Pancreatic pseudocyst:The past,the present,and the future

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a welldefined inflammatory wall with minimal or no necrosis.The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis.The clinical presentation is often nonspecific,with abdominal pain being the most common symptom.If a diagnosis is suspected,contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst.Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty.Pseudocyst of the pancreas can lead to complications such as hemorrhage,infection,and rupture.The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications,such as biliary or gastric outlet obstruction.Management options include endoscopic or surgical drainage.The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions,diagnosis,and management of this condition.

Early endoscopic management of an infected acute necrotic collection misdiagnosed as a pancreatic pseudocyst: A case report

BACKGROUND Infected acute necrotic collection(ANC)is a fatal complication of acute pancre-atitis with substantial morbidity and mortality.Drainage plays an exceedingly important role as the first step in invasive intervention for infected necrosis;however,there is great controversy about the optimal drainage time,and better treatment should be explored.CASE SUMMARY We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancre-atitis;conservative treatment was ineffective,and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography(CT).Endoscopic ultra-sonography(EUS)suggested hyperechoic necrotic tissue within the cyst cavity.The wall was not completely mature,and the culture of the puncture fluid was positive for A-haemolytic Streptococcus.Thus,the final diagnosis of ANC in-fection was made.The necrotic collection was not walled off and contained many solid components;therefore,the patient underwent EUS-guided aspiration and lavage.Two weeks after the collection was completely encapsulated,pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography(ERCP)was performed,and the patient was subsequently successfully discharged.On repeat CT,the pancreatic cysts had almost disappeared during the 6-month fo-llow-up period after surgery.CONCLUSION Early EUS-guided aspiration and lavage combined with late ERCP catheter drainage may be effective methods for intervention in infected ANCs.

Pancreatic Pseudocyst Rupture: Cause of Acute Abdomen

Case report of a 23-year-old male patient with a pancreatic pseudocyst, initially was treated by the Interventional Radiology service by placing percutaneous drainage with poor evolution, abruptly presented abdominal pain, Systemic Inflammatory Response Syndrome and peritoneal irritation, so an urgent exploratory laparotomy was performed with a finding of rupture of the pancreatic pseudocyst into the abdominal cavity. He presented septic shock and died in the immediate postoperative period. Computerized Axial Tomography represents the ideal diagnostic method. Spontaneous rupture is extremely rare and requires urgent surgical intervention.

Percutaneous drainage in the treatment of intrahepatic pancreatic pseudocyst with Budd-Chiari syndrome:A case report

BACKGROUND Intrahepatic pancreatic pseudocyst(IHPP)is an extremely rare complication of acute pancreatitis,with only a few cases previously described in the literature.To the best of our knowledge,IHPP with Budd-Chiari syndrome(BCS)has not yet been described.CASE SUMMARY A 35-year-old male presented with abdominal pain,vomiting and anorexia,followed by severe swelling of the lower body after 4 d.The morphological assessment(using computed tomography revealed the presence of a huge cyst of 18.28 cm×10.34 cm under the liver capsule accompanied by a large amount of ascites.Percutaneous puncture allowed us to detect a high level of amylase in the collection,confirming the diagnosis of IHPP.The cyst was treated by percu-taneous drainage,producing complete resolution of the cyst.CONCLUSION IHPP can be treated with percutaneous drainage,endoscopic drainage,surgery or even conservative treatment,depending on the specific condition.We recommend percutaneous drainage as the first choice of treatment when IHPP with secondary BCS.

Pancreatic pseudocyst

Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications (infection, gastric outlet or biliary obstruction, bleeding). Three different strategies for pancreatic pseudocysts drainage are available: endoscopic (transpapillary or transmural) drainage, percutaneous catheter drainage, or open surgery. To date, no prospective controlled studies have compared directly these approaches. As a result, the management varies based on local expertise, but in general, endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate. A tailored therapeutic approach taking into consideration patient preferences and involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and pancreatic surgeon should be considered in all cases.

Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts: A case report

Pancreatic pseudocysts （PPs） are collections of pancreatic secretions that are lined by fibrous tissues and may contain necrotic debris or blood. The interventions including percutaneous, endoscopic or surgical approaches are based on the size, location, symptoms and complications of a pseudocyst. With the availability of advanced imaging systems and cameras, better hemostatic equipments and excellent laparoscopic techniques, most pseudocysts can be found and managed by laparoscopy. We describe a case of a 30-year-old male patient with a pancreatic pseudocyst amenable to laparoscopic cystogastrostomy. An incision was made through the anterior gastric wall to expose the posterior gastric wall in close contact with the pseudocyst using an ultrasonically activated scalpel. Then, another incision was made for cystogastrostomy to obtain complete and unobstructed drainage. The patient recovered well after operation and was symptom-free during a 6-mo follow-up, suggesting that laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for minimally invasive management of PPs.

Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis:New technical developments

In the last decades,the treatment of pancreatic pseudocysts and necrosis occurring in the clinical context of acute and chronic pancreatitis has shifted towards minimally invasive endoscopic interventions.Surgical procedures can be avoided in many cases by using endoscopically placed,Endoscopic ultrasonography-guided techniques and drainages.Endoscopic ultrasound enables the placement of transmural plastic and metal stents or nasocystic tubes for the drainage of peripancreatic fluid collections.The development of selfexpanding metal stents and exchange free delivering systems have simplified the drainage of pancreatic fluid collections.This review will discuss available therapeutic techniques and new developments.

Differential treatment and early outcome in the interventional endoscopic management of pancreatic pseudocysts in 27 patients

AIM： Pancreatic pseudocysts （PPC） as a complication of pancreatitis are approached only in the case of abdominal pain, infection, bleeding, and compression onto the gastrointestinal tract or biliary tree. METHODS： From 02/01/2002 to 05/31/2004, all con- secutive patients with symptomatic PPC who underwent an interventional endoscopic approach were evaluated in this pilot case-series study： Group （Gr.） Ⅰ-Primary percutaneous （external）, ultrasound-guided drainage. Gr. Ⅱ- Primary EUS-guided cystogastrostomy. Gr. Ⅲ-EUS-guided cystogastrostomy including intracystic necrosectomy. RESULTS： （=＂follow up＂： n = 27）： Gr. Ⅰ （n = 9; 33.3%）： No complaints （n = 3）; change of an external into an internal drainage （n = 4）; complications： （a） bleeding （n = 1） followed by 3 d at ICU, discharge after 40 d; （b） septic shock （n = 1） followed by ICU and several laparotomies for programmed lavage and necrosectomy, death after 74 d. Gr. Ⅱ （n = 13; 48.1%）： No complaints （n = 11）; external drainage （n = 2）; complications/problems out of the 13 cases： 2nd separate pseudocyst （n = 1） with external drainage （since no communication with primary internal drainage）; infection of the residual cyst （n = 1） ＋ following external drainage; spontaneous PPC perforation （n = 1） ＋ following closure of the opening of the cystogastrostomy using clips and subsequently ICU for 2 d. Gr. Ⅲ （n = 5; 18.5%）： No complaints in all patients, in average two endoscopic procedures required （range, 2-6）. CONCLUSION： Interventional endoscopic management of pancreatic pseudocysts is a reasonable alternative treatment option with low invasiveness compared to surgery and an acceptable outcome with regard to the complication rate （11.1%） and mortality （3.7%）, as shown by these initial study results.

Treatment of Retrogastric Pancreatic Pseudocysts by Laparoscopic Transgastric Cystogastrostomy

This paper discusses variations of laparoscopic transgastric cystogastrostomy in management of retrogastric pancreatic pseudocysts for 8 patients with symptom or pseudocysts（larger than 6 cm） companied with clinical manifestations. Using a Harmonic scalpel, two 3–5-cm incisions were made in the anterior and posterior gastric wall respectively. In the last step, the anterior gastrotomy was closed with an Endo-GIA stapler. All cases were successfully treated without large blood loss and without conversion to open surgery. The mean operative time was 114.29±19.24 min, blood loss was 157.14±78.70 mL, and mean hospital stay was 8.29±2.98 days. Gastric fistula occurred in one case on the postoperative day 7, and closed 1 month later. No bleeding was seen in all patients during the perioperative follow-up period. CT scans, given one month after the surgeries, displayed that the pancreatic pseudocysts disappeared or decreased in size, and ultrasounds showed no fluid or food residue in stomas at the third and fifth month following surgery. No patient experienced a recurrence during the follow-up period. Transgastric laparoscopic cystogastrostomy is a minimally invasive surgical procedure with a high rate of success and a low rate of recurrence, accompanied by rapid recovery. It is easy to master, safe to perform and may be the preferred option to treat retrogastric pancreatic pseudocysts.

Pancreatic pseudocyst filled with semisolid lipids mimicking solid mass on endoscopic ultrasound

Pancreatic pseudocysts,which account for 70%-90% of pancreatic cystic lesions,characteristically are non-epithelially lined cystic cavities that are contiguous with the pancreas. Pancreatic pseudocysts can be caused by acute,chronic or traumatic pancreatitis and should be differentiated from other pancreatic diseases with cystic appearances,especially cystic neoplasms. We report a unique case of a pancreatic pseudocyst filled with semisolid lipids,which appeared by endoscopic ultrasound as a solid mass,and was therefore resected.

Sinistral portal hypertension associated with pancreatic pseudocysts - ultrasonography findings: A case report

BACKGROUND Sinistral portal hypertension associated with pancreatic pseudocysts is rare,often caused by extrinsic compression of splenic vein,the follow-up examinations by ultrasonography for early diagnosis are quietly necessary since haematemesis,a life-threatening condition.Few studies have reported the ultrasonography findings of sinistral portal hypertension.CASE SUMMARY A 52-year-old man presented with acute abdominal pain after drinking,steatorrhea,weight loss and accidentally melena in the past 2 mo.He underwent ultrasound-guided fine needle aspiration in other hospital and diagnosed with pancreatic pseudocysts.Ultrasonography imaging,in our department,appeared as cystic heterogeneous hypoechoic area with the size of 4.7 cm×3.8 cm that located posterior to the body and tail of pancreas,adjacent to splenic vein associated with thrombosis resulted from compression.Spleen incrassated to approximately 7.3 cm,but no dilation of main portal vein was presented.Color Doppler Flow Imaging demonstrated the formation of splenic venous collateral,nevertheless no significantly flow signals was observed in splenic vein.Pulsed Doppler revealed that the peak velocity of splenic venous collateral was 18.4 cm/s with continuous waveform.Laparotomy confirmed sinistral portal hypertension associated with pancreatic pseudocysts,subsequently distal pancreatectomy combined with splenectomy and partial gastrectomy was performed.CONCLUSION It’s important clinically to know the ultrasound appearance of sinistral portal hypertension associated with pancreatic pseudocysts for sonographer and physician.

Massive gastric bleeding-perforation of pancreatic pseudocyst into the stomach: A case report and review of literature

BACKGROUND Pancreatic pseudocyst may cause serious gastrointestinal complications including necrosis,infection,and perforation of the gastrointestinal tract wall,but massive gastric bleeding is very rare.CASE We report a rare case of a 49-year-old man with life-threatening gastric bleeding from a pseudoaneurysm of the splenic artery perforating the stomach induced by pancreatic pseudocyst.During hospitalization,gastroscopy revealed a bare blood vessel in an ulcer-like depression of the greater gastric curvature,and computed tomography scan confirmed a pancreatic pseudocyst invading part of the spleen and gastric wall of the greater curvature.Arteriography showed that the bare blood vessel originated from a pseudoaneurysm of the splenic artery.The bleeding was controlled by the trans-arterial embolization,the patient’s recovery was rapid and uneventful.CONCLUSION Massive gastrointestinal bleeding could be a rare complication of pancreatic pseudo aneurysm.

Sequential therapy with combined trans-papillary endoscopic nasopancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts

BACKGROUND Endoscopic retrograde pancreatic drainage(ERPD)and stent implantation has become the major treatment method for pancreatic pseudocysts.However,it is associated with a high recurrence rate and infection.AIM To manage pancreatic pseudocysts by sequential therapy with endoscopic nasopancreatic drainage(ENPD)combined with ERPD and evaluate the treatment outcome.METHODS One hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed.There were 152 cases of intubation via the duodenal papilla,of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD(two-step procedure).The success rate of the procedure,incidence of complications(infection,bleeding,etc.),recurrence,and length and cost of hospitalization were compared between the two groups.RESULTS The incidence of infection was significantly higher in the ERPD group(12 cases)than in the two-step procedure group(2 cases).Twelve patients developed infection in the ERPD group,and anti-infection therapy was effective in five cases but not in the remaining seven cases.Infection presented as fever and chills in the two-step procedure group.The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group(P<0.05).Similarly,the recurrence rate was significantly higher in the ERPD group(19 cases)than in the two-step procedure group(0 cases).CONCLUSION Sequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.

Endoscopic intramural cystogastrostomy for treatment of peripancreatic fluid collection: A viewpoint from a surgeon

Percutaneous or endoscopic drainage is the initial choice for the treatment of peripancreatic fluid collection in symptomatic patients.Endoscopic transgastric fenestration(ETGF)was first reported for the management of pancreatic pseu-docysts of 20 patients in 2008.From a surgeon’s viewpoint,ETGF is a similar procedure to cystogastrostomy in that they both produce a wide outlet orifice for the drainage of fluid and necrotic debris.ETGF can be performed at least 4 wk after the initial onset of acute pancreatitis and it has a high priority over the surgical approach.However,the surgical approach usually has a better success rate because surgical cystogastrostomy has a wider outlet(>6 cm vs 2 cm)than ETGF.However,percutaneous or endoscopic drainage,ETGF,and surgical approach offer various treatment options for peripancreatic fluid collection patients based on their conditions.

Totally laparoscopic Roux-en-Y cystojejunostomy as a sole treatment option for pancreatic pseudocysts： a report of four cases

Pancreatic pseudocyst （PPC） is one of the most common complications of acute pancreatitis,pancreatic injury or surgery.When the pseudocyst exceeds 6 cm in diameter and sustains over 6 weeks,1patients may suffer from abdominal pain, co-morbid illness, or the presence of abdominal mass.As such large pseudocyst is unlikely to resolve spontaneously, surgical treatment is necessary.

Mediastinal pancreatic pseudocyst with hemorrhage and left gastric artery pseudoaneurysm,managed with left gastric artery embolization and placement of percutaneous trans-hepatic pseudocyst drainage

Mediastinal pancreatic pseudocyst(MPP)is a rare,but known,complication of both acute and chronic pancreatitis.Most pseudocysts are associated with alcoholic pancreatitis.Recent advances in endoscopic techniques have shown promising results,with reduced chances of infection and recurrence than with percutaneous drainage,but limited availability restricts widespread use.Left gastric artery pseudoaneurysm with mediastinal pseudocyst has not been described in the literature to date.We report a successful resolution of hemorrhagic MPP with embolization of pseudoaneurysm and percutaneous trans-hepatic pseudocyst drainage.

Comparative outcomes of endoscopic ultrasound-guided lumen-apposing mental stents drainage for pancreatic pseudocysts and walled-off necrosis:Case series and meta-analysis

Background:Endoscopic ultrasound(EUS)-guided transmural drainage for pancreatic fluid collections(PFCs)has become the first-line treatment with quicker recovery and more minor injury compared with surgery and percutaneous drainage.The efficacy of stents implantation and drainage for different PFCs remains controversial,especially lumen-apposing metal stents(LAMS).This study aimed to compare the efficacy and safety of LAMS drainage for pancreatic pseudocysts(PPC)and walled-off necrosis(WON).Methods:A meta-analysis was performed for LAMS drainage for WON and PPC by systematically searching PubMed,Cochrane,and Embase databases from January 2010 to January 2020.From 2017 to 2019,12 patients who were treated with LAMS drainage for PFCs in our medical center were also reviewed and included in this study.Results:Combining 11 copies of documents with the data from our medical center,a total of 585 patients with PFCs were enrolled in this meta-analysis,including 343 patients with WON and 242 with PPC.The technical success rate in WON is not significantly different from that of PPC(P=0.08>0.05).The clinical success of LAMS placement was achieved in 99%vs 89%in PPC and WON,respectively(RR=0.92,95%CI:0.86-0.98,P=0.01<0.05).The further intervention of direct endoscopic necrosectomy was required by 60%of patients in WON group.There was no significant difference in the incidence of adverse events,including infection,bleeding,stent migration and stent occlusion,after LAMS placement between WON and PPC.Conclusions:Endoscopic ultrasound-guided LAMS for PFCs are feasible,effective with preferable technical and clinical success rates.The clinical effect of LAMS on PPC is slightly better than that of WON,but its adverse reactions still need to be verified in a large-sample prospective study.

Pancreatic Abscess: An Infection Occurring with Minimal Tissue Present

Pancreatic abscess typically occurs 4 weeks after acute pancreatitis begins and is defined as an infection of the pancreatic pseudocyst. There are other causes which include but are not limited to iatrogenic intra-abdominal procedures, chronic pancreatitis, and sending from distant sites. These abscesses are typically collections of pus that are within the region of the pancreas. There is also pancreatic necrosis that is seen among these abscesses. Here is a report on a case of a pancreatic abscess of unusual occurrence in a patient that had a near-total distal pancreatectomy. This is uncommon as the patient has very minimal pancreatic tissue remaining, yet still has developed this intra-abdominal abscess. These abscesses must be recognized quickly and removed to prevent further complications from occurring.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence.In the early phase,most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment.However,in some cases,they will develop into pancreatic pseudocyst(PPC)or walled-off necrosis(WON).When causing symptoms or coinfection,both PPC and WON may require invasive intervention.Compared to PPC,which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents,the treatment of WON is more complicated and challenging,particularly in the presence of infected necrosis.In the past few decades,with the development of minimally invasive interventional technology especially the progression of endoscopic techniques,the standard treatments of those severe complications have undergone tremendous changes.Currently,based on the robust evidence from randomized controlled trials,the step-up minimally invasive approaches have become the standard treatments for WON.However,the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected.In this review article,we will mainly discuss the indications of PPC and WON,the timing for intervention,and minimally invasive treatment,especially endoscopic treatment.We also introduced our preliminary experience in endoscopic gastric fenestration,which may be a promising innovative method for the treatment of WON.