Surgical management of a complex uncinate process pancreatic pseudocyst following failed endoscopic intervention and perforation: a case report

Background: Pancreatic pseudocysts are mature, encapsulated pancreatic fluid collections that usually develop as a complication of acute or chronic pancreatitis. Although most symptomatic collections are now treated endoscopically when anatomically accessible, pseudocysts located in the uncinate process remain technically challenging because of their deep retroperitoneal position and close relationship to the duodenum and the superior mesenteric vessels. Case presentation: We report the case of a 52-year-old woman with alcohol-related chronic pancreatitis and two pancreatic pseudocysts, one retrogastric and the other located in the uncinate process. The retrogastric pseudocyst was treated by endoscopic ultrasound-guided drainage using a lumen-apposing metal stent. After stent migration and endoscopic closure of a gastric perforation with an over-the-scope clip, the patient developed peritonitis and persistent sepsis. Initial laparoscopic lavage achieved temporary control; however, inflammatory markers remained elevated, and follow-up computed tomography demonstrated persistence of the uncinate process pseudocyst and a newly developed liver abscess. Results: Because of inadequate source control, a reoperation was performed. Severe inflammation and adhesions required conversion from laparoscopy to laparotomy. The hepatic abscess was drained and the infected uncinate process pseudocyst was treated with a Roux-en-Y pancreaticojejunostomy. The postoperative course was favorable, with no pancreatic fistula or major complications. At the 4- and 8-week follow-ups, the patient remained well, with normal laboratory results and no residual collection on ultrasonography. Conclusion: This case illustrates the limitations of endoscopic therapy in anatomically complex pancreatic pseudocysts and emphasizes that definitive surgical drainage remains an essential option when endoscopic access is unsafe, incomplete, or complicated by ongoing sepsis.