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External drainage was used in cases of misdiagnosis, high risk of anastomotic dehiscence due to infected pseudocyst, or when the wall is immature. It was considered inferior to internal drainage in that external drainage can cause hemorrhage due to mechanical abrasion by the drainage tube, frequent occurrence of secondary infection, persistent pancreatic fistura, which was 10% of all cases, disease rate at 18% and a high 10% mortality. The study revealed a 9% mortality rate for external drainage, often due in turn to the poor condition of the patient.
This last study pointed to internal drainage as the preferable surgical procedure for all uncomplicated cases of pseudocysts (Govil et al. 2004). Cystogastrostomy is the option for cysts, which densely attach to the posterior stomach walls, while cystoduodenostomy should be for pseudocysts in the head and the uncinate process of the pancreas. The authors found that cystojejunestomy would be appropriate for all other types of cysts and for large pseudocysts for proper drainage. All of its 10 patients who underwent internal drainage survived (Govil).
Andersson and Cwiklie (2004) found that pancreatic pseudocysts treated by percutaneous cystogastrostomy yielded good results. They believed that this procedure would be a safe and minimally invasive one that will also produce long-term as well as long-term follow-up results.
Cutress (2004) suggested that the laparoscopic drainage of a pseudocyst of the pancreas would be a straightforward procedure, as it has shown to be successful for a large symptomatic pseudocyst with low morbidity.
Pekmeszci (2002) agreed that laparoscopic surgery could be performed when decompression is indicated. The author reported performing laparoscopic procedures by inserting trocars via the anterior gastric wall and operating intraluminially with gastric insufflation and endoscopic guidance. She stressed on the benefits of discussing the feasibility and features of the technique when performed with a total abdominal approach.
Cantasdemic (2003) believed that the PCD would be a safe and effective front-line treatment for patients with pancreatic pseudocysts.
And Govil and associates (2004) underscored the advantages of choosing internal drainage as the appropriate approach to pancreatic pseudocysts and the efficacy of surgical intervention. Six of those who underwent external drainage later exhibited complications, such as pancreatic fistula, septicemia and infection. However, 19 or the 20 patients were reported as doing well during the follow-ups. In comparison with two other studies on the two procedures, Govil and team claimed that their subjects showed no recurrence and with a low 4.7% mortality rate.
The researchers also said that pseudocysts could complicate 7-15% of episodes of acute pancreatitis and 20-25% of chronic pancreatitis (2004). Persistent pseudocysts, they also concluded, could lead to many serious complications, including infection, abscess, and bleeding from erosions into nearby vessels. The present treatment modalities of choice are percutaneous drainage, surgical intervention and endoscopic drainage (Govil et al.).
But the constant observation has been that most cases of pseudocysts resolve by themselves and without interference and, therefore, most patients will recover without need for intervention (Lambiase 2004). Observed cases also showed that the outcome was worse who developed complications or who resorted to surgical drainage or other surgical interventions to manage their cysts. Moreover, these drainage procedures have a failure rate of about 10%, a recurrence rate of approximately 15% and a complication rate of 15-20%.
Manejo de Hipotehsis
Drainage or any other surgical intervention is not effective or necessary in most cases of pancreatic pseudocysts.
Most cases of pancreatic pseudocysts will resolve by themselves and do not require more than support care. The current surgical modalities also chosen have a high failure level and can lead to complications and infection. There can also be risks of misdiagnosing a cystic neoplasm of the pancreas and treating it as a pseudocyst. On top of everything is the failure to recognize and treat complications of pseudocysts. What is needed is patient education. Patients must learn and understand warning signs of potential complications, such as abdominal pain or fever, which can mean bleeding, fever or the tearing of a pseudocyst.
Andersson, R and W. Cwikiel. Percutaneous Cystogastrostomy in Patients with Pancreatic Pseudocysts, European Journal of Surgery, vol 168 (6) September 1, 2002. Taylor and Francis Ltd. http://ingentaconnect.com/connect/tandf/ssur/2002/00000/68/00000006/art00005
Cantasdemic, M, et al. Percutaneous Drainage for the Treatment of Infected Pancreatic Pseudocysts. Southern Medical Journal, vol 96 (2): 136-1-40, February 2003. http://smalljournalonline.com/pt.re/smi/searchplusresults.htm:jsessionid=CruAvbls0tN28va87ouAqSGITNtLFRuDWtzElV5D
Cutress, Golash. Laparaoscopic Cytogastrostomy for a Giant Pseudocyst of Pancreas, a case report. Department of Surgery: Sultan Qaboos Hospital. The Surgeon, vol 03 (1), February 2005. http://icsed.ac.uk/journal/svol3_1/3010008.html
Govil D. et al. Surgery for Complicated Pancreatic Pseudocysts. Indian Journal of Gastroenterology, vol 23 (1), pp 33-34. (http://www.indianjgastro.com (article.asp?)issn=0254-8860,year=2004,volume=23,issue=1,spage=33,epage=34,aulast=Govil
Lambiase, Louis R. Pancreatic Pseudocysts. Consumer Health: eMedicine.com, June 9, 2004. http://www.emedicine.com/med/topic.2674.htm
Pekmezci, Salih, et al. Total Laparoscopic Cystogastrostomy for Treatment of Pancreatic Pseudocysts. Journal of Laparoendoscopic and Advanced Surgical Techniques, vol 12 (2): pp 119-122, April 2002. Mary Ann Liebert, Inc. http://www.liebertonline.com/doi/abs/10.1089/10926430252939655;jsessionid=jrTURXJhUdH9?cookieSet=19journalCode=/ap
Rossoa, Edoardo, et al. Pancreatic Pseudocysts in Chronic…[continue]
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