Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts. Impact of pretreatment diagnosis
G. T. Marshall, D. A. Howell, B. L. Hansen, S. M. Amberson, G. S. Abourjaily and C. E. Bredenberg
Department of Surgery, Maine Medical Center, Portland, USA.
OBJECTIVE: To determine the effectiveness of thin-section, dynamic-contrast
computed tomography and angiography in detecting the presence of pancreatic
pseudoaneurysms. DESIGN: This case series consisted of 57 patients who were
being examined for endoscopic drainage of pancreatic pseudocysts. SETTING:
All patients were examined in a tertiary care, teaching hospital. PATIENTS:
Fifty-seven consecutive patients were examined for 2 years. Follow-up
ranged from 6 months to 2 years. INTERVENTIONS: All patients underwent
thin-section, high-speed, dynamic-contrast computed tomography. Those
patients with findings that were consistent with the presence of a
pseudoaneurysm underwent angiography. Embolization was attempted if a
pseudoaneurysm was present. Endoscopic retrograde cholangiopancreatography
was used to determine pancreatic ductal anatomy before operation. MAIN
OUTCOME MEASURE: No undetected pseudoaneurysm has complicated this series
of endoscopically drained pseudocysts. RESULTS: Five patients had findings
that were consistent with a pancreatic pseudoaneurysm on computed
tomography. Angiographic findings confirmed a pseudoaneurysm in four
patients, and angiographic embolization was successful in three. Four
patients underwent resection, while one was treated with embolization and
endoscopic stenting of a compressed pancreatic duct. There were no
mortalities. CONCLUSIONS: Before endoscopic drainage of a pancreatic
pseudocyst, a thin-section, high-speed, dynamic-contrast computed
tomographic scan is essential. If there are findings consistent with the
development of a pseudoaneurysm, angiography must be performed. This allows
delineation of the arterial anatomy, as well as the option of performing
angiographic embolization. While patients with pseudoaneurysms in the body
and tail of the pancreas underwent resection, angiographic embolization
alone was an acceptable alternative when the lesion was located in the head
of the pancreas.
