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Patient care — surgical procedures

Drainage of pancreatic pseudocysts (fluid collections): Single or multiple fluid collections that look like cysts on pancreatic imaging are often observed during acute pancreatitis. Because of increasing sensitivity of imaging modalities and improvements in technology providing enhanced therapeutic abilities, the questions of when and whether drainage should be performed and what modality should be used to drain the cysts are often asked. Strictly defining the type of fluid collection is very important when reviewing pancreatic fluid collections. The therapeutic approach is different depending on the type of collection.

Pseudocysts are best defined as a localized fluid collection that is rich in amylase and other pancreatic enzymes, that has a nonepithelialized wall consisting of fibrous and granulation tissue, and that usually appears several weeks after the onset of pancreatitis.

photo These characteristics contrast with those of acute fluid collections, which are more evanescent and are serosanguinous inflammatory reactions to acute pancreatitis. These collections are noted in moderate-to-severe pancreatitis. Acute fluid collections usually have an irregular shape and lack a well-defined wall. In general, they resolve in about 65% of cases.

Two other types of fluid collection should be considered. First, organized necrosis is actually devitalized pancreatic tissue that appears cystlike on CT scan, but it appears to be solid on other imaging modalities. Second, an abscess is an infected area of necrosis or fluid.

Surgical drainage options include the following:

  • Catheter drainage
  • Endoscopic drainage - may be either transpapillary (via ERCP) or transmural. Both modalities require careful patient selection to ensure success and safety.
  • Surgical drainage - is the criterion standard against which all therapies are measured. Internal drainage is the procedure of choice. A laparoscopic approach has been employed in some cases with good results.

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