Spontaneous rupture of pancreatic pseudocyst

Pseudocyst formation is a recognized complication after pancreatitis in any age group. A case of pancreatic pseudocyst and its spontaneous rupture leading to haemorrhage and shock is reported. Prompt management saved the life of the child.     

Splenic artery rupture in pancreatic pseudocyst

Hemorrhage is one of the most threatening complication of pancreatic pseudocyst. It results from erosion of adjacent vessels. Splenic, gastroduodenal, pancreaticoduodenal and middle colic vessels are predominantly involved. Hemorrhage may present different feature: intra and/or extraperitoneal collection, gastrointestinal bleeding. The authors report the rupture of splenic artery into pseudocyst, with the formation of pulsating pseudoaneurysm, increasing progressively until the final rupture. For the diagnosis the authors utilized: ultrasounds (US) which showed the cyst but not its nature and content; the CT scan which disclosed haematic contents; finally the US Color Doppler which proved the dynamic feature of hemorrhage. This technique allows to identify the arterious or venous source of bleeding and the possible presence of arteriovenous fistula. Arteriography was not performed due to circumstances, although it would permit bleeding vessel embolization and the control of hemorrhage. This procedure is not ever achievable, and doesn't exclude the possibility of rebleeding. On surgery, since the intraoperative rupture of the pseudoaneurysm occurred with severe hypovolemic shock, only a timely posterior mesogastric mobilization and the medially displacement of spleen-body-tail pancreatic complex, allowed to clamp the mass and the hemostasis. When such lesion are approached, it is mandatory to be prepared to carry on this maneuver: the severity of bleeding cannot allow intracystic ligature of bleeding vessel.     

Isolated pancreatic neck rupture]

AIM OF THE STUDY: Through four cases of pancreatic neck rupture, the study aim was to emphasize the advantages of an early laparotomy when there is a doubt about a canal disruption and the risks of a later surgical management. PATIENTS AND RESULTS: Four patients were operated on for a neck disruption of the pancreas due to blunt trauma. Two patients underwent laparotomy in the first 48 hours after a radiological exploration and underwent a left pancreatectomy with spleen preservation. There were no associated injuries, no lesions of acute pancreatitis. The two other patients were, at first, medically treated and developed an acute pancreatitis with pseudocyst. They underwent laparotomy, 7 and 10 days after the trauma because of pain and hyperthermia, and a conservative treatment by cystojejunostomy was performed in difficult conditions because of the acute pancreatitis. A late pancreatic pseudocyst (4 and 6 months) occurred in two patients. CONCLUSION: When pancreatic trauma occurs, an exploration with echography, scanner, endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography can suggest a neck disruption and a canal rupture. When the canal is safe, a drainage close to the pancreas is sufficient. When the rupture of the canal is suspected or proved, an early laparotomy is necessary in order to investigate the pancreas and to perform the appropriate procedure. This surgery is easier before the occurrence of pseudocyst and acute pancreatitis.     

Massive gastric bleeding from pancreatic pseudocyst, caused by rupture of pseudoaneurysm

Massive bleeding into a pancreatic pseudocyst is an unusual but life-threatening clinical condition. In this report, we present a case of massive gastric hemorrhage from a pancreatic pseudocyst, caused by rupture of a pseudoaneurysm of the splenic artery. The patient was successfully managed by total gastrectomy with splenectomy and distal pancreatectomy. Of a total of 66 cases in our Japanese literature review, only 5 cases of gastric hemorrhage associated with pancreatic pseudocyst have been reported, including the case herein presented. Diagnosis and therapeutic strategy are discussed.     

Large intestine bleeding caused by the lienal artery pseudoaneurysm rupture complicating a pancreatic pseudocyst

Bleeding pseudoaneurysm of a peripancreatic artery is a rare cause of gastrointestinal haemorrhage. Arterial pseudoaneurysm develops as a result of partial enzymatic damage of arterial wall in acute or chronic pancreatitis. The authors report the case of a 60-years old man with bleeding into the lienal flexure of the colon due to the erosion of the pseudoaneurysm of a branch of splenic artery into the pancreatic pseudocyst in the tail region of the pancreas communicating with the colon. The diagnosis was established by CT-scan and angiography. The patient underwent surgery with the ligation of the bleeding vessel and the resection of the part of the colon.     

Giant pancreatic pseudocyst

A 56 years old man presented with epigastric pain and abdominal distension. He suffered an attack of acute pancreatitis 6 weeks back followed by pseudopancreatic cyst formation. As the cyst kept on enlarging in size despite being on conservative management, the patient was operated after 5 weeks. A huge pancreatic pseudocyst was found containing about 4.5 liters of fluid. Cystogastrostomy was performed and the patient recovered un-eventfully. It was the third largest pancreatic pseudocyst reported so far.     

Management of pancreatic pseudocyst

The natural course, complications, and management of 37 patients with pancreatic pseudocyst treated at our institution were reviewed. The lesions were classified into three groups, cysts secondary to acute pancreatitis, to chronic pancreatitis, and to trauma. Spontaneous resolution or cyst diminution was observed in 75% of the patients with acute pancreatitis and trauma, but in only 33% of those with chronic pancreatitis. The interval until resolution or diminution in chronic pancreatitis was shorter than that in pseudocyst of other etiologies, but the incidence of complications in patients with chronic pancreatitis was not significantly higher than that among patients with other etiologies. Multiple complications were found only among the patients with chronic pancreatitis. Surgical management was performed in 25% of the patients with acute pancreatitis and trauma and 66% of the patients with chronic pancreatitis. The postoperative mortality rate was 10%. Reoperation was necessary in 6 of 7 patients who had undergone external drainage, including 3 patients treated with ultrasonography-guided percutaneous catheter drainage (US-PCD). These results suggest that it is necessary to closely monitor patients with chronic pancreatitis and/or external drainage, and in these patients it may become necessary to reoperate. US-PCD was useful as an emergency procedure in pseudocyst patients whose general condition was poor, despite the disadvantages of the piercing of adjacent organs by the catheter, infection, and pseudocyst recurrence. Offprint requests to: K. Satake     

Free intraperitoneal rupture of a pancreatic pseudocyst: a presentation of acute abdominal trauma

A rare case of traumatic rupture of a pancreatic pseudocyst is presented. Its unique aspect is definitive pseudocyst drainage via a Roux-en-Y cystjejunostomy at initial laparotomy.     

Mediastinal pancreatic pseudocyst.

Pseudocysts of the pancreas are a rare cause of a mediastinal mass. They are clinically characterized by the combination of thoracic symptoms (shortness of breath, dysphagia, pleural effusions) with complaints in the upper abdominal quadrants and weight loss. The diagnosis is usually made by CT scan or MRI including upper abdominal views. Internal drainage via an abdominal route performed either as cystogastrostomy or cystojejunostomy is the treatment of choice.     

胰腺假性囊肿的诊治体会

目的 总结胰腺假性囊肿的诊治体会。方法 回顾性分析46例胰腺假性囊肿患者的临床资料，7例保守治疗，行内引流术12例，外引流术9例，序贯式内外引流术5例，胰腺部分切除术13例。结果 保守治疗者均痊愈，无复发；行内引流术者中有1例发生肠瘘，其余11例恢复良好无复发；行外引流术1例出现胰瘘，2例复发；行胰腺部分切除术者有1例出现胰瘘，其余恢复良好。结论 根据病情和病程选择合适的术式是治疗胰腺假性囊肿的关键。