Research on PPC has focused on adult patients, with most studies excluding results from paediatric cases. According to the "2020 International Guidelines: Endoscopic Intervention in Chronic Pancreatitis" [10], PPC specifically refers to an encapsulated effusion formed by a pseudocystic wall in the peripancreatic tissues.PPC can be classified as either a solitary cyst or multiple cysts of varying shapes and sizes, and PPC can compress the gastrointestinal tract leading to abdominal pain and distension, resulting in severe gastrointestinal obstruction, and rupture of the pancreas itself, with abundant haematological transport, can lead to bleeding and infection. Some patients with PPC may present with no obvious symptoms. In this study, cases 2 and 3 were single pseudocysts and case 3 was multiple pseudocysts.
The diagnosis of PPC is mainly based on clinical history and imaging findings, especially abdominal enhanced CT and MR. Ultrasound provides a more accurate view of pancreatic lesions [11].CT examination is the most commonly used imaging test for the diagnosis of cystic lesions.Magnetic resonance imaging (MRI) examination can be used as an alternative to CT examination, which has the advantage of eliminating the need for the use of contrast agents, providing a clearer view of the intracystic components, and allowing better assessment of pancreatic ductal structures [12]. In this study, the diagnosis was clearly made preoperatively by CT or MR, but no lesion was observed in the pancreatic duct by MR.
No standardised treatment protocol exists for PPC. Cysts smaller than 4 cm are found to be more likely to resolve spontaneously [13, 14], and the American College of Gastroenterology guidelines [15] suggest that asymptomatic pseudocysts following acute pancreatitis can be treated conservatively regardless of their size, with monitoring of changes in the cysts by abdominal ultrasound or other imaging every 3 to 6 months. More than 50% of acute pancreatitis combined with pseudocysts resolve spontaneously, and studies have shown that 71% of paediatric patients with pancreatic pseudocysts are successfully treated conservatively, with only 29% requiring surgical intervention. Chronic pancreatitis has a lower rate of spontaneous regression due to the structural alterations of the pancreatic ducts (ductal stenosis, dissection, stones, etc.) that often accompany it [16, 17].
Percutaneous catheter drainage (PCD) has now replaced open external drainage; however, its postoperative complications (e.g., pancreatic fistula, infection) increase the length of hospital stay, recurrence rate, and morbidity and mortality rate of patients treated with PCD modality, and the complications are haemorrhage, infection, catheter displacement or occlusion, and intestinal fistula, etc. [18], and patients with chronic pancreatitis are usually combined with abnormal pancreatic duct structure or cystic pancreatic duct traffic, which may lead to high drainage flow and inability to extubate, or recurrence after extubation, or pancreatic fistula formation, so the failure rate of percutaneous catheter drainage in chronic pancreatitis combined with pseudocysts is high [19], and at this time, placing pancreatic duct stent drainage under ERCP is helpful. It has been shown that the failure rate, recurrence rate and complication rate of PCD are higher than that of endoscopic drainage [20], and Keshavarz P et al [21] showed that PCD can reduce the clinical discomfort of patients in a short period of time, so PCD is only suitable for the cases of intolerance or inability to carry out the endoscopic treatment or the surgery is very high risk.
Endoscopic treatment of PPC depends to some extent on the relationship between the pseudocyst and the duct, and the location of the pseudocyst in the pancreas. Endoscopic drainage is performed through 2 main routes: transduodenal papillary drainage and transgastric/duodenal wall drainage. Endoscopic transmural drainage (via the gastric or duodenal wall) is feasible for bulging pseudocysts, and the selection conditions mostly depend on the distance of the pseudocyst from the GI wall, with a distance of < 1 cm being an indication for endoscopic internal drainage [22]. Research has shown a success rate of > 90% in paediatric patients [23], equivalent to that of adults [24, 25]. Non-expanding pseudocysts located in the head of the pancreas and parenchymal body connected to a stenotic duct can be drained transduodenal papillary pancreatic duct (PPC) under EUS-guided endoscopy.EUS-guided PPC drainage is a feasible, reasonable, and less complication-prone method, and thus has become a leading first-line treatment approach [26]. However, there are technical difficulties in transendoscopic exploration of pseudocysts, catheter manipulation and analysis of cystic contents [27], and preoperative imaging did not observe pseudocysts < 1 cm from the GI wall; therefore, endoscopic treatment was not chosen in this study.
Symptomatic, pseudocysts > 6 cm or complications such as infection, bleeding or rupture of adjacent organs should be treated surgically [28], and surgical treatment includes open and laparoscopic surgery [29], mainly internal drainage, external drainage and pancreatectomy, including open drainage, cyst-gastric anastomosis, cyst-jejunoenteric anastomosis, distal pancreatectomy, PPC resection and pancreatic-jejunoenteric anastomosis. Partial pancreatectomy is mostly indicated for extensive chronic pancreatitis in the presence of multiple small pseudocysts in the pancreas, large pseudocysts causing biliary and pancreatic duct obstruction, duodenal infarction, haemorrhage and potentially with severe symptoms [18]. Study showed [30] that the morbidity and mortality rate in patients undergoing open surgery is less than 1%, complication rate is nearly 30% and recurrence rate is 6%. With the popularity of endoscopic cyst drainage, open internal drainage of simple pseudocysts has been gradually replaced by endoscopic drainage, while external drainage has now been largely eliminated by percutaneous transluminal drainage due to the high trauma and complications of indwelling catheters. Laparoscopic surgery has the shortest average hospital stay and lowest total hospital costs compared to percutaneous transluminal external drainage and open surgery [31]. The choice of endoscopic or laparoscopic surgical treatment for PPC is controversial; however, a review of cases found that laparoscopic surgical treatment had a higher drainage success rate and fewer complications [32–34].
Laparoscopic duodenal anastomosis for pseudocysts has rarely been reported in the literature. When laparoscopic pseudocyst-gastric anastomosis was compared with pseudocyst-jejunal Roux-en-Y anastomosis, retrospective analyses of the cases of the two surgical procedures did not show any significant advantages or disadvantages, and all of them were safe and effective in the treatment of PPC, with no significant differences in the cure rate, reoperation rate, and morbidity and mortality rates [35–39]. Laparoscopic pseudocyst-gastric anastomosis can be performed via anterior or posterior approach [34], an anterior approach is preferred when PPC is in close contact with the posterior wall of the stomach, and the anastomosis can be selected at the point where the cyst is tightly adherent to the gastric wall [40, 41], and a posterior approach does not rely on the adherence of the cyst to the posterior wall of the stomach; however, the posterior approach still lacks a sufficient number of case samples for statistical analyses of its surgical success rate, length of stay in the hospital, recurrence rate [42–44]. Laparoscopic pseudocyst-jejunal Roux-en-Y anastomosis, which is more demanding for the operator, is indicated for the internal drainage of pseudocysts in the tail of the pancreatic body. In this study, two patients were operated with pseudocysts located in the caudal part of the body. Based on the above reasons, laparoscopic pseudocyst-jejunum Roux- en-Y anastomosis was chosen for the patients in this study, and the healing process was good without any complications. In Case 1, the fluid in the pseudocyst was turbid and flowed into the abdominal cavity, and a large amount of saline was given to flush the abdominal cavity during the operation, so that the postoperative intra-abdominal drainage fluid contained a large amount of saline.
Research on PPC has focused on adult patients, with most studies excluding results from paediatric cases. According to the "2020 International Guidelines: Endoscopic Intervention in Chronic Pancreatitis" [10], PPC specifically refers to an encapsulated effusion formed by a pseudocystic wall in the peripancreatic tissues.PPC can be classified as either a solitary cyst or multiple cysts of varying shapes and sizes, and PPC can compress the gastrointestinal tract leading to abdominal pain and distension, resulting in severe gastrointestinal obstruction, and rupture of the pancreas itself, with abundant haematological transport, can lead to bleeding and infection. Some patients with PPC may present with no obvious symptoms. In this study, cases 2 and 3 were single pseudocysts and case 3 was multiple pseudocysts.
The diagnosis of PPC is mainly based on clinical history and imaging findings, especially abdominal enhanced CT and MR. Ultrasound provides a more accurate view of pancreatic lesions [11].CT examination is the most commonly used imaging test for the diagnosis of cystic lesions.Magnetic resonance imaging (MRI) examination can be used as an alternative to CT examination, which has the advantage of eliminating the need for the use of contrast agents, providing a clearer view of the intracystic components, and allowing better assessment of pancreatic ductal structures [12]. In this study, the diagnosis was clearly made preoperatively by CT or MR, but no lesion was observed in the pancreatic duct by MR.
No standardised treatment protocol exists for PPC. Cysts smaller than 4 cm are found to be more likely to resolve spontaneously [13, 14], and the American College of Gastroenterology guidelines [15] suggest that asymptomatic pseudocysts following acute pancreatitis can be treated conservatively regardless of their size, with monitoring of changes in the cysts by abdominal ultrasound or other imaging every 3 to 6 months. More than 50% of acute pancreatitis combined with pseudocysts resolve spontaneously, and studies have shown that 71% of paediatric patients with pancreatic pseudocysts are successfully treated conservatively, with only 29% requiring surgical intervention. Chronic pancreatitis has a lower rate of spontaneous regression due to the structural alterations of the pancreatic ducts (ductal stenosis, dissection, stones, etc.) that often accompany it [16, 17].
Percutaneous catheter drainage (PCD) has now replaced open external drainage; however, its postoperative complications (e.g., pancreatic fistula, infection) increase the length of hospital stay, recurrence rate, and morbidity and mortality rate of patients treated with PCD modality, and the complications are haemorrhage, infection, catheter displacement or occlusion, and intestinal fistula, etc. [18], and patients with chronic pancreatitis are usually combined with abnormal pancreatic duct structure or cystic pancreatic duct traffic, which may lead to high drainage flow and inability to extubate, or recurrence after extubation, or pancreatic fistula formation, so the failure rate of percutaneous catheter drainage in chronic pancreatitis combined with pseudocysts is high [19], and at this time, placing pancreatic duct stent drainage under ERCP is helpful. It has been shown that the failure rate, recurrence rate and complication rate of PCD are higher than that of endoscopic drainage [20], and Keshavarz P et al [21] showed that PCD can reduce the clinical discomfort of patients in a short period of time, so PCD is only suitable for the cases of intolerance or inability to carry out the endoscopic treatment or the surgery is very high risk.
Endoscopic treatment of PPC depends to some extent on the relationship between the pseudocyst and the duct, and the location of the pseudocyst in the pancreas. Endoscopic drainage is performed through 2 main routes: transduodenal papillary drainage and transgastric/duodenal wall drainage. Endoscopic transmural drainage (via the gastric or duodenal wall) is feasible for bulging pseudocysts, and the selection conditions mostly depend on the distance of the pseudocyst from the GI wall, with a distance of < 1 cm being an indication for endoscopic internal drainage [22]. Research has shown a success rate of > 90% in paediatric patients [23], equivalent to that of adults [24, 25]. Non-expanding pseudocysts located in the head of the pancreas and parenchymal body connected to a stenotic duct can be drained transduodenal papillary pancreatic duct (PPC) under EUS-guided endoscopy.EUS-guided PPC drainage is a feasible, reasonable, and less complication-prone method, and thus has become a leading first-line treatment approach [26]. However, there are technical difficulties in transendoscopic exploration of pseudocysts, catheter manipulation and analysis of cystic contents [27], and preoperative imaging did not observe pseudocysts < 1 cm from the GI wall; therefore, endoscopic treatment was not chosen in this study.
Symptomatic, pseudocysts > 6 cm or complications such as infection, bleeding or rupture of adjacent organs should be treated surgically [28], and surgical treatment includes open and laparoscopic surgery [29], mainly internal drainage, external drainage and pancreatectomy, including open drainage, cyst-gastric anastomosis, cyst-jejunoenteric anastomosis, distal pancreatectomy, PPC resection and pancreatic-jejunoenteric anastomosis. Partial pancreatectomy is mostly indicated for extensive chronic pancreatitis in the presence of multiple small pseudocysts in the pancreas, large pseudocysts causing biliary and pancreatic duct obstruction, duodenal infarction, haemorrhage and potentially with severe symptoms [18]. Study showed [30] that the morbidity and mortality rate in patients undergoing open surgery is less than 1%, complication rate is nearly 30% and recurrence rate is 6%. With the popularity of endoscopic cyst drainage, open internal drainage of simple pseudocysts has been gradually replaced by endoscopic drainage, while external drainage has now been largely eliminated by percutaneous transluminal drainage due to the high trauma and complications of indwelling catheters. Laparoscopic surgery has the shortest average hospital stay and lowest total hospital costs compared to percutaneous transluminal external drainage and open surgery [31]. The choice of endoscopic or laparoscopic surgical treatment for PPC is controversial; however, a review of cases found that laparoscopic surgical treatment had a higher drainage success rate and fewer complications [32–34].
Laparoscopic duodenal anastomosis for pseudocysts has rarely been reported in the literature. When laparoscopic pseudocyst-gastric anastomosis was compared with pseudocyst-jejunal Roux-en-Y anastomosis, retrospective analyses of the cases of the two surgical procedures did not show any significant advantages or disadvantages, and all of them were safe and effective in the treatment of PPC, with no significant differences in the cure rate, reoperation rate, and morbidity and mortality rates [35–39]. Laparoscopic pseudocyst-gastric anastomosis can be performed via anterior or posterior approach [34], an anterior approach is preferred when PPC is in close contact with the posterior wall of the stomach, and the anastomosis can be selected at the point where the cyst is tightly adherent to the gastric wall [40, 41], and a posterior approach does not rely on the adherence of the cyst to the posterior wall of the stomach; however, the posterior approach still lacks a sufficient number of case samples for statistical analyses of its surgical success rate, length of stay in the hospital, recurrence rate [42–44]. Laparoscopic pseudocyst-jejunal Roux-en-Y anastomosis, which is more demanding for the operator, is indicated for the internal drainage of pseudocysts in the tail of the pancreatic body. In this study, two patients were operated with pseudocysts located in the caudal part of the body. Based on the above reasons, laparoscopic pseudocyst-jejunum Roux- en-Y anastomosis was chosen for the patients in this study, and the healing process was good without any complications. In Case 1, the fluid in the pseudocyst was turbid and flowed into the abdominal cavity, and a large amount of saline was given to flush the abdominal cavity during the operation, so that the postoperative intra-abdominal drainage fluid contained a large amount of saline.
Laparoscopic distal pancreatectomy is used for benign, malignant, traumatic and inflammatory lesions of the pancreas, and complications such as pancreatic fistula (10.8%) can occur in a short period of time after distal pancreatectomy in patients with PPC, and the prevention of pancreatic fistula mainly relies on pancreatic stump closure, pancreatic ductal occlusion, and the use of growth-suppressor drugs [42, 45]. However, there is a lack of standardised protocols for the management of pancreatic stumps and the potential risk of pancreatic fistula is high, with other complications including postoperative bleeding, pancreatitis, pancreatic abscess, and pseudocysts as a complication. Therefore, laparoscopic distal pancreatectomy is often considered a therapeutic option after failure of internal drainage .