Obstructive Jaundice secondary to Pancreatic Pseudocyst Taizo KIMURA, Toshiro KONISHI, and Mitsuo SUGIURA A B S T R A C T : A case of obstructive jaundice resulting from the compression of the common bile duct by a pancreatic pseudocyst is reported, which is of rare occurrence. Total excision of the cyst and choledochojejunostomy were performed. Postoperative course was uneventful with rapid disappearance ofjaundice. Nine out often cases of pancreatic pseudocyst were treated by total excision with one death during 1951 through 1974. K E Y W O R D S : pancreatic pseudocyst, obstructive jaundice, total excision, internal drainage. INTRODUCTION
Among clinical features of pancreatic pseudocyst, jaundice is noted in about 10 per cent 8 due to the compression of the bile duct by the cyst itself or to the coexisting disease such as pancreatitis or calculous disease of the biliary tract. The former seems to be uncommon4,6, is and is expected to occur only when the cyst is located in the head of the pancreas, for which internal drainage is considered to be an operation of choice.4, v,9,11,16 In the present case total excision of the cyst and choledochojejunostomy were successfully performed. CASE REPORT
A 16-year-old girl was admitted to the department on Oct. 7, 1974. Her chief complaints were abdominal fullness of three months duration, jaundice and pruritus of three weeks duration, and anorexia and epigastric pain radiating to the back of one week duration. A weight loss of three kg accompanied her present illness. She gave no history of trauma to the abdomen and was quite well until the onset of the present illness. On initial examination, there was obvious icterus of the skin and sclerae. She was febrile mildly and her urine was dark. Examination of the heart and lungs was not remarkable. The liver was not enlarged. A round, hard and smooth-surfaced mass of 10cm in diameter was palpable in the right upper quadrant. It was mildly tender and not movable. Laboratory studies showed that hemoglobin was 11.8g/dl, red cell count 397 • 104, hematocrit 35.3 per cent, white cell count 14,300, total protein 7.54g, albumin 3.04g, total cholesterol 328mg, total bilirubin 24.4mg with a direct component of 14.0mg/dl, alkaline phosphatase 68 King Armstrong units, lactic dehydrogenase 594 units, and amylase 387 International units. Thymol turbidity test gave one unit, serum glutamic pyruvic transaminase 30 units. Serum electrolyte determinations were normal. Her urine determination showed increased bilirubin and decreased urobilinogen. A scout abdominal X-ray did not well delineate the mass and calcification was absent. U p p e r gastrointestinal series demonstrated a right upper guadrant mass which displaced anteriorly and flattened the second portion of the duodenum (Fig. 1). Echogram revealed cystic nature of the
From the Second Department of Surgery, University of Tokyo, Tokyo, Japan. JAPANESEJOURNALOF SURGERY,VOL. 5, No. 2, pp 103-108, 1975
104
Kimura, et al.
Jap. J. Surg. June 1975
Fig. 1. Upper gastrointestinal series showing the flattened duodenal loop displaced anteriorly.
mass. Differential diagnoses at that time included choledochal cyst or pancreatic cyst. On August 14, 1974, exploratory laparotomy was performed. Multiple adhestions were encountered in the upper abdomen. A cyst of 10era in diameter was found in the head of the pancreas. The remainder of the pancreas appeared to be normal. The liver was greenish in color. The biliary tract was dilated and the lower end of the common bile duct was embedded in the cyst wall. Operative cholangiogram showed no stones in the biliary tract, absence of communication between the cyst and the common bile duct and compression of common bile duct by the cyst (Fig. 2). Injection of contrast medium into the cyst revealed no communication between the cyst and the pancreatic duct (Fig. 3). In spite of decompression of the cyst by a needle aspiration yielding 200ml of brownish fluid, stenosis of the common bile duct was not relieved suggesting that the duct had been scarred due to the previous inflammatory process spread from the surrounding cyst wall. Therefore, internal drainage of pancreatic cyst alone is not likely to relieve obstructive jaundice in this particular case. Extirpation of the cyst was performed. Following careful and meticulous dissection of the cyst fi'om the duodenum, the inferior vena cava and the portal vein, the cyst was excised together with the lower end of the common bile duct from which the cyst wall could not be dissected. The duct of Wirsung which was probably occluded, was severed after ligation, while the duct of Santorini was identified and left intact. Thereafter, cholecystectomy and a Roux-en-Y choledochojejunostomy were accomplished. Pathological examination revealed that cyst wall was consisting of fibrous granulation
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Pancreatic Pseudocyst
Fig. 2.
105
Operative chotangiogram demonstrating tile compressed common bile duct.
tissue and necrotic mass without an epithelial lining (Fig. 4). These findings support the diagnosis of pancreatic pseudocyst, although the etiological factors responsible such as trauma or pancreatitis, could not be traced. Postoperative course was uneventful. By Nov. 14, 1974, the serum bilirubin decreased to 1.46mg, with a direct bilirubin of 1.1mg/dl, and all other serum determinations except the amylase became normal. The serum amylase level remained high (500 to 800 International units) but without any symptom. The patient remained asymptomatic since the discharge on Nov. 28, 1974. Discussion O f the 104 cases of pancreatic pseudocysts reported by Becker, et al 4, obstructive jaundice was associated in six patients, but in only three was it definitely established that compression of the common bile duct was due to the cyst in the head of the pancreas. In a series of 16 cases of pancreatic pseudocysts reported by Miyazaki, 12 two had jaundice, for which no particular cause was mentioned. Shimura 14 reported 18 cases of pancreatic pseudocysts, of which none had jaundice. In 1967, Aoki 2 reported a patient with obstructive jaundice due to the compression of the hepatic duct by pancreatic pseudocyst. During a 24 year-period from 1951 through 1974, 14 patients with pancreatic cysts, of which ten were pseudocysts and four true cysts, were admitted to the department but the present case was the only one with obstructive jaundice. Various surgical procedures have been proposed for the treatment of pseudocyst of
Kimura, et al.
106
Fig. 3.
Fig. 4.
Jap. J. Surg. June 1975
Operative cystography after the injection of contrast medium into the cyst. No communication was demonstrated between the cyst and the pancreatic duct.
Surgical specimen showing the thick wall with rough internal surface.
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the pancreas. Becket, et al 4, tabulated 1,020 patients from the literature between 1945 and 1966 treated by excision and external or internal drainage. The excision was done in 126 with a mortality rate of 12.5 per cent and a recurrence rate of 2.6 per cent, external drainage in 443 with a mortality rate of 6.3 per cent and a recurrence rate of 22.2 per cent and internal drainage in 495 with a mortality rate of 5.3 per cent and a recurrence rate of 3.5 per cent. They concluded that total excision should be restricted to the pseudocysts present in the distal part of the pancreas which were usually not densely adherent to the surrounding structures. The most pseudocysts could be safely and effectively treated by internal drainage. Five patients with obstructive jaundice resulting from the compression of the common bile duct by a pancreatic pseudocyst reported by Gonzalez, 6 were treated T a b l e 1.
Pancreatic cyst
Case No.
Age
Sex
Classification
1 2 3
23 33 43
M F M
Pseudocyst Pseudocyst Pseudocyst
body body body
4 5 6
44 51 60
F M F
Retentioncyst Pseudocyst Cystadenoma
body body head
7 8
17 21
M F
Pseudocyst Pseudocyst
tail tail
9
23
F
Pseudocyst
tail
10
20
F
Pseudocyst
tail
11 12 13
68 28 16
F F F
Pseudocyst Retentioncyst Pseudocyst
body tail head
14
38
M
Retentioncyst
body
Location
Operative procedure employed total excision total excision partial excision and external drainage total excision total excision total excision and pancreaticojejunostomy total excision distal pancreatectomy, splenectomy and pancreaticojejunostomy total excision and pancreaticojejunostomy total excision and tube drainage total excision distal pancreatectomy total excision and choledochojejunostomy sphincteroplasty
(The 2nd Department of Surgery of Tokyo University Hospital between 1951 and 1974) successfully by the internal drainage. However we believe that excision is the best form of treatment when feasible, because recurrence, hemorrage and abscess formation3 may occur from the cyst not removed. Postoperative hemorrage from the cyst was reported at a rate of 5-17 per centl,5,11 in case of internal drainage. Although dissection of the cyst wall from the surrouding adherent structures is often difficult and involves great risks, we believe that many of the pseudocysts can be removed safely, if the dissection is done meticulously even located in the head of pancreas as the present case shows. In addition to the present case nine cases of pseudocyst located in the body and tail of the pancreas were operated between 1951 and 1974. Total excision of the pseudocyst was accomplished in eight patients (Table 1). One (No. 7) died because of the spontaneous rupture of the cyst into the free peritoneal cavity before the operation was undertaken. To avoid leakage of pancreatic secretions, pancreaticojejunostomy was performed in two cases and
108
Kimura, et al.
Jap. J. Surg. June 1975
t u b e d r a i n a g e i n o n e . A n y o f t h e s e v e n cases d i d n ' t h a v e a r e c u r r e n c e o f t h e cyst n o r a n y complication that needed an additional operation. In the present case obstructive jaundice would not have been relieved by internal drainage and total extirpation was mandatory. (Received for publication on M a y 15, 1975)
References 1. Anderson, M. C.: Management of pancreatic pseudocysts, Amer. J. Surg. 123: 209-221, 1971. 2. Aoki, S., Sugioka, G., Kitamura, K., Aikawa, K. and Hatano, S.: A case report of portal hypertension and obstructive jaundice due to pancreatic cyst, Naika (Internal Medicine) 20: 584-588, 1967 (in Japanese). 3. Balfour, J. F. : Pancreatic pseudocysts : complication and their relation to the timing of treatment, Surg. Clin. N. Amer. 50: 395402, 1970. 4. Becker, W. F., Pratt, H. S. and Ganji, H.: Pseudocysts of the pancreas, Surg. Gynec. Obst. 127: 744-747, 1968. 5. Folk, F. A. and Freeark, R. J.: Reoperations for pancreatic pseudocyst, Arch. Surg. 100: 430437, 1970. 6. Gonzalez, L. L., Jaffe, M. S., Wiot, J. F. and Ahemeier, W. A.: Pancreatic pseudocyst: a cause of obstructive jaundice, Ann. Surg. 161 : 569-576, 1965. 7. Harewood, I. H., Leffall, L. D. and Syphax, B. : Pseudocysts of the pancreas, experimences in diagnosis and treatment: a review of 13 cases, J. Nat. Med. Ass. 62: 50-55, 1970. 8. Howared, J. M. and Jordan, G. L." Surgical diseases of the pancreas, pp. 290-291, J. B. Lippincott Company, Philadelphia, 1960.
9. Hoxworth, P. L., Mattheis, H., Coith, R. L. and Altemeier, W. A. : Internal drainage for pseudocyst of the pancreas, Surg. Gynec. Obstet. 122: 327-333, 1963. 10. Hutson, D. G., Zeppa, R. and Warren, W. D. : Prevention of postoperative hemorrhage after pancreatic cystogastrostomy, Ann. Surg. 177: 689-693, 1973. 11. Masih, B., Lowenfels, A. B., Pendse, P. D. and Rohman, M.: Jaundice from pancreatic pseudocyst, NY. State, J. Med. 71: 23122313, 1971. 12. Miyazaki, I.: Pancreatic cyst, Nihon-Rinsho (Japan Clinics) 31:605-612, 1973 (in Japanese). 13. Scharplatz, D. and White, T. T.: A review of 64 patients with pancreatic cysts, Ann. Surg. 176: 638-640, 1972. 14. Shimura, H.: Clinical features and operative indication of pancreatic cysts, Rinsho to Kenkyu (Clinic and Research) 50: 652-659, 1973 (in Japanese). 15. Sidel, V. W., Wilson, R. E. and Shipp, J. C.: Pseudocyst formation in chronic pancreatitis, a cause of obstructive jaundice, Arch. Surg. 77: 933-937, 1958. 16. Warren, K. W. and Badosa, F.: Individulization in treatment of pancreatic cysts. Amer. Surg. 39: 555-561, 1973.
Among clinical features of pancreatic pseudocyst, jaundice is noted in about 10 per cent 8 due to the compression of the bile duct by the cyst itself or to the coexisting disease such as pancreatitis or calculous disease of the biliary tract. The former seems to be uncommon4,6, is and is expected to occur only when the cyst is located in the head of the pancreas, for which internal drainage is considered to be an operation of choice.4, v,9,11,16 In the present case total excision of the cyst and choledochojejunostomy were successfully performed. CASE REPORT
A 16-year-old girl was admitted to the department on Oct. 7, 1974. Her chief complaints were abdominal fullness of three months duration, jaundice and pruritus of three weeks duration, and anorexia and epigastric pain radiating to the back of one week duration. A weight loss of three kg accompanied her present illness. She gave no history of trauma to the abdomen and was quite well until the onset of the present illness. On initial examination, there was obvious icterus of the skin and sclerae. She was febrile mildly and her urine was dark. Examination of the heart and lungs was not remarkable. The liver was not enlarged. A round, hard and smooth-surfaced mass of 10cm in diameter was palpable in the right upper quadrant. It was mildly tender and not movable. Laboratory studies showed that hemoglobin was 11.8g/dl, red cell count 397 • 104, hematocrit 35.3 per cent, white cell count 14,300, total protein 7.54g, albumin 3.04g, total cholesterol 328mg, total bilirubin 24.4mg with a direct component of 14.0mg/dl, alkaline phosphatase 68 King Armstrong units, lactic dehydrogenase 594 units, and amylase 387 International units. Thymol turbidity test gave one unit, serum glutamic pyruvic transaminase 30 units. Serum electrolyte determinations were normal. Her urine determination showed increased bilirubin and decreased urobilinogen. A scout abdominal X-ray did not well delineate the mass and calcification was absent. U p p e r gastrointestinal series demonstrated a right upper guadrant mass which displaced anteriorly and flattened the second portion of the duodenum (Fig. 1). Echogram revealed cystic nature of the
From the Second Department of Surgery, University of Tokyo, Tokyo, Japan. JAPANESEJOURNALOF SURGERY,VOL. 5, No. 2, pp 103-108, 1975
104
Kimura, et al.
Jap. J. Surg. June 1975
Fig. 1. Upper gastrointestinal series showing the flattened duodenal loop displaced anteriorly.
mass. Differential diagnoses at that time included choledochal cyst or pancreatic cyst. On August 14, 1974, exploratory laparotomy was performed. Multiple adhestions were encountered in the upper abdomen. A cyst of 10era in diameter was found in the head of the pancreas. The remainder of the pancreas appeared to be normal. The liver was greenish in color. The biliary tract was dilated and the lower end of the common bile duct was embedded in the cyst wall. Operative cholangiogram showed no stones in the biliary tract, absence of communication between the cyst and the common bile duct and compression of common bile duct by the cyst (Fig. 2). Injection of contrast medium into the cyst revealed no communication between the cyst and the pancreatic duct (Fig. 3). In spite of decompression of the cyst by a needle aspiration yielding 200ml of brownish fluid, stenosis of the common bile duct was not relieved suggesting that the duct had been scarred due to the previous inflammatory process spread from the surrounding cyst wall. Therefore, internal drainage of pancreatic cyst alone is not likely to relieve obstructive jaundice in this particular case. Extirpation of the cyst was performed. Following careful and meticulous dissection of the cyst fi'om the duodenum, the inferior vena cava and the portal vein, the cyst was excised together with the lower end of the common bile duct from which the cyst wall could not be dissected. The duct of Wirsung which was probably occluded, was severed after ligation, while the duct of Santorini was identified and left intact. Thereafter, cholecystectomy and a Roux-en-Y choledochojejunostomy were accomplished. Pathological examination revealed that cyst wall was consisting of fibrous granulation
Volume 5 Number 2
Pancreatic Pseudocyst
Fig. 2.
105
Operative chotangiogram demonstrating tile compressed common bile duct.
tissue and necrotic mass without an epithelial lining (Fig. 4). These findings support the diagnosis of pancreatic pseudocyst, although the etiological factors responsible such as trauma or pancreatitis, could not be traced. Postoperative course was uneventful. By Nov. 14, 1974, the serum bilirubin decreased to 1.46mg, with a direct bilirubin of 1.1mg/dl, and all other serum determinations except the amylase became normal. The serum amylase level remained high (500 to 800 International units) but without any symptom. The patient remained asymptomatic since the discharge on Nov. 28, 1974. Discussion O f the 104 cases of pancreatic pseudocysts reported by Becker, et al 4, obstructive jaundice was associated in six patients, but in only three was it definitely established that compression of the common bile duct was due to the cyst in the head of the pancreas. In a series of 16 cases of pancreatic pseudocysts reported by Miyazaki, 12 two had jaundice, for which no particular cause was mentioned. Shimura 14 reported 18 cases of pancreatic pseudocysts, of which none had jaundice. In 1967, Aoki 2 reported a patient with obstructive jaundice due to the compression of the hepatic duct by pancreatic pseudocyst. During a 24 year-period from 1951 through 1974, 14 patients with pancreatic cysts, of which ten were pseudocysts and four true cysts, were admitted to the department but the present case was the only one with obstructive jaundice. Various surgical procedures have been proposed for the treatment of pseudocyst of
Kimura, et al.
106
Fig. 3.
Fig. 4.
Jap. J. Surg. June 1975
Operative cystography after the injection of contrast medium into the cyst. No communication was demonstrated between the cyst and the pancreatic duct.
Surgical specimen showing the thick wall with rough internal surface.
Volume 5 Number 2
107
Pancreatic Pseudocyst
the pancreas. Becket, et al 4, tabulated 1,020 patients from the literature between 1945 and 1966 treated by excision and external or internal drainage. The excision was done in 126 with a mortality rate of 12.5 per cent and a recurrence rate of 2.6 per cent, external drainage in 443 with a mortality rate of 6.3 per cent and a recurrence rate of 22.2 per cent and internal drainage in 495 with a mortality rate of 5.3 per cent and a recurrence rate of 3.5 per cent. They concluded that total excision should be restricted to the pseudocysts present in the distal part of the pancreas which were usually not densely adherent to the surrounding structures. The most pseudocysts could be safely and effectively treated by internal drainage. Five patients with obstructive jaundice resulting from the compression of the common bile duct by a pancreatic pseudocyst reported by Gonzalez, 6 were treated T a b l e 1.
Pancreatic cyst
Case No.
Age
Sex
Classification
1 2 3
23 33 43
M F M
Pseudocyst Pseudocyst Pseudocyst
body body body
4 5 6
44 51 60
F M F
Retentioncyst Pseudocyst Cystadenoma
body body head
7 8
17 21
M F
Pseudocyst Pseudocyst
tail tail
9
23
F
Pseudocyst
tail
10
20
F
Pseudocyst
tail
11 12 13
68 28 16
F F F
Pseudocyst Retentioncyst Pseudocyst
body tail head
14
38
M
Retentioncyst
body
Location
Operative procedure employed total excision total excision partial excision and external drainage total excision total excision total excision and pancreaticojejunostomy total excision distal pancreatectomy, splenectomy and pancreaticojejunostomy total excision and pancreaticojejunostomy total excision and tube drainage total excision distal pancreatectomy total excision and choledochojejunostomy sphincteroplasty
(The 2nd Department of Surgery of Tokyo University Hospital between 1951 and 1974) successfully by the internal drainage. However we believe that excision is the best form of treatment when feasible, because recurrence, hemorrage and abscess formation3 may occur from the cyst not removed. Postoperative hemorrage from the cyst was reported at a rate of 5-17 per centl,5,11 in case of internal drainage. Although dissection of the cyst wall from the surrouding adherent structures is often difficult and involves great risks, we believe that many of the pseudocysts can be removed safely, if the dissection is done meticulously even located in the head of pancreas as the present case shows. In addition to the present case nine cases of pseudocyst located in the body and tail of the pancreas were operated between 1951 and 1974. Total excision of the pseudocyst was accomplished in eight patients (Table 1). One (No. 7) died because of the spontaneous rupture of the cyst into the free peritoneal cavity before the operation was undertaken. To avoid leakage of pancreatic secretions, pancreaticojejunostomy was performed in two cases and
108
Kimura, et al.
Jap. J. Surg. June 1975
t u b e d r a i n a g e i n o n e . A n y o f t h e s e v e n cases d i d n ' t h a v e a r e c u r r e n c e o f t h e cyst n o r a n y complication that needed an additional operation. In the present case obstructive jaundice would not have been relieved by internal drainage and total extirpation was mandatory. (Received for publication on M a y 15, 1975)
References 1. Anderson, M. C.: Management of pancreatic pseudocysts, Amer. J. Surg. 123: 209-221, 1971. 2. Aoki, S., Sugioka, G., Kitamura, K., Aikawa, K. and Hatano, S.: A case report of portal hypertension and obstructive jaundice due to pancreatic cyst, Naika (Internal Medicine) 20: 584-588, 1967 (in Japanese). 3. Balfour, J. F. : Pancreatic pseudocysts : complication and their relation to the timing of treatment, Surg. Clin. N. Amer. 50: 395402, 1970. 4. Becker, W. F., Pratt, H. S. and Ganji, H.: Pseudocysts of the pancreas, Surg. Gynec. Obst. 127: 744-747, 1968. 5. Folk, F. A. and Freeark, R. J.: Reoperations for pancreatic pseudocyst, Arch. Surg. 100: 430437, 1970. 6. Gonzalez, L. L., Jaffe, M. S., Wiot, J. F. and Ahemeier, W. A.: Pancreatic pseudocyst: a cause of obstructive jaundice, Ann. Surg. 161 : 569-576, 1965. 7. Harewood, I. H., Leffall, L. D. and Syphax, B. : Pseudocysts of the pancreas, experimences in diagnosis and treatment: a review of 13 cases, J. Nat. Med. Ass. 62: 50-55, 1970. 8. Howared, J. M. and Jordan, G. L." Surgical diseases of the pancreas, pp. 290-291, J. B. Lippincott Company, Philadelphia, 1960.
9. Hoxworth, P. L., Mattheis, H., Coith, R. L. and Altemeier, W. A. : Internal drainage for pseudocyst of the pancreas, Surg. Gynec. Obstet. 122: 327-333, 1963. 10. Hutson, D. G., Zeppa, R. and Warren, W. D. : Prevention of postoperative hemorrhage after pancreatic cystogastrostomy, Ann. Surg. 177: 689-693, 1973. 11. Masih, B., Lowenfels, A. B., Pendse, P. D. and Rohman, M.: Jaundice from pancreatic pseudocyst, NY. State, J. Med. 71: 23122313, 1971. 12. Miyazaki, I.: Pancreatic cyst, Nihon-Rinsho (Japan Clinics) 31:605-612, 1973 (in Japanese). 13. Scharplatz, D. and White, T. T.: A review of 64 patients with pancreatic cysts, Ann. Surg. 176: 638-640, 1972. 14. Shimura, H.: Clinical features and operative indication of pancreatic cysts, Rinsho to Kenkyu (Clinic and Research) 50: 652-659, 1973 (in Japanese). 15. Sidel, V. W., Wilson, R. E. and Shipp, J. C.: Pseudocyst formation in chronic pancreatitis, a cause of obstructive jaundice, Arch. Surg. 77: 933-937, 1958. 16. Warren, K. W. and Badosa, F.: Individulization in treatment of pancreatic cysts. Amer. Surg. 39: 555-561, 1973.
