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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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2
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Tomsan H, Olivas-Chacon C, Hayeri MR, Babu AS. Spontaneous pancreatic pseudocyst - superior mesenteric vein fistula: A rare complication of chronic pancreatitis. Radiol Case Rep 2020; 15:1939-1942. [PMID: 32874387 PMCID: PMC7452026 DOI: 10.1016/j.radcr.2020.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 11/18/2022] Open
Abstract
Pseudocyst formation is common in chronic pancreatitis. A rare subset of these patients may develop fistulization between the pseudocyst and the portal vein system. We report a case of spontaneous pancreatic pseudocyst – superior mesenteric vein fistula in a 61-year-old male with a history of chronic recurrent calcifying pancreatitis. The fistulous connection was correctly identified on both computed tomography and magnetic resonance cholangiopancreatography (MRCP), and the patient was treated successfully with a conservative approach. Our case report aims to educate on this rare and potentially fatal vascular complication of chronic pancreatitis and to discuss the role of modern noninvasive imaging techniques, such as T2-weighted MRI/MRCP, in establishing this diagnosis and making a decision regarding its management.
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Kimura A, Hayashi K, Oda C, Hosaka K, Kimura N, Tominaga K, Ikarashi S, Tsuchiya A, Terai S. Effectiveness of Endoscopic Pancreatic Stenting for Pancreatic Pseudocyst-Portal Vein Fistula. Case Rep Gastroenterol 2020; 14:570-576. [PMID: 33250699 PMCID: PMC7670380 DOI: 10.1159/000510331] [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: 06/07/2020] [Accepted: 07/20/2020] [Indexed: 11/19/2022] Open
Abstract
Pancreatic pseudocyst-portal vein (PP-PV) fistula, mostly occurring after pseudocyst formation following acute/chronic pancreatitis, is a rare but life-threatening condition. The majority of treatments are based on conservative or surgical interventions. We report the case of a 70-year-old man with a PP-PV fistula and PV thrombosis. We adopted conservative treatment at first due to his mild symptoms. However, after resuming food intake, the patient had severe abdominal pain. Following endoscopic retrograde cholangiopancreatography, we found that the pseudocyst was connected with the PV through the fistula. Subsequently, an endoscopic nasopancreatic drainage (ENPD) catheter was inserted into the main pancreatic duct to establish pancreatic drainage, which resulted in a decrease in the abdominal pain. After the ENPD tube had been exchanged for endoscopic pancreatic stenting, his abdominal pain did not recur. Therefore, this case demonstrated endoscopic treatment as an effective treatment option for PP-PV fistula.
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Affiliation(s)
- Atsushi Kimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Chiyumi Oda
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Kazunori Hosaka
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Naruhiro Kimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Satoshi Ikarashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Atsunori Tsuchiya
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Perry LM, Loehfelm T, Pillai R, Pan DY, Tejaswi S, Gholami S. Shifting the Treatment Paradigm for Pancreaticoportal Fistula Causing Hepatic Necrosis. Dig Dis Sci 2020; 65:1955-1959. [PMID: 31919639 DOI: 10.1007/s10620-020-06045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Lauren M Perry
- Division of Surgical Oncology, Department of Surgery, University of California, 2279 45th Street, Davis, Sacramento, CA, 95817, USA
| | - Thomas Loehfelm
- Division of Abdominal Imaging, Department of Radiology, University of California, Davis, USA
| | - Rex Pillai
- Division of Interventional Radiology, Department of Radiology, University of California, Davis, USA
| | - Dana Y Pan
- Division of Gastroenterology, Department of Internal Medicine, University of California, Davis, USA
| | - Sooraj Tejaswi
- Division of Gastroenterology, Department of Internal Medicine, University of California, Davis, USA
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, University of California, 2279 45th Street, Davis, Sacramento, CA, 95817, USA.
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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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Eccles J, Wiebe E, D’Souza P, Sandha G. Pancreatic pseudocyst-portal vein fistula with refractory hepatic pseudocyst: Two cases treated with EUS cyst-gastrostomy and review of the literature. Endosc Int Open 2019; 7:E83-E86. [PMID: 30652118 PMCID: PMC6333533 DOI: 10.1055/a-0754-2247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/02/2018] [Indexed: 11/24/2022] Open
Abstract
Background and study aims Pseudocysts are the most common pancreatic cystic lesions and they usually develop in association with pancreatitis of at least 4 weeks' duration. Extra-pancreatic pseudocysts, although reported, are relatively uncommon. Secondary liver pseudocysts are recognized within the literature, and most patients described have required percutaneous or surgical drainage due to infection or symptoms. The mechanism of hepatic pseudocyst formation is not entirely clear but it is postulated that this phenomenon may occur through pseudocyst-portal vein fistulization. We describe two cases of patients presenting with pancreatic pseudocysts invading the portal venous system with embolization of pancreatic fluid to the liver and subsequent hepatic pseudocyst formation. Interestingly, liver pseudocyst resolution was incomplete with antibiotics and percutaneous drainage alone, and only occurred following endoscopic ultrasonography-guided pancreatic cyst-gastrostomy and metal stent insertion. We have reviewed the current literature on the diagnosis and management of pseudocyst-portal vein fistula formation and we believe that our cases represent the first published within the literature to describe this treatment approach.
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Affiliation(s)
- John Eccles
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Edward Wiebe
- Department of Diagnostic Imaging, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Pernilla D’Souza
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Gurpal Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada,Corresponding author Dr. Gurpal Sandha, MBBS, FRCPC Professor of Medicine, Division of GastroenterologyUniversity of Alberta Hospital2-76 Zeidler-Ledcor Centre, 8540-112 StreetEdmonton, AlbertaT6G 2X8 Canada+780-492-8170+780-492-1699
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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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Abstract
Open surgical intervention for treatment of simple pancreatic pseuodocyst (PP) has a high success rate and has been the historical gold standard. Open surgical intervention, however, confers significant morbidity and mortality, which has spurred the development of less invasive techniques. Laparoscopic approaches are feasible with the potential for lower complication rates and length of stay. The endoscopic approach has the appeal of potentially shorter hospitalization length of stays and does not require general anesthesia. Complicated PPs or those that arise in the setting of chronic pancreatitis warrant additional workup and special consideration.
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Affiliation(s)
- Lea Matsuoka
- Department of Surgery, Vanderbilt University, 801 Oxford House, 1313 21st Avenue South, Nashville, TN 37232, USA.
| | - Sophoclis P Alexopoulos
- Department of Surgery, Vanderbilt University, 801 Oxford House, 1313 21st Avenue South, Nashville, TN 37232, USA
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Ng TSC, Rochefort H, Czaplicki C, Teixeira P, Zheng L, Matsuoka L, Van Dam J, Alexopoulos SP. Massive pancreatic pseudocyst with portal vein fistula: case report and proposed treatment algorithm. Pancreatology 2014; 15:88-93. [PMID: 25500342 DOI: 10.1016/j.pan.2014.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 11/11/2014] [Accepted: 11/14/2014] [Indexed: 12/11/2022]
Abstract
Pancreatic pseudocyst is a relatively common occurrence resulting from acute or chronic pancreatitis. However, a rare subset of these patients present with a pseudocyst fistulizing into the portal vein. We present the case of a 58 year-old woman with a rapidly expanding pancreatic pseudocyst with portal venous fistulization causing portal vein thrombosis, in addition to biliary and duodenal obstruction. The patient underwent surgical decompression with a cyst-gastrostomy and was well until one week post-operatively when she experienced massive gastrointestinal hemorrhage leading to her death. A review of the literature is presented and a treatment algorithm to manage patients with pancreatic pseudocyst to portal vein fistula is proposed.
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Affiliation(s)
- Thomas S C Ng
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Holly Rochefort
- Division of Hepatobiliary, Pancreatic and Abdominal Organ Transplant Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Pedro Teixeira
- Division of Hepatobiliary, Pancreatic and Abdominal Organ Transplant Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lin Zheng
- Visualization & Interface Design Innovation (VIDI) Research Group, University of California, Davis, Davis, CA, USA
| | - Lea Matsuoka
- Division of Hepatobiliary, Pancreatic and Abdominal Organ Transplant Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jacques Van Dam
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sophoclis P Alexopoulos
- Division of Hepatobiliary, Pancreatic and Abdominal Organ Transplant Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Raza SS, Hakeem A, Sheridan M, Ahmad N. Spontaneous pancreatic pseudocyst-portal vein fistula: a rare and potentially life-threatening complication of pancreatitis. Ann R Coll Surg Engl 2013. [PMID: 23317711 PMCID: PMC3964669 DOI: 10.1308/003588413x13511609955616] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Pseudocyst formation following acute and chronic pancreatitis is a well known complication. A pancreatic pseudocyst fistulating into the portal vein is a rare and potentially fatal complication. We report a case of pancreatic pseudocyst – portal vein fistula, which was managed with a conservative approach.
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Affiliation(s)
- S S Raza
- Leeds Teaching Hospitals NHS Trust, UK
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