Transenteric rupture of pancreatic pseudocysts: management of pseudocystenteric fistulas

Among the protean presentations of pancreatic pseudocyst, spontaneous transenteric perforation is being reported with increasing frequency. Review of the literature revealed 37 cases in which the diagnosis of transenteric perforation of a pseudocyst could be substantiated, 21 reported since 1960. Five additional cases are described, including the first case of pseudocystesophageal fistulization. Of the 26 recent cases, chronic alcoholism was associated with fistulization in 73 per cent (19/26), males outnumbered females 2:1, and the age at diagnosis ranged from 23-74. No predilection for any particular segment of intestine was apparent. All the patients had symptomatology suggestive of pancreatic disease. In addition, 54 per cent (14/26) had intestinal hemorrhage. In that group of patients with a palpable abdominal mass, the sudden disappearance of the mass as transenteric decompression occurred was pathognomonic. Defivitive diagnosis was best established by a combination of ultrasound and barium intestinal studies. The overall mortality rate was 27 per cent (7/26), all of the deaths occurring in those patients with hemorrhage complicating the pseudocystenteric fistula. Since spontaneous closure of the fistula may be expected, surgery should be reserved for those patients with incomplete spontaneous drainage or uncontrollable hemorrhage.