Successful surgical internal drainage of postoperative pancreatic pseudocyst through pancreaticojejunostomy with distal pancreatectomy: a case report
© Sakata et al. 2015
Received: 25 February 2015
Accepted: 10 June 2015
Published: 26 June 2015
Pancreatic pseudocyst is usually treated by percutaneous external drainage, endoscopic internal or external drainage, or surgical internal drainage such as cystogastrostomy. Surgical external drainage is an option if these procedures fail. We describe a case of a 70-year-old man with a pancreatic body pseudocyst that developed postoperatively. It was improved by endoscopic external drainage, and the stent was changed to an internal stent. However, surgery was required as the pseudocyst grew again. A direct approach to the pseudocyst was not possible because of severe adhesion. A distal pancreatectomy with pancreaticojejunostomy was performed, and an external pancreatic stent tube was inserted from the cut end into the duodenum to drain the pseudocyst. One month later, the pseudocyst disappeared, and the stent was removed.
Pancreatic pseudocyst (PPC) is associated with acute pancreatitis and chronic pancreatitis, and develops as a postoperative complication . PPC is a localized collection of amylase-rich fluid located within or adjacent to the pancreas and is devoid of an epithelial wall . Treatment is only required for persisting PPC symptoms such as abdominal pain, infection, or compression of the gastrointestinal tract, pancreatic duct, or the common bile duct . Although it is usually treated by percutaneous or endoscopic drainage , surgery is necessary in some cases, which is associated with a relatively high percentage of complications and even death . We herein describe successful surgical external drainage of postoperative PPC through pancreaticojejunostomy with distal pancreatectomy (DP).
PPCs may develop in 10–20 % and 20–40 % of patients with acute and chronic pancreatitis, respectively [6, 7]. Currently, endoscopic drainage is recommended as a first-line treatment for accessible PPCs because the outcomes are excellent in terms of costs, duration of hospital stay, and quality of life, as was demonstrated in a recent prospective randomized study . However, in the present case, surgery was required because endoscopic drainage had failed and hemorrhage occurred.
A variety of surgical techniques exist for PPC [9, 10]. Internal drainage via cystojejunostomy has been the treatment of choice . However, this type of anastomosis was unsuitable in the present case because severe adhesions were seen around the PPC. Adhesiolysis is associated with a high risk of bowel injury . Instead of cystojejunostomy, an external pancreatic drainage tube was inserted from the cut pancreatic tail into the duodenum to treat the PPC. To our knowledge, there are no similar published cases in the English literature.
In our case, the pancreatic cut end was not closed directly but was anastomosed to the jejunum. Klein et al. compared pancreatoenteral anastomosis with direct closure of the pancreatic remnant for POPF after DP and reported that pancreatoenteral anastomosis may be considered a safe alternative for direct closure in certain cases . Pancreatoenteral anastomosis might have contributed to bilateral drainage of pancreatic juice to the head and tail sides in the present case, even if the main pancreatic duct was stenosed.
Appropriate drainage was important in managing PPC, and external drainage through pancreaticojejunostomy with DP is an effective procedure for PPC if endoscopic treatment is unsuccessful.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank all staffs, who were employed at Kumamoto University for treating and caring for this patient.
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