Roux-en-Y Pancreatic Cyst-jejunostomy for Giant Bleeding Pancreatic Pseudocyst. A Time Bomb

Purpose: Pancreatic pseudocyst represents 75% of pancreatic cystic lesions. Different therapeutic approaches have been proposed with controversial results. Bleeding from pancreatic pseudocysts due to destruction of the vascular wall by pancreatic enzymes, portal hypertension and/or compression has been described. In cases of hemorrhagic pancreatic cysts, surgical evaluation is mandatory. The aim of this study is to present a 68-year-old man who presented with a bleeding pancreatic pseudocyst that required the performance of a cyst-jejunostomy. Method: Clinical case review. Results: A 68-year-old male was transferred to our hospital for abdominal pain in the epigastrium associated with a regular general condition. During his stay in the emergency room, a computed tomography (CT) scan was performed. This CT revealed a large pancreatic pseudocyst (12x10x14 cm) that depended on the tail of the pancreas, with heterogeneous images inside compatible with hemorrhagic complication (a). Given the hemodynamic stability of the patient, he was admitted to the intensive care unit for monitoring and planning a scheduled surgery. A three-dimensional reconstruction was performed using CT images (b), which showed the relationship of the cyst with the pancreas, stomach, spleen and vascular structures in contact with it. Due to the size of the cyst, its relationship with the spleen and other large vessels, we decided to perform a bypass of the cyst using a Roux-en-Y cyst-jejunostomy. Being the patient clinically and hemodynamically stable, a scheduled intervention was programmed. In the operating room a large pancreatic pseudocyst that depended on the tail of the pancreas was revealed. It was then opened and drained, obtaining abundant tarry material that suggested to be related with previous bleeding remains, without finding signs of active bleeding at the time of surgery (c). Subsequently, a jejunal loop was approached in its caudal portion, performing a transmesocolic cyst-jejunostomy, and the cyst was sutured using continuous resorbable monofilament suture (d).The patient evolved favorably, without presenting new bleeding episodes or any other complications. Conclusion: In the presented case, a chronic pseudocyst evolves with a major complication acutely. The need to operate on patients with bleeding complications is relatively frequent and the recommended surgical intervention consists of hemostasis, drainage, and bypass of the pseudocyst, whenever possible.