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The Abdomen
Published in Kenneth D Boffard, Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
Accurate diagnosis and surgical treatment of pancreatic injuries should result in a rate of pseudocyst formation of about 2%–3%. Accurate evaluation of the state of the duct will dictate management, and if the duct is intact, percutaneous drainage is likely to be successful. However, a pseudocyst together with a major ductal disruption will not be cured by percutaneous drainage, which will convert the pseudocyst into a chronic fistula. Current options include cystogastrostomy (open or endoscopic), endoscopic stenting of the duct, or resection.
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Published in V.K. Kapoor, Hans G. Beger, Acute Pancreatitis, 2017
An attempt must be made to make the internal drainage of a pseudocyst dependent as far as possible. For cysts in the lesser sac protruding into the posterior wall of the stomach, a cystogastrostomy will achieve this. For cysts below and inferior to the stomach and near the tail of the pancreas, cystogastrostomy may not be dependent and cystojejunostomy is preferable. Cysts near the head of the pancreas may be better drained into the duodenum—cystoduodenostomy.
Pyrexia Two Weeks after an Attack of Alcohol-Induced Acute Pancreatitis
Published in Savio George Barreto, Shailesh V. Shrikhande, Dilemmas in Abdominal Surgery, 2020
The dilemma in this case is the cause of the patient’s temperature. There are several possibilities, including a cytokine-mediated systemic inflammatory response syndrome response, bacteremia secondary to gut translocation, extra-pancreatic infection, and/or infected local complication the pancreas. It is most likely, in the absence of any other infections, that this patient was readmitted because of bacteremia secondary to bacterial translocation or early infection of the acute necrotic fluid collection. Either way, a full set of blood cultures should be collected, and antibiotics commenced. If the patient is stable (or improves) then continued conservative management is indicated. It has been shown that occasionally some patients have required no more than antibiotic treatment. On careful monitoring, and with clinical evidence of deterioration, drainage of the collection will be required. Drainage can be done either endoscopically (with endosonographic guidance) or percutaneously (with fluoroscopic or ultrasound guidance). The choice is primarily based on the location of the collection. Centrally located collections are suitable for endoscopic transgastric drainage (with the added advantage including dilatation, insertion of metal stents, and endoscopic debridement). Collections that extend into the paracolic gutters are suitable for percutaneous drainage. On this basis, this patient would have been referred for endoscopic drainage. However, owing to the immaturity of the wall with the attendant risk of leakage into the lesser sac and peritonitis, a percutaneous approach was preferred. If endoscopic and radiological expertise are not available, then this patient should be transferred to a referral center. Early drainage (less than three weeks) not only permits the ability to obtain a specimen for bacteriology, but it also helps to “buy time”, allowing patients to improve, the necrosum to sequester, and walls of the collection to become more defined. This makes it safer for subsequent debridement should that be required (enabling insertion of a guidewire for dilatation, insertion of a metal stent, and debridement). Drainage alone can suffice in up to 50% of patients. If drainage is not available, a cystojejunostomy or cystogastrostomy (open or laparoscopic) can be considered in large or symptomatic mature cysts a few weeks down the track[6].
Surgical Management of Life Threatening Bleeding after Endoscopic Cystogastrostomy
Published in Journal of Investigative Surgery, 2018
Ashish George, Rajesh Panwar, Sujoy Pal
A 25-year-old male underwent EUS guided endoscopic cystogastrostomy for drainage of a pseudocyst. The patient developed bleeding from the puncture site which resolved spontaneously. A relook endoscopy done next day did not show any active bleeding. However, one day later, he developed hematemesis with hemodynamic instability. Patient was resuscitated, but had to be taken up for emergency surgery in view of persistent hypotension despite resuscitation. An open cystogastrostomy was quickly performed using the technique as described in the first case. There was active spurt, likely from the gastroduodenal artery which was initially controlled by applying digital pressure from inside the pseudocyst through the cystogastrostomy site. The bleeder was suture ligated and the hemostasis was secured. Postoperative recovery was uneventful and patient was doing well till postoperative day 8. However, on that day, he developed sudden loss of consciousness due to ventricular tachycardia. He was resuscitated and revived but had to be kept on a ventilator. Thereafter, he developed recurrent episodes of ventricular tachycardia caused by suspected Long QT syndrome. An implantable defibrillator was planned in consultation with the cardiologist but the patient expired before that.
Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom
Published in Scandinavian Journal of Gastroenterology, 2018
Chander Shekhar, Ben Maher, Colm Forde, Brinder Singh Mahon
The classification and management of pancreatic pseudocyst (PP) has evolved since being first mentioned in case reports from exploratory laparotomies in the early 1920s [1]. An early retrospective study on the natural history of PP reported spontaneous resolution in the majority with only symptomatic or enlarging PP requiring intervention [2]. Over the last decade, endoscopic ultrasound guided transmural drainage (EUS-TD) of PP has gradually displaced surgical cystogastrostomy to become the treatment of choice and shown to be equally effective in a randomised trial with shorter hospital stay, lower costs and better physical and mental health outcomes for patients [3].
Stent migration following treatment of pancreatic pseudocyst by cyst gastrostomy
Published in Baylor University Medical Center Proceedings, 2019
Steven Smith, Patrick Ramirez, Alisha Hinds, Raymond Duggan, Jonathan Ramirez
Historically, surgical drainage involving either open or laparoscopic cystogastrostomy was primarily performed. Later, percutaneous drainage using an external drainage catheter became an efficacious option for pseudocyst drainage. However, with the advancement of endoscopic therapies, including conventional transmural drainage and EUS-guided transmural drainage, endoscopic procedures have been increasingly utilized due to their similar success rates and comparable complication rates. Furthermore, endoscopic therapy has been associated with a shorter hospital stay, lower cost, and improved quality of life scores compared with surgical drainage.4