Distal pancreatectomy for giant pancreatic pseudocyst with splenic rupture in a patient with chronic pancreatitis

Abstract

Pancreatic pseudocysts are a frequent complication of chronic pancreatitis. Spontaneous splenic rupture and subcapsular hematoma is a rare and fatal event in a pseudocyst. In the literature, the real incidence of this kind of complication is not clearly defined. We herein present a case of a 31 year-old male with a large pseudocyst associated with splenic rupture. The patient had a history of acute alcoholic pancreatitis three months ago in another hospital centre. He presented at our emergency department with abdominal pain and poor general condition (hemodynamic instability). After resuscitation, an abdominal CT scan was performed, which showed a giant pseudocyst (16x17x24cm, APxLxCC) causing a splenic rupture contained by the spleen capsule. After multidisciplinary committee, we proposed a minimally invasive surgical approach. Previously, we proposed drainage by percutaneous approach of the pseudocyst. The procedure were performed without incidences. After drainage, we performed a minimally robot-assisted distal pancreatectomy with splenectomy using Da Vinci Xi system. Five trocars were used, the operative time was 321min, we used Echelon black cartridge-mechanical staple for pancreatic transection. A grade B pancreatic fistula occured in the immediate postoperative period, adequately drained and treated with somatostatin analogues. We removed the drain at the outpatient consultation three weeks after surgery. The anatomo-pathology reported a peripancreatic pseudocyst with extensive acute and subacute bleeding and inflammatory changes. Keywords: Angiographic drainage, pseudocyst, spleen rupture, robot-assisted surgery. Figure legend: △: main pancreatic duct (pancreatic tail); →:splenic capsular dissection; ✱: spleen; ✱: pseudocyst