Drainage of Pancreatic Pseudocysts

Drainage of Pancreatic PseudocystsGerard V. Aranha, Lawrence W. Way, Scott G. Houghton

Introduction

The goals of surgical treatment of most pancreatic pseudocysts are to provide a pathway of internal (enteric) drainage of the “leaking” exocrine secretions to allow thepseudocyst cavity to collapse, thereby either “sealing off” the ductal leak or creating a permanent internal fistula for drainage. Internal drainage includes cystogastrostomy,cystojejunostomy, and less commonly cystoduodenostomy. Internal drainage can also be accomplished by endoscopic cystogastrostomy or cystoduodenostomy in selectedpatients.

Indications and Contraindications

Indications ■ Cystogastrostomy: symptomatic or very large pseudocysts of the pancreas adherent to the posterior wall of the stomach, i.e., the posterior wall of the stomach forms the anterior wall of the pseudocyst

■ Cystojejunostomy: a pseudocyst not adhering to the posterior gastric wall in anylocation in the pancreas – head, body, or tail or Pseudocysts that bulge through thetransverse mesocolon

■ Cystoduodenostomy: a pseudocyst of the head of the pancreas anatomically placedso that only a cystoduodenostomy is possible

Contraindications ■ Cystogastrostomy: Pseudocyst in the head or tail of the pancreas not adherent to stomach, or a pseudocyst that bulges through the transverse mesocolon only partially adherent to the stomach

■ When the surgeon is not entirely certain that the cystic mass is a pseudocyst of the pancreas

■ Grossly infected pseudocysts■ Cystojejunostomy: Pseudocysts more amenable to cystogastrostomy or

cystoduodenostomy■ Cystoduodenostomy: Pseudocyst not immediately adjacent to duodenum,

or concern about disrupting pancreatic ductal entry into duodenum (major or minor ampulla)

Preoperative Investigations and Preparation for the Procedure

History: Vague abdominal or back pain after an attack of acutepancreatitis, nausea, vomiting, and weight loss

Clinical: Fullness or mass in the epigastriumLaboratory tests: Persistent increase in serum amylase after attack of acute

pancreatitisDiagnostic imaging: CT can identify one or more pseudocysts in the pancreas and

may help to differentiate a cystic neoplasm from a pseudocystERCP Rarely used but can differentiate a pseudocyst that communi-

cates with the main pancreatic duct from a cystic neoplasm,which should not occur unless it is an IPMN (intraductalpapillary mucinous neoplasm)

Preoperative preparation: NPO two to four hours before operation. A perioperativeprophylactic I.V. antibiotic is repeated depending on theduration of operation

SECTION 6 Pancreas730

Procedures

Open Cystogastrostomy

STEP 1 Exposure of pseudocyst

A bilateral subcostal incision is preferred; alternatively, a midline incision may be used.After routine abdominal exploration, a mechanical ring retractor is placed to retract

the liver and abdominal wall.The pseudocyst adherent to the posterior gastric wall is visualized or palpated

transgastrically.Seromuscular stay sutures are placed in the anterior gastric wall over the cyst.A long gastrotomy is made, and the anterior gastric wall is retracted using stay

sutures.

Drainage of Pancreatic Pseudocysts 731

STEP 2 Transgastric opening of pseudocyst

The cyst is palpated through the posterior gastric wall.The cyst is aspirated using a 22-gauge needle; usually, clear, opalescent, or brownish

fluid is obtained; if thick mucoid fluid is obtained, the diagnosis of cystic neoplasm must be entertained (A-1).

After aspiration, the syringe is removed from the needle, which is left in place andsecured with a hemostat.

A #11 blade knife is used to enter the cyst alongside of the needle (A-2).Once the cyst is entered, the needle is removed and a right-angled clamp is inserted

into the opening, elevating the posterior wall to enlarge the opening to at least 3–4cmor longer if possible.

Biopsy of the cyst wall using a long-handled, #15 blade knife should be imperative (A-3).

The cyst is probed with a finger, loculations gently broken down, and contents aspirated. Thick debris is removed carefully with packing forceps.


A-1

A-2 A-3

STEP 3 Oversewing of cystogastrostomy

The posterior common cyst/gastric wall is oversewn (“reefed”) with running 3-0 silksuture. One suture is run from 3o’clock to 9o’clock and tied, the other suture is run from9o’clock to 3o’clock; this avoids a “pursestring” effect on the opening and allows the cystto communicate freely with the stomach.

The gastrotomy is closed in two layers; the inner, running 3-0 polyglyconate suture isplaced in a Connell fashion to invert the mucosa and obtain hemostasis; the outer layerconsists of interrupted 3-0 silk seromuscular sutures.

The abdomen is closed without drainage using running 1-0 polydioxanon for theanterior and posterior rectus fasciae for a subcostal incision and 1-0 polyglycolic acidfor a midline incision.

The skin incision is closed with staples.


Open Cystoduodenostomy

STEP 1

Specific indications include a pseudocyst in the head of the pancreas anatomically placed so that only a cystoduodenostomy is possible.

The same approach/setup as for cystogastrostomy above.The pseudocyst is visualized and palpated.The cyst is aspirated with a 22-gauge needle.A clear, opalescent, or brownish fluid should be obtained; mucoid fluid suggests

a cystic neoplasm.The syringe is removed from the needle, and a #11 blade knife is used to enter the

cyst along the needle.A right-angled clamp is inserted to elevate the cyst wall, for enlarging the opening

to at least 2–3cm of longer; a biopsy is taken of the cyst wall.


STEP 2

The duodenum is well Kocherized.In this depiction, a lateral-to-lateral or side-to-side cystoduodenostomy is shown.Creation of an anterior vertical duodenotomy of at least 2–3cm is carried out (A-1).Posterior sutures between the cyst and the duodenum are placed in a single inter-

rupted layer using 3-0 silk (A-2).Sutures are placed from the duodenum to the cyst to create an anterior wall using

a single layer of interrupted 3-0 silk (A-3).If a transduodenal cystoduodenostomy can be used, it is similar to cystogastrostomy.

However, pseudocyst drainage into the posterior duodenum is done into the first orthird portion of the duodenum to avoid injuring the common duct; staying in themidline of the posterior duodenal wall avoids injury to the gastroduodenal and pancre-aticoduodenal vessels. Intraoperative ultrasonography can be used to identify thecommon bile duct and vessels if necessary.

Abdominal incision closed as for cystogastrostomy.


A-1

A-2

A-3

Open Cystojejunostomy

STEP 1 Exposure of pseudocyst

Specific indications include a pseudocyst not adhering to the posterior gastric wall in any location in the pancreas – head, body, or tail and those pseudocysts that bulgethrough the transverse mesocolon.

We prefer a bilateral subcostal incision with a mechanical ring retractor.The pseudocyst is intimate with the transverse mesocolon.Aspirate the cyst with a 22-gauge needle.


STEP 2

The jejunum is transected with a mechanical stapler 20cm from the ligament of Treitz.The distal end is oversewn and brought up to the cyst as a Roux limb.3-0 interrupted silk sutures are placed between the cyst wall and midway between

the antimesenteric and mesenteric borders of the posterior jejunal wall for 4–5cm or longer and tied down after all sutures are placed (A-1).

A cystotomy is made in similar fashion as for cystogastrostomy and cystoduodenos-tomy; a biopsy is taken of the cyst wall (A-2).

An interrupted single layer of 3-0 silk sutures is placed between the cyst and thejejunum to create an anterior wall (A-3).

The cystojejunostomy is completed as for side-to-side cystoduodenostomy (A-4).


A-1 A-2 A-3

A-4

STEP 3

The proximal jejunum is anastomosed to the Roux limb 60cm distally.


STEP 4

When the pseudocyst does not bulge through the mesocolon and is not adherent to thestomach or duodenum, the gastrocolic ligament is taken down to enter the lesser sac.

The Roux limb is brought retrocolic either to the right or left of the mesocolic vessels.The anastomosis of the pseudocyst is done as in Step 2.


Laparoscopic Cystogastrostomy

STEP 1

Alternatives to open cystogastrostomy include either a totally endoscopic approach tocystogastrostomy or a less-well standardized, percutaneous, radiologic, transgastriccystogastric tube placement attempting to accomplish the same overall goals. The laparo-scopic approach provides another “access route” that allows a better visualization as wellas the ability to use laparoscopic surgical techniques not limited to the narrow access portof the gastroscope. Two trocars are placed into the lumen of the gas-distended stomach toprovide the access for the cystogastrostomy. The gastric lumen becomes the counterpartof the gas-filled peritoneal cavity used for conventional laparoscopic operations (A-1).

The operation begins by placing a periumbilical trocar for introduction of a laparo-scope (5mm or 10mm). Two additional trocars are inserted in the mid clavicular lineseveral centimeters rostrally on either side of the camera trocar.

A nasogastric tube is passed into the stomach and attached to a laparoscopic insuf-flator. CO2 gas is instilled to inflate the gastric lumen until the anterior gastric wallcomes within a few millimeters of the anterior abdominal wall as visualized via thelaparoscope. A radially expanding 10-mm trocar is inserted into the stomach as follows.First, pass the trocar through the abdominal wall where the anterior surface of thestomach abuts the abdominal wall, usually in the left epigastrium. Then poise it at thedesired entry site on the anterior gastric wall and pop it into the stomach using a quicksnap of the wrist. Pass a 5-mm, 30 degree laparoscope down the trocar and look into thegastric lumen; because the gastric walls reflect light so well, the view is bright and full ofdetail. Insert a second trocar into the stomach 6–10cm from the first one. Check thatpositioning is satisfactory for intragastric surgery by passing the 5-mm scope down eachof the trocars. The radially expanding trocars create snug, gas-tight puncture wounds inthe stomach; conventional cutting trocars make wounds that leak (A-2).


A-2A-1

STEP 1 (continued)

Next, shut off gas insufflation into the peritoneal cavity and open the valves on thesetrocars to room air to allow any small amount of gas that might leak from inside thestomach around the gastric trocars to escape instead of accumulating in the peritonealcavity and competing for space with the distended stomach. The insufflation pressure in thegastric lumen should be set at 20cm/H2O with insufflation connected to one of the trocars.

It is usually possible to see a convexity on the posterior gastric wall created by thepseudocyst. To localize the pseudocyst, pass a long aspirating needle through the back wall of the stomach into the cyst and aspirate some cyst fluid. If fluid is not found, eitherthe needle is not in the cyst or the cyst contents are too thick to aspirate. The latter isuncommon, however, so the first alternative is most likely. Check the CT, recalculate thecyst location, and try again. In our experience, finding the cyst has rarely been difficult andhas never required use of laparoscopic ultrasonography; however, use of this techniquemay prove helpful.

Having located the cyst, use the hook monopolar electrocautery (at a high powersetting) to cut a hole through the posterior gastric wall into the pseudocyst; do not makethe full cystogastrostomy incision, just a 1-cm hole (A-3).

Next, aspirate the cyst contents and pass the scope into, or almost into, the cyst cavity.After determining where your entry hole lies in relation to the cyst’s circumference and areaof contact with the stomach, extend the cystogastrostomy incision so it involves the centerof the common wall between cyst and stomach and spans one-third to one-half of the cystdiameter. Check for bleeding and control with further electrocautery or suture ligation.

Remove semi-solid necrotic debris from within the cyst lumen and temporarilydeposit this material in the dependent fundus of the stomach; the debris should bepushed through the pylorus into the duodenum before removing the gastric trocars.Do not try to “debride” the wall of the pseudocyst.


A-3

STEP 2

The intragastric scope and any other instruments are withdrawn from the gastrictrocars, the pneumoperitoneum reinstated, and a laparoscope is inserted in the perium-bilical trocar. The gastric trocars are withdrawn from the stomach under direct vision,but not pulled out of the abdomen because the port sites will leak gas. Decompress thestomach through the nasogastric tube.

Using intracorporeal suturing and knot tying (or alternatively an endoscopic stapler),place two interrupted Lembert stitches of 2-0 silk to close the puncture sites in the ante-rior gastric wall. All five trocars and the nasogastric tube can be removed (A-1, A-2).


A-1

A-2

Postoperative Care

■ Observation in the Intensive or Intermediate Care Unit is required only in selectedpatients.

■ Nasogastric suction for 48h.

Local Postoperative Complications

■ Early:– Upper GI bleeding – usually from the anastomotic site– Anastomotic leak and/or intra-abdominal abscess– Beware alcohol withdrawal

■ Late:– Recurrent pseudocyst– Error in diagnosis, i.e., mistaking a cystic neoplasm of pancreas for a pseudocyst;

this leads to a persistent recurrent cyst with symptoms


Tricks of the Senior Surgeon

Open internal drainage of pseudocysts:■ Always make sure that the cyst contents are that of a pseudocyst; i.e., clear,

opalescent or brownish and not mucoid as in a cystic neoplasm.■ Leave the aspirating needle in place to enter the cyst with a knife alongside the

needle.■ Use a right-angled clamp to elevate the cyst wall to make an adequate sized

opening.■ Virtually always biopsy the cyst wall.■ If the cyst contents appear purulent, send the fluid for gram stain. If only white

cells are seen, then internal drainage can be done; however, if numerous bacteriaare seen and the fluid is purulent, external drainage is preferable.

■ Use intraoperative ultrasonography liberally, because it can identify and locatemore than one cyst. It can also locate the common bile duct and pancreatic duct.Finally, it can reveal the relationship of the pseudocyst to adjacent visceral andvascular structures.

Laparoscopic cystogastrostomy:■ This laparoendoscopic approach recapitulates the open transgastric cystogas-

trostomy. While others have described a side-to-side cystogastrostomy via alaparoscopic approach using a linear endoscopic stapler, the risk of an intra-peritoneal “anastomotic leak” is avoided by the approach we have described.

■ The initial short cystogastrostomy can be lengthened using an endoscopic linearstapler or even the harmonic scalpel, but we have not found this necessary andthese techniques just increase the cost of the procedure.

■ Carefully inspect the site of the cystogastrostomy; if there is any bleeding, theincision can either be reefed/oversewn intragastrically via the two trocars using a 2-0 silk suture or further controlled with electrocautery.

■ Beware of the patient with a large “pseudocyst” of the pancreatic body after anepisode of necrotizing pancreatitis. Be certain to exclude the presence of splenicvein compression/occlusion and gastric varices; these varices can be quite largeand lead to severe hemorrhage during the cystogastrostomy.


Drainage of Pancreatic Pseudocysts

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