Pancreatic pseudocysts

Abstract

Introduction: Pancreatic pseudocysts are best defined as localized fluid collections that are rich in amylase and other pancreatic enzymes, that have a non-epithelialized wall consisting of fibrous and granulation tissue, they usually appear several weeks after the onset of pancreatitis. They are to be distinguished from acute fluid collections, organized necrosis, and abscesses. The purpose of this study was to optimize the diagnosis methods and to elaborate a rational surgical management of the pancreatic pseudocyst, through the correlation of surgical techniques with the optimal surgical timing, given by the maturation degree of pseudocystic walk thus the complications and recurrences rates to be minimum. Materials and methods: In this retrospective study I have described the results of the complex treatment of 121 patients with pancreatic pseudocyst, communicating or not with pancreatic duct, and wirsungian hypertension, operated at the Surgical Clinic No. 2 during the period of 2006 to 2013. The studies propose a contemporary diagnosis algorithm, which includes clinical, and laboratory data and imagistic explorations (echography, simple abdominal radiography, gastro- and duodenography, retrograde endoscopic colangiopancreatography - ERCP, CT, MR1, wirsungography and intraoperative echography). Results: The surgical indication was mature pancreatic pseudocyst in 45 (37,2% ) cases, by pancreatic pseudocyst during maturation (less than 6 month from the debut) in 17 (14% ) cases, and by pancreatic pseudocyst with postoperative complications in 59 (48,8%) cases, facts which bring to the elaboration of a self surgical management. Cystopancreatojejunostomy on isolated Roux loop, was made in 50 (41,3%) cases - 16 (29,7%) in group I, 34 (49,55%) in group II. External drainage was made in 49 (40,5%) cases. Minimally invasive operations were made in 5 (4,1%) cases. Retrograde endoscopic ERCP with papilosphincterotomy were made in 2 (1,65% ) cases. In 4 (3,3 %) cases there were applied cystopancreato-jejuno anastomosis on Omega loop. In 5(4,1%) cases there were made cystopancreato-jejuno anastomosis with colecysto-jejuno anastomosis, respectively coledoco-jejuno anastomosis in patients with pancreatic pseudocyst anastomosis and colecystectomy. In one case (0,83%) was made chistopancreato-jejuno anastomosis with colecisto-jejuno anastomosis on Omega loop, and 2 cases (1,65%) had benefit from another types of anastomosis. Caudal pancreatic resection with pancreatico-jejunal derivation and splenectomy was made to 1 patient (0,83 %). The postoperative complications rate were 26 (21,48%) cases -group 1 - 16 (29,62%), group II -10 (14,92%), early 21(17,35%) cases - group 1-14 (25,92%), group II -7 (10,44%) with an average of hospitalizing days of 15,73 days - group I (21,11 days), group II (11,40 days); late 5 (4,1%) - group I - 2 (1,65%), group II - 3 (2,5%). These difficulties in postoperative evolution necessitated urgent conservative therapeutic maneuvers and just in 5 (23,80%) cases - group I -3 (21,42%) cases, group II - 2 (28,57%) cases, clinical situation determinate surgical reintervention. It was necessary a surgical reintervention of internal derivation at distance to 25,51% cases. From a total of 25 reinterventions: 12% - all from group I - had benefit of external drainage, 4% - from group I - of miniinvasive drainage, and the rest of 84% had benefit of chistojejuno anastomosis on isolated Roux loop in “Y”. It has to be mentioned that any of cystojejuno anastomosis on isolated Roux loop (50 made as first surgical step and 21 as reintervention) had not developed postoperative fistulas and had proved permeable at ERCP and MRI control. At 1 year from surgical intervention, 71 (72,45%) patients - group I - 29 (76,3%), group II -42 (48.33%), took back their previous activities, having an active job. 19 (19,2%) patients - group I -7 (26,92%), group 11-12 (20,0%), renounced to some activities which necessitated intense physical effort, and 5 (5,1%) patients - group I -2 (2,63%), group II -3 (6,67%), renounced completely to all previous activities. From 13 (10,75%) - group I - 6 (15,8%), group II - 7 (11,66%) persons with handicap, preoperatively integrated in invalidation financial help, postoperatively just 5 (5%) persons -group I -2 (25%), group II - 3 (5%) maintained this state, 3 (3%) - group I -2 (5,26%), group II -1 (1,66%) having a relatively normal life, and 5 (5%) - group I - 2 (5,26%), group II - 3 (5%) lost this state, regaining their work capacity, being not invalid anymore. Satisfaction was reached in 94,9% patients, just 1,02% patients being unsatisfied with their actual state. Postoperative mortality reported on a period of 12 month was 3,3%. Conclusions: The analysis of precocious and late results after interventions of cysto-jejunal decompression derivation made us to consider these operations being elective in the decompression of the pancreatic pseudocyst and in the reestablishment of the pancreatic juice flux in digestive tract, allowing a good socio-professional reintegration, but with an attentive monitoring of the patients.