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Distant dissection of a pancreatic pseudocyst into the right groin
Distant Dissection of a Pancreatic Pseudocyst into the Right Groin
AnthonyF. Salvo, MD, Portland, Maine Heidar Nematolahi, MD, Columbia, Missouri
Pancreatic pseudocyst, although reported regularly in the literature,is a rare disease. Howard and Jordan [I], quoting several studies, give an overall estimate of the incidence of this entity as 0.007 per cent of all hospital admissions. Rosenberg, Kahn, and Walt [2] report forty-six cases of pancreatic pseudocysts in 2,271 hospital admissions for pancreatitis, a rate of 2 per cent of all patients admitted for inflammatory disease of the pancreas. The Maine Medical Center, a general hospital with 525 beds, recorded five cases of pancreatic pseudocyst during 1971. With an annual admission rate of 18,100 patients, the five cases convert to a rate of approximately 0.03 per cent of our" hospital admissions. From 1938 to 1967, 104 cases of pseudocyst of the pancreas were seen in four separate New Orleans hospitals [3]. Such a low incidence certainly limits the experience any one general surgeon might have with this problem. The following case is submitted beause the patient presented in a very unusual manner, even for such a variabledisease as. pseudocyst of the pancreas. Because of the meandering Characteristics. exhibited by pancreatic pseudocysts [4], We must be constantly vigilant, especially when a mass is discovered in an alcoholic with known chronic pancreatitis. From the Department of Radiology, Maine Medical Center, Portland, Maine, and the Department of Surgery, Ellis Ftschel Cancer Research Center, Col.umbla, MissoUri. Reprint requests shouJd be addressed to Dr Salvo. Department of Radiology," Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102.
430
Case Report This was the first Maine Medicai Center admission of this forty-nine year old white man, who had noted swelling and pain in the right groin for three days. Until three days prior to admission, the patient had been in his usual state of good health. At that time he noted a "straining sensation" in the right groin which later became a constant pain radiating to the right testicle. The patient did not find anything which relieved or worsened the pain. He denied having had fever, chills, nausea, vomiting, a ,:hange in bowel habits, and urinary symptoms. He had not had jaundice. History revealed peptic ulcer disease for several years, treated medically. He had had no major illnesses or other hospitalizations. He also stated that he drank at least one six-pack of beer each day, and had smoked twenty cigarettes per day for approximately thirty-five years. At the time of admission, physical examination revealed a thin white man in no acute distress. Temperature was 100.6°F orally. Pulse was 96 and regular. Respirations were 20 and blood pressure was 140/78 mm Hg. There was no sign of icterus or jaundice nor spider angiomas. He had slight palmar erythema. Thoracic and cardiac examinations showed no abnormalities. Abdominal examination revealed a tense, firm mass in the right inguinal area. Erythema and exquisite tenderness were also present locally. No organomegaly or other masses were palpable. Rectal examination showed nothing abnormal, but the stool gave a trace positive test with guaiac reagents. Laboratory data at the time of admission revealed a hematocrit of 44.8 per cent. The white blood cell count was 12,000 per mm 3 with 95 per cent neutrophils, 3 per cent lymphocytes, 1 per cent monocytes, and 1 per cent eosinophils. Urinalysis was within normal limits.
The American Journal of Surgery
Dissection of Pancreatic Pseudocyst
Because the initial impression was one of an incarcerated right inguinal hernia, immediate exploration was carried out. When the transverse incision was made through the skin, edema and fatty necrosis of the subcutaneous tissues were found. The subcutaneous tissue was dissected down to the external oblique aponeurosis, and the aponeurosis was incised in the direction of the skin incision down to and including the external inguinal ring. No evidence of an incarcerated hernia or a hernial sac was found. Necrotic adipose tissue and lymphatics were excised and sent to the laboratory for culture and microscopic examination. The external oblique aponeurosis and skin were closed, leaving a Penrose drain in place. On the second hospital day, further studies were made. Alkaline phosphatase was 170 international units. The total protein was 5.5 gm per 100 ml with an albumin fraction of 2.8 gm per 100 ml. The bilirubin was 0.4 rag per 100 ml, blood glucose 90 mg per 100 ml, and serum amylase 1,128 caraway units. Postoperatively, the wound drained voluminous amounts of serous fluid. Because of the patient's history of chronic alcohol ingestion, and because multiple calcifications had been seen in the area of the pancreas on plain films, the fluid was tested for amylase. The drainage from the wound had an amylase level of 36,000 caraway units. A pancreaticocutaneous fistula was suspected, and a sinogram was performed. Approximately 50 ml of 50 per cent sodium diatrizoate was introduced by gravity via a catheter into the subcutaneous tissues through the incision in the right groin. The contrast flowed immediately into the retroperitoneal space on the right. After several minutes, the contrast material reached the area of the head of the pancreas. Other roentgenographic gastrointestinal studies revealed chronic duodenal ulcer disease with a duodenal ulcer crater, sigmoid diverticulitis, and no visualization of the gallbladder on several attempts. An abdominal aortogram taken on t h e twenty-eighth postoperative day, with selected celiac and superior mesenteric injections, revealed equivocal changes in several small vessels about the head of the pancreas, but no mass lesions. Drainage from the wound gradually decreased until the twenty-second postoperative day when it stopped completely. The patient's serum amylase level by then had decreased to 110 caraway units. The patient's hospital course was complicated by a urinary tract infection Which responded well to antibiotic therapy. He was discharged on the thirty-sixth hospital day. He has been followed up in t h e Out-Patient Clinic for ten months since discharge and has been asymptomatic. Comments
A b d o m i n a l s u r g e r y has n o t been p e r f o r m e d in this p a t i e n t nor has an a b d o m i n a l m a s s b e e n discovered b y a n y d i a g n o s t i c m e a n s . W e be-
Volume 12S, September 1973
lieve, however, t h a t t h e r e is c o n c l u s i v e e v i d e n c e of a p a n c r e a t i c p s e u d o c y s t with dissection retroperit o n e a l l y to t h e r i g h t inguinal a r e a , with subseq u e n t f a t necrosis a n d a u t o d e c o m p r e s s i o n a f t e r biopsy of t h e right inguinal mass. A p s e u d o c y s t grows b y dissecting along t h e p a t h of least resistance, which is usually the lesser p e r i t o n e a l sac or the leaves of the t r a n s v e r s e m e s o c o l o n or greater o m e n t u m . It will occasionally traverse t h e diap h r a g m via the aortic or e s o p h a g e a l h i a t u s a n d p r e s e n t as a m e d i a s t i n a l m a s s [5,6]. In our p a t i e n t ; t h e d r a i n a g e of clear fluid, which o c c u r r e d from the right inguinal incision a n d which h a d an a m y l a s e level of 36,000 c a r a w a y u n i t s ( n o r m a l r a n g e 60 to 160 units), led us to the very s t r o n g belief t h a t t h e r e was a d i r e c t c o m m u nication b e t w e e n t h e p a n c r e a t i c d u c t s y s t e m a n d the incision. T h i s belief was c o n f i r m e d by a sinegram t a k e n on April 6, 1972. A Foley c a t h e t e r was inserted in t h e d r a i n i n g sinus of t h e healing surgical w o u n d a n d i n f l a t e d to o b s t r u c t a n y leakage, and 50 per c e n t s o d i u m d i a t r i z o a t e was allowed to flow b y gravity. T h e sinus t r a c t was seen to course r e t r o p e r i t o n e a l l y on the right, a n d t h e n to the head of the pancreas, w h i c h was identified b y its m u l t i p l e calcifications. T o o u r knowledge, the only o t h e r r e p o r t e d case of a n i n f l a m m a t o r y pancreatic collection p r e s e n t i n g as a mass in t h e groin was d e s c r i b e d by S t e e d m a n , Deering, a n d C a r t e r [7]. T h e p a t i e n t p r e s e n t e d w i t h a left scrotal mass which d r a i n e d 1,000 ml of p u r u l e n t m a t e r i a l a n d was s h o w n b y sinogram to have a d i r e c t p a n c r e a t ic c o m m u n i c a t i o n . In a r e c e n t r e p o r t d e s c r i b i n g a c u t e p a n c r e a t i t i s in renal h o m o g r a f t recipients, P e n n a n d colleagues [8] p r e s e n t a p a t i e n t w h o h a d an abscess in t h e left l a b i u m m a j u s w h i c h was shown by s i n o g r a m to e x t e n d t o the p a n c r e a s t h r o u g h a r e t r o p e r i t o n e a l route. H o d s o n - W a l k e r a n d Woods [9] r e p o r t e d on a p a t i e n t who was an alcoholic a n d p r e s e n t e d with bilateral f l u c t u a n t masses in the groin which, when biopsied, showed fat necrosis. T h e y suggeste d t h e possibility t h a t the inguinal lesions were d i r e c t e x t e n s i o n s of p a n c r e a t i c e n z y m e s retroperitoneally. O u r p a t i e n t bears a close r e s e m b l a n c e to this p a t i e n t , b u t in our case t h e cause of the fat necrosis was d o c u m e n t e d with a sinogram a n d b i o c h e m i c a l analysis of p a n c r e a t i c drainage. Diffuse s u b c u t a n e o u s fat necrosis associated with p a n c r e a t i t i s d e p e n d s on some o t h e r m e c h a n i s m , possibly h e m a t o g e n o u s t r a n s p o r t of p a n c r e a t i c enzymes []0]. Our p a t i e n t r e m a i n s essentially u n t r e a t e d , except for h a v i n g received a u t o d e c o m p r e s s i o n of the p s e u d o c y s t . E x c i s i o n of a p s e u d o c y s t is usually
431
Salvo and N e m a t o l a h i
difficult and incomplete. Internal drainage procedures are generally thought to result in lower mortality, morbidity, and recurrence rates, b u t external drainage sometimes is the only feasible method of treatment. The choice of either of these drainage methods must be tailored to the individual patient.
Summary A case is reported of an alcoholic patient with chronic pancreatitis who presented with a right inguinal mass. The mass was found to be fat necrosis, and a clear liquid, which was found to have a very high amylase content, drained from the incision. A sinogram was performed demonstrating the direct communication from the incision to the head of the pancreas. The extensions and presenting features of pancreatic pseuodcysts are known to vary widely, and complicationssuch as spontaneous rupture, infection, hemorrnage, and direct compression on various organs are well known. This case is presented as an unusual retroperitoneal dissection of a pancreatic pseudocyst with subsequent fat necrosis in the right inguinal area and autodecompression of the pseudocyst after biopsy.
432
Acknowledgment: We wish to express our gratitude to our secretary, Mrs Elaine Gilpatrick, who patiently t y p e d our manuscript. References 1. Howard JH, Jordan GL: Surgical Diseases of the Pancreas. Philadelphia, Llppincott, 1960. 2. Rosenberg IK, Kahn JA, Walt AJ: Surgical experience with pancreatic pseudocysts. Amer J Surg 117: 11, 1969. 3. Becker WF, Pratt HS, Ganjt H: Pseudocysts of the pancreas. Surg Gynec Obstet 127: 744, 1968. 4. Poppel MH: Some migratory aspects of inflammatory collections of pancreatic origin. Radiology 72: 323, 1959. 5. Gee W, Foster ED, Doohen DJ: Mediastinal pancreatic pseudocyst. Ann Surg 169:420, 1969. 6. Sybers HD, Shelp WD, Morrlssey JF" Pseudocyst of the pancreas with fistulous extension into the neck. New EngJ Mad 278: 1058, 1968. 7. Steedman RA, Deering R, Carter R: Surgical aspects of pancreatic abscess. Surg Gynec Obstet 125: 757, 1967. 8. Penn I, Durst At, Machado M, Halgrtmson CG, Starzl TE: Acute pancreatltis and hyperamylasemia In renal homograft recipients. Arch Surg 105, 167, 1972. 9. Hodson-Walker NJ, Woods JM:.Acute pancreatitis with peripheral fat necrosis. Canad Med Ass J 103: 382, 1970. 10. Lucas PF, Owen TK: Subcutaneous fat necrosis. 'polyarthrttts', and pancreatic disease. Gut 3: 146, 1962.
The Amedcan Journal c~ $uqlery
AnthonyF. Salvo, MD, Portland, Maine Heidar Nematolahi, MD, Columbia, Missouri
Pancreatic pseudocyst, although reported regularly in the literature,is a rare disease. Howard and Jordan [I], quoting several studies, give an overall estimate of the incidence of this entity as 0.007 per cent of all hospital admissions. Rosenberg, Kahn, and Walt [2] report forty-six cases of pancreatic pseudocysts in 2,271 hospital admissions for pancreatitis, a rate of 2 per cent of all patients admitted for inflammatory disease of the pancreas. The Maine Medical Center, a general hospital with 525 beds, recorded five cases of pancreatic pseudocyst during 1971. With an annual admission rate of 18,100 patients, the five cases convert to a rate of approximately 0.03 per cent of our" hospital admissions. From 1938 to 1967, 104 cases of pseudocyst of the pancreas were seen in four separate New Orleans hospitals [3]. Such a low incidence certainly limits the experience any one general surgeon might have with this problem. The following case is submitted beause the patient presented in a very unusual manner, even for such a variabledisease as. pseudocyst of the pancreas. Because of the meandering Characteristics. exhibited by pancreatic pseudocysts [4], We must be constantly vigilant, especially when a mass is discovered in an alcoholic with known chronic pancreatitis. From the Department of Radiology, Maine Medical Center, Portland, Maine, and the Department of Surgery, Ellis Ftschel Cancer Research Center, Col.umbla, MissoUri. Reprint requests shouJd be addressed to Dr Salvo. Department of Radiology," Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102.
430
Case Report This was the first Maine Medicai Center admission of this forty-nine year old white man, who had noted swelling and pain in the right groin for three days. Until three days prior to admission, the patient had been in his usual state of good health. At that time he noted a "straining sensation" in the right groin which later became a constant pain radiating to the right testicle. The patient did not find anything which relieved or worsened the pain. He denied having had fever, chills, nausea, vomiting, a ,:hange in bowel habits, and urinary symptoms. He had not had jaundice. History revealed peptic ulcer disease for several years, treated medically. He had had no major illnesses or other hospitalizations. He also stated that he drank at least one six-pack of beer each day, and had smoked twenty cigarettes per day for approximately thirty-five years. At the time of admission, physical examination revealed a thin white man in no acute distress. Temperature was 100.6°F orally. Pulse was 96 and regular. Respirations were 20 and blood pressure was 140/78 mm Hg. There was no sign of icterus or jaundice nor spider angiomas. He had slight palmar erythema. Thoracic and cardiac examinations showed no abnormalities. Abdominal examination revealed a tense, firm mass in the right inguinal area. Erythema and exquisite tenderness were also present locally. No organomegaly or other masses were palpable. Rectal examination showed nothing abnormal, but the stool gave a trace positive test with guaiac reagents. Laboratory data at the time of admission revealed a hematocrit of 44.8 per cent. The white blood cell count was 12,000 per mm 3 with 95 per cent neutrophils, 3 per cent lymphocytes, 1 per cent monocytes, and 1 per cent eosinophils. Urinalysis was within normal limits.
The American Journal of Surgery
Dissection of Pancreatic Pseudocyst
Because the initial impression was one of an incarcerated right inguinal hernia, immediate exploration was carried out. When the transverse incision was made through the skin, edema and fatty necrosis of the subcutaneous tissues were found. The subcutaneous tissue was dissected down to the external oblique aponeurosis, and the aponeurosis was incised in the direction of the skin incision down to and including the external inguinal ring. No evidence of an incarcerated hernia or a hernial sac was found. Necrotic adipose tissue and lymphatics were excised and sent to the laboratory for culture and microscopic examination. The external oblique aponeurosis and skin were closed, leaving a Penrose drain in place. On the second hospital day, further studies were made. Alkaline phosphatase was 170 international units. The total protein was 5.5 gm per 100 ml with an albumin fraction of 2.8 gm per 100 ml. The bilirubin was 0.4 rag per 100 ml, blood glucose 90 mg per 100 ml, and serum amylase 1,128 caraway units. Postoperatively, the wound drained voluminous amounts of serous fluid. Because of the patient's history of chronic alcohol ingestion, and because multiple calcifications had been seen in the area of the pancreas on plain films, the fluid was tested for amylase. The drainage from the wound had an amylase level of 36,000 caraway units. A pancreaticocutaneous fistula was suspected, and a sinogram was performed. Approximately 50 ml of 50 per cent sodium diatrizoate was introduced by gravity via a catheter into the subcutaneous tissues through the incision in the right groin. The contrast flowed immediately into the retroperitoneal space on the right. After several minutes, the contrast material reached the area of the head of the pancreas. Other roentgenographic gastrointestinal studies revealed chronic duodenal ulcer disease with a duodenal ulcer crater, sigmoid diverticulitis, and no visualization of the gallbladder on several attempts. An abdominal aortogram taken on t h e twenty-eighth postoperative day, with selected celiac and superior mesenteric injections, revealed equivocal changes in several small vessels about the head of the pancreas, but no mass lesions. Drainage from the wound gradually decreased until the twenty-second postoperative day when it stopped completely. The patient's serum amylase level by then had decreased to 110 caraway units. The patient's hospital course was complicated by a urinary tract infection Which responded well to antibiotic therapy. He was discharged on the thirty-sixth hospital day. He has been followed up in t h e Out-Patient Clinic for ten months since discharge and has been asymptomatic. Comments
A b d o m i n a l s u r g e r y has n o t been p e r f o r m e d in this p a t i e n t nor has an a b d o m i n a l m a s s b e e n discovered b y a n y d i a g n o s t i c m e a n s . W e be-
Volume 12S, September 1973
lieve, however, t h a t t h e r e is c o n c l u s i v e e v i d e n c e of a p a n c r e a t i c p s e u d o c y s t with dissection retroperit o n e a l l y to t h e r i g h t inguinal a r e a , with subseq u e n t f a t necrosis a n d a u t o d e c o m p r e s s i o n a f t e r biopsy of t h e right inguinal mass. A p s e u d o c y s t grows b y dissecting along t h e p a t h of least resistance, which is usually the lesser p e r i t o n e a l sac or the leaves of the t r a n s v e r s e m e s o c o l o n or greater o m e n t u m . It will occasionally traverse t h e diap h r a g m via the aortic or e s o p h a g e a l h i a t u s a n d p r e s e n t as a m e d i a s t i n a l m a s s [5,6]. In our p a t i e n t ; t h e d r a i n a g e of clear fluid, which o c c u r r e d from the right inguinal incision a n d which h a d an a m y l a s e level of 36,000 c a r a w a y u n i t s ( n o r m a l r a n g e 60 to 160 units), led us to the very s t r o n g belief t h a t t h e r e was a d i r e c t c o m m u nication b e t w e e n t h e p a n c r e a t i c d u c t s y s t e m a n d the incision. T h i s belief was c o n f i r m e d by a sinegram t a k e n on April 6, 1972. A Foley c a t h e t e r was inserted in t h e d r a i n i n g sinus of t h e healing surgical w o u n d a n d i n f l a t e d to o b s t r u c t a n y leakage, and 50 per c e n t s o d i u m d i a t r i z o a t e was allowed to flow b y gravity. T h e sinus t r a c t was seen to course r e t r o p e r i t o n e a l l y on the right, a n d t h e n to the head of the pancreas, w h i c h was identified b y its m u l t i p l e calcifications. T o o u r knowledge, the only o t h e r r e p o r t e d case of a n i n f l a m m a t o r y pancreatic collection p r e s e n t i n g as a mass in t h e groin was d e s c r i b e d by S t e e d m a n , Deering, a n d C a r t e r [7]. T h e p a t i e n t p r e s e n t e d w i t h a left scrotal mass which d r a i n e d 1,000 ml of p u r u l e n t m a t e r i a l a n d was s h o w n b y sinogram to have a d i r e c t p a n c r e a t ic c o m m u n i c a t i o n . In a r e c e n t r e p o r t d e s c r i b i n g a c u t e p a n c r e a t i t i s in renal h o m o g r a f t recipients, P e n n a n d colleagues [8] p r e s e n t a p a t i e n t w h o h a d an abscess in t h e left l a b i u m m a j u s w h i c h was shown by s i n o g r a m to e x t e n d t o the p a n c r e a s t h r o u g h a r e t r o p e r i t o n e a l route. H o d s o n - W a l k e r a n d Woods [9] r e p o r t e d on a p a t i e n t who was an alcoholic a n d p r e s e n t e d with bilateral f l u c t u a n t masses in the groin which, when biopsied, showed fat necrosis. T h e y suggeste d t h e possibility t h a t the inguinal lesions were d i r e c t e x t e n s i o n s of p a n c r e a t i c e n z y m e s retroperitoneally. O u r p a t i e n t bears a close r e s e m b l a n c e to this p a t i e n t , b u t in our case t h e cause of the fat necrosis was d o c u m e n t e d with a sinogram a n d b i o c h e m i c a l analysis of p a n c r e a t i c drainage. Diffuse s u b c u t a n e o u s fat necrosis associated with p a n c r e a t i t i s d e p e n d s on some o t h e r m e c h a n i s m , possibly h e m a t o g e n o u s t r a n s p o r t of p a n c r e a t i c enzymes []0]. Our p a t i e n t r e m a i n s essentially u n t r e a t e d , except for h a v i n g received a u t o d e c o m p r e s s i o n of the p s e u d o c y s t . E x c i s i o n of a p s e u d o c y s t is usually
431
Salvo and N e m a t o l a h i
difficult and incomplete. Internal drainage procedures are generally thought to result in lower mortality, morbidity, and recurrence rates, b u t external drainage sometimes is the only feasible method of treatment. The choice of either of these drainage methods must be tailored to the individual patient.
Summary A case is reported of an alcoholic patient with chronic pancreatitis who presented with a right inguinal mass. The mass was found to be fat necrosis, and a clear liquid, which was found to have a very high amylase content, drained from the incision. A sinogram was performed demonstrating the direct communication from the incision to the head of the pancreas. The extensions and presenting features of pancreatic pseuodcysts are known to vary widely, and complicationssuch as spontaneous rupture, infection, hemorrnage, and direct compression on various organs are well known. This case is presented as an unusual retroperitoneal dissection of a pancreatic pseudocyst with subsequent fat necrosis in the right inguinal area and autodecompression of the pseudocyst after biopsy.
432
Acknowledgment: We wish to express our gratitude to our secretary, Mrs Elaine Gilpatrick, who patiently t y p e d our manuscript. References 1. Howard JH, Jordan GL: Surgical Diseases of the Pancreas. Philadelphia, Llppincott, 1960. 2. Rosenberg IK, Kahn JA, Walt AJ: Surgical experience with pancreatic pseudocysts. Amer J Surg 117: 11, 1969. 3. Becker WF, Pratt HS, Ganjt H: Pseudocysts of the pancreas. Surg Gynec Obstet 127: 744, 1968. 4. Poppel MH: Some migratory aspects of inflammatory collections of pancreatic origin. Radiology 72: 323, 1959. 5. Gee W, Foster ED, Doohen DJ: Mediastinal pancreatic pseudocyst. Ann Surg 169:420, 1969. 6. Sybers HD, Shelp WD, Morrlssey JF" Pseudocyst of the pancreas with fistulous extension into the neck. New EngJ Mad 278: 1058, 1968. 7. Steedman RA, Deering R, Carter R: Surgical aspects of pancreatic abscess. Surg Gynec Obstet 125: 757, 1967. 8. Penn I, Durst At, Machado M, Halgrtmson CG, Starzl TE: Acute pancreatltis and hyperamylasemia In renal homograft recipients. Arch Surg 105, 167, 1972. 9. Hodson-Walker NJ, Woods JM:.Acute pancreatitis with peripheral fat necrosis. Canad Med Ass J 103: 382, 1970. 10. Lucas PF, Owen TK: Subcutaneous fat necrosis. 'polyarthrttts', and pancreatic disease. Gut 3: 146, 1962.
The Amedcan Journal c~ $uqlery