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

Abstract

BackgroundPancreatic cysts are being diagnosed more frequently because of the increasing usage of imaging techniques. A pseudocyst with the major diameter of 10 cm is termed as a giant cyst. Asymptomatic pseudo-cysts up to 6 cm in diameter can be safely observed and monitored without intervention, but larger and symptomatic pseudocysts require intervention.Case presentationA 27-year-old Sri Lankan male, with history of heavy alcohol use, presented with progressive abdominal distension following an episode of acute pancreatitis. Contrast enhanced CT scan of the abdomen showed a large multilocular cystic lesion almost occupying the entire abdominal cavity and displacing the liver medially and the right dome of the diaphragm superiorly. The largest locule in the right side measured as 30 cm × 15 cm × 14 cm. Endoscopic ultrasound guided drainage of the cyst was performed. The cyst was entered into with an electrocautery-assisted cystotome and a lumen-opposing metal stent was deployed under fluoroscopic vision followed by dilatation with a 10 mm controlled radial expansion balloon. Repeat endoscopic ultrasound was done a week later due to persistence of the collection and a second stent was inserted. Then 10 French gauge × 10 cm double ended pigtails were inserted through both stents. The cysts were not visualized on subsequent Ultra sound scans. Stent removal was done after 3 weeks, leaving the pigtails insitu. The patient made an uneventful recovery.ConclusionGiant pancreatic pseudocysts are rare and earlier drainage is recommended before clinical deterioration. Some experts suggest that cystogastrostomy may not be appropriate for the treatment of giant pancreatic pseudocysts and in some instances external drainage of giant pancreatic pseudocysts may be safer than cystogastrostomy. Video-assisted pancreatic necrosectomy with internal drainage and laparoscopic cystogastrostomy were also tried with a good outcome. With our experience we suggest endoscopic guided internal drainage as a possible initial method of management of a giant pseudo cyst. However long-term follow up is needed with repeated imaging and endoscopy. In instances where the primary endoscopic internal drainage fails, surgical procedures may be required as a second line option.

An unusual presentation of a giant pancreatic pseudocyst extending through the lateral abdominothoracic wall into the subcutaneous plane

“…However, pseudocysts >6 cm carry a higher risk of becoming symptomatic and requiring intervention. 6,7 If symptomatic common symptoms are anorexia, abdominal discomfort, persistent pain, nausea and vomiting. Indications for intervention include persistent symptoms, infection, haemorrhage, persistent growth on serial imaging, pleural effusions or obstructive symptoms including gastric, duodenal, biliary and vascular obstruction.…”

An Unusual Case of Gallbladder Carcinoma with Pseudopancreatic cyst

“…17 Acute pancreatitis leads to necrosis of peri-pancreatic tissue or parenchyma which can cause liquefaction and subsequent organization resulting in pseudocysts. 18 Chronic pancreatitis leads to an acute exacerbation of pancreatitis or progressive ductal obstruction which can also lead to pseudocyst formation. 18 There is no specific treatment for most of the pancreatic pseudocysts because it resolves spontaneously.…”

“…18 Chronic pancreatitis leads to an acute exacerbation of pancreatitis or progressive ductal obstruction which can also lead to pseudocyst formation. 18 There is no specific treatment for most of the pancreatic pseudocysts because it resolves spontaneously. However, drainage may be required when symptoms due to compression of adjacent organs appear or when complications like rupture, infection or bleeding arise.…”

A Rare Case of Walled-off Pancreatic Necrosis Complicated by Splenic Artery Rupture Manifested After Surgical Internal Drainage - Diagnostic and Therapeutic Aspects

“…The management of WON and PP range from conservative treatment, usually in case of small collections, to operative techniques for large collections (10). The armamentarium of surgical techniques consists in minimal invasive procedures, such as endoscopic or endoscopic internal drainage, to open surgery (11). Internal drainage techniques vary in efficacy, with cystogastrostomy providing a less effective drainage of the cyst compared to the anastomosis with a defunctionalized loop of jejunum, or even in some instances to the external drainage, especially in case of large collections (12).…”