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272 Atlas of Gastrointestinal Surgery: Pancreas
After retracting the transverse mesocolon in a cephalad direction, the pseudocyst can be seen and felt to be presenting through the transverse mesocolon. This allows ideal access for dependent drainage into a Roux-en-Y jejunal loop. At
this point, generally the cyst is aspirated to confirm its presence in the area palpated (2). In addition, at some point the
cyst wall should be biopsied to be certain that one is not dealing with a cystic neoplasm. If there is any discrepancy
between the size of the mass that is palpated and the size of
the cyst identified on CT scan, a cystogram can be performed by injecting contrast media into the cyst and taking an operative x-ray. This operative x-ray should produce an image that corresponds to the size of the
palpable mass. If it does not, one has to be concerned that there may be a second pseudocyst
2
or a loculated pseudocyst that would not be
drained entirely through the access route
identified with the needle aspiration.
Transverse
colon
Transverse
mesocolon
Pseudocyst
Middle colic a.
Ligament
of Treitz
Aspiration of
cyst contents
Drainage of Pancreatic Pseudocyst into a Roux-en-Y Jejunal Loop 273
A Roux-en-Y loop 60 cm in length is constructed. Construction
of the Roux-en-Y jejunal loop has previously been described.
The Roux-en-Y loop is placed in a comfortable position
adjacent to the cyst, which has been previously identified by needle aspiration. The cystojejunostomy
is performed in two layers. The outer posterior layer consists of a series of interrupted
3-0 silk sutures (3).
Transverse
mesocolon
Pseudocyst
3
Transverse
colon
Roux-en-Y
jejunal loop
274 Atlas of Gastrointestinal Surgery: Pancreas
Transverse
colon
Pseudocyst
Middle colic a.
Cystotomy
Outer layer
Roux-en-Y
jejunal loop
After the outer posterior layer is completed, an
opening is made into the cyst. This can be performed
with either a scalpel or with the electrocautery.
Once the cyst is open, the contents are aspirated
with the suction tip (4). If the cyst wall has not
4
Biopsy
been biopsied and previously sent for frozen section,
a section of the cyst is excised (5) to eliminate any
concern about the lesion being a cystic tumor. The inner
layer of the posterior row is then placed using a continuous
locking suture of 3-0 absorbable synthetic suture (6). It is
continued anteriorly for the inner layer with a Connell type stitch
(7). The outer interrupted layer of the anterior row is completed with 3-0 silk (8).
5
Drainage of Pancreatic Pseudocyst into a Roux-en-Y Jejunal Loop 275
Inner layer of
posterior row
6
Outer layer of
anterior row
Inner layer of
anterior row
7
8
276 Atlas of Gastrointestinal Surgery: Pancreas
Transverse
colon
Transverse
mescolon
Cystojejunostomy
9
Once the anastomosis is
Sagittal section
Liver
Stomach
Pancreas
completed, one should be able to easily palpate a sizable anastomosis (9). The anastomosis is drained with two closed suction Silastic drains, but it
is rare to have such an anastomosis leak. The inset depicts the
anatomy from a lateral view. In this instance, the cyst is firmly
adherent to the posterior wall of the stomach, so a cystogastrostomy could easily have been performed. As this diagram
demonstrates, however, a Roux-en-Y jejunal loop provides
ideal dependent drainage to a segment of the intestinal tract
that is defunctionalized (10).
Duct
Duodenum
Roux-en-Y
jejunal loop
10
Transverse
mesocolon
Transverse
colon
Omentum
Drainage of Pancreatic Pseudocyst
into the Stomach
Operative Indications:
The operative indications for drainage of a pseudocyst into the stomach are the same as listed for drainage of a pancreatic pseudocyst into a Roux-en-Y jejunal loop. Drainage of a pseudocyst into a Roux-en-Y loop is our preferred approach.
In some instances, however, the cyst resides high in the abdomen and does not present through the transverse mesocolon,
so dependent drainage with a Roux-en-Y jejunal loop is not possible. In most of these instances, the cyst is adherent to
the posterior wall of the stomach; the posterior wall of the stomach makes up the anterior wall of the pancreatic pseudocyst (2). In this circumstance cystogastrostomy is the procedure of choice.
Operative Technique:
Either a bilateral subcostal or midline incision is appropriate. Once the abdomen is
entered, the pseudocyst can be easily palpated and visualized displacing the stomach.
278 Atlas of Gastrointestinal Surgery: Pancreas
Liver
1
Gastrotomy
Spleen
Gall bladder
2
Pseudocyst
behind
stomach
Stomach
Omentum
Hepatic flexure
Sagittal section
Liver
Aspiration
Stomach
Omentum
Transverse
colon
Transverse
mesocolon
Pancreas
Duct
Pseudocyst
Duodenum
3
Gastrotomy
Aspiration of
cyst contents
Drainage of Pancreatic Pseudocyst into the Stomach 279
Stay sutures of 3-0 silk are
placed in the anterior wall of
Posterior wall
gastroromy
Stomach
the stomach and a gastroto-
my is performed with the
electrocautery directly over
the pseudocyst (1). The
4
location of the cyst is con-
firmed by aspirating through
the posterior wall of the
stomach into the cyst
with a 20-gauge nee-
5
dle and a 10-ml
syringe (2, 3).
Not all of the
cyst contents should
Anterior wall
of stomach
Biopsy of
cyst wall
Pseudocyst
cavity
be aspirated, as this
will make subsequent
entry into the cyst
more difficult.
Posterior wall
of stomach
If there is a discrepan-
cy between the size of the
palpable mass and the size or num-
ber of pseudocysts as identified preoperatively by
CT scan, a cystogram can be performed by injecting contrast media into the cyst and performing an operative radiograph.
The cross-section demonstrates the anatomic relationships between the pancreas, the disrupted pancreatic duct, the
pseudocyst, and the stomach (2). Note that the posterior wall of the stomach comprises a portion of the anterior wall of
the pseudocyst. This diagram also nicely demonstrates that the pseudocyst does not present through the root of the transverse mesocolon. After the position of the pseudocyst has been confirmed by needle aspiration, the cyst is entered by
incising through the posterior wall of the stomach using the electrocautery (4). A portion of the cyst wall is sent for frozen
section to be certain that one is not dealing with a cystic neoplasm (5). If the incision into the cyst does not appear to
gape widely open, an ellipse of stomach and cyst wall can be excised.
280 Atlas of Gastrointestinal Surgery: Pancreas
Once good communication between the
stomach and cyst cavity has been established, the
Pseudocyst
cavity
6
edges of the pseudocyst and stomach are sutured
together with a continuous locking suture of 3-0
synthetic absorbable suture (6). This row is
placed primarily for hemostasis, but it also probably aids in keeping the communication between
the cyst and stomach open until the cyst has collapsed and resolved. The anterior gastrotomy is
then closed with an inner layer of 3-0 synthetic
absorbable sutures placed in a continuous Connell
fashion. The outer layer is placed utilizing interrupted 3-0 silk sutures (7).
Cyst wall
Posterior wall
of stomach
7
Closure of
gastrotomy
Drainage of Pancreatic Pseudocyst
into the Duodenum
Operative Indications:
The vast majority of pseudocysts can be drained into a Roux-en-Y jejunal loop or into the stomach. Rarely, however, a
pseudocyst is located in the head of the pancreas so that the only option for drainage is into the adjacent duodenum. The
same indications for cyst drainage that were outlined for cystojejunostomy and cystogastrostomy pertain to drainage of a
pseudocyst into the duodenum.
Operative Technique:
The abdomen is entered through either a right subcostal or upper midline incision. The
pseudocyst which resides in the duodenal C loop in the head of the pancreas is exposed
(1), and the omentum is cleaned from the anterior wall of the cyst. The duodenum is
kocherized. A posterior row of interrupted 3-0 silk sutures is placed between the cyst
and the medial aspect of the duodenum. After the cyst location has been identified by
needle aspiration as depicted for cystojejunostomy and cystogastrostomy, an opening into
the pseudocyst is made with the electrocautery. A portion of the cyst wall is sent for
frozen section to be certain one is not dealing with a cystic neoplasm.