ultrasound guided fine needle aspiration cytology did not show neoplastic cells and cyst fluid analysis revealed high amylase concentration. Preoperative exams were suggestive but not conclusive for a benign lesion. Laparotomy was necessary to confirm the presence of large communicating pseudocysts whose drainage was performed by cystogastrostomy. Histology confirmed the inflammatory nature of the cyst wall. Subsequently, the patient had progressive jaundice resolution.ConclusionPancreatic cystic masses include several pathological entities, ranging from benign to malignant lesions. Rarely pseudocysts present as complex cystic pancreatic lesions with biliary compression in absence of history of acute pancreatitis. We describe the rare case of multiple pancreatic pseudocysts due to Wirsung duct rupture in absence of previous trauma or acute pancreatitis. Magnetic resonance showed the presence of communication with the main pancreatic duct and endoscopic ultrasound fine needle aspiration suggested the benign nature of the lesion.

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“…The authors concluded that the laparoscopic approach should be preferred where relevant expertise is available [16]. A meta-analysis of 5 comparative studies, including 255 patients, published in 2015 and comparing endoscopic with surgical treatment for pancreatic pseudocysts concluded that the endoscopic approach may be the first line treatment [17]. The surgical group had a higher success rate than the endoscopic group (OR=0.43, 95%CI 0.2 to 0.95, p=0.04), with no statistical significant differences between the two groups regarding the adverse events (OR=0.67, 95% CI 0.33 to 1.36, p=0.27) and recurrence rate (OR=1.53, 95% CI 0.37 to 6.39, p=0.56) [ [19].…”

Section: Discussionmentioning

confidence: 99%

Laparoscopic Transgastric versus Endoscopic Drainage of a Large Pancreatic Pseudocyst. A Case Report

Beuran

Negoi

Catena

et al. 2016

JGLD

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Case report: A 37 year-old woman was admitted three months after an episode of severe acute pancreatitis with a large tumor mass located in her left abdomen, abdominal tenderness and asthenia. Abdominal Computed Tomography (CT) revealed a giant pancreatic pseudocyst of 23/15/12 centimeters. We performed an anterior laparoscopic transgastric cystogastrostomy. The postoperative clinical course was uneventful, and she was discharged nine days later. After another month she was re-admitted for general malaise and fever. We performed endoscopic evaluation of the cystogastrostomy patency followed by lavage of the pseudocyst cavity. After five days of broad spectrum antibiotic therapy the clinical course started to improve and the patient was discharged after another eight days. One- and two-year follow-ups revealed no remnant cavity. Conclusions: Laparoscopic transgastric cystogastrostomy is a feasible option for selected patients with pancreatic pseudocysts. Careful patients’ evaluation in a multidisciplinary team, including imaging specialists, dedicated gastroenterologists with experience in advanced interventional techniques and pancreatic surgeons, balancing between watchful waiting and step-up minimally invasive approach offers the best tailored approach for a specific patient.

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Endoscopic versus surgical treatment for pancreatic pseudocyst

Abstract: Endoscopic treatment may be the first-line treatment approach for patients with pancreatic pseudocyst.

Cited by 41 publications

References 26 publications

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

Wirsung atraumatic rupture in patient with pancreatic pseudocysts: a case presentation

Laparoscopic Transgastric versus Endoscopic Drainage of a Large Pancreatic Pseudocyst. A Case Report

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