Treatment of pancreatic pseudocysts by laparoscopic cystogastrostomy

AIM: To evaluate the clinical results of laparoscopic cystogastrostomy and to determine the potential advantages of this new therapeutic option. PATIENTS AND METHODS: This study concerned 12 patients presenting with pancreatic pseudocyst and operated on by laparoscopic cystogastrostomy between 1997 and 2002. There were five men and seven women with a median age of 46 years (range: 30-72). In ten patients, the pseudocyst developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients, the pseudocyst was associated with chronic pancreatitis. All the patients had a single cyst bulging into the posterior wall of the stomach and the median cyst diameter was 9 cm (range: 5-14). RESULTS: Endoluminal gastric laparoscopy was used in six patients and intraperitoneal transgastric laparoscopy in six patients. Conversion to open surgery was required in one patient because the cyst could not be correctly localised by laparoscopy. The median size of the cystogastrostomy was 3 cm (range: 2-5). In eight patients, necrotic debris were still present within the cyst. The median operative time was 90 min (range: 60-140) and the median postoperative hospital stay was 6 days (range: 4-24). No mortality was recorded and postoperative morbidity was limited to one haematoma of the rectus sheath on a port site. One patient was readmitted on the 20th postoperative day because of cyst infection due to partial closure of the cystogastrostomy and was treated by endoscopic placement of a stent. One patient was lost for follow-up 2 months after surgery. With a median clinical and radiological follow-up of 12 months (range: 6-36), no recurrence of pancreatic pseudocyst was observed. CONCLUSIONS: In this series, laparoscopic cystogastrostomy is associated with a low postoperative morbidity and an effective permanent result. Laparoscopy has two main advantages: an excellent control of haemostasis and the creation of a wide communication with debridement of the cyst contents thus minimizing the risk of infection or recurrence of the pseudocyst.     

Percutaneous cystogastrostomy for chronic pancreatic pseudocyst

During the years 1984–1992, 74 patients of mean age 45 (range 6–71) years with chronic pancreatic pseudocyst were treated by percutaneous cystogastrostomy. They comprised 45 men and 29 women. A diagnosis of chronic pancreatitis was verified in 55 patients (74 per cent); pain was the indication for treatment in all cases. The catheter was successfully placed at the first attempt in 68 patients (92 per cent). Immediate complications occurred in four patients (5 per cent); there have been none since 1986. Abscess formation was seen in eight patients (11 per cent). One patient died 4 days after the procedure from myocardial infarction giving a mortality rate of 1 per cent; no death has occurred since 1986. The mean observation time was 27 (range 0–108) months. Pain disappeared or decreased in almost 90 per cent of patients and weight gain was seen in 80 per cent. The method described is less traumatic than operation, and mortality and complication rates compare favourably with those seen after surgery; the results are at least as good.     

Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts in children

Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The management is based upon the pseudocyst size and presence of symptoms. Those requiring intervention are often drained using several available options. The use of laparoscopic cystogastrostomy for large and recurrent PPSs has been described in adult patients as a less morbid alternative to open drainage procedures. This technique is considered a novel approach in children.We describe 2 children who had PPSs amenable to laparoscopic cystogastrostomy. The first was an 11-year-old girl who had blunt abdominal trauma from a bicycle handlebar. The second patient was a 7-year-old girl who developed idiopathic pancreatitis. Briefly, 2 ports were placed through the anterior abdominal and gastric walls, and into the lumen of the stomach. This intraluminal placement provided access to the posterior gastric wall. Using electrocautery diathermy, an incision was made through the posterior gastric wall and into the adjacent pseudocyst to obtain complete and unobstructed drainage. Both children tolerated the procedures well with resolution of their PPSs. The patients were each discharged on the fourth postoperative day and have been asymptomatic on 2 years follow-up.Laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for the minimally invasive management of PPSs in the pediatric population.     

Percutaneous catheter drainage of pancreatic pseudocysts.

Pancreatic pseudocysts represent a complication of severe pancreatic inflammatory disease. Although operative drainage is the cornerstone of therapy for pseudocysts, we have undertaken percutaneous catheter drainage in a selected group of 28 patients over a six-year period (1982-88). This represents 42 per cent of pseudocyst patients managed by the senior author and 1.7 per cent of admissions for pancreatitis at the Medical University Hospitals during that period of time. There were 26 men and two women with an age range of 26-66 years (mean = 42.1). Twenty-six patients had alcohol abuse as the cause of pancreatitis; two were due to surgical trauma. Nondilated pancreatic ducts were demonstrated in 25 patients. Six had pancreatic ascites associated with pseudocysts. Four had previous operative drainage (2 internal and 2 external drainage procedures). Five patients received octreotide acetate, a synthetic peptide which mimics the action of somatostatin, in an attempt to aid closure of external fistulas. The mean length of catheter drainage was 48 days (range 7-210 days). Eight (29%) patients developed procedure-related complications (1 pneumothorax, 1 sheared guidewire, six drain tract infections). There was no mortality. Successful resolution of pseudocysts was achieved in 26 patients (93%). Two patients subsequently had elective caudal pancreaticojejunostomy (CPJ), and one lateral pancreaticojejunostomy (LPJ) to drain obstructed pancreatic ducts. One patient has required repeat external drainage. Percutaneous external drainage is successful in pseudocyst eradication. When underlying pancreatic pathology remains uncorrected, elective surgical decompression of obstructed, dilated ducts may be necessary.     

Percutaneous drainage of traumatic pancreatic pseudocysts in children

To determine the effectiveness of percutaneous drainage of traumatic pancreatic pseudocysts, we reviewed the courses of 13 children. Six pseudocysts resolved on complete bowel rest and total parenteral nutrition. Seven required further therapy. Two pseudocysts were treated operatively; five were drained percutaneously with fluoroscopic guidance. These five ranged from 5 to 15 cm in diameter and were present for 10 to 42 days (mean, 26 days). In all cases, the cyst fluid was clear, had an amylase level of greater than 40,000 IU/L, and grew no organisms. The pigtail catheters left in place in four of the five children were removed when drainage stopped. Patients were followed by ultrasound while still in the hospital and 1 month after discharge. There were no complications nor any pseudocyst recurrence. Percutaneous drainage of traumatic pancreatic pseudocysts in children is an effective alternative to the standard operative therapy of pseudocystenteric anastomosis.     

Bleeding after pancreatic cystogastrostomy.

Two cases of postoperative bleeding after pancreatic cystogastrostomy are presented. From literature studies it is found that mortality in such cases varies greatly. Compiled literature studies reveal a frequency of 11% after cystogastrostomy and 7.4% after cystojejunostomy, but because of the differences in technique the frequencies cannot be examined statistically. It is still a matter of discussion which operation technique is the more suitable in preventing this complication. The various theories concerning the aetiology of the postoperative bleeding are discussed. As postoperative bleeding after cystogastrostomy is a life-threatening condition, immediate surgical intervention is imperative.     

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.     

Percutaneous drainage of pancreatic pseudocysts: A prospective study

We classify pancreatic pseudocysts in 3 types: post-necrotic type I, related to acute pancreatitis; post-necrotic type II, related to an acute attack superimposed on chronic pancreatitis; and retention type III, due to chronic pancreatitis with ductal stricture. A prospective study on percutaneous catheter drainage of post-necrotic pseudocysts (type I and II) was undertaken from 1987 to 1990. Twenty-three pseudocysts in 21 patients were drained. Overall recurrence rate was 4%; 2 patients had fistulization of the catheter into bowel; no deaths occurred. The procedure was successful in all type I cysts; in type II cysts it was associated with prolonged drainage and increased risk of complications when cyst-duct communication was present. Percutaneous drainage has no role to play in type III retention cysts. Guidelines regarding indications for treatment and the techniques employed are described.

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Resumen Clasificamos los seudoquistes pancreáticos en tres tipos: Tipo I, post-necrótico, el que está relacionado con pancreatitis aguda; Tipo II, post-necrótico, el que está relacionado con un ataque agudo en un paciente con pancreatitis crónica; tipo III, de retención, el que se debe a pancreatitis crónica con estenosis ductal. Se realizó un estudio prospectivo sobre el drenaje percutáneo con catéter de los quistes post-necróticos (tipos I y II) entre 1987 y 1990. Se drenaron 23 seudoquistes en 21 pacientes. La tasa global de recurrencia fue 4%; dos pacientes desarrollaron fistulización del catéter al intestino; no se presentaron muertes. El procedimiento fue exitoso en todos los quistes tipo I; en los quistes tipo II apareció asociado con drenaje prolongado y con un mayor riesgo de complicaciones cuando había comunicación quiste-canal pancreático. El drenaje percutáneo no está indicado en los quistes de retención tipo III. Se describen las directrices en cuanto a tratamiento y a las técnicas empleadas.

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Résumé Nous avons classé les pseudokystes pancréatiques en trois groupes: type I: postnécrotique, secondaire à une pancréatite aiguë, type II: postnécrotique secondaire à une poussée aiguë sur pancréatite chronique, et type III: rétentionel, en rapport avec une sténose du canal de Wirsung au cours d'une pancréatite chronique. Une étude prospective sur le drainage percutané des pseudokystes nécrotiques: (type I et II) a été entreprise entre 1987 et 1990. Vingt trois pseudokystes chez 21 patients ont été drainés. Le taux de récidive global a été de 4%. Une fistulisation kysto-entérique s'est produite chez deux patients sans entrainer de déces. Le procédé a été couronné de succès dans tous les pseudokystes du type I. Lorsqu'il s'agissait d'un pseudokyste de type II, le drainage a été souvent prolongé, et des complications ont été plus fréquentes lorsqu'une communication kysto-canalaire était présente. Le drainage percutané n'a aucun rôle à jouer dans les pseudokystes du type III. Des recommandations quant aux indications et la technique à employer sont décrities.

     

Endoscopic laser pancreatic cystogastrostomy

Traditionally the drainage of pancreatic pseudocysts has been carried out operatively, forming a cystenterostomy. A simple endoscopic method of forming a pancreatic cystogastrostomy with laser is presented. This procedure does not require a general anesthetic, is safe, and allows resolution of symptoms.     

Mediastinal pancreatic pseudocysts in children.

Mediastinal pseudocyst is an unusual complication of pancreatitis, with only four cases previously reported in children. The extent of the pseudocyst can be defined by computed tomography or magnetic resonance imaging scan and preoperative aspiration of cyst fluid for amylase level can establish the diagnosis. Endoscopic retrograde cholangiopancreatography to define ductal anatomy can help plan the appropriate drainage procedure. Although exceedingly rare, the diagnosis of pseudocyst should be considered for any cystic mass in the abdomen or thorax, even in the absence of elevated amylase or history suggesting pancreatitis.     

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).     

Gastroscopic-assisted laparoscopic cystogastrostomy in the management of pseudocysts of the pancreas

Once pancreatic pseudocysts become persistent, unresolving, and symptomatic, surgical drainage is mandatory. Between January 1998 and December 2001, we performed five laparoscopic cystogastrostomies for such pseudocysts with the simultaneous use of the gastroendoscope. The mean cyst diameter was 20 cm (range, 18.5-24). In the first four cases, the anterior wall of the stomach was entered through two 10-mm balloon cannulae under gastroscopic guidance. By introducing the laparoscope through one port and a harmonic scalpel through the other, a wide cystogastrostomy was performed. In the fifth case, a modification of the above technique was carried out. A single 10-mm cannula was used to enter the stomach and, with the use of a side-viewing gastroduodenoscope as the camera source, the harmonic scalpel was used to create the cystogastrostomy. The punctures in the wall of the stomach were repaired with endosutures. The gallbladder was removed in all cases. The mean operating time was 110 minutes (range, 92-128) for the combined procedure. There were no postoperative complications, and the mean hospital stay was 4 days. Postoperative follow-up with ultrasonography over a period of 1 year in each case revealed complete resolution of the cyst. Laparoscopic cystogastrostomy using harmonic scalpel under gastroscopic control is an effective and rapid method of surgically managing such lesions.     

Intrapancreatic duodenal duplication associated with pancreatic pseudocysts.

A rare case of intrapancreatic duodenal duplication causing pancreatitis is reported. At 2 years of age, the patient presented with a recurrent pancreatic pseudocyst. Intraoperative pancreatogram showed the presence of cystic duodenal duplication in the aberrant lobe of the pancreas communication with the pancreatic duct. Since the resection of the duplication, she has been free from recurrence of pancreatitis. In this case, intraoperative pancreatography was of great value.     

Percutaneous puncture and drainage under ultrasonic control of pancreatic pseudocysts]

Eighty-seven pancreatic pseudocysts have been treated with a single or repeated puncture, which was or was not followed by percutaneous drainage. When the diameter of the cyst was smaller than 5 cm, it was healed in 83.3% of all cases. When the size of the cysts ranged from 6 to 10 cm, puncture alone allowed curing them in 57.1% of all cases, otherwise it had to be completed by drainage. On the other hand, puncture alone was not sufficient for cysts with a diameter exceeding 10 cm, and an associated suction or surgical drainage was required. In the light of this experience, we can bring out the respective indications of single and multiple puncture and of percutaneous drainage, while taking account both of the size and of the etiological and clinicopathological features of the pseudocysts. In addition, this study allows assessing the incidence of the complications associated to this type of treatment.     

Unresolved problems of pancreatic pseudocysts.

The treatment of 54 patients with pancreatic pseudocysts was reviewed. The operative mortality was 11% and after an average followup of 3 years the recurrence rate was 3.8%. Hemorrhage was the most significant complication of pseudocysts and occurred in 4 patients preoperatively and three patients postoperatively. The patients who developed recurrence or died had been operated within one day after the diagnoses of pseudocysts were made. The deaths were due to the conditions that necessitated the emergency operations rather than to the fact that the cyst wall had not adequately matured. Ideally, operation should be performed when the patient has reached an optimal clinical condition and the walls of the cyst are sufficiently thick. Currently there is no guide for estimation of the state of cyst maturation, although this may develop with the use of ultrasound. Since complications can develop during a prolonged observation period it was our policy to proceed with surgery as soon after diagnosis as the patient was in satisfactory clinical condition. It is evident from this study that internal drainage can be performed safely in less time than the 6 weeks frequently recommended. Morbidity and mortality were not adversely affected by a short interval between diagnosis and operation if the timing was a matter of election rather than a condition of emergency.     

Surgical management of pancreatic pseudocysts.

Pancreatic pseudocyst is a complication of pancreatitis or pancreatic trauma. A review of the experience with surgical treatment of pseudocyst of the pancreas at the University of Iowa was carried out. Pancreatitis associated with alcoholism accounted for a smaller percentage of the pseudocysts than is usually reported and reflects the nature of the population. Internal drainage of the pseudocyst obviates the development of pancreatic fistula which is often associated with external drainage; however, the mortality for each method of drainage was comparable.     

Calcified pancreatic pseudocysts

Extensive calcification of a pancreatic pseudocyst that permits visualization on plain abdominal radiographs is unusual. When such x-ray findings are encountered, a broad differential diagnosis can be made, which includes tumors, cysts, abscesses, or malformations of the adjacent structures. Two cases of calcified pancreatic pseudocysts are discussed. Calcified pancreatic pseudocysts may be a potential source of complications such as pain, bleeding, or infection. Because the cyst wall is mature and spontaneous resolution is unlikely, proper treatment of calcified pseudocysts consists of timely resection or internal drainage.