Aortocystoduodenal Rare
Complication
of Pancreatic
Fistula
Pseudocyst
William F. Sindelar, MD, PhD, G. Robert Mason, MD, PhD \s=b\ An upper
gastrointestinal tract hemorrhage resulting from aortocystoduodenal fistula developed in a patient with a pancreatic pseudocyst. The fistula was exposed through a duodenotomy, necrotic material was debrided from the pseudocyst and the aortic wall, the aortic defect was closed primarily, and the pseudocyst was drained through a cystoduodenostomy. The case is discussed as a rare hemorrhagic complication of pancreatic pseudocysts and as an illustration that under certain circumstances of infection in areas where aortic bypass can be difficult to perform, primary vascular repair can be a successful method of managing aortoenteric fistulas. (Arch Surg 114:953-955, 1979) an
pseudocysts Pancreaticpancreatic
tions of versy exists
are
well-recognized complica¬
inflammation.'-· Although contro¬ over methods of clinical management of pseudocysts,11' " much current evidence favors surgical intervention early in the course of pseudocyst develop¬ ment1 in order to minimize the chances of complications of abscess formation, rupture, or hemorrhage. The most serious complication of pancreatic pseudocyst is hemorrhage, a rare but always life-threatening and usually fatal occurrence.71" The most frequent sources of hemorrhage in pancreatic pseudocysts are diffuse oozing from the cyst wall, erosion of the splenic artery, or involvement of the gastroduodenal artery.13 Pseudocyst hemorrhage with erosion into the gastrointestinal (GI) tract can uncommonly be the source of major GI bleed¬
ing.11117' The
present
case
nation he was thin and normotensive, with tachycardia, mild scierai icterus, and moderate diffuse abdominal tenderness with an epigastric mass present on deep palpation. The hemoglobin level was 9.8 g/dL, and the WBC count was 12,500/cu mm. Serum chemistry determinations were normal except for an elevated total bilirubin level of 2.8 mg/dL and an elevated alkaline phosphatase determination of 212 King-Armstrong units/mL. The amylase level was normal at 80 Somogyi units/dL. Stool was positive for occult blood. Small amounts of old blood returned through a nasogastric tube. Vital signs were stabilized by administration of intravenous fluids and transfusion with 2 units of blood. Fiberoptic esophago¬ gastroduodenoscopy was carried out, showing small esophageal varices with no evidence of recent hemorrhage, normal stomach without inflammation or erosion, and the duodenal bulb free of ulcers or other lesions. Sigmoidoscopy showed no abnormalities. Approximately 24 hours after admission, the patient had an
report illustrates successful surgical
treatment of a pancreatic pseudocyst that eroded into the aorta and subsequently into the duodenum, resulting in massive upper GI tract hemorrhage.
REPORT OF A CASE with known chronic alcoholism was admitted 52-year-old University of Maryland Hospital in 1975 with acute pancreatitis. He was treated with fluids given intravenously, nasogastric suction, and anticholinergics, and his condition improved. The acute episode resolved within seven days, but a pseudocyst developed in the head of the pancreas, as shown both on roentgenography of the upper GI tract and on ultrasonography. The patient was discharged and followed up regularly in the medical clinic. He remained asymptomatic except for occasional complaints of epigastric fullness. Approximately 20 months after discharge from the hospital for pancreatitis, the patient was seen in the emergency room with complaints of syncope, epigastric pain radiating to the back, and A
man
to the
hematemesis. He
was
admitted to the medical service. On exami-
Accepted
for publication Feb 5, 1979. From the Department of Surgery, University of Maryland School of Medicine, Baltimore. Dr Sindelar is now with the Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Md. Reprint requests to Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20205 (Dr Sindelar).
Fig 1.—Superior mesenteric arteriogram showing filling of pseu¬ docyst in region of head of pancreas. Fistula is shown at junction of superior mesenteric artery and aorta.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/07/2015
episode of hematemesis, requiring 4 L of fluid replacement and 4 units of blood to correct hypotension. After clinical stabilization, repeat endoscopy showed
no source of upper GI tract bleeding. A negative. An upper GI tract film series showed gastric and duodenal displacement by a mass in the head of the pancreas, but no abnormalities suggestive of a bleeding source were detected. Abdominal sonography showed an 8-cm cyst in the
barium
enema was
pancreas.
After his condition had remained clinically stable for 48 hours, the patient had another episode of hematemesis, with hematoche¬ zia. A third upper GI endoscopy showed no new findings. Again the patient's condition stabilized and showed no further signs of hemorrhage for two days. Surgical consultation was obtained on the fifth day of hospital¬ ization, and angiography was performed. A flush aortogram with selective superior mesenteric injection showed immediate filling of a large pancreatic cyst at the origin of the superior mesenteric artery (Fig 1). A celiac injection showed no specific abnormalities; the pancreatic cyst did not fill from the gastroduodenal artery. The patient suffered a massive upper GI tract hemorrhage six hours after angiography and became profoundly hypotensive. He was vigorously resuscitated with fluid and blood replacement and was brought to the operating room for emergency laparotomy. At surgery (Fig 2), the stomach and small bowel were seen to be filled with blood. A tense, pulsatile, 8-cm mass was present in the pancreatic head. The common bile duct was dilated. The duodenum was opened revealing a fistula in the medial duodenal wall, just
Fig 2.—Diagram
of
aortocystoduodenal
distal to the ampulla of Vater, which was edematous and partially obstructed from an intramural hematoma. The fistula communi¬ cated with the cavity of the pancreatic pseudocyst, which was filled with clotted blood. Control of the aorta was gained above and below the pancreas. The clot was then extracted from the pseudo¬ cyst, resulting in extensive arterial hemorrhage from the dorsal wall of the cyst. Bleeding was initially controlled by pressure, and the bleeding source was found to be an area of erosion of the cyst into the anterior wall of the aorta, below the celiac axis and just proximal to the origin of the superior mesenteric artery. Because of the patient's precarious clinical status, a complete pseudocyst extirpation with aortic disruption at the level of the fistula was considered not feasible. Such an approach would have required reconstitution of the superior mesenteric artery and distal aortic circulation through an extra-anatomic bypass out of a field potentially contaminated by the enteric fistula. Consequently, it was decided to attempt primary repair of the fistula through the pseudocyst. The aorta was occluded above and below the pancreas. The pseudocyst wall and the anterior aortic wall were extensively debrided back to tissue that appeared normal and uninflamed. The defect in the aorta was repaired by primary suture with monofil¬ ament polypropylene. Hemorrhage was completely controlled. The pseudocyst was drained internally through a 5-cm cystoduodenostomy at the site where the pseudocyst had eroded into the duodenum. Because of partial obstruction of the ampulla of Vater by edema and hematoma in the duodenal wall, a sphincterotomy was performed. The surgical field was irrigated with diluted (1%)
fistula and
operative approach (left to right).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/07/2015
povidone-iodine aqueous solution, and the patient was maintained on systemic broad-spectrum antibiotics (clindamycin phosphate and gentamicin sulfate) for seven days. Postoperatively, the patient recovered without complications and had no further GI tract bleeding. Ultrasonography performed seven days after surgery showed near-complete collapse of the pseudocyst. The patient was discharged on the tenth postoperative day and was followed up closely as an outpatient for six months, during which interval he remained completely well, without GI complaints and without evidence of continuing intermittent hemorrhage. COMMENT
This
case
illustrates erosion of the aorta and duodenum
by a chronic pancreatic pseudocyst, resulting in hemor¬ rhage from an aortocystoduodenal fistula. The pseudocyst appeared to erode the anterior aortic wall, probably from a combination of effects from pressure necrosis and lytic pancreatic enzymes. Hemorrhage from the aorta into the fistula presumably resulted in acute cyst expansion and tamponade of the bleeding point. Erosion into the duode¬ num then occurred, likely from pressure exerted by the expanding cyst. Periodic dislodging of the tamponading clot within the cyst cavity would result in intermittent hemorrhage into the GI tract lumen. Bleeding from pancreatic pseudocysts has been reported with extremely high mortal¬ as a rare complication8*1" ity ranging from 40% to 100% in literature reviews."·111G1T Typically pseudocyst hemorrhage results from vessels in the cyst wall or from erosion of the splenic or gastroduode¬ nal arteries.11 Fistulas between pseudocysts and the aorta are quite rare. Reports have indicated surgical interven¬ *-'
">
*'
the treatment of choice, with conservative manage¬ ment offering little benefit.1111·1'1 Surgical management depends necessarily on the type and location of the pseu¬ docyst and the site of hemorrhage, but treatment generally involves ligation of the bleeding vessel in combination with drainage of the pseudocyst7*"1:'1'1 or extirpation of the cyst and involved structures.1'1" In the case of massive hemor¬ rhage, control of the aorta prior to manipulations of the pseudocyst may prevent excessive hemorrhage.1'1 In the present case, direct aortic repair of a potentially bacterially contaminated aortoenteric fistula was per¬ formed successfully. Generally, because of risks of infec¬ tious contamination of the site of vascular repair, aortoen¬ teric fistulas are best treated by complete aortic interrup¬ tion proximal to the fistula. The distal aortic circulation is then reconstituted with a graft through uncontaminated tissues, typically requiring an extra-anatomic bypass. Such a treatment strategy is easily applicable to distal aortic fistulas, with infarenal aortic closure and distal aortic circulation established with axillofemoral or other grafts. However, for fistulas in the region of the celiac-superior mesenteric axis, aortic reconstruction is complex, and reconstruction with grafts through virgin tissue planes may be impossible. This can be particularly true in emer¬ gent situations, where a critical clinical condition may mandate an expeditious procedure. The present case illus¬ trates that primary repair of an aortoenteric fistula with associated pseudocyst in the celiac-superior mesenteric tion
as
region is feasible, in the absence of a viable alternative for bypassing the area of fistula. Adequate debridement of
contaminated tissues in and around the aortic wall appears to be important, ensuring healthy tissue for the vascular repair. Use of prosthetic materials in the area of repair is contraindicated, and a vein patch would be recommended for closure of aortic defects that, after adequate debride¬ ment, are too large to close primarily without compromise of aortic flow. Adequate internal drainage of the pancreat¬ ic pseudocyst probably is important in maintaining integ¬ rity of the repair by promoting collapse and resolution of the cyst. Although simple observation of pseudocysts arising after pancreatitis has been advocated because of the possibility of spontaneous resolution,1' it has become clear that a high risk of serious complications exists if pseudo¬ cysts are managed medically.1 In a review of 54 patients, Pollak et al·1 found that nonoperative management of suspected pseudocysts had 70% failure rate, including 11% mortality from complications. Because of the high failure and complication rates of nonoperative management of pseudocysts, it is reasonable to advocate surgical interven¬ tion for pseudocysts persisting after episodes of pancreati¬ tis.1 Aggressive surgical management of pseudocysts could well diminish the frequency of life-threatening '
'
"
complications.
Nonproprietary Name Gentamicin
and Trademark of
Drug
sulfate—Garamycin. References
1. Elliott DW: Pancreatic pseudocysts. Surg Clin North Am 55:339-362, 1975. 2. Hillis W: The surgical management of pseudocysts of the pancreas. Am J Surg 105:651-658, 1963. 3. Pollak EW, Michas CA, Wolfman EF: Pancreatic pseudocyst: Management in fifty-four patients. Am J Surg 135:199-201, 1978. 4. Van Heerden JA, ReMine WH: Pseudocysts of the pancreas: Review of 71 cases. Arch Surg 110:500-505, 1975. 5. Warren KW, Badosa F: Individualization in treatment of pancreatic cysts. Am Surg 39:555-561, 1973. 6. Czaja AJ, Fisher M, Marin GA: Spontaneous resolution of pancreatic masses (pseudocysts?): Development and disappearance after acute pancreatitis. Arch Intern Med 135:558-562, 1975. 7. Bardenheimer JA, Quintero 0, Barner HB: False aneurysm in a pancreatic pseudocyst. Ann Surg 172:53-55, 1970. 8. Bucknam CA: Arterial hemorrhage in pseudocyst of pancreas. Arch Surg 92:405-406, 1966. 9. Cogbill CL: Hemorrhage in pancreatic pseudocysts: Review of literature and report of two cases. Ann Surg 167:112-115, 1968. 10. Cordero OC, Khademi M, Lazaro E, et al: Intracystic hemorrhage: A complication of pseudocyst of the pancreas. Br J Radiol 48:602-603, 1975. 11. Dalton WE, Lee HM, Williams GM, et al: Pancreatic pseudocyst causing hemobilia and massive gastrointestinal hemorrhage. Am J Surg 120:106-107, 1970. 12. Dardik I, Dardik H: Patterns of hemorrhage into pancreatic pseudocysts. Am J Surg 115:774-776, 1968. 13. Greenstein A, DeMaio EF, Nabseth DC: Acute hemorrhage associated with pancreatic pseudocysts. Surgery 69:56-62, 1971. 14. Sykes BJ: Aortic hemorrhage into a pseudo-cyst of the pancreas. Br J Clin Pract 21:245-248, 1967. 15. Wolstenholme JT: Major gastrointestinal hemorrhage associated with pancreatic pseudocyst. Am J Surg 127:377-381, 1974. 16. Wu TK, Zaman SN, Gullick HD, et al: Spontaneous hemorrhage due to pseudocysts of the pancreas. Am J Surg 134:408-410, 1977. 17. Schecter LM, Gordon HE, Passaro E: Massive hemorrhage from the celiac axis in pancreatitis. Am J Surg 128:301-305, 1974. 18. Stanley JC, Frey CF, Miller TA, et al: Major arterial hemorrhage: A complication of pancreatic pseudocysts and chronic pancreatitis. Arch Surg 111:435-440, 1976.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/07/2015
Complication
of Pancreatic
Fistula
Pseudocyst
William F. Sindelar, MD, PhD, G. Robert Mason, MD, PhD \s=b\ An upper
gastrointestinal tract hemorrhage resulting from aortocystoduodenal fistula developed in a patient with a pancreatic pseudocyst. The fistula was exposed through a duodenotomy, necrotic material was debrided from the pseudocyst and the aortic wall, the aortic defect was closed primarily, and the pseudocyst was drained through a cystoduodenostomy. The case is discussed as a rare hemorrhagic complication of pancreatic pseudocysts and as an illustration that under certain circumstances of infection in areas where aortic bypass can be difficult to perform, primary vascular repair can be a successful method of managing aortoenteric fistulas. (Arch Surg 114:953-955, 1979) an
pseudocysts Pancreaticpancreatic
tions of versy exists
are
well-recognized complica¬
inflammation.'-· Although contro¬ over methods of clinical management of pseudocysts,11' " much current evidence favors surgical intervention early in the course of pseudocyst develop¬ ment1 in order to minimize the chances of complications of abscess formation, rupture, or hemorrhage. The most serious complication of pancreatic pseudocyst is hemorrhage, a rare but always life-threatening and usually fatal occurrence.71" The most frequent sources of hemorrhage in pancreatic pseudocysts are diffuse oozing from the cyst wall, erosion of the splenic artery, or involvement of the gastroduodenal artery.13 Pseudocyst hemorrhage with erosion into the gastrointestinal (GI) tract can uncommonly be the source of major GI bleed¬
ing.11117' The
present
case
nation he was thin and normotensive, with tachycardia, mild scierai icterus, and moderate diffuse abdominal tenderness with an epigastric mass present on deep palpation. The hemoglobin level was 9.8 g/dL, and the WBC count was 12,500/cu mm. Serum chemistry determinations were normal except for an elevated total bilirubin level of 2.8 mg/dL and an elevated alkaline phosphatase determination of 212 King-Armstrong units/mL. The amylase level was normal at 80 Somogyi units/dL. Stool was positive for occult blood. Small amounts of old blood returned through a nasogastric tube. Vital signs were stabilized by administration of intravenous fluids and transfusion with 2 units of blood. Fiberoptic esophago¬ gastroduodenoscopy was carried out, showing small esophageal varices with no evidence of recent hemorrhage, normal stomach without inflammation or erosion, and the duodenal bulb free of ulcers or other lesions. Sigmoidoscopy showed no abnormalities. Approximately 24 hours after admission, the patient had an
report illustrates successful surgical
treatment of a pancreatic pseudocyst that eroded into the aorta and subsequently into the duodenum, resulting in massive upper GI tract hemorrhage.
REPORT OF A CASE with known chronic alcoholism was admitted 52-year-old University of Maryland Hospital in 1975 with acute pancreatitis. He was treated with fluids given intravenously, nasogastric suction, and anticholinergics, and his condition improved. The acute episode resolved within seven days, but a pseudocyst developed in the head of the pancreas, as shown both on roentgenography of the upper GI tract and on ultrasonography. The patient was discharged and followed up regularly in the medical clinic. He remained asymptomatic except for occasional complaints of epigastric fullness. Approximately 20 months after discharge from the hospital for pancreatitis, the patient was seen in the emergency room with complaints of syncope, epigastric pain radiating to the back, and A
man
to the
hematemesis. He
was
admitted to the medical service. On exami-
Accepted
for publication Feb 5, 1979. From the Department of Surgery, University of Maryland School of Medicine, Baltimore. Dr Sindelar is now with the Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Md. Reprint requests to Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20205 (Dr Sindelar).
Fig 1.—Superior mesenteric arteriogram showing filling of pseu¬ docyst in region of head of pancreas. Fistula is shown at junction of superior mesenteric artery and aorta.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/07/2015
episode of hematemesis, requiring 4 L of fluid replacement and 4 units of blood to correct hypotension. After clinical stabilization, repeat endoscopy showed
no source of upper GI tract bleeding. A negative. An upper GI tract film series showed gastric and duodenal displacement by a mass in the head of the pancreas, but no abnormalities suggestive of a bleeding source were detected. Abdominal sonography showed an 8-cm cyst in the
barium
enema was
pancreas.
After his condition had remained clinically stable for 48 hours, the patient had another episode of hematemesis, with hematoche¬ zia. A third upper GI endoscopy showed no new findings. Again the patient's condition stabilized and showed no further signs of hemorrhage for two days. Surgical consultation was obtained on the fifth day of hospital¬ ization, and angiography was performed. A flush aortogram with selective superior mesenteric injection showed immediate filling of a large pancreatic cyst at the origin of the superior mesenteric artery (Fig 1). A celiac injection showed no specific abnormalities; the pancreatic cyst did not fill from the gastroduodenal artery. The patient suffered a massive upper GI tract hemorrhage six hours after angiography and became profoundly hypotensive. He was vigorously resuscitated with fluid and blood replacement and was brought to the operating room for emergency laparotomy. At surgery (Fig 2), the stomach and small bowel were seen to be filled with blood. A tense, pulsatile, 8-cm mass was present in the pancreatic head. The common bile duct was dilated. The duodenum was opened revealing a fistula in the medial duodenal wall, just
Fig 2.—Diagram
of
aortocystoduodenal
distal to the ampulla of Vater, which was edematous and partially obstructed from an intramural hematoma. The fistula communi¬ cated with the cavity of the pancreatic pseudocyst, which was filled with clotted blood. Control of the aorta was gained above and below the pancreas. The clot was then extracted from the pseudo¬ cyst, resulting in extensive arterial hemorrhage from the dorsal wall of the cyst. Bleeding was initially controlled by pressure, and the bleeding source was found to be an area of erosion of the cyst into the anterior wall of the aorta, below the celiac axis and just proximal to the origin of the superior mesenteric artery. Because of the patient's precarious clinical status, a complete pseudocyst extirpation with aortic disruption at the level of the fistula was considered not feasible. Such an approach would have required reconstitution of the superior mesenteric artery and distal aortic circulation through an extra-anatomic bypass out of a field potentially contaminated by the enteric fistula. Consequently, it was decided to attempt primary repair of the fistula through the pseudocyst. The aorta was occluded above and below the pancreas. The pseudocyst wall and the anterior aortic wall were extensively debrided back to tissue that appeared normal and uninflamed. The defect in the aorta was repaired by primary suture with monofil¬ ament polypropylene. Hemorrhage was completely controlled. The pseudocyst was drained internally through a 5-cm cystoduodenostomy at the site where the pseudocyst had eroded into the duodenum. Because of partial obstruction of the ampulla of Vater by edema and hematoma in the duodenal wall, a sphincterotomy was performed. The surgical field was irrigated with diluted (1%)
fistula and
operative approach (left to right).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/07/2015
povidone-iodine aqueous solution, and the patient was maintained on systemic broad-spectrum antibiotics (clindamycin phosphate and gentamicin sulfate) for seven days. Postoperatively, the patient recovered without complications and had no further GI tract bleeding. Ultrasonography performed seven days after surgery showed near-complete collapse of the pseudocyst. The patient was discharged on the tenth postoperative day and was followed up closely as an outpatient for six months, during which interval he remained completely well, without GI complaints and without evidence of continuing intermittent hemorrhage. COMMENT
This
case
illustrates erosion of the aorta and duodenum
by a chronic pancreatic pseudocyst, resulting in hemor¬ rhage from an aortocystoduodenal fistula. The pseudocyst appeared to erode the anterior aortic wall, probably from a combination of effects from pressure necrosis and lytic pancreatic enzymes. Hemorrhage from the aorta into the fistula presumably resulted in acute cyst expansion and tamponade of the bleeding point. Erosion into the duode¬ num then occurred, likely from pressure exerted by the expanding cyst. Periodic dislodging of the tamponading clot within the cyst cavity would result in intermittent hemorrhage into the GI tract lumen. Bleeding from pancreatic pseudocysts has been reported with extremely high mortal¬ as a rare complication8*1" ity ranging from 40% to 100% in literature reviews."·111G1T Typically pseudocyst hemorrhage results from vessels in the cyst wall or from erosion of the splenic or gastroduode¬ nal arteries.11 Fistulas between pseudocysts and the aorta are quite rare. Reports have indicated surgical interven¬ *-'
">
*'
the treatment of choice, with conservative manage¬ ment offering little benefit.1111·1'1 Surgical management depends necessarily on the type and location of the pseu¬ docyst and the site of hemorrhage, but treatment generally involves ligation of the bleeding vessel in combination with drainage of the pseudocyst7*"1:'1'1 or extirpation of the cyst and involved structures.1'1" In the case of massive hemor¬ rhage, control of the aorta prior to manipulations of the pseudocyst may prevent excessive hemorrhage.1'1 In the present case, direct aortic repair of a potentially bacterially contaminated aortoenteric fistula was per¬ formed successfully. Generally, because of risks of infec¬ tious contamination of the site of vascular repair, aortoen¬ teric fistulas are best treated by complete aortic interrup¬ tion proximal to the fistula. The distal aortic circulation is then reconstituted with a graft through uncontaminated tissues, typically requiring an extra-anatomic bypass. Such a treatment strategy is easily applicable to distal aortic fistulas, with infarenal aortic closure and distal aortic circulation established with axillofemoral or other grafts. However, for fistulas in the region of the celiac-superior mesenteric axis, aortic reconstruction is complex, and reconstruction with grafts through virgin tissue planes may be impossible. This can be particularly true in emer¬ gent situations, where a critical clinical condition may mandate an expeditious procedure. The present case illus¬ trates that primary repair of an aortoenteric fistula with associated pseudocyst in the celiac-superior mesenteric tion
as
region is feasible, in the absence of a viable alternative for bypassing the area of fistula. Adequate debridement of
contaminated tissues in and around the aortic wall appears to be important, ensuring healthy tissue for the vascular repair. Use of prosthetic materials in the area of repair is contraindicated, and a vein patch would be recommended for closure of aortic defects that, after adequate debride¬ ment, are too large to close primarily without compromise of aortic flow. Adequate internal drainage of the pancreat¬ ic pseudocyst probably is important in maintaining integ¬ rity of the repair by promoting collapse and resolution of the cyst. Although simple observation of pseudocysts arising after pancreatitis has been advocated because of the possibility of spontaneous resolution,1' it has become clear that a high risk of serious complications exists if pseudo¬ cysts are managed medically.1 In a review of 54 patients, Pollak et al·1 found that nonoperative management of suspected pseudocysts had 70% failure rate, including 11% mortality from complications. Because of the high failure and complication rates of nonoperative management of pseudocysts, it is reasonable to advocate surgical interven¬ tion for pseudocysts persisting after episodes of pancreati¬ tis.1 Aggressive surgical management of pseudocysts could well diminish the frequency of life-threatening '
'
"
complications.
Nonproprietary Name Gentamicin
and Trademark of
Drug
sulfate—Garamycin. References
1. Elliott DW: Pancreatic pseudocysts. Surg Clin North Am 55:339-362, 1975. 2. Hillis W: The surgical management of pseudocysts of the pancreas. Am J Surg 105:651-658, 1963. 3. Pollak EW, Michas CA, Wolfman EF: Pancreatic pseudocyst: Management in fifty-four patients. Am J Surg 135:199-201, 1978. 4. Van Heerden JA, ReMine WH: Pseudocysts of the pancreas: Review of 71 cases. Arch Surg 110:500-505, 1975. 5. Warren KW, Badosa F: Individualization in treatment of pancreatic cysts. Am Surg 39:555-561, 1973. 6. Czaja AJ, Fisher M, Marin GA: Spontaneous resolution of pancreatic masses (pseudocysts?): Development and disappearance after acute pancreatitis. Arch Intern Med 135:558-562, 1975. 7. Bardenheimer JA, Quintero 0, Barner HB: False aneurysm in a pancreatic pseudocyst. Ann Surg 172:53-55, 1970. 8. Bucknam CA: Arterial hemorrhage in pseudocyst of pancreas. Arch Surg 92:405-406, 1966. 9. Cogbill CL: Hemorrhage in pancreatic pseudocysts: Review of literature and report of two cases. Ann Surg 167:112-115, 1968. 10. Cordero OC, Khademi M, Lazaro E, et al: Intracystic hemorrhage: A complication of pseudocyst of the pancreas. Br J Radiol 48:602-603, 1975. 11. Dalton WE, Lee HM, Williams GM, et al: Pancreatic pseudocyst causing hemobilia and massive gastrointestinal hemorrhage. Am J Surg 120:106-107, 1970. 12. Dardik I, Dardik H: Patterns of hemorrhage into pancreatic pseudocysts. Am J Surg 115:774-776, 1968. 13. Greenstein A, DeMaio EF, Nabseth DC: Acute hemorrhage associated with pancreatic pseudocysts. Surgery 69:56-62, 1971. 14. Sykes BJ: Aortic hemorrhage into a pseudo-cyst of the pancreas. Br J Clin Pract 21:245-248, 1967. 15. Wolstenholme JT: Major gastrointestinal hemorrhage associated with pancreatic pseudocyst. Am J Surg 127:377-381, 1974. 16. Wu TK, Zaman SN, Gullick HD, et al: Spontaneous hemorrhage due to pseudocysts of the pancreas. Am J Surg 134:408-410, 1977. 17. Schecter LM, Gordon HE, Passaro E: Massive hemorrhage from the celiac axis in pancreatitis. Am J Surg 128:301-305, 1974. 18. Stanley JC, Frey CF, Miller TA, et al: Major arterial hemorrhage: A complication of pancreatic pseudocysts and chronic pancreatitis. Arch Surg 111:435-440, 1976.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/07/2015
