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International Journal of Surgery Case... Jul 2024Percutaneous endoscopic lumbar discectomy (PELD) is increasingly being utilized to treat patients with lumbar disc herniation. PELD is unique in that it uses a single...
Contrast enhancing epidural fluid accumulation after percutaneous endoscopic lumbar discectomy: A case report of recurrent disc herniation within pseudocyst secondary to irrigation fluid.
INTRODUCTION
Percutaneous endoscopic lumbar discectomy (PELD) is increasingly being utilized to treat patients with lumbar disc herniation. PELD is unique in that it uses a single working port endoscope with constant irrigation of the surgical field to visualize pathology. The current report is of a case of postoperative epidural irrigation fluid accumulation presenting as peripherally enhancing epidural lesions, masking an underlying re-herniation.
PRESENTATION OF CASE
A patient with a Lumbar 5-Sacral 1 level disc herniation presenting with radiculopathy was treated using PELD. Following the operation, the patient experienced recurrent pain, prompting a repeat MRI of the lumbar spine. Multiple ring-enhancing lesions within the epidural space were observed, creating diagnostic dilemmas. The differential diagnoses included epidural abscess, pseudomeningocele from unintended durotomy, epidural hematoma, or trapped epidural fluid collection presenting as a pseudocyst with or without recurrent disc herniation. A repeat endoscopic discectomy was performed to confirm the diagnosis of pseudocyst, revealing a recurrent disc herniation.
DISCUSSION
Pseudocysts are not an uncommon complication of PELD, typically believed to be due to an inflammatory response to disc fragments. However, in this case, the epidural fluid collection was likely the result of trapped irrigation fluid from continuous irrigation during the procedure, which masked an underlying re-herniation on imaging.
CONCLUSION
With the increasing utilization of PELD, it is important to acknowledge unique complications such as fluid accumulation from irrigation within the epidural space. Fluid accumulation can lead to contrast-enhancing pseudocyst formation, which can theoretically lead to mass effect or increased intracranial and intraspinal pressure and may mask additional underlying pathology.
PubMed: 38875830
DOI: 10.1016/j.ijscr.2024.109884 -
Medical Science Monitor : International... Jun 2024BACKGROUND Hemorrhagic cysts are rarely discussed subtypes of pancreatic pseudocysts that occur in about 10% of these cases. They are caused by erosion of the walls of...
BACKGROUND Hemorrhagic cysts are rarely discussed subtypes of pancreatic pseudocysts that occur in about 10% of these cases. They are caused by erosion of the walls of neighboring vessels by extravasated proteolytic pancreatic enzymes. A retrospective analysis was performed to clinically characterize risk factors, treatment, and outcome in patients with hemorrhagic cysts of the pancreas. MATERIAL AND METHODS The retrospective study included patients from the Department of Digestive Tract Surgery in Katowice, Poland, who were treated surgically for a pancreatic hemorrhagic cyst from January 2016 to November 2022. We gathered and assessed data on cyst etiology, symptoms, imaging examinations, risk factors, time, type, and complications of surgery. RESULTS The main symptom was abdominal pain, noted in 5 (62.5%) patients. The most common etiology of cyst was acute pancreatitis, which occurred in 5 patients (62.5%). The most common localization was the tail of pancreas, found in 3 patients (36.5%). The largest dimension of the cyst was 98±68 (30-200) mm. Every patient needed surgical intervention. Patients underwent distal pancreatectomy (n=3) or marsupialization (n=5). One (12.5%) postoperative complication was observed, while mortality was 0%. CONCLUSIONS Hemorrhagic cyst is a life-threatening complication of pancreatitis requiring immediate treatment. In most cases, open surgery is the treatment of choice. Despite the continuous development of minimally invasive techniques, surgical treatment remains the only effective treatment method. Depending on the cyst localization and technical possibilities, pancreatectomy or marsupialization can be applied, and both of them have low complication and mortality rates.
Topics: Humans; Male; Female; Middle Aged; Risk Factors; Retrospective Studies; Pancreatic Cyst; Aged; Hemorrhage; Treatment Outcome; Adult; Pancreatectomy; Poland; Pancreas; Pancreatic Pseudocyst; Pancreatitis; Postoperative Complications; Abdominal Pain
PubMed: 38872280
DOI: 10.12659/MSM.941955 -
Clinical Practice and Cases in... May 2024Visceral arterial aneurysms and pseudoaneurysms are rare but dangerous pathologies, with reported incidence of 0.01-0.2% of the worldwide population, as found on...
INTRODUCTION
Visceral arterial aneurysms and pseudoaneurysms are rare but dangerous pathologies, with reported incidence of 0.01-0.2% of the worldwide population, as found on autopsy. Pancreaticoduodenal artery pathology accounts for approximately 2% of all visceral aneurysms; it is commonly caused by chronic inflammatory processes, such as pancreatitis or adjacent pseudocysts. Morbidity and mortality commonly result from rupture of the aneurysm itself, leading to life-threatening hemorrhage into the peritoneum or gastrointestinal tract.
CASE REPORT
Here we present the case of a 64-year-old male patient with previous history of alcohol use disorder leading to chronic pancreatitis and prior embolization of an inferior pancreaticoduodenal pseudoaneurysm, who presented to the emergency department (ED) with abdominal pain, nausea, and vomiting, and was found to have a large recurrent inferior pancreaticoduodenal pseudoaneurysm with associated obstructive cholangitis and pancreatitis via contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The patient was managed emergently by interventional radiology angiography with embolic coiling and percutaneous biliary catheter placement, and he subsequently underwent biliary duct stenting with gastroenterology. The patient was successfully discharged after a brief hospitalization after resolution of his pancreatitis and associated hyperbilirubinemia.
CONCLUSION
Pancreaticoduodenal artery aneurysms and pseudoaneurysms are rare and dangerous visceral pathologies. Patients can be diagnosed rapidly in the ED with CT imaging and need urgent endovascular management to prevent morbidity and mortality.
PubMed: 38869334
DOI: 10.5811/cpcem.1598 -
Cureus May 2024Here, we report a case of tardive peritonitis after endoscopic ultrasound (EUS)-guided transmural pancreatic pseudocyst drainage. A 50-year-old man was diagnosed with...
Here, we report a case of tardive peritonitis after endoscopic ultrasound (EUS)-guided transmural pancreatic pseudocyst drainage. A 50-year-old man was diagnosed with acute pancreatitis and a pancreatic pseudocyst measuring 5 cm. Ten months later, his pancreatic pseudocyst was 10 cm. We performed EUS-guided transmural drainage using a lumen-apposing metal stent. After two months, the stent was replaced with a double-pigtail plastic stent. Two months later, the patient developed fever and abdominal pain, and computed tomography revealed abdominal free air. He was diagnosed with peritonitis due to free air caused by a fistula rupture. The double-pigtail plastic stent was removed, and clipping was performed at the fistula site to achieve closure. The patient's symptoms subsequently improved. Long-term placement of a plastic stent for pancreatic pseudocysts makes recurrence less likely, but late adverse events due to stent placement can occur. Notably, fistula rupture can occur even when the fistula is well-formed several months after the initial drainage.
PubMed: 38868273
DOI: 10.7759/cureus.60179 -
Cureus Jun 2024Disconnected pancreatic duct syndrome (DPDS) is a rare complication of a common disease. Typically, DPDS occurs in acute necrotizing pancreatitis (ANP), chronic...
Disconnected pancreatic duct syndrome (DPDS) is a rare complication of a common disease. Typically, DPDS occurs in acute necrotizing pancreatitis (ANP), chronic pancreatitis, abdominal surgery, or trauma. We present a case of DPDS from acute non-necrotizing pancreatitis (ANNP). A 41-year-old male with a history of alcohol use and prior AP presented with progressive, severe left-sided abdominal pain that was worse with movement. Labs revealed a lipase of 95 U/L (normal range 11-82 U/L). Computed tomography (CT) of the abdomen/pelvis (A/P) with IV contrast demonstrated a large left-sided pleural effusion, non-necrotic pancreatic pseudocysts, and a large subdiaphragmatic fluid collection. Thoracentesis of the pleural effusion revealed an amylase of 601 U/L confirming pancreatic etiology. A subsequent magnetic resonance cholangiopancreatography (MRCP) confirmed complex peripancreatic ascites, rapid subdiaphragmatic fluid accumulation, and a fistula from the pancreatic tail to retroperitoneum concerning for a rapidly dissecting pancreatic pseudocyst. He ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the main pancreatic duct. His left-sided abdominal pain rapidly improved, and the patient was discharged. CT A/P one week after discharge showed a reduced size of subdiaphragmatic fluid collection. DPDS is usually seen in patients with a history of ANP. Our case demonstrates that it can also occur in ANNP, which has not previously been described in the literature. Therefore, a high index of clinical suspicion must be maintained for DPDS even in ANNP given its potential for severe complications.
PubMed: 38855497
DOI: 10.7759/cureus.61894 -
Cureus May 2024Another name for the Puestow surgery is a lateral pancreaticojejunostomy. The primary pancreatic duct, which runs from the head to the tail of the organ, is opened,...
Another name for the Puestow surgery is a lateral pancreaticojejunostomy. The primary pancreatic duct, which runs from the head to the tail of the organ, is opened, exposing the pancreas. In order to allow the pancreas to empty straight into the intestines, the opening of the pancreatic duct is subsequently joined to a tiny intestinal loop. For more than 50 years, this process has been used to effectively relieve pain caused by chronic pancreatitis. This technique has a very low mortality rate and a low rate of surgical complications, and a high success rate. The gradual fibrosis of the pancreas resulting in the loss of exocrine and endocrine function is known as chronic pancreatitis. Intense pain is the disease's most typical symptom. It is unclear what causes the discomfort in chronic pancreatitis. Nonetheless, a large number of these patients have dilated ducts that are made up of intervening structures and saccular dilations, a condition known as the "chain of lakes" phenomenon. Radiological investigations can be used for diagnosis in these patients. Lateral pancreaticojejunostomy is the most effective treatment option for these individuals. Preservation of endocrine and exocrine pancreatic function is another benefit of lateral pancreaticojejunostomy. With lateral pancreaticojejunostomy, chronic fibrocalcific pancreatitis that manifests as pancreatic ductal dilatation and persistent discomfort can be effectively treated. Excellent early outcomes have been observed in terms of pain alleviation as well as post-operative morbidity and mortality; however, the patient's overall outcome and long-term follow-up have not been as well defined.
PubMed: 38854193
DOI: 10.7759/cureus.59843 -
Ophthalmology. Retina Jun 2024To differentiate intraretinal fluid (IRF) cysts from degenerative pseudocysts in neovascular age-related macular degeneration by quantitative multimodal imaging.
OBJECTIVE
To differentiate intraretinal fluid (IRF) cysts from degenerative pseudocysts in neovascular age-related macular degeneration by quantitative multimodal imaging.
DESIGN
Observational, cross-sectional.
PARTICIPANTS
Patients affected by macular neovascularization (MNV) secondary to AMD.
METHODS
All patients were analyzed by optical coherence tomography (OCT), optical coherence tomography angiography (OCTA) and dense ART (DART) OCTA. Newly onset cysts were considered IRF, whereas those cysts that were found to be persistent persistent for at least 3 months have been categorized as degenerative pseudocysts. Intraretinal cysts were automatically segmented to calculate cyst circularity. Peri-cyst space was quantitatively analyzed to assess the presence of perfusion signal and hyperreflective foci (HF).
MAIN OUTCOME MEASURES
Best-corrected visual acuity (BCVA), cyst circularity, peri-cyst perfusion, peri-cyst HF, fibrosis, outer retinal atrophy.
RESULTS
We analyzed 387 cysts collected from 35 eyes of 35 neovascular AMD patients (14 males; mean age 80±5 years). We classified 302 IRF cysts and 85 degenerative pseudocysts. IRF cysts were characterized by significantly higher circularity (0.86 (range 0.81-0.91), perfusion signal in the peri-cyst space and peri-cyst HF in 89% of cases (all p<0.05). Degenerative pseudocysts showed significantly lower circularity (0.68 (range 0.64-0.76), no perfusion signal in the peri-cyst space and peri-cyst HF only in 29% of cases (all p<0.05). The adopted quantitative metrics significantly correlated with disease duration, number of injections, fibrosis and outer retinal atrophy.
CONCLUSIONS
IRF can be discriminated from degenerative pseudocysts by quantitative multimodal imaging approach. These findings resulted clinically relevant and should be included in future training models for artificial intelligence algorithms to improve the diagnostic power and the fluids monitoring in neovascular AMD.
PubMed: 38848872
DOI: 10.1016/j.oret.2024.05.019 -
Journal of Surgical Case Reports Jun 2024Pancreatic pseudocysts are surrounded by a non-epithelialized wall confined to the pancreas and localized to the pancreatic tissue or adjacent pancreatic cavity. In...
Pancreatic pseudocysts are surrounded by a non-epithelialized wall confined to the pancreas and localized to the pancreatic tissue or adjacent pancreatic cavity. In contrast, pancreatic cystic tumors occur less frequently than solid lesions and are often detected incidentally on imaging. Regarding the qualitative diagnosis of pancreatic pseudocysts, it is important to differentiate them from neoplastic cysts. We report the case of a 74-year-old woman with a giant hemorrhagic pancreatic pseudocyst and a suspected cystic pancreatic tumor, wherein distal pancreatectomy and splenectomy with lymph node dissection were performed. The patient was discharged 11 days postsurgery, with a good postoperative course. There are no reports of giant pancreatic pseudocysts larger than 10 cm with hematoma contents. The presumptive diagnosis of pseudocysts based on imaging alone may be difficult. Surgical resection is considered when it is difficult to distinguish a giant pancreatic pseudocyst from a cystic neoplasm.
PubMed: 38832062
DOI: 10.1093/jscr/rjae393 -
Cureus May 2024Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome presents a unique challenge in diagnosis and management because of its rarity and heterogeneous initial...
Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome presents a unique challenge in diagnosis and management because of its rarity and heterogeneous initial presentation. This manuscript presents a case series of two patients with PPP syndrome, shedding light on the diagnostic process and care for this uncommon condition. PPP syndrome is characterized by the simultaneous occurrence of pancreatitis or pseudocysts alongside polyarthritis and panniculitis. While its exact pathophysiology remains obscure, pancreatic inflammation is assumed to trigger the hematogenous dissemination of pancreatic enzymes, leading to fat necrosis and subsequent panniculitis, as well as chondronecrosis and/or osteonecrosis causing polyarthritis. Despite its recognition in medical literature since the late 1980s, PPP syndrome remains poorly understood, with only a limited number of cases reported globally. Its rarity and varied initial manifestations often result in misdiagnosis, causing delays in appropriate treatment. The presented case series highlights key clinical features and diagnostic clues of PPP syndrome. Both patients exhibited initial symptoms of inflammatory polyarthritis, accompanied by characteristic findings of "ghost cells" on skin biopsy. Additionally, radiographic and laboratory evidence revealed pancreatic changes consistent with this syndrome. This case series underscores the importance of multidisciplinary collaboration in managing PPP syndrome. Early recognition and accurate diagnosis are pivotal in initiating prompt and effective therapeutic interventions, thereby improving patient outcomes and minimizing long-term sequelae.
PubMed: 38826929
DOI: 10.7759/cureus.59471 -
Cureus Apr 2024Hepatic artery pseudoaneurysm (HAP) is an uncommon yet critical complication of acute pancreatitis. This case delves into the unusual scenario of a two-month-old male...
Hepatic artery pseudoaneurysm (HAP) is an uncommon yet critical complication of acute pancreatitis. This case delves into the unusual scenario of a two-month-old male infant with a familial history of pancreatitis who develops the condition himself. Despite initial treatment, the infant's symptoms worsened, unveiling a pancreatic pseudocyst (PCC) and an atypical pseudoaneurysm stemming from the hepatic artery, a rare complication in acute pancreatitis. The pseudoaneurysm's confirmation through selective angiography and its subsequent management using embolization is highlighted. This report emphasizes the rarity of hepatic artery pseudoaneurysm in the context of acute pancreatitis, stressing the need for thorough imaging to spot arterial involvement. Early identification via selective angiography remains crucial due to the high risks associated with pseudoaneurysm rupture, underscoring the urgency for prompt intervention. In summary, this case spotlights the infrequent occurrence of hepatic artery pseudoaneurysm secondary to acute pancreatitis in an infant. It stresses the importance of swift recognition and intervention to avert potentially life-threatening complications.
PubMed: 38817530
DOI: 10.7759/cureus.59348