The treatment of a simple pancreatic pseudoaneurysm or one associated with hemosuccus pancreaticus]

When a permanent communication occurs between an artery and a pancreatic pseudocyst, the pseudocyst becomes a pseudoaneurysm. Pancreatic pseudoaneurysms are primarily found in patients with alcoholic chronic pancreatitis. Fistulization of a pseudoaneurysm into the main pancreatic duct results in ductal hemorrhage. From 1980 to 1990, 43 cases of pancreatic pseudoaneurysm and 24 cases of ductal hemorrhage (15 of these secondary to pancreatic pseudoaneurysm) have been published. Pancreatectomy, ligation of the affected vessel (alone or in combination with a drainage procedure), or intraarterial embolization have all been used to treat pancreatic pseudoaneurysms. We herein describe two patients with alcoholic chronic pancreatitis and pancreatic pseudoaneurysm; one patient presented with ductal hemorrhage. The inferior pancreatico-duodenal artery was the affected vessel. Both patients were treated with suture-ligation; an internal drainage was added to the patient presenting with ductal hemorrhage.     

A case of successful treatment with transcatheter arterial embolization for a ruptured aneurysm of the gastroduodenal artery presenting with a hemosuccus pancreaticus]

A 55-year-old male heavy drinker was taken to another hospital because of loss of consciousness. Laboratory data showed anemia and endoscopy of the upper gastrointestinal tract disclosed intraduodenal bleeding from the ampulla of Vater. Further examinations were scheduled. However, three days later, he was given emergency admission to our hospital because of massive rectal bleeding and circulatory shock. Abdominal contrast-enhanced CT showed a pseudoaneurysm in a pseudocyst in the head of the pancreas. Emergency angiography revealed a ruptured pseudoaneurysm of the gastroduodenal artery 15 mm in diameter. He was successfully treated with transcatheter arterial embolization. ERCP demonstrated the pseudocyst communicating from the main pancreatic duct in the pancreatic head. The final diagnosis was ruptured pseudoaneurysm of the gastroduodenal artery into a pseudocyst, presenting with hemosuccus pancreaticus, secondary to chronic pancreatitis.     

Hemorrhagic pseudocyst and pseudocyst with pseudoaneurysm successfully treated by pancreatectomy: report of three cases

Hemorrhagic pseudoaneurysm of pancreatic pseudocyst is one of the serious complications of acute pancreatitis. We successfully treated three patients who had hemorrhagic pseudocyst and pseudocyst with pseudoaneurysm by pancreatectomy. Case 1 was 43-year-old Japanese man who had had several episodes of acute pancreatitis and was diagnosed with hemorrhagic pseudoaneurysm of the splenic artery in a pseudocyst in the pancreatic tail, shown on computed tomography (CT) and angiography. Transarterial embolization (TAE) yielded hemostasis of the pseudoaneurysm, but rebleeding occurred 2 weeks after the TAE. Distal pancreatectomy and splenectomy was successfully performed. Case 2 was a 64-year-old Japanese man who presented to us with several attacks of acute pancreatitis. Imagings showed bleeding pseudoaneurysm of the transverse pancreatic artery in a pseudocyst in the pancreatic body. Because of marked stenosis in the proximal portion of the transverse pancreatic artery, TAE was unsuccessful. Distal pancreatectomy and splenectomy was performed successfully. Case 3 was a 40-year-old Japanese woman who had a history of abdominal trauma. Imagings showed bleeding pseudoaneurysm of the splenic artery in a posttraumatic pseudocyst in the pancreas. TAE of the pseudoaneurysm was unsuccessful because of the proximity of the pseudoaneurysm and the splenic artery. Distal pancreatectomy and splenectomy was successfully performed and her postoperative outcome was satisfactory. Whenever interventional radiology (IVR) is not indicated or has failed, aggressive and immediate surgical intervention should be considered for early and definitive recovery in these patients.     

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.     

Transcatheter embolization of a giant pancreatic pseudoaneurysm: A tale of two bleeds and one thrombus!

Erosion of a peripancreatic artery into the pseudocyst as a result of enzymatic digestion of vessel wall gives rise to a pancreatic pseudoaneurysm (PSA), which is a rare complication seen in patients with chronic pancreatitis.¹ Angiographic embolization as a treatment method for acute hemorrhage from pancreatic PSA has become increasingly popular. Here we report a unique case with bleeding from a giant pancreatic PSA where the single PSA had blood supply originating from the branches of both the celiac artery and superior mesenteric artery.     

Disruption of both dorsal and ventral ducts in a patient with pancreas divisum presenting with two pseudocysts

A 35-year-old man, a chronic alcohol consumer with clinical features of acute pancreatitis, presented with obstructive jaundice and melena. On radiological evaluation two large pseudocysts, one each in relation to pancreatic head and tail regions, were noted with a gastro-duodenal artery pseudoaneurysm in the pseudocyst in the head region. He also had narrowing of the common bile duct. On endoscopic retrograde cholangiopancreatography (ERCP) he had evidence of chronic pancreatitis with morphology of pancreas divisum with disruption of both the dorsal and ventral ducts. After the relieving of bile duct obstruction with endoscopically placed stent, he underwent surgery for the pseudoaneurysm and the two pseudocysts. The case highlights the rare occurrence of both dorsal and ventral ductal disruption in a patient with pancreas divisum. ERCP was helpful in providing the diagnosis and guiding further management.     

Disrupted pancreatic duct treated with a combination of endoscopic cystoduodenostomy and pancreatic duct fistualization through a pseudocyst wall using a lumen‐apposing metal stent

Management of disconnected pancreatic duct syndrome is complex and is increasingly approached using emerging endoscopic techniques. Herein, we present a case of recurrent pancreatitis in an elderly woman complicated by pseudocyst formation and complete pancreatic duct disruption. Her condition was treated with a novel combination of transpapillary stenting and cystduodenostomy in which a pancreatic duct stent was placed into an opening in the pseudocyst wall through a lumen‐apposing metal stent. This allowed for effective drainage into the gastrointestinal tract and resolution of duct disruption. Post‐procedure, the patient has had recovery of nutritional status and no further recurrence of pancreatic fluid collection. Endoscopic approaches to complete pancreatic duct disruption represent a viable and less invasive alternative to surgical management in selected cases.     

Hemoductal Pancreatitis Secondary to Gastroduodenal Artery-Ruptured Pseudoaneurysm: A Rare Cause of Hematemesis

A 65-yr-old alcoholic man with a history of calcific pancreatitis presented with massive hematemesis complicated by lipothymia. Physical examination disclosed stigmata of chronic liver disease. The laboratory picture was predominantly of cholestatic type with impaired liver protein synthetic activity. Emergency esophagogastroduodenoscopy was unable to provide definitive diagnosis, but reendoscopy with a side-viewing duodenoscope revealed active bleeding through the ampulla of Vater. An ultrasound examination showed a large, complex pancreatic lesion that computed tomography showed to be a pancreatic pseudocyst with an inside pseudoaneurysm. A visceral angiography revealed an anomalous arising of the common hepatic artery from the superior mesenteric artery and a pseudoaneurysm of the gastroduodenal artery at its origin. A second massive hemorrhage required an emergency operation, and surgical liver biopsy revealed focal steatosis. In conclusion, bleeding of a pancreatic pseudoaneurysm may be massive but intermittent, and side-viewing duodenoscopy, even prolonged, is essential in the diagnosis.     

Value of arteriography in the evaluation of a sonolucent pancreatic mass

A pseudoaneurysm of the pancreaticoduodenal artery secondary to chronic pancreatitis was erroneously diagnosed as a pancreatic pseudocyst by abdominal plain films, barium gastrointestinal studies, and abdominal ultrasound. Because of the operative findings, it was necessary to interrupt surgery undertaken to drain the presumed pseudocyst. Angiography is strongly recommended as a preoperative study in patients with sonolucent pancreatic masses to distinguish pseudoaneurysms of pancreatic vessels from pseudocyts.     

Two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization

Hemosuccus pancreaticus is a rare complication of chronic pancreatitis. We report two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization (TAE). The first patient was a 47-year-old man with alcoholic chronic pancreatitis. He presented with upper abdominal pain and hematemesis. Upper GI endoscopy failed to detect the source of bleeding, but computed tomography (CT) showed a hypervascular area about 3?cm in diameter in a pseudocyst at the pancreatic tail. Angiography revealed a pseudoaneurysm in the caudal pancreatic artery. Hematemesis was considered to be due to rupture of the pseudoaneurysm. TAE of the splenic artery was performed selectively, and this successfully stopped the bleeding. The second patient was a 52-year-old man with alcoholic chronic pancreatitis. He presented with hematemesis. Upper GI endoscopy detected bleeding from the papilla of Vater. CT showed hemorrhage in a pseudocyst at the pancreatic body. Angiography revealed angiogenesis around the pseudocyst. Hematemesis was considered to result from rupture of the pseudoaneurysm. TAE of the dorsal pancreatic artery and posterior superior pancreaticoduodenal artery was performed and hemostasis was achieved. We conclude that TAE is a minimally invasive and highly effective treatment for hemosuccus pancreaticus.     

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.     

Angiographic demonstration of gastrointestinal bleeding through the pancreatic duct

This article describes the angiographic findings in the case of a bleeding stump of the left gastric artery, following subtotal gastrectomy, into a pancreatic pseudocyst with instantaneous opacification of the pancreatic duct and duodenum. This is the first reported case to demonstrate a frank bleed with total opacification of the pancreatic duct. Based on our experience and previously reported cases, we conclude that subselective catheterization of the bleeding vessel is necessary to demonstrate total opacification of the pancreatic duct in such cases.     

Pancreatic transection from blunt trauma associated with vascular and biliary lesions： A case report

Major injuries of the pancreas may result in considerable morbidity and mortality when associated with vascular and visceral injuries. In such cases, a right diagnosis and a prompt surgical intervention are necessary to give a chance to the patient. We herein describe a case of blunt abdominal trauma in a 29-year- old man whose pancreatic rupture was associated with hepatic artery, splenic vein and extrahepatic bile duct damage. Immediate surgery was performed after computer tomograghy （CT）, the haemorrhagic lesions dictat the emergency transfer to the operating room. Spleno-pancreatic resection was done with reconstruction of the hepatic artery, ligation of the splenic vein and a Roux-en-Y bilio-jejunal diversion. The early post-operative course was complicated by stenosis of the arterial reconstruction, which was treated by endovascular angioplasty followed by percutaneous drainage of symptomatic pseudocyst, rest and antibiotics. Finally, the patient was discharged and was alive without clinical problems at the time when we wrote this case report. The present case underlines the clinical relevance of vascular and visceral injuries associated with pancreatic trauma and the problems arising in the diagnostic evaluation and the surgical strategy of complex multiple visceral and vascular lesions in blunt abdominal trauma.     

Pseudoaneurysm following laparoscopic cholecystectomy

BACKGROUND:Laparoscopic cholecystectomy(LC)is the operation of choice for removal of the gallbladder. Unrecognized bile duct injuries present with biliary peritonitis and systemic sepsis.Bile has been shown to cause damage to the vascular wall and therefore delay the healing of injured arteries leading to pseudoaneurysm formation.Failure to deal with bile leak and secondary infection may result in pseudoaneurysm formation. This study was to report the incidence and outcomes of pseudoaneurysm in patients with bile leak following LC referred to our hospital. METHODS:A retrospective analysis of our prospectively maintained liver database using pseudoaneurysm, bile leak and bile duct injury following laparoscopic cholecystectomy from January 2000 to December 2005 was performed. RESULTS:A total of 86 cases were referred with bile duct injury and bile leak following LC and of these,4 patients (4.5%)developed hepatic artery pseudoaneurysm(HAP) presenting with haemobilia in 3 and massive intra- abdominal bleed in 1.Selective visceral angiography confirmed pseudoaneurysm of the right hepatic artery in 2 cases,cystic artery stump in one and an intact but ectatic hepatic artery with surgical clips closely applied to the right hepatic artery at the origin of the cystic artery in the fourth case.Effective hemostasis was achieved in 3 patients with coil embolization and the fourth patient required emergency laparotomy for severe bleeding and hemodynamic instability due to a ruptured right hepatic artery.Of the 3 patients treated with coil embolization, 2 developed late strictures of the common hepatic duct. . (CHD)requiring hepatico-jejunostomy and one developed a stricture of left hepatic duct.All the 4 patients are alive at a median follow up of 17 months(range 1 to 65)with normal liver function tests. CONCLUSIONS:HAP is a rare and potentially life- threatening complication of LC.Biloma and subsequent infection are reported to be associated with pseudoaneurysm formation.Late duct stricture is common either due to unrecognized injury at LC or secondary to ischemia after embolization.     

Management of a rare case of fulminant hemobilia due to arteriobiliary fistula following total pancreatectomy

Hemobilia is a rare cause of acute upper gastrointestinal bleeding and is often associated with a history of hepatic or biliary tract injury, tumor growth, hepatic artery aneurysm, cholecystitis, or hepatic abscess. We report a case of a 76-year-old patient with massive hemobilia due to intrahepatic bleeding from the segment 8 hepatic artery without evidence of a true aneurysm, abscess, or metastatic disease 4 weeks following pylorus-preserving total pancreatectomy for pancreatic cancer. Gastroduodenoscopy suggested hemorrhage from the duodenojejunostomy but failed to achieve hemostasis, and the patient underwent exploratory laparotomy. It was realized intraoperatively that the bleeding originated from the intrahepatic biliary tract. Bleeding was controlled by blocking the right hepatic bile duct with a Fogarty catheter and subsequent transarterial embolization. Computed tomography did not reveal any local liver or vascular pathology. Retrospectively, the cause of delayed profuse hemobilia was most likely a traumatic intrahepatic pseudoaneurysm following endoscopic bile duct stenting 3 weeks before the pancreatectomy. The reported case is exceptional and of particular interest because of the absence of a typical history or cause of hemobilia, preoperative misleading diagnostic results in an altered anatomic situation, and the operative management to achieve bleeding control in this emergency setting.     

Intracystic arteries in a chronic pancreatic pseudocyst

Background

An enlarging pancreatic pseudocyst can incorporate adjacent vessels into its wall, leading to pseudoaneurysm formation in the presence of proteolytic enzymes. Intact arteries running through the cyst cavity are very rare, however.

Case outline

A 54-year-old man with a chronic pancreatic pseudocyst (15 cm diameter) underwent internal drainage by means of cystjejunostomy Roux-en-Y. Two large pulsating arteries running through the cyst cavity were identified as the middle colic artery and one of its branches. Temporary clamping of the transcystic arteries revealed no signs of ischaemia in the transverse colon, so the vessels were ligated and the cystjejunostomy completed. The patient remains well one year later.

Discussion

Bleeding following internal drainage procedures carries a higher mortality rate than spontaneous bleeding in chronic pancreatic pseudocysts but is easier to prevent.This case highlights the importance of thorough exploration of the pseudocyst to identify any vessels in its cavity or wall.     

Clinical features of pseudoaneurysms complicating pancreatitis: single center experience and review of Korean literature]

BACKGROUND/AIMS: Pseudoaneurysm is a life-threatening complication of chronic or acute pancreatitis. This study was undertaken to evaluate the clinical features of pseudoaneurysm complicating pancreatitis. METHODS: We reviewed the medical records of 7 patients diagnosed as pseudoaneurysms with chronic pancreatitis in Korea University Guro and Anam Hospital from January 1995 to March 2006 and analyzed their demographics, clinical courses and outcomes. RESULTS: All patients were men and mean age was 54.6 years (range, 43-67 years). All the cases occurred in the setting of chronic alcoholic pancreatitis complicated by pseudocyst. Abdominal pain was the unique initial clinical symptom in 5 cases, hematemesis in 1 case, and simultaneous abdominal pain with hematemesis in 1 case. Bleeding into pseudocyst developed in 5 cases, flowing into duodenum through pancreatic duct in 1 case and rupture into the descending colon in 1 case. Mean duration between onset of symptom and diagnosis of pseudoaneurysm was 7.8 days (range, 1-23 days). Six cases were diagnosed by abdominal computed tomography disclosing characteristic finding of focal high density area in the pseudocyst. Pulsed doppler abdominal sonography was performed before computed tomography in 3 cases and results were negative in 2 cases. Transcatheter arterial embolizations were initially performed in 6 cases, and there was no recurrent bleeding except one case of splenic infarction. Distal pancreatectomy was initially performed in 1 case. CONCLUSIONS: Pseudoaneurysms complicating chronic pancreatitis shows various clinical features. Transcatheter arterial embolization can be recommended as a primary therapeutic modality.     

Pancreatico-bronchial fistula with communication to a pseudoaneurysm of the arteria lienalis as a rare complication in chronic pancreatitis

Thoracic manifestations of internal pancreatic fistulas caused by chronic pancreatitis are rare conditions. The three main types of these manifestations are mediastinal pseudocysts, pancreatico pleural fistulas and pancreaticobronchial fistulas. We report on one patient with the clinical presentation of all three thoracic internal pancreatic fistulas with a communication to a pseudoaneurysm of the splenic artery caused by chronic alcohol-related pancreatitis. Conservative therapy over four weeks was not successful. Resection of the pseudoaneurysm, debridement of the mediastinal pseudocyst and duodenum preserving resection of the pancreas treated all complications and prevents recurrence in this patient with chronic pancreatitis.     

Biliopancreatic fistula with portal vein thrombosis caused by a pancreatic pseudocyst

We encountered a very rare case of biliopancreatic fistula with portal vein thrombosis caused by pancreatic pseudocyst. A 57-year-old man was referred to our hospital because of abdominal pain, obstructive jaundice, and portal vein thrombosis due to acute pancreatitis. Computed tomography showed a 7-cm-diameter pseudocyst around the superior mesenteric vein extending towards the pancreatic head, dilatation of the intrahepatic bile duct, and portal vein thrombosis. Endoscopic retrograde pancreatography revealed a main pancreatic duct with a pseudocyst communicating with the common bile duct. After pancreatic sphincterotomy, a 7-F tube stent was endoscopically placed into the pseudocyst. However, a 6-F nasobiliary tube could not be inserted into the bile duct because the fistula had a tight stenosis. Subsequently, the patient’s abdominal pain improved, the pancreatic cyst disappeared, and the serum amylase level normalized. Two months after the endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage was required because the patient’s jaundice became aggravated. Two weeks after the choledochojejunostomy, the patient left the hospital in good condition. A follow-up computed tomography showed cavernous transformation of the portal vein and no pancreatic pseudocyst. The patient remains asymptomatic for 2 years and 7 months after surgery. Biliary drainage may be necessary for biliopancreatic fistula with obstructive jaundice in addition to pancreatic cyst drainage. Biliopancreatic fistula can be treated by endoscopic procedure in some cases; however, surgical treatment should be required in cases that are impossible to insert a biliary stent because of hard stricture.     

Extrahepatic collaterals and liver damage in embolotherapy for ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery

AIM： To evaluate the effects of extrahepatic collaterals to the liver on liver damage and patient outcome after embolotherapy for the ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery.
METHODS： We reviewed 9 patients who underwent transcatheter arterial embolization （TAE） for the ruptured hepatic artery pseudoaneurysm following major hepatobiliary pancreatic surgery between June 1992 and April 2006. We paid special attention to the extrahepatic arterial collaterals to the liver which may affect post-TAE liver damage and patient outcome.
RESULTS： The underlying diseases were all malignancies, and the surgical procedures included hepatopancreatoduodenectomy in 2 patients, hepatic resection with removal of the bile duct in 5, and pancreaticoduodenectomy in 2. A total of 11 pseudoaneurysm developed： 4 in the common hepatic artery, 4 in the proper hepatic artery, and 3 in the right hepatic artery. Successful hemostasis was accomplished with the initial TAE in all patients, except for 1. Extrahepatic arterial pathways to the liver, including the right inferior phrenic artery, the jejunal branches, and the aberrant left hepatic artery, were identified in 8 of the 9 patients after the completion of TAE. The development of collaterals depended on the extent of liver mobilization during the hepatic resection, the postoperative period, the presence or absence of an aberrant left hepatic artery, and the concomitant arterial stenosis adjacent to the pseudoaneurysm. The liver tolerated TAE without significant consequences when at least one of the collaterals from the inferior phrenic artery or the aberrant left hepatic artery was present. One patient, however, with no extrahepatic collaterals died of liver failure due to total liver necrosis 9 d after TAE.
CONCLUSION： When TAE is performed on ruptured hepatic artery pseudoaneurysm, reduced collateral pathways to the liver created by the primary surgical procedure and a short postoperative interval may lead to an unfavorable ou