Endoscopic diagnosis of a pancreatic pseudoaneurysm after lateral pancreaticojejunostomy

Abstract

Lateral pancreaticojejunostomy (Puestow procedure) is occasionally used to ameliorate the abdominal pain of chronic pancreatitis. Local complications that have been reported include anastomotic leak, wound infection, hemorrhage, subphrenic abscess, and pancreatic ascites.1-3 We report here a postoperative case complicated by a bleeding pseudoaneurysm. CASE REPORT A 42 year-old Caucasian man presented with abdominal pain caused by chronic pancreatitis. The patient had had symptoms including abdominal pain, nausea, and anorexia for many years. Evaluation had included ERCP which revealed pancreas divisum with dorsal ductal changes of chronic pancreatitis. Therapeutic modalities including minor papilla sphincterotomy and stent placement, trials of pancreatic enzyme replacement, and celiac ganglion blockade were unsuccessful in ameliorating the patient’s symptoms. The patient ultimately underwent lateral pancreaticojejunostomy. Intraoperatively, a hard, chronically inflamed pancreas was exposed and the pancreatic duct identified. In the process of opening the duct, an artery overlying the duct was transected and sutureligated. The pancreatic duct was anastomosed to a jejunal Roux-en-Y. Hemostasis appeared adequate. The patient’s postoperative course was benign and he reported relief of abdominal pain. Three weeks after the operation, the patient presented with melena and weakness. His hemoglobin level was 6.9 gm/dL on admission with a baseline hemoglobin of 15.4 gm/dL three weeks before. The patient underwent upper GI endoscopy and ERCP. A shallow, clean-based duodenal bulb ulcer without bleeding stigmata was seen. No evidence of bleeding was seen from the major or minor papilla. The pancreatogram showed a short segment of patent dorsal duct with flow into the jejunal Roux-en-Y limb. A catheter was passed through the pancreas into the jejunal limb and clear fluid was aspirated. The patient had recurrent melena and repeat hemoglobin was 2.6 gm/dL.