Definition and Overview
A pseudocystogastrostomy is a procedure wherein a pancreatic pseudocyst is connected to the stomach. This allows drainage of the pseudocyst contents into the gastrointestinal tract.
Who Should Undergo and Expected Results
A pancreatic pseudocyst is usually a complication of pancreatitis. It is a sac that contains pancreatic fluid that leaks resulting in the accumulation of pancreatic fluid that is eventually sealed off and enclosed by granulation tissue.
Approximately 10% of patients who experience acute pancreatitis, and up to 38% of those with chronic pancreatitis develop this type of cyst on the pancreas or near it.
However, it is important to note that not all pancreatic pseudocysts require intervention. Approximately half of the cases, especially those that are very small, are simply observed and if needed, managed conservatively. Symptomatic pseudocysts, on the other hand, require intervention. Symptoms usually include abdominal pain radiating to the back, bloating, and early fullness. Difficulty digesting food can also occur and a lump or a mass can be palpated when the pseudocyst is large. Complications of pseudocysts are also indications for surgery such as secondary infection that results in an abscess that needs to be aspirated. Large pseudocysts can also cause the compression of adjacent structures, such as thrombosis of nearby veins or erosion of arteries resulting in pseudoaneurysms. They may also obstruct other nearby organs, such as the biliary tract and the intestines. Rupture of a pseudocyst can cause shock, and may require emergent surgery.
Failure of conservative management of a pseudocyst requires surgical intervention. External drainage is generally avoided, if possible, as this can result in the formation of a fistula. There are several internal drainage procedures for a pancreatic pseudocyst, one of which is a pseudocystogastrostomy. Other operations include a cystojejunostomy or a cystoduodenostomy. The decision of what operation to perform is based on the location of the pseudocyst. A pseudocystogastrostomy is usually indicated for pseudocysts that are located in either the tail or the body of the pancreas, and the cyst should ideally be adherent to the stomach to minimise leakage.
A pseudocystogastroctomy is associated with high success rates, reported to be 80% and above. Mortality rates have remained low at around 5-10%.
How is the Procedure Performed?
There are several techniques for performing a pseudocystogastrostomy. It can be carried out through open surgery, by endoscopic technique, or via a laparoscopic approach.
Although the approaches to open surgery and laparoscopy vary, the basic premise is generally the same. Laparoscopic pseudocystogastrostomy is a minimally invasive technique for performing the open procedure. While the latter requires an abdominal incision, the former involves several small incisions where special instruments are inserted to gain access to the abdomen. The major advantage of the laparoscopic over the open technique is decreased pain severity after surgery, allowing faster recovery. Also, since the incisions are smaller, laparoscopy also results in better cosmetic outcomes.
Once inside the abdominal cavity, the pseudocyst is identified. Some surgeons may opt to aspirate or drain the contents of the pseudocyst upon identification. The anterior wall of the stomach is opened to gain access to the posterior wall. An opening of approximately 5 cm is then made on the back of the stomach longitudinally, and another opening in the wall of the pseudocyst. The two openings are then sewn together using interrupted or continuous locking absorbable sutures, ensuring that the walls are sealed and bleeding is adequately controlled. The incision on the anterior wall of the stomach is then closed, followed by the reconstruction of the abdominal wall. Surgeons typically take a routine biopsy of the wall of the pseudocyst and send it for histopathologic examination to definitively rule out a malignancy.
Meanwhile, endoscopic pseudocystogastrostomy utilises fluoroscopy and ultrasound to guide the placement of a stent between the pseudocyst and the stomach. A needle is used to locate the pseudocyst and create a connection to the stomach. Success rates are slightly lower than the open and laparoscopic techniques.
After the operation, feeding is gradually restarted. The cavity is typically allowed to drain first and the anastomosis to heal.
Possible Risks and Complications
Complications that may occur when performing a pseudocystogastrostomy include:
- Bleeding, which may be experienced in the area of the anastomosis. For this reason, meticulous suturing and hemostasis during the operation are emphasised. In some cases, electrocoagulation via endoscopy can be performed to manage postoperative bleeding.
- Fever after the operation, which may indicate the development of an abscess
- Infection - There have been reports regarding closure of the pseudocystogastrostomy or blockage of stents, resulting in infection of the cyst
- Recurrence, which develops in as much as 15% of patients. A wide opening is necessary to prevent this complication. Multiple pseudocysts that drain inadequately may also result in recurrence. Studies have revealed that the median time of recurrence of pseudocysts after a pseudocystogastrostomy is generally longer than 5 years.
Most of the serious complications following a pseudocystogastrostomy require surgical intervention for definitive management.
Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013 [Retrieved 22 October 2014];145(3):583-590.
Lutfi R, Jyot B, Rossi M, Jefferson E, Salti G. Hand-sewn cystogastrostomy using the novel single-incision laparoscopy with flexible-tip laparoscope. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2010 Nov;20(9):761–766.