Laparoscopic Management of Pancreatic Pseudocysts

Chapter 20 Laparoscopic Management of Pancreatic Pseudocysts



Basil J. Ammori, Georgios D. Ayiomamitis


The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.image


A pancreatic pseudocyst (PP) is a collection of amylase-rich pancreatic fluid enclosed by a wall of fibrous granulation tissue without a true epithelial lining. In general, a peripancreatic fluid collection should be present for 5 to 6 weeks before the diagnosis of PP is considered. A collection that is present for less than this time is more accurately referred to as an acute peripancreatic fluid collection. An acute PP is defined as occurring after an episode of acute pancreatitis and complicates 2% to 10% of these patients with acute pancreatitis in whom the main pancreatic duct has been disrupted. A chronic PP is defined as occurring in association with chronic pancreatitis and arises in 10% to 30% of patients with this diagnosis. Pseudocysts also can complicate pancreatic trauma or ductal obstruction due to stricture or stone. The rate of spontaneous resolution of acute PPs has ranged from 30% to 85% in various reports.


Regarding the management of PP disease, it is essential to establish a diagnosis of pseudocyst while considering the possibility of a cystic neoplasm (see later). The management of PPs has evolved to include radiologic, endoscopic, and laparoscopic approaches. Endoscopic internal drainage of “acute” pseudocysts has been associated with low resolution rates; there also is a risk for secondary bacterial infection from inadequately débrided necrotic tissue within the pseudocyst cavity. Although endoscopic drainage techniques will continue to evolve, large persistent and symptomatic acute pseudocysts probably are best treated with an operative procedure.


Surgical treatment involves the creation of an internal communication between the PP and the gastrointestinal tract to allow the amylase-rich fluid within the PP to drain into the intestinal lumen. Open internal drainage consistently has produced good long-term results and therefore has been considered the treatment of choice. Open internal drainage most often was accomplished with a pseudocyst-gastrostomy or, if there was extensive infracolic extension, a Roux-en-Y pseudocyst-jejunostomy. These procedures now can be performed safely and effectively using laparoscopic techniques, and the literature contains a number of confirmatory series. Laparoscopic pseudocyst drainage adheres to the same principles as the open procedure, differing only in the nature of operative access.



Operative indications


Because most PPs resolve spontaneously, internal drainage is reserved for pseudocysts that cause symptoms (e.g., abdominal pain and distention) or produce complications, such as gastric outlet obstruction, obstructive jaundice, abscess formation, pseudoaneurysm, gastrointestinal or intracystic bleeding, or pseudocyst rupture. In addition, PPs that are large (>6 cm), persistent (no regression after 6 weeks), or growing in size warrant intervention; if left untreated, these pseudocysts have a considerable complication risk.


If a PP patient fulfills the previously mentioned operative indications for internal drainage, then the surgeon should consider the following factors to determine the approach and timing of the laparoscopic intervention.



Availability of Endoscopic Drainage


If local expertise is available, a chronic PP can be drained endoscopically if (1) there is minimal necrotic debris in its cavity; (2) it has a retrogastric or juxtaduodenal location; and (3) the wall is less than 1 cm thick. Long-term resolution of a PP after stenting of the pancreatic duct is dependent on the presence of a communication between the duct and the PP and the subsequent absence of a stent-induced stricture in the proximal duct. The presence of necrotic debris within a PP (demonstrable on cross-sectional imaging or endoscopic ultrasound) may obstruct an endoscopically placed stent and predispose the cavity to infection. Endoscopic drainage of PP secondary to acute necrotizing pancreatitis has been associated with drainage failure (15%), other morbidity (13%), and recurrence (11%). With appropriate patient selection, success rates with endoscopic PP drainage can approach 100%.



Location of the PP


A retrogastric or juxtagastric PP can be drained by pseudocyst-gastrostomy. A PP that protrudes into the infracolic region may be drained in a dependent fashion using a pseudocyst-jejunostomy. A PP located in the tail of the pancreas may be managed by internal drainage or distal pancreatosplenectomy (open or laparoscopic).



Maturity of the Pseudocyst Wall


To create a stable anastomosis between the PP and the gastrointestinal tract, it is essential that a defined pseudocyst wall be demonstrable on a preoperative computed tomography (CT) scan. A PP wall with more than 1 cm thickness is a relative contraindication to endoscopic internal drainage; such a pseudocyst is best drained surgically.



Presence of Local Complications


An associated pseudoaneurysm should be embolized before surgical drainage of the PP. If gastric outlet or biliary obstruction is present, then PP drainage invariably will result in resolution of the obstruction. Percutaneous drainage by an interventional radiologist usually is reserved for the septic patient with an infected fluid collection because this procedure is associated with a considerable risk for pancreatocutaneous fistula and PP recurrence. If the patient has portal hypertension with varices, then surgical internal drainage may be safer, with a lower risk for bleeding, than endoscopic drainage.



Preoperative testing, evaluation, and preparation


Although cystic neoplasm of the pancreas is rare, this tumor can be mistaken for a PP. A history of acute pancreatitis suggests PP, but a pancreatic neoplasm also can precipitate an acute attack of pancreatitis. Radiologically documented development of a PP during the course of acute or chronic pancreatitis is somewhat reassuring. Weight loss, the lack of preexisting pancreatic disease (particularly in women), multilocularity or nodularity on imaging, a highly viscous cyst aspirate, and a markedly elevated carcinoembryonic antigen (>192 ng/mL) all make a cystic malignancy more likely.


The location, size, wall characteristics, and the presence of local complications (e.g., pseudoaneurysm) should be assessed with contrast-enhanced (intravenous and oral) CT. If the diagnosis is not clear after CT scanning, then additional information may be obtained with magnetic resonance imaging or endoscopic ultrasound (EUS). In addition to its high sensitivity (93% to 100%) and specificity (92% to 98%), the linear EUS probe can facilitate a cyst wall biopsy and cyst aspirate for tumor marker analysis.



Patient positioning and placement of trocars


All procedures are performed under general anesthesia, with broad-spectrum antibiotic coverage and prophylaxis against deep venous thrombosis. For laparoscopic pseudocyst-gastrostomy, the patient is placed in the French (lithotomy) position, with the surgeon standing between the legs, the first assistant and scrub nurse to either side, and the monitor over the patient’s head. The surgeon’s position for pseudocyst-jejunostomy may be on either side of the table or between the legs, depending on the PP location. The pneumoperitoneum is set at 12 mm Hg. A 10-mm port for the 30-degree laparoscope is placed one handbreadth away from the target (the PP-gastric or PP-jejunal anastomosis), and two or three 5- or 10-mm ports are placed on either side in order to achieve triangulation (Fig. 20-1). An additional 5-mm port may be placed laterally to retract the liver, spleen, and stomach if these organs impinge on the operative field.


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FIGURE 20-1 Placement of trocars. 1 = laparoscope (5-12 mm); 2, 3 = operating ports (5 mm); 4 = optional port for transgastric approach (5 mm); 5 = optional port for epigastric approach (5 mm).



Anatomic classification of pancreatic pseudocysts


The following section describes a surgically oriented approach to the classification of PP disease.



Large Retrogastric PP


This type is by far the most common and is readily visible and palpable on laparoscopy (Fig. 20-2). Internal drainage is readily achieved by the transgastric approach.


image image

FIGURE 20-2 Large retrogastric pancreatic pseudocyst displacing the stomach. A, Sagittal schematic. B, Axial computed tomography image showing pseudocyst (c). This type of pseudocyst is visible and palpable at laparoscopy and can be drained through a transgastric approach (cystgastrostomy).

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Jul 20, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Laparoscopic Management of Pancreatic Pseudocysts

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