Internal Drainage of Giant Acute Pseudocysts

Abstract

Background: Internal drainage of giant pancreatic pseudocysts secondary to acute pancreatitis is frequently complicated with postoperative retroperitoneal infection and hemorrhage. Recent data suggest that the risk factor is unrecognized pancreatic necrosis; presumably, pancreatic necrosis becomes infected with bacteria introduced by the cystoenteric anastomosis. Hypothesis: Video-assisted pancreatic necrosectomy, performed at the time of internal drainage, may prevent postoperative retroperitoneal complications in patients with giant acute pseudocysts. Design: A consecutive case-series. Setting: An urban, university-affiliated, tertiary referral center. Patients: Ten consecutive patients with acute pseudocysts measuring 10 cm or more in major diameter. The mean extent of pancreatic necrosis, as shown by contrast-enhanced computed tomography, was 50%. All patients were operated on electively, at an average time of 7.7 weeks from onset of the attack to surgical treatment. Intervention: Through a midline incision, a 4-cm opening is made at the base of the pseudocyst. Standard laparoscopic instruments are introduced into the pseudocyst and video-assisted pancreatic necrosectomy is performed. The opening is then anastomosed to a Rouxen-Y limb of the jejunum. Main Outcome Measures: Feasibility and safety of video-assisted pancreatic necrosectomy, postoperative morbidity and mortality, hospital stay, and resolution of pseudocysts. Results: Complete necrosectomy was safely performed throughout. There were neither postoperative retroperitoneal complications nor mortality. Mean hospital stay was 8.2 days and all pseudocysts resolved at a mean follow-up of 6.9 months. Conclusions: Video-assisted pancreatic necrosectomy at the time of internal drainage seems to prevent postoperativeretroperitonealcomplicationsinpatientswithgiantacute pseudocysts. Depending on appropriate surgical timing, video-assisted necrosectomy is a feasible and safe procedure.

A case report of giant pancreatic pseudocyst following acute pancreatitis: experience with endoscopic internal drainage

“…Ten patients with acute giant pseudocysts underwent video-assisted pancreatic necrosectomy at the time of internal drainage and this was shown to prevent postoperative retroperitoneal complications. This study illustrated that depending on appropriate surgical timing, video-assisted necrosectomy is a feasible and safer procedure when managing giant pseudocysts [ 3 ]. Laparoscopic cystogastrostomy was successfully done on a 60-year-old lady with a giant pseudocyst of the pancreas with a good outcome [ 24 ].…”

“…They can be single or multiple and present with a wide range of clinical manifestations depending upon the location, size and the presence of infection. A pseudocyst with the major diameter of 10 cm is termed as a giant cyst [ 3 , 4 ] and now infrequently seen due to modern diagnostic and therapeutic methods. The diagnosis of a pancreatic pseudocyst needs imaging with ultra-sonography, CT scan or MRI.…”

A case report of gastroduodenal artery pseudoaneurysm and giant pancreatic pseudocyst following acute pancreatitis revealed by obstructive jaundice

“…12 However, MRI and magnetic resonance cholangiopancreatography, of which the interest is to specify the existence of communication with the pancreatic duct, are important contributions considering that they enable the therapeutic strategy to be adapted, as was the case with the current patient. 14 The term giant pancreatic pseudocyst is traditionally used when the size is greater than 10 cm, 15 but only a few cases of pseudocysts larger than 20 cm, as in our case, had been published in the literature. 13,16,17 Therapeutic strategies include observation, endoscopic drainage, percutaneous drainage, and surgical interventions.…”

Right Hemithoracic Pseudocyst with Splenic Artery Aneurysm: Two Rare Complications of Uncommon Disease

“…Surgical cystoenteric drainage is the ultimate procedure [12]; however, surgical drainage is technically difficult if done early in the disease course since the pseudocyst has no real boundaries and the pseudocyst wall in general is shaggy and frail [14]. …”