Laparoscopic pancreatic cystgastrostomy

Background/Purpose: Internal drainage of acute pancreatic pseudocysts is indicated after the first 6 weeks of pseudocyst documentation. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When a pseudocyst is in close contact with the posterior wall of the stomach, it is best drained by pseudocyst gastrostomy. Methods: Intragastric surgical techniques were used in 18 patients with retrogastric pseudocysts. Intragastric ports were successfully placed in all patients, and the presence of pseudocysts was confirmed by needle aspiration in 17. Results: The intragastric approach was successful in 14 patients. In three cases a small abdominal would 8 cm in length was needed. The reasons for such conversion included uncontrollable bleeding from the cystic wall in two cases and a cystic wall in contact with, but not adherent to, the posterior gastric wall in one. Bleeding was controlled through a gastrotomy, and cystgastrostomy was performed. The wound required for conversion was much smaller than that needed for planned open surgery. These procedures are called laparoscopy-assisted cystgastrostomy. Good short- and long-term results were obtained. One patient, in whom the cystgastrostomy was too small, developed a cyst infection and underwent reoperation. Except for this case, no recurrence was observed, and no further treatment was needed. Conclusions: This experience demonstrates that cystgastrostomy with the intragastric surgical technique is a safe, less invasive procedure for effectively draining a retrogastric pseudocyst. Received: April 20, 2002 / Accepted: May 13, 2002 Offprint requests to: T. Mori     

Endoscopic transgastric drainage of pancreatic pseudocyst with the use of Nd:YAG laser

Pancreatic pseudocysts have been successfully managed with endoscopic drainage recently. This report describes a case of endoscopic transgastric drainage using endoscopic ultrasonography (EUS) and an Nd:YAG laser. EUS was used to detect an optimal puncture site of the pseudocyst and to reduce the risk of bleeding and perforation. An Nd:YAG laser was used to minimize the risk of bleeding and to penetrate the thick wall of the pseudocyst. After transgastric cystgastrostomy was performed, an internal stent was placed between the pseudocyst and the stomach. There were no complications associated with endoscopic interventions. Complete resolution of the pseudocyst was observed. Endoscopic transgastric drainage of pancreatic pseudocysts is a recommended approach for selected patients with pancreatic pseudocysts that are uncomplicated and are located adjacent to the stomach. Safe and effective drainage can be achieved without hemorrhage and perforation with the use of EUS, an Nd:YAG laser, and a stent. Furthermore, the Nd:YAG laser facilitated passage through a markedly indurated pseudocyst wall and it seemed to be an effective instrument, especially for pseudocysts with a thick wall.     

Laparoscopic pancreatic cystogastrostomy

The purpose of the review was to evaluate the feasibility and outcome of laparoscopic pancreatic cystogastrostomy for operative drainage of symptomatic pancreatic pseudocysts. A retrospective review of all patients who underwent laparoscopic pancreatic cystogastrostomy between June 1997 and July 2001 was performed. Data regarding etiology of pancreatitis, size of pseudocyst, operative time, complications, and pseudocyst recurrence were collected and reported as median values with ranges. Laparoscopic pancreatic cystogastrostomy was attempted in 6 patients. Pseudocyst etiology included gallstone pancreatitis (3), alcohol-induced pancreatitis (2), and post-ERCP pancreatitis (1). The cystogastrostomy was successfully performed laparoscopically in 5 of 6 patients. However, the procedure was converted to open after creation of the cystgastrostomy in 1 of these patients. There were no complications in the cases completed laparoscopically and no deaths in the entire group. No pseudocyst recurrences were observed with a median followup of 44 months (range 4-59 months). Laparoscopic pancreatic cystgastrostomy is a feasible surgical treatment of pancreatic pseudocysts with a resultant low pseudocyst recurrence rate, length of stay, and low morbidity and mortality.     

A comparison of anterior and posterior approaches for the surgical treatment of pancreatic pseudocyst using laparoscopic cystogastrostomy

BACKGROUND: Laparoscopic treatment of pancreatic pseudocyst allows for definitive drainage with faster recovery. Although many groups have reported their experience with an anterior approach, only a few have done so with a posterior approach. This paper compares the approaches, analyzing their potential benefits and pitfalls. MATERIALS AND METHODS: Seven females and one male underwent laparoscopic cystgastrostomy to treat pancreatic pseudocysts. The anterior approach was performed by opening the stomach anteriorly, localizing the pseudocyst ultrasonographically, draining the cyst with a needle and, via the same opening, using a stapler to form a cystgastrostomy. The posterior approach was performed by directly visualizing the posterior gastric wall and the pseudocyst, opening and draining the cyst with a needle, and using a stapler and running sutures for closure. RESULTS: All patients had gallstone pancreatitis. Cystgastrostomy via the anterior approach was used in 4 patients and via the posterior approach in 4 patients. Dense adhesions required one attempted posterior cystgastrostomy to be converted to an anterior approach. The mean age of the anterior group was 38 years (range, 18-58 years) and hospital stay was 6 days (range, 4-8 days): for the posterior group, mean age was 42 years (range, 40-44 years) and length of stay was 3 days (range, 2-4 days). CONCLUSION: Although both approaches had good results with no complications and short hospital stays, the posterior approach is safer, with a more precise cyst visualization and dissection that permits more tissue to be sent for histopathologic examination. Furthermore, the posterior approach?s larger anastomosis would seem to yield fewer occlusions, which are commonly seen with the anterior approach. The anterior approach is easier to learn, but it requires the opening of the anterior stomach and the use of ultrasound.     

Laparoscopic pancreatic cystgastrostomy via the lesser sac approach

Laparoscopic cystgastrostomy offers the benefits of a minimally invasive procedure while providing effective drainage for pancreatic pseudocysts. The lesser sac approach to laparoscopic cystgastrostomy provides adequate working space with excellent visualization. This assures meticulous hemostasis, debridement of the cyst, and wide internal drainage of the pancreatic pseudocyst. Additionally, the laparoscopic approach to this difficult problem can be augmented by other minimally invasive therapies. This video outlines the management of a patient with a pancreatic pseudocyst and concomitant splenic vein thrombosis treated with preoperative splenic embolization and laparoscopic cystgastrostomy via the lesser sac approach.     

Laparoscopic pancreatic cystgastrostomy

Internal drainage of acute pancreatic pseudocysts is indicated 6 weeks after the first documentation of pseudocyst. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When pseudocysts are located in close contact with the posterior wall of the stomach, they are best drained by pseudocyst-gastrostomy. This procedure can also be completed making use of intragastric surgical techniques. Under standard laparoscopic observation, three intragastric ports are placed through the abdominal and anterior gastric walls, establishing working channels for a telescope and hand instruments. After the presence of pseudocysts is confirmed, the posterior wall of the stomach and the cyst wall can be incised by electrocautery. After a sufficient drainage orifice is made and the cyst contents are thoroughly debrided, the intragastric ports are removed and defects in the gastric wall are closed with sutures placed via the standard laparoscopic approach. This approach is much less invasive than the conventional approach, which entails a large gastrotomy in the anterior wall of the stomach. This procedure should be the method of choice when interventional radiology or endoscopic intervention fails to effectively drain retrogastric pseudocysts. Received for publication on April 21, 1999; Accepted on Sept. 1, 1999     

Laparoscopic intragastric stapled cystogastrostomy for pancreatic pseudocyst

BACKGROUND: Mature symptomatic pancreatic pseudocysts require surgical intervention for their management. In this era of minimal access surgery, several reports are now available of laparoscopic management of pancreatic pseudocysts. PATIENTS AND METHODS: We have performed this procedure in five patients over the past 2 years. Four patients developed the pseudocyst after acute alcoholic pancreatitis and one following acute biliary pancreatitis. The diameter of the pseudocyst ranged from 8 to 12 cm. The procedure was performed using five ports. The Harmonic Scalpel was used to create two ports in the anterior stomach wall through which two balloon trocars were placed into the gastric lumen. Following balloon inflation, the trocars were used to lift up the anterior gastric wall. This created the space for the cystogastrostomy to be fashioned laparoscopically through the balloon trocar. The ball probe of the Harmonic Scalpel was used to puncture the cyst through the posterior gastric wall. The cystogastrostomy was completed by firing an Endo-GIA30 stapler across the fused posterior gastric wall and anterior wall of the cyst. RESULTS: The mean operative time was 90 minutes (range 80-125 minutes). The mean postoperative stay was 3.0 days. One patient had intraoperative bleeding at the anastomotic site, which was easily controlled. CONCLUSION: Laparoscopic cystogastrostomy offers a feasible and safe therapeutic option for selected patients with large symptomatic pancreatic pseudocysts.     

Minimally invasive open cystgastrostomy for pancreatic pseudocyst

One of the complications of pancreatitis is pancreatic pseudocyst. Many different techniques have been described for internal drainage of pancreatic pseudocyst. Indication for surgery is either symptomatic or large cysts that can turn into complications such as hemorrhage, obstruction, infection, rupture and malignancy. Our technique includes an incision between 5 cm to 9 cm below the left subcostal margin and the opening of the anterior stomach and a posterior cystgastrostomy performed with a reticulated laparoscopic staple. We have been able to perform surgery in a very large pseudocyst (up to 26 cm) in a small amount of time, within 45 min, and with a shorter length of hospital stay (36 h). In this paper, we present our technique on how to approach large pseudocysts utilizing a minimally invasive small incision.     

Laparoscopic intragastric stapled cystgastrostomy of pancreatic pseudocyst in a child

Abstract The current management for pancreatic pseudocysts in children is predicated on adult techniques and includes open, endoscopic, percutaneous, and laparoscopic drainage. In this paper, we report our technique using two intragastric cannulas for the creation of a laparoscopic stapled pancreatic cystgastrostomy.     

胰腺假性囊肿治疗方式的临床分析

目的对胰腺假性囊肿的治疗方式和临床效果进行分析。方法对2002年1月至2008年6月收治的42例胰腺假性囊肿的治疗方式、效果、并发症进行回顾性分析。结果非手术治疗4例,在随访期间均能自行吸收;手术治疗38例:包括胰腺假性囊肿-胃吻合9例,术后有1例出现吻合口出血;囊肿-十二指肠吻合2例;囊肿-空肠Roux-en-Y吻合21例,术后有2例出现吻合口出血;腹腔镜囊肿-胃内引流术1例;胰腺假性囊肿外引流术2例,术后有1例出现胰瘘;胰腺假性囊肿切除术3例,术后有1例出现胰漏。结论胰腺假性囊肿的治疗已趋于多样化,需根据患者的具体病情来选择不同的治疗方式;手术治疗中囊肿内引流术仍是主要术式,根据囊肿的具体情况选择不同的吻合方式;其中腹腔镜胰腺假性囊肿-胃内引流术,安全微创,疗效确切,值得推广。     

Laparoscopic cystogastrostomy for pancreatic pseudocyst is safe and effective.

Between March 1997 and March 1998, three consecutive patients underwent laparoscopic cystogastrostomy for persistent giant retrogastric pancreatic pseudocyst complicating an attack of acute pancreatitis. The mean cyst diameter was 15 +/- 1 cm (range 14-16). The procedure was performed with four trocars. The anterior wall of the stomach was opened longitudinally. The pseudocyst was entered through the posterior wall of the stomach. A cystogastrostomy was created by suturing the margins of the communication by interrupted nonabsorbable sutures. The mean operative time was 123 +/- 15 min, and there were no postoperative complications. The mean postoperative hospital stay was 4 +/- 1 days. Computed tomography demonstrated complete resolution of the pseudocyst. Laparoscopic cystogastrostomy represents a good therapeutic option for persistent retrogastric pancreatic pseudocyst.     

胰腺假性囊肿治疗方式的选择与评价

目的 对胰腺假性囊肿的治疗方式和效果进行评价。方法 对1990年1月至2002年3月收治的114例胰腺假性囊肿的处理方式、效果及并发症进行回顾性分析。结果 25例未行手术治疗,其中23例在随访期间囊肿自行吸收。CT引导下经皮置管引流组29例,有效率67．85％。外科手术治疗60例,死亡率5％(3／60),手术方式包括：外引流8例,死亡率12．5％(1／8);假性囊肿切除13例;囊肿十二指肠吻合1例;囊肿胃吻合19例,术后消化道出血的发生率为36．8％(7／19),死亡率5．26％(1／19);囊肿空肠Roux-en-Y吻合19例,术后消化道出血的发生率为15．8％(3／19),死亡率5．26％(1／19)。结论 CT引导下经皮置管引流创伤小,操作相对简单,是传统开腹外引流术的有效替代方式。虽然微创技术使胰腺假性囊肿的治疗方式多样化,但仍有不少患者需要外科手术治疗。囊肿胃吻合术后消化道出血的发生率高于囊肿空肠Roux-en-Y吻合术,但多数易于控制,仍然是一种简单合理的内引流术式。对于难以排除恶性的假性囊肿,应尽量手术切除。     

Treatment of pancreatic pseudocysts.

According to the Atlanta classification an acute pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of acute pancreatitis or pancreatic trauma, whereas a chronic pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of chronic pancreatitis and lack an antecedent episode of acute pancreatitis. It is generally agreed that acute and chronic pseudocysts have a different natural history, though many reports do not differentiate between pseudocysts that complicate acute pancreatitis and those that complicate chronic disease. Observation--"conservative treatment"--of a patient with a pseudocyst is preponderantly based on the knowledge that spontaneous resolution can occur. It must, however, be admitted that there is substantial risk of complications or even death; first of all due to bleeding. There are no randomized studies for the management protocols for pancreatic pseudocysts. Therefore, today we have to rely on best clinical practice, but still certain advice may be given. First of all it is important to differentiate acute from chronic pseudocysts for management, but at the same time not miss cystic neoplasias. Conservative treatment should always be considered the first option (pseudocysts should not be treated just because they are there). However, if intervention is needed, a procedure that is well known should always be considered first. The results of percutaneous or endoscopic drainage are probably more dependent on the experience of the interventionist than the choice of procedure and if surgery is needed, an intern anastomosis can hold sutures not until several weeks (if possible 6 weeks).     

Operative management of pancreatic pseudocysts in infants and children: a review of 75 cases.

This report combines the findings and treatment in 15 infants and children with pancreatic pseudocysts with 60 additional cases from a literature review. The mean age at diagnosis was 7.5 years with pseudocyst being more common in boys (44:31). Sixty per cent were due to trauma, while in 32% the cause was unknown. Abdominal pain (68%), a mass (64%), and vomiting (52%) were the most frequent findings. The serum amylase was elevated and the upper gastrointestinal contrast study consistent with a mass in 88% of cases. Operative treatment included external drainage in 25 children (33%), cystgastrostomy or cyst-jejunostomy in 34 (45%), excision in 10 (13%) and miscellaneous procedures in 6 (8%). Complications were relatively few and there were no deaths recorded. Recurrence rate for cyst-gastrostomy was 4.7%, cyst-jejunostomy 7.6%, external drainage 8% and cyst-duodenostomy 50%. External drainage operations had prolonged cutaneous drainage. These observations suggest the appropriate operation is determined by the location and duration of pseudocyst. Internal drainage is preferred and avoids complications seen following resection and external drainage. Cyst-gastrostomy is effective when the pseudocyst is retrogastric and adherent to the stomach wall. Cyst-jejunostomy is most useful in instances in which the pseudocyst in not adherent to the stomach wall. Low recurrence rates and a zero mortality rate makes operative treatment highly acceptable therapy. Low recurrence rates are expected in childhood cases, (particularly related to trauma) due to an absence of underlying pancreatic disease and ductal obstruction.     

Primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts

Background  Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts. Methods  Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis. Results  There were no significant differences (p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m²), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1–40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher (p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy (n = 13), percutaneous drainage (n = 3), and repeat endoscopic drainage (n = 6). Conclusions  Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.     

Minilaparoscopic transgastric cystgastrostomy

BACKGROUND: A technique combining upper endoscopy with percutaneous transgastric minilaparoscopic instrumentation for the formation of pancreatic cystgastrostomy is safe and effective for the internal drainage of pancreatic pseudocysts. METHODS: At a tertiary-care academic medical center, 6 patients with pancreatic pseudocysts with a mean size of 19 cm (range, 16-23 cm) were selected for combined endoscopic and percutaneous transgastric minilaparoscopic (1.7-2 mm) pancreatic cystgastrostomy. All pseudocysts had been followed-up for a minimum of 5 weeks (range, 5-22 wk) and were noted to significantly displace the stomach anteriorly. RESULTS: The mean surgical time was 98 minutes (range, 45-150 min). The mean amount of fluid removed from the pseudocysts was 2167 mL (range, 1600-2600 mL). All ports were removed from the stomach without the need to suture the gastric wall or skin except for 2 gastric serosal sites that were closed with a single intracorporeal stitch. The length of hospital stay averaged 2.2 days (range, 0-6 d). All patients were discharged in good condition, tolerating a regular diet. With a mean follow-up period of 13.4 months (range, 1-30 mo), all patients remain asymptomatic from their pancreatic pseudocysts. CONCLUSIONS: The technique of combining upper endoscopy with percutaneous transgastric minilaparoscopic instruments to create a pancreatic cystgastrostomy can be used to apply well-established surgical principals for internal drainage and has the potential to be used for the management of other gastric pathology.     

A simple,safe technique for the drainage of pancreatic pseudocysts

Background: A number of methods are available for the drainage of pancreatic pseudocysts, including percutaneous, endoscopic and open approaches. In Leicester, we developed a combined radiological and endoscopic technique (predating the use of endoscopic/ultrasound) to allow drainage of pancreatic pseudocysts into the stomach. The aim of the study was to evaluate the long‐term results of this approach. Methods: This is a retrospective study of patients undergoing combined endoscopic/ultrasound‐guided percutaneous stenting between 1994 and 2007. Data were extracted from case records and our computerised radiology database. Results: Thirty‐seven combined endoscopic/ultrasound‐guided procedures were undertaken. Median patient age was 52 years (range 26–84 years). Nineteen pseudocysts were secondary to acute pancreatitis and 18 were in patients with chronic pancreatitis. The diameter of pseudocysts on pre‐procedure imaging ranged from 4 to 21 cm (median 11 cm). Median duration of hospital stay was 7 days (range 1–44 days) and 30‐day mortality was 0%. Stents were inserted in 70.3% of patients (n= 26). Of those patients stented during the combined procedure, three developed infection of the pseudocyst, necessitating open cystgastrostomy within the first month. During a mean follow‐up period of 41 months, two patients developed recurrent pseudocysts which were successfully drained with a further combined procedure (16 and 43 months). Repeat imaging in the remainder of patients failed to show any evidence of a persistent or recurrent pseudocyst beyond 2 months. Conclusion: Combined radiological and endoscopic drainage is safe, cost‐effective and highly efficient in preventing recurrent pseudocyst formation.     

假性胰腺囊肿的外科手术治疗

目的对假性胰腺囊肿的外科手术治疗方式和效果进行评价。方法回顾性分析了我院1990年1月至2003年10月68例假性胰腺囊肿行手术治疗的方式、效果及并发症。结果行外科手术治疗的病人人数占同期假性胰腺囊肿治疗病人的48．9％(68／139)。手术方式包括：外引流术9例，死亡率11．1％(1／9)；囊肿胃吻合20例，术后消化道出血的发生率为35％(7／20)，死亡率5％(1／20)；囊肿空肠Roux-en-Y吻合23例，术后消化道出血的发生率为13％(3／23)，死亡率4．3％o(1/23)；假性囊肿切除14例；囊肿十二指肠吻合1例；胰十二指肠切除1例。结论虽然目前假性胰腺囊肿的治疗可有多种选择，但仍有许多病人需要外科手术治疗。手术治疗应尽可能行内引流术，其中囊肿胃吻合术是一种简单合理的内引流术式，应作为首先。对于难以排除恶性的假性囊肿，应尽量手术切除。     

Management of pancreatic pseudocysts

BACKGROUND: This review analyses the outcome for patients with acute and chronic pancreatic pseudocysts managed in two major referral centres. PATIENTS AND METHODS: From 1987 to 1997, 33 patients were treated with either acute (n = 19) or chronic (n = 14) pseudocysts. Procedures performed included cystgastrostomy (64%), cystduodenostomy (6%), cystjejunostomy (3%), distal pancreatectomy with resection of pseudocyst (12%), laparotomy with external drainage (9%), endoscopic transpapillary stenting (3%) and endoscopic pancreatic duct sphincterotomy with percutaneous drainage of the pseudocyst (3%). RESULTS: All patients had resolution of their pseudocyst and no patient developed recurrence. There were no deaths in this series. There was a 9% incidence of major complications and a 21% incidence of minor complications. Outcome was excellent in 63% and good in 27% of patients. Two patients (6%) had persistent chronic pain and one patient (3%) had evidence of exocrine pancreatic insufficiency with malabsorption. CONCLUSIONS: Surgical internal drainage of pancreatic pseudocysts can be performed safely with low morbidity and mortality provided patients are carefully selected and their medical management is optimized. Although minimally invasive techniques now offer a variety of treatment options, open surgical drainage is still indicated for a significant number of cases.     

Are cystgastrostomy and cystjejunostomy equivalent operations for pancreatic pseudocysts?

To compare the effectiveness of cystgastrostomy and cystjejunostomy for treatment of pancreatic pseudocysts, 39 patients with cystgastrostomy were compared to 59 patients with cystjejunostomy. The groups were comparable in age, sex, cause of pancreatitis, pseudocyst location, symptoms, and preoperative serum amylase level. Cysts treated with cystgastrostomy were larger (mean diameter, 11.1 +/- 0.9 cm) than cysts treated by cystjejunostomy (mean diameter, 6.7 +/- 0.7 cm) (p less than 0.05). Mean duration of surgery was 148 +/- 11 minutes for cystgastrostomy versus 265 +/- 15 minutes for cystjejunostomy (p less than 0.05). Mean blood loss was 397 +/- 82 ml for cystgastrostomy versus 703 +/- 80 ml for cystjejunostomy (p less than 0.05) Mean intraoperative fluid requirements were 2640 +/- 313 ml for cystgastrostomy and 4403 +/- 362 ml for cystjejunostomy (p less than 0.05). Cyst recurrence was 10% for cystgastrostomy versus 7% for cystgastrostomy. Postoperative gastrointestinal bleeding occurred in 8% of patients with cystgastrostomy and in 2% of patients with cystjejunostomy. Infection problems with cystjejunostomy included two wound infections and one case of septicemia; infection problems with cystjejunostomy included five intraabdominal abscesses, two wound infections, and one case of pneumonia. Two patients died with cystgastrostomy (both from gastrointestinal bleeding); two patients died with cystjejunostomy (one from intraabdominal sepsis and one from pulmonary embolus). Cystgastrostomy was used for significantly larger pseudocysts and was associated with significantly less blood loss and operating time than cystjejunostomy (p less than 0.05). Morbidity and mortality from cystgastrostomy and cystjejunostomy were comparable, although gastrointestinal bleeding was more common with cystgastrostomy and intraabdominal abscess was more common with cystjejunostomy. Since cystgastrostomy can usually be performed more quickly and with less blood loss, it should be considered whenever anatomically feasible.