Clinicopathologic characteristics and endoscopic treatment of post-traumatic pancreatic pseudocysts.

OBJECTIVE: Surgery is the treatment of choice for traumatic pseudocyst. Minimally invasive management of these collections has been used. The aim was to analyze the outcome after endoscopic treatment and the integrity of the main pancreatic duct caused by abdominal trauma. METHODS: A total of 51 patients with traumatic pseudocyst who underwent endoscopic therapy were studied. All were symptomatic with a persistent collection for more than 6 weeks. Endoscopic retrograde pancreatography allowed characterization according to Takishima classification (1, 2, and 3), in which guided therapy was divided into transpapillary drainage (Takishima 2 and 3 without bulging), transmural (type 1), or combined (type 2 or 3 with bulging). RESULTS: Endoscopic retrograde pancreatography was obtained in 47 (90%) of 51 patients. Drainage was transmural in 13, combined in 24, and transpapillary in 10. The success and recurrence rates of endoscopic treatment were 94% and 8%, respectively. There were 9 complications but no procedure-related deaths. Patients with penetrating trauma had more recurrences (P = 0.01) and risk for development of infection (P = 0.045) than those with blunt trauma. CONCLUSIONS: Endoscopic treatment of traumatic pancreatic collection is safe and effective and can be considered a first-choice alternative to surgical treatment. Endoscopic retrograde pancreatography and Takishima classification are useful in determining the best endoscopic approach.

Different clinical aspects of Wirsungocele: case series of three patients and review of literature.

The association of Santorinicele with pancreas divisum has been described. This anatomic condition creates ideal conditions for acute pancreatitis episodes and chronic abdominal pain. Saccular dilation of main pancreatic duct has also been described as incidental finding and causing episodes of acute pancreatitis. However, there is no description of associated chronic abdominal pain. Three detailed cases of Wirsungocele demonstrated by endoscopic retrograde cholangiopancretography are presented. Two of them had episodes of acute pancreatitis and one had chronic abdominal pain. All patients were treated by endoscopic biliopancreatic sphincterotomy. After a follow-up for more than two years, none presents clinical recurrence. Endoscopic biliopancreatic sphincterotomy for symptomatic patients with this anatomic condition seems safe and effective.

Pancreatite aguda sem etiologia aparente: a microlitíase deve ser pesquisada? [revisão] / Unexplained acute pancreatitis: the microlithiasis must be searched? [review]

In a large number of patients, with episodes of acute pancreatitis the etiology is not identified, even after initial clinical history, detailed physical examination, laboratory tests and biochemical exams and an transabdominal ultrasound. This patient are considered with a unexplained acute pancreatitis. In this cases the treatment is restricted to improvement of symptoms. These patients after treated tend to have new episodes with the risk of raising the rates of morbidity and mortality. Therefore, the identification of a cause and its prompt treatment prevent at recurrent episodes of pancreatitis. This review aims to draw attention to how best diagnostic approach when the light of evidence-based medicine, to search for causes of difficult identification with microlithiasis, occult stones, the anatomical variations of biliary and pancreatic duct and in addition to sphincter of Oddi dysfunction.

Endoscopic ultrasound-guided fine-needle aspiration using helical computerized tomography for TN staging and vascular injury in operable pancreatic carcinoma.

CONTEXT: EUS-FNA is increasingly being used in operable pancreatic carcinoma cases identified by CT. OBJECTIVES: Determine the safety, accuracy and clinical utility of EUS-FNA for T, N and TN staging and vascular injury assessment in proven ductal pancreatic carcinoma. PATIENTS: Fifty-two consecutive patients (29 women and 23 men) with histologically ductal pancreatic carcinoma, with an excellent possibility of mass resection assessed by helical computerized tomography, were studied. Mean age was 62.4 years (range: 27-82 years). Tumor locations were in the head (43 cases), body (5 cases) and tail (4 cases) of the pancreas. Mean tumor size from EUS was 3.7 cm (range: 0.8-6.2 cm). METHODS: We reviewed medical records and abdominal ultrasound, CT, EUS-FNA and the results were compared to surgical and histological findings. RESULTS: Ultrasound identified pancreatic abnormalities in 38 out of 52 patients (73.1%): pancreatic mass (25 cases), pancreatic head enlargement (8 cases), dilation of main pancreatic duct (3 cases), pancreatic cyst (1 case) and pancreatic calcification (1 case). CT showed a pancreatic mass (30 cases), pancreatic enlargement (17 cases), pancreatic cystic lesion (2 cases) and pancreatic calcification (1 case) in 50 out of 52 patients (96.2%). EUS-FNA found a clear pancreatic tumor image in all patients (100%). The accuracy of EUS for evaluating portal blood vessels, superior mesenteric artery, T alone, N alone and combined TN staging was 86.5%, 94.2%, 84.7%, 67.3% and 55.8%, respectively. In addition to cytological material from 50 patients, microfragments from 43 patients were sent for histological analysis. Two patients (3.8%) showed minor complications: self-limited bleeding and acute pancreatitis. CONCLUSIONS: EUS-FNA is safe, and can help gastroenterologists and surgeons make surgical decisions regarding pancreatic carcinoma patients.

[Unexplained acute pancreatitis: the microlithiasis must be searched?]. / Pancreatite aguda sem etiologia aparente: a microlitíase deve ser pesquisada?

In a large number of patients, with episodes of acute pancreatitis the etiology is not identified, even after initial clinical history, detailed physical examination, laboratory tests and biochemical exams and an transabdominal ultrasound. This patient are considered with a unexplained acute pancreatitis. In this cases the treatment is restricted to improvement of symptoms. These patients after treated tend to have new episodes with the risk of raising the rates of morbidity and mortality. Therefore, the identification of a cause and its prompt treatment prevent at recurrent episodes of pancreatitis. This review aims to draw attention to how best diagnostic approach when the light of evidence-based medicine, to search for causes of difficult identification with microlithiasis, occult stones, the anatomical variations of biliary and pancreatic duct and in addition to sphincter of Oddi dysfunction.

Intraoperative ultrasonography of the liver in patients with abdominal tumors: a new approach.

OBJECTIVES: To compare liver intraoperative ultrasonography (IOU), computed tomography (CT), preoperative ultrasonography (USG), and intraoperative inspection and palpation in the detection of hepatic lesions in patients with abdominal tumors. METHODS: This was a prospective study including 60 patients with abdominal tumors evaluated by USG, CT, inspection and palpation, and hepatic IOU during exploratory laparotomy. Sensitivity, specificity, and positive and negative predictive values for all methods were calculated. Agreement of methods with histopathologic results was calculated by kappa statistics and the Spearman coefficient. RESULTS: Of the 60 patients, 49 (81.6%) had positive findings for hepatic lesions. Lesions could not be counted in 3 patients. The 46 remaining cases were diagnosed by histologic examination. Sensitivity, specificity, and positive and negative predictive values were 42.9%, 88.9%, 90%, and 40% for USG; 59.5%, 77.8%, 86.2%, and 45.2% for CT; 69.0%, 88.9%, 93.5%, and 55.2% for inspection and palpation; and 90.5%, 77.8%, 90.5%, and 77.8% for IOU, with histologic examination used as a criterion standard. Fair to moderate agreement was found for USG, CT, and inspection and palpation (kappa = 0.24, 0.31, and 0.49, respectively). Substantial agreement was found for IOU (kappa = 0.68). Changes in surgical strategy were made in 19 (41.3%) of the 46 cases with positive findings. CONCLUSIONS: High sensitivity associated with substantial agreement with histopathologic findings shows that IOU is an indispensable evaluation method for hepatic screening in patients with abdominal tumors who undergo laparotomy and should become a routine procedure wherever available.