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Goble S, Ayoub A, Boeke S, Matlock R, Malli A. Spontaneous Pancreatic Pseudocyst-Superior Mesenteric Vein Fistula. ACG Case Rep J 2023; 10:e01092. [PMID: 37441624 PMCID: PMC10335823 DOI: 10.14309/crj.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
Pancreatic pseudocyst formation is a common complication of chronic pancreatitis. Rarely, a fistula develops between the pseudocyst and the portal venous system. We present a case of a 50-year-old man who was found to have a pancreatic pseudocyst-superior mesenteric vein fistula after being evaluated for several months of abdominal pain and weight loss. The patient was treated with endoscopic stenting of the pancreatic duct along with early enteral nutrition and suppressive antibiotics, which resulted in improvement in his condition. This case report highlights clinical presentation and the complexity of treatment of this rare diagnosis.
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Affiliation(s)
| | - Alan Ayoub
- University of Zagreb Medical School, Zagreb, Croatia
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Masuda S, Koizumi K, Uojima H, Tazawa T, Kimura K, Nishino T, Tasaki J, Ichita C, Sasaki A, Egashira H, Kako M. Pancreatic pseudocyst-portal vein fistula: a case treated with EUS-guided cyst-drainage and a review of the literature. Clin J Gastroenterol 2020; 13:597-606. [PMID: 32215857 DOI: 10.1007/s12328-020-01105-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 02/04/2020] [Indexed: 11/30/2022]
Abstract
Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula (PPVF) is a rare and life-threatening complication. In PPVF patients, drainage or operative therapy is necessary under certain conditions, including communication between the pseudocyst and pancreatic duct, pancreatic duct stricture, pancreatic duct stone, and infection that is difficult to control with antibiotics. We describe the case of a 78-year-old woman who presented with an infected pancreatic pseudocyst invading the portal venous system with obstruction due to thromboembolization. Conservative therapy with antibiotics was insufficient. We, therefore, performed endoscopic ultrasound-guided cyst-drainage (EUS-CD). During EUS-CD, PPVF and pseudocyst-pancreatic duct fistula were confirmed by contrast medium injection. Despite the presence of the pseudocyst-pancreatic duct fistula, the pancreatic duct was not visualized in the pancreatic head, suggesting stricture in the main pancreatic duct. We, therefore, performed endoscopic retrograde pancreatography, which revealed pancreatic stone in the main pancreatic duct. Then, we added a 7-Fr pancreatic stent. She was discharged after 89 days of hospitalization. We reviewed the literature on the management of PPVF formation, and EUS-CD is considered to be a good treatment option for PPVF patients without portal vein patency.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Kazuya Koizumi
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Kanagawa, 252-0375, Japan
| | - Tomohiko Tazawa
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Karen Kimura
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Takashi Nishino
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Junichi Tasaki
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Chikamasa Ichita
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Akiko Sasaki
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Hideto Egashira
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Makoto Kako
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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Peterson KJ, Serrano OK, Flanagan S, Chinnakotla S. Vascular reconstruction technique of a perforated portal vein during a pediatric total pancreatectomy and islet autotransplant. Am J Transplant 2018; 18:2342-2346. [PMID: 29790286 DOI: 10.1111/ajt.14943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/18/2018] [Accepted: 05/15/2018] [Indexed: 01/25/2023]
Abstract
Hereditary pancreatitis (HP) is a progressive disease that can manifest in childhood with debilitating, relapsing pain. A total pancreatectomy and islet autotransplant (TPIAT) is a surgical option to relieve chronic pain while preserving the available β-cell mass. The clinical course of HP is fraught with pancreatitis-related sequelae that can both necessitate and complicate a TPIAT. We describe a child with HP who developed a pancreatic pseudocyst-portal vein (PV) fistula. Active hemorrhage of the perforated PV into the pseudocyst and PV thrombosis complicated the planned TPIAT procedure and, preoperatively, required urgent image-guided stenting. During the TPIAT procedure, the endovascular stent was found to be protruding through the PV into the pseudocyst. Using the autologous splenic vein from the TPIAT specimen, we performed a vascular reconstruction of the perforated PV. This case underscores the need for evaluation of children with HP by a multidisciplinary pancreatic TPIAT care team to best prepare for the potential ramifications of pancreatitis-related complications. It also illustrates a useful vascular reconstruction technique for PV complications.
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Affiliation(s)
- Kent J Peterson
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Oscar K Serrano
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Siobhan Flanagan
- Department of Interventional Radiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Srinath Chinnakotla
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Imamura N, Nanashima A, Tsuchimochi Y, Hamada T, Yano K, Hiyoshi M, Fujii Y, Nakamura K. Intrahepatic portal vein thrombosis due to postoperative biliary obstruction successfully treated by a partial thrombectomy combined with thrombolytic drug therapy. Int J Surg Case Rep 2017; 42:20-23. [PMID: 29202352 PMCID: PMC5723364 DOI: 10.1016/j.ijscr.2017.11.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/21/2017] [Indexed: 11/29/2022] Open
Abstract
Portal vein thrombosis due to constriction of hepaticojejunostomy is rarely occured, in which increased biliary pressure by obstructive jaundice decreased portal flow. Re-anastomosis and postoperative thromolytic therapy recovered occluded portal flow.
Introduction This case report aims to inform pancreatic surgeons about our perioperative management of intrahepatic portal vein thrombosis caused by an obstruction of hepaticojejunostomy (HJ) after pancreaticoduodenectomy (PD). Case presentation A 65-year-old woman was diagnosed with pancreas head carcinoma involving the superior mesenteric vein (SMV). Pancreaticoduodenectomy combined with SMV resection was followed by HJ. Twisting or narrowing was not evident during anastomosis. Total bilirubin values progressively increased to 13 mg/dL on day 5. At that time, we suspected anastomotic occlusion and found complete portal thrombosis of the left liver. Therefore, emergency re-anastomosis of the HJ was followed by thrombectomy, which was not completely successful and did not completely recover initial portal flow. Thrombolytic drugs improved obstructive jaundice, eradicated the organized thrombosis and recovered the portal flow by day 30. The post-operative course was uneventful. Discussion A thrombosis immediately formed in the portal vein due to biliary obstruction of an anastomotic site. We speculated that biliary dilation and related inflammation caused a relative increase in arterial flow and decreased portal flow at the localized part of the umbilical portion. Although early surgical thrombectomy was attempted soon after the primary operation, the organized thrombosis persisted. However, thrombolytic therapy eradicated the thrombosis. Conclusion Careful anastomosis of HJ during PD was necessary to avoid postoperative biliary stricture. This type of complication affects intrahepatic blood flow, particularly via the portal vein. Although immediate re-anastomosis or thrombectomy is applied, organized thrombosis cannot always be surgically removed.
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Affiliation(s)
- Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan.
| | - Yuki Tsuchimochi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yoshiro Fujii
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Kunihide Nakamura
- Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
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Mediastinal Pseudocyst: Varied Presentations and Management-Experience from a Tertiary Referral Care Centre in India. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2017; 2017:5247626. [PMID: 28392624 PMCID: PMC5368372 DOI: 10.1155/2017/5247626] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 02/01/2017] [Accepted: 02/26/2017] [Indexed: 11/23/2022]
Abstract
Pseudocysts are a recognised complication following acute or chronic pancreatitis. Usually located in peripancreatic areas, they have also been reported to occur in atypical regions like liver, pelvis, spleen, and mediastinum. Mediastinal pseudocysts are a rare entity and present with myriad of symptoms due to their unique location. They are a clinical challenge to diagnose and manage. In this paper, we describe the clinical and radiological characteristics of mediastinal pseudocysts in 7 of our patients, as well as our experience in managing these patients along with their clinical outcome.
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Hakim S, Bortman J, Orosey M, Cappell MS. Case report and systematic literature review of a novel etiology of sinistral portal hypertension presenting with UGI bleeding: Left gastric artery pseudoaneurysm compressing the splenic vein treated by embolization of the pseudoaneurysm. Medicine (Baltimore) 2017; 96:e6413. [PMID: 28353569 PMCID: PMC5380253 DOI: 10.1097/md.0000000000006413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION A novel case is reported of upper gastrointestinal (UGI) bleeding from sinistral portal hypertension, caused by a left gastric artery (LGA) pseudoaneurysm (PA) compressing the splenic vein (SV) that was successfully treated with PA embolization. CASE REPORT A 41-year-old man with previous medical history of recurrent, alcoholic pancreatitis presented with several episodes of hematemesis and abdominal pain for 48 hours. Physical examination revealed a soft abdomen, with no abdominal bruit, no pulsatile abdominal mass, and no stigmata of chronic liver disease. The hemoglobin declined acutely from 12.3 to 9.3 g/dL. Biochemical parameters of liver function and routine coagulation profile were entirely within normal limits. Abdominal CT revealed a 5-cm-wide peripancreatic mass compressing the stomach and constricting the SV. Esophagogastroduodenoscopy showed blood oozing from portal hypertensive gastropathy, small nonbleeding gastric cardial and fundal varices, gastric compression from the extrinsic mass, and no esophageal varices. MRCP and angiography showed that the mass was vascular, arose from the LGA, compressed the mid SV without SV thrombosis, and caused sinistral portal hypertension. At angiography, the PA was angioembolized and occluded. The patient has been asymptomatic with no further bleeding and a stable hemoglobin level during 8 weeks of follow-up. DISCUSSION Literature review of the 14 reported cases of LGA PA revealed that this report of acute UGI bleeding from sinistral portal hypertension from a LGA PA constricting the SV is novel; one previously reported patient had severe anemia without acute UGI bleeding associated with sinistral portal hypertension from a LGA PA. CONCLUSION A patient presented with UGI bleeding from sinistral portal hypertension from a LGA PA compressing the SV that was treated by angiographic obliteration of the PA which relieved the SV compression and arrested the UGI bleeding. Primary therapy for this syndrome should be addressed to obliterate the PA and not the secondarily constricted SV.
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Affiliation(s)
- Seifeldin Hakim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, William Beaumont Hospital
| | - Jared Bortman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, William Beaumont Hospital
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Molly Orosey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, William Beaumont Hospital
| | - Mitchell S. Cappell
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, William Beaumont Hospital
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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