Management of Pancreatic Pseudocysts

Spivak, Hadar; Galloway, John R.; Amerson, J R; Fink, Aaron S.; Branum, Gene D.; Redvanly, Richard D.; Richardson, William; Mauren, Susan J.; Waring, J. Patrick; Hunter, John G.

doi:10.1016/s1072-7515(98)00088-x

Cited by 67 publications

(46 citation statements)

References 12 publications

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“…13,17 Interventional radiological procedures, in addition to a morbidity of 10-30% and a mortality of 2-6%, are associated with a recurrence rate of 6-22%. 6,[18][19][20] Surgical drainage has a reported morbidity of 20-30%, mortality of 2-6% with a 5% recurrence rate. 9,[21][22][23][24] Despite huge advances in the field of radiology and the current knowledge of the natural history of the pancreatic pseudocyst, we are still handicapped by our inability to predict complications in individual patients.…”

Section: Discussionmentioning

confidence: 99%

Conservative treatment as an option in the management of pancreatic pseudocyst

Cheruvu¹,

Clarke²,

Prentice³

et al. 2003

ann r coll surg engl

122

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Background: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Tr aditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. Patients and Methods: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). Results: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. Conclusions: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.

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Section: Discussionmentioning

confidence: 99%

Conservative treatment as an option in the management of pancreatic pseudocyst

Cheruvu¹,

Clarke²,

Prentice³

et al. 2003

ann r coll surg engl

122

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“…Initial studies comparing surgical drainage to percutaneous drainage found both procedures to be efficacious [20,21] . However, more recent comparative studies have generally favored percutaneous drainage [22] , with some studies even demonstrating a mortality benefit [23] .…”

Section: Percutaneous Drainagementioning

confidence: 99%

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

Tyberg¹,

Karia²,

Gabr³

et al. 2016

WJG

169

154

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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. However, with improving pathophysiologic under standing and improving diagnostic tools, it became clear that a more detailed organizational system was required. More specifically, one that distinguished between collections containing fluid alone vs those arising from necrosis and/or containing solid components. As such, a new classification system was developed known as the revised Atlanta criteria [4] . Similar to the original Atlanta Criteria, PFCs are classified as acute (< 4 wk after the pancreatitis episode) or chronic (> 4 wk after the pancreatitis episode). However, in the revised criteria, both acute and chronic collections are further subdivided based on the presence of necrosis within the collection. Acute collections are divided into: acute peripancreatic fluid collections (APFC) and acute necrotic collections (ANC); chronic fluid collections are divided into: pseudocysts or walledoff pancreatic necrosis (WOPN). These new classifications are important because the treatment and management varies depending on the type of collection. ENTERAL FEEDINGThe first step in the management of any PFC is ensuring adequate nutritional support. In mild to moderate acute pancreatitis, oral feeding can be initiated when...

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“…23 Radiologically guided percutaneous drainage of PFCs has been shown to be an effective and safe treatment. 24,25 Inevitably, the percutaneous approach (computed tomography or US-guided) was compared with the "gold standard" approach of surgical cystogastrostomy and early studies showed a marginal survival benefit with the percutaneous approach. 26 An indwelling catheter is required for the percutaneous technique; this may become a focus for infection and potentially end up in the formation of a pancreatico-cutaneous fistula, which are the 2 main long-term complications of the technique.…”

Section: Eus-guided Transmural Drainage Of Pfcsmentioning

confidence: 99%

Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions

Madácsy

Kaltsidis²

2017

Int J Gastrointest Interv

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A B S T R A C TEndoscopic ultrasound (EUS)-guided management of abdominal fluid collections adjacent to the gastroduodenal lumen is a relatively new concept attracting a lot of interest in recent years. The ability of EUS to identify and drain these collections in the same session accounts for the surge of interest in these novel techniques. On the other hand, the complexity of these interventions and associated serious complications has moderated the enthusiasm of novice endoscopists to some extent and reiterated that focused research and technical innovations are needed to make EUS-guided drainage simpler and safer. Self-expandable metallic stents (SEMS) have emerged in the last decade in the endoscopic management of malignant luminal gastrointestinal strictures. The use of SEMS in the management of benign conditions (biliary, pancreatic, and colonic strictures) is also rapidly expanding. Recently, fully-covered (FC)-SEMS have been successfully used for drainage of peripancreatic and pericholecystic fluid collections. Here we will review the existing data and future directions in the use of FC-SEMS for such drainage procedures. We will also review the literature on novel "purpose-made" prostheses, such as the lumen-apposing metallic stents, which aim to address technical problems arising in EUS-guided drainage procedures when conventional SEMS are used. Further development of these and other similar devices may transform EUS-guided drainage procedures from an esoteric concept to "mainstream", first-line intervention.

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Management of Pancreatic Pseudocysts

Cited by 67 publications

References 12 publications

Conservative treatment as an option in the management of pancreatic pseudocyst

Conservative treatment as an option in the management of pancreatic pseudocyst

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

Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions

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