Unusual manifestations of pancreatic pseudocysts and their surgical management

Six cases representing selected complications of pancreatic pseudocyst are reported and their surgical management is discussed. Patients with mediastinal extension of a pseudocyst frequently present with symptoms in the chest rather than in the abdomen. Chronic recurrent pleural effusion, rich in protein and amylase, often accompanies mediastinal extension of a pancreatic pseudocyst. It is important to recognize that such an effusion almost certainly represents disruption of the pancreatic duct with formation of a pancreatic pseudocyst or a pancreaticopleural fistula. Internal drainage from below the diaphragm is the treatment of choice for pancreatic pseudocysts extending into the mediastinum.To be certain that obstructive jaundice is due to a pancreatic pseudocyst, there must be operative demonstration of compression of the common bile duct by the pseudocyst, relief of the obstruction by surgical drainage of the cyst, and subsequent disappearance of jaundice. Cysts that cause jaundice are located in the head of the pancreas, and cystoduodenostomy is the treatment of choice.Intraperitoneal rupture has been associated with a high mortality, but with adequate fluid replacement, prompt evacuation of the cyst contents from the peritoneal cavity, and adequate drainage, mortality can be lowered.Pancreatic ascites is much more common than is generally supposed and may result from a leaking pancreatic pseudocyst. In contrast to cirrhotic ascites, pancreatic ascites produces elevation of both the serum amylase level and protein concentration.Massive hemorrhage from pancreatic pseudocysts is usually due to the development of a false aneurysm in a branch of the celiac axis in the wall of the pseudocyst, with subsequent rupture of the aneurysm into the gut or peritoneal cavity. Any patient with a pancreatic pseudocyst who shows signs of bleeding should have prompt arteriography for determination of the bleeding site and appropriate surgical control.Pancreaticobronchial fistula is a rare complication. Treatment should be directed toward adequate drainage of the pseudocyst in the abdomen.     

Pancreatic cyst associated with pancreas divisum treated by laparoscopy-assisted cystgastrostomy in the intragastric approach: a case report and a review of the literature

A 39-year-old Japanese man was admitted to our hospital after experiencing recurrent episodes of pancreatitis over the previous 2 years. On the first episode, he had been admitted to our hospital with elevated serum amylase levels and epigastralgia. Abdominal computed tomography (CT) revealed a diffuse, uncircumscribed area with heterogeneous density in the pancreas. No previous history of pancreatitis, gallstones, drinking, or abdominal injury was elicited. Magnetic resonance cholangiopancreatography (MRCP) demonstrated that the Wirsung duct was unconnected to the Santorini's duct. Endoscopic retrograde cholangiopancreatography through the papilla of Vater and accessory papilla revealed an enlarged ventral pancreatic duct, pancreas divisum, and a cystic lesion in the pancreatic body. On the second and third episodes, endoscopic drainage of the pancreatic pseudocysts through the accessory papilla and ultrasonography-guided transmural drainage were unsuccessful. A follow-up CT and MRCP demonstrated that the pancreatic cyst had enlarged to 9 x 8 cm in diameter. A laparoscopy-assisted cystgastrostomy was performed with an intragastric approach. An anastomosis was performed using an endoscopic linear stapler through the small cystotomy and gastrotomy openings on the posterior wall of the stomach. The postoperative clinical course was uneventful. Over 6 months later, the patient remains well and with a good quality of life. A laparoscopy-assisted cystgastrostomy, using an intragastric surgical technique, offers a safe, less-invasive procedure for cyst drainage by the pancreas divisum.     

Mucin-Producing Tumor of the Pancreas Associated with Pyothorax: Report of a Case

We report herein the case of a 76-year-old man for whom an invasive mucin-producing tumor of the pancreas (MPTP) was successfully treated by surgery. A cystic lesion of the pancreas had been found by computed tomography (CT) 9 years earlier, 2 years following which suction drainage for left pyothorax had been carried out. A pancreatic cyst fistula to the thorax had subsequently been found during decortication for recurrent pyothorax 2 years later. Methicillin-resistant Staphylococcus aureus was detected in the pleural discharge after the thoracotomy, and thoracic fenestration was performed. A CT scan done 4 years later showed enlargement of the pancreatic cysts and a cystography revealed communication to the duodenum via the main pancreatic duct. Endoscopic retrograde cholangio-pancreatography (ERCP) showed dilatation of the main pancreatic duct. The pancreatic cyst fistulated to the stomach and to the fenestrated thorax. Since MPTP was suspected from this clinical course, a distal pancreatectomy, partial gastrectomy, and omentopexy to the thorax were performed. The pathological diagnosis was intraductal papillary-mucinous tumor of the pancreas with a megacyst. While MPTP is recognized as a low-grade malignancy, some cases of invasive disease have been reported. To the best of our knowledge, this is the first case of MPTP associated with pyothorax due to fistula formation. Received: February 21, 2000 / Accepted: November 20, 2000     

Major gastrointestinal hemorrhage associated with pancreatic pseudocyst

Although the pancreas is not a frequent source of major gastrointestinal hemorrhage, bleeding in patients with pancreatitis is not an uncommon complication. In patients with bleeding who are known to have pancreatitis or a pseudocyst, this organ must be considered a possible site of hemorrhage.It is recommended that celiac axis and superior mesenteric artery angiography be performed prior to barium contrast studies.If bleeding is originating from a pancreatic pseudocyst, aggressive surgical intervention should be undertaken. Three cases are described in which prompt operation was successful.Intracystic suture-ligation of the bleeding vessel together with cystogastrostomy was performed in two cases. One case of bleeding from a pseudocyst in the head of the pancreas and involving the gastroduodenal artery was treated by excision of the cyst and head of the pancreas.     

胰腺假性囊肿的诊治

目的 探讨胰腺假性囊肿（ＰＰＣ）的有效诊治方法。方法 对１０５例ＰＰＣ患者的临床资料进行回顾性分析。结果 ４１例行逆行胰胆管造影（ＥＲＣＰ）和／呀窦道造影检查,１６例（３９．０２％）被证实囊肿与胰管交通。保守治疗治愈例此皮穿刺置管引流２０例,复发５例。手术治疗５４例（包括非手术治疗后中转手术５例）,行囊肿空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术３０例,复发３例;囊肿胃吻合术９例,并发胃出血２例,其中１例死亡;     

Management of pancreatic injuries

This is a retrospective analysis of the treatment of 18 patients with pancreatic injuries at our institution. 13 were victims of blunt abdominal trauma. 17 sustained a polytrauma and had an ISS > 15. They had 2.4 associated intraabdominal and 2.7 associated extraabdominal injuries. The mean pancreatic organ injury scale was II. A partial duodenopancreatectomy was performed in one case. In 5 cases a distal pancreatic resection was necessary. In the remaining patients drainage procedures were applied. 3 additional injured organs had to be treated during the first operation. 2 of them were situated intraabdominally. The primary operative procedure was performed in 13 cases during the first 6 hours after the trauma. 7 patients (39%) died during the hospitalisation. None deceased during an operation. 5 patients (28%) died because of abdominal complications. 4 of 5 patients with injuries to the great vessels died. 12 had abdominal complications. The mean hospitalisation time was 49 days. The mean drainage time was 26 days. The patients sustained parenteral nutrition for 21 days. The priority in the primary operative approach is damage control. This consists of bleeding control, control of enteral spillage, assessment of pancreatic damage, especially recognition of any ductal injury and generous drainage of the injured pancreas. Definitive treatment in the severely injured patient has to be performed after hemodynamic stabilisation without delay by an experienced surgeon.     

Management of pancreatic injuries

This is a retrospective analysis of the treatment of 18 patients with pancreatic injuries at our institution. 13 were victims of blunt abdominal trauma. 17 sustained a polytrauma and had an ISS > 15. They had 2.4 associated intraabdominal and 2.7 associated extraabdominal injuries. The mean pancreatic organ injury scale was II. A partial duodenopancreatectomy was performed in one case. In 5 cases a distal pancreatic resection was necessary. In the remaining patients drainage procedures were applied. 3 additional injured organs had to be treated during the first operation. 2 of them were situated intraabdominally. The primary operative procedure was performed in 13 cases during the first 6 hours after the trauma. 7 patients (39 %) died during the hospitalisation. None deceased during an operation. 5 patients (28 %) died because of abdominal complications. 4 of 5 patients with injuries to the great vessels died. 12 had abdominal complications. The mean hospitalisation time was 49 days. The mean drainage time was 26 days. The patients sustained parenteral nutrition for 21 days. The priority in the primary operative approach is damage control. This consists of bleeding control, control of enteral spillage, assessment of pancreatic damage, especially recognition of any ductal injury and generous drainage of the injured pancreas. Definitive treatment in the severly injured patient has to be performed after hemodynamic stabilisation without delay by an experienced surgeon.     

Case Report: Pancreas Graft With a Duodenal Complication Rescued Using Total Duodenectomy

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for type 1 diabetics with end-stage renal disease. Recently patients with type 2 diabetes have been considered for transplantation. Despite that the patient and graft survival rates have improved over the past years, it continues to be a procedure with high surgical complication rates. We herein report a case of a pancreatic graft with a duodenal complication rescued using a total duodenectomy, a procedure that is seldom used. A 57-year-old type 2 diabetic underwent a SPK transplantation with systemic-enteric drainage. He was converted to a Roux en Y at day 7 for a small duodenal fistula without peritonitis. At day 13, with good graft function, he presented with gastrointestinal and abdominal bleeding. At laparotomy he had a congestive duodenum with intraluminal bleeding and an anastomotic fistula. We performed a total duodenectomy with enteric drainage. The patient was discharged home on day 39 with a pancreatic fistula on intramuscular Octretotide that lasted for 3 months. He was never readmitted and has good pancreas and kidney function at 16 months of follow-up. We think this is an option to rescue a pancreas graft with duodenal complications in selected cases.     

Results of cystoduodenostomy for treatment of pancreatic pseudocysts

To evaluate the safety and efficacy of cystoduodenostomy, the cases of 117 patients operated on for pancreatic pseudocysts during the last 14 years have been reviewed. Eleven patients were treated with cystoduodenostomy. They included ten men and one woman whose ages ranged from 26 to 56 years (mean 41 years). The etiology of pancreatitis was alcohol abuse in nine patients, alcohol abuse and gallstones in one, and trauma in one. Three patients had another cyst located within the body or tail of the pancreas which was identified preoperatively by ultrasound. Each patient underwent transduodenal cystoduodenostomy and three had a concomitant cystogastrostomy for a second pseudocyst. There was no operative mortality. Morbidity included postoperative pancreatitis in one patient, a wound infection and pancreatic fistula in one, and excessive bleeding from the cyst in one. There were no injuries to the common bile duct. Upon follow-up, which ranges from 6 months to 8 years, none of the patients has had a persistent or recurrent pseudocyst. This has been confirmed by ultrasound or computerized tomography (CT scan) in nine patients. Transduodenal cystoduodenostomy is a safe, reliable means of internal drainage for mature pseudocysts that are located in the head of the pancreas adjacent to the duodenum. Preoperative evaluation of the pancreas to rule out multiple pseudocysts and intraoperative care to avoid injury to the common bile duct are important factors in obtaining these good results.     

Lymphoepithelial cyst in the pancreas: a case report and review of the literature

BACKGROUND: Lymphoepithelial cysts of the pancreas constitute a rare clinicopathologic entity. CASE REPORT: We report a case of lymphoepithelial cyst of the pancreas and review the world literature. RESULTS: Lymphoepithelial cysts are true pancreatic cysts lined by squamous epithelium and surrounded by mature lymphoid tissue. The cyst arises typically in middle aged men, and is usually asymptomatic or causes nonspecific abdominal complaints. There is no specific serologic marker for this entity. None of its radiologic characteristics can help differentiate it from other cystic lesions of the pancreas. Fine-needle aspiration cytology may be able to suggest its benign nature and identify it as a true cyst of the pancreas. The outcome after surgical excision is uniformly good with good symptom control and no recurrences. RECOMMENDATIONS: In the symptomatic patient or the asymptomatic patient with acceptable surgical risk a simple cyst excision should be performed after verification of the diagnosis with frozen section. In the asymptomatic patient with a high surgical risk, in whom fine-needle aspiration suggests the diagnosis of a lymphoepithelial cyst, observation of the lesion is recommended. When simple cyst excision is technically not possible, extensive resections/reconstructions should be avoided and drainage/bypass procedures may be considered.     

Surgical treatment of complicated cysts of the pancreas

The removal or internal drainage of complicated cysts of the pancreas can be performed but in 17-20% of the patients. The external aspiration-irrigation draining of the cyst in most of the patients is thought to be a saving method of treatment allowing to reduce lethality to 9% and achieve the elimination of the cyst and external pancreatic fistula in 78% of the patients. Different methods of surgery depending on the pathological process allow liquidation of the cyst and external pancreatic fistula in 87% of the patients and obtaining complete socio-labour rehabilitation in 90% of the patients.     

Laparoscopic cystogastrostomy for pancreatic pseudocyst: a case report.

A 49-year-old man with a history of acute pancreatitis was hospitalized with a diagnosis of pancreatic pseudocyst. Ultrasonography, computed tomography, and magnetic resonance imaging all demonstrated a homogeneous cyst, 9 x 4 cm in size, at the tail of the pancreas without mural nodules or septa. Because an intestinal structure was identified between the cyst and stomach preoperatively by computed tomography and endoscopic ultrasonography, laparoscopic cystogastrostomy was carried out instead of percutaneous or endoscopic cyst drainage. The cyst was exposed by dissecting the lesser omentum and found to have no adhesion to the surrounding tissues. Anastomosis was performed using an endoscopic linear stapler via small cystotomy and gastrotomy openings on the lesser curvature, which were then sutured laparoscopically. The postoperative course was uneventful. Laparoscopic surgery is recommended as a safe, reliable, and minimally invasive treatment for managing pancreatic pseudocyst.     

Mucinous cystadenoma of the pancreas associated with acute pancreatitis and concurrent pancreatic pseudocyst

We report an unusual occurrence of a recurrent pancreatic pseudocyst caused by an underlying mucinous cystadenoma of the distal pancreas. A 54-year old female was admitted for acute pancreatitis. Her only risk factors included the use of hydrochlorothiazide and two or three glasses of wine daily. Abdominal computed tomography (CT) done a week after onset of her symptoms showed a 5-cm cystic lesion in the tail of the pancreas suspected to be a pseudocyst. Her symptoms subsequently resolved. One month later, she had another episode of pancreatitis and an abdominal CT showed an 11 x 16 cm pseudocyst along with the previously mentioned cystic lesion. Approximately 6 weeks after her initial presentation, she was taken to the operating room for an exploratory laparotomy and cyst gastrostomy for a symptomatic pseudocyst. An intraoperative frozen section of the cyst wall showed a fibrous wall with acute and chronic inflammation without an epithelial lining. Six weeks after her cyst gastrostomy, she returned with abdominal pain, early satiety, and anorexia. Abdominal CT showed reaccumulation of fluid within the pseudocyst and endoscopic retrograde cholangiopancreatography (ERCP) revealed a normal caliber pancreatic duct with an abrupt cutoff at the distal duct. She underwent exploratory laparotomy with drainage of 3 L of fluid from the pancreatic pseudocyst. After gaining access to the lesser sac, a 6-cm cystic lesion was identified in the tail of the pancreas. She underwent a distal pancreatectomy and splenectomy. The intraoperative and final pathology confirmed the presence of a benign mucinous cystadenoma. The patient had an uneventful recovery, began to tolerate oral intake, and was discharged 7 days after surgery. The differentiation between a pancreatic pseudocyst and benign cystic neoplasms of the pancreas is crucial to determine treatment options. Cystic neoplasms of the pancreas, whether mucinous or serous, have the potential to harbor malignancy, and resection is recommended.     

Management of complications of simultaneous kidney–pancreas transplantation with temporary venting jejunostomy

Abstract: Background/Aims: The majority of simultaneous kidney–pancreas (SPK) transplants are being performed with portal-enteric drainage, which does not allow easy access to the donor pancreas. By adding a temporary venting jejunostomy (TVJ) we have been able to closely monitor patients for bleeding, anastomotic leak and rejection.
Methods: Retrospective chart review of 29 patients undergoing SPK with PE drainage from December 1996 to December 2001.
Results: Median follow-up was 32 months. Patient, kidney and pancreas graft survival were 93%, 90% and 93%, respectively. The most common early complications were wound infections and bleeding. No patient suffered vessel thrombosis. The most common late (greater than 3 months post-transplant) complication was gastro-intestinal bleeding. Adequate tissue was obtained for biopsy in 100% of patients with suspected pancreatic rejection. The TVJ allowed one patient to undergo donor pancreas ERCP that demonstrated the site of a pancreatic duct leak. Duodenal stump leak and anastomotic bleeding were diagnosed in one patient each via the TVJ. The median time to takedown of the TVJ was 14 months.
Conclusion: TVJ allows patients an easy method of graft surveillance, is well tolerated, and has an acceptable complication rate. The TVJ allows access to diagnose anastomotic leak, cauterize bleeding mucosa, perform ERCP and biopsy the pancreas allograft.     

Surgical treatment of cysts and cyst-like formations of pancreas

Results of treatment of 87 patients with cystic pancreatic formation were analyzed. In 38 patients pancreatic cyst had formatted after destructive pancreatitis, in 28--after pancreatic trauma, in 6--due to virsungolithiasis, in 9--cystadenoma was revealed, in 6--cystadenocarcinoma. In 29 patients operation of internal drainage of cyst was performed. Basing on accumulated experience the authors recommend to perform puncture-cathetherizational intervention under ultrasonic investigation and computeric tomography control, when nonformated or complicated pancreatic cyst is present; in the treatment of uncomplicated nonformated pancreatic cyst the operation of internal drainage, using different organs, stomach, duodenum, small intestine, constitutes the method of choice. When it is impossible to perform puncture-cathetherizational intervention, external drainage of cyst and complex conservative therapy may become the method of choice for the treatment of complicated pancreatic cyst. In the presence of benign cystose tumor it is necessary widely apply radical operation--pancreatic resection. The largest frequency of complications occurrence have been noted after external drainage of cyst, performance of cystogastrostomy, pancreatic resection for cystadenoma and cystadenocarcinoma. The principal of them are: the external pancreatic fistula occurrence (in 9.1% of observations), the cyst recurrency (in 5.7%), erosive hemorrhage (in 4.6%), pancreatitis (in 5.4%), suppuration of postoperative wound (in 8%), stenosis of cystodigestive anastomosis (in 2.3%). Postoperative mortality was 6.8%.     

Lymphoepithelial cysts of the pancreas: Case report and review of the literature

The aim of this report was to describe the clinical and pathologic features of lymphoepithelial cysts of the pancreas, establish the differential diagnosis of other pancreatic cysts, and review the literature.A 53-year-old man was incidentally diagnosed with a pancreatic lesion after an abdominal CT scan. This study showed a solid mass in the tail of the pancreas not enhanced by helical CT. Endoscopic ultrasound examination revealed a low-density tissue mass on the surface of the pancreas, less echogenic than the surrounding parenchyma. Distal pancreatectomy and splenectomy were performed with a suspected diagnosis of mucinous cystic tumor. The patient has had an uneventful postoperative period, and the pathologic finding was a lymphoepithelial cyst of the pancreas. Lymphoepithelial cyst of the pancreas is an unusual and benign entity that must be taken into consideration when evaluating a cystic lesion of the pancreas because a different therapeutic approach may be required.     

Surgical management of pancreatic pseudocyst.

BACKGROUND: Pancreatic pseudocysts were once considered to be an unusual complication of acute chronic and traumatic pancreatitis. METHODS: This work was made in order to study the results of the operative methods in 24 patients with acute chronic and traumatic pancreatic pseudocysts, treated by external or internal drainage during the years 1990-1995 at the Athens Red Cross Hospital and compare these results with those of international literature. Pain was the common symptom for all patients. Gallstones were the most important aetiological agent in thirteen of the 24 patients, while alcoholic pancreatitis was diagnosed in only 6 of them. Fifteen patients (62.5%) were treated by surgical drainage or resection and 9 patients (37.5%) were treated by observation, one by percutaneous and one by endoscopic drainage. The rest had small cysts (less than 5 cm) and were treated by observation. RESULTS: The most frequent complication of internal cyst drainage was upper gastrointestinal haemorrhage. The rate of mortality was 7%. CONCLUSIONS: Anatomical considerations dictate the choice of operation. Cystogastrostomy, for example is inappropriate unless the stomach is closely applied to the front of the cyst. We preferred cystojejunostomy Rouen-y because the Roux loop can be anastomosed to the lower part of the cyst. Cystoduodenostomy should be reserved for pseudocyst in the head of the pancreas. Resection is an alternative to internal drainage for chronic pseudocyst of moderate proportions, for those that have largely replaced a portion of the pancreas.     

超声内镜引导下经胃引流治疗早期胰腺假性囊肿23例

目的 探讨超声内镜引导下经胃引流治疗早期胰腺假性囊肿的疗效.方法 回顾性分析2003至2008年在超声内镜引导下早期经胃穿刺置管引流进行治疗的23例巨大胰腺假性囊肿患者的临床资料.结果 假性囊肿位于胰头部3例,胰体部11例,胰尾部9例,囊肿平均直径11 cm(8～18 cm),均为单发囊性,所有病例在超声内镜引导下经胃引流治疗胰腺假性囊肿,假性囊肿发现至穿刺手术间隔17～65d,平均31 d.2例术后发生囊肿感染,1例改用外引流,另1例改用手术内引流治疗治愈;3例出现消化道出血,保守治疗后治愈.2～3个月后CT复查,6例患者假性囊肿完全消失,余15例患者囊肿明显缩小,所有患者腹胀、腹痛症状缓解.随访1年,无溃疡、出血、囊腔感染等并发症发生.结论 超声引导下早期经胃穿刺置管引流治疗胰腺假性囊肿是安全、有效的.     

Diagnosis and treatment of complicated postnecrotic cysts of pancreas

Experience of complex treatment of 137 patients with complicated postnecrotic pancreatic cysts (PPC) is analyzed. Indications to different surgical methods are formulated differentially depending on complications of cysts, localization, sizes, "maturity" of cyst walls, communication with main pancreatic duct. Treatment of festered PPC should be started with minimally-invasive methods; at negative result the omentobursocystostomy with staged endoscopic sanations should be done that permits to decrease the number of postoperative complications and to reduce lethality from 14.3 to 4.5%. Resection of pancreas along with cyst is the operation of choice at pancreatic cysts complicated with bleeding; lethality has been reduced from 28.6 to 5.6%. Perforation of cysts into abdominal cavity is the indication to omentobursocystostomy with staged sanations of omental bursa, perforation into pleural cavity -- to distal resection of pancreas.