Surgery for Obesity and Related Diseases 11 (2015) 975–977
Video case report
Laparoscopic cyst-gastrostomy after laparoscopic sleeve gastrectomy Hamzeh M. Halawani, M.D., Ramzi S. Alami, M.D., F.A.C.S.*, George S. Abi Saad, M.D., F.A.C.S. Department of General Surgery, American University of Beirut Medical Centre, Beirut, Lebanon Received January 28, 2015; accepted February 2, 2015
Keywords:
Pseudocyst; Pancreatitis; Bariatric cyst-gastrostomy
Pancreatic pseudocysts (PP) are confined collections of fluid from the pancreatic gland surrounded by nonepithelialized granulation tissue containing pancreatic juices. PP are not common, but they are usually a complication of pancreatitis. At this time, numerous classification systems are being used depending on the origin of the PP, its relation to the pancreatic duct, and the presence or absence of a pseudocyst–duct communication [1]. Diagnosis is often made with a computed tomographic (CT) scan, endoscopic retrograde cholangiopancreaticography (ERCP), or ultrasound. The vast improvement in diagnostic modalities has assisted in the detection of PP with a high sensitivity and specificity [2]. There are several therapeutic operative and nonoperative interventions for the treatment of symptomatic or large PP. These consist of endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or surgical drainage [3,4]. Herein, we report a laparoscopic cyst-gastrostomy in a patient who had previously undergone a laparoscopic sleeve gastrectomy and then developed a symptomatic PP. Case presentation A 51-year-old male patient who had undergone a laparoscopic sleeve gastrectomy in 2012, presented with symptoms of biliary colic. There was no evidence of common bile duct stones on preoperative ultrasound and laboratory tests so an intraoperative cholangiogram was not performed. Thus, he underwent an uneventful laparoscopic cholecystectomy with no intraoperative cholangiography. The postoperative period *
Correspondence: Dr. Ramzi S. Alami, American University of Beirut, Dept. of Surgery, AUB Medical Center, Beirut 1107 2020, Lebanon. E-mail: [email protected]
was complicated, with severe pancreatitis. The patient was treated conservatively and was discharged after 10 days. However, the patient presented 6 weeks later to the emergency department with epigastric pain radiating to the back, associated with nausea and decreased oral intake. The initial CT scan indicated a 12.8 cm 9.3 cm fluid collection along the body of the pancreas in keeping with PP formation. The patient was admitted for pain control and he dramatically improved. Later, the patient was followed in the outpatient clinic and a repeat triphasic CT scan indicated slight shrinkage of the PP which measured 11.8 cm 9.3 cm. Two months later, another CT scan indicated a further decrease in size to 7.1 9.5 cm. He did well until January 2013, when he had recurrent symptoms, including intractable pain necessitating intramuscular opioid analgesia. The PP size had increased to 11.1 cm 12.6 cm 10.8 cm. At this point, the cyst wall was deemed mature and amenable to intervention. The PP was abutting the whole surface of the posterior wall of the stomach, and not extending below the transverse colon, limiting it to the lesser sac. An attempt at endoscopic cyst-gastrostomy failed due to limited working space, and the inability to visualize the posterior aspect of the stomach due to the patient’s sleeve gastrectomy. Thus, a laparoscopic transgastric cyst-gastrostomy procedure was considered to be ideal.
Management Four laparoscopic ports were used. The anterior gastric wall was incised at the antrum transversely for 3 cm with an intention to close it longitudinally to minimize stricture at the level of incisura. A bulging mass at the posterior gastric
http://dx.doi.org/10.1016/j.soard.2015.02.002 1550-7289/r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
976
H. M. Halawani et al. / Surgery for Obesity and Related Diseases 11 (2015) 975–977
wall was identified immediately. The mass was ballotable and fixed. To confirm that the bulging mass was the PP, a laparoscopic needle was used to aspirate fluid, which was brown. The posterior gastric wall was incised along with the thick PP using ultrasonic scalpel. The opening was widened to accommodate a 60 mm linear stapler with 4.8 mm staple load. A volume of 800 mL of typical brown fluid was aspirated. Because of the previous sleeve procedure, the stapler was oriented along the longitudinal axis of the stomach and cyst with care not to sever the left or right gastric arteries. After stapling, the anastomosis and PP cavity were examined. No debris, necrotic material, or bleeding were present at the staple line, and the cyst collapsed. The anterior gastrostomy was closed using 2-0 polydioxanone (PDS) running sutures in a longitudinal manner to avoid stenosis. A drain was placed and trocars removed. The patient tolerated the procedure well and was started on clear fluids per oram on day 2 postsurgery. A CT scan indicated a wide and patent communication between the stomach and the PP with no evidence of leak. The drain was removed on day 3 postsurgery. The patient was shifted to a full fluid diet and discharged on the fourth day with followup at 2 weeks and 3 months postsurgery with complete resolution of symptoms and no evidence of PP on CT scan or significant weight gain.
communication with the cyst, a transpapillary approach is feasible. The success rates are relatively high, with complications in up to 7% of patients. [12]. Surgical intervention carries the best long-term results. Cyst enteric anastomosis to drain the PP is the mainstay surgical principle. Depending on the PP location and its vicinity to nearby organs, cyst-gastrostomy, cyst-duodenostomy, or cystjejunostomy can be done. In this case, cyst-gasgtrostomy was ideal because the bulk of the PP was abutting the posterior wall of the stomach and extended medially beyond the lesser curvature. A recent report collected large case series (410 cases) of laparoscopic PP drainage and found a 10% conversion rate to laparotomy, bleeding complications of 6.7%, PP recurrence of 3.4%. The mortality rate was low at 1.1% [3]. A recent case series also described Natural Orifice Translumenal Endoscopic Surgery (NOTES) for PP drainage. In that case series of 6 patients, stapled cyst-gastrostomy was described as a less invasive surgical procedure [13]. Our case was challenging in regards to the patient’s previous history of laparoscopic sleeve gastrectomy, which prevented a successful endoscopic intervention due to the narrow space and limited access to posterior angles. Thus we chose to perform a laparoscopic cyst-gastrostomy in a patient who previously had a sleeve gastrectomy.
Discussion
Conclusions
Acute PP as concluded by the Atlanta classification is a well-defined wall composed of fibrous or granulation tissue containing pancreatic juice forming a pseudo-capsule. It usually occurs 4–6 weeks after an episode of acute pancreatitis, chronic pancreatitis, or trauma [5]. PP are 30%–40% more likely to form after chronic pancreatitis (CP) compared with acute pancreatitis (AP) 5%–16% [6,7]. The causes of PP are numerous; however, alcohol use and biliary tract disease are the most common [8]. Currently, it is acceptable to observe PP if they are asymptomatic. Nonetheless, active management for symptomatic PP or ones growing in size is advocated [9]. Symptoms may range from abdominal pain and discomfort to tragic complications such as gastric outlet obstruction, infection of the cyst, free rupture, or even erosion into adjacent vessels [10]. Until now, there have been no randomized controlled trials comparing the different approaches available for PP drainage. Often, the PP characteristics and patients’ symptoms and co-morbidities dictate the most appropriate algorithm for drainage. More advances are being observed in minimally invasive operative and nonoperative interventions. In contrast to surgical drainage, percutaneous external drainage is associated with higher mortality rates (16% versus 0%), a higher incidence of complications, a longer hospital stay, and failure rates reaching up to 58% [11]. Endoscopic drainage is a minimally invasive choice. Where anatomically possible, a transmural approach may be chosen. On the other hand, when there is direct duct
Laparoscopic cyst-gastrostomy for PP is a feasible option in patients who previously had a sleeve gastrectomy. Disclosures There are no conflicts of interests to disclose. Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2015.02.002. References [1] Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol 2009;15(1):38–47. [2] Chahal P, Baron TH, Topazian MD, Levy MJ. EUS-guided diagnosis and successful endoscopic transpapillary management of an intrahepatic pancreatic pseudocyst masquerading as a metastatic pancreatic adenocarcinoma (with videos). Gastrointest Endosc 2009;70(2):393–6. [3] Bergman S, Melvin MS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2007;87(6):1447–60. ix. [4] Aljarabah M, Ammori BJ. Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series. Surg Endosc 2007;21(11):1936–44. [5] Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11–13, 1992. Arch Surg 1993;128(5):586–90.
Laparoscopic Cyst-Gastrostomy After Laparoscopic Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 975–977 [6] Boerma D, Obertop H, Gouma DJ. Pancreatic pseudocysts in chronic pancreatitis. Surgical or interventional drainage? Ann Ital Chir 2000;71(1):43–50. [7] Aghdassi AA, Mayerle J, Kraft M, Sielenkämper AW, Heidecke C-D, Lerch MM. Pancreatic pseudocysts–when and how to treat? HPB (Oxford) 2006;8(6):432–41. [8] Walt AJ, Bouwman DL, Weaver DW, Sachs RJ. The impact of technology on the management of pancreatic pseudocyst. Fifth annual Samuel Jason Mixter Lecture. Arch Surg 1990;125(6):759–63. [9] Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992;111(2):123–30.
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[10] Jones DR, Vaughan RA, Timberlake GA. Pancreatic pseudocyst: diagnosis and management. South Med J 1992;85(7):729–34. [11] McFarlane ME. The role of percutaneous drainage in the modern management of pancreatic pseudocysts. Int J Clin Pract 2005;59 (4):383–4. [12] Bhattacharya D, Ammori BJ. Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature. Surg Laparosc Endosc Percutan Tech 2003;13(3):141–8. [13] Pallapothu R, Earle DB, Desilets DJ, Romanelli JR. NOTES stapled cystgastrostomy: a novel approach for surgical management of pancreatic pseudocysts. Surg Endosc 2011;25(3):883–9.
Video case report
Laparoscopic cyst-gastrostomy after laparoscopic sleeve gastrectomy Hamzeh M. Halawani, M.D., Ramzi S. Alami, M.D., F.A.C.S.*, George S. Abi Saad, M.D., F.A.C.S. Department of General Surgery, American University of Beirut Medical Centre, Beirut, Lebanon Received January 28, 2015; accepted February 2, 2015
Keywords:
Pseudocyst; Pancreatitis; Bariatric cyst-gastrostomy
Pancreatic pseudocysts (PP) are confined collections of fluid from the pancreatic gland surrounded by nonepithelialized granulation tissue containing pancreatic juices. PP are not common, but they are usually a complication of pancreatitis. At this time, numerous classification systems are being used depending on the origin of the PP, its relation to the pancreatic duct, and the presence or absence of a pseudocyst–duct communication [1]. Diagnosis is often made with a computed tomographic (CT) scan, endoscopic retrograde cholangiopancreaticography (ERCP), or ultrasound. The vast improvement in diagnostic modalities has assisted in the detection of PP with a high sensitivity and specificity [2]. There are several therapeutic operative and nonoperative interventions for the treatment of symptomatic or large PP. These consist of endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or surgical drainage [3,4]. Herein, we report a laparoscopic cyst-gastrostomy in a patient who had previously undergone a laparoscopic sleeve gastrectomy and then developed a symptomatic PP. Case presentation A 51-year-old male patient who had undergone a laparoscopic sleeve gastrectomy in 2012, presented with symptoms of biliary colic. There was no evidence of common bile duct stones on preoperative ultrasound and laboratory tests so an intraoperative cholangiogram was not performed. Thus, he underwent an uneventful laparoscopic cholecystectomy with no intraoperative cholangiography. The postoperative period *
Correspondence: Dr. Ramzi S. Alami, American University of Beirut, Dept. of Surgery, AUB Medical Center, Beirut 1107 2020, Lebanon. E-mail: [email protected]
was complicated, with severe pancreatitis. The patient was treated conservatively and was discharged after 10 days. However, the patient presented 6 weeks later to the emergency department with epigastric pain radiating to the back, associated with nausea and decreased oral intake. The initial CT scan indicated a 12.8 cm 9.3 cm fluid collection along the body of the pancreas in keeping with PP formation. The patient was admitted for pain control and he dramatically improved. Later, the patient was followed in the outpatient clinic and a repeat triphasic CT scan indicated slight shrinkage of the PP which measured 11.8 cm 9.3 cm. Two months later, another CT scan indicated a further decrease in size to 7.1 9.5 cm. He did well until January 2013, when he had recurrent symptoms, including intractable pain necessitating intramuscular opioid analgesia. The PP size had increased to 11.1 cm 12.6 cm 10.8 cm. At this point, the cyst wall was deemed mature and amenable to intervention. The PP was abutting the whole surface of the posterior wall of the stomach, and not extending below the transverse colon, limiting it to the lesser sac. An attempt at endoscopic cyst-gastrostomy failed due to limited working space, and the inability to visualize the posterior aspect of the stomach due to the patient’s sleeve gastrectomy. Thus, a laparoscopic transgastric cyst-gastrostomy procedure was considered to be ideal.
Management Four laparoscopic ports were used. The anterior gastric wall was incised at the antrum transversely for 3 cm with an intention to close it longitudinally to minimize stricture at the level of incisura. A bulging mass at the posterior gastric
http://dx.doi.org/10.1016/j.soard.2015.02.002 1550-7289/r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
976
H. M. Halawani et al. / Surgery for Obesity and Related Diseases 11 (2015) 975–977
wall was identified immediately. The mass was ballotable and fixed. To confirm that the bulging mass was the PP, a laparoscopic needle was used to aspirate fluid, which was brown. The posterior gastric wall was incised along with the thick PP using ultrasonic scalpel. The opening was widened to accommodate a 60 mm linear stapler with 4.8 mm staple load. A volume of 800 mL of typical brown fluid was aspirated. Because of the previous sleeve procedure, the stapler was oriented along the longitudinal axis of the stomach and cyst with care not to sever the left or right gastric arteries. After stapling, the anastomosis and PP cavity were examined. No debris, necrotic material, or bleeding were present at the staple line, and the cyst collapsed. The anterior gastrostomy was closed using 2-0 polydioxanone (PDS) running sutures in a longitudinal manner to avoid stenosis. A drain was placed and trocars removed. The patient tolerated the procedure well and was started on clear fluids per oram on day 2 postsurgery. A CT scan indicated a wide and patent communication between the stomach and the PP with no evidence of leak. The drain was removed on day 3 postsurgery. The patient was shifted to a full fluid diet and discharged on the fourth day with followup at 2 weeks and 3 months postsurgery with complete resolution of symptoms and no evidence of PP on CT scan or significant weight gain.
communication with the cyst, a transpapillary approach is feasible. The success rates are relatively high, with complications in up to 7% of patients. [12]. Surgical intervention carries the best long-term results. Cyst enteric anastomosis to drain the PP is the mainstay surgical principle. Depending on the PP location and its vicinity to nearby organs, cyst-gastrostomy, cyst-duodenostomy, or cystjejunostomy can be done. In this case, cyst-gasgtrostomy was ideal because the bulk of the PP was abutting the posterior wall of the stomach and extended medially beyond the lesser curvature. A recent report collected large case series (410 cases) of laparoscopic PP drainage and found a 10% conversion rate to laparotomy, bleeding complications of 6.7%, PP recurrence of 3.4%. The mortality rate was low at 1.1% [3]. A recent case series also described Natural Orifice Translumenal Endoscopic Surgery (NOTES) for PP drainage. In that case series of 6 patients, stapled cyst-gastrostomy was described as a less invasive surgical procedure [13]. Our case was challenging in regards to the patient’s previous history of laparoscopic sleeve gastrectomy, which prevented a successful endoscopic intervention due to the narrow space and limited access to posterior angles. Thus we chose to perform a laparoscopic cyst-gastrostomy in a patient who previously had a sleeve gastrectomy.
Discussion
Conclusions
Acute PP as concluded by the Atlanta classification is a well-defined wall composed of fibrous or granulation tissue containing pancreatic juice forming a pseudo-capsule. It usually occurs 4–6 weeks after an episode of acute pancreatitis, chronic pancreatitis, or trauma [5]. PP are 30%–40% more likely to form after chronic pancreatitis (CP) compared with acute pancreatitis (AP) 5%–16% [6,7]. The causes of PP are numerous; however, alcohol use and biliary tract disease are the most common [8]. Currently, it is acceptable to observe PP if they are asymptomatic. Nonetheless, active management for symptomatic PP or ones growing in size is advocated [9]. Symptoms may range from abdominal pain and discomfort to tragic complications such as gastric outlet obstruction, infection of the cyst, free rupture, or even erosion into adjacent vessels [10]. Until now, there have been no randomized controlled trials comparing the different approaches available for PP drainage. Often, the PP characteristics and patients’ symptoms and co-morbidities dictate the most appropriate algorithm for drainage. More advances are being observed in minimally invasive operative and nonoperative interventions. In contrast to surgical drainage, percutaneous external drainage is associated with higher mortality rates (16% versus 0%), a higher incidence of complications, a longer hospital stay, and failure rates reaching up to 58% [11]. Endoscopic drainage is a minimally invasive choice. Where anatomically possible, a transmural approach may be chosen. On the other hand, when there is direct duct
Laparoscopic cyst-gastrostomy for PP is a feasible option in patients who previously had a sleeve gastrectomy. Disclosures There are no conflicts of interests to disclose. Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2015.02.002. References [1] Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol 2009;15(1):38–47. [2] Chahal P, Baron TH, Topazian MD, Levy MJ. EUS-guided diagnosis and successful endoscopic transpapillary management of an intrahepatic pancreatic pseudocyst masquerading as a metastatic pancreatic adenocarcinoma (with videos). Gastrointest Endosc 2009;70(2):393–6. [3] Bergman S, Melvin MS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2007;87(6):1447–60. ix. [4] Aljarabah M, Ammori BJ. Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series. Surg Endosc 2007;21(11):1936–44. [5] Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11–13, 1992. Arch Surg 1993;128(5):586–90.
Laparoscopic Cyst-Gastrostomy After Laparoscopic Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 975–977 [6] Boerma D, Obertop H, Gouma DJ. Pancreatic pseudocysts in chronic pancreatitis. Surgical or interventional drainage? Ann Ital Chir 2000;71(1):43–50. [7] Aghdassi AA, Mayerle J, Kraft M, Sielenkämper AW, Heidecke C-D, Lerch MM. Pancreatic pseudocysts–when and how to treat? HPB (Oxford) 2006;8(6):432–41. [8] Walt AJ, Bouwman DL, Weaver DW, Sachs RJ. The impact of technology on the management of pancreatic pseudocyst. Fifth annual Samuel Jason Mixter Lecture. Arch Surg 1990;125(6):759–63. [9] Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992;111(2):123–30.
977
[10] Jones DR, Vaughan RA, Timberlake GA. Pancreatic pseudocyst: diagnosis and management. South Med J 1992;85(7):729–34. [11] McFarlane ME. The role of percutaneous drainage in the modern management of pancreatic pseudocysts. Int J Clin Pract 2005;59 (4):383–4. [12] Bhattacharya D, Ammori BJ. Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature. Surg Laparosc Endosc Percutan Tech 2003;13(3):141–8. [13] Pallapothu R, Earle DB, Desilets DJ, Romanelli JR. NOTES stapled cystgastrostomy: a novel approach for surgical management of pancreatic pseudocysts. Surg Endosc 2011;25(3):883–9.
