Open Cystojejunostomy

The goals of surgical treatment of most pancreatic pseudocysts are to provide a pathway of internal (enteric) drainage of the “leaking” exocrine secretions to allow the pseudocyst cavity to collapse, thereby either “sealing off” the ductal leak or creating a permanent internal fistula for drainage. Internal drainage includes cystogastrostomy, cystojejunostomy, and less commonly, cystoduodenostomy. Internal drainage can also be accomplished by endoscopic cystogastrostomy or cystoduodenostomy in selected patients. Indications and Contraindications - Cystogastrostomy: symptomatic or large pseudocysts of the pancreas adherent to the posterior wall of the stomach (i. e., the posterior wall of the stomach forms the anterior wall of the pseudocyst) - Cystojejunostomy: a pseudocyst not adherent to the posterior gastric wall in any location in the pancreas (head, body, or tail), or pseudocysts that bulge through the transverse mesocolon - Cystoduodenostomy: a pseudocyst of the head of the pancreas anatomically placed so that only a cystoduodenostomy is possible - Cystogastrostomy: Pseudocyst in the head or tail of the pancreas that is not adherent to the stomach, or a pseudocyst that bulges through the transverse mesocolon with the most caudal extent substantially caudal to the stomach - When the surgeon is not entirely certain that the cystic mass is a pseudocyst of the pancreas - Grossly infected pseudocysts - Cystojejunostomy: Pseudocysts more amenable to cystogastrostomy or cystoduodenostomy - Cystoduodenostomy: Pseudocyst not immediately adjacent to the duodenum, or concern about disrupting pancreatic ductal entry into the duodenum (major or minor ampulla) Preoperative Investigations and Preparation for the Procedure - History: Vague abdominal or back pain after an attack of acute pancreatitis; nausea, vomiting, and weight loss, especially in an alcoholic - Clinical: Fullness or mass in the epigastrium Laboratory tests: Persistent increase in serum amylase after an attack of acute pancreatitis Diagnostic imaging: CT scans can identify one or more pseudocysts in the pancreas and may help to differentiate a cystic neoplasm from a pseudocyst - ERCP: Endoscopic retrograde cholangiopancreatography (ERCP) is rarely used but can differentiate a pseudocyst that communicates with the main pancreatic duct from a cystic neoplasm, which should not communicate with the pancreatic duct unless it is an intraductal papillary mucinous neoplasm (IPMN) - Preoperative preparation: NPO for 2 to 6 hours before operation. A perioperative prophylactic intravenous antibiotic is repeated, depending on the duration of operation

Open cystojejunostomy Specific indications include a pseudocyst not adhering to the posterior gastric wall in any location in the pancreas (head, body, or tail) and those pseudocysts that bulge through the transverse mesocolon. STEP 1 Exposure of pseudocyst - We prefer a bilateral subcostal incision with a mechanical ring retractor. - The pseudocyst is adherent to the transverse mesocolon. - Aspirate the cyst with a 22-gauge needle (. Fig. 87.6).

STEP 2 The jejunum is transected with a mechanical stapler 20 cm from the ligament of Treitz. The distal end is oversewn and brought up to the cyst as a Roux limb. - 3-0 interrupted silk sutures are placed between the cyst wall and midway between the antimesenteric and mesenteric borders of the posterior jejunal wall for 4–5 cm or longer and tied down after all sutures are placed (. Fig. 87.7a). - A cystotomy is made avoiding the middle colic vessels in similar fashion as for cystogastrostomy and cystoduodenostomy; a biopsy is taken of the cyst wall (. Fig. 87.7b). - An interrupted single layer of 3-0 silk sutures is placed between the cyst and the jejunum to create an anterior wall (. Fig. 87.7c). - The cystojejunostomy is completed as for side-to-side cystoduodenostomy (. Fig. 87.8).

STEP 3 The proximal jejunum is anastomosed to the Roux limb 60 cm distally (. Fig. 87.9).

STEP 4 When the pseudocyst does not bulge through the mesocolon and is not adherent to the stomach or duodenum, the gastrocolic ligament is taken down to enter the lesser sac. - The Roux limb is brought retrocolic either to the right or left of the middle colic vessels (. Fig. 87.10). - The anastomosis of the pseudocyst is done as in Step 2.