Laparoscopic Intervention for Massive, Rapidly Progressive Pancreatic Pseudocyst Disease with Endocrine and Exocrine Dysfunction

Introduction: Therapeutic interventions for pancreatic pseudocyst disease are most often based on symptoms, lesion size, and in particular duration of the lesion. Conventional wisdom typically avoids early surgical therapy for “immature” pseudocysts, citing concerns of cyst wall thickness, durability, and ability to hold suture material for a secure anastomosis. We present a case of a woman with biliary pancreatitis and a rapidly enlarging pseudocyst, complicated by endocrine and exocrine insufficiency. Prompt surgical therapy resulted in symptom relief and improved pancreatic function.

Case Report: A 53 year old woman with a 6-week history of biliary pancreatitis had initially undergone a CT scan that revealed an edematous pancreas without other lesion. Her symptoms included abdominal pain, diarrhea, and malaise, and were not responsive to medical therapy. New-onset diabetes mellitus was diagnosed along with steatorrhea. She became insulin dependent and required pancreatic enzyme supplementation. Repeat CT scan revealed a massive cystic lesion of the pancreas had developed in just a few weeks time. Pressure necrosis on the remaining pancreatic parenchyma was suspected. The lesion was not amenable to endoscopic drainage; she was referred by gastroenterology for surgical evaluation. Three-dimensional modeling using computerized volumetric analysis systems techniques (CVAS) demonstrated the extensive and complex nature of the lesion. A laparoscopic approach via the lesser sac allowed access to both the lesion and the posterior stomach. A satisfactory cystgastrostomy was constructed using a combination of stapled and suture technique. Flexible gastroscopy was performed across the anastomosis and into the pseudocyst cavity, verifying an airtight closure. Laparoscopic cholecystectomy completed the operation. The patient recovered uneventfully with prompt restoration of pancreatic endocrine and exocrine function.

Discussion: Insufficient published data exists to confirm or refute the traditional teaching that pancreas pseudocyst disease should be managed non-operatively early in its presentation. Rapidly progressive lesions causing pancreatic parenchymal destruction with resultant exocrine and/or endocrine insufficiency demand prompt intervention. When endoscopic intervention is not possible or available, the surgeon may be called upon for management. Laparoscopy provides an effective means to assess cyst characteristics and provide therapy, with minimal morbidity to the patient.

Conclusions: Pancreatic pseudocyst disease can be rapidly progressive, resulting in prompt loss of gland function, and significant morbidity. Internal drainage to decompress the lesion can result in prompt relief of symptoms, and restoration of gland function. Minimally invasive techniques can be used to achieve this end, with little to no added morbidity, even in the face of a massive lesion. Traditional wait times to allow cyst wall maturity may need to be reconsidered in the face or progressive pancreatic failure, particularly if a surgical team experienced in advanced laparoscopic techniques is available.

Session: Podium Video Presentation

Program Number: V035

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