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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].
362 Săndulescu S. et al.Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4Also, the authors suggest that the rate ofspontaneous resolution does not dependstrictly on the size of PP.The rate of spontaneous resolution ofpancreatic pseudocysts depends on severalfactors:- multiple pseudocysts [13];- caudal location [14];- wall thickness [15];- communication with the pancreaticduct, associated proximal stricture;- enlargement at successiveexaminations;- biliary etiology of AP [16].- chronic pancreatic pseudocyst.The severity of acute pancreatitis andextent of pancreatic necrosis seem toinfluence the rate of spontaneous resolutionof PP.Chronic pseudocysts occurring duringthe evolution of chronic pancreatitis arecalled retention pseudocysts due toobstructions in the pancreatic ductal system.Morphological lesions of chronicpancreatitis (calcification) and structuralchanges of pancreatic duct (strictures, ductalanomalies) are criteria that suggest a lack ofspontaneous resolution of these pseudocysts.PP classification based on etiology andpancreatic duct anatomy is proposed byNealon and Walser [17]:- Type I: normal ductal anatomy withoutcommunication with the cyst;- Type II: normal duct, with cystcommunicating;- Type III: pancreatic duct strictureswithout cystic communication;- Type IV: strictures in the pancreaticduct and communication with the cyst;- Type V: completely obstructed duct;- Type VI: ductal lesions of chronicpancreatitis without communicationwith PP;- Type VII: ductal lesions of chronicpancreatitis, and PP communication.THERAPEUTIC MODALITIESExperience gained over the years intreating these asymptomatic pseudocystssuggest that PP, which do not grow ordecrease in size, can be treatedconservatively, with symptomatic medicaltherapy. Systematic periodic follow-up(ultrasound, CT) is mandatory forcomplications or adverse outcome. In thesecases, appropriate treatment is necessary.In the present, at least three therapeuticoptions are available for interventionaltreatment of these pseudocysts: guidedpercutaneous external drainage eco/CT,endoscopic transgastric and transpapillaryinternal drainage and open surgical internaldrainage or laparoscopic.These therapeutic modalities areaddressed to symptomatic pseudocysts,usually those over 6 cm, manifested by pain,nausea, vomiting, jaundice, weight loss dueto compression of the neighboring organs(stomach, duodenum, bile duct, colon), andsome of them will evolve and thecomplications (bleeding, infection,fistulization). [4]Each patient requires an individualassessment of the characteristics of PP andhas chosen the best method of treatment ofPP for long-term favorable results.In recent years, conventional surgery isoutclassed by the new minimally invasiveinterventional techniques represented byguided endoscopic drainage, percutaneousdrainage or even laparoscopic approach.These interventions are characterized by alow rate of complications and mortality, anda higher rate of success.CT/ultrasound guided percutaneousdrainageThe drainage is achieved byintroducing a catheter under ultrasoundguidance or tomography within PP contentand removal of it. It is recommended forpatients with symptomatic PP but high riskfor other interventions, PP with immaturewalls or infected. [18-22]This treatment method is to be avoidedin case of PP communicating with pancreaticductal system (shown by ultraso und, CT,ERCP) as the drainage becomes a pancreaticfistula with risk of infection through thedrainage tube.
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Page 24 and 25: Ecografia cu substanţă de contras
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