A Hybrid Laparoscopic-Endoscopic Cystogastrostomy for Pancreatic Pseudocysts

Michael P Meara, MD, MBA1, Edward L Jones, MD2, David R Renton, MD1. 1The Ohio State University Wexner Medical Center, 2Univ. of Colorado and The Denver VA Medical Center

Background:  Cystogastrostomy has been the procedure of choice for large, symptomatic pancreatic pseudocysts.   Multiple methods have been developed for creating cystogastrostomies.  These include traditional open techniques, laparoscopic approaches, and endoscopic drainage procedures.  This video presents a novel method for a combined laparoscopic and endoscopic approach to pancreatic pseudocyst drainage.

The patient is a 48 year-old Caucasian female.  She has a past surgical history significant for 14 previous abdominal operations including cholecystectomy and a combination of 11 previous hernia repairs.  The patient’s repairs have been complicated by dehiscence and multiple fistulas.  She presented to the hospital for admission with medication-induced pancreatitis and a large, well formed pancreatic pseudocyst  

Methods:  In light of the patients previous operations, the decision was made to attempt a combined laparoscopic and endoscopic cystogastrostomy to avoid formal laparotomy.  Standard upper endoscopy was performed and the cyst was immediately encountered upon entering the stomach.  The scope was advanced distally and placed within the retroflexion view for the best visual approach to the superior cyst.  A site on the anterior abdominal wall was selected and a 12 mm trocar was placed under direct visualization.

Next, a laparoscopic aspiration needle was introduced into the stomach and the cyst was accessed.  Old blood and liquefactive pancreas was freely aspirated from the cyst.  A wire was left in the cyst to maintain the tract within the cyst.  An injection catheter was then advanced into the cyst cavity.  The cyst was distended with radiopaque dye to confirm adequate positioning prior to the creation of the cyst gastrostomy. 

The catheter was removed and an ultrasonic dissection device was introduced into the common channel between the gastric and cyst wall.  The channel was widened to facilitate introduction of a laparoscopic stapler.  A laparoscopic staple load was introduced into the cyst and fired.  The endoscope was then advanced into the cyst cavity under direct vision confirming that all collections within the cyst were adequately drained.  A second firing of the stapler was performed to complete our cystogastrostomy.  Finally, in light of the patient’s additional issues, a feeding tube was placed via the trocar site to allow for healing of the tract and reliable enteric access.

Conclusions: This maneuver can be completed safely and effectively.  This hybrid approach represents a novel method for drainage of pancreatic pseudocysts in this complex patient.

Key Words: Endoscopic Cystogastrostomy – Laparoscopic Cystogastrostomy – Pancreatic Pseudocyst – Walled-Off Pancreatic Necrosis  

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