¿Supuración crónica o pseudoquiste infectado? Una complicación de la eventroplastia con malla / Chronic suppuration or infected pseudocyst? A complication of incisional hernia repair with mesh

RESUMEN Las infecciones crónicas posteriores a reparaciones de la pared abdominal pueden presentarse como colecciones que involucran a la malla y suelen obligar a su extracción, mientras que los pseudoquistes son colecciones estériles con una gruesa pared fibrótica que debe ser extirpada para lograr la curación. Presentamos una paciente de 75 años con antecedente de eventroplastia, que consultó por un tumor abdominal de 6 meses de evolución, con características imagenológicas de pseudoquiste parietal. Durante la operación se encontró una malla preperitoneal no integrada a los tejidos y rodeada de "biofilm" y líquido turbio. La prótesis se retiró fácilmente y la aponeurosis, muy engrosada, se cerró borde a borde. El posoperatorio transcurrió sin incidentes y el cultivo desarrolló estafilococo aureus sensible a trimetoprima-sufametoxazol. Seis meses después, la evolución fue favorable y sin signos de recidiva.

ABSTRACT Chronic infections after abdominal wall repairs may present as collections involving the mesh which usually require removing the mesh, while pseudocysts are sterile collections with a thick fibrotic wall that must be removed to achieve healing. We report the case of a 75-year-old female patient with a history incisional hernia repair who sought medical advice due to an abdominal tumor which appeared 6 months before consultation with imaging tests suggestive of an abdominal wall pseudocyst. Surgery revealed a preperitoneal mesh without tissue integration surrounded by biofilm and cloudy fluid. The mesh was easily removed and the edges of the thick aponeurosis were sutured. The postoperative period evolved uneventful and the fluid culture was positive for staphylococcus aureus sensitive to trimethoprim-sufamethoxazole. Six months later the patient evolved with favorable outcome without recurrence.

Pseudoquiste peritoneal: una complicación inusual en paciente con diálisis peritoneal / Peritoneal pseudocysts: an unusual complication in a patient with peritoneal dialysis

Resumen Introducción: La terapia de sustitución renal con diálisis peritoneal es una modalidad segura para la enfermedad renal crónica terminal. Los resultados son comparables con pacientes en hemodiálisis por lo que lo hace una modalidad costo efectiva, especialmente en países en vía de desarrollo. Algunas complicaciones que se pueden presentar debido a diálisis peritoneal son: peritonitis, fuga, hernias, falla de filtración y disfunción del catéter. Una de las complicaciones infrecuentes de la diálisis peritoneal es la formación de un pseudoquiste peritoneal. Caso Clínico: Presentamos un caso de un paciente en terapia de sustitución renal con diálisis peritoneal, el cual presenta un pseudoquiste peritoneal como complicación de diálisis peritoneal.

Introduction: Renal replacement therapy with peritoneal dialysis is now a well-established, mature treatment modality for End-Stage Renal Disease. Patient outcomes with peritoneal dialysis are comparable than those with hemodialysis so does a more cost-effectiveness modality, especially in developing countries. Some complications of peritoneal dialysis are peritonitis, leaks, hernias, ultrafiltration failure, and catheter dislocation. One of the rare complications of peritoneal dialysis is peritoneal pseudocyst formation. Clinical Case: We report one such case of a patient with a history of renal replacement therapy managed on long-term peritoneal dialysis, which presents as a complication a peritoneal pseudocyst.

Outer retinal tubulation and inner retinal pseudocysts in a patient with maternally inherited diabetes and deafness evaluated with optical coherence tomography angiogram

A 47-year-old lady (index case) with diabetes and deafness showed multiple oval circumferential areas of perifoveal atrophy in both eyes. Autofluorescence revealed areas of hypoautofluorescence. Optical coherence tomography (OCT) showed depression of inner retinal surface, inner retinal hyporeflective spaces (pseudocysts), disorganization/thinning of outer retina, outer retinal tubulation, loss of external limiting membrane, ellipsoid and interdigitation zone, and thinning of the retinal pigment epithelium and choriocapillaris. The patient was evaluated using OCT angiogram. Retinal lesions of her mother (68-year-old) were very obvious on autofluorescence imaging. The result of A3243G mutation in MTTL1 gene was positive in the index case confirming the diagnosis of maternally inherited diabetes and deafness (MIDD).

Diagnosis and treatment of 50 children with pancreatic pseudocysts / 中华肝胆外科杂志

Objective To study the clinical features,diagnosis and treatment of pancreatic pseudocysts in children.Methods A retrospective study was conducted on 50 children with pancreatic pseudocysts diagnosed and treated in the Children's Hospital of Chongqing Medical University from September 2006 to August 2017.36 of these 50 children were treated with external drainage (including 2 patients after conservative treatment),5 internal drainage (including 2 patients after external drainage),and 13 conservative treatment.Results 47 patients were diagnosed by clinical symptoms,amylase examinations,ultrasound and CT scans;and 3 patients by surgical exploration.Of the 36 patients who were treated with external drainage,29 recovered and 5 improved.Two patients relapsed and underwent internal drainage.Five patients who were treated with internal drainage recovered.Of 13 patients who were treated with conservation treatment,10 were cured,1 recovered well,and the remaining 2 developed relapse and underwent external drainage.Conclusions The incidence of pancreatic pseudocyst in children was low.The diagnosis depended on clinical symptoms,biochemical and radiological examinations.For patients with small cysts,no complications and asymptomatic,conservative treatment is suggested.There were no obvious differences in the treatment results between internal and external drainage,and external drainage is advocated because of its advantages.Differences in the etiology play a vital role in the choice of treatment.In elective surgery for a pancreatic pseudocyst caused by trauma,external drainage is preferred.For those who developed after pancreatitis,internal drainage is advocated.

Drenaje de pseudoquiste pancreático guiado por ecoendoscopia sin fluoroscopia: serie de casos / Case Series of Drainage of Pancreatic Pseudocysts Guided by Echoendoscopy without Fluoroscopy

Resumen Introducción: los pseudoquistes pancreáticos pueden ser drenados por métodos quirúrgicos, laparoscópicos, percutáneos y endoscópicos. Este último es el más aceptado en la actualidad dado que es más simple y genera menos morbimortalidad; sin embargo, siempre se ha descrito asociado con el uso de la fluoroscopia, lo cual le suma complejidad. En este trabajo presentamos nuestra técnica de drenaje sin fluoroscopia guiado por ecoendoscopia. Materiales y métodos: el objetivo de este trabajo es describir una técnica de drenaje de pseudoquistes pancreáticos sin el uso de fluoroscopia y con la guía del ecoendoscopio. Se reporta una serie de casos de 10 pacientes a quienes se les realizó drenaje transgástrico, en los que se describen la técnica, complicaciones y resultados en el seguimiento. Resultados: se incluyeron 10 pacientes consecutivos, 5 pacientes eran mujeres y 5 hombres. El 90% de los casos comprometía el cuerpo del páncreas. Se implantó exitosamente 1 stent (metálico) transmural (cistogastrostomía) solo con guía ecoendoscópica en 9 pacientes; en 1 paciente no se logró liberar el stent, por lo cual se realizó el drenaje por aspiración. Los 9 pacientes a quienes se les implantó stent no presentaron recidiva; la paciente a quien se realizó drenaje por aspiración presentó recidiva a nivel del cuerpo de páncreas. La principal complicación fue la migración del stent hacia la cavidad del pseudoquiste en 1 paciente, el cual requirió segundo tiempo endoscópico para retirarlo. Conclusiones: el drenaje transmural del pseudoquiste pancreático con implante de stent es una técnica mínimamente invasiva, segura y efectiva para el tratamiento del pseudoquiste pancreático.

Abstract Introduction: Pancreatic pseudocysts can be drained by surgical, laparoscopic, percutaneous, and endoscopic methods. Endoscopic methods have become the most widely accepted nowadays since they are simpler and generate less morbidity and mortality. They have always been associated with the use of fluoroscopy, which adds complexity. This study presents our drainage technique which is guided by echoendoscopy rather than fluoroscopy. Materials and methods: The objective of this study is to describe a technique for drainage of pancreatic pseudocysts which does not use fluoroscopy to guide the endoscope. Instead, echoendoscopy guides the instrument. We report a case series of 10 patients who underwent transgastric drainage and describe the technique, complications and results during follow-up. Results: Ten consecutive patients, five women and five men, were included in this study. Ninety percent were cases in which the body of the pancreas had been compromised. Cystogastrostomy was successfully performed in nine patients. It consisted of implantation of a transmural metallic stent under single endoscopic guidance. In one patient the stent was not released and aspiration drainage was performed. The nine patients who had stents implanted have presented no recurrences, but the patient who underwent aspiration drainage presented recurrence in the body of the pancreas. The main complication was migration of the stent into the pseudocyst cavity which occurred in one patient and which required a second endoscopic procedure to remove the stent. Conclusions: Transmural drainage of pancreatic pseudocysts through placement of stents is a safe, effective and minimally invasive technique for the treatment of pancreatic pseudocysts.

Mediastinal Pancreatic Pseudocysts

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

Prevention of wrong absorption of pancreatic pseudocyst using guided transmural drainage under endoscopic ultrasonography / 中国内镜杂志

Objective To discuss how to preven wrong absorption of pancreatic pseudocyst using guided transmural drainage under endoscopic ultrasonography.Methods Retrospectively analyzed the clinical data of patients with pancreatic pseudocysts underwent operations of Endoscopic ultrasonography guided transmural drainage.Results 16 cases of pancreatic pseudocysts were finished with guided transmural drainage under endoscopic ultrasonography using needling to place bypass grafting with successful rate 100.0% of guided transmural drainage by needling. After needling, 2 cased happened regurgitation which led to wrongly absorbed, rate of occurrence is 12.5%. Generally, pancreatic pseudocysts of 16 cases disappeared completely with cure rate 100.0%. From above, stents were pulled out by endoscope in 3 cases while stents were removed voluntarily in another 13 cases.Conclusion Dorsal elevated position, detailed operation and esophageal annular tubes can effectively prevent wrong absorption of guided transmural drainage under endoscopic ultrasonography of pancreatic pseudocysts.

Understanding the international consensus for acute pancreatitis: classification of atlanta 2012 / Entendendo o consenso internacional para as pancreatites agudas: classificação de atlanta 2012

ABSTRACT Introduction: Contrast computed tomography and magnetic resonance imaging are widely used due to its image quality and ability to study pancreatic and peripancreatic morphology. The understanding of the various subtypes of the disease and identification of possible complications requires a familiarity with the terminology, which allows effective communication between the different members of the multidisciplinary team. Aim: Demonstrate the terminology and parameters to identify the different classifications and findings of the disease based on the international consensus for acute pancreatitis ( Atlanta Classification 2012). Methods: Search and analysis of articles in the "CAPES Portal de Periódicos with headings "acute pancreatitis" and "Atlanta Review". Results: Were selected 23 articles containing radiological descriptions, management or statistical data related to pathology. Additional statistical data were obtained from Datasus and Population Census 2010. The radiological diagnostic criterion adopted was the Radiology American College system. The "acute pancreatitis - 2012 Rating: Review Atlanta classification and definitions for international consensus" tries to eliminate inconsistency and divergence from the determination of uniformity to the radiological findings, especially the terminology related to fluid collections. More broadly as "pancreatic abscess" and "phlegmon" went into disuse and the evolution of the collection of patient fluids can be described as "acute peripancreatic collections", "acute necrotic collections", "pseudocyst" and "necrosis pancreatic walled or isolated". Conclusion: Computed tomography and magnetic resonance represent the best techniques with sequential images available for diagnosis. Standardization of the terminology is critical and should improve the management of patients with multiple professionals care, risk stratification and adequate treatment.

RESUMO Introdução: A tomografia computadorizada contrastada e a ressonância magnética são exames amplamente utilizados no estudo da morfologia pancreática e peripancreática. O entendimento dos diversos subtipos da doença e identificação de suas possíveis complicações requer familiaridade com a terminologia padrão, a qual permite comunicação efetiva entre os diversos membros da equipe multidisciplinar. Objetivo: Demonstrar terminologia e os parâmetros para identificação das diferentes classificações da doença a partir do consenso internacional para as pancreatites agudas (Classificação de Atlanta 2012. Método: Busca e análise de artigos no "Portal de Periódicos da CAPES" com descritores "pancreatite aguda" e "Revisão de Atlanta". Resultado : Foram selecionados 23 artigos que continham descrições radiológicas, manejo ou dados estatísticos relacionados à doença. Dados estatísticos adicionais foram obtidos no sistema Datasus e Censo Demográfico 2010. O critério de diagnóstico radiológico adotado foi o do Colégio Americano de Radiologia. A "Classificação da pancreatite aguda - 2012: revisão da classificação de Atlanta e definições por consenso internacional" tenta eliminar a inconsistência e divergências a partir da determinação de uniformidade para os achados radiológicos, em especial à terminologia relacionada às coleções de fluidos. Termos mais abrangentes como "abscesso pancreático" e "flegmão" entraram em desuso e a evolução da coleção de fluidos pode ser descrita como: "coleções peripancreáticas agudas", "coleções necróticas agudas", "pseudocisto" e "necrose pancreática murada ou isolada". Conclusão: A tomografia computadorizada e a ressonância magnética representam as melhores técnicas com cortes sequenciais disponíveis para diagnóstico. A adequação da terminologia é ponto crítico e deve permitir o manejo do paciente por múltiplos profissionais, estratificação de risco e adequação de tratamento.

Clincal value of contrast-enhanced ultrasound in differential diagnosis of pancreatic pseudocysts, cystadenomas and cystadenocarcinomas / 中国基层医药

Objective To investigate the value of contrast-enhanced ultrasound (CEUS) in differential diagnosis of pancreatic pseudocysts,cystadenomas and cystadenocarcinomas,so as to improve diagnostic accuracy of the condition.Methods The results of CEUS and conventional ultrasound for 71 patients with pancreatic cystic lesions were analyzed retrospectively,and compared with the finally obtained surgical-pathological examination to assess the ability of qualitative diagnosis between two methods.Results In 71 pancreatic cystic lesions,there were 32 pancreatic pseudocysts,24 cystadenomas and 15 cystadenocarcinomas.The sensitivity and accuracy of CEUS for pancreatic pseudocysts and cystadenocarcinomas were 84.4％,93.0％ and 86.7％,88.7％,which were higher than those of conventional ultrasound 56.3 ％,80.3 ％ and 53.3 ％,74.6％ (x2 =6.06,4.92,3.97,4.71,all P ＜ 0.05).Conclusion There are some similarities in terms of imaging manifestations among pancreatic pseudocysts,cystadenomas and cystadenocarcinomas.Combining conventional ultrasound with CEUS can help the differential diagnosis of pancreatic cystic lesions.

Pancreatitis necrohemorrágica en un niño de 11 años: Caso clínico / Necrotizing pancreatitis in a 11 year-old boy: Case report

La pancreatitis aguda es un problema emergente, con una incidencia de 3,6-13,2 casos/100000 niños. Sin embargo, la pancreatitis necrotizante (necrosis mayor del 30% del páncreas y/o mayor de 3 cm de un área del páncreas) es un proceso poco frecuente (< 1% de las pancreatitis agudas), con presentación similar a los casos de pancreatitis no complicada y con una elevada morbimortalidad. La tomografía axial computada permite valorar, en estos casos, la gravedad del cuadro y el riesgo de complicaciones (puntaje de Balthazar). Las pancreatitis no complicadas tienen una evolución favorable, pero los casos de pancreatitis necrotizante precisan tratamiento médico intensivo y, en ocasiones, cirugía. Presentamos el caso de un varón de 11 años con clínica compatible con una pancreatitis aguda confirmada mediante ecografía abdominal. Ante el empeoramiento analítico, se realizó una tomografía axial computada, que mostró una pancreatitis necrotizante y pseudoquistes de gran tamaño. Se decidió la monitorización estrecha y la adopción de una actitud conservadora, con mejoría clínico-analítica. Después de un año de seguimiento, el paciente permanece asintomático y han desaparecido los pseudoquistes. La pancreatitis necrohemorrágica es una entidad infrecuente en la edad pediátrica pero potencialmente grave que debemos tener presente en el diagnóstico diferencial de un abdomen agudo.

Acute pancreatitis is an emerging problem with an incidence between 3.6 and 13.2 cases/100,000 children. However, necrotizing pancreatitis (necrosis greater than 30% of the pancreas and/or greater than 3 cm in an area of the pancreas) is a rare condition (< 1% of acute pancreatitis), with a presentation similar to not complicated pancreatitis cases and with high morbidity and mortality. Computed tomography allows an assessment of the severity of the disease and the risk of complications (Balthazar Score). Not complicated pancreatitis cases have a favorable outcome, but necrotizing pancreatitis cases require intensive medical treatment and sometimes surgical treatment. We report the case of an 11 year-old boy with clinical presentation compatible with acute pancreatitis and confirmed by abdominal ultrasonography. Due to worsening of laboratory test, an abdominal computed tomography was performed showing a necrotizing pancreatitis and large pseudocysts. Close monitoring and a conservative approach was adopted, with clinical and analytical improvement. After one year follow-up, the patient is asymptomatic, normal ancillary tests and no evidence of pancreatic pseudocyst. The pediatric necrohaemorragic pancreatitis is an uncommon and potentially severe entity; we must keep this complication in mind for an adequate differential diagnosis of acute abdomen.

Tratamiento de pseudoquiste pancreático con drenaje transpapilar por vía endoscópica: reporte de caso / Case report: treatment of pancreatic pseudocysts with endoscopic transpapillary drainage

Reportamos el caso de un paciente con pseudoquiste pancreático como complicación de un episodio de pancreatitis aguda, el cual se manifestó con dolor abdominal epigástrico, vómito y sensación de plenitud posprandial. El paciente no presentó mejoría clínica después de realizar manejo expectante durante más de 12 meses y en el seguimiento con tomografías de abdomen se evidenció persistencia de la lesión con aumento en el tamaño hasta 4 cm de diámetro mayor. El paciente fue remitido para manejo a nuestra institución. En imagen de colangiopancreatografía por resonancia magnética se encontró que el pseudoquiste estaba comunicado con el ducto pancreático proximal. Se realizó manejo endoscópico con drenaje por vía transpapilar con inserción de stent pancreático, el cual fue realizado con resultado exitoso, observando desaparición de la lesión a los 30 días después del drenaje sin recurrencia de los síntomas a los 60 días de seguimiento.

We report on the case of a patient with pancreatic pseudocysts. They presented as complications of an episode of acute pancreatitis which had manifested as epigastric pain, vomiting, and a postprandial sensation of fullness. After 12 months of watchful waiting the patient had not improved. Instead, an abdominal CAT scans revealed that the lesion persisted and had grown an additional 4 cm in diameter. The patient was referred to our institution for treatment. A magnetic resonance cholangiopancreatography (MRCP) image revealed that the pseudocyst passed through the proximal pancreatic duct. Endoscopic transpapillary drainage was successfully performed with the insertion of a pancreatic stent. The lesion had disappeared 30 days after drainage. Symptoms had not recurred 60 days after drainage.

Early risk factors for the formation of pancreatic pseudocysts after severe acute pancreatitis / 中华胰腺病杂志

Objective To investigate the early risk factors of the formation of pancreatic pseudocysts after severe acute pancreatitis. Methods One hundred patients with severe acute pancreatitis admitted from Jul. 2005 to Mar. 2007 were included. Clinical and laboratory data within 24 hours of admission and radiological tests of chest, abdominal dynamic contrast-enhanced computed tomography and abdominal ultrasound within 3 days after admission were analyzed and multiple stepwise logistic regression analysis was performed. Results 30 patients developed pancreatic pseudocysts and the incidence of pancreatic pseudocysts in the clinical course of severe acute pancreatitis was 30%. There were significant difference between group A (pancreatic pseudocyst group) and group B (non-pancreatic pseudocyst group) in serum albumin[(33.23±4.810g/L vs (36.07±4.92)g/L], CT severity index (CTSI) (3~6 vs 2~4 points) ,length of hospital stay[(26.83±19.760) day vs (14.51±7.71) days, (P<0.05)]. Meanwhile, there were no significant differences between the two groups in age, gender proportion, body temperature, heart rate, breath rate and mean arterial pressure in admission,urine volume within 24 hours, early defaecation within 24 hours after admission, blood routine, liver function, kidney function, electrolytes, blood cholesterol and triglycerol, PT, APTr, arterial blood gas analysis, blood amylase, C-reaction protein, APACHE Ⅱ, RANSON scoring, early ascites and pleural effusion. But multiple stepwise logistic regression analysis showed that the serum albumin and CTSI were associated with the formation of pancreatic pseudocysts after severe acute pancreatids. Conclusions The serum albumin and CTSI were the independent risk factors of the formation of pancreatic pseudocysts after severe acute pancreatitis.

Case Report: A Plunging Ranula Extended into the Parapharyngeal Space

The efficacy and clinical application value of endoscopic transpapillary cyst drainage on the huge pancreatic pseudocysts and pancreatic abscess / 中国实用内科杂志

Objective To evaluate the efficacy and clinical application value of endoscopic transpapillary cyst drainage(ETCD)on huge pancreatic pseudocysts(HPP)and pancreatic abscess.Methods According to unification standard from 2003 Jun to 2006 Jun,to select 10 disquisitive cases,in which patients with uninfected HPP were 8 cases and that with infected HPP was 1 case,and pancreatic abscess was 1 case.ETCD was adopted in all cases.The clinical treatment process and the change of relative investigation subjects were retrospectively studied.Results Endoscopic transpapillary treatment failed in 1 case,postoperative infection of HPP occurred in 2 cases and acute pancreatitis was found in 1 case.Mean follow-up was 16.5 months in 8 cases.Finally,four patients had complete resolution of HPP,3 cases had partial resolution,and the remains cavity of HPP was formed in 1 caes.Acute grave pancreatitis were cured in 2 cases and Chronic pancreatitis had resolution in 6 cases.Conclusion ETCD was safe and efficient in HPP and pancreatic abscess.Postoperative infection of HPP was the familiar complication,and obstruction of drainage path of HPP was major cause.So the crux of complications precaution and treatment was that the drainage path of HPP was unhindered.

Pancreatic Pseudocysts and Ascites as Complications of Chronic Pancreatitis

A case of pancreatic pseudocysts and bloody pancreatic ascites as complications of chronic pancreatitis in eleven-year-old girl was reported. She was admitted to the pediatric ward with chief complaints of abdominal distension and bloody ascites. About nine months prior to admission, when she was stuck by a bicycle, she had sustained a blow on her abdomen. She has been apparently well until four months prior to admission, when she began to feel colidy and intermittent abdominal pain and her appetits became poor. About a week prior to admission, her mother noticed that the girl's abdomen was distended. One day prior to admission, bloody ascites was revealed by paracenteis at a local clinic. Clinical and laboratory pictures were observed for 3 months. Ascites amylase at preoperative state were 496~705 u/dl and 740~772 u/dl Protein in ascites was 2,390mg%~4,820mg%. On the fifty fifth hospital day, an exploratory laparotomy was performed. About 7,000cc of bloody ascites was drained. A 30 x 20cm sized pseudocyst with thin wall was found between stomach and transverse colon. The portion of disrupted pancreatic duct was drained with sump tube. Abdomen distension and pain was markedly relieved after operation. On the 60 th postoperative day, ultrasonography of abdomen revealed no cysts. So sump tube was removed. A brief review of the literature was done.