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Reports of pancreatic pseudocyst drainage during metabolic bariatric surgery are extremely rare. Our patient is a 38-year-old female suffering from obesity grade IV and presents a persistent symptomatic pancreatic pseudocyst 8 months after an episode of acute biliary pancreatitis. After an extensive evaluation and considering other treatment options, our multidisciplinary team and the patient decided to perform a one-stage procedure consisting of laparoscopic cystogastrostomy, cholecystectomy, and one-anastomosis gastric bypass. After bringing the patient to the operating room, the surgeon performed an anterior gastrostomy to access the stomach's posterior wall, followed by a 6-cm cystogastrostomy on both the stomach's posterior wall and the cyst. Next, a cholecystectomy which involved dissecting the triangle of Calot was performed. Then, an 18-cm gastric pouch using a 36-Fr calibration tube was created. The cystogastrostomy was left in the remaining stomach. Finally, gastrojejunal anastomosis is done. The patient's postoperative course proceeded smoothly, leading to her home discharge on the third postoperative day. At the 1-year follow-up, the patient had lost 56 kg and was symptom-free; a computer tomography scan showed that the pancreatic pseudocyst had resolved. This case shows a video of a successful laparoscopic cystogastrostomy, cholecystectomy, and one-anastomosis gastric bypass (OAGB) used to treat persistent abdominal pain and obesity grade IV. We also conduct a bibliographic review. [ABSTRACT FROM AUTHOR]

Xanthogranulomatous inflammation is a chronic inflammatory reaction microscopically characterized by aggregation of foamy histiocytes, fibrous tissue, and infiltration of various inflammatory cells. In contrast to xanthogranulomatous inflammation in the gallbladder or kidney, xanthogranulomatous pancreatitis is rare. We herein present a case of xanthogranulomatous pancreatitis in a patient who underwent distal pancreatectomy with splenectomy under preoperative suspicion of a pancreatic pseudocyst or pancreatic tumor. A 77-year-old woman with a 1 month history of epigastric pain, anorexia, and general fatigue was admitted to our hospital. Contrast-enhanced computed tomography revealed a cystic mass with ill-defined margins at the pancreatic tail together with a splenic abscess. Contrast-enhanced endoscopic ultrasound detected a hyperechoic cystic lesion at the tail of the pancreas with heterogeneous internal echogenicity, and part of the intra-cystic content was enhanced by the contrast agent. Endoscopic retrograde cholangiopancreatography showed a cystic lesion at the tail of the pancreas that continued into the main pancreatic duct, and the main pancreatic duct was slightly narrowed downstream of the cystic lesion. Pancreatic juice cytology revealed suspicious cells, leading to the possibility of intraductal papillary mucinous carcinoma. Distal pancreatectomy with splenectomy was performed, and the histopathological diagnosis was xanthogranulomatous pancreatitis with no malignant findings. [ABSTRACT FROM AUTHOR]

Background: Pancreatic neuroendocrine tumors (PNET) account for less than 2% of all pancreatic tumors, while cystic PNETs account for only 10–18% of all resected PNETs. The most common site for metastasis is the liver. Few detailed guidelines currently exist for management of stage 4 cystic PNETs. This is a unique case that was managed with complete surgical resection in one sitting. Case presentation: Our report is on a young male patient who was initially misdiagnosed as having a pancreatic pseudocyst and treated accordingly. He was finally diagnosed with PNET but was reluctant to undergo surgery until he developed bilobar hepatic metastasis. We performed a pylorus-preserving pancreaticoduodenectomy with a Roux-en-Y hepaticojejunostomy and wedge resection of both hepatic metastatic deposits. Conclusion: Cystic PNETs are rare and commonly misdiagnosed as pancreatic pseudocysts. Surgical resection is considered ideal, but sparse literature exists on the management due to a paucity of cases. We have reported this case as it was successfully managed with single-stage surgery for both the primary tumor as well as bilobar hepatic metastatic deposits, and no similar cases have been reported in literature. The follow-up scan revealed no residual disease. [ABSTRACT FROM AUTHOR]

Copyright of Die Radiologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background and Aims: Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach. Methods: This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption. Results: PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients. Conclusions: Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities. [ABSTRACT FROM AUTHOR]

Background: A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD. Methods: This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD. Results: We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68–97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91–136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33–29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs. Conclusion: Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings. Clinical registration number: UMIN 000030898. [ABSTRACT FROM AUTHOR]

Background: A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts. Methods: The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann–Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates. Results: Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07–1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23–0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27–0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15–5.82, p = 0.02). Conclusions: Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database. [ABSTRACT FROM AUTHOR]

Copyright of Der Gastroenterologe is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Internist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A 42-year-old Caucasian female presented with lower limb panniculitis and bilateral ankle arthritis in the absence of abdominal or other localizing symptoms. Abdominal imaging revealed subacute pancreatitis with pseudocyst formation. The clinical manifestations were compatible with pancreatitis, panniculitis, and polyarthritis syndrome (PPP syndrome), a very rare complication of pancreatic disease. The patient improved with conservative treatment for the pancreatic disease and systemic corticosteroids for the cutaneous and articular manifestations. We identified 59 patients with the PPP syndrome from the literature, the majority of patients being male (74.6%) with a median age of 49 (IQR 41–63.5) years. Acute pancreatitis is the most frequent underlying disorder (54.2%), but gastrointestinal symptoms are absent in 45.8% of patients. Pancreatic panniculitis has a predilection for the lower limbs, which are affected in 98.3% of cases. However, the cutaneous lesions may also involve the upper limbs and trunk. Arthritis is typically symmetric and polyarticular in nature, affecting both large and small joints. Of all patients who received treatment, 78.6% had a poor response. Death occurred in 27.1% of cases after a median duration of 8 (IQR 3.5–14) weeks [ABSTRACT FROM AUTHOR]

A 43-year-old man was admitted to a local hospital because of acute left abdominal pain. Chronic alcoholic pancreatitis and a 10-cm pancreatic pseudocyst in the tail of the pancreas had been found 5 years previously. He had not stopped drinking alcohol since then. On admission, laboratory tests revealed severe anemia, and contrast-enhanced computed tomography showed extravasation in the pancreatic pseudocyst. The spleen was retracted by the pancreatic pseudocyst, and its configuration was indistinct. The patient was diagnosed with acute bleeding within the pancreatic pseudocyst and splenic rupture. He was transferred to our university hospital on an emergency basis. Abdominal angiography of the splenic artery was immediately performed, but the bleeding point was not found. Although the bleeding stopped spontaneously, an infection of the pancreatic pseudocyst and a splenic hematoma subsequently developed. Endoscopic ultrasound-guided pseudocyst drainage was performed. The infection improved after the drainage, and the size of the pancreatic pseudocyst and splenic hematoma decreased. Five months later, the pancreatic pseudocyst had almost disappeared, and the splenic hematoma was even smaller. We herein report a rare case of splenic rupture caused by a pancreatic pseudocyst. Although the patient's condition became complicated by severe infection, treatment by endoscopic ultrasound-guided drainage was successful. [ABSTRACT FROM AUTHOR]

The last decade has seen a dramatic paradigm shift for the treatment of pancreatitis and its related complications away from surgery to minimally invasive endoscopic approaches. In this review, we provide an overview of the indications, techniques and outcomes of endoscopic interventions in the management of acute and chronic pancreatitis. Emphasis is placed on drainage of pancreatic pseudocysts and treatment of pain in chronic pancreatitis. [ABSTRACT FROM AUTHOR]

Pancreatic pseudocysts (PPs) can be accompanied by infection, pseudoaneurysm ruptures, and fistulae to other organs, which can be fatal without appropriate treatment. Herein, we present the case of an 82-year-old man with PPs accompanied by infection, pseudoaneurysm rupture, and pseudocystocolonic fistula that were managed via multidisciplinary treatment. Computed tomography (CT) revealed two inflamed PPs, one each in the pancreatic head and tail. He was, therefore, diagnosed with infectious PPs. The pancreatic head PP shrunk on endoscopic nasopancreatic drainage (ENPD), but the pancreatic tail PP did not. Endoscopic ultrasound (EUS)-guided transluminal drainage was performed to treat the pancreatic tail PP; his symptoms improved. However, he vomited blood at 14 day post-drainage. Angiography revealed pseudoaneurysm rupture in a left gastric artery branch. After successful angioembolization, he developed hematochezia 2 days later. We suspected re-bleeding of the pseudoaneurysm. The bleeding stopped spontaneously, but CT and radiography revealed the presence of a pseudocystocolonic fistula. Careful follow-up was performed, and he has not had any symptoms at 9 month post-discharge. We managed PP-related complications via ENPD, EUS-guided transluminal drainage, angioembolization, and careful follow-up. Infection, pseudoaneurysm rupture, and pseudocystocolonic fistula are rare, but can occur simultaneously. Therefore, clinicians should consider these complications when treating patients with PPs. [ABSTRACT FROM AUTHOR]

Background: The use of fully covered metal stents (FCSEMS) and specifically designed lumen apposing metal stents for transmural drainage of pancreatic fluid collections has become widespread. A systematic review published in 2015 did not support the routine use of metal stents for drainage of pancreatic fluid collections. However, recent studies have shown conflicting data; therefore a systematic review and meta-analysis was performed.Method: We conducted a database search for original comparative studies between plastic and metal stents. The random effects model was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). Outcomes analysed were clinical success, adverse events and requirement of further intervention.Results: The search identified 936 studies, 7 studies with 681 (340 metal, 341 plastic) patients met inclusion criteria and were included in the meta-analysis. Clinical success was achieved in 93.8% versus 86.2% in the metal and plastic groups, respectively, RR 1.08 [95% CI 1.02-1.14]; p = 0.009. Adverse events were reduced for metal stents when compared with plastic (10.2% vs. 25.0%), RR 0.42 [95% CI 0.22-0.81]; p = 0.010. Metal stent usage reduced bleeding (2.8% vs. 7.9%), RR 0.37; [95% CI 0.18-0.75]; p = 0.006. Further intervention was required in 12.4% of patients in the metal stent group versus 26.7% for plastic stents, RR 0.54; [95% CI 0.22-1.29]; p = 0.165.Conclusions: The use of metal stents for drainage of pancreatic fluid collections is associated with improved clinical success, fewer adverse events and reduced bleeding compared to plastic stents. [ABSTRACT FROM AUTHOR]

Copyright of Der Internist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In recent years, technological advancements including endoscopic ultrasound (EUS) guidance and availability of specifically designed stents further expanded the indications and possibilities of interventional endoscopy. Although technically demanding and associated with non-negligible morbidity, advanced pancreatic endoscopic techniques now provide an effective minimally invasive treatment for complications of acute and chronic pancreatitis. Aiming to provide radiologists with an adequate familiarity, this pictorial essay reviews the indications, techniques, results and pre- and post-procedural cross-sectional imaging appearances of advanced endoscopic interventions on the pancreas and pancreatic ductal system. Most of the emphasis is placed on multidetector CT and MRI findings before and after internal drainage of pseudocysts and walled-off necrosis via EUS-guided endoscopic cystostomy, and on stent placement to relieve strictures or disruption of the main pancreatic duct, respectively in patients with chronic pancreatitis and disconnected pancreatic duct syndrome. [ABSTRACT FROM AUTHOR]

Pancreatic fluid collections are a frequent complication of acute pancreatitis. The revised Atlanta criterion classifies chronic fluid collections into pseudocysts and walled-off pancreatic necrosis (WON). Symptomatic PFCs require drainage options that include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, minimally invasive endoscopic drainage has now become the preferred approach. An endoscopic ultrasonography (EUS)-guided approach for pancreatic fluid collection drainage is now 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 WON. Direct endoscopic necrosectomy is often required in WON. Lumen apposing metal stents allow for direct endoscopic necrosectomy and debridement through the stent lumen and are now preferred in these patients. Endoscopic retrograde cholangiopancreatography with pancreatic duct exploration should be performed concurrent to PFC drainage in patients with suspected PD disruption. 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. Ideally, pancreatic ductal disruption should be bridged with endoscopic stenting. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Chronic pancreatitis is a disease that leads to irreversible changes in the pancreatic morphology and function. The loss of function can lead to diabetes mellitus and exocrine pancreatic insufficiency. The inflammation and fibrosis can also lead to other complications including a chronic abdominal pain syndrome, metabolic bone disease, and pancretic cancer. This article reviews our current understanding of the mechanisms and management of these complications of chronic pancreatitis. [ABSTRACT FROM AUTHOR]

A 53-year-old male visited his primary physician for epigastric and back pain. Abdominal-enhanced computed tomography (CT) revealed a simple cyst of the pancreatic tail attached to the stomach. A distal main pancreatic duct (MPD) was clearly dilated, but no pancreatic tumor was identified around the stenosis of MPD by CT scan and magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde pancreatography (ERP) revealed stenosis and distal dilation of the MPD located between the body and tail of the pancreas. Endoscopic ultrasound (EUS) revealed a low density mass of 7 mm in size with distal dilation of the MPD. With the suspicion of a small pancreatic cancer, the patient underwent distal pancreatectomy and splenectomy with lymph node dissection (D2). On histopathological evaluation, a small pancreatic adenocarcinoma of 6 mm in size was detected around the stenosis of MPD. Final pathological diagnosis was moderately differentiated invasive ductal adenocarcinoma of the pancreas with no lymph node metastasis (Japan Pancreatic Society (JPS) classification 7th edition; Pbt, TS1 (6 mm), tub2, intermediate type, INF β, ly1, v1, ne1, mpd(-), pT1b, pN0, pM0, stage IA,PCM(-), DCM(-) and the Union International Control Cancer (UICC) classification of malignant tumors 6th edition; pT1, pN0, pM0, stage IA, R0). We herein reported a patient who underwent radical resection for T1 pancreatic adenocarcinoma of 6 mm in diameter which caused acute pancreatitis and a pseudocyst due to obstruction of the MPD. [ABSTRACT FROM AUTHOR]

Background: Acute pancreatitis is defined as an acute condition presenting with abdominal pain, and is usually associated with raised pancreatic enzyme levels in the blood or urine, as a result of pancreatic inflammation. Acute pancreatitis may recur, severe episodes, however, may involve a progression to sterile and infected peripancreatic fluid collections, pancreatic necrosis and pancreatic abscess, pancreatic pseudocyst, pancreatic ascites and pancreaticopleural fistulas. These can be divided into acute or delayed, depending on whether such a collection is of less than or more than 4 weeks' duration. Pancreatic Abscess is a circumscribed intra-abdominal collection of pus, usually in proximity to pancreas. Pancreatic abscess is often a late complication of acute necrotizing pancreatitis, occurring more than 4 weeks after the initial attack. The reported mortality rate due to pancreatic abscesses after acute pancreatitis has been 30 to 50%, a statistic that has remained unchanged for decades. Materials and methods: We report a single case of acute pancreatitis progressing to pancreatic abscess, showing a spectrum phenomenon in evolution of the disease at a tertiary care apex institution of Eastern India. [ABSTRACT FROM AUTHOR]

Background and Aim: Pancreatic pseudocysts (PPC) are a complication that occurs in acute and chronic pancreatitis. They comprise 75% of cystic lesions of the pancreas. There are scarce data about surgical versus endoscopic treatment on PPC. The aim of this study was to compare both treatment modalities regarding clinical success, complication rate, recurrence, hospital stay and cost.Methods: Retrospectively, data obtained prospectively from 2000 to 2012 were analyzed. A PPC was defined as a fluid collection in the pancreatic or peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis. Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller.Results: Overall, 64 procedures in 61 patients were included: 21 (33%) cases were drained endoscopically guided by EUS and 43 (67%) cases were drained surgically. The clinical success of the endoscopic group was 90.5 versus 90.7% for the surgical group (P = 0.7), with a complication rate of 23.8 and 25.6%, respectively (P = 0.8), and a mortality rate of 0 and 2.3% for each group, respectively (P = 0.4). The hospital stay was lower for the endoscopic group: 0 (0-10) days compared with 7 (2-42) days in the surgical group (P < 0.0001). Likewise, the cost was lower in the endoscopic group (P < 0.001). The recurrence rate was similar in both groups: 9.5 and 4.5% respectively (P = 0.59). The two recurrences found in the endoscopic group were associated with stent migration, and the recurrence in the surgical group was due to the type of surgery performed (open drainage).Conclusion: Endoscopic treatment of PPC offers the same clinical success, recurrence, complication and mortality rate as surgical treatment but with a shorter hospital stay and lower costs. [ABSTRACT FROM AUTHOR]

Introduction: Pancreatic pseudocysts and walled-off necrosis are well-known complications, described in 10% of cases of acute pancreatitis. Open cystogastrostomy is usually proposed after failure of minimally invasive drainage or in the presence of septic shock. The objective of this study was to evaluate the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy for treatment of symptomatic pancreatic pseudocyst with pancreatic necrosis.Materials and Methods: Between January 2011 and October 2014, all patients with pseudocyst and pancreatic necrosis undergoing open cystogastrostomy were included. Surgical procedure was standardized. The primary efficacy endpoint was the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy as treatment of symptomatic pancreatic pseudocyst. Secondary endpoints included demographic data, preoperative management, operative data, postoperative data and follow-up.Results: Laparoscopy-assisted open cystogastrostomy was performed in 11 patients [six men (54%)], with a median age of 61 years (45-84). Nine patients received preoperative radiological or endoscopic management. First-line open cystogastrostomy was performed in two cases. Median operating time was 190 min (110-240). There was one intraoperative complication related to injury of a branch of the superior mesenteric vein. There were no postoperative deaths and two postoperative complications (18%) including one major complication (postoperative bleeding). The median length of hospital stay after surgery was 16 days (7-35). The median follow-up was 10 months (2-45). One patient experienced recurrence during follow-up.Conclusion: Open cystogastrostomy for necrotizing pancreatitis promotes adequate internal drainage with few postoperative complications and a short length of hospital stay. However, this technique must be performed very cautiously due to the risk of vascular injury which can be difficult to repair in the context of severe local inflammation related to pancreatic necrosis. [ABSTRACT FROM AUTHOR]

Pancreatic pseudoaneurysm is a rare but potentially fatal complication in pancreatitis; however, the incidence in children is not well established. Surgery has been the mainstay of treatment; however, we report a case of PSA associated with pancreatitis in a 6-year-old boy, which was successfully managed endovascularly. [ABSTRACT FROM AUTHOR]

The article presents a case study of children suffering from pancreatic pseudocyst who were admitted to a hospital in Egypt. The study was based on 19 infants on whom surgery was performed and a report is presented on the post-operative prognosis. Surgical procedures including cystogastrostomy, cystojejunostomy, and pancreatectomy were followed on the children.

Pancreatic necrosis may result as a complication of acute pancreatitis, often causing significant morbidity and mortality. There are many recommendations concerning the management of pancreatic necrosis, including non-operative management with supportive care and antibiotics, computed tomography (CT)-guided percutaneous drainage, endoscopic transluminal drainage, and operative necrosectomy. Historically, pancreatic necrosis has been treated surgically. However, surgical management of pancreatic necrosis is associated with high mortality (6-28 %) and morbidity (19-62 %). Thus, endoscopic therapy has emerged as a relatively new minimally invasive technique for treating infected and/or symptomatic pancreatic necrosis in the last decade. Although there have been two randomized trials comparing endoscopic transluminal drainage versus operative necrosectomy, there is little data regarding timing, indication, and outcomes of these procedures. [ABSTRACT FROM AUTHOR]

Background: Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach. Methods: We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed. Results: From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m, 77 % had an ASA score ≥3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections. Conclusion: This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity. [ABSTRACT FROM AUTHOR]

Background and Aims: The transpapillary approach can be used for draining pancreatic pseudocysts (PPs) with pancreatic-duct abnormalities. The purpose of this study was to analyze prognostic factors for clinical success of transpapillary drainage. Patients and Methods: Data for all patients who underwent transpapillary drainage between November 2000 and September 2009 were obtained by retrospective review and entered into a computerized database. Patient data were prospectively followed up to determine long-term outcomes. Results: Seventy interventional ERCP procedures were performed for 43 patients. Technical success was 90.7 % (39/43). Overall clinical success was 79.5 % (31/39). Clinical success for pancreatic head pseudocyst was significantly different from that for body or tail pseudocyst (62.5 vs. 91.3 %, P = 0.043). Logistic regression analysis showed that location of the PPs predicted the success of endoscopic transpapillary pseudocyst drainage ( P = 0.025). Conclusion: Transpapillary drainage is the least traumatic approach for drainage of PPs, and is also effective for patients with no communicating pseudocysts. Clinical success for pancreatic body or tail pseudocyst drainage was higher than that for pancreatic head pseudocyst drainage. It was found that the location of PPs predicted the success of transpapillary pseudocyst drainage. None of the other factors tested was a significant predictor of clinical success. [ABSTRACT FROM AUTHOR]

Acute pancreatitis is one of the common causes of the acute abdomen that should be included in any differential diagnosis for acute abdominal pain; it is also well known with its variant causes, of which most common is biliary tree stones, alcoholic pancreatitis, followed by a long list of other less common causes. We have reported a rare case of relapsing acute pancreatitis due to atypical sporadic hypertriglyceridemia (Frederickson's type IV) in a young male patient who was seen in the accident and emergency department presenting with severe agonizing abdominal pain, with history of recurrent similar attacks, which were unfortunately misdiagnosed elsewhere. [ABSTRACT FROM AUTHOR]

Pancreatitis associated with the extension of a pancreatic collection, pseudocyst or abscess into the groin is a rare phenomenon with few reports in the English literature. Nevertheless, it remains a clinically important differential diagnosis as it may be mistaken for more common pathologies in the groin and with a subsequent unnecessary surgical intervention. A case of this rare complication of pancreatitis is reported, together with a review of the literature. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to characterize the clinical course and outcomes of children with pancreatic pseudocysts that were initially treated non-operatively or with percutaneous drainage. Methods: A retrospective review of children with pancreatic pseudocysts over a 12-year period was completed. Categorical variables were compared using Fischer's exact method and the Student's t test was used to compare continuous variables. Analysis was done using logistic and linear regression models. Results: Thirty-six children met the criteria for pancreatic pseudocyst and 33 children were treated either non-operatively or with percutaneous drainage. Of the 22 children managed non-operatively, 17 required no additional intervention (77 %) and five required surgery. Operative procedures were: Frey procedure (3), distal pancreatectomy (1), and cystgastrostomy (1). Eight of the 11 children treated with initial percutaneous drainage required no additional treatment (72 %). The other three children underwent distal pancreatectomy. Success of non-operative management or percutaneous drainage was not dependent on size or complexity of the pseudocyst Logistic regression did not identify any patient demographic (gender, age, and weight), etiologic (trauma, non-traumatic pancreatitis) or pseudocyst characteristic (size, septations) that predicted failure of non-operative therapy. Conclusions: In children, pancreatic pseudocysts can frequently be managed without surgery regardless of size or complexity of the pseudocyst. When an intervention is needed, percutaneous drainage can be performed successfully, avoiding the need for major surgical intervention in the majority of patients. [ABSTRACT FROM AUTHOR]

On abdominal CT scans asymptomatic cystic lesions of the pancreas are accidentally detected in 1-2% of patients. Congenital cysts and pancreatic pseudocysts account for two thirds of these lesions. Pancreatic pseudocysts are a frequent complication of acute and chronic pancreatitis. Among resected cystic neoplasms serous cystic adenoma accounts for 30%, mucinous cystic neoplasms for 45% and intraductal papillary mucinous neoplasms for 25%. The diagnosis of a cystic pancreatic lesion is usually made by diagnostic imaging. Symptomatic lesions require definitive therapeutic treatment after appropriate diagnostic work-up. In the diagnosis of asymptomatic cystic lesions several factors are important, among them whether the cyst is connected to the pancreatic duct (as in IPMN and pseudocysts), the size of lesion (for treatment indications) and whether nodules form in the wall of the cyst (a sign of potential malignancy). EUS-guided fine needle aspiration of the cyst fluid adds to the discrimination between benign, premalignant and malignant cystic lesions. Measuring lipase activity, CEA, viscosity and mucin as well as cytology can help in differentiating cystic lesions. An algorithm is discussed for the differential diagnosis and for selection of the appropriate treatment for pancreatic cystic lesions, most of which never require surgery. [ABSTRACT FROM AUTHOR]

Background: Endoscopy has been regarded as an effective modality for draining pancreatic collections, pseudocysts, and abscesses. This study analyzes our experience with endoscopic transmural drainage of pancreatic pseudocysts and compares the outcomes in patients with postsurgical and pancreatitis-associated ones. Methods: Patients who underwent endoscopic drainage of a pancreatic pseudocyst from January 1999 through June 2008 were included in this retrospective analysis. The specific indication for attempting the procedure was the presence of direct contact between the pseudocyst and the gastric wall. All the drainages were carried out via a transgastric approach, and one or two straight plastic stents (10 or 11.5 French) were positioned. A comparative analysis of short- and long-term results was made between patients with postoperative pseudocysts (group A) and patients with pancreatitis-associated pseudocysts (group B). Results: Fifty-five patients were included in the study, 25 in group A and 30 in group B. Overall, a single stent was inserted in 84.0% of patients, while two stents were needed in the remaining 16.0%. The technical success rate was 78.2%, whereas procedure-related complications were 16.4%. Complications included pseudocyst superinfection and major bleeding and were managed mainly by surgery. Mortality rate was 1.8% (1 patient). There were no significant differences in the technical success rate and procedure-related complications between the two groups ( p = 0.532 and 0.159, respectively) Recurrences were 13.9% and significantly more common in group B ( p = 0.021). In such cases, a second endoscopic drainage was successfully performed. Conclusion: Transmural endoscopic treatment of pancreatic pseudocysts is feasible and has a technical success rate of 78.2%, without differences related to the pseudocyst etiology. Recurrences, on the other hand, are more common in patients with pancreatitis. Given the severe complications that may occur after the procedure, we recommend that endoscopic drainage be performed in a tertiary-care center with specific expertise in pancreatic surgery. [ABSTRACT FROM AUTHOR]

Background: Traditional approach for surgical management of mature pancreatic pseudocysts is by internal surgical drainage. Endoscopic drainage procedures have also been described. We describe Natural Orifice Translumenal Endoscopic Surgery (NOTES) stapled cystgastrostomy as a less invasive surgical procedure. Study design: Case series. Methods: NOTES cystgastrostomy was performed in six patients with mature pseudocysts from June 2007 to July 2009 under institutional review board (IRB) protocol. The size of the pseudocysts varied from 8 to 23 cm, and all of the pseudocysts were considered complex pseudocysts. The operative team included two general surgeons and a gastroenterologist. The procedure included endoscopic ultrasound (EUS)-guided puncture of the stomach just below the gastroesophageal (GE) junction to gain access to the pseudocyst, guidewire placement, and then dilatation with a balloon to 18-20 mm. Endoscopic necrosectomy and debridement were performed when possible, followed by transoral surgical anastomosis under endoscopic visualization with the SurgAssist™ SLC 55 (Power Medical Interventions, Langhorne, PA) 4.8-mm stapler. Anastomotic length varied from 5.5 to 8 cm. In one patient, diagnostic laparoscopy was performed after the procedure due to inadvertent pneumoperitoneum; no leak or perforation was identified. Results: Length of stay varied between 2 and 14 days. All patients had routine esophagogastroduodenoscopy (EGD) at 1 and 6 weeks postoperatively to evaluate patency; computed tomography (CT) scan was done at 2-3 months to demonstrate resolution of the pseudocyst. All patients had significant decrease in pseudocyst size with patent anastomosis on postoperative EGD, although one patient required endoscopic anastomotic dilatation due to continued symptoms 6 weeks after the operation. Her pseudocyst completely resolved 4 months postoperatively. An additional patient required subsequent distal pancreatectomy due to recurrent symptoms of chronic pancreatitis. Conclusion: NOTES cystgastrostomy is comparable to previously described surgical approaches, yet is as minimally invasive as endoscopic drainage procedures previously described for management of pseudocysts. It is less invasive than laparoscopic or open cystgastrostomy, yet provides definitive treatment. [ABSTRACT FROM AUTHOR]

Pancreatitis is a relatively rare but severe manifestation in systemic lupus erythematosus (SLE) patients. We report a case of a 39-year-old woman with previous SLE diagnose treated with prednisone and mycophenolate mofetil who developed an acute pancreatitis complicated by pancreatic pseudocysts within the context of a severe lupus flare. Elevated serum amylase and computerized tomography confirmed the diagnosis and mechanical obstruction or toxic-metabolic etiologies were ruled out. In the present case, we opted for the clinical surveillance of pancreatic pseudocyst and not perform invasive medical procedures to drainage. A steroid therapy was started in order to achieve SLE and pancreatitis remission, however, it was unable to avoid the development of multiorgan failure and patient died a few days after diagnosis was made. [ABSTRACT FROM AUTHOR]

With the emergence of minimally invasive techniques, percutaneous drainage has been applied to the management of symptomatic pancreatic pseudocysts in lieu of conventional surgical or endoscopic therapy. Percutaneous insertion of internalized drainage catheters represents an attractive method for pseudocyst drainage, but has been limited by the usual need for cross-sectional imaging or endoscopic guidance. Herein, we describe the use of a simple fluoroscopically guided technique for percutaneous transgastric cystgastrostomy with internalized drainage catheter placement in two cases. [ABSTRACT FROM AUTHOR]

Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts. Records of 83 patients undergoing laparoscopic ( n = 16), endoscopic ( n = 45), and open ( n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis. There were no significant differences ( p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m2), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1–40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher ( p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy ( n = 13), percutaneous drainage ( n = 3), and repeat endoscopic drainage ( n = 6). Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients. [ABSTRACT FROM AUTHOR]

Few series describe endoscopic drainage of pancreatic abscesses. Abscesses are complications of pancreatitis, presenting with sepsis, peritonitis, or both. This report describes the feasibility and efficacy of natural orifice translumenal endoscopic surgery for pancreatic abscesses. This study reviewed 35 consecutively treated patients for the period 1994–2007. The approaches alone or in combination were transmural (transgastric or transduodenal) and transpapillary. The criteria for abscesses were two or more of the following: fever, abdominal pain, elevated white blood count (WBC), and positive fluid cultures. The 35 patients (19 men and 16 women) had a mean age of 49 years. The abscesses had idiopathic (37%), gallstone (32%), alcohol (20%), and divisum (11%) etiologies. The presenting signs were abdominal pain (80%), positive cultures (69%), fever (57%), elevated WBC (51%), and nausea/vomiting (39%). The approaches for abscess drainage were as follows: transgastric ( n = 15, 43%), transduodenal ( n = 4, 11%), transgastric combined with transpapillary ( n = 8, 23%), transduodenal combined with transpapillary ( n = 1, 3%), and transpapillary alone ( n = 7, 20%). A total of 28 patients (80%) achieved successful endoscopic pancreatic abscess drainage, whereas 7 (20%) required surgery. Of these seven patients, two (6%) required emergent laparotomy to control bleeding, and the remaining five (14%) were explored after failure to demonstrate clinical improvement from endoscopic drainage. Three patients required internal drainage, and two patients required distal pancreatectomy. The mean follow-up period was 15 months, and the complication rate was 6%. No one died from the procedure. Endoscopic surgery for pancreatic abscess is feasible and effective. It is an alternative to surgery that currently can be considered a primary treatment option for selected pancreatic abscesses. [ABSTRACT FROM AUTHOR]

We encountered a very rare case of biliopancreatic fistula with portal vein thrombosis caused by pancreatic pseudocyst. A 57-year-old man was referred to our hospital because of abdominal pain, obstructive jaundice, and portal vein thrombosis due to acute pancreatitis. Computed tomography showed a 7-cm-diameter pseudocyst around the superior mesenteric vein extending towards the pancreatic head, dilatation of the intrahepatic bile duct, and portal vein thrombosis. Endoscopic retrograde pancreatography revealed a main pancreatic duct with a pseudocyst communicating with the common bile duct. After pancreatic sphincterotomy, a 7-F tube stent was endoscopically placed into the pseudocyst. However, a 6-F nasobiliary tube could not be inserted into the bile duct because the fistula had a tight stenosis. Subsequently, the patient’s abdominal pain improved, the pancreatic cyst disappeared, and the serum amylase level normalized. Two months after the endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage was required because the patient’s jaundice became aggravated. Two weeks after the choledochojejunostomy, the patient left the hospital in good condition. A follow-up computed tomography showed cavernous transformation of the portal vein and no pancreatic pseudocyst. The patient remains asymptomatic for 2 years and 7 months after surgery. Biliary drainage may be necessary for biliopancreatic fistula with obstructive jaundice in addition to pancreatic cyst drainage. Biliopancreatic fistula can be treated by endoscopic procedure in some cases; however, surgical treatment should be required in cases that are impossible to insert a biliary stent because of hard stricture. [ABSTRACT FROM AUTHOR]

Background: In the era of minimally invasive surgery, laparoscopy has a great role to play in the management of pseudocyst of pancreas. We present our surgical experience over the past 12 years (May 1994 to April 2006) in the management of pancreatic pseudocysts.Materials and Methods: The total number of cases was 108, with 76 male and 32 female patients. Age ranged from 18 to 70 years. Duration of symptoms ranged from 45 days to 7 months. Fifty-nine patients presented with pain abdomen. Sixty-one patients had co-morbid illness. Ten patients had abdominal mass on clinical examination. Predisposing factors were gallstones in 58 cases, alcohol in 20 cases, trauma in eight cases and post-pancreatectomy in one case. In 21 cases there are no predisposing factors.Results: All the cases were successfully operated without any significant intraoperative complication. Laparoscopic cystogastrostomy was done in 90 cases (83.4%), laparoscopic cystojejunostomy in eight cases (7.4%), open cystogastrostomy in two cases (1.8%), and laparoscopic external drainage in eight cases (7.4%). Laparoscopic cholecystectomy was done in 47 cases along with the drainage procedure. The mean operating time was 95 minutes. Mean blood loss was 69 ml. Mean hospital stay was 5.6 days. Percutaneous tube drain to assist decompression of the cyst was kept in all the laparoscopic cystojejunostomy (LCJ) group. Two patients were re-operated for bleeding and gastric outlet obstruction. We had no mortality in the postoperative period. With mean follow up of 54 months (range 3-145 months); only one patient who underwent laparoscopic cystogastrostomy (LCG) earlier in this series had recurrence due to inadequate stoma size. This patient later underwent OCG CONCLUSION: Laparoscopy has a significant role to play in the surgical management of pseudocysts with excellent outcome. It offers all the benefits of minimally invasive surgery to the patients. [ABSTRACT FROM AUTHOR]

Acute or chronic blood loss from pseudoaneurysms of the splanchnic artery in chronic pancreatitis poses diagnostic and management challenges. Arteriographic examination offers both diagnostic and therapeutic options, with success rates of 76%-100% for both modalities. In cases of failure of embolization, repeat embolization is also an option. Surgical intervention is advocated for rebleeding and failure of embolization. Evidence-based guidelines regarding the optimal treatment modality for this condition are lacking. There has been a reported case of dislodgement of coil into the stomach through a gastropseudocystic fistula. We report the case of a migrating steel-wire coil through the gastrointestinal tract and splenic artery pseudoaneurysm. We highlight the potential complications of pseudoaneurysm and other available therapeutic management options. [ABSTRACT FROM AUTHOR]

Ultrasound imaging has made significant advances in recent years and plays an important role in the detection, characterization and staging of pancreatic diseases. Conventional ultrasonography (US) is a noninvasive imaging modality, which continues to be the first diagnostic step in the evaluation of the pancreas. Over its various decades of application, US have detected pancreatic pathology of great diversity. This article reviews the wide utility of US and the many examinations techniques, such as filling the stomach with water, changing the patient's position or suspending inspiration or expiration, allowing us to visualize all portions of the pancreas in a high percentage of patients. [ABSTRACT FROM AUTHOR]

Interventional ultrasonography (US) is often used for the diagnosis and therapy of pancreatic pathologies, and its diffusion has definitely modified the diagnostic and therapeutic management of some diseases. US is particularly suitable for targeting percutaneous pancreatic interventional procedures and important technical features contribute to this result. First of all, US is dynamic, and thus the ongoing procedure can be continually monitored. Then, the high spatial resolution achieved by US imaging in recent years, its speed and availability and the low-cost of the technique, together with the technical features, have led to an ever-increasing use of US in pancreatic interventional procedures. This article will review the application of US as guide of diagnostic and interventional procedures in the different pancreatic pathologies. [ABSTRACT FROM AUTHOR]

The introduction of contrast-enhanced ultrasonography (CEUS) has lead to great developments in the diagnostic capabilities of ultrasound. Second generation contrast media, characterized by harmonic responses at low mechanical index of the ultrasound beam, have already proven usefulness in the study of the liver but other abdominal organs can take advantage from the dynamic study during continuous ultrasonographic scans. The dynamic observation of the enhancement allows the perfect evaluation of the abdominal organs perfusion. The perfusion of the pancreas is well correlated to the semeiology of the gland parenchymography at CEUS. The study of the pancreas is a new and promising application of CEUS. CEUS can be used to better identify pancreatic lesions respect to conventional Ultrasound (US) or to characterize pancreatic lesions already visible at US. Moreover the staging of some pancreatic lesions can be improved by the use of contrast media. This article will review the clinical application of CEUS in the different pancreatic pathologies. [ABSTRACT FROM AUTHOR]

Background: In the past decade, laparoscopy has shown its efficacy also for advanced surgery. In this report, the authors retrospectively review their experience with the distal pancreas.Methods: From April 1999 to October 2004, 19 patients underwent a laparoscopic procedure for pathologies of the distal pancreas. The authors performed one distal pancreatectomy (DP) with conservation of the spleen and section of the splenic vessels, four distal splenopancreatectomies (DSP), one DSP plus a left adrenalectomy, two enucleations, seven DPs with conservation of the spleen and the splenic vessels, and four cystojejunostomies.Results: One procedure was converted to open surgery because of a hemorrhagic complication. No other significant intraoperative complications occurred. The postoperative course was characterized by one bleed managed conservatively, two pancreatic fistulas (one requiring a second operation), one abscess drained under echographic view, and one reactive pancreatitis. The mean postoperative stay was 8.5 days. The histologic report showed 16 benign diseases and 3 malignant tumors. The mean follow-up period was of 42 months. The patient who had DP spleen preservation with section of the splenic vessels reported mild pain in the left hypochondrium, probably attributable to chronic splenic ischemia, during the first 3 postoperative months. One incisional hernia occurred in the patient who underwent conversion to an open procedure, and one patient affected by adenocarcinoma died 10 months after the operation.Conclusions: The authors can affirm that laparoscopy for the distal pancreas is a successful procedure in terms of results and surgical feasibility. Prospective studies are necessary to confirm their positive impression. [ABSTRACT FROM AUTHOR]

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically. [ABSTRACT FROM AUTHOR]

Background:The goal of this study was to assess tile clinical outcome of patients undergoing laparoscopic stapled cystgastrostomy for pancreatic pseudocysts in contact with the posterior wall of the stomach. Methods: We performed a case note review of all patients who have undergone stapled taparoscopic cystgastrostomy in Norwich. UK. The cystgastrostomy was fashioned through an anterior gastrotorny using a vascular ETS stapling device in all cases. Results: Fifteen patients have undergone stapled laparoscopic cystgastrostomy. The procedure was completed successfully in 12 patients. Three procedures were converted to open surgery for technical reasons. There were no complications due to bleeding from the cystgastrostomy. Early complications included systemic sepsis(one) bleeding gastric ulcer (one) and pseudocyst recurrence due to partial closure of the cystgastrostomy (two). No late recurrences or other complications have been found at a median follow-up of 37 months. Conclusion: Stapled laparoscopic cystgastrostomy is a safe and effective procedure for draining pancreatic pseudocysts in contact with the posterior wall ot the stomach. The use of a hemostatic stapling device to fashion the cysigastrostomy may reduce the risk of catastrophic hemorrhage from the pseudocyst wall. [ABSTRACT FROM AUTHOR]

Background: A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP). Methods: We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30–72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2–24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5–20). Results: According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80–300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2–5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4–24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6–36), no recurrence of PP was observed. Conclusions: The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage. [ABSTRACT FROM AUTHOR]

We evaluated the usefulness of three-dimensional (3D) sonography in percutaneous fine-needle pancreatic pseudocyst puncture. We examined 52 patients diagnosed as having pancreatic pseudocysts on the basis of clinical symptoms and two-dimensional (2D) ultrasonography findings. The decision to qualify certain patients for percutaneous fine-needle aspiration guided by ultrasonography was made on the basis of 2D and 3D scan results. Spiral computed tomography was done when the presence of connections between pseudocyst and pancreatic duct was suspected. In these cases diagnosis was confirmed in operative procedures. 3D sonography was used to monitor the tip of the needle making its way to the pancreatic pseudocyst and later inside the fluid collection. Pancreatic pseudocysts were diagnosed in all 52 cases; 48 patients underwent percutaneous fine-needle biopsies. 3D presentation can better visualize irregular shapes, local thickenings, and calcification of pseudocyst walls than classical 2D ultrasound scans. The use of subtraction in 3D scans of blood vessels increases the safety in performing biopsies. We have shown that 3D sonography collects extremely useful information about the status of the pseudocyst structure, and it should become a complementary method to classical ultrasonography. This technique when used on a routine basis should help us change the inclusion criteria for guided biopsies. [ABSTRACT FROM AUTHOR]

Calcium deposition may occur in walls of blood vessels and other conduits, within solid organs and tumors, and in the lumen of nearly every hollow structure. Occasionally, calculi seen in one radiograph may present in a different location on subsequent films. These “rolling stones” can make medical management difficult, and an understanding of the forces influencing the movement of calcifications is important when interpreting radiographs. We present examples of calculi which move over time and discuss the factors involved in their movement. [ABSTRACT FROM AUTHOR]