Open cystogastrostomy, retroperitoneal drainage, and G-J enteral tube for complex pancreatitis-associated pseudocyst: 19 patients with no recurrence.
BACKGROUND
Various techniques have been described to achieve definitive resolution of complex acute pancreatitis associated pseudocysts (PACs). Many of these strategies, inclusive of open, minimally invasive, and radiological procedures, are hampered by high recurrence or failed resolution, particularly for PAC near the pancreatic head. The present series describes a multimodal strategy combining a minilaparotomy for anterior gastrostomy for the creation of a stapled posterior cystogastrostomy, placement of an 8F secured silastic tube for intentional formation of a cystogastric fistula tract in combination with gastric drainage, and postduodenal enteral alimentation.


METHODS
Using a prospectively maintained hepatobiliary database, patients with complex PAC undergoing the above procedures were identified. PAC location, postoperative length of stay (LOS), and time to start enteral feeding were identified. PAC were assessed by computed tomography (CT) scan prior to operation, 1 month after drainage, and patients with PAC resolution were started on oral diet, with the fistula silastic tube kept in place for an additional month.


RESULTS
Over the interval 2003 to 2008, 19 patients were managed with the stated strategy. PACs were located at the pancreatic body/tail in 12 patients, and 7 patients had PAC at the level of the pancreatic head/neck area. In this cohort, prior to surgical drainage, 17/19 patients had undergone failed endoscopic retrograde cholangiopancreatography (ERCP) with decompressive stent placement and 13/19 had a failed percutaneous PAC drainage. There was no perioperative mortality after open surgical drainage. All patients started on jejunal tube feeding 24 h after surgical procedure. Median postoperative LOS was 7 days (4-13). At 1 month, 16/19 (84%) of patients showed complete resolution of the PAC on CT scan and were started on oral diet; 3/19 required additional month for complete resolution. After a mean follow-up of 31 months, there was no PAC recurrences in any of these patients demonstrated on follow-up.


CONCLUSIONS
The described strategy is safe, efficient, and allows early restoration of enteral feeding with early hospital discharge. High resolution rates and absence of PAC recurrences in this series supports this approach for complex PAC.
Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, RI, USA.
Cherif
C
Boutros
Ponandai
P
Somasundar
N Joseph
NJ
Espat
D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002767:Cholecystostomy / Q000379:methods*; D003937:Diagnosis, Differential; D004322:Drainage / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000295:instrumentation*; D007813:Laparotomy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010192:Pancreatic Pseudocyst / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D019283:Pancreatitis, Acute Necrotizing / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D011446:Prospective Studies; D012008:Recurrence; D012187:Retroperitoneal Space / Q000601:surgery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome