胰腺假性囊肿诊治进展

胰腺假性囊肿多在急慢性胰腺炎及胰腺创伤后发生,是最为常见的胰腺囊性病变,超声、超声内镜、CT及MRI等是有价值的检查,内窥镜已成为胰腺假性囊肿的一线治疗手段,内科保守治疗、经皮置管引流及外科手术是必要补充。     

胰腺假性囊肿的治疗研究进展

目的总结近年来胰腺假性囊肿的治疗方法。方法通过检索相关文献资料,就近年来关于胰腺假性囊肿的治疗方法的进展作一综述。结果胰腺假性囊肿是胰腺炎或者胰腺损伤的常见并发症,常因囊肿较大或出现并发症而引起严重症状,并可造成严重后果。主要的治疗方法有保守治疗、经皮穿刺引流、外科手术治疗、内镜引导下引流技术、中西医结合等治疗方法,而每种方法各有其适应证及优缺点。结论胰腺假性囊肿的治疗方法多种多样,应根据不同的适应证、不同的患者及病情的发展阶段采取个体化治疗。     

胰腺假性囊肿的治疗

胰腺假性囊肿(pancreatic pseudocyst,PPC)是继发于急、慢性胰腺炎、胰腺外伤、胰腺肿瘤及胰腺手术等情况下的常见并发症。胰腺实质或胰管损伤,胰液外渗,坏死组织等积聚于胰周,刺激纤维组织增生、包裹形成囊肿,因囊壁无上皮细胞被覆而称之为假性囊肿,与真性囊肿相不同。胰腺假性囊肿的治疗方法较多,包括保守治疗,介入治疗,内镜及手术治疗等,本文就其治疗现状做简要介绍。     

胰腺囊性病变鉴别诊断中临床评价与囊液分析的比较(英)

成人中80％～90％的胰腺囊性病变为假性囊肿,其余的为真性囊肿并且大多为肿瘤。良性浆液腺瘤、粘液囊腺瘤和粘液囊腺癌是最常见的胰腺瘤性囊肿。无症状及并发症小的假性囊肿可不治疗,但有持续性症状及并发症则需治疗。常不必切除,经内窥镜、经皮穿刺或手术引流已经足够。无症状的浆液囊腺瘤类似假性囊肿,因很少为恶性,不需治疗。但粘液性囊肿常应切除,因其有潜在恶性。非手术的鉴别诊断对胰腺囊肿治疗计划的选择是理想的方式。人们提出经穿刺抽吸和囊液分析（包括淀粉酶、肿瘤标记物、粘滞度、细胞学检查）在疑难的鉴别诊断中是有帮助的。     

胰腺假性囊肿的治疗现状及进展

胰腺假性囊肿是胰腺炎的常见并发症之一。胰腺假性囊肿治疗方法的选择一直成为医学界的争论热点。本文就近年来针对胰腺假性囊肿的分期分型及相应的治疗方法作一综述。     

胰腺损伤14例临床分析

回顾性分析14例胰腺损伤的诊断、治疗及并发症。结果示非手术治疗胰腺损伤其所形成胰腺假性囊肿远多于手术治疗者，非手术治疗适应证为胰腺轻度损伤而胰管无损伤者。结果提示，手术治疗胰腺损伤有利于防治并发症，尤其假性囊肿。应根据剖腹探查正确判定胰腺损伤的部位，程度和范围来选择合理的手术方式。     

胰腺假性囊肿的研究进展

胰腺假性囊肿是急性胰腺炎的并发症,发病率可达1%~5%。关于胰腺假性囊肿的治疗,采取观察、内科或外科治疗,以及手术适应证、手术方式等尚有争议。现就国内外胰腺假性囊肿的现状作一综述。     

胰腺假性囊肿诊治

胰腺假性囊肿多由急慢性胰腺炎引起，在不伴临床症状和并发症的情况下可予以保守观察治疗，尤其对直径〈6cm和病程6周内的单发假性囊肿多数可以自行消退。但对于囊肿进行性增大、感染、出血、压迫症状、怀疑恶变时应积极手术治疗，包括PCD、内镜治疗、腹腔镜及开腹手术治疗。无论何种方式处理胰腺假性囊肿，均有其优缺点，关键是根据患者的具体情况、术者的经验和医院条件，合理选择治疗方法。     

胰腺假性囊肿28例的诊断和治疗

胰腺假性囊肿是重症急性胰腺炎的局部并发症之一，部分发生于胰腺外伤后，极少数出现于胰腺手术后，其诊断上时有误诊，治疗上不断创新，并且胰腺假性囊肿因各种原因再手术者时有报道。2000年2月至2007年2月本站及本市二院共收治胰腺假性囊肿病人28例，现总结如下：     

个体化治疗胰腺假性囊肿31例分析

目的探讨胰腺假性囊肿的个体化治疗。方法回顾性分析收治的31例胰腺假性囊肿的临床特点和治疗方法的选择,本组9例保守治疗,4例行经皮囊肿穿刺引流,4例行囊肿外引流术,12例行囊肿空肠Roux-en-Y吻合术,2例行胰尾切除术。结果全组无死亡病例,手术后无严重并发症发生。结论胰腺假性囊肿的外科治疗要根据发病机制、囊肿形成的原因、患者全身情况、囊肿的部位及大小、性质和是否有并发症等因素,并结合临床经验及以往的治疗效果,决定个体化治疗方案,采取实用而有效的手术方式是决定预后的关键。     

Endoscopic transgastric drainage of pancreatic pseudocyst with the use of Nd:YAG laser

Pancreatic pseudocysts have been successfully managed with endoscopic drainage recently. This report describes a case of endoscopic transgastric drainage using endoscopic ultrasonography (EUS) and an Nd:YAG laser. EUS was used to detect an optimal puncture site of the pseudocyst and to reduce the risk of bleeding and perforation. An Nd:YAG laser was used to minimize the risk of bleeding and to penetrate the thick wall of the pseudocyst. After transgastric cystgastrostomy was performed, an internal stent was placed between the pseudocyst and the stomach. There were no complications associated with endoscopic interventions. Complete resolution of the pseudocyst was observed. Endoscopic transgastric drainage of pancreatic pseudocysts is a recommended approach for selected patients with pancreatic pseudocysts that are uncomplicated and are located adjacent to the stomach. Safe and effective drainage can be achieved without hemorrhage and perforation with the use of EUS, an Nd:YAG laser, and a stent. Furthermore, the Nd:YAG laser facilitated passage through a markedly indurated pseudocyst wall and it seemed to be an effective instrument, especially for pseudocysts with a thick wall.     

Endoscopic management of pancreatic pseudocyst in children-a long-term follow-up

Background

Literature on long-term outcome after endoscopic management of pediatric pancreatic pseudocyst is not available. The aim of the present study is to report long-term outcome after endoscopic drainage of pancreatic pseudocyst in children.

Methods

Nine patients younger than 15 years, subjected to endoscopic pseudocyst drainage, were included in this study (between 1994 and 2004). Eight patients were subjected to endoscopic cystogastrostomy and stenting, whereas 1 patient was subjected to cystoduodenostomy and stenting. A follow-up of patients was done at 1 month and at 2 to 10 years after drainage. Endoscopic retrograde cholangiopancreatography (ERCP) was done in 2 patients at the time of drainage, and it was repeated in both the patients at the time of final follow-up.

Results

Mean age of the patients was 9.6 years. Trauma was the most common cause (n = 8). Mean follow-up of these patients was 5.7 years (2-10 years). No recurrence was seen in any patient. Endoscopic retrograde cholangiopancreatography revealed complete pancreatic duct block in prevertebral region in 2 posttraumatic patients, and it was persisting on repeat ERCP at final follow-up.

Conclusions

Endoscopic drainage of pancreatic pseudocyst is safe in children with a very good long-term outcome. Pancreatic duct block seen on ERCP may not be clinically important on long-term follow-up.     

Minimally Invasive Management of Pancreatic Abscess, Pseudocyst, and Necrosis: A Systematic Review of Current Guidelines

BACKGROUND: Minimally invasive techniques have been used to manage infected pancreatic necrosis and its local complications, although there are no randomised trials to evaluate these techniques. The aims of this study were to review the scope and quality of recommendations in current clinical practice guidelines on the role of percutaneous catheter drainage and endoscopic techniques for pancreatic abscess, pseudocyst, and infected pancreatic necrosis and identify the degree of consensus between guidelines. METHODS: A MEDLINE search was performed to identify current guidelines from any professional body published in the English language. Guidelines were analysed to determine their specific recommendations for using percutaneous catheter drainage and endoscopic techniques to manage pancreatic abscess, infected pseudocyst, and infected pancreatic necrosis. RESULTS: Sixteen guidelines were reviewed. Percutaneous catheter drainage for pancreatic abscess was recommended by eight guidelines; for infected pseudocysts, one guideline did not recommend its use and six recommended its use; for infected necrosis, two guidelines did not recommend its use and four recommended its use. Endoscopic management of both pancreatic abscess and infected pseudocyst was recommended by seven guidelines; for infected necrosis, endoscopic management was recommended by ten guidelines. Ten guidelines did not include levels of evidence to support their recommendations. CONCLUSIONS: Guidelines lacked consensus in their recommendations for minimally invasive management of pancreatic abscess, infected pseudocyst, and infected necrosis, and few recommendations were graded according to the strength of the evidence. More prospective trials are needed to provide evidence where it is lacking, which should be incorporated into clinical practice guidelines.     

超声内镜检查与胰腺疾病内镜治疗

超声内镜检查原理与腹部超声相似,其区别只是将微型高频超声探头安装在内镜顶端,进行实时超声扫描.胰腺是腹膜后器官,由于EUS插入胃和十二指肠肠腔内扫查,可清晰显示胰腺结构.随着EUS的广泛应用和内镜附件发展,EUS在胰腺疾病微创治疗中的地位越来越高.EUS-FNA与注射技术、EUS-CPN、EUS介导放射粒子植入术和内镜超声引导下胰腺假性囊肿穿刺引流等治疗技术会逐步推广应用,成为继ERCP内镜治疗后胰腺疾病微创治疗的重要方法.     

Personal experience with the endoscopic treatment of pancreatic pseudocysts. Long-term results and analysis of prognostic factors

BACKGROUND: The aim of this study was to assess the safety and utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome of endoscopic drainage were assessed in a prospective analysis. METHODS: Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients. RESULTS: Successful drainage was achieved in 27/30 (90%) of patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications; 2 patients had bleeding, 2 had mild pancreatitis, 8 had cyst infection, in relation to the presence of necrosis (5 patients) or stent clogging (3 patients). Nine patients (20.9%) had recurrence of pseudocyst. Endoscopic drainage was a definitive treatment in 37 out of 49 (75.5%) patients (median follow-up: 25.9 months). Presence of necrosis was the only significant prognostic factor for infectious complication. CONCLUSIONS: Endoscopic drainage provides a successful and safe minimally invasive approach to the management of pancreatic pseudocysts.     

超声内镜引导下穿刺引流治疗胰腺假性囊肿

目的探讨超声内镜引导下经胃肠壁穿刺置管引流治疗胰腺假性囊肿的疗效及并发症。方法选择2004年8月至2011年3月胰腺假性囊肿患者28例,首先使用线阵型超声内镜扫查,明确病变部位后选择合适穿刺点,导丝沿穿刺针道进入囊肿,沿导丝放置双猪尾硅胶支架1～3支。术后定期随访,囊肿消失后拔除支架。结果本组28例患者,穿刺引流成功25例,成功率为89．3％,其中经胃19例,经十二指肠6例。发生并发症3例,支架移位、出血、感染各1例。随访8—34个月,19例假性囊肿完全消失,6例腹痛症状消失、囊肿明显缩小、但持续存在2年以上,所有患者均未见假性囊肿复发。结论超声内镜引导下经胃肠壁穿刺置管引流术是治疗胰腺假性囊肿的较好方法之一,其疗效确切,并发症少。     

Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis

OBJECTIVE: To test a hypothesis that definitive management of pseudocyst associated with chronic pancreatitis is predicated on addressing pancreatic ductal anatomy. SUMMARY BACKGROUND DATA: The authors have previously confirmed the impact of pancreatic ductal anatomic abnormalities on the success of percutaneous drainage of pancreatic pseudocyst. The authors have further defined a system to categorize the pancreatic ductal abnormalities that can be seen with pancreatic pseudocyst. The authors have published, as have others, the usefulness of defining ductal anatomy when managing pancreatic pseudocysts associated with chronic pancreatitis. METHODS: Beginning in 1985, all patients with pseudocyst who were candidates for intervention (operative, percutaneous, or endoscopic) have undergone endoscopic retrograde cholangiopancreatography (ERCP). An associated diagnosis of chronic pancreatitis was established by means of ERCP findings. Patients were candidates for longitudinal pancreaticojejunostomy (LPJ) if they had a pancreatic ductal diameter greater than 7 mm. In a nonrandomized fashion, patients were managed with either combined simultaneous LPJ and pseudocyst drainage or with LPJ alone. RESULTS: Two hundred fifty-three patients with pseudocyst have been evaluated. Among these there have been 103 patients with chronic pancreatitis and main pancreatic duct (MPD) dilatation (>7 mm). Among these 103 patients, 56 underwent combined LPJ/pseudocyst drainage and 47 had LPJ alone. Compared to combined LPJ/pseudocyst drainage, the patients undergoing LPJ alone had a shorter operative time, slightly less transfusion requirement, slightly reduced length of hospital stay, and slightly reduced complication rate. Long-term pain relief was achieved in 90%, and pseudocyst recurrence was less than 1%. Rates of each of these long-term outcomes were nearly incidental among the two groups. CONCLUSIONS: Ductal drainage alone (LPJ) is sufficient in patients with chronic pancreatitis (MPD > 7 mm) and an associated pseudocyst. Simultaneous drainage of pseudocyst is not necessary.     

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??Endoscopic??laparoscopic individualized treatment for pancreatic pseudocysts: An analysis of 68 cases YUAN Hai-cheng??QIN Ming-fang??WU Yu??et al. Minimally Invasive Surgery Center, Tianjin Nankai Hospital??Tianjin 300100??China
Corresponding author??YUAN Hai-cheng??E-mail??ironyhc2002@Gmail.com
Abstract Objective To investigate endoscopic??laparoscopic individualized treatment strategies for pancreatic pseudocysts based on the guidance of endoscopic??laparoscopic treatment program of pancreatic pseudocysts. Methods The clinical data of 68 cases of pancreatic pseudocysts treated in accordance with endoscopic??laparoscopic treatment program of pancreatic pseudocysts between March 2000 and December 2010 in Tanjin Minimally Invasive Surgery Center were analyzed retrospectively. The data included the general information??treatment methods, success rate??recurrence rate and complications. Results There were 28 cases of EUS-guided through the stomach cyst drainage??12 cases of laparoscopic cyst-gastric anastomosis??5 cases of laparoscopic cyst-jejunal Roux-en-Y anastomosis??23 cases of ERPD (5Fr pancreatic duct stent placed by endoscopy). Three cases had fever after EUS internal drainage. One case had peritonitis. There was no complication in other forms of treatment. Follow-up was last from six months to nine years in 82% (56/68) of cases without recurrence. Conclusion The endoscopic??laparoscopic treatment for pancreatic pseudocyst is more minimally invasive??can become individualized treatment strategies.     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated. Methods After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct. Results ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far. Conclusions ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

Endoscopic retrograde cholangiopancreatography for surgeons

Endoscopic retrograde cholangiopancreatography remains an important tool for the management of biliary and pancreatic disease. Endoscopic removal of common bile duct stones is the procedure of choice for retained stones and is a common option preoperatively with the gallbladder in place. Cholangitis is best treated by endoscopic sphincterotomy and stenting along with intravenous antibiotics initially with the possibility of definitive treatment with endoscopic stone removal and/or dilatation and stenting for strictures. Endoscopic sphincterotomy is also recommended in severe or rapidly worsening gallstone pancreatitis or in those with combined pancreatitis and rising bilirubin or cholangitis. Palliation with internal stents for malignant strictures has been possible with good outcome and very little difference in efficacy, complications, mortality, and long-term survival compared to surgical treatment. Biliary fistulae are easily treated by endoscopic stenting, particularly when the source is the cystic or an accessory duct. Benign biliary strictures can be dilated and stented for prolonged periods with good long-term success in selected cases. Pancreatic stenting is useful to treat pancreatic duct strictures and duct hypertension with considerable improvement of pain. Endoscopic drainage of pancreatic pseudocyst appears to be a safe, effective, and definitive treatment for patients in whom anatomic considerations allow its use. In summary, therapeutic uses of ERCP are of broad interest to the general surgeon and should be understood and utilized appropriately by the surgical community.