Lapaproscopic Transgastric Endolumenal Cystogastrostomy

Andrei Coria, MD, Hugo A Sanchez, MD, Miguel F Herrera, MD, PhD. ABC Medical Center

Here we show the case of a 60 years old female patient who presented to emergency room with a 24-hrs history of nausea, vomiting and severe abdominal pain. She referred symptoms of intolerance  during the last six months.

An abdominal ultrasound reported gallstones without evidence of acute gallbladder disease, and a CT scan was performed showing an increase in the density of the head and the uncinate process of pancreas, pararrenal fluid collection and peripancreatic fat necrosis compatible with Balathazar D

In spite of clinical evolution courses without evidence of metabolic nor organ failure, patient management was performed in intermediate care unit to provide close supportive care including pain control, fluid resuscitation and nutritional support. Liquid oral feeding and total parenteral nutrition was employed during the following two weeks. The patient evolved with persistent vomiting so it was necessary to install a naso-enteral feeding tube during another two weeks. On 4th week of evolution a new CT scan showed a pancreatic pseudocyst formation, however, patient was able to tolerate polymeric diet and she was discharged home. 

7 weeks from pancreatitis onset, a new CT scan showed a thick-walled pancreatic pseudocyst.

Patient underwent to a laparoscopic exploration assisted with an upper gastrointstinal endoscopy. The Operation starts with approach of the gastric camera using balloon blunt tip trocars through the anterior gastric wall.  

An intraoperartive ultrasound was performed to assess the relationship between the pancreatic pseudocyst  and the posterior gastric wall.

A wide opening on the posterior gastric wall was performed using ultrasonic energy.  The cysto gastrostomy was developed using a unique fire of a linear stapler. The pancreatic and peripancreatic necrosis is then thoroughly debrided and removed as much as possible. 

We make no reinforcement of the stapler line, however some authors have recommended a hand sewing reinforcement to diminish the risk of bleeding or leak of the anastomotic junction.

A nasogastric drain tube is place widely into the pseudocyst cavity for postoperative drain. The trocars are removed and the gastric defects are closed using one fire of lineal stapler for each one.

Postoperative recovery was uneventful; patient was able to eat polimeric diet and was discharged of the hospital on the third postoperative day.

Actually patient has normal endocrine and exocrine pancreatic function, tolerates normal diet and a recent CT scan shows total resolution of the residual cavity.