7183 Transpapilliary drainage (tpd) for symptomatic pseudocysts (psdc)

Frederick C. Johlin; Gail C. Crowe; Crystal L. Youngs

doi:10.1016/S0016-5107(00)14854-0

Intro: Pancreatic PSDCs are the result of pancreatic necrosis. They may enlarge if they communicate with the main pancreatic duct. The drainage of the PSDC by stenting the main pancreatic duct is not the most common therapy utilized. We describe a prospective case series. Study: Patients (PTs) with PSDCs that were causing pain, obstruction or were suspected to be infected were offered TPD. In 30 months, 24 PTs (21:3 M:F) with symptomatic PSDC were drained by a TPD. The believed etiologies were alcohol-15, gallstones-5, lipids-1, genetic-1 and cancer-2. PT inclusion required at ERCP that some evidence for a communication be demonstrated. Cyst access was obtained by TPD technique in all PTs. Drains were custom-made wedge stents with radial holes, min. size was 8 French. Procedure antibiotics (ATB) and IV sedation were utilized but prolonged ATB only if the cultures and symptoms suggested an active infection. All patients were encouraged to utilize jejunal nutrition and not oral nutrition. The need for surgery or transgastric or percutaneous drains (PCD) indicated a treatment failure. Negative outcome measurements were stent occlusion and un-scheduled hospitalizations. Results: Initial access to the cyst cavity was obtained in 24 PTs with one (21 PTs) or a second procedure (4). Malnutrition was evident in 15 of 15 alcohol related PSDCs but only one of the other patients, yet all were asked to use jejunal feedings. 20 of 24 complied with exclusive jejunal nutrition. 3 of 15 continued to use alcohol. Infectious complications occurred in 3 with the most severe being an infection in a portal vein clot. 3 had surgery before the referral and 5 had surgery for complications (non healing fistulas to colon in 1, bile duct encasement in 3 and non-resolution of the cyst in 1). PCD was necessary in 2 and TGD in 1. Five patients relapsed with PSDC recurrence with symptoms and all were offered TPD with success. 3 of those had been treated previously with surgery. Five deaths were recorded: 2 from cancer progression, and 2 from pre-existing coronary disease, and one 2 years post treatment “in his sleep”. Seven alcoholics are drinking again, 3 with heavy consumption. Conclusion: TPD can provide symptom control in the majority of patients. Malnutrition was common in the alcoholic patients. Recurrence does occur and stent therapy can be effective. Persistent bile duct encasement after 6 weeks of therapy always required surgery.

7183 Transpapilliary drainage (tpd) for symptomatic pseudocysts (psdc)

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