Pancreatitis and pseudocyst formation as a complication of laparoscopic left retroperitoneal nephrectomy

The true incidence of pancreatic complications, although uncertain, would seem to be approximately one in 600 cases as reported by Liapis et al. ¹ This incidence reflects our experience at Portsmouth Hospitals NHS Trust. Analysis of the BAUS 2014 Nephrectomy Dataset reveals three pancreatic injuries out of 7703 upper tract procedures performed (two occurring in patients undergoing minimally invasive surgery). ²

Given the increasing complexity of renal surgery being tackled retroperitoneoscopically, we wanted to highlight this as a rare but potential complication to be considered in patients with a protracted postoperative course and non-specific abdominal pain.

We present two cases of pancreatitis occurring after retroperitoneoscopic nephrectomy, one of which was further complicated by pancreatic pseudocyst development. Both patients were successfully managed conservatively. The first patient was a 76-year-old man with an 8 cm renal tumour, suspicious for renal cell carcinoma (RCC) identified on renal tract ultrasound scan (USS) as part of investigations into painless visible haematuria (see Figure 1 for preoperative computed tomography (CT)). His comorbidities consisted of diabetes and hypertension, for which he was taking insulin, lisinopril, simvastatin and felodipine. He did not drink any alcohol and had no history of gallstone disease. Histological analysis of the left kidney specimen confirmed a Fuhrman grade 2/3 pT3bN0M0 tumour. The operation itself was uneventful. However, two days postoperatively the patient complained of non-specific abdominal pain, nausea and sluggish bowel action. Physical examination revealed generalised upper abdominal tenderness, without peritonism. Laboratory tests are shown in Table 1. An abdominal CT was performed which showed a large collection in the left renal bed (9 cm × 10 cm × 15 cm), which was presumed to be haematoma (Figure 2). However, low attenuation of the pancreatic tail, raising the possibility of pancreatitis (Figure 3), was also noted and on further radiological review the collection was attributed to a large pancreatic pseudocyst. The patient was commenced on Creon and improved symptomatically.

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Figure 1.

Preoperative computed tomography (CT) showing proximity of left kidney tumour to the pancreas.

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Table 1.

Post-operative serum blood test results for our first patient.

Day	0	1	2	3	4	5	6
CRP	3	24	230	260	208	185	168
Amylase	–	–	–	–	–	–	76
ALT	15	11	21	23	38	34	29
eGFR	>90	62	50	42	45	51	54

CRP: C-reactive protein; ALT: alanine aminotransferase; eGFR: estimated glomerular filtration rate.

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Figure 2.

Computed tomography(CT) showing pseudocyst which was initially thought to be haematoma.

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Figure 3.

Postoperative computed tomography (CT) showing evidence of pancreatitis.

The second patient was a 72-year-old man with urolithiasis referred for nephrectomy for a large pelvico-ureteric junction (PUJ) stone (shown in Figure 4), associated with a large renal collection which had previously been managed with a failed stenting procedure, and subsequent percutaneous drainage. He also had a T2N1 sigmoid tumour and underwent a laparoscopic low anterior resection at the same time as his laparoscopic left simple nephrectomy. His other comorbidities consisted of Type 2 diabetes mellitus and gastro-oesophageal reflux for which he was prescribed saxagliptin, gliclazide and omeprazole. He also did not drink any alcohol and had no history of gallstone disease. His postoperative CT showing the development of pancreatitis is shown in Figure 5. This was associated with an elevated serum amylase, which peaked at 418 U/l on Day 1 postoperatively, and fell back to normal levels by Day 3.

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Figure 4.

Preoperative computed tomography (CT).

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Figure 5.

Postoperative computed tomography (CT) showing pancreatitis.