Pancreatic Pseudocysts

Pancreatic pseudocysts as complications of acute and chronic pancreatitis are being tackled more frequently by experienced endoscopists (Lehman, 1999). A word of caution if you as the endoscopist consider wading into pseudocyst territory: Obtain and review a pre-ERCP high quality pancreas CT scan, become very familiar with transpapillary and transluminal drainage techniques, have experienced interventional radiology and surgical back-up, and have an understanding of potential complications. A high quality CT scan of the pancreas and surrounding structures will define the proximity of the pseudocyst to the luminal wall (< 10 mm thickness between lumen and pseudocyst is optimal), contents of pseudocyst, the presence of splenic artery aneurysm, splenic thrombosis and/or gastric varices, and the extent of pancreatic necrosis. At the initial ERCP, a pancreatogram is attempted to evaluate whether duct communication is present. Transpapillary drainage of pseudocysts may be performed by placing the stent either into the duct upstream from the communication ("bridging the disruption") or placing the stent into the pseudocyst cavity itself. Pancreatic sphincterotomy is commonly performed to ablate the sphincter pressure gradient, and downstream pancreatic strictures, if present, are dilated with balloon or passage catheter dilators. In a large series of endoscopic therapy for acute and chronic pancreatic pseudocysts by Baron and colleagues (2002), 63% of 136 patients had communication of the collection, with the main pancreatic duct affording the potential for transpapillary therapy.

Transluminal drainage via transduodenal or transgas-tric approach may be the preferred technique in patients with pancreatic duct cut-off, noncommunicating pseudo-cysts, large tail of pancreas pseudocysts. Endoscopy with the therapeutic duodenoscope is performed to assess for a bulge on the gastric wall or duodenal wall. Once localized, sampling or injection of the pseudocyst with the Howell aspiration needle (Wilson-Cook Inc, Winston-Salem, NC) may be performed prior to needle-knife puncture into the pseudocyst. The needle-knife puncture is performed perpendicular to the lumen with short bursts of cautery and a forceful entry into the pseudocyst cavity. This perpendicular approach will minimize tracking into the gut wall and reduce bleeding. A guide wire is placed into the pseudocyst and coiled in the cavity to maintain access. Balloon catheter dilation of the fistulous tract is performed and single or multiple double-pigtail stents are placed. Technical success with proper patient selection approaches 90% in most series. In Baron's series, complete endoscopic resolution was achieved in 113 of 138 patients. Patients with chronic pseudocysts obtained the best result (59 of 64 resolved, 92%) as compared to patients with acute pseudocysts (23 of 31, 74%) or necrosis (31 of 43, 72%). Complications of transluminal endoscopic drainage of pseudocysts, including bleeding, infection, and perforation, total 20% in combined series. Death has been reported in 1% of over 500 patients undergoing endoscopic drainage of pseudocysts, similar to the reported mortality of surgically treated patients.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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