Splenocystojejunostomy for the treatment of a symptomatic splenic pseudocyst

Abstract

Pancreatic pseudocyst is a widely recognised local complication following acute pancreatitis. Typically occurring more than four weeks after acute pancreatitis, a pseudocyst is a mature, encapsulated collection found within the peripancreatic tissues manifesting as abdominal pain, structural compression, gastroparesis, sepsis and organ dysfunction. Therapeutic interventions include endoscopic transpapillary or transmural drainage, percutaneous catheter drainage and open surgery. We present our management of idiopathic chronic pancreatitis complicated by a pancreatic pseudocyst extending to the splenic capsule in a 38-year-old man. A trial of conservative management was sought, but later escalated to percutaneous fluoroscopic drainage. Despite a period of volume reduction of the pseudocyst, reaccumulation occurred. We describe successful surgical treatment via means of a splenocystojejunostomy and subsequent pain reduction.

Background

Pancreatic pseudocysts represent one of four widely recognised local complications that can occur following an episode of pancreatitis. According to the revised Atlanta classification of 2012, pancreatic pseudocysts are defined as mature, encapsulated collections of fluid, surrounded by a well-defined inflammatory wall, occurring more than four weeks after the onset of interstitial oedematous pancreatitis.¹ Although generally found in peripancreatic tissues, it is not uncommon for either parts or the entirety of the pseudocyst to be found within the pancreas.¹

Diagnosis is based on a combination of clinical and biochemical features, including persistent or recurrent episodes of abdominal pain, sepsis, organ dysfunction and elevation in lipase/amylase.¹ The incidence of pancreatic pseudocysts varies depending on the type of pancreatitis, ranging from 5% to 16% in acute pancreatitis and from 20% to 40% in chronic pancreatitis.²

The management of pancreatic pseudocysts can be conservative, endoscopic, radiological or surgical. Indications for therapeutic intervention include compressive symptoms, infection or haemorrhage of the pancreatic pseudocyst, gastric or duodenal outlet obstruction, or fistulas. Therapeutic interventions used in the management of pancreatic pseudocysts include endoscopic transpapillary or transmural drainage, percutaneous catheter drainage and surgery.

We present the surgical management of an atypical case of a pancreatic pseudocyst within the splenic capsule of a 38-year-old man.

Case history

In September 2017, a 38-year-old man was investigated locally for epigastric pain on a background of idiopathic chronic pancreatitis (first episode in 2007), albinism, recurrent renal stones, hypertension, type two diabetes mellitus and hypercholesterolaemia. Abdominal computed tomography (CT) demonstrated multiple left renal calculi with features of chronic pancreatitis, splenic vein occlusion with resultant gastric varices and splenomegaly (Figure 1).

Figure 1 .

Axial image from computed tomography of the abdomen (2017) demonstrating: (a) pancreatic calcification (arrow) and dilated distal pancreatic duct (arrowhead) with splenomegaly – the appearances are of chronic pancreatitis; (b) gastric varices (arrow) secondary to splenic venous occlusion; (c) note that there is no splenic venous opacification beyond the white arrow.

In March 2018, gastroscopy for iron deficiency anaemia demonstrated slow-bleeding gastric varices. On admission, pancreatic pseudocysts were noted on imaging, compatible with chronic pancreatitis (Figure 2), together with continuing splenic vein occlusion and gastric varices. He was managed conservatively and, since there was no active bleeding, he was later discharged home.

Figure 2 .

Axial image from follow-up computed tomography (March 2018) demonstrating pancreatic pseudocysts (arrows) and persistent splenomegaly

The patient was readmitted in June 2018 with acute-on-chronic pancreatitis. CT of the abdomen and pelvis demonstrated a new subcapsular splenic collection. He was managed conservatively as the collection and pseudocyst were not amenable to drainage. However, he continued to experience episodic abdominal pain and vomiting.

He was readmitted to hospital in July 2018 and CT showed a new large subcapsular splenic collection of mixed attenuation in keeping with haemorrhage into the pseudocyst (Figure 3). He was transferred to the regional tertiary hepatopancreatobiliary centre and percutaneous ultrasound guided drainage was performed, draining 1.4 litres (Figure 4). Endoscopic drainage was deemed unsafe due to the presence of significant perigastric varices. At the time, the splenic collection was thought to have resulted from erosion of the pancreatic tail pseudocyst into the splenic hilum. By December 2018, the splenic collection had reaccumulated, measuring 16cm in diameter. Magnetic resonance cholangiopancreatography performed in March 2019 demonstrated communication between the subcapsular splenic collection and the pseudocyst (Figure 5).

Figure 3 .

Coronal image from contrast enhanced computed tomography (mid-July 2018) demonstrating a subcapsular splenic haematoma (arrow)

Figure 4 .

Axial image from follow-up computed tomography (late July 2018) demonstrating resolution of the splenic haematoma, but with a large residual subcapsular splenic collection (arrow)

Figure 5 .

Three-dimensional render from magnetic resonance cholangiopancreatography, showing a large subcapsular splenic collection (black arrow) in continuity with the pancreatic pseudocysts (white arrowheads)

A decision was made to proceed with surgical intervention and, in September 2019, an open Roux-en-Y splenocystojejunostomy was performed. During the procedure, significant perigastric varices were confirmed due to left-sided portal hypertension. Adhesions were carefully dissected from the cyst and ultrasound was used to guide the anterior incision point away from the splenic parenchyma (Figure 6). Following needle aspiration of the pseudocyst to confirm the diagnosis, the wall was opened and the pseudocyst aspirated to dryness (1.3 litres). To fashion the splenocystojejunostomy, the jejunum was divided 30cm distal to the duodenojejunal flexure and a handsewn anastomosis using 4/0 polydioxanone (PDS) was fashioned between the distal jejunal limb and the cyst wall, creating a splenocystojejunal anastomosis. The proximal jejunal limb was anastomosed distal to the splenocystojejunal anastomosis with 4/0 PDS using a two-layered handsewn technique, forming a jejunojejunostomy. The mesenteric defect was closed, and a Robinson drain inserted next to the splenocystojejunostomy. The patient’s postoperative course was uneventful, and he was discharged home a week later, having had the drain removed.

Figure 6 .

Intraoperative imaging (September 2019) showing the point of extension of the pancreatic pseudocyst into the spleen

A follow-up CT four weeks postoperatively (Figure 7) demonstrated a significant reduction in the size of the perisplenic aspect of the pseudocyst. Furthermore, at four months follow-up he reported feeling generally well, with only minimal weight loss and significant pain reduction.

Figure 7 .

Axial image from postoperative abdominal computed tomography (October 2019) following surgical cyst enterostomy showing a small residual pseudocyst (arrow) containing gas locules (arrowhead) due to the enteral anastomosis

Discussion

The type of treatment and management of pancreatic fluid collections is contingent upon the type of fluid collection. According to the revised Atlanta criteria from 2012, pancreatic fluid collections are differentiated by their duration (onset greater or less than four weeks from onset of acute pancreatitis) and the presence of necrosis. This ultimately results in four subtypes: acute peripancreatic fluid collections, pseudocysts, acute necrotic collections and walled-off pancreatic necrosis.⁴

Acute peripancreatic fluid collections are fluid collections that result from the oedema of the inflamed pancreas or from ductal disruption following an acute episode of pancreatitis. They develop anytime from the day of onset of pancreatitis up to four weeks. Collections which persist beyond four weeks are technically defined as pseudocysts since, at this stage, these collections would have become encapsulated. Peripancreatic fluid collections are generally treated conservatively. External drainage should be avoided as this risks the introduction of infection and development of pancreatic fistulae.^2,4 Pancreatic pseudocysts, as in the case described, are mature, encapsulated collections of fluid occurring more than four weeks after the onset of interstitial oedematous pancreatitis. Asymptomatic pseudocysts require no intervention, but interventions are indicated if they are symptomatic or associated with local complications.

Acute necrotic collections are pancreatic collections occurring in the setting of pancreatic necrosis within four weeks of the onset of acute pancreatitis.¹ Sterile necrosis should be treated conservatively. Infected necrosis is the most feared complication of acute pancreatitis and is associated with a high risk of mortality.⁴ Patients with infected necrosis will definitively require an intervention to completely debride the cavities containing the necrosis and these interventions may be radiological or surgical. Walled-off pancreatic necroses are collections that contain necrotic debris from the pancreatic tissue and according to the Atlanta classification, these occur after four weeks from the onset of acute pancreatitis. Similarly, to acute necrotic collections, sterile necrosis can be managed conservatively, while infected necrosis requires radiological or surgical treatment.⁴

In the case of pseudocysts, endoscopic drainage of pseudocysts can achieve over 80% success rate, shorter associated hospital stays, and lower morbidity and mortality compared with other interventional procedures. Furthermore, this method allows for repeat drainage in cases of complications or recurrence.² Endoscopic drainage is not suitable when there is suspicion of pseudoaneurysms, portal hypertension or gastric varices, owing to the risk of haemorrhage. Transpapillary drainage, which is preferable to transmural drainage, requires communication of the pseudocyst with the pancreatic duct. Otherwise, a transmural approach is adopted, with the option of a connection through the stomach or duodenum dependent on proximity of the pseudocyst to the gastrointestinal lumen.

On the other hand, image-guided percutaneous drainage is typically used for the management of symptomatic, infected or immature pseudocysts. Depending on pseudocyst topography, this allows for transretroperitoneal, transperitoneal or transgastric aspiration, or catheter placement. It is not recommended for the management of chronic pseudocysts as outcomes are varied, with success rates of only 42% compared with 88% with surgery.²

In our patient, pancreatic multiloculated pseudocysts were incidentally diagnosed in March 2018 and were initially managed conservatively. However, the patient continued to be symptomatic, with multiple hospital admissions and progressive disease. Initially, a splenic collection developed with subsequent haemorrhage into the collection. The formation of the haematoma is suspected to have been due to the extension of the pancreatic pseudocyst into the splenic hilum. Pancreatic pseudocysts may occur within peripancreatic tissue but their extension to involve the spleen is rare. A complicating issue was the finding of sinistral portal hypertension leading to gastric varices as a result of splenic vein occlusion. This case highlights the imaging features of subcapsular splenic pancreatic pseudocysts and the importance of their early diagnosis and definitive management.