TEACHING POINTS
■ Adrenal pseudocysts are cystic masses often intimately involved with adjacent organs. They can be easily mistaken for benign adrenal cysts, adrenal tumors, or renal cysts.
■ Distinguishing adrenal pseudocysts from other adrenal masses may be difficult and requires radiographic and histopathologic confirmation.
■ The treatment is complete excision when the cyst is symptomatic, enlarged, or suspicious for neoplasm.
■ During evaluation and treatment of abdominal masses, collaborative dialogue between surgeons and radiologists, good communication with patients and family members, collegial collaboration among members of the clinical team, and decision making based on evidence-based review of the surgical literature are all essential for a good outcome.
CASE
A 62-year-old female with diabetes, hypertension, and hepatitis C presented with right upper quadrant pain and stable angina. She reported an increase in her abdominal girth over 2 years and complained of occasional fleeting left flank pain. She denied any changes in bowel or bladder function. She had no history of upper or lower endoscopy and claimed to generally adhere to her medication regimens. On evaluation, she described pain under her right shoulder but reported no history of gallstones, pancreatitis, recent weight loss, constitutional symptoms, or history of trauma. The extended review of systems was negative. Her surgical history included a previous total abdominal hysterectomy with bilateral salpingo-oophorectomy. The physical examination revealed a positive Murphy's sign with peritoneal findings. A large, tender, mobile mass was palpable left of the midline with no obvious bruit or thrill. The rest of the physical examination was nonfocal.
Diagnostic testing Laboratory results were normal for a CBC and electrolyte studies, though mild elevations in hepatic enzymes suggested a cholestatic pattern. Abdominal ultrasonography revealed cholelithiasis with pericholecystic fluid plus hydrops of the gallbladder with a positive sonographic Murphy's sign. Additionally, a large, complex abdominal mass with central necrosis was identified. Contrast-enhanced CT of the abdomen and pelvis showed a 13.3×14.7×17.4-cm mass arising near the distal tail of the pancreas; the mass contained homogenous fluid with scattered calcifications along the periphery (Figure 1).
Laparotomy With a working diagnosis of acute cholecystitis secondary to cholestasis caused by a concurrent symptomatic pancreatic mass, plans were made to perform an abdominal exploration, open cholecystectomy, and pancreatic mass excision. The exploratory laparotomy revealed a large retroperitoneal mass, as expected. The open cholecystectomy was uneventful, with no obstructive choleliths noted in the common bile duct (intraoperative cholangiography was not performed).
The left colon was mobilized, and the retroperitoneal mass was approached carefully. Once the mass was isolated, the posterior pedunculated stalk was the only remaining attachment to free the mass, and therefore an attempt was made to place a right angle clamp around this stalk to ligate these attachments in standard fashion. The tissue was unexpectedly friable and ripped, leading to extensive bleeding. Approximately 1,500 mL of blood immediately filled the operative field; there was no definitive source and there were no consequential hemodynamic manifestations. The mass was freed and removed, and the bleeding vessel was followed down to the left adrenal gland. Intraoperatively, it became clear that the mass had no pancreatic attachments and that the pedunculated stalk perhaps arose from the left adrenal gland.
Once adequate hemostasis was achieved, another re view of the images suggested a hypervascular adrenal source. The patient remained hemodynamically stable through the operative course, further suggesting cystic (adrenal) pathology. The 1.2-kg specimen measured 16.0 °— 14.5 °— 8.0-cm and appeared heterogeneously yellowish gray with a smooth surface. The contents were variegated, with areas of hemorrhage and necrosis (Figure 2). The permanent section microscopic examination revealed no epithelial lining, vascular proliferation with foci of calcification in the peripheral zone, and normal adrenal tissue surrounding the cyst (Figure 3). Postoperatively the patient did well, and she was discharged home on day seven. The final pathology combined with the operative report and re-review of the images confirmed the diagnosis of an adrenal pseudocyst.