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.

Giant complex hepatic cyst causing pseudocystitis:A case report

BACKGROUND Hepatic cysts are common benign liver tumors that are typically asymptomatic.However,larger cysts,particularly giant liver cysts,can potentially induce symptoms.If the diameter of the cyst exceeds 10 cm,it can exert pressure on adjacent organs,leading to manifestations of corresponding symptoms.Here,we report the case of a complex giant hepatic cyst that caused pseudocystitis.CASE SUMMARY A 16-year-old girl was admitted to our hospital with frequent and urgent urination.Ultrasonography revealed no obvious uterine adnexal abnormalities but showed a hypoechoic,cystic mass(173 mm×84 mm×138 mm)with clear boundaries,and an unclear blood flow signal in the abdominal cavity(extending from the lower edge of the left lobe of liver to the upper edge of the bladder).Abdominal contrast-enhanced computed tomography revealed a giant cystic mass in the abdominal and pelvic cavities,possibly originating from the liver,and a small amount of free fluid in the pelvic cavity,which subsequent magnetic resonance imaging confirmed.The imaging characteristics were consistent with a benign lesion.The patient underwent laparoscopic resection of the giant liver cyst with partial liver resection.Post-surgery her symptoms urinary symptoms were relieved completely and she was discharged on the sixth postoperative day.CONCLUSION Our patient presented with symptoms suggestive of pseudocystitis,stressing the need for considering possibilities of other etiologies and differential diagnoses.

Comparison of the treatment duration and nursing requirements of the EarWell infant ear correction system for different types of auricle deformities

Objective:To observe whether the Ear Well infant ear correction system makes any difference in terms of the treatment effect,duration,complication rate,and nursing care requirements in different types of infant auricle deformities.Methods:A total of 93 infant patients with auricular deformity(age:<3 months of age)who were diagnosed and treated in Guangzhou Children and Women’s Medical Center from April 2018 to September 2020 were selected and treated with the Ear Well infant ear correction system.We observed and recorded the effects of the Ear Well infant ear correction system,the treatment duration,the number of rebound cases,and complications that are likely to occur during treatment,and noted the related factors causing complications and the relative requirements for nursing care.Results:The Earwell infant ear correction system could effectively correct infant auricle deformities.Among the 93 cases,90 cases had positive therapeutical outcome and the effective rate was 96.77%.The treatment duration for lop ear and protruding ear was longer than for other auricle deformities;the deformity recoil and the treatment compilation rates were much higher for these 2 deformity types,and the difference was statistically significant(P<0.05).Conclusions:The treatment suggestion for the wearing duration of the Ear Well infant ear correction system for lop ear and protruding ear is a prolonged duration compared with that for other infant auricle deformities.Fur ther,the requirements for nursing care intensity and infant patient’s guardian’s nursing knowledge and skill are obviously increased for these 2 types of auricle deformities.

Abdominal Cerebrospinal Fluid Pseudocyst—A Rare Complication of Ventriculoperitoneal Shunt

An abdominal cerebrospinal fluid pseudocyst is a rare complication of ventriculoperitoneal shunt. Several theories have been suggested to explain its occurrence. The main symptoms are painful abdominal distension and vomiting, abdominal distension on examination, as abdominal ultrasound and computed tomography confirm its diagnosis. The treatment involves drainage associated with drain relocation and resection of the pseudocyst’s wall. We report two patients diagnosed with this condition who underwent surgical treatment. The first patient had an unremarkable 12-month follow-up, while the second died on the seventh postoperative day due to intravascular disseminated coagulation. In these patients, the cause has not been identified;however, an infection cannot be ruled out.

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.

Multiple intrahepatic pseudocysts in acute pancreatitis

Liver pseudocysts are a very rare complication in acute pancreatitis with only a few cases previously described. The lack of experience and literature on this condition leads to difficulties in the differential diagnosis and management. We report herein a case of acute pancreatitis who developed multiple intrahepatic pseudocysts. After complete imaging evaluation, the diagnosis was still unclear and the patient was operated on. The presence of liver lesions in patients with acute pancreatitis should raise the possibility of intrahepatic pseudocysts.

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 pseudocystocolonic fistula treated without surgical or endoscopic intervention

We report here a case of pancreatic pseudocystocolic fistula that was treated without surgical or endoscopic intervention.A 76-year-old woman,presenting with a fever and epigastric pain,was referred to our institution.Three months prior to this admission,the patient had been admitted to the hospital for acute pancreatitis.Abdominal computerized tomography(CT)revealed a 9 cm pseudocyst containing air,and a fistular opening was observed via colonoscopy.After colonoscopy,the abdominal pain was slightly improved,the fever subsided and laboratory results showed decreased C-reactive protein levels.The observed improvement was likely due to the cleansing of the bowel,which induced spontaneous drainage from the pseudocyst into the colon.Antibiotic therapy was administered and daily bowel cleansing was performed using a polyethylene glycol solution.After three weeks,a follow-up CT revealed that the size of the pseudocyst had decreased significantly from 9 to 5.3 cm.In addition,laboratory tests were improved.The patient was able to resume a normal diet and was discharged in good overall health from the hospital,without aggravation of the symptoms.A colonoscopy performed 3 mo later and a follow-up CT performed 6 mo later confirmed that both the fistula and pseudocyst had completely disappeared.

Minimally invasive treatment of pancreatic pseudocysts

A pancreatic pseudocyst(PPC) is typically a complication of acute and chronic pancreatitis, trauma or pancreatic duct obstruction. The diagnosis of PPC can be made if an acute fluid collection persists for 4 to 6 wk and is enveloped by a distinct wall.Most PPCs regress spontaneously and require no treatment, whereas some may persist and progress until complications occur. The decision whether to treat a patient who has a PPC, as well as when and with what treatment modalities, is a difficult one. PPCs can be treated with a variety of methods: percutaneous catheter drainage(PCD), endoscopic transpapillary or transmural drainage, laparoscopic surgery, or open pseudocystoenterostomy. The recent trend in the management of symptomatic PPC has moved toward less invasive approaches such as endoscopic- and image-guided PCD. The endoscopic approach is suitable because most PPCs lie adjacent to the stomach. The major advantage of the endoscopic approach is that it creates a permanent pseudocysto-gastric track with no spillage of pancreatic enzymes. However, given the drainage problems, the monitoring, catheter manipulation and the analysis of cystic content are very difficult or impossible to perform endoscopically, unlike in the PCD approach. Several conditions must be met to achieve the complete obliteration of the cyst cavity.Pancreatic duct anatomy is an important factor in the prognosis of the treatment outcome, and the recovery of disrupted pancreatic ducts is the main prognostic factor for successful treatment of PPC, regardless of the treatment method used. In this article, we review and evaluate the minimally invasive approaches in the management of PPCs.

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.

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.

Interventional endoscopic ultrasound for a symptomatic pseudocyst secondary to gastric heterotopic pancreas

Heterotopic pancreas(HP) is a relatively uncommon entity that is defined as pancreatic tissue without a true anatomical or vascular connection to the pancreas. HP does not cause symptoms in most cases but can occasionally produce various manifestations, including nausea, vomiting, abdominal pain, and even heterotopic pancreatitis. Here, we report an unusual case in which heterotopic pancreatitis complicated by the formation of a pseudocyst that caused gastric outlet obstruction was diagnosed based on serum hyperamylasemia and findings from endoscopic ultrasonography(EUS)-guided fine needle aspiration(EUS-FNA) cytology. EUS-guided single pigtail stent insertion was successfully performed for recurrent gastric outlet obstruction. The patient has remained healthy and symptom-free during 4 years of surveillance. In the context of the relevant literature, the described case is a rare case of HP complicated by a pseudocyst treated via EUS-FNA and stent insertion.

Use of a novel covered self-expandable metal stent with an anti-migration system for endoscopic ultrasound-guided drainage of a pseudocyst

The development of pseudocysts in patients with chronic pancreatitis has been reported in 23%-60% of cases and drainage is indicated when they become symptomatic. Endoscopic ultrasound-guided drainage with the placement of plastic or metallic stents to create a cystogastric anastomosis has been shown to be a reliable and efficacious maneuver. Metallic stent use appears to be a safe and effective alternative that shortens the length of time of the procedure and maintains a greater diameter in the cystogastric communication. However, important migration rates have been reported. The use of new metallic stents that are specially designed to prevent migration represents a promising development in the treatment of these group of patients that appears to be safe and effective for pseudocyst drainage and could importantly reduce migrationrates, while at the same time having the advantage of a single step procedure and a larger fistula diameter in the endoscopic cystogastric anastomosis.

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.

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.