Surgical versus nonsurgical management of pancreatic pseudocysts^-www.drkeyurbhatt.in*

J Clin Gastroenterol. 2009 Jul;43(6):586-90.

Johnson MD, Walsh RM, Henderson JM, Brown N, Ponsky J, Dumot J, Zuccaro G, Vargo J.

Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.

Abstract

GOALS: Compare patient characteristics and outcome and also physician referral patterns between surgically and nonsurgically managed patients with pancreatic pseudocysts.

BACKGROUND: Treatment of pancreatic pseudocysts can be accomplished by surgical, endoscopic, or percutaneous procedures. The ideal treatment method has not yet been defined.

PATIENTS: All patients treated for pancreatic pseudocyst between 1999 and 2005 were identified in our health services database. Patients were treated with surgical, endoscopic, and percutaneous drainage procedures at the discretion of the treating physician. Main outcome measures included complications, pseudocyst resolution, and treatment modality as a function of the treating physician's specialty.

RESULTS: Thirty patients (49%) were treated surgically, 24 endoscopically (39%), and 7 (11%) with percutaneous drainage. The most common indications for treatment were symptoms of pain, and biliary or gastric outlet obstruction (81%). Patients treated surgically and endoscopically were similar in terms of age (49 vs. 52 y), mean cyst diameter (9.1 vs. 9.5 cm, P=0.74), incidence of chronic pancreatitis (50% vs. 32%, P=0.26) and complicated pancreaticobiliary disease (69% vs. 60%). There were no differences in complications (20% vs. 21%) or pseudocyst resolution (93.3% vs. 87.5%, P=0.39) between the surgical and endoscopic groups. There was no significant difference in the rate of surgical versus nonsurgical treatment in patients initially evaluated by surgeons versus nonsurgeons.

CONCLUSIONS: Surgical and endoscopic interventions for pancreatic pseudocysts are equally safe and effective with percutaneous drainage playing a less important role. Endoscopic drainage should be considered for initial therapy in appropriate patients.

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Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis^-www.drkeyurbhatt.in*

Santosh D, Lakhtakia S, Gupta R, Reddy DN, Rao GV, Tandan M, Ramchandani M, Guda NM.

Department of Anesthesiology, Asian Institute of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India. sant_dari@yahoo.com

Abstract

BACKGROUND: Coeliac plexus block (CPB) is a management option for pain control in chronic pancreatitis. CPB is conventionally performed by percutaneous technique with fluoroscopic guidance (PCFG). Endoscopic ultrasound (EUS) is increasingly used for CPB as it offers a better visualization of the plexus. There are limited data comparing the two modalities.

AIM: To compare the pain relief in chronic pancreatitis among patients undergoing CPB either by PCFG technique or by EUS guided technique.

METHODS: Chronic pancreatitis patients with abdominal pain requiring daily analgesics for more than 4 weeks were included. Fifty six consecutive patients (41 males, 15 females) participated in the study. EUSG-CPB was performed in 27 and PCFG-CPB in 29 patients. In both the groups, 10 mL of Bupivacaine (0.25%) and 3 mL of Triamcinolone (40 mg) were given on both sides of the coeliac artery through separate punctures.

RESULTS: Pre and post procedure pain scores were obtained using a 0-10 visual analogue scale. Improvement in pain scores was seen in 70% of subjects undergoing EUS-CPB and 30% in Percutaneous- block group (P = 0.044).

CONCLUSIONS: EUS-guided coeliac block appears to be better than PCFG-CPB for controlling abdominal pain in patients with chronic pancreatitis.

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Surgical treatment of chronic pancreatitis--a 14 years experience^-www.drkeyurbhatt.in*

Stroescu C, Dima S, Scarlat A, Ivanov B, Bouaru O, Ionescu M, Vasilescu C, Popescu I.

Centrul de Chirurgie Generală si Transplant Hepatic, Institutul de Boli Digestive si Transplant Hepatic Fundeni, Bucureşti. cezar.stroescu@gmail.com

Abstract

BACKGROUND: Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or in the presence of complications of the disease.

AIMS: This study evaluates a single-center experience with operative management of chronic pancreatitis over a period of time of 14 years, regarding indication, surgical technique, early and late results.

PATIENTS AND METHODS: The records of 265 consecutive patients who underwent surgery for chronic pancreatitis between 1995 and 2008 were retrospectively reviewed and analyzed. Long-term outcomes were assessed by patient survey, with a median follow-up of 40 months.

RESULTS: 265 patients underwent 275 operations for chronic pancreatitis with the main indication abdominal pain (46.8%), followed by suspected malignancy in 24.8% and recurrent episodes of acute pancreatitis in 18.6%. Resection procedures 54.5% (150), drainage procedures 1.09% (3), bypass and denervation procedures 44.36% (122) and exploratory laparotomy 3.27% (9) were performed with an overall morbidity of 22% and an in-hospital mortality rate of 2.64%. After a median follow-up of 40 months survival information was available for 137 patients (51.69%) with a 5-and actuarial survival rate of 74.7% and quality of life improvement in most patients, especially in the resected group.

CONCLUSION: Our results suggest that in chronic pancreatitis the type of surgery has to be individualized in each patient (resection VS drainage) and organ preserving operations are safe and effective in providing long-term pain relief and in treating CP-related complications

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SMA Thromboembolism^-www.drkeyurbhatt.in*

COMPLICATIONS:

Because of the high prevalence of atherosclerosis, one of the most common complications involves MI. 

Acute renal failure in the immediate postoperative period can be prevented by keeping the patient well hydrated and administering mannitol before the aorta is cross-clamped.

Other possible complications include bleeding, infection, bowel infarction, prolonged ileus, and graft infection.

Follow-up

• Because of the high likelihood of concomitant vascular disease in the rest of the arterial tree, patients must be closely monitored.
• Any laboratory or radiologic examinations not previously performed in the hospital are performed in an outpatient setting.
• The patient should have frequent visits to monitor the prothrombin time, activated partial thromboplastin time, and international normalized ratio to assure proper anticoagulation.

Outcome and Prognosis

Because of the delay in diagnosis, mesenteric artery ischemia is typically a lethal disease, with a mortality rate of 45-65%. 

When more than half the bowel is removed, mortality rates of up to 80% have been reported. 

A review of 45 studies demonstrated that the prognosis for patients with acute mesenteric ischemia differs when one looks at the etiology. 

Mortality rates are highest for patients with arterial thrombosis (70-87%), followed by nonocclusive mesenteric ischemia (70-80%), arterial embolism (66-71%), and venous thrombosis (44%). 

Mortality rates have been improving over the last 4 decades.

Future and Controversies

Over the past 20 years, diagnosis and treatment of mesenteric ischemia has advanced only minimally.

• In a review of 57 cases, only 18% of patients were properly diagnosed with mesenteric ischemia before operation or death. Of the 57 patients in this review, 46 died.
• Some advances in diagnosis include magnetic resonance imaging and laser Doppler flowmetry. Preliminary results for these modalities are encouraging.
• Percutaneous transluminal angioplasty with stenting has proven valuable as a treatment option in selected patients. A study demonstrated that, at 6 months, patency was equivalent between stenting and open revascularization; however, freedom from symptoms was less in the stented group.
• As previously mentioned, similar results were found in a study by Kougias et al, in which the effectiveness of balloon angioplasty and/or endovascular stenting (48 patients, 58 vessels) was compared with that of open revascularization (96 patients, 157 vessels) in the treatment of chronic mesenteric ischemia.The investigators determined that members of the endovascular group had a shorter hospital stay (3 days) than did patients in the open revascularization group (12 days, P <0.03) and that the 30-day mortality rate, frequency of inhospital complications, and 3-year cumulative survival rate were the same for both groups.
• Three years after the procedures, however, cumulative freedom from recurrent symptoms was found in a higher percentage of open revascularization patients than in members of the endovascular group (66% vs 27%, P <0.02). The authors suggested that this was because the percentage of patients who underwent a 2-vessel procedure rather than a 1-vessel intervention was higher in the open group than in the endovascular one.
• Some authors recommend a trial of thrombolytic therapy if patients can be treated within 8 hours of presentation and do not have signs of bowel necrosis or peritonitis.If no evidence of improvement is noted within 4 hours, patients should undergo exploration.
• Local tissue plasminogen activator may reduce the amount of bowel requiring resection.

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Obscure G I BLEEDING^-www.drkeyurbhatt.in*

GASTROINTESTINAL ENDOSCOPY,  VOLUME 58, NO. 5, 2003

For the following points: (A), prospective controlled trials; (B), observational studies; (C), expert opinion.

OGIB comprises approximately 5% of all patients with GI bleeding, with the majority of lesions located in the small intestine. (B)  Common small intestine lesions include angiodysplasia, tumors, NSAID enteropathy, and Meckel’s diverticulum-associated ulcers. (B)  Obscure GI bleeding can either be occult, manifesting

as IDA, or overt, manifesting as hematochezia or melena. (C)  Once upper and lower GI lesions have been

excluded by carefully performed repeated EGD and colonoscopy to the terminal ileum, examination

of the small intestine is warranted. (C)  Diagnostic tests include PE, CE, barium studies (SBFT or enteroclysis), nuclear medicine testing, angiography, and IOE. (B) While large published comparative trials are lacking, PE has been shown to be superior to EGD and SBFT, and CE is similarly superior to SBFT and possibly to PE as well. (A) Choice among tests has yet to be established and will be dictated by the clinical scenario, availability, and local expertise. (C) Intra-operative enteroscopy is reserved for patients with refractory severe recurrent bleeding, transfusion dependency, or those in whom a lesion is identified that cannot be treated by using PE or colonoscopy with ileoscopy. (C)

 

Once a diagnosis is established, appropriate medical and/or surgical therapy must be individualized. (C)

American Society For Gastrointestinal Endoscopy

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