Pseudocysts and pseudoaneurysms: surgical strategy

Eight patients over an 8-year period required operation for spontaneous hemorrhage as a complication of a pancreatic pseudocyst. Three patients presented with abdominal pain or jaundice and bled in hospital while undergoing work-up. Four patients were admitted with upper gastrointestinal bleeding and one with intraperitoneal bleeding. Five patients were managed by pancreatic resection (two of the head and three of the tail) and three were managed by arterial ligation and internal drainage. There was one death (mortality rate, 12.5%). The first four patients in the series had their operations delayed secondary to a perceived need for further work-up or an inability to make an exact diagnosis of the bleeding site. All rebled, necessitating an emergency operation. The last four patients underwent an expedited workup and operation. Successful treatment of bleeding pancreatic pseudocysts requires good surgical judgment, especially when nonoperative methods fail or aren't applicable. The risk of recurrent hemorrhage is high, suggesting the need for immediate intervention once the diagnosis is made. Resection provides definitive control, although selected patients with easily accessible vessels may be managed more conservatively with ligation and drainage.