From
StayCurrentMD
Endoscopic & Surgical Interventions: Pancreatic Disease
With Dr. Tom Lynn & Dr. Milton Smith
Chapter 1 of 10 · Case-Based Learning
Case 1 presentation
Case 1 Introduction: 11-Year-Old with Recurrent Inflammatory Mass and Fluid Collection
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Catheters for cyst-gastrostomy are generally left in for about 1 month to 6 weeks with repeat imaging, and before taking catheters out it is important to evaluate the status of the pancreatic duct to see if there's any evidence of communication, ductal disruption, or stricture.
Transpapillary pancreatic stent placement has a greater likelihood of success if capable of bridging the defect, but certain leaks can still resolve despite not being able to successfully bridge the defect within the pancreatic duct.
Patients who have undergone Puestow procedure followed by total pancreatectomy have compromised islet yield, which is an important consideration in children with genetic pancreatitis who may need total pancreatectomy in the future.
A few days after cyst-gastrostomy catheters come out, the fistula closes, and it's usually not brisk enough flow to keep it open even if there's a persistent leak.
When draining cysts through the GI tract, you want to know what's going on with the pancreatic duct, and you don't have to necessarily do ERCP and drainage at the same time, though sometimes they are performed in the same session.
When looking for pancreatic necrosis on CT, you look for foci of absent or hypo-enhancement of the pancreas that may be sites of necrosis that then portend the risk for developing chronic duct leaks.
Management intervention choice for pseudocysts can be very much based on local expertise that the facility has as well as the presence or severity of patients' comorbidities.
The revised Atlanta classification from 2012 is a classification scheme described for adult patients that specifically calls out they were not considering pediatric patients, so we're largely extrapolating those criteria to the pediatric population, though it seems to hold true in defining acute fluid collections, necrosis, pseudocysts, etc.
In the setting of a planned total pancreatectomy, introducing a connection between stomach and pseudocyst via trans-gastric drainage might create more scarring in the retroperitoneum and make surgery more challenging, which is why percutaneous approach may be preferred despite being more technically difficult.
Puestow procedure (lateral pancreaticojejunostomy) is considered for isolated large duct disease or chain-of-lakes appearance without inflammatory mass in the head of the pancreas, typically not in the setting of hereditary pancreatitis.
Intraoperative ultrasound can be used to find the pancreatic duct during Bern procedure, and sometimes the duct can be found by sticking a needle into it under ultrasound guidance in the operating room.
In children with genetic etiology of pancreatitis, which represents about 70% of chronic pancreatitis patients, conventional surgical procedures should be considered cautiously because limited resection will not change the genetic makeup of the pancreas.
Whipple procedure is uncommonly considered in children with head-predominant pancreatic disease and would be reserved for situations where there is concern about a tumor or cancer, though the likelihood of cancer in a child is exceedingly low.
Pancreatic duct leaks can manifest internally as peripancreatic fluid collections, pseudocysts, pancreatic ascites, pleural effusion, and pancreaticoenteric, biliary, or bronchial fistulas, or externally as pancreaticocutaneous fistulas.
Risks of endoscopic intervention (EUS or ERCP) include elevated risk for developing or exacerbating pancreatitis, introducing infection into an initially sterile fluid collection, and developing ductal changes including pancreatic duct stricture from temporary endoprosthesis due to foreign body inflammatory response.
Acute peripancreatic fluid collections develop early in the course of acute pancreatitis, are rare to become infected, and occur in up to 40% of acute pancreatitis patients regardless of etiology, with the majority resolving spontaneously and less than 5% evolving into pseudocysts.
Pancreatic pseudocysts are formally defined when they reach a time threshold of 4 weeks or greater, contain high amylase-rich content with low fluid and little to no internal debris, and have a well-defined non-epithelialized wall.
Endoscopic ultrasound provides high resolution imaging of the pancreatic parenchyma as well as the ductal structures both biliary and pancreatic, has both diagnostic and therapeutic capabilities, and these interventions have been clearly well established and beneficial in adults.
The information and available literature regarding endoscopic ultrasound use in pediatrics is rather limited due to limited data, limited number of pediatric indications currently understood, insufficient awareness of potential capabilities, and very limited number of pediatric gastroenterologists who have attained appropriate training to perform EUS safely and effectively.
Approximately 50% of chronic pancreatitis patients will eventually require surgery, with indications including obstructive complications (bile duct, duodenal), pseudocysts, suspicion of malignancy, and most commonly debilitating pain that fails to respond to medical and endoscopic treatment.
There are few studies examining optimal timing for conventional surgical options for chronic pancreatitis; some advocate earlier surgery to avoid progressive destruction from inflammation, while others advocate watch-and-wait because surgical approaches are not uniformly successful, resulting in no clear consensus.
There is no single surgical procedure recommended for all patients with chronic pancreatitis; procedures are selected based on severity of pain, pancreatic duct abnormalities (dilated vs. not dilated), location of most diseased pancreas, presence of dominant head disease, local complications, and overall patient condition.
Puestow procedure provides short-term pain relief in 75% of patients, but greater than 50% have recurrent pain, largely related to inability to decompress the duct fully or continued inflammation in the head of the pancreas.
Whipple procedure eliminates obstructive head mass but offers a substantial operation with multiple anastomoses, sacrifices non-diseased organs (bile duct, duodenum) requiring reconstruction, has relatively high morbidity due to leaks, provides good pain relief at 4-6 years, but results in late endocrine and exocrine dysfunction in 50% of patients.
Beger procedure involves coring out the head of the pancreas leaving a rim along the duodenum, dividing the pancreas over the portal vein, and reconstructing with two anastomoses (duodenojejunal limb to distal pancreas and to head cavity), providing good pain relief in 80-85% at 5 years with minimal endocrine and exocrine insufficiency compared to Whipple.
Bern procedure is a technical simplification of Beger with similar extent of head resection but does not require dissection over the portal vein and requires only a single anastomosis to the cavity, providing pain relief in 85-90% with equivalent pain and quality of life outcomes versus Beger procedure.
Frey procedure combines drainage and head resection by coring out the head of the pancreas for dominant disease and opening the entire main pancreatic duct longitudinally (adding a Puestow-type approach), then placing a Roux-en-Y duodenal limb over the entire opening.
Conventional surgical operations for chronic pancreatitis provide initial pain relief in most cases, but over the long term approximately 50% of patients have recurrence of pain, potentially requiring rescue with total pancreatectomy.