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V. Golash R. Cutress
Department of Surgery, Sultan Qaboos Hospital, Salalah, Sultanate of Oman
Correspondence to: V. Golash, Department of Surgery, Sultan Qaboos Hospital, P O Box 98, Salalah, Pin Code 211, Sultanate of Oman Email: golash@omantel.net.om; haritagolash@hotmail.com
Background: Conventionally, a large symptomatic and unresolved pancreatic pseudocyst is treated surgically by internal drainage to a neighboring adherent viscus such as stomach, duodenum or jejunum. Recently, the various minimal invasive approaches have been used to treat this condition. Depending on the expertise available, the cyst can be also be drained endoscopically or laparoscopically. We present a case of a large pseudocyst treated laparoscopically. Method: A 60-year-old lady was admitted for an elective laparoscopic cholecystectomy as a day case. Under general anaesthesia during her elective laparoscopic cholecystectomy a mass was visible and palpable in the left upper abdomen. Post-operatively, a CT scan of abdomen confirmed the presence of a giant pseudocyst of the pancreas. She successfully underwent a laparoscopic cystogastrostomy four weeks later. Conclusion: Laparoscopic cystogastrostomy for pseudocyst of the pancreas is safe, feasible and with good outcome
Keywords: Pseudopancreatic cyst, laparoscopy Surgeon, 1 February 2005, 37-41
A 60-year-old woman was admitted for an elective laparoscopic cholecystectomy as a day case.
Her past history included a wide local excision and axillary clearance, followed by radiotherapy for a carcinoma of her left breast one year previously. She also had an attack of pancreatitis at this time and a computerised tomography (CT) scan had demonstrated a 4cm diameter cyst in the body of the pancreas. She was followed-up and a repeat CT scan a few months later showed that the cystic mass in the pancreas was unchanged but a further ultrasound scan demonstrated dilation of her common bile duct and a stone in the lower end of the duct. She subsequently underwent an endoscopic retrograde cholangiopancreatography (ERCP), sphinterotomy and removal of the common bile duct stone a few months prior to this admission. At ERCP, there was no communication seen between the pancreatic duct and the cyst.
During her laparoscopic cholecystectomy, under general anesthesia, a mass was visible and palpable in the left upper abdomen which on laparoscopy was seen displacing the stomach anteriorly.
A laparoscopic cholecystectomy was performed. Later on in the day when she had recovered from the anaesthesia, her operative findings were discussed with her. She admitted having nausea, loss of appetite, loss of weight, feeling full all the time and aware of a mass in her abdomen. She thought these symptoms were due to her gall bladder stone and she would get better after cholecystectomy.
A CT scan performed prior to her discharge demonstrated a massive unilocular cyst lying between the spleen, left kidney and the posterior surface of the fundus and body of her stomach. The cyst was thick walled and contained some debris. It was 16cm in its longest axis extending from the diaphragm to the true pelvis and arose from the distal body and tail of the pancreas (Figure 1). She was discussed at the multi-disciplinary meeting and it was decided that she would benefit from surgical drainage.
Figure 1: CT scan of the abdomen showing a large pseudocyst.
She was readmitted four weeks after her laparoscopic cholecystectomy for an elective laparoscopic drainage of the pseudocyst.
Through a standard port placement, the clinical and CT findings were confirmed. The body of the stomach was displaced laterally and stretched out anteriorly. A 7cm longitudinal anterior gastrostomy was performed using diathermy scissors (Figure 2). The position of the cyst was confirmed by needle aspiration through the posterior stomach wall (Figure 3). The aspirate was sent for cytology and biochemical analysis. Next, with the help of diathermy scissors and ultracision, a longitudinal 5cm long posterior gastrostomy was made (Figure 4). The cyst contents welled out under pressure and about 1500 ml of fluid and debris was removed by suction. The cyst cavity was thoroughly irrigated with saline until it was clear. Cyst wall biopsy was taken.
Figure 2: Longitudinal anterior gastrostomy.
Figure 3: Aspiration through the posterior wall of stomach.
Figure 4: Longitudinal gastronomy performed.
Figure 5: Cytogastrostomy between posterior wall of stomach and cyst wall.
Cystogastrostomy was performed between the posterior gastric wall and the cyst wall using 10 interrupted nonabsorbable sutures (Figure 5). A nasogastric tube was left in the stomach. The operative time was 120 minutes. There was no bleeding during or after the surgery. The nasogastric tube was removed after 48 hours and the patient was allowed liquids orally. She was discharged home on the sixth post-operative day on a soft diet. There was no complication of the operation. The cytology of the cyst fluid and the biopsy of the cyst wall showed no evidence of malignancy. The amylase content of the cyst fluid was high. On review three months following her surgery she had complete resolution of the cyst and was asymptomatic and eating a normal diet.
The indication and timing for drainage of a pseudocyst is controversial.1-3 A rough guide is six weeks if it is 6cm, but it can vary depending on the symptoms, complications and suspicion of malignancy. The choice of a drainage procedure depends on the size, number, location, presence or absence of communications with the pancreatic and bile duct, and the presence or absence of infection. With advances in endoscopic technology (transmural and transpapillary) it is now possible to drain a pseudocyst of the pancreas efficiently into a neighboring viscus, with or without the help of endoscopic ultrasound.4 Such expertise may not be widely available, however, and the majority of clinicians would still drain a cyst by a technique they are more familiar with. There are, in addition, limitations of the endoscopic techniques. For example, surgical drainage is advisable when dealing with a large cyst containing thick contents, when there is haemorrhage into a cyst, in a cyst associated with a long pancreatic duct or bile duct strictures. Surgical drainage is also indicated in cases where malignancy cannot be ruled out, when the distance is more than 1cm between the cyst wall and the viscus, and following failure of endoscopic drainage. Endoscopic drainage also has the potential of introducing infection, and causing perforation and bleeding that would then require surgery. There have been reports of using a laparoscopic surgical approach to drain a pancreatic pseudocyst with excellent outcome.5-7 The results of the laparoscopic approach are comparable to the endoscopic approach in terms of morbidity and mortality. Laparoscopically, the cyst can be drained in the same way as is done in an open procedure (as in this patient) but others have used different laparoscopic methods. Laparoscopically, the pseudocyst can also be approached via the lesser sac or through the stomach by directly introducing two balloon trocars in the stomach and using the circular stapler for cystogastrostomy.5-7 The laparoscopic approach also facilitates concomitant debridement of necrotic tissue.
Laparoscopic drainage of a pseudocyst of the pancreas is a straightforward procedure, and is successful for a large symptomatic pseudocyst, with minimal morbidity.
Copyright 26 October 2004
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