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appunti personali del dott. Claudio Italiano, gastroenterologo
Esse si formano a seguito di una pancreatite acuta, e ciò accade nel 16-50% dei casi, ma anche nella pancreatite cronica, nel 20-40% dei casi, soprattutto a livello della testa del pancreas e possono essere multifocali, oppure a seguito di un trauma del dotto di Wirsung, che come sappiamo è il canale che drena il succo pancreatico. Le cisti possono essere in comunicazione con i dotti del pancreas, almeno nei 2/3 dei casi. Sono delle cavità cistiche legate al pancreas da tessuto necrotico ed infiammatorio.
Si parla di pseudocisti quando esiste una parete priva di epitelio proprio ma costituita da tessuto fibroso di granulazione, cisti che appunto al suo interno contiene i prodotti di degradazione del tessuto pancreatico andato distrutto, cioè i frustoli necrotici e succo pancreatico che nel frattempo si è raccolto dentro. Le cisti possono essere solitarie o multiple e di dimensioni che variano, in genere localizzate al corpo ed alla coda del pancreas ma nel 30% dei casi anche alla testa. Sono asintomatiche nel 40% dei casi, e si riscontrano occasionalmente nel follow-up delle pancreatite
Trattamento delle pseudocisti.
Il drenaggio endoscopico si attua realizando una comunicazione cisto-digestiva di circa un cm, usando uno stent, ma la distanza tra cisti e stomaco, per esempio, deve essere < 1 cm; anche questa tecnica non è scevra di rischi perché complica nel 20% dei casi con emorragia (8-10%) e con infezioni per il resto, e può dare recidive. Altra tecnica ancora più sofisticata è quella perendoscopica, attraverso un accesso trans-papillare con posizionamento di uno stent ed il drenaggio rimane almeno 10 settimane. La tecnica chirurgica, ove sia possibile attuarla, cioè in paziente con rischio ASA adeguato e centri di chirurgia esperti in questo senso, dà successo in una buona percentuale di casi, ma va tentata, sicuramente, solo dove hanno fallito le altre tecniche più semplici e meno invasive, nonostante quello che vogliono far credere i signori chirurghi(!), che si scelgono i migliori pazienti e fanno sempre figura nei congressi con le loro casistiche. La cisti deve avere consistenza adeguata per essere abboccata allo stomaco, al digiuno ed duodeno e deve rimane per almeno 6 settimane, cioè la parete non può essere flaccida, ma fibrosa, dimodocchè sia abboccata e suturata bene. E’ considerata “ estrema ratio” come scrive W.H. Nealon et al., tecnica cioè eseguita solo nel 10% dei casi, in centri specializzati, con rischio di insuccesso è morbilità nel 10%, ovviamente perché i pazienti sono selezionati, giovani, con adeguata funzione di pompa cardiaca, senza compromissione dell'apparato respiratoriom, senza insufficienza renale, senza segni di sepsi. Nel drenaggio esterno il paziente può avere MOF nel 30%; ma se è il caso e non si interviene la pseudocisti si può rompere verso l’interno con mortalità fino al 25% dei casi, con quadro di addome acuto, anemia, shock e shock settico se è infetta. Morale della favola:il medico, comunque, vada è sempre quello che sbaglia, fino a quando qualcuno non si renderà conto che in questo clima il medico non può operare le scelte giuste, ma solo vivere in trincea!! segue la letteratura scientifica che ho raccolto per voi.
Letteratura internazionale: [The role of percutaneous external drainage in the treatment of fluid collections associated with severe acute pancreatitis. What, when and how to drain?]
[Article in Hungarian] Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Orvostudományi Kar Sebészeti Intézet, Auguszta Sebészeti Központ Debrecen. Szentkerzs@freemail.hu The percutaneous drainage of the fluid collections associated with severe acute pancreatitis mainly in sterile cases is not a commonly accepted method. The aim of the present paper is to analyse the indications, the technic, the limits and results of the percutaneous drainage on the basis of the literature. The percutaneous drainage plays an important role in the treatment of the acute fluid collection, the acute pseudocyst, the pancreas abscess, and the liquified necrosis, accompanying the severe acute pancreatitis. For the septic fluid collections the percutaneous drainage is preferred as the first line treatment. In cases of sterile acute fluid collections and pseudocysts because of its relatively high iatrogenic infection rate the drainage is indicated only if it causes severe complaints. The rules of sterility have to be kept. For successful treatment of liquified necrosis the possible methods are the use of large-bore (20-30F) catheter drainage, sinus tract endoscopy, or laparoscopic assisted necrosectomy. In more than 25% of the cases drainage, along with the conservative treatment, leads to the complete recovery of the patient. In the remaining cases it is helpful in postponing the date of the operation and avoiding early surgery.
Curr Gastroenterol Rep. 1999 Apr;1(2):139-44.Links Comment in: Curr Gastroenterol Rep. 1999 Apr;1(2):87-8. Management of fluid collections and necrosis in acute pancreatitis. Division of Gastroenterologic and General Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA. According to the Atlanta classification, the most widely accepted clinically based classification system for acute pancreatitis, four pathologic entities of fluid collections and necrosis are recognized. Acute fluid collections occur early as an exudative reaction to the pancreatic inflammation, have no fibrous wall, and resolve spontaneously. Pancreatic necrosis, the most severe form of acute pancreatitis, is diagnosed on dynamic contrast-enhanced computerized tomography and requires early aggressive cardiorespiratory resuscitation, nutritional support, and appropriate systemic antibiotics to prevent superinfection. Development of infection (infected necrosis) is the indication for operative debridement, preferably as late in the course of the disease as possible. Acute pseudocysts are collections of pancreatic, enzyme-rich fluid caused by pancreatic ductal disruption that occur 3 to 6 weeks after onset of acute pancreatitis and have a well-defined, nonepithelial fibrous wall. If communication with the ductal system is present, internal enteric drainage (either operative or endoscopic) is more effective; if communication is not present, the pseudocysts are amenable to percutaneous drainage. A pancreatic abscess is an infected, circumscribed peripancreatic collection, associated with minimal or no parenchymal necrosis, that occurs late (4 to 6 weeks) after onset of severe pancreatitis and may represent an infected pseudocyst; percutaneous drainage is the treatment of choice. Chirurgia (Bucur). 2006 May-Jun;101(3):259-65. [The pancreatic pseudocyst--late complication of the severe acute pancreatitis. Therapeutic options]
[Article in Romanian] Nemeş R, Georgescu I, Mărgăritescu D, Săftoiu A, Chiutu L, Georgescu E, Surlin V, Cârtu D, Dumitrescu D. Clinica I Chirurgie, UMF Craiova. AIM: the assessment of the therapeutical methods in the pancreatic pseudocyst occurred after severe acute pancreatitis. MATERIAL AND METHOD: 30 (33.3%) pancreatic pseudocysts (18 men and 12 women aged between 28-64) occurred in the evolution of 90 severe acute pancreatitis in the last 5 years (2000-2004) were analyzed. The diagnosis was established on the clinical and imaging aspects on average 1 month after the onset of the severe acute pancreatitis. The treatment was different, depending on size, anatomo-clinical form, pseudocyst age, presence of complications and the biological status of the patient. 14 uncomplicated pseudocysts, with the diameter less than 6 cm, were treated conservatively, until their complete resorption. 6 cases were operated on (2 cysto-gastrostomy, 1 cysto-jejunostomy and 3 external drainage). We performed percutaneous external CT guided drainage in 2 cases and endoscopic drainage in other 8 cases (trans-papillary-trans-ductal drainage 3 cases and endoscopic US guided drainage in 5 cases: transgastric 2, transduodenal 2 and transesophageal 1). RESULTS: 28 (93.3%) cases had a fair evolution (complete resorption in 14 uncomplicated pseudocysts after 3-6 weeks of conservative treatment). We registered 2 gastro-duodenal bleeding during endoscopic US guided drainage, which required operation (haemostasis cysto-gastrostomy). Mortality rate was 0. CONCLUSIONS: 1. The pseudocyst is the main late complication of the severe acute pancreatitis (33.3% in our study). 2. The uncomplicated pseudocysts with the diameter less than 6 cm, benefit of the conservative treatment and monitoring in progress until their complete resolution. 3. There are 3 therapeutical methods for the pseudocysts more than 6 cm in diameter and/or complicated: the percutaneous external US/CT guided drainage, the endoscopic drainage and surgery. 4. The option for the drainage procedure must take into account the morphological and evolutionary aspects of the pseudocyst, the age and biological status of the patient. PMID: 16927914 [PubMed - indexed for MEDLINE]
Cardiovasc Intervent Radiol. 2006 Jan-Feb;29(1):102-7. Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration. Walser EM, Nealon WH, Marroquin S, Raza S, Hernandez JA, Vasek J. Department of Radiology, University of Texas Medical Branch, Galveston, TX 77555, USA. walser.eric@mayo.edu PURPOSE: To compare the clinical outcome of needle aspiration versus percutaneous catheter drainage of sterile fluid collections in patients with acute pancreatitis. METHODS: We reviewed the clinical and imaging data of patients with acute pancreatic fluid collections from 1998 to 2003. Referral for fluid sampling was based on elevated white blood cell count and fevers. Those patients with culture-negative drainages or needle aspirations were included in the study. Fifteen patients had aspiration of 10-20 ml fluid only (group A) and 22 patients had catheter placement for chronic evacuation of fluid (group C). We excluded patients with grossly purulent collections and chronic pseudocysts. We also recorded the number of sinograms and catheter changes and duration of catheter drainage. The CT severity index, Ranson scores, and maximum diameter of abdominal fluid collections were calculated for all patients at presentation. The total length of hospital stay (LOS), length of hospital stay after the drainage or aspiration procedure (LOS-P), and conversions to percutaneous and/or surgical drainage were recorded as well as survival. RESULTS: The CT severity index and acute Ransom scores were not different between the two groups (p = 0.15 and p = 0.6, respectively). When 3 crossover patients from group A to group C were accounted for, the duration of hospitalization did not differ significantly, with a mean LOS and LOS-P of 33.8 days and 27.9 days in group A and 41.5 days and 27.6 days in group C, respectively (p = 0.57 and 0.98, respectively). The 60-day mortality was 2 of 15 (13%) in group A and 2 of 22 (9.1%) in group C. Kaplan-Meier survival curves for the two groups were not significantly different (p = 0.3). Surgical or percutaneous conversions occurred significantly more often in group A (7/15, 47%) than surgical conversions in group C (4/22, 18%) (p = 0.03). Patients undergoing catheter drainage required an average of 2.2 sinograms/tube changes and kept catheters in for an average of 52 days. Aspirates turned culture-positive in 13 of 22 patients (59%) who had chronic catheterization. In group A, 3 of the 7 patients converted to percutaneous or surgical drainage had infected fluid at the time of conversion (total positive culture rate in group A 3/15 or 20%). CONCLUSIONS: There is no apparent clinical benefit for catheter drainage of sterile fluid collections arising in acute pancreatitis as the length of hospital stay and mortality were similar between patients undergoing aspiration versus catheter drainage. However, almost half of patients treated with simple aspiration will require surgical or percutaneous drainage at some point. Disadvantages of chronic catheter drainage include a greater than 50% rate of bacterial colonization and the need for multiple sinograms and tube changes over an average duration of about 2 months.
Gastrointest Endosc. 2006 Apr;63(4):635-43. Comment in: Gastrointest Endosc. 2006 Apr;63(4):644-7. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Hookey LC, Debroux S, Delhaye M, Arvanitakis M, Le Moine O, Devière J. Gastroenterology Division, Queen's University, Kingston, Ontario, Canada. BACKGROUND: Pancreatic-fluid collections are frequent sequelae of acute and chronic pancreatitis, and endoscopic drainage of these collections has gained acceptance as an alternative to surgical drainage. METHODS: Patient data, collection characteristics, drainage technique, and outcomes were obtained through chart review and prospective follow-up for 116 patients with attempted endoscopic drainage of symptomatic pancreatic-fluid collections. RESULTS: A total of 116 patients presented with fluid collections classified as acute fluid collection (n = 5), necrosis (n = 8), acute pseudocyst (n = 30), chronic pseudocyst (n = 64), and pancreatic abscess (n = 9). The median diameter of the collection drained was 60 mm (15-275 mm). Median follow-up after drainage was 21 months. The drainage technique was transpapillary in 15 patients, transmural in 60, and both in 41. Successful resolution of symptoms and collection occurred in 87.9% of cases. No difference in success rates was observed between patients with acute pancreatitis and those with chronic pancreatitis. However, drainage of organized necrosis was associated with a significantly higher failure rate than other collections. No significant differences were observed regarding success when disease, drainage technique, or site of drainage was considered. Complications occurred in 13 patients (11%), and there were 6 deaths in the 30 days after drainage, including one that was procedure related. CONCLUSIONS: Endoscopic drainage of pancreatic-fluid collections is successful in the majority of patients and is accompanied by an acceptable complication rate.
Ann Surg. 2005 Jun;241(6):948-57; discussion 957-60 Comment in: Ann Surg. 2006 Jul;244(1):161-2; author reply 162-3. Ann Surg. 2006 Oct;244(4):630. Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas. Department of Surgery, Division of General Surgery, University of Texas Medical Branch, Galveston, Texas 77555-0544, USA. wnealon@utmb.edu OBJECTIVE: To study the magnitude of complications associated with the nonoperative management of peripancreatic fluid collections and pseudocysts and to assess the surgical management of these complications. These are compared with complications associated with operative management. SUMMARY BACKGROUND DATA: Pancreatic pseudocysts and peripancreatic fluid collections associated with acute pancreatitis have been managed with success using nonoperative techniques for more than a decade. When successful, these techniques have clear advantages compared with operative management. There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. Our report focuses on these complications and pseudocysts and on the surgical management. We have been struck by the high percentage of patients who sustain significant and at times life-threatening complications related to the nonoperative management of fluid collections. We further define an association between the main pancreatic ductal anatomy and the likelihood of major complications after nonoperative management. METHODS: Between 1992 and 2003, all patients admitted to our service with peripancreatic fluid collections or pseudocysts were monitored. We evaluated complications patients managed with percutaneous (PD) or endoscopic drainage (E). Data were collected regarding patient characteristics, need for intensive care unit (ICU) stays, hemorrhage, hypotension, renal failure, and ventilator support. We further focused on the duration of fistula drainage from patients who have had a percutaneous drainage, and we assessed the necessity for urgent or emergent operation. By protocol, all patients had pancreatic ductal anatomy evaluated by means of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Patients with complications of E and PD were compared with 100 consecutive patients who underwent operative management of pseudocyst and fluid collections as their sole mode of intervention. RESULTS: A total of 79 patients with complications of PD, E, or both were studied. There were 41 males and 38 females in the group of patients who sustained complications (mean age 49 years). Sixty-six of the 79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent. The mean elapsed time from diagnosis to nonoperative intervention was 18.1 days. This group of 79 patients had mean 3.1 +/- 0.7 hospitalization (range, 1-7) and length-of-stay 42.7 +/- 4.1 days. ICU stays were required in 36 of the 79 (46%). A defined episode of clinical sepsis was identified in 72 of 79 (91%) and was by far the most common complication. Hemorrhage requiring transfusion was identified in 16 of the 79 (20%), clinical shock 51 of the 79 (65%), renal failure 16 of the 79 (20%), ventilator support for longer than 24 hours 19 of the 79 (24%). A persistent pancreatic fistula occurred in 66 of the 79 patients (84%); mean duration was 61.4 +/- 9.6 days. Sixty-three of the 79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct. Among the 100 operated patients, 69 complications occurred in 6 of the 100 (6%). Operation was initiated electively a mean interval of 42.7 days after diagnosis of pseudocyst. Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients. CT imaging obtained at least 6 months after intervention documented complete resolution after surgery alone in 91 and 9 with cystic structures less than 2 cm. In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions less than 2 cm in diameter. CONCLUSION: These data support the premise that a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. It is vital to recognize the magnitude and severity of complications of nonoperative measures as one chooses a modality. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.
Hepatogastroenterology. 2002 Nov-Dec;49(48):1696-8.Links CT-guided percutaneous peripancreatic drainage: a possible therapy in acute necrotizing pancreatitis. Szentkereszty Z, Kerekes L, Hallay J, Czako D, Sápy P. 2nd Department of Surgery, University of Debrecen Medical and Health Science Center, School of Medicine, Móricz Zs.krt. 22., Debrecen, 4004, Hungary. BACKGROUND/AIMS: To examine the effectiveness of therapeutic percutaneous drainage of peripancreatic fluid in the treatment of acute necrotizing pancreatitis. METHODOLOGY: Twenty-eight patients treated for serious acute necrotizing pancreatitis (19 male, 9 female; average age 47.3 years) took part in the study. The cause of acute necrotizing pancreatitis was alcohol abuse in 20 of the cases, gallstone disease in 7 cases, endoscopic retrograde cholangiopancreatography in 2 cases, trauma in one case, and 4 of the cases had unknown cause. In all cases preventative antibiotics were given as part of intensive therapy, early nasojejunal nutrition was used, and we endeavored to avoid surgery or to delay it depending on the case. The acute peripancreatic fluid was drained percutaneously. In total, percutaneous drainage was used in 12 patients. RESULTS: Of the 28 patients, only 3 patients recovered solely with conservative therapy, without drainage. Three patients recovered using only percutaneous drainage without surgery. In 9 patients surgery was necessary after percutaneous drainage was performed. In the remaining 13 patients, only surgical treatment was used, without percutaneous drainage. In total 20 reoperations were done in 10 patients. Of the 12 patients treated with percutaneous drainage, one patient died. The total mortality was 14.3%. CONCLUSIONS: In certain cases the percutaneous drainage of the acute peripancreatic fluid that collects in acute necrotizing pancreatitis is sufficient for the total recovery of acute necrotizing pancreatitis, in other cases can be used to postpone surgery.
Ann Chir. 2004 Nov;129(9):497-502. [Percutaneous ultrasound-guided drainage in the surgical treatment of acute severe pancreatitis]
[Article in French] Delattre JF, Levy Chazal N, Lubrano D, Flament JB. Service de chirurgie générale digestive et endocrinienne, hôpital Robert-Debré, rue du Général-Koenig, 51092 Reims cedex, France. jfdelattre@chu-reims.fr AIM OF THE STUDY: To report results of percutaneous ultrasound-guided drainage, performed by a surgeon, in the treatment of complications of acute pancreatitis (AP), and to determine the role of this technique in the therapeutic armamentarium of severe AP. PATIENTS AND METHODS: From 1986 to 2001, 59 patients were included in this retrospective study. All patients initially had severe necrotizing AP (mean Ranson score = 4.1 ; range : 2-7). Anatomical lesions included pancreatic abscess in 6 patients and necrosis in 53 (17 stage D and 36 stage E according to Balthazar's classification). Necrosis was infected in 42 and sterile in 11 respectively. Drainage was performed under ultrasound guidance and local anaesthesia using small-diameter drains (7-14 French). RESULTS: Drainage was performed on average 23 days after onset of AP. Infection was proven by fine-needle aspiration in 47 (80 %) patients (41 infected necrosis and 6 localized abscess). In one patient, culture of aspirated fluid was negative but necrosis was infected (one false negative). Culture of aspirated fluid was negative and necrosis was sterile in 11 patients. Nineteen (32%) patients healed without subsequent surgery: 7 (16%) in the infected necrosis group, 6(55%) in the sterile necrosis group, and 6 (100%) in the abscess group. Forty (68%) patients had subsequent necrosectomy including 8 (14%) who died. Twenty (34 %) digestive fistulas healed spontaneously, except one treated by diversion stomia. Of the 16 (27 %) pancreatic fistulas, 6 needed subsequent interventional treatment. CONCLUSION: In selected patients, percutaneous drainage can represent an alternative to surgery with a 14% mortality rate. The high rate of subsequent necrosectomy suggests that drains with larger diameter, possibly associated with continuous irrigation, should be used.
J Chir (Paris). 1996 Jul;133(5):208-13.Links [Acute pancreatitis treated in a surgery ward. Apropos of 57 cases]
[Article in French] Benchimol D, Firtion O, Bereder JM, Chazal M, Bourgeon A, Richelme H. Service de Chirurgie Abdominale et Thoracique, Hôpital Pasteur, Nice. The aim of this study was to examine the results of a policy in the treatment of acute pancreatitis (AP): initial abstention, management in intensive care unit, surgery in cases of complication (infection and/or failure of medical treatment). The modalities of the surgical treatment were guided by CT scan findings: transperitoneal approach for diffuse lesions, posterior approach for localized lesions. From 1986 to 1994, 57 patients (32 males, 25 females, mean age 59.2 years) were referred to our department for AP. Etiology was gallstones in 29 cases, alcohol in 14 cases (Ranson < 3), moderate in 27 cases (Ranson < or = 5) and serious in 12 cases (Ranson > or = 6). According to the initial CT scan findings (56 cases), 9 patients were classified grade A, 11 grade B, 13 grade C, 8 grade D ans 15 grade E. Thirty eight patients were managed conservatively (mean Ranson stage 3.3), while 19 patients underwent surgical treatment (mean Ranson stage 4.6), in emergency for misdiagnosis (4 cases), or secondarily because of failure of medical management (15 cases). Surgery consisted in necrosectomy with active drainage in 13 cases and drainage alone in 6 cases. Associated maneuvers included: cholecystectomy in 8 cases, cholecystostomy in 2 cases, jejunostomy in 7 cases and colic resection for necrosis in 3 cases. Two patients (5%) managed conservatively died (multiple organ failure and cardiac insufficiency) while 4 patients (21%: NS) who underwent surgery died (2 multiple organ failures, 1 septic shock, 1 myocardic infarction). Mortality was correlated with the Ranson score: 42% for serious AP, 3.7% for moderate AP and nil for mild AP (p < 0.01). It was not correlated with CT scan grade, the onset or the type of operation. These results allow us to conclude that surgical treatment should be indicated only in cases of failure of conservative management, the best indication being uncontrolled sepsis. In this situation, active drainage provides good results since only one sepsis recurred among the 14 patients who underwent this procedure.
Surg Gynecol Obstet. 1992 Nov;175(5):429-36.Links Treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis. Feig BW, Pomerantz RA, Vogelzang R, Rege RV, Nahrwold DL, Joehl RJ. Department of Surgery, Northwestern University Medical School, Chicago, Illinois. We reviewed an experience with treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis to identify clinical and computed tomography (CT) parameters that are helpful in the selection of patients for treatment and to assess treatment outcome. The extent of CT abnormalities determined a CT severity score (mild = 1, severe = 4). From 1985 to 1990, 650 patients were hospitalized with acute pancreatitis; a peripancreatic fluid collection was found in 36 patients (5.5 percent). Ten of 11 patients with successful outcome after no invasive treatment (group 1) had a low CT severity score of 1 or 2; mean serum albumin was 4.0 gram percent. Of 25 patients who had some form of drainage, 12 had a high CT severity score of 3 or 4 (p < 0.05) and a mean serum albumin of 3.4 grams percent (p < 0.05). Nine patients had only operative drainage (group 2) and 16 had CT-directed percutaneous catheter drainage (group 3). In group 3, percutaneous catheter drainage successfully drained the fluid collection in six patients, while ten patients needed an operation, in addition to percutaneous drainage, to effectively débride and drain the necrotizing pancreatic problem. As a result of the current review, we propose an algorithm for treatment of these patients
Timing of intervention in acute pancreatitis. University Surgical Unit, Southampton General Hospital, UK. This review examines the appropriate timing of intervention in acute pancreatitis. In gallstone pancreatitis, it is now clear that cholecystectomy during the primary admission carries no greater risk of complications than delayed cholecystectomy and enables earlier recovery to normal activity. This course of action pre-empts a second, possibly fatal attack of acute pancreatitis. Cholecystectomy should be done after the acute phase has settled, before discharge from hospital. Patients with gallstones should now be offered endoscopic sphincterotomy within 48 hours of admission. This approach is safe, and reduces the risk of complications. When complications develop, early necrosectomy is only indicated if conservative measures fail. Delayed (> 10 days) necrosectomy is appropriate if there is evidence of sepsis, or clinical failure to improve. Pancreatic pseudocysts can often be managed expectantly; a high proportion will resolve spontaneously. After a delay of 12 weeks, persistent cysts require evaluation by endoscopic pancreatography, which gives crucial information in the choice between percutaneous or surgical drainage of the pseudocyst. A patient with pancreatitis is usually treated under the care of a surgeon, who has traditionally taken the decision on the timing of any intervention, and has performed such intervention at open operation. Recently, the development of alternative techniques has enabled the surgeon to call on the skills of his colleagues in endoscopy and interventional radiology. However, the availability of these alternatives to surgery should not affect the timing of intervention unless it can be clearly shown that such a change in timing combined with the minimally invasive technique can improve the outcome for the patient. Intervention may be required to deal with gallstones in the gallbladder or in the bile duct, to deal with, or ideally prevent, the deleterious systemic effects of pancreatic and peripancreatic necrosis, or to drain a peripancreatic abscess. Peripancreatic fluid collections and pancreatic pseudocysts may also require either internal or external drainage to relieve symptoms or prevent complications.
Gastroenterol Clin North Am. 1999 Sep;28(3):661-71.Links Surgical approach in patients with acute pancreatitis. Is infected or sterile necrosis an indication--in whom should this be done, when, and why? Department of Surgery, University of California Los Angeles School of Medicine, USA. The morbidity and mortality rates of severe acute pancreatitis are related to the degree of pancreatic necrosis that accompanies the attack and to the presence of infection. The decision about whether and when to operate on these patients is often difficult, and it requires mature clinical judgment. Proven infection of pancreatic necrosis is an absolute indication for surgical intervention, at which time surgical doffebridement and drainage should be performed. Most patients with sterile necrosis eventually respond to conservative nonsurgical medical management. In patients who remain critically ill for weeks or whose clinical course deteriorates despite maximal intensive care, surgery may be appropriate. Even when these guidelines are followed, the mortality (15% to 40%) and morbidity (approximately 80%) rates remain high.
Int J Pancreatol. 1999 Apr;25(2):123-33.Links Nonoperative management of pancreatic pseudocysts. Problems in differential diagnosis. Boggi U, Di Candio G, Campatelli A, Pietrabissa A, Mosca F. Dipartimento di Oncologia, Università di Pisa, Italy. u.boggi@patchir.med.unipi.it CONCLUSION: The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. Awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively. BACKGROUND: The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic errors occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature. METHODS: Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo. RESULTS: Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12-154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period. sul sito gastroepato Il fegato La cirrosi epatica: come curare La cirrosi biliare primitiva, di tutto e di più: come curarla L'albumina: quando usarla, come e perchè? La calcolosi della via biliare principale: come trattare? Un trauma chiuso dell'addome, la frattura del fegato. Le cure idropiniche:la Fonte di Venere! La peritonite batterca spontanea, come curarla La terapia delle epatiti croniche La pancreatite cronica, eziologia, diagnosi e cura Il morbo di Wilson da accumulo di rame
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Trattamento
delle pseudocisti del pancreas
Va
senza’altro detto che le pseudociti, in genere, si riassorbono nel
tempo da sole e, quindi, non vanno fatti interventi invasivi per la
loro cura in una buona percentuale dei casi, forse anche più della
metà. La maggior parte degli autori concorda però nell’affermare che
cisti di notevoli dimensioni, cioè > di 6 cm di diametro,
poiché possono complicarsi (infettarsi, rompersi, andare in contro
ad emorragia ecc.) vanno trattate. Altro nodo controverso è come
trattarle. La maggior parte degli autori, ancora, concorda nel
ritenere che il primo approccio deve essere quello meno invasivo,
cioè il trattamento di drenaggio percutaneo, con catetere eco o,
meglio, TC guidato, con posizionamento del drenaggio, lavaggio in
loco con soluzione fisiologica sterile, per rimuovere i frustoli e
fare drenare meglio la poltiglia necrotica ed impiego in loco e per
via sistemica, se del caso, di antibioticoterapia (in genere si
impiegano i carbapenemici, le cefalosporine, talora i
fluorochinoloni. E’ possibile, anche, un approccio perendoscopico
delle pseudocisti, cioè un drenaggio con tecnica endoscopica di
posizionamento di uno stent o, ove possibile, di tecnica chirurgica.
Comunque sia il trattamento chirurgico e quello percutaneo sono
sempre gravati da alte percentuali di insuccesso ei morbidità e
mortalità nell’ordine del 15-30% dei casi; pertanto la decisione di
intervenire o meno spetta sempre al medico che si basa sulle
condizioni cliniche del paziente. Inoltre il trattamento è sempre
riservato alle cisti sintomatiche, per esempio se danno compressione
sullo stomaco e, dunque, ostacolano lo svuotamento gastrico, se
hanno rapporto con il dotto pancreatico, se derivano da una sospetta
neoplasia e/o se tendono ragionevolmente ad infettarsi, ad
ascessualizzare, a rompersi, o a dare emorragie e dolore, con
rischio di emoperitoneo (
Il
drenaggio percutaneo che in genere è la metodica più semplice
da attuarsi specie quando le condizioni del paziente sono severe e
non consentono metodiche più invasive è sempre preferibile come
metodica meno invasiva, anche se è gravato da insuccesso nel 10-15%
dei casi e dal rischio notevole di infezione, poichè il catatere
deve drenare per molto tempo, in genere per un mese e deve
avere dimensioni considerevoli, di 8-10 french; se vi è
comunicazione con i dotti pancreatici è questa una metodica
controindicata. Noi abbiamo esperienze in tal senso, di pazienti che
abbiamo drenato con la collaborazione della radiologia
interventistica del P.O. di Patti, diretta dal dott. Ilario Carella.
Si trattava di un paziente che abbiamo seguito in regime di DH
ospital, sottoponendolo ai controlli del caso (emocromo, indici di
flogosi, colture dell'aspirato, controlli ecografici e TAC).