Drainage of pancreatic pseudocysts. The importance of cyst wall biopsy in the recent era.

OBJECTIVE: While open internal drainage has been the standard treatment for pancreatic pseudocysts, less invasive techniques which pay little attention to cyst wall biopsy, are becoming popular. The aim of this study is to report on our experience in draining pancreatic pseudocysts and probe the necessity or otherwise of obtaining a wall biopsy at drainage. METHODS: Operation theatre registry, operation log books and medical records at Aseer Central Hospital, Abha, Kingdom of Saudi Arabia, were reviewed to retrieve the clinical details of patients with pancreatic pseudocyst who required a drainage procedure in a 13 years period from August 1989 to November 2002. RESULTS: Sixteen patients were identified. Cyst wall biopsy was obtained in 10 cases, in 8 of them the diagnosis was confirmed, while a true cyst was found in the remaining 2 excluding them from further analysis. In the remaining 14 cases (8 males, 6 females, mean age 38 years, range 4-60), pain was the main presenting feature. Open internal drainage was offered to 12 cases while one patient received external drainage under ultrasound guidance and the other received open external drainage. The type of operation was cystogastrostomy in 9 patients and cystojejunostomy in 3 patients. The recurrence rate after internal drainage was 16.7%, while after external drainage was 100%. There was no mortality in this series. A procedure-related complication occurred in 3 (21.4%) patients. CONCLUSION: The mortality, morbidity and recurrence rates in this series are compared favorably with other reports. The final diagnosis of a presumed pancreatic pseudocyst should rest on the histopathologic examination of the cyst wall.

Giant retroperitoneal ancient schwannoma: Is preoperative biopsy always mandatory?

INTRODUCTION: Schwannoma is the term given to tumours arising from Schwann cells of any nerve sheath. It may arise in the retroperitoneum, where it can attain enormous sizes and cause considerable diagnostic and therapeutic difficulties. A variety of incapacitating symptoms may arise, depending on its size alone and the related contagious organs. PRESENTATION OF CASE: A 71-year-old female, who was incapacitated by a giant abdominal mass, associated with weight loss, immobility, general weakness and constipation. Radiologically, the presence of a huge pelviabdominal tumour was confirmed. A preoperative tissue diagnosis was entertained but omitted, and we resorted to direct surgical excision instead. During surgery, significant bleeding from the surrounding lumbar vessels was encountered, but it was controlled and the tumour was excised intact. Histopathologically, it showed the histologic features of ancient schwannoma. DISCUSSION: In the patient presented here, who was rendered immobile by the tumour, total excision or at least debulking seemed appropriate, regardless of any biopsy result. CONCLUSION: The diagnosis of retroperitoneal schwannoma and its variant "ancient schwannoma" should be considered when a huge pelviabdominal tumour is encountered. Although CT guided biopsy may be helpful in reaching a preoperative diagnosis, this might not change the decision for the need of total tumour excision or at least debulking, in the presence of incapacitating symptoms. With large tumours, the possibility of perioperative exanginating haemorrhage should be remembered and the necessary precautions activated.