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Hypothesis: Widespread use of computed tomography and ultrasound has led to the identification of increasing numbers of patients with asymptomatic cystic lesions of the pancreas., Design: Retrospective case series of patients with pancreatic cystic lesions., Setting: University-affiliated tertiary care referral center., Patients: Two hundred twelve patients with pancreatic cystic lesions seen in our surgical practice during 5 years (April 1997-March 2002)., Main Outcome Measures: Presence or absence of symptoms, cyst size and location, cytologic or pathologic diagnosis, surgical treatment, and outcome., Results: Seventy-eight (36.7%) of 212 patients were asymptomatic. Incidental cysts were smaller (3.3 +/- 1.9 vs 4.6 +/- 2.7 cm; P<.001) and were found in older patients (65 +/- 13 vs 56 +/- 15 years; P<.001). Seventy-eight percent of the asymptomatic patients and 87% of those with symptoms underwent surgery, with a single operative death in the entire group (0.5%). Seventeen percent of asymptomatic cysts were serous cystadenomas; 28%, mucinous cystic neoplasms; 27%, intraductal papillary mucinous neoplasms; and 2.5%, ductal adenocarcinomas. The respective numbers for symptomatic cysts were 7%, 16%, 40%, and 9%. Ten percent of asymptomatic patients had a variety of other cystic lesions, and in 12%, no definitive cytologic or pathologic diagnosis was obtained. Overall, 17% of asymptomatic patients had in situ or invasive cancer, and 42% had a premalignant lesion. When evaluated as a function of size, only 1 (3.5%) of 28 asymptomatic cysts smaller than 2 cm had cancer compared with 13 (26%) of 50 cysts larger than 2 cm (P =.04). The proportion of premalignant lesions, however, remained high in both groups (46% and 38%, respectively). Pseudocysts comprised only 3.8% of asymptomatic cysts compared with 19.4% of symptomatic cysts (P =.003)., Conclusions: Incidental pancreatic cysts are common, occur in older patients, are smaller than symptomatic cysts, and are unlikely to be pseudocysts. More than half of them are either malignant or premalignant lesions and therefore cannot be dismissed.

Hypothesis: Laparoscopic ultrasound examination combined with biopsy of the cystic wall and aspiration of cystic fluid improves differential diagnosis of pancreatic cystic lesions contributing to surgical decision making., Study Design: A prospective evaluation of the impact of laparoscopic ultrasound on surgical decision making in patients with pancreatic cysts., Setting: A general community hospital; the department of surgery serves as referral for pancreatic surgery., Patients: During a 36-month period, 15 patients with pancreatic cystic lesions were prospectively evaluated by laparoscopy and laparoscopic ultrasound with ultrasound-guided biopsy of the cystic wall and aspiration of cystic fluid for cytologic study, viscosity, and determination of levels of amylase and tumor markers (carcinoembryonic antigen, cancer antigen 19.9)., Results: Laparoscopic ultrasound contributed new, additional data in 8 patients (53%) when compared with compiled imaging data obtained by conventional ultrasound, computed tomography, magnetic resonance imaging, and endoscopic ultrasound. A solid cystic component was detected in 6 patients and additional small (<1 cm) cysts in 3 patients. Amylase and tumor marker levels, biopsy of the cystic wall, and cytologic examination had significant impact on surgical decision making in 6 patients. Nine patients underwent resection of the cystic lesion. Three patients diagnosed as having benign cysts had laparoscopy with laparoscopic ultrasound only. Three patients with suspicious lesions refused surgery. Laparoscopic ultrasound predicted correctly the nature of the cyst in 7 of 9 surgically treated patients (sensitivity, 78%). Two patients with serous cystadenoma had high levels of tumor markers (false-positive)., Conclusion: Although a rather invasive procedure that requires general anesthesia and hospitalization, laparoscopy with laparoscopic ultrasonography was found to significantly contribute to the differential diagnosis of pancreatic cystic lesions.

The records of 299 patients with 357 admissions for pancreatic pseudocysts seen between 1960 and 1989 were studied; 233 patients underwent operation. The natural history of pancreatic pseudocysts has been clarified by newer technology, such as ultrasonography, computer tomography, amylase isoenzyme measurements, and endoscopic retrograde cholangiopancreatography. All have influenced diagnosis, nonoperative management, and surgical operation. Differences between pancreatic pseudocysts associated with acute pancreatitis in contrast with chronic pancreatitis, and the complications of obstruction, hemorrhage, rupture, pancreatic ascites, infection, and jaundice can now be more rationally treated. Pancreatic pseudocysts and pancreatic ductal changes are now revealed earlier, especially by endoscopic retrograde cholangiopancreatography. Paradoxically, this information has encouraged nonoperative conservative therapy and also larger operations, eg, resection and adjunctive pancreaticojejunostomy. Partial resection of the pancreas together with the pancreatic pseudocysts was performed in 58 (25%) of the 233 patients. Recent technology permits cautious exploration of selective pancreatic pseudocyst drainage percutaneously or transgastroduodenally avoiding laparotomy.

Records from 87 consecutive patients undergoing lateral pancreaticojejunostomy (LPJ) for chronic pancreatitis were reviewed to determine the incidence of pseudocyst and the safety of combined pancreatic duct and pseudocyst drainage. Twelve patients had undergone previous pancreatic pseudocyst drainage; four of them also had pancreatic pseudocysts present at the time of LPJ. In addition, 22 patients had pseudocysts identified preoperatively and/or confirmed at operation. The overall incidence of pseudocyst was 39%. Twenty-six patients (group 1) underwent pancreaticojejunostomy combined with pseudocyst drainage. Sixty-one patients (group 2) underwent pancreaticojejunostomy only. Operative morbidity and mortality results (19% and 8%, respectively, in group 1; 18% and 2%, respectively, in group 2) were similar. Patient outcome was also similar in the two groups (81% and 84% of patients obtained pain relief in groups 1 and 2, respectively). There were no pseudocyst recurrences in either group. Thus, there is a high incidence (39%) of pancreatic pseudocyst in patients undergoing LPJ for chronic pancreatitis. Combined drainage of the pancreatic duct and pseudocyst is safe and effective.

The treatment of choice for most persistent, mature pseudocysts of the pancreas is internal drainage. Cystogastrostomy, cystojejunostomy with a Roux-en-Y loop, and, less frequently, cystoduodenostomy are the surgical techniques most commonly employed to attain effective internal drainage. We present the case of a patient with a pseudocyst arising from the cephalic portion of the pancreatic head and extending into the porta hepatis, causing obstructive jaundice, who was treated by cystocholedochostomy. This simple procedure was performed after an intraoperative cholangiogram showed no ductal obstruction distal to the pseudocyst. A cholecystectomy was also done, and the common bile duct was drained with a T tube. This expeditious procedure, rather than a Roux-en-Y cystojejunostomy, was elected because of the firm adherence of the posterior wall of the common bile duct to the anterior surface of the pseudocyst. The patient had an uncomplicated recovery and has been completely asymptomatic for 2 years. We believe this is the first report of a pancreatic cystocholedochostomy for a pancreatic pseudocyst.

Seventy-five operative procedures were done in 63 patients to correct one or more complications of chronic pancreatitis. Operations included resection, pancreaticojejunostomy, choledochoduodenostomy, draining and/or excision of pseudocysts, sphincteroplasty, and bypass surgery for relief of duodenal obstruction. All patients were followed up for up to 10 years, with 22 being followed up longer than five years. Recurrent pancreatitis occurred in three patients after resection and in two after drainage procedures, but attacks were milder with only an occasional occurrence. Operative procedures to relieve specific complications of chronic pancreatitis provided good results. However, because internal drainage of pseudocysts associated with chronic pancreatitis was frequently accompanied by recurrence of symptoms, excision offered better results. When the pancreatic duct was dilated, good results were obtained by pancreaticojejunostomy. In the absence of dilation, after strict preoperative slection of patients, and in the presence of diffuse parenchymal fibrosis, subtotal pancreatectomy is the procedure of choice.

The difficulties in employing standard techniques in the management of pancreatic pseudocysts led to the development and evaluation of a new approach. The advent of surgical stapling instruments has allowed the anastomotic procedures to be done in a more expeditious manner. For that reason, it was decided to treat pancreatic pseudocysts in two patients by constructing a pancreaticocystogastrostomy with the use of an automatic stapling instrument. The performance of the technique and the uneventful postoperative course encourages its continued use in cysts that are adjacent to the posterior gastric wall.

The use of endoscopic retrograde pancreatography (ERP) provides important information in the management of pancreatic pseudocysts unavailable by other methods. When the pseudocysts communicate with a hollow viscus, the surgeon is better able to deal with the problem if aware of this fact prior to operative intervention. A pancreatic pseudocyst communicating with the stomach was demonstrated by ERP in each of four patients. One of these patients had pancreatic ascites and the other had left-sided pleural effusion, and both were treated successfully by distal pancreatectomy. The other two patients responded to nonoperative treatment. This report emphasizes the potential diagonstic value of ERP in determining the presence and the fate of pseudocysts.

In a patient with chronic ascites, an abnormally raised ascitic fluid amylase concentration and a protein content above 2.5 gm/100 ml is diagnostic of pancreatic ascites. Thirty-one episodes in 26 patients treated between 1958 and 1975 have been analyzed. Twenty patients (65%) experienced abdominal pain and ten (32%) had concomitant pleural effusions roentgenographically. Although a leaking pancreatic pseudocyst was the cause of ascites in at least 21 episodes (70%), an abdominal mass could only be palpated in two of 26 patients. Roentgenographic series of the upper part of the gastrointestinal tract failed to demonstrate pancreatic pseudocyst in 7 of 21 episodes (33%). Endoscopic retrograde pancreatography is invaluable in delineating the pancreatic ductal system and, in conjunction with intraoperative pancreatography, makes a vital contribution to rational surgical therapy. Medical treatment or external drainage during 18 episodes resulted in death in four (22%) and recurrences of ascites or pancreatic pseudocyst in nine (64%). Since routine pancreatography followed by pancreatic resection or internal drainage has been instituted, mortality and recurrence have been reduced to zero.

Common bile duct stricture secondary to chronic pancreatitis is difficult to detect clinically. Surgical bypass is necessary if complications from biliary obstruction develop. In 21 patients operated on between 1968 and 1979, the earliest typical biochemical finding was a persistently elevated serum alkaline phosphatase level. The SGOT level was minimally elevated in seven patients, but did not correlate with changes in the stricture. An increased bilirubin level was noted either during an acute exacerbation of pancreatitis or late in the course of the stricture development, when obstruction was almost complete. Operative cholangiograms taken in 12 of these patients and transhepatic cholangiograms taken in nine demonstrated a stricture of the intrapancreatic bile duct more than 2 cm long. Operations were performed for treatment of obstructive jaundice (11), ascending cholangitis (three), suspected pancreatic cancer (three), and progressive biliary cirrhosis (two). Sphincteroplasty, initially attempted in four patients, uniformly failed to relieve the obstruction due to the length of strictured duct. Satisfactory drainage was obtained for up to ten years with choledochoduodenostomy (12), choledochojejunostomy (three), and cholecystojejunostomy (six).

During routine cholecystectomy, a 39-year-old woman suffered an injury to the common bile duct, which resulted in a choledochal stricture and a choledochopancreatic fistula with pseudocyst formation. Treatment consisted of a choledochoduodenostomy for the common bile duct stricture and a pancreaticoduodenostomy for internal drainage of the pancreatic pseudocyst. A long-term follow-up has yielded an excellent clinical result.

A review of 81 patients with pancreatic pseudocyst was conducted to assess the value of different treatment modalities. Resection was associated with 18% mortality (two of 11 patients) and 36% morbidity. In three of nine patients undergoing external drainage a recurrent pseudocyst developed, and in one additional patient, a pancreatic fistula persisted. Internal drainage by cystogastrostomy (21 patients) resulted in 9.5% mortality and 9.5% morbidity, whereas cystojejunostomy (33 patients) was associated with a 6% mortality and 6% morbidity. Endoscopic drainage through the posterior wall of the stomach was unsuccessful in the two patients in which it was used. Internal drainage into the stomach, duodenum, or jejunum is a safe and effective approach for most pseudocysts. Persistent symptoms following surgical treatment were primarily related to failure to recognize multiple cysts and/or pancreatic duct obstruction and dilation characteristic or chronic pancreatitis.

During the period of 1962 to 1972, 71 patients underwent surgical treatment of pancreatic pseudocysts. Internal drainage was performed in 73% of these patients in comparison to only 20% in a series during the previous decade. From an analysis of results, it would appear that the treatment of choice is internal drainage via either cystogastrostomy or cystojejunostomy. Postoperative bleeding and sepsis were of negligible consequence. An unexpected finding was that the long-term results of these patients seemed to be better than those of patients with pancreatitis in whom pseudocysts did not develop.

An upper gastrointestinal tract hemorrhage resulting from an aortocystoduodenal fistula developed in a patient with a pancreatic pseudocyst. The fistula was exposed through a duodenotomy, necrotic material was debrided from the pseudocyst and the aortic wall, the aortic defect was closed primarily, and the pseudocyst was drained through a cystoduodenostomy. The case is discussed as a rare hemorrhagic complication of pancreatic pseudocysts and as an illustration that under certain circumstances of infection in areas where aortic bypass can be difficult to perform, primary vascular repair can be a successful method of managing aortoenteric fistulas.

After diagnostic needle aspiration guided by computed tomography and/or ultrasound, 11 infected pseudocysts in ten patients were treated nonoperatively by percutaneous catheter drainage and intravenously administered antibiotics. Nine infected pseudocysts resolved after 11 to 37 days (mean, 21 days) with no recurrences at follow-up 16 to 42 months (mean, 24.4 months) later. All were confirmed by Gram's stain, culture, and elevated amylase levels. Ten of the pseudocysts were acute; one was chronic; five were polymicrobial; six had a single organism. There were no major complications. There was one failure when a pancreatic abscess developed in a patient who died following operative drainage. There was one successful palliation of a postoperative-infected pseudocyst in a patient with an obstructing nonresectable carcinoma of the head of the pancreas. A trial of percutaneous catheter drainage is indicated in patients with infected pancreatic pseudocysts.

The results of 64 total pancreatectomies performed at the Mayo Clinic between 1942 and 1973 have been reviewed. Improvement in recent results as compared to the previously reported series is probably related to improvements in operative techniques and in selection of patients with more favorable malignant lesions. The recent results are more favorable than those reported for a group of comparable patients undergoing standard Whipple procedures for malignant lesions at this institution. Diabetes was easily managed in 76% of patients. Hypoglycemia due to insulin sensitivity is the major problem, and ketoacidosis seldom occurs. Recognition of this has resulted in better management of diabetes with relatively small doses of insulin. The sequels of long-standing diabetes do not appear to be a problem. Gastrointestinal tract hemorrhage has been greatly decreased through the use of more extensive gastric resection.

A patient with a persistent external pancreatic fistula was studied by endoscopic cholangiopancreatography (ERCP). The ERCP demonstrated the probable site of the fistula and a high-grade, main pancreatic ductal stricture. This information prompted early, successful surgical correction of the pancreatic fistula by drainage into a Roux-en Y jejunal loop.