1/482. Haemosuccus pancreaticus: a clinical challenge. BACKGROUND: Haemosuccus pancreaticus is a rare complication of pancreatitis. It is a diagnostic problem for even the most astute clinician and a challenge for the expert endoscopist. We report a 25-year-old male patient who had all the features usually seen in haemosuccus pancreaticus patients: recurrent obscure upper gastrointestinal bleeding, pancreatitis, pseudocyst formation, ductal disruption, fistula and pancreatic ascites. The patient was treated by subtotal pancreatectomy, splenectomy and drainage of the pseudocyst. Although pancreatic duct communication with the surrounding vasculature could not be ascertained, we strongly believe the patient had haemosuccus pancreaticus because, over a follow-up period of 3 years, the patient was not only ascites free, but did not experience any further upper gastrointestinal bleeding. We believe that in evaluating patients with recurrent obscure gastrointestinal bleeding, one should always remember that the pancreas is a part of the gastrointestinal tract and, like other organs, is prone to blood loss. ( info) |
2/482. The development of a pancreatic abscess, suppurative pylethrombosis, and multiple hepatic abscesses after a pancreatojejunostomy for chronic pancreatitis: report of a case. We present herein an autopsy case of 63-year-old Japanese man who died as a result of pancreatic abscess, suppurative pylethrombosis, and multiple liver abscesses that had developed 10 years after a pancreato- and cystojejunostomy with side-to-side anastomosis for chronic pancreatitis. Even after this operation, the patient had continued to consume excessive amounts of alcohol. He had first experienced back pain with leukocytosis 9 years after the operation, which relapsed the following year. Despite percutaneous transhepatic gallbladder drainage, his icterus had deteriorated into hepatic insufficiency. Computed tomographic scans of the abdomen had disclosed multiple liver abscesses. At autopsy, a pancreatic abscess and suppurative pylethrombosis as well as multiple liver abscesses were found. There have been few reported cases of such lethal complications developing after a pancreato- and cystojejunostomy for chronic pancreatitis. As the consumption of alcohol would have exacerbated the chronic pancreatitis, such patients should be strongly advised to abstain from drinking alcohol. ( info) |
3/482. Operative indications for cystic lesions of the pancreas with malignant potential--our experience. BACKGROUND/AIMS: There are still many important but unclear points regarding the differential diagnosis and operative indications of cystic lesions of the pancreas with malignant potential. Studies of the clinicopathological and molecular biological characteristics of such diseases are necessary. In this paper, we discuss operative indications for this condition based on a review of the literature and our own experience. METHODOLOGY: Seven cases of serous cystadenoma and 9 cases of mucinous cystadenoma or cystadenocarcinoma of the pancreas that were operated on or autopsied in our department from 1980 to 1996 were analyzed clinicopathologically. Small cystic lesions incidentally found in 300 autopsied cases were also studied. Finally, mucin-producing tumors described in several reports were reviewed, and the branch type of this tumor was especially investigated. RESULTS: A marked disappearance of pancreatic acini in the upstream pancreas was found when serous cystadenoma became large. Papillary projection was histologically found in all of the cases. Tumorous invasion to the interstitium was suspected in tumors more than 5 cm in diameter, and malignancy was reported when tumors were larger than 6 cm. As for mucinous cystadenocarcinoma, the patients had a poor prognosis. In 2 of 42 cases with a pseudocyst, small duct cell carcinoma was incidentally found adjacent to the pseudocyst on the duodenal side. With regard to branch-type intraductal papillary neoplasm, 80% of the tumors larger than 4 cm were malignant. Most of the small cystic lesions found in elderly autopsy cases were accompanied by hyperplastic epithelia without evidence of malignancy. CONCLUSIONS: Based on our experience, an operation should be considered and resection is recommended under the following circumstances: 1) cystic lesions in the body and tail of the pancreas in middle-aged women; 2) typical serous cystadenoma larger than 4 cm; 3) mucinous cystadenoma of any size; 4) branch-type intraductal papillary neoplasm larger than about 3 cm; and, 5) pseudocysts of unknown cause. Small cystic lesions in elderly patients should not necessarily be operated on, but should be followed-up carefully. ( info) |
4/482. Acute hemorrhage into the peritoneal cavity--a complication of chronic pancreatitis with pseudocyst: a case report from clinical practice. Acute hemorrhage due to a pseudocyst of the pancreas is a dangerous complication of chronic pancreatitis (CP). Without operative treatment, mortality is as high as 90%. Immediate recognition of this complication as well as urgent operative treatment allowing the survival of 70% of patients is imperative. Described is the case of a patient with CP and pseudocyst in which hyperamylasemia and unclarified anemia developed following sudden abdominal pain. The suspicion of hemorrhage into the peritoneal cavity was confirmed by selective visceral angiography showing hemorrhage from the splenic artery in the region of the hilus of the spleen. Operative treatment was successful. During the procedure, a ligature was applied to the hemorrhaging splenic artery and a splenectomy was carried out with 2500 ml of bloody contents being removed from the abdominal cavity. Acute hemorrhage into the peritoneal cavity as a complication of chronic pancreatitis with pseudocyst (CPP) requires immediate identification, confirmation by visceral angiography, and urgent operative treatment. ( info) |
5/482. First clinical application of a newly developed device for intragastric surgery for the treatment of pancreatic pseudocysts. BACKGROUND: Instruments that have been used during GI endoscopy have always been confined to the accessory channel of the endoscope. We have therefore developed a device that allows transabdominal manipulation in the stomach under gastroscopic control. Here we report the first clinical application of this device, which was used for the drainage of pancreatic pseudocysts. methods: The device is similar to a PEG tube and consists of a 7 mm polyethylene tube that is inserted by the "thread pull through" method. A trocar valve is mounted at the external tip of the tube. Four pseudocysts were treated in three patients. The retrogastric pseudocysts were punctured through the device under endoscopic (n = 2) and CT (n = 2) guidance. External drainage was used for 3 to 5 days; thereafter the drain was cut and internalized. The device was also cut and sealed. After 10 days it was removed as with a standard PEG tube. RESULTS: No complications related to the device occurred. In two patients the pseudocysts resolved completely. One patient had to undergo pseudocystojejunostomy for an infected pseudocyst containing large amounts of necrotic material. CONCLUSIONS: We believe that our new device is valuable to the further development of intragastric surgery and can be used to safely perform pseudocystogastrostomy. ( info) |
6/482. Frantz's tumour of the pancreas presenting as a post-traumatic pancreatic pseudocyst. A case of a solid, pseudopapillary and cystic tumour of the pancreas in a 13-year-old girl was presented. Shortly after a blunt abdominal trauma, an abdominal mass became manifest. Clinical features and radiological findings suggested a traumatic pseudocyst of the pancreas. laparotomy and pathology revealed a Frantz's tumour, which was totally resected. Twelve months after surgery the patient is asymptomatic and CT-scan shows no signs of recurrence or metastasis. To our knowledge, no such acute presentation has ever been described in the literature since the first clinical report of this tumour in 1959. ( info) |
7/482. Nonoperative management of pancreatic pseudocysts. Problems in differential diagnosis. CONCLUSION: The evaluation of pancreatic cystic lesions entails a misdiagnosis risk. awareness of the problem, knowledge of the natural history of these lesions, and meticulous posttreatment follow-up can reduce the consequences of diagnostic errors. If all these precautions are adopted, pancreatic pseudocysts can be safely treated nonoperatively. BACKGROUND: The accurate diagnosis of pancreatic cystic lesions remains a problem. The aim of this study was to ascertain the incidence of and the reasons the diagnostic errors occurred in a series of pseudocysts drained percutaneously and to compare these data to those reported in the literature. methods: Data from 70 patients bearing one or more pseudocysts who underwent a percutaneous drainage were reviewed. The pretreatment workup included medical history, physical examination, ultrasound (US) and computed tomography (CT) scans, amylase assay in both the serum and the cystic fluid, culture and cytology of the cystic fluid. After removal of the drainage, the minimum follow-up period was 12 mo. RESULTS: Four patients died, and two cancer-associated pseudocysts were identified before removal of the drainage. Sixty-four patients were followed up for a mean of 51.9 mo (range 12-154 mo). A third cancer and a mucinous cystic tumor, fully communicating with the main duct, were further detected during this period. ( info) |
| In patients with acute pancreatitis, profuse gastrointestinal bleeding is associated with a high death rate. The cause of such bleeding must be evaluated and the bleeding controlled urgently. aneurysm formation is usually the cause of the bleeding. angiography is needed to make a definitive diagnosis and the bleeding site should be controlled by angiographic embolization if possible. If this fails, aneurysm resection is necessary. Two patients are described. Both had aneurysms of the splenic artery, presenting as massive gastrointestinal bleeding in one patient and bleeding into an associated pseudocyst in the other. They required surgical repair, which was successful in both cases. ( info) |
9/482. Management of pancreatic pseudocysts by endoscopic cystogastrostomy. Open surgical drainage is currently the treatment of choice for pancreatic pseudocysts, but endoscopic transmural drainage is another minimally invasive surgical alternative. In this report, we describe two patients with symptomatic pancreatic pseudocysts treated with endoscopic cystogastrostomy. The first patient, a 15-year-old boy, had an episode of traumatic pancreatitis after abdominal injury from a car accident, and complained of postprandial vomiting and abdominal distention 4 weeks later. A large pancreatic pseudocyst, about 10 cm x 6 cm, was noted. The second patient, a 44-year-old man, had a 1-year history of recurrent alcoholic pancreatitis prior to this admission. He suffered from abdominal distention for several weeks. Sonography revealed a large pancreatic pseudocyst, about 18 cm x 9 cm in size. Both patients underwent successful endoscopic cyst-drainage without recurrence. These cases illustrate that endoscopic transmural drainage provides a minimally invasive and effective approach to the management of pancreatic pseudocysts. ( info) |
10/482. Proximal bile duct stricture caused by a pancreatic pseudocyst: intra-operative placement of a metallic stent. A 61 year-old man presented with a proximal bile duct stricture caused by a pancreatic pseudocyst, which is of rare occurrence. Although it could not be determined pre-operatively whether the lesion was caused by cholangiocarcinoma or inflammatory disease, a laparotomy revealed that the proximal extrahepatic bile duct was surrounded and constricted by a pancreatic pseudocyst extending into the hepatoduodenal ligament. Since the stricture was not relieved only by removing the contents of the pseudocyst and surgical biliary diversion was considered too difficult, a self-expandable metallic stent was placed intra-operatively, at the strictured site, under ultrasonic guidance, via the transhepatic approach. The post-operative course of the patient was uneventful, and he remains well 22 months after the operation. The intra-operative placement of a metallic stent into the biliary tract can be an alternative option in the relief of biliary obstruction. ( info) |