PDF (5 MB) - Jurnalul de Chirurgie

Pancreatic pseudocyst 363Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4Short-term results of external drainageare good, with improvement of symptoms.Persistent drainage for a long time, over fourweeks may require further interventionalmethod for solving PP (fistula -digestiveanastomosis, endoscopic internal drainage orsurgical resection of pseudocyst).Endoscopic drainageEndoscopic drainage is recommendedto the patients with PP closely adjacent to adigestive lumen, as an alternative toconventional or laparoscopic surgery. Theapproach can be achieved through thedigestive wall (trans -gastric or transduodenal)or trans-papillary for PPcommunicating with the pancreatic duct, butshowing strictures or stenosis as in chronicpancreatitis [23,24].Endoscopic ultrasound appreciatepseudocyst wall thickness (“wall maturity”),distance to the cavity of PP, gastric varicesand collateral circulation that preventspuncture marked by increased risk ofbleeding, PP content more or less fluid thatmay require insertion of multiple cathetersor even external naso-cystic drainage [22].Success rate is over 90% in selected cases,with favorable effects on symptoms andminimal immediate complications: bleeding(may require emergency surgery if notresolved endoscopically), perforation withperitonitis [4]. Late complications are stentobstruction, its migration, infection ofpancreatic pseudocyst [21]. Thesecomplications may require repeated drainageprocedures by endoscopic or surgicalapproach [23].Surgical treatmentIt was for a long time the standardtreatment of pancreatic pseudocyst, but itsimportance decreased with improvingtechniques of guided external or endoscopicdrainage, which have a lower mortality andmorbidity.Different surgical treatment techniqueswere described: external drainage, internaldrainage (cysto -gastrostomy, cystoduodenostomy,cysto-jejunostomy), PPresection (especial ly for the caudal PP).Some of these interventions can beperformed laparoscopic, with better resultsand faster postoperative recovery.External drainage is indicated when PPis infected or it is insufficiently mature walland fit for digestive anastomosis [21]. Therisk of pancreatic fistula with prolongeddrainage may lead to the need for furthersurgery to deal with it (fistula -jejunostomyor pancreatic resection) [17].Transgastric cysto-gastrostomy orcysto-jejunostomy using a Roux “Y” loop isthe classical surgical treatment of PP. Forbest results it is essential that the wall of PPis suitable for an anastomosis and this issufficiently large (at least 3cm) to preventstenosis [25].Pancreatic resection is possible whenPP is located on the tail of the pancreasand/or it isn’t possible to exclude apancreatic cystadenocarcinoma. Howeverintervention is difficult becauseinflammatory changes after acutepancreatitis [26].Laparoscopic approach may be carriedout with a cysto-jejunostomy or cystogastrostomy.Experience is still quitelimited, with long lasting interventions, butwith apparently rapid postoperative recovery[27. Teixeira J, Gibbs KE, Vaimakis S, Rezayat C, LaparoscopicRoux-en-Y pancreatic cyst-jejunostomy, Surg Endosc 200317:1910-1913].CONCLUSIONSIn patients not fit for surgery or withsevere comorbidities, percutaneous orendoscopic drainage can be done to improvepatient status. The risk is represented by theformation of an external pancreatic fistulawhich may require further interventions.There are no randomized studies todevelop a therapeutic protocol for pancreaticpseudocyst; the PP management isindividualized for each case depending onthe morphological PP characteristics,procedures availability and team experience.Endoscopic internal drainage is aneffective therapeutic approach for selectedcases with minimal complications.