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Chapter 47
https://t.me/med1917
Case on Pseudocyst of the Pancreas,
Suzanne S. Gisbertz and Maarten A.J.M. Jacobs
Keywords Pseudocyst • Pancreas • Endoscopy • Surgery • Laparotomy •
Gastroscopy • Stent
First Patient
Noninfected giant pancreatic pseudocyst, drained transgastrically.
Diagnosis and Indication for Operation
A 32-year-old obese male patient (BMI 35), known with hyperlipidemia, was
admitted to the hospital because of abdominal pain and fever. Patient was in shock
and was admitted to the Medium Care department. He was feeling sick and had a
heart frequency of 140 PM , blood pressure of 90/45 mmHg, and temperature of
38.7 °C. Abdominal exploration was painful with tenderness in the upper abdomen.
After reposition of fl uids with good response, a CT scan was performed. There an
acute pancreatitis was seen, and no gallstones. No necrotizing component was
observed, but the patient was continually observed at the Medium Care department.
His reaction to fl uids remained satisfactory, but his abdominal pain and fever
persisted. One week later, a new CT scan showed a pseudocyst of the pancreas at a
retrogastric position (Fig. 47.1 ). Enteral feeding was given through a duodenal tube.
S. S. Gisbertz , M.D.
Department of Surgery , Academic Medical Centre , Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
M.A. J.M. Jacobs
Department of Gastroenterology , VU University Medical Center , Amsterdam ,
The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_47,
© Springer International Publishing Switzerland 2014
251
252
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Fig. 47.1 CT scan, the
pseudocyst in retrogastric
position to subhepatic area
Fig. 47.2 MRCP: pancreatic
pseudocyst becoming larger
S.S. Gisbertz and M.A.J.M. Jacobs
Weekly controls showed an increasing growth of the cyst with important elevation
of the diaphragm and respiratory worsening (Fig. 47.2 ). Given that there were no
signs of infection, our approach was initially conservative. However, due to the
increasing abdominal distension and respiratory problems, it was decided to drain
the pseudocyst transgastrically by endoscopy.
47 Case on Pseudocyst of the Pancreas, Endoscopically or Surgical Treatment?
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Fig. 47.3 CT scan after
transgastric drainage
253
Operation
This was performed without problems, draining almost three liters of pancreatic
fl uid. Various stents were left to communicate the stomach and cyst. Important clinical and imaging improvements were seen immediately after drainage (Fig. 47.3 and
Illustration 47.1 ).
Second Patient
Noninfected giant pancreatic pseudocyst, drained by laparotomy following failed
drainage by gastroscopy.
Diagnosis and Indication for Operation
A young obese architecture student, 29-year-old, known with diabetes mellitus type
I and insulin treatment, presented acutely with abdominal pain, high amylase, and
lipase in the serum. Patient felt sick, had tachycardia, and an upper abdominal tenderness could be palpated. Differential diagnosis was made amongst either acute
cholecystitis, duodenal perforation, or acute pancreatitis.
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Fig. 47.4 ( a ) CT scan,
necrotizing acute pancreatitis
with pseudocyst forming. ( b )
CT scan, pancreatic
pseudocyst behind stomach
S.S. Gisbertz and M.A.J.M. Jacobs
a
b
On the CT scan, a necrotizing acute pancreatitis-type Balthazar stage E (score 4),
with extensive necrosis score 6, was seen. He was admitted to the Medium Care
department and treated initially with oxygen, broad spectrum iv antibiotics, TPN,
and physiotherapy. Yet, the situation of the patient worsened, involving fever and
more abdominal distension, without respiratory insuffi ciency. Each ensuing week a
control CT scan showed different images. Eventually a growing pseudocyst with
retrogastric position was observed (Fig. 47.4a, b ). No signs of infection could be
47 Case on Pseudocyst of the Pancreas, Endoscopically or Surgical Treatment?
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Fig. 47.5 Open transgastric
drainage of a pancreatic
pseudocyst
seen, but respiratory problems with fever arose. At the multidisciplinary sessions
this patient was repeatedly discussed, with a conservative attitude displayed by our
side and a more aggressive stance held by the gastroenterologist. The issue was
whether to engage transgastric drainage because of the size of the cyst (20 cm),
abdominal distension, and progressive respiratory diffi culties. Finally 5 weeks after
admission, a decision was taken to drain the cyst.
255
Operation
During gastroscopy and after localizing the cyst, it was possible to pass a guide into
the cyst. Yet while putting in the fi rst stent, the patient developed hypotension with
gastric bleeding. The gastroenterologist considered the possibility of arterial damage or gastric damage with bleeding and so a decision was made to operate the
patient immediately. At upper abdomen laparotomy, bleeding was found present
along the small gastric curvature, with damage along the curvature (Fig.
47.5 ). After
repair of this by stitches transgastrically, the huge cyst was drained by opening the
posterior gastric wall (Illustration 47.1 ). Patient recovered on the Intensive Care
unit, and his cyst decreased signifi cantly, but did not disappear entirely, being
reduced to 5 cm. He is now stable, at home, and resuming his studies.
Discussion
In comparison with the past, surgical attitude to pancreatic pseudocyst has changed
to conservative treatment. Pseudocysts do vary by shape and size during the whole
acute process and should be controlled by ultrasonography or CT scan. Those that
have become infected should be percutaneously drained. The two patients here presented each had a huge growing noninfected pseudocyst while increasingly
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S.S. Gisbertz and M.A.J.M. Jacobs
Illustration 47.1 In the case that a huge pseudocyst should be drained the fi rst option will be
endoscopically. If failed or because of complications, surgical transgastric drainage should be done
experiencing respiratory problems. In spite of an initial conservative attitude in both
cases, drainage was decided. Endoscopic transgastric drainage appears to be the
right choice, but in the case of complications the surgeon should always stand by.
Chapter 48
https://t.me/med1917
Case on Pancreatic Pseudocyst Far from the
Stomach
Mariëlle L.A.W. Vehmeijer-Heeman
Keywords Pancreatic pseudocyst • Acute necrotizing pancreatitis •
Cystojejunostomy
Diagnosis and Indication for Surgery
A female patient of 32 years of age (previously presented above in case 47 ), and
who now had been diagnosed with SLE-like autoimmune necrotizing acute pancreatitis that was complicated by several pseudocysts, fi nally went home after a
stay of 6 months at the hospital, largely in the Intensive Care department. During
her revalidation period, the patient had developed a mechanical bowel obstruction with important abdominal distension. CT scan demonstrated an increase in
diameter of the known pseudocyst in the left abdominal cavity. Three months
before, she experienced a short period of blood loss in the feces with signifi cant
diarrhea. At that time, we did not dare to perform a colonoscopy because the
descending colon was located at the wall of the pseudocyst and the bleeding had
no hemodynamic consequences. The patient was then transfused with two erythrocyte concentrated units. At readmission, an MRI showed the pseudocyst with a
maximum diameter of 20 by 15 cm in the left abdominal cavity. Because of the
mechanical problems caused by the pseudocyst, a decision was taken to drain the
cyst by laparotomy.
M.L. A.W. Vehmeijer-Heeman , M.D.
Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: m.heeman@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_48,
© Springer International Publishing Switzerland 2014
257
258
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M.L.A.W. Vehmeijer-Heeman
Operation
The problem was considered how to drain the pseudocyst far from the stomach.
Percutaneous drainage was not considered an option, because of the high chance of
recurrence. Through an infraumbilical laparotomy, the pseudocyst was drained
(2,300 ml debris was evacuated and cultured), followed by a Roux-en-Y reconstruction at the lowest aspect of the cyst with proximal jejunal loop, and leaving a drain
along the anastomosis. An Enterococcus faecalis was cultured and the antibiotic
therapy was iv administered.
Postoperative Course: Identifi cation and Treatment
of Complication
On the fi rst postoperative day, she had an acute onset of abdominal pain with
tenderness, local peritonitis, fever, and drain of cyst content through the drain.
Relaparotomy showed a normal anastomosis but leakage of the cystic wall as
caused by perforation of the drain. After repair, she recovered and was discharged 1
month after surgery without symptoms. After 6 months, follow-up control showed
no recurrence of symptoms.
Discussion
Approximately 75–80 % of the cystic lesions of the pancreas are pancreatic
pseudocysts. There is a difference in pathogenesis of the several pseudocysts [ 1 , 2 ].
The most common etiologies for pancreatic pseudocysts include chronic pancreatitis (40 %), acute pancreatitis, pancreatic trauma, pancreatic duct obstruction, and
pancreatic malignancies. Complications of pancreatic pseudocyst include infection,
hemorrhage (caused by a leaking pseudoaneurysm of the splenic artery), rupture,
gastric outlet obstruction, and biliary obstruction.
A pseudocyst is a localized fl uid collection that contains pancreatic enzymes and
necrotic tissue. Pseudocysts have a non-epithelialized wall consisting of fi brous and
granulation tissue and therefore are distinguished from true cysts with epithelial lining.
Pseudocysts are usually in continuity with the pancreas. Most frequently, the
pseudocysts are located in the lesser peritoneal sac behind the stomach. Large pseudocysts may extend beyond the lesser sac and become remote from the pancreas in
the area of the paracolic gutters, the pelvis, and the mediastinum. The traditional
guidelines for management of larger pseudocysts call for drainage after a 6-week
observation period. As a vast majority of the pseudocysts resolve spontaneously,
asymptomatic pseudocysts should therefore not be drained. In case of complications or persistent symptoms, pseudocysts should be treated. Pseudocysts can be
48 Case on Pancreatic Pseudocyst Far from the Stomach
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Fig. 48.1 Abdomen X-ray
showing the pseudocyst in
the left lower abdomen with
compression of descending
colon
259
managed by several types of interventions. Three different types of interventions are
available: endoscopic drainage, imaging guided percutaneous drainage, and laparoscopic or open cystogastrostomy or cystojejunostomy (Figs. 48.1 , 48.2 , and 48.3 ).
When possible, an endoscopic drainage through the stomach is preferred as it provides high success and low complication rates. Feasibility of endoscopic drainage
is highly dependent on the anatomy and topography of the pseudocyst, considering
the relation with the posterior wall of the stomach and local vessels (see cases 47).
In this current case, involving a pseudocyst far from the stomach in the left abdominal cavity, applying an endoscopic procedure, was not an option. Imaging-guided
percutaneous drainage may give rise to a signifi cant number of complications such
as a high risk of infection, persistent leakage from the drain, and repositioning of
the drain. However, percutaneous drainage is useful if the pseudocyst has become
infected. The type of surgical procedure to follow depends on the location of the cyst.
When a retrogastric cyst is not attached to the stomach, high suspicion for malignant
process should be in order. And fi nally, if the pseudocyst is not in contact with the
stomach, a Roux-Y-reconstruction needs to be performed. Generally speaking, an
operation of pseudocysts might be complicated by anastomosis leakage, postoperative bleeding, and in some cases a mistaken diagnosis as in cystadenocarcinoma.
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Fig. 48.2 MRI showing
preoperative imaging of the
cyst and relation with
descending colon
M.L.A.W. Vehmeijer-Heeman
Fig. 48.3 MRI after surgical
drainage of the pseudocyst
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