Pancreatic pseudocyst... - Forum

  • Similar Topics
    Replies
    Views
    Last post
Jorjo

Pancreatic pseudocyst... - Ärzteforum

Post#1 »

Have a male patient, 53 y.o. with a biliary acute pancreatitis that started about one and a half month ago,relatively mild in its clinical manifestations,when USN was done,showed a gallbladder full with stones, a normal CBD and a notorious enlargment of the pancreas...LFT within normal ranges,high levels of amylase and lypase...seven days later,a CT scan was performed and showed important diffuse enlargment of the whole pancreas with a huge cyst growing near the body and tail that rejected forwardly the stomach.

We made the diagnosis of a pseudocyst and waited for about one month before checking again with CT scan that showed that the cyst had grew reaching some 8 x 9 cms in diameter.

Two weeks ago, through endoscopy, a transgastric punction was done and a 7F catheter installed into the cavity...Some 700 mls. of a pinky fluid was aspirated...Since then,the cath has continue to drain about 180 - 200 cc of the same fluid, rich in amylases,around 33.000 U...New CT scan shows reduction of the cavity in some 40 % of its previous volume...The pt has continue to present fever, leucocitosis but no septic condition...He is under enteral nutrition through a naso yeyunal tube advanced quite distal to the angle of Treitz.

We are expecting to do an ERCP to see if there's a wide communication with pancreatic ducts...Depending on that,do you think surgical approach should be consider?.

Any comments or suggestions?


canadian

Re: Pancreatic pseudocyst... - Ärzteforum

Post#2 »

The $64 dollar question is whether your catheter is efficiently draining the pseudocyst. If it isn't,.... a marsupialization into the back wall of the stomach breaking down any loculations as only your finger can do. Unless there is a segregated collection in another part of the pancreas, I think ERCP will only be used as the drunkard uses the lampost, for support rather than illumination. If there should be proximal ductal obstruction, good distal drainage into the stomach, or a loop of jejunum for that matter, should take care of it....Regards from a sweltering summer in southwestern Ontario Canada, percolating my Celtic blood.

canadian

Re: Pancreatic pseudocyst... - Ärzteforum

Post#3 »

Sorry, but one would of course be doing this at the time of open cholecystectomy and CBD clearance. Maybe trying to do this endoscopically/laparoscopically is grandstanding a bit too much at this point...? So this guy can get out of hospital a few days earlier?? It sounds like he's already been through the bloody mill already. But let's hear from the others.

User avatar
Surgeon

Re: Pancreatic pseudocyst... - Ärzteforum

Post#4 »

I'm not sure I understand what you have done. When I
have done this, the endoscopic transgastric puncture has resulted in a
massive rush of fluid and prompt collapse of the cyst (only 2
cases). I didn't put in any catheter. If you have a catheter
one meter long going into the cyst and out the nose or wherever, I
suspect that the resistance of the catheter is preventing adequate
drainage. Or perhaps I don't understand what you have done.

There are numerous reports of intragastric endoscopic surgery; put a
trocar into the stomach and insert a laparoscope. Put in the
gastroscope or another port and open further the communication with the
pseudocyst... you get the idea.

User avatar
Lady Surgeon

Re: Pancreatic pseudocyst... - Ärzteforum

Post#5 »

I think some endoscopists are burning a wide communication between the
pancreatic pseudocyst and the stomach using either the colonoscopic hot
biopsy forceps or the polypectomy snare or perhaps the gastroscopic
heater probe or similar endoscopic cautery devices. You already have
found a good location--if you could just make a bigger hole
endoscopically this would be easiest.

Poland

Re: Pancreatic pseudocyst... - Ärzteforum

Post#6 »

your pseudocyst is inadequately drained, it should
be mature by now so do an open posterior cyst gastrostomy and while you are
in there whip out the GB. If it looks dangerous then do a subtotal
cholecystectomy taking care to remove all stones.

User avatar
A Doctor

Re: Pancreatic pseudocyst... - Ärzteforum

Post#7 »

I read the recent discourse of the PP case.
I could not comment about the therapy because it was difficult to
understand from his message whether
the patient underwent external, internal or external-internal drainage.

I note, however, that the discussants did not attempt classifying the cyst
they suggested treating.

Below please find a method of PP classification by Bornamn et al from
Cape Town.

Jorjo

Re: Pancreatic pseudocyst... - Ärzteforum

Post#8 »

In reference to the recent discourse of the PP classification I want to point out that:

1.- I must excuse myself for my mistakes when I write in english because
it happens that my native langue is spanish...

2.- I'll try to clear out what was performed to this patient in order to
understand well the issue and get back his very
interesting comments...The patient underwent an endoscopic transgastric
punction of the PP, first with a wire guideline and second, introducing
into the cavity a Teflon Tube 7F as a nasogastric tube which was left in
place after emptying around 700 cc of prune clear fluid.

3.- I appreciate greatly the information regarding
the recent classification of PPs and,after reading it,it helps me to
understand better with what we are dealing...I think that this case
corresponds to a IA ot IB type of Bornamn's classification...The patient
continued to drain 150 cc of the prune clear fluid during a week and
pain was almost inmediately relieved and food ingestion became well
tolerated because the anterior gastric rejection produced by the
cyst,was alleviated...During all this period the patient was covered
with antibiotics,in this case,Clindamycin and Flagyl...The patient
evolved without fever,WBCC turned back to normality,10 K environ,
general condition improved and drainage from the tube stopped so it was
removed...A previous CT scan,showed almost complete reduction of the
cavity

Return to “General surgery”

Who is online

Users browsing this forum: No registered users and 0 guests

cron