Postoperative Bleeding After the Modified Frey Procedure With Laparoscopic Distal Pancreatectomy for a Hemorrhagic Pancreatic Pseudocyst: A Case Report

Abstract

We report a case of a hemorrhagic pancreatic pseudocyst (PPC) in which a laparoscopic distal pancreatectomy and modified Frey procedure were performed. These procedures resulted in postoperative bleeding from a small hole in the pancreatic duct wall, caused by the removal of a pancreatic duct stone. A 76-year-old man had been undergoing follow-up treatment for six years for alcoholic chronic pancreatitis (CP). While the main pancreatic duct had gradually dilated, and its intraluminal stones had increased in number and size, a PPC had appeared and enlarged gradually at the distal end of the pancreatic tail. During a periodic follow-up, an abdominal computed tomography (CT) scan showed a new, small PPC at the duodenal side of the original, containing a hemorrhagic pseudoaneurysm. Abdominal angiography showed extravasation into the small PPC from arterial branches of the great pancreatic artery, which were subsequently embolized. Nine days after the arterial embolization, a modified Frey procedure with a laparoscopic distal pancreatectomy was performed. The postoperative course was uneventful until 13 days after the operation, when the patient exhibited epigastralgia and melena. An abdominal CT scan revealed hemorrhagic dilatation of the cavity of the longitudinal pancreaticojejunostomy, without pseudoaneurysms or active bleeding. Surgical exploration revealed arterial bleeding from a small hole in the pancreatic duct wall, which had been created during the removal of a pancreatic stone in a previous operation. Hemostasis was achieved through suture closure of the hole, and a pancreaticojejunostomy was performed again. The patient has been alive and well for five years since the surgery, without recurrence of pancreatitis, PPCs, or hemorrhage. The Frey procedure is one of the most common procedures for CP. During this operation, as many stones as possible are removed from the pancreatic duct, which may sometimes be incarcerated in a small branch of the pancreatic duct; therefore, a small hole is sometimes observed after their removal. However, it is unpredictable whether the hole may contact the wall of an arterial branch of the pancreas. Therefore, to prevent postoperative bleeding after the removal of pancreatic duct stones, suture closure of the hole should be considered.

Keywords: frey procedure; hemorrhagic pancreatic pseudocyst; intracystic hemorrhage; pancreatic stone; postoperative bleeding; treatment of chronic pancreatitis.

Figure 1. CT scan

CT scans 7 years ago (A, B) and 1 year ago (C, D) show that the main pancreatic duct gradually dilates, its intraluminal stones increase in number and size (arrow), and a pancreatic pseudocyst appears and gradually enlarges at the distal end of the pancreatic tail (arrowhead). CT, computed tomography

Figure 2. Plain CT scan and arterial phase of dynamic contrast-enhanced CT scan

Plain CT scans (A, B) and arterial phase of dynamic contrast-enhanced CT scans (C, D) showing a new, small pancreatic pseudocyst (white arrows) on the duodenal side of the original one (arrowheads), and a hemorrhagic pseudoaneurysm within it (yellow arrow). CT, computed tomography

Figure 3. Splenic arteriography

Splenic arteriography showing extravasation (arrow) into the small pancreatic pseudocyst from branches of the great pancreatic artery (A), which were embolized (B).

Figure 4. (A) Intraoperative view of the pancreas; (B) Macroscopic view of the resected specimen

White arrows depict the cut end of the pancreatic body; Black arrows depict the opened main pancreatic duct; Black arrowheads depict the pancreatic pseudocyst; Blue arrow depicts the stomach; Yellow arrow depicts the spleen.

Figure 5. Abdominal CT imaging 13 days after the Frey operation

(A)-(B) These images reveal hemorrhagic dilatation of the cavity of the longitudinal pancreaticojejunostomy, without a pseudoaneurysm or active bleeding (arrows). CT, computed tomography