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Liu H, Phillips A, Sholosh B, Novelli P, Romutis S, D'Alesio M, Lebowitz S, Singh H, Yadav D, Zureikat A, Lee K, Paniccia A, Dasyam AK. Pancreatic-Portal Vein Fistula: a Rare Diagnosis with Wide-Ranging Complications-13-Year Experience of a Pancreas Center of Excellence. J Gastrointest Surg 2021; 25:3137-3148. [PMID: 34254216 DOI: 10.1007/s11605-021-05071-5] [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: 04/06/2021] [Accepted: 06/04/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE To determine factors affecting mortality, and long-term patency of portal vein, in patients with pancreatic-portal vein fistula (PPVF). METHODS Consecutive cases of PPVF at the University of Pittsburgh Medical Center from 2008 to 2020 were retrospectively identified. Clinical history, imaging studies, management strategies, complications, and long-term outcomes were analyzed. RESULTS Fourteen patients, representing the largest PPVF cohort reported to date (mean age 58.6 years, 64.3% women, median follow-up 10 months [1-98 months]) were identified. Underlying chronic pancreatitis was seen in 9 (64.3%) patients, while 5 (35.7%) developed PPVF with first attack of acute pancreatitis. PPVF involved proximal main portal vein (MPV) in 10 (78.6%) patients. Of the 5 patients (35.7%) who died, all had occlusive (n=4) or near-occlusive (n=1) PPVF-associated filling defect (FD) in the MPV. Conversely, 7 of 9 survivors (87.5%) had subocclusive FD and patent MPV. In patients with sepsis (n=5), 1 underwent surgical necrosectomy and survived, while 3 of 4 (75%) patients without debridement died. CONCLUSION Occlusive/near-occlusive PPVF-associated MPV FD, and sepsis, are associated with high mortality rates, while subocclusive MPV FD is associated with survival and long-term MPV patency. PPVF is a potentially life-threatening, and possibly under-diagnosed, entity that warrants early clinical suspicion for timely diagnosis, to facilitate optimal management.
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Affiliation(s)
- Hao Liu
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Anna Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Biatta Sholosh
- Abdominal Imaging Division, Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Paula Novelli
- Interventional Radiology Division, Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Stephanie Romutis
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Mark D'Alesio
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Steven Lebowitz
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Harkirat Singh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Amer Zureikat
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Kenneth Lee
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Alessandro Paniccia
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Anil K Dasyam
- Abdominal Imaging Division, Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA.
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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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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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Ramachandran A, Sharma S, Shalimar, Sharma R, Madhusudhan KS. Pancreatic Walled-Off Necrosis Eroding into the Inferior Vena Cava. Curr Probl Diagn Radiol 2018; 48:519-521. [PMID: 29496357 DOI: 10.1067/j.cpradiol.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 01/19/2018] [Indexed: 11/22/2022]
Abstract
Walled-off necrosis (WON) is a well-known delayed local complication of acute necrotizing pancreatitis. Occasionally, WON may spontaneously rupture into the gastrointestinal tract or peritoneal cavity. However, erosion of a WON to a systemic vein has not been reported in literature so far. We report an unusual case of a 63-year-old male with acute necrotizing pancreatitis in whom WON was eroding into the inferior vena cava resulting in its thrombosis. Our patient also had a bunch of other well-described complications of pancreatitis including splanchnic venous thrombosis.
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Affiliation(s)
- Anupama Ramachandran
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sanchit Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Alessandrino F, Strickland C, Mojtahed A, Eberhardt SC, Mortele KJ. Clinical and cross-sectional imaging features of spontaneous pancreatic pseudocyst-portal vein fistula. Clin Imaging 2017; 44:22-26. [PMID: 28407511 DOI: 10.1016/j.clinimag.2017.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/23/2017] [Accepted: 03/29/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate clinical and imaging features of pancreatic pseudocyst-portal vein fistula (PPVF). METHODS Patients with evidence of PPVF on CT/MRI were included. Clinical presentation, outcomes, imaging appearance of the portal vein were recorded. RESULTS 75% of patients developed portal hypertension, 62% cavernous transformation of the portal vein and 25% portal biliopathy. PPVF presented on CT as fluid-attenuated portal vein, and on MRI as T2-weighted hyperintense fluid-filled portal vein. PPVF was misdiagnosed as portal vein thrombosis in all patients who underwent CT as initial examination. CONCLUSIONS Whenever PPVF is suspected on CT, MRI can be helpful to achieve accurate diagnosis and avoid unnecessary interventions.
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Affiliation(s)
- Francesco Alessandrino
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States.
| | - Corinne Strickland
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States; Department of Radiology, University of New Mexico Hospital, Albuquerque, United States
| | - Amirkasra Mojtahed
- Department of Radiology, University of New Mexico Hospital, Albuquerque, United States
| | - Steven C Eberhardt
- Department of Radiology, University of New Mexico Hospital, Albuquerque, United States
| | - Koenraad J Mortele
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
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Ronot M, Allaham W, Lagadec M. An Exceptional Cause of Abdominal Pain. Gastroenterology 2016; 151:817-818. [PMID: 27697510 DOI: 10.1053/j.gastro.2016.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/18/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Maxime Ronot
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, and University Paris Diderot, Sorbonne Paris Cité, INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, Paris, France
| | - Wassim Allaham
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, and University Paris Diderot, Sorbonne Paris Cité, INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, Paris, France
| | - Matthieu Lagadec
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, and University Paris Diderot, Sorbonne Paris Cité, INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, Paris, France
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7
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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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Brown A, Malden E, Kugelmas M, Kortz E. Diagnosis of pancreatic duct-portal vein fistula; a case report and review of the literature. J Radiol Case Rep 2014; 8:31-8. [PMID: 24967026 DOI: 10.3941/jrcr.v8i3.1552] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pseudocysts containing activated enzymes are a common complication of pancreatitis. Pseudocysts can rupture into adjacent structures including the peritoneal cavity, adjacent organs, and rarely vascular structures. While arterial pseudoaneurysms and venous thrombosis or occlusion are well known complications of acute and chronic pancreatitis, only 17 cases of pancreas-portal venous fistula have been encountered in review of the literature. A patient with chronic pancreatitis presented with a history of weight loss, fatigue and was found to have a pancreatic duct-portal vein fistula. The patient was treated surgically with good outcome.
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Affiliation(s)
- Anthony Brown
- Department of Radiology, University of Colorado hospital, Denver, USA
| | - Eric Malden
- Department of Radiology, Swedish hospital, Denver, USA
| | | | - Eric Kortz
- Department of Surgery, Swedish hospital, Denver, 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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10
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Efthymiou M. Spontaneous decompression of pancreatic pseudocyst presenting as haematemesis. ANZ J Surg 2009; 79:769-70. [PMID: 19878190 DOI: 10.1111/j.1445-2197.2009.05081.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
A patient with a pancreatic pseudocyst rupture into the portal vein with a resultant noninfectious systemic inflammatory response syndrome and subsequent portal vein thrombosis diagnosed by computed tomography and ultrasonography is reported. A review of the existing English literature on this rare complication is also provided.
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