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.

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.

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.

Systematic review comparing endoscopic, percutaneous and surgical pancreatic pseudocyst drainage

AIM: To perform a systematic review comparing the outcomes of endoscopic, percutaneous and surgical pancreatic pseudocyst drainage.METHODS: Comparative studies published between January 1980 and May 2014 were identified on Pub Med, Embase and the Cochrane controlled trials register and assessed for suitability of inclusion. The primary outcome was the treatment success rate. Secondary outcomes included were the recurrence rates, re-interventions, length of hospital stay, adverse events and mortalities.RESULTS: Ten comparative studies were identified and 3 were randomized controlled trials. Four studies reported on the outcomes of percutaneous and surgical drainage. Based on a large-scale national study, surgical drainage appeared to reduce mortality and adverse events rate as compared to the percutaneous approach. Three studies reported on the outcomes of endoscopic ultrasound(EUS) and surgical drainage. Clinical success and adverse events rates appeared to be comparable but the EUS approach reduced hospital stay, cost and improved quality of life. Three other studies comparedEUS and esophagogastroduodenoscopy-guided drainage. Both approaches were feasible for pseudocyst drainage but the success rate of the EUS approach was better for non-bulging cyst and the approach conferred additional safety benefits.CONCLUSION: In patients with unfavorable anatomy, surgical cystojejunostomy or percutaneous drainage could be considered. Large randomized studies with current definitions of pseudocysts and longer-term follow-up are needed to assess the efficacy of the various modalities.

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.

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.

Pancreatic pseudocyst drainage guided by endoscopic ultrasound

Pancreatic pseudocysts can be managed conservatively in the majority of patients but some of them will require surgical,endoscopic or percutaneous drainage. Endoscopic drainage represents an efficient modality of drainage with a high resolution rate and lower morbidity and mortality than the surgical or percutaneous approach.In this article we review the endoscopic pseudocyst drainage procedure with special emphasis on technical details.

Comparison of treatment modalities in pancreatic pseudocyst: A population based study

BACKGROUND Current therapeutic techniques for pancreatic pseudocyst include surgical management with a laparoscopic approach or an open surgical procedure,percutaneous catheter drainage and endoscopic drainage.Yet it remains controversial whether different treatment approaches affect inpatient outcome.AIM To investigate inpatient outcome of different treatment approaches in treating pancreatic pseudocyst.METHODS Here we conducted a retrospective analysis of pancreatic pseudocyst-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.International Classification of Diseases 10 clinical modification and procedure codes are used.RESULTS A total of 7060 patients meeting the above criteria were identified.Our study revealed laparoscopic approach associated with the lowest rate of red blood cell transfusion(P<0.001),and it had lower short-term complications including acute renal failure(P=0.01),urinary tract infection(P=0.01),sepsis(P<0.001)and acute respiratory failure(P=0.01).Laparoscopic surgical approach associated with the shortest mean length of stay(P=0.009),and it had the lowest total charge(P=0.03).All three modalities have similar inpatient mortality(P=0.28).The study also revealed that percutaneous drainage associated with more emergent admission(P<0.001),rural hospital performs the most open surgical drainage(P<0.001)and patients who received laparoscopic drainage are more likely to be discharged home(P<0.001).CONCLUSION Laparoscopic drainage of pancreatic pseudocysts associated with the least shortterm complications and had better outcomes comparing to percutaneous and open surgical drainage from 2016 National Inpatient Sample database.

Balloon dilator controls massive bleeding during endoscopic ultrasound-guided drainage for pancreatic pseudocyst:A case report and review of literature

Pancreatic pseudocyst(PPC), a common sequela of acute or chronic pancreatitis, was defined by the revised Atlanta classification as "a collection." Endoscopic ultrasound(EUS)-guided drainage is often considered a standard first-line therapy for patients with symptomatic PPC. This effective approach exhibits 90%-100% technical success and 85%-98% clinical success. Bleeding is a deadly adverse event associated with EUS-guided drainage procedures, and the bleeding rate ranges from 3% to 14%. Hemostasis involves conservative treatment, endoscopy, interventional radiology-guided embolization and surgery. However, few studies have reported on EUSguided drainage with massive, multiple hemorrhages related to severe pancreatogenic portal hypertension(PPH). Thus, the aim of this case report was to present a case using a balloon dilator to achieve successful hemostasis for PPH-related massive bleeding in EUSguided drainage of PPC. To our knowledge, this method has not been previously reported.

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.

Covered self expandable metallic stent with flared plastic one inside for pancreatic pseudocyst avoiding stent dislodgement

Endoscopic ultrasound-guided drainage has recently been recommended for increasing the drainage rate of endoscopically managed pancreatic fluid collections and decreasing the morbidity associated with conventional endoscopic trans-mural drainage. The type of stent used for endoscopic drainage is currently a major area of interest. A covered self expandable metallic stent (CSEMS) is an alternative to conventional drainage with plastic stents because it offers the option of providing a larger-diameter access fi stula for drainage, and may increase the fi nal success rate. One problem with CSEMS is dislodgement, so a metallic stent with flared or looped ends at both extremities may be the best option. An 85-year-old woman with severe comorbidity was treated with percutaneous approach for a large (20 cm) pancreatic pseudocyst with corpuscolated material inside. This approach failed. The patient was transferred to our institute for EUS-guided transmural drainage. EUS confi rmed a large, anechoic cyst with hyperechoic material inside. Because the cyst was large and contained mixed and corpusculated fluid, we used a metallic stent for drainage. To avoid migration of the stent and potential mucosal growth above the stent, a plastic prosthesis (7 cm, 10 Fr) with flaps at the tips was inserted inside the CSEMS. Two months later an esophagogastroduodenoscopy was done, and showed patency of the SEMS and plastic stents, which were then removed with a polypectomy snare. The patient experienced no further problems.

Miniprobe EUS in management of pancreatic pseudocyst

Pancreatic pseudocysts(PP) arise from trauma and pancreatitis;endoscopic gastro-cyst drainage(EGCD) under endoscopic ultrasonography(EUS) in symptomatic PP is the treatment of choice.Miniprobe EUS(MEUS) allows EGCD in children.We report our experience on MEUS-EGCD in PP,reviewing 13 patients(12 children;male:female = 9:3;mean age:10 years,4 mo;one 27 years,malnourished male Belardinelli-syndrome;PP:10 post-pancreatitis,3 post-traumatic).All patients underwent ultrasonography,computed tomography and magnetic resonance imaging.Conservative treatment was the first option.MEUS EGCD was indicated for retrogastric cysts larger than 5 cm,diameter increase,symptoms or infection.EGCD(stent and/or nasogastrocystic tube) was performed after MEUS(20-MHz-miniprobe) identification of place for diathermy puncture and wire insertion.In 8 cases(61.5%),there was PP disappearance;one,surgical duodenotomy and marsupialization of retro-duodenal PP.In 4 cases(31%),there was successful MEUS-EGCD;stent removal after 3 mo.No complications and no PP relapse in 4 years of mean followup.MEUS EGCD represents an option for PP,allowing a safe and effective procedure.

Novel endoscopic management for pancreatic pseudocyst with fistula to the common bile duct

Pancreatic pseudocyst formation is a well-known complication of pancreatitis. It represents about 75% of the cystic lesions of the pancreas and might be located within or surrounding the pancreatic tissue. Sixty percent of the occurrences resolve spontaneously and only persistent, symptomatic or complicated cysts need to be treated. Complications include infection, hemorrhage, gastric outlet obstruction, splenic infarction and rupture. The formation of fistulas to other viscera is rare and most commonly occurs within the stomach, duodenum or colon. We report a case of a patient with a pancreatic pseudocyst in communication with the common bile duct. There have been only few cases reported in the literature. We successfully managed our case by performing an endoscopicultrasound-guided drainage of the pancreatic collection and a contemporaneous stenting of the common bile duct. Performed independently, both drainages are effective, safe and well-coded and the expertise on these procedures is widespread. By our knowledge this therapeutic approach was never reported in literature but we retain this is the most correct treatment for this very rare condition.

Uncomplicated spontaneous rupture of pancreatic pseudocyst into stomach: A case report

Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography(CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.

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.

Endoscopic approach to pancreatic pseudocysts:An American perspective

Pancreatic pseudocysts,abscesses,and walled-off pancreatic necrosis are types of pancreatic fluid colle-ctions that arise as a consequence of pancreatic injury.Pain,early satiety,biliary obstruction,and infection are all indications for drainage.Percutaneous-radiologic drainage,surgical drainage,and endoscopic drainage are the three traditional approaches to the drainage of pancreatic pseudocysts.The endoscopic approach to pancreatic pseudocysts has evolved over the past thirty years and endoscopists are often capable of draining these collections.In experienced centers endoscopic ultrasound-guided endoscopic drainage avoids complications related to percutaneous drainage and is less invasive than surgery.

Autoimmune pancreatitis associated with a large pancreatic pseudocyst

Pancreatic cystic lesions comprise various entities with different histopathological characteristics and their dif-ferential diagnosis is often a challenge for clinicians. Autoimmune pancreatitis (AIP) is usually not considered in the differential diagnosis of cystic lesions, but often mimics the morphological aspects of pancreatic neo-plasm. We report the case of a 64-year-old male patient with a cystic pancreatic head lesion (diameter 5 cm) and stenosis of the distal bile duct requiring repeated stent-ing. Because of the clinical presentation together with moderate elevation of serum CA19-9 and massive eleva-tion of cyst fluid CA19-9 (122.695 U/L; normal range: < 37.0 U/L), the patient underwent explorative laparotomy and pylorus preserving partial pancreaticoduodenectomy. Histology revealed surprisingly AIP with an inflammatory pseudocyst. In conclusion, cyst fluid analysis of tumor markers and cyst fluid cytology lack high accuracy to clearly differentiate cystic pancreatic lesions. Although AIP is rarely associated with pseudocysts, the disease has to be considered in the differential diagnosis of cys-tic pancreatic lesions. Early examination of serum IgG, IgG4 and auto-antibodies might save these patients from unnecessary endoscopical and surgical procedures.