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Pancreatic cyst drainage postoperative

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This article is co-written by Anthony Stark, EMR. Anthony Stark is a Certified Ambulance Paramedic from British Columbia. He currently works at the British Columbia Ambulance Service.

The number of sources used in this article is 18. You will find a list of them at the bottom of the page.

A cyst on the surface of the skin can hurt and cause irritation. No matter how you want to poke or squeeze it, it can lead to infection and scar. If you have a cyst, the best thing you can do is to see a doctor for medical help. You can try to drain the cyst at home, and then look after it while it heals.

Attention:The information in this article is for informational purposes only. Before using any methods, consult your doctor.

LAPAROSCOPIC INNER DRAINING Pseudocyst of the pancreas

Pancreatic pseudocysts not amenable to conservative therapy are usually treated with internal drainage into the stomach, duodenum or jejunum, depending on the location of the cyst. Most often, internal gastric drainage is performed under ultrasound or x-ray control. The literature gives the positive results of using this technique with a frequency of 60 to 80% of cases, however, until the pseudocysts are completely resolved with this treatment, it takes from 4 to 12 weeks.

The advantage of laparoscopic internal drainage of the pseudocyst of the pancreas lies in the possibility of atraumatic application of full anastomoses and in the absence of the need for external drainage. The first laparoscopic cystogastrostomy was performed in 1991.

The most commonly used cystogastrostomy technique proposed by L. Way. According to this technique, carbon dioxide is insufflated into the stomach through a nasogastric tube, and then a trocar is introduced into it. A bloated stomach is used as a workspace for surgery.

Laparoscopic transgastric cystogastrostomy

There are two techniques for such an operation. The first begins with diagnostic lapaproscopy through umbilical access. Two additional trocars are introduced for exposure in the retrogastric space. Intraoperatively performed endoscopy. In the case when the back wall of the stomach is poorly visualized, drainage can be installed. Laparoscopic control allows the formation of an anastomosis between the posterior wall of the stomach and the anterior wall of the cyst under visual control and, if necessary, maneuver the pseudocyst.

The second transgastric cystogastrostomy technique is performed intraluminally (from the stomach) using a special trocar with an expanding cuff. These trocars have an inflated balloon at the end for fixation in the stomach so that intraluminal surgery can be performed with two additional trocars. Used trocars have a diameter of 5 and 7 mm and therefore do not allow the use of a clip applicator or ELSA. However, due to such a small diameter, the openings in the wall of the stomach are small, and they can be sutured with single seams 2-0 (silk or absorbable material).

The patient on the operating table is lying on his back. Pneumoperitoneum is applied. Three trocars are introduced: in the umbilical region (11 mm), to the left of the midline (11 mm) and on the left side (5 mm). The first intraluminal trocar is injected in the epigastric region above the pseudocyst through the abdominal wall and the anterior wall of the stomach. After removing the stylet, the cuff of the trocar inflates, thus fixing the instrument to the wall of the stomach and creating a tightness in its lumen. Intraoperative administration of a gastroscope allows you to install a nasogastric tube and insufflate gas into the stomach during the entire operation. To visualize the posterior wall of the stomach, a 5 mm direct laparoscope is introduced. The second intraductal trocar is installed about 8 cm to the left or right of the irrigation-flushing system.

A cyst is identified with the help of long needles inserted percutaneously through the front wall of the stomach, and under the laparoscopic intraluminal visual control, the posterior wall of the stomach is fixed in the area of ​​cyst localization. Aspiration of the contents of the cyst confirms the correct location of the instruments and indicates the absence of damage to the vessels. Gastrostomy with a length of 4-5 cm is performed along the back wall with the help of "holders". The contents of the cyst are evacuated, the cavity is cleaned and examined. To exclude a cystadenomatous tumor, a biopsy of the cyst wall is performed.

The nasogastric tube remains in the stomach, the trocar balloon desufflates and the instruments are removed. Punctures in the stomach are closed with separate intracorporeal sutures with silk 2-0. For 24-48 hours, Jackson-Pratt drainage is brought to the area of ​​the anastomosis. Enteral fluid can be given from the second day after laparoscopic drainage of the pancreatic cyst. Then check the viability of the anastomosis - gastrography with liquid contrast. After laparoscopic drainage of the pancreatic cyst, patients can be discharged on the fifth day.

Features of drainage of the pancreatic cyst

An important way to study and treat pancreatic cysts is through drainage. This process is carried out under the supervision of ultrasound using special drains. Using this procedure, you can remove the formation without resorting to surgical intervention. The process is carried out under the influence of anesthesia. This procedure is also carried out after surgery. Modern drainage subsequently helps to avoid complications, since foci with purulent sagging adequately open.

How is a pancreatic cyst puncture performed?

Pancreatic puncture is performed on an empty stomach. Before conducting the diagnosis, the patient must pass general tests. The duodenum is a convenient place to get a puncture, because it closely borders the pancreas. A biopsy makes it possible to obtain a liquid for analysis for the presence of cancer cells or other formations. This diagnostic procedure is designed to study the formed and unformed gland cysts. A safe puncture path is selected under the control of ultrasound scanning. The puncture process is carried out using needles that have developed marks, which eliminates the risk of an accidental puncture during a similar procedure. This diagnostic procedure allows you to get a liquid for further analysis of the origin of the formation. After this procedure, the patient is monitored for two hours, after which he goes home.

Laparoscopy of the pancreatic cyst

Before surgery, the presence or absence of metastases in the pancreas can be determined using the modern method of laparoscopy. Using this diagnostic method, you can choose an effective course of treatment, drawing up its individual plan. Laparoscopy is a simple and safe method for treating pancreatic cysts; it is not accompanied by a large number of injuries compared to others. Using this type of diagnosis, the nature of education can be clarified. The use of this method can significantly reduce postoperative pain, reducing the duration of hospitalization and recovery time. The rapid recovery of the body is explained by the absence of the need to make a large laparotomy incision for strong manipulation with internal organs in order to gain access to them. Thanks to this method of treatment, an excellent anatomical picture can be obtained, which is important when performing operations with the pancreas, which has a large number of large vessels in the operable area.

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Pancreas anatomy

The pancreas (pancreas) is located in the upper abdominal cavity between the small intestine and spleen. It produces an important pancreatic (pancreatic) juice, which contains enzymes responsible for the breakdown of fats, proteins and carbohydrates during digestion.

The gastric (digestive) juice enters the duodenum through the main (pancreatic) duct, the final segment of which coincides with the final segment of the bile duct, through which the bile juice also enters the duodenum. The next important function of the pancreas is to produce the hormones insulin and glucagon, which regulate blood sugar and they have the opposite effect. These hormones are produced in special cells of the pancreas. Diseases of the pancreas (pancreas) can be caused by many causes.

Acute pancreatitis

If it is difficult to drain the digestive juice, e.g. due to cholelithiasis (the common end segment of the ducts of the pancreas and bile ducts) or due to excessive stimulation of the cells (excessive consumption of alcohol), there may be a malfunction in the flow of enzymes into the intestines - or due to their excessive production, one part of them will remain in the pancreas, damaging the cells of the pancreas and even destroying them. As a result, inflammation occurs, which leads to pancreatic edema, further complicating the outflow of digestive juice.

If you do not take the inflammation of the pancreas under control, it will spread and the “aggressive” gastric juice can begin to affect the structures of the pancreas, as well as the structures adjacent to it, destroying them. A particularly dangerous form of pancreatic inflammation (the so-called necrotizing pancreatitis) in some cases can be fatal.

Treatment of acute pancreatitis

First of all, conservative treatment is carried out, i.e., non-surgical. At the same time, abstinence from food is important so as not to stimulate the production of gastric juice, and the intake of a sufficient amount of fluid to maintain digestive processes. To prevent infection due to possibly dead tissue, antibiotics are prescribed in some cases. Only with confirmed infection of dead tissue or the occurrence of a false cyst (as described below), surgical treatment of the pancreas is necessary. It is also necessary to find out the causes of inflammation, so that they can be eliminated. If the cause, for example, is gallstone disease, stones must be removed - in some cases, the removal of the entire gall bladder may be required.

Chronic pancreatitis

In some cases, acute inflammation of the pancreas is treated without leaving consequences, but it can also cause cell death and the formation of non-functioning scar tissue. If scar tissue causes narrowing of the pancreatic ducts, this can trigger further inflammation of the pancreas. Experts speak of chronic pancreatitis with prolonged, recurring inflammation of the pancreas.

Each exacerbation of inflammation is fraught with cell death and, as a consequence, a restriction of the functions of the pancreas, which is no longer able to produce enough digestive enzymes. In this regard, a greater amount of nutrients enter the intestine, which provoke excessive reproduction of bacteria, which leads to diarrhea (diarrhea). Also observed "fatty stools" due to a lack of enzymes involved in the process of splitting fats and pain in the upper abdominal cavity, emanating in the back.

At a progressive stage, diabetes may occur due to an insufficient amount of hormones (insulin and glucagon) that regulate blood sugar. The most common cause of pancreatitis in Western countries is alcohol, while it is not always about alcohol abuse, because in some people even a small dose of alcohol can serve as an impetus for the development of the disease. Other important causes of chronic pancreatitis: chronic cholelithiasis, genetic defect, congenital malformation of the pancreatic duct and metabolic (metabolic) disorder. In some cases, the cause cannot be identified.

Pancreatic cyst

Even a few years after acute inflammation of the pancreas, a false cyst (saccular protrusion) of the pancreas can occur. This cyst is called false because its inner wall is not lined with mucous membranes. A false cyst has no clinical significance and, in the presence of complaints (a feeling of heaviness in the stomach, nausea, pain, etc.), it is only subject to surgical treatment.

Pancreatic Cancer - Pancreas Cancer

The so-called ductal pancreatic adenocarcinoma is the most common type of pancreatic tumor. Pancreatic cancer is particularly aggressive, because it is a rapidly growing tumor that can grow into neighboring tissues. Along with the hereditary factor (genetic predisposition), there are a number of risk factors for pancreatic cancer. Such factors include nicotine, alcohol, foods high in cholesterol and nitrosamine, as well as chronic pancreatitis.

In most cases, the disease makes itself felt at an already progressing stage and its symptoms depend on the location of the tumor. If the tumor is located in the head of the pancreas, then, as the tumor grows, the bile ducts narrow. This leads to stagnation of bile and yellowing of the skin of the face and eye sclera (lat. Icterus).

If the tumor is located in the middle part or tail of the pancreas, then this often leads to pain in the upper abdominal cavity and back, because the nerve centers located behind the pancreas are irritated. The appearance of diabetes can also indicate pancreatic cancer. Surgical treatment of the pancreas is still the only method that gives the patient a chance to cure the disease.

What examinations must be done before pancreatic surgery?

The location of the pancreas in the body complicates access to it. In the immediate vicinity of it are the stomach, small intestine and gall bladder with bile ducts, which often complicates the examination. Therefore, recommendations for screening for the early detection of cancer in patients without complaints make little sense.When it comes to pancreatic cancer, diagnosis is hampered by the late onset of symptoms. Due to the fact that the pancreas is located directly in front of the spine and the nerve plexuses located there, its diseases can cause back pain, thereby complicating the detection of the disease.

Usually held blood test. determining the amount of pancreatic enzymes in the blood, and if cancer is suspected, an oncomarker test (CEA, carbohydrate antigen-19-9) is performed. In any case, carried out Ultrasound of the pancreas and as a rule, depending on the question, CT scan and MRCP (magnetic resonance cholangiopancreatography). through which the bile ducts and ducts of the pancreas can be visualized. If there is a need for therapeutic intervention (e.g. removal of stones and bile ducts), the priority is ERCP (endoscopic retrograde cholangiopancreatography). since during the examination you can immediately carry out treatment.

Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is used to visualize the gallbladder and bile ducts, as well as the excretory duct of the pancreas through a contrast agent and x-rays. Due to the proximity of the pancreas to neighboring organs, they also need to be examined. This includes the stomach, intestines, and abdomen.

Puncture for confirmation of oncological diagnosis is not required

Confirmation of an oncological diagnosis before pancreatic surgery by means of a puncture or biopsy (tissue sample) is generally not recommended and sometimes impossible due to the anatomical location of the pancreas (behind the abdominal cavity). In addition, bleeding or fistula may form during a puncture. Given all these factors, specialists seek to create surgical access to the pancreas and completely remove the tumor tissue as part of pancreatic surgery.

Reconstruction after surgery on the pancreas

Due to the special location of some tumors in the area of ​​the pancreatic head, sometimes removal of part of the duodenum and stomach, gall bladder, and also part of the pancreas itself is required. Surgeons create artificial joints (anastomoses) - intestinal loops, as well as the connection of the intestinal loop with the bile duct and pancreas, in order to restore transit through the gastrointestinal tract.

Pancreatic Surgery: Postoperative

After partial removal of the pancreas, it is necessary to take digestive enzymes with food. Dosage is determined individually, depending on the removed amount of the gland and its part, as well as on the postoperative condition of the patient. If the spleen has been removed, then regular monitoring of the platelet count is necessary. If they are elevated in the blood, thrombosis prophylaxis measures may be required.

Even if at the time of the operation on the pancreas and immediately after it, the patient does not have diabetes, it is recommended to conduct tests for blood sugar, because as a result of surgery on the pancreas there is a likelihood of this disease. The test can be carried out 1-2 times a year using daily monitoring of blood glucose levels or an oral glucose tolerance test (sugar load).

If, in spite of the improvement of surgical methods of treatment, when the stomach is not removed, nutrition problems still arise, you can resort to the services of dietetic consultants. After surgical removal of pancreatic cancer, regular follow-up by a doctor is necessary. Along with a physical examination, an ultrasound of the upper abdominal cavity is performed, as well as monitoring of CEA tumor markers and carbohydrate antigen 19-9 in the blood.

Subsequent examination of patients undergoing surgery to remove pancreatic cancer at the initial stage is carried out every three months. Further, according to medical prescriptions and recommendations of the attending physician, the distance between examinations can be increased. Possible further treatment with chemotherapy is carried out as prescribed by the oncologist.

The risk and complications of surgical treatment of the pancreas

Pylorus-preserving pancreatoduodenal resection is a very serious surgical intervention, but complications are rare. A more serious complication is a temporary stenosis of the outlet stomach, caused by edema of the gastric anastomosis. This phenomenon is temporary and goes away as soon as the swelling of the tissues subsides. Problems with artificially created compounds occur in 10-15% of patients. Secondary bleeding opens in 5-10% of all patients.

Content

  • Indications for pancreatic surgery
  • Types of operations by volume of intervention
    • Organ conservation operations
    • Surgery to remove the gland parenchyma
  • Operations Technologies
    • Open operations
    • Minimally invasive surgery
    • Bloodless operations
  • Gland transplant
  • After surgery: complications, consequences, prognosis

Indications for pancreatic surgery

The need for pancreatic surgery arises only in cases where it is not possible to cure the disease with other methods, and when there is a threat to the patient's life. From the point of view of surgery, iron is a very delicate and "capricious" organ with the most delicate parenchyma, many blood vessels, nerves and excretory ducts. In addition, it is located in close proximity to large vessels (aorta, inferior vena cava).

All this creates a high likelihood of developing complications, requires a great skill and experience from the surgeon, as well as a rigorous approach to determining indications.

The pancreas has a complex structure and is adjacent to the largest vessels extending directly from the aorta

When do pancreatic surgery? It is necessary when the following diseases do not leave another choice:

  1. Acute pancreatitis with increasing edema of the gland, not amenable to conservative treatment.
  2. Complicated pancreatitis (hemorrhagic, pancreatic necrosis, gland abscess).
  3. Chronic pancreatitis with severe atrophy, glandular fibrosis,

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    Median cyst of the neck

    The median cyst of the neck (thyroglossal) is formed at 6-7 weeks of pregnancy, forming when the primordium of the thyroid gland is moved from the place of formation, along the duct, to the front surface of the neck. The thyroid-lingual duct, along which the movement passes, should be reduced to the end of intrauterine development, but with an anomaly, a closed cavity is formed - the median cyst of the neck. Education is often not diagnosed until the age of 2-3 years, and sometimes it is detected much later. The median cyst is located in the midline on the surface of the neck. In some cases, it can cause speech impairment and difficulty swallowing, if formed at the root of the tongue.

    The clinical picture of the median cyst of the neck

    The formation usually has a rounded shape, to the touch is dense, elastic, not exceeding 2 cm in diameter, it does not have adhesions to the skin, which allows it to move. On palpation, pain is not felt, with age it can increase in size and sometimes reaches up to 7cm. Suppuration occurs in more than half of cysts of the neck, accompanied by:

    • Skin redness
    • Increase in size,
    • Temperature rise
    • Soreness when swallowing,
    • Swelling of the surrounding tissue.

    The transparent, viscous contents of the cyst during infection turns into a muddy purulent mass. Median fistulas of the neck are formed during spontaneous opening of the cyst, with a breakdown of suppuration, in some cases after surgery. Fistulas can be punctate, almost imperceptible, or they can be clearly defined, periodically they can overgrow, and then reopen. The outlet of the fistula can form on the skin of the neck, as well as on the mucous membrane of the oral cavity.

    Diagnosis of the median cyst

    You need to know the differences between the median cyst of the neck and dermoid cysts, lipomas and lymphangiomas. Unlike the median, the dermoid cyst is denser. With swallowing movements, she does not shift, she is not palpated. Lipomas and lymphangiomas are softer, have large sizes and fuzzy borders. The median cyst of the neck is diagnosed on the basis of history and clinical data. To clarify the diagnosis, examinations using ultrasound, MRI, as well as cyst puncture with further cytological examination are used. To study fistulas, probing and fistulography are used.

    Lateral cyst of the neck

    The lateral cyst of the neck (branchiogenic) is usually detected immediately after birth, it is more common than the median. The lateral cyst, as well as the median cyst, is formed as a result of abnormal development of the fetus, but its exact origin has not been elucidated. Most scientists believe that it is formed during the development of gill slits in the second month of pregnancy. With normal development of the fetus, they should disappear in the future, but with pathology, a cavity remains in the remains of the gill pockets. The formation is located on the anterior lateral surface of the neck below or above the level of the hyoid bone, and is localized on the neurovascular bundle near the internal jugular vein.

    The clinical picture of the lateral cyst of the neck

    The lateral cyst of the neck is an oval-shaped tumor formation, which is especially distinguished when the head is turned in the opposite direction. A cyst can reach a diameter of up to 10 cm, with significant dimensions it compresses blood vessels, nerve endings and adjacent organs. The formation can be single-chamber or multi-chamber, when feeling soft and elastic, has a clear shape, does not shift during swallowing movements. Lateral cysts of the neck do not provoke respiratory failure, in contrast to the median. Small formations, in the absence of suppuration, are painless. With a puncture, a dirty white liquid is found in the cavity of the cyst. In the process of infection, the tumor grows in size, there is an edema, the skin turns red, painful sensations appear. Later, at the opening of the cyst, a fistula is formed. As a complication, phlegmon of the neck can occur - purulent inflammation of the soft fatty tissues, and then the muscles. With this complication of the neck cyst, the patient needs surgery immediately. Lateral cysts of the neck can also lead to Branchiogenic cancer. Diagnose the disease using ultrasound, sounding and fistulography with radiopaque substance.

    Neck cyst treatment

    When treating neck cysts, surgery is a necessity, as conservative treatment is not acceptable. The operation of the neck cysts is indicated for children from the age of three years, adults immediately after the detection of the tumor. When suppuration of the cyst with subsequent fluctuation, it is opened and drainage is performed. After the elimination of signs of inflammation, the patient can be removed with a tumor. To prevent possible relapses, the cyst must be excised with the capsule, the operation is performed under intravenous anesthesia. An incision is made over the area of ​​the cyst, then the contents are removed along with the shell. With surgical intervention for the median cyst, there is a need to remove part of the hyoid bone, since a cord from the neoplasm passes through it. Treatment associated with a lateral cyst may be difficult due to closely spaced vessels and nerves. A cyst located at the root of the tongue is removed either through an incision in the skin or through the mouth, depending on its size. With a closed fistula and the presence of an acute inflammatory process, emergency surgical intervention is required. Fistulas, like cysts of the neck also need to be removed, before surgery, staining preparations are injected into the fistulous inputs, for their complete identification and subsequent removal. This is necessary to prevent relapse.

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