Recurrent Pancreatic Pseudocyst

Carlos M Nuño-Guzmán, José Arróniz-Jáuregui, José I Gómez-Ontiveros,
Haydée Hernández-Estrada, Haydee I Estrada-Castañeda,
Juan R Araiza-Navarro, Nereida Esparza-Arias
Department of General Surgery, Antiguo Hospital Civil de Guadalajara “Fray Antonio Alcalde”.
Guadalajara, Jalisco, México
ABSTRACT
Context A pancreatic pseudocyst is defined as a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue
which is not lined by epithelium. Acute pseudocysts occur in acute pancreatitis but can be found after an acute exacerbation of
chronic pancreatitis. Chronic pancreatic pseudocysts are typically found in chronic pancreatitis but may develop after an occurrence
of acute pancreatitis as well. Most acute fluid collections and pseudocysts will show spontaneous resolution while the remaining may
persist with or without symptoms, or progress to produce complications. Treatment is indicated for persistent, symptomatic
pseudocysts and, in the case of complications. There is no clear consensus regarding the optimal clinical or radiologic follow-up
after treatment. Detection of late recurrence is not common, and the possibility of a cystic neoplasm must be ruled out. Case report
We report the case of a 67-year-old female patient who was referred to our institution as the result of a pancreatic pseudocyst. The
patient had presented a pancreatic pseudocyst 9 years earlier which had been surgically treated by a cystogastrostomy. No additional
acute pancreatic episodes occurred. The diagnostic and treatment approach of this unusual late recurrent pancreatic pseudocyst is
herein described. Conclusion The unusual late presentation of a recurrent pancreatic pseudocyst requires clinical, laboratory and
radiological evaluation. In the present case, the clinical background, amylase fluid levels and tomographic findings were highly
suggestive of a pancreatic pseudocyst.
INTRODUCTION
A pancreatic pseudocyst is defined as a collection of
pancreatic juice enclosed by a wall of fibrous or
granulation tissue which is not lined by epithelium [1].
Pseudocysts represent about two-thirds of pancreatic
cystic lesions, found in 10-20% of acute pancreatitis
cases and 20-40% of chronic pancreatitis patients.
Most acute fluid collections and pseudocysts will show
spontaneous resolution while some may persist with or
without symptoms, or progress to produce
complications. Treatment is indicated for persistent,
symptomatic pseudocysts, and in the case of
complications [2, 3]. There is no clear consensus
regarding the optimal clinical or radiologic follow-up
after treatment. Detection of late recurrence is not
common, and the possibility of a cystic neoplasm must
be ruled out.
CASE REPORT
A 67-year-old woman was referred to our department
with the presence of an abdominal mass in the upper
abdomen, detected during a routine gynecologic visit.
She had had an episode of acute pancreatitis 9 years
earlier, with the subsequent development of a
pancreatic pseudocyst, which was surgically managed
by a cystogastrostomy 2 months later in another
institution; a cholecystectomy was performed as well.
She denied any episode of abdominal pain thereafter
and did not recall post-surgical follow-up beyond one
year. There was no history, or clinical nor laboratory
data of diabetes or exocrine pancreatic insufficiency.
Physical examination revealed a midline surgical scar,
minimal tenderness upon palpation of a non-mobile
mass in the upper abdomen. Laboratory serum results
showed no abnormalities. The abdominal computed
tomography (CT) scan revealed a 135x58 mm well-
circumscribed unilocular cystic lesion in the region of
the pancreas (Figure 1).
The diagnosis of pancreatic pseudocyst was highly
probable but, considering the uncommon chronic
presentation, and, in order to measure amylase, tumor
marker CA 19-9 and carcinoembryonic antigen levels
(CEA) in the cystic fluid, an image-guided puncture
Received March 6th, 2011 - Accepted March 31st, 2011
Key words Pancreatic Pseudocyst; Pancreatitis
Correspondence Carlos M Nuño-Guzmán
Calle 68 No. 138. Sector Reforma; Guadalajara; Jalisco CP 44800;
México
Phone: +133-3614.5501; Fax: +133-3609.6229
E-mail: carlosnunoguzman@hotmail.com
Document URL http://www.joplink.net/prev/201105/14.html

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was planned. To demonstrate possible communication
between the pseudocyst and the main pancreatic duct,
an endoscopic retrograde cholangiopancreatography
(ERCP) was planned as well but, since the patient was
reluctant to undergo both procedures, surgical drainage
was carried out instead. Since the pseudocyst appeared
to be adherent to the posterior gastric wall on CT scan,
a cystogastrostomy was scheduled. At laparotomy, by
means of an anterior gastrotomy and a 5 cm incision
using electrocautery at the posterior gastric wall, where
the bulging pseudocyst was visualized, abundant non-
viscous clear brownish fluid was drained immediately.
A fluid sample and pseudocyst wall biopsy were sent
for determination of amylase level and
histopathological exam. The amylase fluid level was
8,524 IU/L. The cystogastrostomy was completed
using a running 2-0 polypropylene suture. The anterior
gastrotomy was sutured as was the abdominal wall.
Both frozen section and definite histopathological
examination demonstrated fibrous tissue, with no
epithelial lining, epithelial tissue or malignant
transformation. With an uneventful recovery, the
patient was discharged 10 days after surgery. At
follow-up 12 months later, an abdominal wall
protrusion was noted upon exertion. An abdominal
wall defect was palpated at the surgical scar. A control
CT scan demonstrated a midline abdominal wall
defect, but no evidence of a pancreatic pseudocyst
(Figures 2 and 3). Incisional hernia surgery was
performed. Six months after this latter surgery, the
patient remains in good condition.
DISCUSSION
The natural history of pancreatic pseudocysts following
acute pancreatitis is well known; while about 40% of
acute fluid collections show spontaneous resolution
within 6 weeks, a thick wall of granulation tissue takes
4 to 6 weeks to develop around the remaining 60%.
The pancreatic pseudocyst may then regress
spontaneously, persist with or without symptoms, or
progress to produce complications [3]. In contrast,
pancreatic pseudocysts do not follow the same rate of
spontaneous resolution in chronic pancreatitis [4].
Regression rates for asymptomatic chronic pancreatic
pseudocysts vary between 9 and 31% [2, 5]. Acute
pancreatitis, small pseudocyst size, intrapancreatic
location, pseudocyst of the head of the pancreas,
persistence for less than 6 weeks and a thin wall have
been associated with spontaneous resolution whereas
chronic pancreatitis, persistence for more than 6 weeks,
a wall thickness greater than 1 cm, lack of
communication with the Wirsung duct, proximal ductal
stenosis and an increase in size on follow-up are
associated with failure to resolve [2, 6, 7]. Acute
pseudocysts occur in acute pancreatitis but can be
found after an acute exacerbation of chronic
pancreatitis. Chronic pancreatic pseudocysts are
typically found in chronic pancreatitis but may develop
after an occurrence of acute pancreatitis as well [8, 9].
Although not specific, the most common clinical
manifestations are abdominal pain (76-94%), early
satiety, nausea and vomiting (50%), weight loss (20-
51%), and obstructive jaundice (20%). Upper
Figure 1. CT scan showing a well-circumscribed unilocular
pancreatic pseudocyst in close apposition to the posterior gastric
wall.
Figure 2. Pancreatic CT scan with absence of a pseudocyst.
Figure 3. Midline abdominal wall defect with partial protrusion of
the omentum.

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abdominal tenderness and epigastric fullness (60%), or
an abdominal mass may be present [2, 10, 11, 12, 13].
Although larger pancreatic pseudocysts may be
asymptomatic, there is a 10% risk of developing
complications such as bile duct or duodenal
compression/stenosis, rupture, portal hypertension
secondary to compression of one or more of the hepatic
portal, superior mesenteric and splenic veins,
pseudoaneurysm, hemorrhage, pancreatic ascites and
infection [2, 10].
When an acute fluid collection results after an episode
of acute pancreatitis, and persists on serial imaging
over a period of weeks, the diagnosis of an acute
pseudocyst is almost certain. But, even in patients who
have suffered from acute pancreatitis or a pancreatic
pseudocyst, detection of late recurrence is not common,
and the possibility of a cystic neoplasm must be ruled
out.
Laboratory serum test utility may be limited in the
diagnostic approach. White blood cell count, and
amylase and lipase levels may be elevated. Serum
bilirubin and liver function tests may be above normal
values as well [10, 13].
Diagnostic evaluation may begin with a
transabdominal ultrasonography. Sensitivity rates in
pancreatic pseudocyst detection range between 75%
and 90%, usually showing an echoic structure and
distal acoustic enhancement contained within a smooth
wall [10]. Abdominal CT is the method of choice,
showing a thick-walled, round or oval, fluid-filled
unilocular mass adjacent to the pancreas which, in a
patient with a history of acute or chronic pancreatitis, is
virtually pathognomonic. CT has a sensitivity of 82 to
100% and specificity of 98%. An important weakness
of the CT scan is its relative inability to differentiate a
pseudocyst from a cystic neoplasm [7, 10]. Endoscopic
ultrasound (EUS) is the test of choice for
distinguishing a pancreatic pseudocyst from a cystic
neoplasm of the pancreas. A cyst wall thickness of
more than 3 mm, macroseptation, the presence of a
mass or nodule, and cystic dilatation of the main
pancreatic duct are highly suggestive of a cystic
neoplasm. EUS may also be used together with fine
needle aspiration (FNA) of the cyst for laboratory
evaluation [10].
Analysis of the cystic fluid is particularly useful in
differentiating pancreatic pseudocysts and cystic
tumors. High amylase levels are typical in pancreatic
pseudocysts while low levels are seen in serous
cystadenomas; values above 5,000 U/mL show 94%
sensitivity and 74% specificity [14]. Carcinoembryonic
antigen (CEA) in the cystic fluid has been shown to
have low levels in pancreatic pseudocysts and serous
cystadenomas while it has elevated levels in mucinous
cystadenomas [10, 14, 15]. Although cytological
analysis by FNA may be useful for mucinous cysts but
of limited value for serous cystadenomas, the potential
risk of tumor seeding must be considered. Even
intraoperative biopsy of the cystic wall for frozen
section histopathology may be unreliable (incorrect in
20% or more of cases) [2]. The absence of epithelial
lining or epithelial tissue in pseudocysts excludes a
diagnosis of cystic neoplasm [16].
Treatment is indicated in symptomatic cases,
manifested as a persistent or recurrent feeling of
fullness, early satiety, abdominal distention, nausea or
vomiting, and pain or upper gastrointestinal bleeding.
Intervention is mandatory in case of complications:
compression of major abdominal vessels; compression
of the stomach, duodenum or main bile duct; pancreatic
ascites or a pancreatopleural fistula; infection and
hemorrhage [2, 7, 10]. Treatment is indicated in
asymptomatic pseudocysts with the following relative
risk factors: pseudocysts greater than 4 cm, no
evidence of regression after 6 weeks, a thick capsule of
more than 5 mm, chronic pancreatitis, main pancreatic
duct stones or strictures and suspicion of a neoplastic
cyst [2, 7].
Percutaneous drainage is the least invasive modality,
but requires an external drainage catheter which can be
placed under US or CT guidance. Recent studies have
reported disappointing results for drainage in 40 to
60% of cases. Those patients treated by percutaneous
drainage tend to have higher morbidity and mortality
rates when compared to surgery [2, 17].
Endoscopic drainage of pseudocysts is a widely used
therapeutic modality, either by means of a
transpapillary approach using ERCP or by means of a
transmural route through the stomach or duodenal wall.
A transpapillary approach is possible only if the
pseudocyst communicates with the pancreatic duct,
which occurs in 36 to 69% of patients. The clinical
success of transpapillary drainage ranges from 80 to
100%, with morbidity ranging from 10 to 20%, and
recurrence rates ranging from 10 to 20%. No
procedure-related mortality has been reported with this
approach [2, 10, 17]. With the transmural approach,
access to the cyst cavity is achieved through an incision
made in the gastric or duodenal wall. The pseudocyst
must be in close apposition to the stomach or
duodenum, and an area of bulging by luminal
compression will mark the location of the pseudocyst.
However, this bulging is present in only 42 to 45% of
cases. Endoscopic ultrasound-guided drainage has the
advantage of not relying on bulging to locate the site of
the pseudocyst and excludes the presence of interposed
blood vessels. The technical success rates in non-EUS-
guided transmural drainage range from 70 to 100%,
with morbidity rates ranging from 0 to 33% and
recurrence rates ranging from 0 to 30%. When
performed using EUS guidance, technical success rates
range from 95 to 100%. The endoscopic success rates
range from 80 to 100%, and do not vary whether or not
EUS is used [2, 10, 17]. The collective data regarding
endoscopic drainage show mortality rates of 0 to 1%,
long-term follow-up success rates of 62 to 75% of
cases and recurrence rates with long-term follow-up of
0 to 23% [2, 9].
Surgical drainage is accomplished by creating
communication between the pseudocyst and the

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stomach, duodenum or jejunum. There are several
surgical options. The primary considerations are the
anatomic location, the size of the pseudocyst and the
degree of chronic pancreatic disease. Wide internal
drainage is the most effective therapy for most patients.
Surgical drainage is the reference standard, with a
success rate of 70 to 100%, morbidity of 6 to 37%,
mortality of 1 to 16% and recurrence rates of 2 to 30%.
[2, 9, 12]. Surgical drainage options include
pseudocystogastrostomy, pseudocystoduodenostomy
and pseudocystojejunostomy. A pseudocystogastro-
stomy is recommended for pseudocysts directly
adherent to the posterior gastric wall. Small
pseudocysts (less than 4 cm) in the head and uncinate
process of the pancreas impinging on the duodenal wall
are best managed by a pseudocystoduodenostomy
while a pseudocystojejunostomy is a good surgical
option for all other pseudocysts [2, 18]. Minimally
invasive pseudocystogastrostomy and pseudocysto-
jejunostomy provides adequate internal drainage. Case
series suggest that the laparoscopic approach is safe,
although there is still a lack of definitive evidence [18,
19]. No prospective, controlled study has compared
surgical, percutaneous and endoscopic drainage results.
After a definitive treatment of pseudocysts,
surveillance imaging with US, CT or MRI is often
used. If the symptoms do not improve after treatment,
follow-up imaging is warranted. There is no clearly
defined value for a longitudinal follow-up after
treatment in an asymptomatic patient [19].
Grewal et al. reported the case of a 45-year-old man
with epigastric pain and a 10-year history of numerous
episodes of acute pancreatitis secondary to alcohol
abuse [20]. Nine years previously, a pancreatic
pseudocyst had been drained by a surgical
cystogastrostomy. After conservative treatment,
symptom recurrence and pyloric obstruction, a
5.5x5.3x6.0 cm pseudocyst was drained utilizing
endoscopic “needle-knife” cystogastrostomy, upon
reluctance on the patient to accept additional surgery.
Struve reported the case of an 82-year-old woman
having spontaneous resolution of a 7 cm pancreatic
pseudocyst 10 years after detection which had been
followed by ultrasonography since the patient refused
percutaneous or surgical management, due to the
absence of symptoms [21]. During the 10-year period,
no recurrence of pancreatitis was noted.
In the case herein reported, after the acute pancreatitis
episode and the initial pseudocyst surgical drainage,
there were no further episodes of abdominal pain
reported by the patient. The lack of symptoms and of
clinical or radiological post-surgical follow-up makes it
impossible to determine the time of recurrence. The CT
findings were also suggestive of a pancreatic
pseudocyst which made surgical treatment the most
appropriate option for drainage and biopsy of the cyst
wall.
In our hospital, a public institution, EUS is not
available, and access to it in our city is still very
limited. Once available, it will constitute an ideal
diagnostic modality with a known potential for guiding
endoscopic transmural drainage. The high
intraoperative amylase cyst fluid level was also highly
suggestive of a pseudocyst.
In summary, we reported an unusual late presentation
of a patient having a recurrent pancreatic pseudocyst,
with no symptoms, which was diagnosed by computed
tomography. The patient herein reported had a previous
history of acute pancreatitis and had had a pancreatic
pseudocyst treated by a cystogastrostomy 9 years
earlier.
Disclosure There is no financial support or conflict of
interest to declare by the authors
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