Pseudocyst drainage to Jan

[Guest guest]

> He said they are all trying to help me but I won't listen to what

they recommend... surgery to drain the two large pseudocysts

one on my pan , the other covering my left kidney... draining

them into my small intestine has HAS to be done..

>I could not afford the surgery. All 3 doc's got together and

decided that they would do the surgery for free...... given my state

of affairs!! I can't believe how nice and generous they all are to

help me.

> could you please help me with any details.... how long

operation...... etc...... what to expect?

> i'm not afraid because i know God only gives us what we can

handle.... he knows I am tough.... I think my loved ones... my two

sons could use some strength at this point.

>......... jan

Dear Jan,

My largest pseudocyst was partially drained by fine needle

aspiration, a procedure quite different than what the doctors are

proposing for you. I have several articles on percutaneous

drainage of pseudocysts that I would be happy to send you,

should you wish. One article on endoscopic drainage is pasted

below. The other articles on percutaneous drainage are very

lengthly, so I would need to send them to you through regular

email, so email me if you would like them at:

hhessgriffeth@...

My procedure took about two hours, but I was required to be

there early in the a.m. for observation while a sedative took effect

and for several hours afterward, so it actually took over half the

day. Since yours is major surgery, and there are two

pseudocysts involved, I would imagine this will be a lengthly

procedure. This is a question for your surgeon. You will also

need to ask how long they anticipate that you will be required to

stay in the hospital afterward.

As it is very dangerous for these pseudocysts to be untreated,

intervention is necessary. You are indeed very fortunate that

these doctors have agreed to do the procedure for free!

My adult children (30 and 26) were very concerned for their mom,

too. I raised them on my own for six years before I remarried

and we are very close. The best you can do for your sons is to

learn as much as you can about the procedure, what to expect

afterward and let them know that you have confidence in your

doctors and faith in the success of the procedure and yourself. If

they know you are not afraid, they will feel less concerned.

With hope and prayers,

Heidi

Heidi H. Griffeth

South Carolina

hhessgriffeth@...

Southeastern Representative

Pancreatitis Association, Intl.

MANAGEMENT OF FLUID COLLECTIONS DUE TO ACUTE

PANCREATITIS BY INTERVENTIONAL TECHNIQUES

Vimal Someshwar

Interventional Radiologist, Bhatia General Hospital, Mumbai.

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Intra-abdominal fluid collection following pancreatitis is

associated with high degree of morbidity and mortality especially

when infected. Symptoms like pain, discomfort and distension of

abdomen, can be quite distressing. Surgery used to be the

mainstay of management of these fluid collections. Over the last

2 to 3 decades, percutaneous and endoscopy guided catheter

drainage procedures, have helped improve the prognosis of this

morbid condition.

Wide availability of cross sectional imaging modalities like

ultrasonography and CT scanning have helped early diagnosis,

as also, guided percutaneous drainage procedures. Of the two

modalities, CT scan is preferred, as it thoroughly and

systematically helps evaluate the entire abdominal cavity.

USG or CT guided percutaneous catheter drainage procedures

are associated with a mortality rate of 6%. The normal anatomy

is also less disrupted and therefore less morbidity is associated

with this form of therapy.

Two types of pancreatic fluid collections which can be drained by

percutaneous techniques are : (A) Pseudocysts and (

Abscesses and necrotic collections.

(A) Pseudocysts

Cysts which are either large, causing pain, distension or are at

high risk of rupture, require percutaneous drainage. Infection

complicating a cyst needs early drainage.

Various procedures considered are:-

(a) Percutaneous needle aspiration

( Percutaneous catheter drainage

© Percutaneous cysto-gastrostomy

(d) Endoscopic cystogastrostomy

(e) Endosonographic cystogastrostomy

Simple needle aspiration can be performed under USG/CT

guidance. 18G/16G needle is directed into the collection, as fluid

is aspirated. Recurrence rate of 5% to 7% is expected following

this therapy. Secondary infection and bleeding within the cyst are

possible complications.

Percutaneous Catheter Drainage is the most preferred method.

CT guidance is preferred. Seldingers technique is used to

catheterise the fluid cavity. Cure for pseudocyst by this technique

is expected to be 67-80%. Communication with the pancreatic

duct determines the duration for which the catheter is to be kept

in place.

Cystogastrostomy : The principle of this procedure is to allow

formation of a mature tract between the cyst and the stomach

and hence, facilitate drainage of the fluid through the fibrous

tract. To achieve this fibrous tract, a catheter or stent is placed for

at least 3 weeks. The procedure was first performed by the

percutaneous technique. Endoscopy was found to be a better

mordality, since there was no external tube placement.

Endoscopic Ultrasonography/Doppler further reduced the risk of

injuring a blood vessel

( Abscesses and Necrotic Tissue

Aggressive approach is necessary as these abscesses are

associated with a mortality rate of 70-80%. The present

approach for the management of pancreatic abscesses, is to

delay surgical explorations for 3 to 4 weeks. During this period

percutaneous drainage is preferred. Multiple catheters placed

simultaneously, draining all possible cavities, is mandatory.

Drainage using large bore catheters (14 Fr. - 24 Fr.) are used.

Antibiotic lavage technique, wherein, antibiotic solutions are

introduced from one catheter and drained after 3 hours from

another catheter, have yielded better results. However, catheter

drainage may be incomplete as often, necrotic tissue may

occlude the catheter. Surgery should be contemplated once the

sepsis is under control.

Percutaneous Interventional Technique : Salient features

i. Shortest possible route to the fluid cavity should be selected,

avoiding puncturing bowel or organ.

ii. Gravity drainage should be facilitated, otherwise, suction

drainage systems like Redivac, should be attached.

iii. Try to a demonstrate communication of the cavity with hollow

viscera, by injecting contrast in the cavity.

iv. Catheters should be properly fixed to avoid accidental

displacement. Self-retaining catheters like Pigtail, Cope-loop,

Malecot's type etc., are used. Proper skin fixation and dressing

helps prevent displacement.

v. The caliber of the drainage tube should be wide with no

reduction.

Percutaneous drainage procedure play an important role in the

management of acute pancreatitis.

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