Re: questions about surgery for pseudocysts/ pancreatectomy

[Guest guest]

I am not surprised that no other Dr. had ever seen the pseudocyst, I

recently had an MRCP and was diagnosed with an extrememly enlarged

common bile duct and was told I also had a common bile duct full of

stones, some measuring 3mm, after having had so many ercps I cannot

remember how many and swore I would NEVER have another but I

thought maybe this would help with my pain so I relented and guess

what NOT ONE STONE FOUND must have been air bubbles seen on the MRCP

in my common bile duct. What eles can one do but laugh.

[Guest guest]

Keri,

A pseudocyst is a collection of tissue and enzyme debris that is

formed after an acute pancreatitis attack. The pseudocyst does

not have a solid encapsuled wall, thus the term " pseudo " , which

means false.

The decisions made to drain the pseudocyst(s) usually depend

upon the size and location of the pseudocyst. Normally,

pseudocysts smaller than 6 cm. are not drained, and are left to

resolve naturally. It is believed by most doctors that there is no

benefit to interfering with the pancreas by performing an invasive

procedure with smaller pseudocysts.

My largest pseudocyst was the size of a soft ball and was

partially drained by CT-guided fine needle aspiration two years

ago. The smaller one 4 x 5 cm. was left alone to resolve. Both

pseudocysts resolved to less than 2 cm., but then did fill back up

again during my attack earlier this year. One is in the tail, the

other buried in the head. They appear to be resolving again, and

I will know more after my next scan in September.

I have pasted an article on psueodcysts and accepted

procedures for their treatment.

MANAGEMENT OF FLUID COLLECTIONS DUE TO ACUTE

PANCREATITIS BY INTERVENTIONAL TECHNIQUES

Vimal Someshwar

Interventional Radiologist, Bhatia General Hospital, Mumbai.

------------------------------------------------------------------------

Intra-abdominal fluid collection following pancreatitis is

associated with high degree of morbidity and mortality especially

when infected. Symptoms like pain, discomfort and distension of

abdomen, can be quite distressing. Surgery used to be the

mainstay of management of these fluid collections. Over the last

2 to 3 decades, percutaneous and endoscopy guided catheter

drainage procedures, have helped improve the prognosis of this

morbid condition.

Wide availability of cross sectional imaging modalities like

ultrasonography and CT scanning have helped early diagnosis,

as also, guided percutaneous drainage procedures. Of the two

modalities, CT scan is preferred, as it thoroughly and

systematically helps evaluate the entire abdominal cavity.

USG or CT guided percutaneous catheter drainage procedures

are associated with a mortality rate of 6%. The normal anatomy

is also less disrupted and therefore less morbidity is associated

with this form of therapy.

Two types of pancreatic fluid collections which can be drained by

percutaneous techniques are : (A) Pseudocysts and (

Abscesses and necrotic collections.

(A) Pseudocysts

Cysts which are either large, causing pain, distension or are at

high risk of rupture, require percutaneous drainage. Infection

complicating a cyst needs early drainage.

Various procedures considered are:-

(a) Percutaneous needle aspiration

( Percutaneous catheter drainage

© Percutaneous cysto-gastrostomy

(d) Endoscopic cystogastrostomy

(e) Endosonographic cystogastrostomy

Simple needle aspiration can be performed under USG/CT

guidance. 18G/16G needle is directed into the collection, as fluid

is aspirated. Recurrence rate of 5% to 7% is expected following

this therapy. Secondary infection and bleeding within the cyst are

possible complications.

Percutaneous Catheter Drainage is the most preferred method.

CT guidance is preferred. Seldingers technique is used to

catheterise the fluid cavity. Cure for pseudocyst by this technique

is expected to be 67-80%. Communication with the pancreatic

duct determines the duration for which the catheter is to be kept

in place.

Cystogastrostomy : The principle of this procedure is to allow

formation of a mature tract between the cyst and the stomach

and hence, facilitate drainage of the fluid through the fibrous

tract. To achieve this fibrous tract, a catheter or stent is placed for

at least 3 weeks. The procedure was first performed by the

percutaneous technique. Endoscopy was found to be a better

mordality, since there was no external tube placement.

Endoscopic Ultrasonography/Doppler further reduced the risk of

injuring a blood vessel

( Abscesses and Necrotic Tissue

Aggressive approach is necessary as these abscesses are

associated with a mortality rate of 70-80%. The present

approach for the management of pancreatic abscesses, is to

delay surgical explorations for 3 to 4 weeks. During this period

percutaneous drainage is preferred. Multiple catheters placed

simultaneously, draining all possible cavities, is mandatory.

Drainage using large bore catheters (14 Fr. - 24 Fr.) are used.

Antibiotic lavage technique, wherein, antibiotic solutions are

introduced from one catheter and drained after 3 hours from

another catheter, have yielded better results. However, catheter

drainage may be incomplete as often, necrotic tissue may

occlude the catheter. Surgery should be contemplated once the

sepsis is under control.

Percutaneous Interventional Technique : Salient features

i. Shortest possible route to the fluid cavity should be selected,

avoiding puncturing bowel or organ.

ii. Gravity drainage should be facilitated, otherwise, suction

drainage systems like Redivac, should be attached.

iii. Try to a demonstrate communication of the cavity with hollow

viscera, by injecting contrast in the cavity.

iv. Catheters should be properly fixed to avoid accidental

displacement. Self-retaining catheters like Pigtail, Cope-loop,

Malecot's type etc., are used. Proper skin fixation and dressing

helps prevent displacement.

v. The caliber of the drainage tube should be wide with no

reduction.

Percutaneous drainage procedure play an important role in the

management of acute pancreatitis.

Sorry, I can't help you with questions about a PT-with auto islet

transplant, but I'm sure someone else can.

With hope and prayers,

Heidi

Heidi H. Griffeth

South Carolina

SC & SE Regional Rep.

PAI, Intl.

Note: All comments or advice are personal opinion only, and

should not be substituted for professional medical consultation.

I am not sure I fully understand what a pseudocyst is. What

exactly is in the cyst? Do they usually require surgery? Do they

often resolve on their own? I am scheduled for a CT in a little

over a week to see what it looks like now.

Hoping God will bless you all,

Keri Beck in IL

[Guest guest]

Hi, Keri!

My husband has two pseudocysts - and I have to state it again - from

a mishap from an ERCP that created necrotizing pancreatitis (with all

the ERCPs that pancreatitis sufferers undergo, I'm surprised more

people don't have more problems with pancreatitis as a result of

ERCPs).

Anyway, the doctors prefer and recommend doing nothing with the

pseudocysts (one is approximately 11 cm in size). If they are not

causing pain - do not touch them! If you can wait even years to see

if they shrink or dissolve, that's the way to go.

One doctor wanted to aspirate them early on ... a major no no and I'm

glad we didn't let anyone stick them with a needle with the

possibility of creating infection.

Good wishes to you!

Beth

[Guest guest]

Good morning, Dave!

Did your pseudocysts ever re-fill? Are you glad you had them

aspirated? How long did you have them before they aspirated ... were

they 'mature' enough with less dense fluid? How large were the

pseudocysts? Did you have discomfort with them? (Am I shooting

enough questions at ya?!)

Hopefully they don't re-fill ... hopefully gone forever! You went

through a lot.

Doctors seem to have different ideas on how to handle these babies.

Thanks for relaying a tiny bit of your story ... it's good to hear

what others have gone through. Anything other information you'd like

to relay, I'm happy to listen (read)!

I wish you well, Dave!

Beth

> wow they aspirated mine and pounded me with anti-fungals and anti

biotics i wore the j tube drain for 4 months till the drainage

cleared and was way reduced in volume

>

dave

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