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Management of a Complicated Pancreatic Pseudocyst: Report of a Case and Review of the Literature JOP. J Pancreas (Online) 2018 May 33; 19(3):157-163. CASE REPORT Management of a Complicated Pancreatic Pseudocyst: Report of a Case and Review of the Literature Apostolos Αngelis, Stylianos Kykalos, Zoe Garoufalia, Elli Karatza, Nikolaos Garmpis, Christos Damaskos, Theodore Karatzas Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Greece ABSTRACT Case report Herein we present a case of a huge complicated pancreatic pseudocyst following an episode of acute necrotizing pancreatitis, the treatment approaches and a short review of the literature. Methods An on-line survey in PubMed was conducted using the terms the patient regarding his treatment. Results Treatment of a pancreatic pseudocyst is a challenging process requiring a close follow-up of the“acute patient pancreatitis-complications”, and a fully equipped institution “pancreatic with pseudocyst” medical team and ready “pancreatic to cope against pseudocyst any possible treatment”. complications We also used of the the different data from therapeutic the file of interventions including open surgery. Conclusion Pancreatic pseudocyst is a complication of acute or chronic pancreatitis which should be managed closely for a longstanding period and treated effectively by endoscopic and surgical means, either alone or in combination, so that the outcome of this complication to be in favor of the patient. INTRODUCTION In this case we present a patient with a huge pancreatic pseudocyst complicated after endoscopic drainage episodes of pancreatitis that result in tissue necrosis a short review of the literature of the different treatment or Pancreaticdisruption pseudocystof a pancreatic is a fluid-filled duct. According cavity after to acute the strategiesprocedures of and the finallypancreatic resolved pseudocysts. by open surgery, and also CASE REPORT developsRevised Atlanta an enhancing classification, capsule as earliera pseudocyst than fourshould week be A sixty-two-years-old man was referred to our hospital, aftercharacterized onset of acuteevery pancreatitis. acute pancreatic The communication fluid collection withthat 5 months after an episode of severe acute necrotizing the pancreatic ductal system is initially always present pancreatitis in a district hospital. The patient was and may further remain or seal off spontaneously during diagnosed with pancreatic pseudocyst, three weeks after the clinical course [1]. Most pseudocysts present minor the remission of the episode. The pseudocyst was 18 cm in symptoms and are uncomplicated. The vast majority of diameter and was causing restrictive symptoms, mostly of pseudocysts (less than 6 cm) have thin wall and usually early satiety and loss of weight (15 kg) during his hospital resolve spontaneously. Large pseudocysts are often in stay. The patient’s history includes goiter, hyperlipidemia continuity with the pancreas, and thick-walled rarely and chronic obstructive pulmonary disease. communicate with the pancreatic ductal system [2]. On CT scan with pros and IV contrast agent there was Most large pancreatic pseudocysts are likely to remain requiring intervention only in the presence of complications (bleeding, infection, splenic vein thrombosis areafound of a the large lesser fluid sac. collection Also, there of 18 was cm found in diameter a pancreatic with etc.), and obstructive symptoms of duodenum, bile duct, or necrosisdebris (hemorrhagic of 70-80%. fluid and necrotic material) in the stomach. The most common complaints of the patients are early satiety, nausea and vomiting after meals [3]. In our hospital, the patient continued to present symptoms of early satiety and epigastric discomfort Received March 24th, 2018 - Accepted May 29th, 2018 after meals and was severely debilitated. On a second CT Keywords Case Management; Pancreatic Pseudocyst; Pancreatitis Correspondence Theodore Karatzas (Figure 1) Second Department of Propedeutic Surgery scan the pancreatic fluid collection was further enlarged Laiko General Hospital, Medical School endoscopic drainage of the pseudocyst, so the patient was National and Kapodistrian University of Athens referred to another. As a first-line hospital fortreatment interventional was decided endoscopy. the 17 Agiou Thoma Street, 11527, Athens, Greece The endoscopic EUS showed a cystic mass behind the Tel +30 2107462553 Fax +30 2132061772 stomach pressing its lumen with a large amount of debris E-mail [email protected] inside. Drainage of the pseudocyst through the stomach JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 19 No. 3 – May 2018. [ISSN 1590-8577] 157 JOP. J Pancreas (Online) 2018 May 33; 19(3):157-163. Figure 1. Abdominal CT scan showing a huge (18 cm of diameter) chronic lobulated pancreatic pseudocyst located mainly on the body and tail of the pancreas, surrounded by a thick, dense wall and containing debris with necrotic materialpancreas within was its healthy.fluid-filled Thecavity. patient started having normal material (debris), and a metallic stent was inserted into meals and he was discharged from the hospital in good thewas cyst performed cavity. A with nasogastric 500cc oftube necrotic was placed fluid inand order solid to clinical status. Ten months later the patient remains in avoid aspiration. very good conditions. The patient returned back to our department. The DISCUSSION next day the patient was febrile. The site of infection was attributed to aspiration because of inadequate drainage collections surrounded by a wall composed of collagen of the pancreatic pseudocyst. Another attempt, for more andPancreatic granulation tissuepseudocysts without epithelium.are well Thedefined prevalence fluid has been reported to range from 6% to 18% in the acute EUS. During this new examination there was found that the and from 20% to 40% in chronic pancreatitis respectively. stentefficient remained drainage in placeof the but pseudocyst the debris was of the made, pseudocyst with a newwas Pseudocysts may be drained using a variety of approaches not fully drained. Attempts were made to remove the necrotic or a combination of techniques, especially if an internal material with a basket. A nasogastric tube was inserted drainage is feasible. The decision making concerning directly into the cavity of the pseudocyst aiming to wash out treatment indication and optimal approach is quite the cavity with continuous lavage with normal saline, which eventually would shrink in second phase (Figure 2). accurately the peripancreatic collections accompanying or The symptoms, however, continued and the patient followingchallenging. an Theacute Revised pancreatitis Atlanta [4]. classification categorizes remained highly febrile. Because the clinical status of the patient was getting worse and he became septic it was early in the course of acute pancreatitis (without cystic decided to take him in the operating room for open surgery wall)Acute and/or pancreatic necrosis fluid may collection or may not(APFC) be present. that develops Acute and drainage of the pseudocyst through the stomach. At necrotic collection (ANC) is the development of necrotizing laparotomy there was found a huge pancreatic pseudocyst strictly attached to the posterior wall of the stomach and material. The distinction between those two conditions to surrounding tissues. Through a posterior gastrotomy an pancreatitis which contains both fluid and necrotizing opening of the pseudocyst was performed and was drained CT images in ANC become more complex. Pancreatic is difficult in it he first week. As the disease progresses debris inside. Also, an extensive necrosectomy of the body without necrosis and form after 4 weeks. Walled-off a large amount of infected pancreatic fluid with necrotic and tail of the pancreas was performed (Figure 3), followed necrosispseudocysts (WON) which is another are encapsulatedcondition which fluid usually collections appears by a large anastomosis between the pseudocyst and the after 4 weeks of the ANC episode and develops a thickened stomach. Post-operatively the patient’s clinical status was nonepithelialized wall between the necrosis and the adjacent improved rapidly and his recovery was uneventful. His tissue. Like ANC, WON may involve pancreatic parenchymal symptoms regressed and he remained afebrile. Repeated tissue. The distinction between WON and pancreatic CT scan showed that pseudocyst regressed on imaging, the pseudocyst is very important as a pseudocyst can be treated necrotic pancreatic bed excised was clean and the remnant JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 19 No. 3 – Mayeffectively 2018. [ISSN by1590-8577] draining the fluid in most cases. 158 JOP. J Pancreas (Online) 2018 May 33; 19(3):157-163. Figure 2. Endoscopic image of the stent in the stomach: transgastric stenting using endoscopic approach into the pseudocyst cavity with a naso-gastric tube inserted through the cysto-gastrostomy transmural stenting. a b Figure 3. Open surgical procedure. (a). Transgastric drainage of the pseudocyst; (b). Removal of extensive necrotic tissue from the body and tail of the pancreas. All these entities can be distinguished by patient’s that helps the clinician to distinguish the characteristics of history, imaging studies or even biochemical analysis of needle aspirate if necessary. cytology and estimation of tumor markers may help towardsa pseudocyst. distinguishing Aspiration cysticof fluid malignancies content with fromconcomitant simple Diagnostic Evaluation pseudocysts.
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