Pasternak, Artur

Richter, Piotr

Wawok, Przemysław

English

Jagiellonian Univeristy Repository

FOLIA MEDICA CRACOVIENSIAVol. LVI, 2, 2016: 53–56PL ISSN 0015-5616A giant pancreatic pseudocyst treated by open cystogastrostomyArtur Pasternak1,2, Przemysław Wawok1, Piotr Richter11First Department of General, Oncological and Gastrointestinal SurgeryJagiellonian University Medical College, ul. Kopernika 40, 31-501 Kraków, Poland2Department of Anatomy, Jagiellonian University Medical Collegeul. Kopernika 12, 31-034 Kraków, PolandCorresponding author: Artur Pasternak; Department of Anatomy, Jagiellonian University Medical Collegeul. Kopernika 12, 31-034 Kraków, PolandPhone/Fax: +48 12 422 95 11; E-mail: artpast@tlen.plAbstract: We report a case of a giant pancreatic pseudocyst in a 33-year-old woman presenting with ab-dominal pain, loss of appetite and abdominal distension. CT scans revealed a giant pancreatic pseudocyst measuring 10.3 cm × 9.6 cm × 9.3 cm anteroposteriorly, with signifi cant compression of the stomach. An open retrogastric cystogastrostomy was performed through a midline incision, and 3 L of fl uid was drained from the pseudocyst. Recovery has been uneventful.Key words: Giant Pancreatic Pseudocyst, Cystogastrostomy.IntroductionPancreatic pseudocysts are the most common cystic lesions of the pancreas, asso-ciated with infl ammatory and traumatic conditions of pancreas. Most of the pseu-docysts usually resolve spontaneously and rarely produce complications. Pancreatic pseudocysts are defi ned as localized collections of pancreatic-enzyme-rich fl uid and originating in or adjacent to the pancreas. Because these cavities are not lined with an epithelium, pseudocysts are not labeled as true cysts. We present a case of a large pseudocyst located in the tail of pancreas. Retrogastric cystogastrostomy (modifi ed Jurasz procedure) was the procedure advocated for treatment.54 Artur Pasternak, Przemysław Wawok, et al.Case presentationA 33-year-old female presented to our department with recurrent giant pancreatic pseudocyst aft er the episode of acute pancreatitis. She was admitted with history of abdominal pain, loss of appetite and abdominal distension. She had already under-gone extracorporeal drainage twice before. Laboratory tests showed elevated level of amylase in the cystic fl uid with normal levels of CA19-9 and carcinoembryonic an-tigen (CEA). Endoscopic retrograde cholangiopancreatography with sphincterotomy was also performed. An ultrasound examination and computed tomography (CT) scan revealed the presence of a cystic mass (10.3 cm × 9.6 cm × 9.3 cm) located in the pancreatic tail which compressed the gastric wall. Finally our patient was qualifi ed for open surgery. Peritoneal access was established through midline incision. Operative fi ndings showed a 20 × 20 cm cystic mass with a thick, grey white wall, tightly con-nected to the pancreatic tail and compressing stomach with dilation of gastrosplenic vessels (Fig. 1). Cystic wall was incised and 3 L of dark coloured fl uid was drained. Debris were removed, cyst was cleaned with saline and part of its wall was excised for Fig. 1. Pancreatic pseudocyst — intraoperation view. A giant pancreatic pseudocyst treated by open cystogastrostomy 55histopathology. Free posterior gastric wall along the greater curvature was mobilized and gastrotomy with subsequent anastomosis by vicryl suture in double layers to the incised cyst. Th e tube drain was placed in the peritoneal cavity. Postoperatively, the patient had an uneventful recovery and was discharged on the 7th postoperative day. Two months aft er discharge, follow-up evaluation with upper endoscopy and CT re-vealed complete resolution of the pseudocyst and no sign of recurrence. Th e patient was later routinely followed up with a repeat USG that showed no pseudocyst. His-tological analysis of the specimen revealed nonepithelialized granulation tissue and fi brosis typical for pancreatic pseudocyst.DiscussionDiff erential diagnosis of pancreatic pseudocysts includes acute fl uid collections, pancreatic abscesses, cystic pancreatic neoplasms, congenital or other pancreatic true cysts, parasitic cysts and extrapancreatic cysts. Mostly, pancreatic pseudocysts occur in the setting of previous pancreatic pathology such as infl ammatory pancreatitis or posttraumatic ductal leakage. However, pancreatic pseudocysts can appear similar to radiographically to pancreatic cystic neoplasms such as c ystadenomas and cystadenocarcinomas. In general, intracystic fl uid from pseudocysts contains low levels of CEA, CA19-9, CA125, CA72-4 and viscosity but high pancreatic amylase and/or lipase activity. Th e treatment of pancreatic pseudocysts today comprises invasive procedures i.e. percutaneous or endoscopic drainage and surgery. Decompression of the pseudocyst by percutaneous or internal drainage is advocated for symptomatic patients and the latter one can in turn be performed by endoscopic or surgical cystogastrostomy. Endoscopic cystogastrostomy is accomplished by the creation of a fi stula and stent placement between the pseudocyst and the stomach and has technical and treatment success rates of 89%–100% and 82%–100%, respectively, and a mortality rate of less than 1% [1–6]. Surgical cystogastrostomy is the gold standard against other drainage procedures and involves creating an anastomosis between the pancreatic pseudocyst and the stomach and has technical and treatment success rates of greater than 90% and a mortality rate of 5%–10% [7–9]. It was fi rst described in 1921 by Jedlicka and later (1931) modifi ed by Jurasz [10, 11]. Until the early 1960s, transgastric or transventricular cystogastrostomy became a standard procedure in the treatment of mature pancreatic pseudocysts contacting the stomach. Antoni Tomasz Jurasz  ( 1882–1961) described an approach to a pancreatic cyst through a transverse incision in the anterior gastric wall. A drainage opening between the cyst and the gastric lumen is created by incision in an area of the posterior gastric wall already adherent to the cyst through infl ammation. Currently, the anastomosis is further secured by a continuous suture for hemostasis [12, 13]. In our case the position of the cyst was not satisfactory for transgastric approach and the 56 Artur Pasternak, Przemysław Wawok, et al.stomach was not involved in the infl ammatory reaction so we decided to perform the retrogastric or external cystogastrostomy. It involves mobilization of the free posterior gastric wall along the greater curvature and gastrotomy with subsequent anastomosis by suture to the incised cyst. During the last decade, the conventional open approach for drainage of pancreatic pseudocysts has given way to laparoscopy — assisted pseudocystogastrostomy, a minimally invasive procedure with standardized stapler-performed anastomosis. In our department we prefer open vs. laparoscopic approach due to our own surgical experience, lower costs associated with quicker surgical time for the open approach, and elimination of the costs for laparoscopic equipment. Although laparoscopy is considered less invasive than open surgery, this technique is not widely used and, furthermore, there is no data about randomized trials that have directly compared the outcomes of both procedures. References 1. Bergman S., Mel vin W.S.: Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am. 2007; 87: 1447–1460. 2. Binmoeller K.F. , Seifert H., Walter A., et al.: Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc. 1995; 42: 219–224. 3. Ahn J.Y., Seo D .W., Eum J., et al.: Single-step EUS-guided transmural drainage of pancreatic pseudocysts: analysis of technical feasibility, effi  cacy, and safety. Gut Liver. 2010; 4: 524–529. 4. Kahaleh M., Sha mi V.M., Conaway M.R., et al.: Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy. 2006; 38: 355–359. 5. Antillon M.R.,  Shah R.J., Stiegmann G., et al.: Single-step EUS-guided transmural drainage of simple and complicated pancreatic pseudocysts. Gastrointest Endosc. 2006; 63: 797–803. 6. Azar R.R., Oh Y .S., Janee E.M., et al.: Wire-guided pancreatic pseudocyst drainage by using a modifi ed needle knife and therapeutic echoendoscope. Gastrointest Endosc. 2006; 63: 688–692. 7. Parks R.W., Tzo varas G., Diamond T., et al.: Management of pancreatic pseudocysts. Ann R Coll Surg Engl. 2000; 82: 383–387. 8. Melman L., Azar R., Beddow K., et al.: Primary and overall success rates for clinical outcomes aft er laparoscopic, endoscopic, and open pancreatic cystogastrostomy for pancreatic pseudocysts. Surg Endosc. 2009; 23: 267–271. 9. Johnson M.D., W alsh R.M., Henderson J.M., et al.: Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol. 2009; 43: 586–590.10. Magowska A.: A  doctor facing turbulent times: Antoni Tomasz Jurasz, citizen of the world. World J Surg. 2011; 35 (9): 2167–2171.11. Varadarajulu S., Bang J.Y., Sutton B.S., et al.: Equal Efficacy of Endoscopic and Surgical Cystogastrostomy for Pancreatic Pseudocyst Drainage in a Randomized Trial Gastroenterology. 2013; 145 (3): 583–590.12. Karavias T., Dol linger P., Häring R.: Cystogastrostomy in the Treatment of Pancreatic Pseudocysts. In: Standards in Pancreatic Surgery. Eds. H.G. Beger, M. Büchler, P. Malfertheiner. Berlin, Heidelberg: Springer 1993; 540–543.13. Wang G.C., Misra  S.: A giant pancreatic pseudocyst treated by cystogastrostomy. BMJ Case Rep pii. 2015. bcr2014207271. doi: 10.1136/bcr-2014-207271.

A giant pancreatic pseudocyst treated by open cystogastrostomy

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A giant pancreatic pseudocyst treated by open cystogastrostomy

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