PDF (5 MB) - Jurnalul de Chirurgie

Pancreatic pseudocyst 361Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4Ten patients (21.7%) were submittedto endoscopic drainage as follows: 2transpapillary drainage, 5 and 3transduodenal and transgastric drainage,respectively. Endoscopic drainage waseffective in decreasing the size of PP leaksthrough the stent placed inside the cyst. Tothe other 6 patients endoscopic approachwas tempted but it failed for differentreasons: technical, collateral circulation,inhomogeneous content, thick wall,significant bleeding at puncture site. Onepatient required emergency surgery due tohemorrhage.Surgical procedures were performed in8 patients (17.39%): 4 cysto -gastrostomy, 3cysto-jejunostomy and 3 external drainages(2 patients with double localization of PP).We have noted a complication aftercysto-jejunostomy: upper gastrointestinalbleeding at 6th postoperative day because ofan erosion of the splenic artery inside the PP.It was diagnosed by angiography and neededsurgical re-intervention for hemostasis.In other 2 patients who haveundergone external drainage of PP(immature wall not adequate foranastomosis) a pancreatic fistula followedwith prolonged external drainage (50 and 62days respectively.The postoperative course wasuneventful for the other patients.DISCUSSIONSAccording to Atlanta classification [1],there are 4 distinct concepts that definepancreatic collections:- acute fluid collections occurring earlyin evolution of PA, without welldefinedwall;- acute pancreatic pseudocyst, which is awell established wall of granulationtissue and fibrosis, which occurs in 4-6weeks after the onset of PA;- chronic pseudocyst occurring in theevolution of chronic pancreatitis;- pancreatic abscess, infection occurringthrough one of the three collections.Recently described, a new entity in theclassification of pancreatic collections,namely “walled-off pancreatic necrosis” [2]tends to replace the term pancreatic abscessor infected pancreatic collection, either focalpancreatic necrosis or pancreatic pseudocyst.An acute pancreatic pseudocyst isdefined as a fluid collection containingpancreatic juice, delimited by a fibrous wallof granulation tissue without epitheliumconsequence of acute pancreatitis orpancreatic trauma. Chronic pancreaticpseudocyst is a fluid collection of pancreaticjuice enclosed by a wall and fibrousgranulation tissue that occurs in thedevelopment of chronic pancreatitis in theabsence of an episode of acute pancreatitis.In general, acute and chronic pseudocystshave a different natural history, althoughmany studies do not distinguish acute fromchronic pseudocyst.Acute pseudocysts following anepisode of acute pancreatitis are calledpostinflammatory/postnecrotic pseudocystsas it further develops pancreatic necrosis andextravasations of pancreatic juice. Theycontain pancreatic enzymes and develop atmore than 4 weeks from the episode ofsevere acute pancreatitis, a necessary timefor maturation of the pseudocyst wall andappearance of granulation tissue. This acutepancreatic pseudocyst and pancreaticnecrosis are differentiated pancreatic fluidcollections occurring early in the evolutionof acute pancreatitis. All patients with theacute pancreatic pseudocyst and pancreaticnecrosis areas [3], but not all patients withpancreatic or peripancreatic necrosis willsubsequently develop pancreatic pseudocyst[4].Pancreatic pseudocysts that thisevolution in size over 6 cm, persists morethan 4 weeks are symptomatic, have a highrisk of complications: infection,compression, rupture into the peritoneum orhollow organs, bleeding. In the literatureindicated that spontaneous resolution ofpseudocyst varies between 8 and 70% ofpatients [5-11].The pancreatic pseudocyst persists formore than 6 weeks episode of PA with thespontaneous resolution rate decreases [12].