GAP-107
Pancreatic Pseudocyst: What is lurking behind the cyst’s walls?
1Williams J, 2Spitznagel R, 2LeRiger M
1University of Nebraska Medical Center, Omaha, NE, USA; 2Children's Hospital & Medical Center, Omaha, NE, USA
Pseudocyst of the pancreas (PP) is a relatively common complication of pancreatitis in the adult population; however, it is uncommon in pediatrics. Typically, PP in children results from blunt abdominal trauma; whereas, in adults it is sequelae of chronic pancreatitis. While pancreatic pseudocysts come with nagging morbidity, a rare but devastating complication is the development of a pseudoaneurysm involving an adjacent artery, secondary to chronic inflammation from pancreatic enzymatic digestion of the vessel wall. If the pseudoaneurysm ruptures, it carries up to 43% mortality. This rare complication has been reported in 2% of adult pseudoaneurysms, but has only been sporadically reported in the pediatric population [1, 2].
A 13-year-old, 31 kg male patient 2 weeks s/p surgical resection of a pheochromocytoma returned to the hospital with a right upper extremity DVT and abdominal pain. A PP along with hepatic and splenic infarcts was diagnosed. The patient remained hospitalized with medical management for 3 weeks in stable condition until the morning of hospital day 26 when he was found unresponsive in cardiopulmonary arrest. He was noted to have a distended abdomen along with a hemoglobin level of 3 g/dL. Active resuscitation efforts were initiated and he was emergently taken to the OR. An exploratory laparotomy revealed a ruptured superior mesenteric pseudoaneurysm that required massive transfusion administration. Over the next 24 hours multiple re-operations occurred requiring 45 units of PRBC, 33 units of FFP, 10 units of platelets, cryoprecipitate, factor VII, prothrombin complex concentrate, aminocaproic acid and tranexamic acid infusions in resuscitation efforts. Over the next several days acute renal failure ensued requiring continuous dialysis along with hemodynamic instability resulting in V-A ECMO and necrotic bowel resection. On POD 7, a neurological status change prompted a head CT, which revealed massive intracerebral hemorrhage. This led to compassionate extubation and ECMO discontinuation, resulting in the child’s death.
This case illustrates the importance of recognizing the devastating sequelae associated with PP. While rare in the pediatric population, pseudoaneurysm should be on the anesthesiologist's differential diagnosis to aid in both the rapid recognition and appropriate management. Our patient likely developed a PP secondary to manipulation of the pancreas and celiac access during removal of the adrenal tumor, leading to an SMA pseudoaneurysm that ultimately ruptured. Anesthesiologists need to prepare for significant bleeding and hemodynamic changes when dealing with a PP as a pseudoaneurysm may be lurking within the adjoining tissue [3].
Resources
1. Janarthanan K, Balalakshmoji D, Sanathkumar H, Suthakaran P. Chronic Pancreatitis Present with Peudocyst of Pancreas and Pseudo-aneurysm of Hepatic Artery. Indian J Pediatr. 2012;79(7):952—954.
2. Carr J, Cho J, Shepard A, Nypaver T, Reddy D. Visceral peudoaneurysms due to pancreatic pseudocysts: Rare but lethal complications of pancreatitis. J Vasc Surg. 2000;32:722—30.
3. Teh S, Pham T, Lee A, Stavlo P, Hanna A, Moir C. Pancreatic pseudocyst in children: the impact of managment strategies on outcome. J Ped Surg. 2006;41:1889—1893.
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