Laparoscopic loop cystojejunostomy: An alternative to Roux-en-Y cystojejunostomy for pancreatic pseudocyst.

Surgical internal drainage of pancreatic pseudocyst can be done into the stomach, duodenum or jejunum depending on the anatomic relation of pseudocyst with hollow viscera. For cystojejunostomy, a Roux-en-Y loop is preferred over loop cystojejunostomy as former is thought to avoid the reflux of jejunal contents into the cyst cavity. This study presents our experience with laparoscopic loop cystojejunostomy showing loop cystojejunostomy for the pseudocyst of the pancreas can be safely performed laparoscopically with simpler technique with no complications including reflux.

INTRODUCTION

Pancreatic pseudocyst (PP) is well-circumscribed fluid collection, with no associated tissue necrosis that develops following an attack of pancreatitis.[1] The incidence of pseudocysts is extremely low ranging from 1.6% to 4.5% per 100,000 adults per year.[2] The prevalence of PPs is ranging from 10% to 26% in acute pancreatitis and 20%–40% in chronic pancreatitis.[34]

Persistent and symptomatic PP are treated by internal drainage which can be done by surgical or endoscopic approaches.[3456] The commonly performed surgical drainage procedures for PP include cystogastrostomy, cystoduodenostomy and cystojejunostomy. The choice depends on the anatomical proximity of PP to the surrounding hollow viscus. Cystojejunostomy is preferred in cyst which are not in contact with the stomach and duodenum.[5] Open and laparoscopic cystojejunostomy with a Roux-en-y jejunal loop is a standard procedure.[56] An easier alternative technique of simple loop cystojejunostomy is an option for pseudocyst drainage but with extremely limited literature.[7] This study presents our experience with laparoscopic loop cystojejunostomy in terms of operative technique and early and late outcomes.

Aim

The aim of this study is to develop a simpler technique of laparoscopic cystojejunostomy for the internal drainage of pseudocyst of the pancreas.

MATERIALS AND METHODS

From May 2017 to May 2018, four patients of PP, after taking medical ethics committee approval were subjected to laparoscopic loop cystojejunostomy at a tertiary health-care centre in Mumbai, India. Detailed clinical history and clinical examination were documented, particularly history of acute or chronic pancreatitis. Complete blood count (CBC), fasting blood sugar, renal profile, liver function tests (LFT), coagulation profile, serum lipase and amylase were done in all patients. Ultrasonography (USG) was done as a screening modality. Contrast-enhanced computerised tomography (CECT) was done to document the anatomical position of the cyst and its relation with surrounding hollow viscus. Magnetic resonance cholangiopancreatography (MRCP) was done to document the possible communication of PP with main pancreatic duct (MPD). Upper gastrointestinal (UGI) flexible endoscopy was done to document the presence or absence of bulge into the stomach and to rule out gastric varices. All patients were operated under general anaesthesia. Third-generation cephalosporin was used as peri-operative antibiotic prophylaxis.

Decision to do loop cystojejunostomy was based on the computed tomography (CT) scan findings which showed in all four cases, PP to be away from the stomach and duodenum and bulging through the transverse mesocolon.

Operative technique

The patient was placed in the French position, and the operating surgeon stood between the legs of the patient. The camera port (10 mm) was placed through the umbilicus by the open insertion technique, and pneumoperitoneum was created. 10-mm 30° telescope was introduced. Three additional ports were introduced under vision; 10-mm port was placed lateral to the umbilicus in the left mid clavicular line; two 5 mm ports were placed, one in the right hypochondrium in mid clavicuar line and other in the left iliac fossa in the anterior axillary line. Pneumoperitoneum was maintained at 15 mmHg.

Transverse colon was lifted up with the help of three sutures passed through mesocolon and pulled out through the anterior abdominal wall and held with artery forceps [Figure 1a]. Cyst was seen bulging through the transverse mesocolon to the left of duodeno-jejunal (DJ) flexure. Laparoscopic aspiration needle was introduced into the cyst to confirm its content [Figure 1b]. The cyst wall was opened up transversely to a length of 7 cm with an harmonic shear, and contents were evacuated [Figure 1c]. Interior of the cyst was inspected to rule out the presence of any solid components. A jejunal loop was identified 20 cm distal to DJ flexure, placed from left to right and fixed to cyst wall horizontally with interrupted 2-0 silk seromuscular sutures [Figure 1c]. The jejunum was incised to the same length as opening in the cyst. Laparoscopic sutured loop cystojejunostomy was performed with 3-0 PDS continuous suturing. Anterior seromuscular sutures were taken as the second layer between the jejunum and cyst wall [Figure 1d]. Tube abdominal drain was placed beside the anastomosis.

Figure 1

(a) Transverse colon, lifted up with the help of sutures to the anterior abdominal wall. (b) Laparoscopic aspiration of the pseudocyst bulging through the transverse mesocolon. (c) Opened up pseudocyst with the jejunum to be anastomosed. (d) Laparoscopic hand sewn loop cystojejunostomy

Postsurgery nasogastric tube was removed on day 1–2, orally liquids were started on day 2–3 and full diet was started by day 3–4. All patients were discharged on day 5–7.

Postoperative CECT abdomen of each patient was performed on day 7 to look for any anastomotic leak and reflux of orally administered contrast into the cyst cavity. At 1–3 months follow-up, an MRCP with MRI abdomen was done to check for any residual cyst (effectiveness of the drainage procedure) and a CT scan with oral contrast was done to look for reflux of any contrast from the jejunum into the pseudocyst.

Case 1

A 40-year-old male patient, previously diagnosed case of acute-necrotising pancreatitis admitted with the complaints of upper abdominal pain and multiple episodes of vomiting for 2 days. In past, the patient had a history of exploratory laparotomy with pancreatic necrosectomy 7 years ago at another centre after which the patient developed pancreatic fistula, ERCP findings suggestive of total duct disruption for which stent in pancreatic duct was placed which was subsequently removed 6 months later after healing of the pancreatic fistula.

On admission, the patient was vitally stable, afebrile and per abdominal examination was noncontributory. His blood investigations, including total leucocyte count (TLC), were normal except elevated serum lipase (375 U/L) and serum amylase (175 U/L). A CECT abdomen showed atrophic pancreas with calcific foci in the head and proximal body suggestive of chronic pancreatitis. CT scan also showed the presence of a pseudocyst anterior to mid pancreatic body (5.8 cm × 5.7 cm; HU 15; wall thickness 3 mm) and away from the stomach bulging through transverse mesocolon. MPD was dilated (4 mm) and coursing posterior to the cyst [Figure 2]. UGI endoscopy with endoscopic EUS showed no bulge into the stomach or dilated veins and no evidence of pseudoaneurysm. The patient underwent laparoscopic loop cystojejunostomy.

Figure 2

Contrast-enhanced computed tomography of the abdomen sagittal view showing PP anterior to mid pancreatic body

Case 2

A 45-year-old male patient admitted with complaints of fever and pain in epigastric region radiating to back. He was a known case of hypertension, dyslipidaemia and cholelithiasis and had an episode of acute pancreatitis 4 months back. On admission, he was vitally stable, and per abdominal examination was noncontributory. His blood investigations were normal except elevated serum amylase (250 U/L), lipase (201 U/L) and TLCs 35,400/cmm. CECT of the abdomen [Figure 3b] showed bulky pancreas with walled off collection in retropancreatic region (6.5 cm × 3.7 cm × 3 cm; HU 20) along with complete thrombosis of splenic vein in the region of body of the pancreas with few peripancreatic collaterals. The patient responded to conservative treatment including intravenous antibiotics, analgesics and fluids, but pain in the abdomen persisted. After 13 days of admission, MRCP [Figure 3a] was done which showed large PP (15 cm × 8.5 cm × 9.2 cm; cystic content) located predominantly posterior to the body and tail of pancreas along with focal disruption of MPD in the neck which was communicating with PP, also showed cholelithiasis. UGI endoscopy with EUS showed no bulge or contact with the stomach.

Figure 3

(a) Magnetic resonance cholangiopancreatography (transverse view) showing large cyst posterior to the pancreas with the disruption of main pancreatic duct. (b) Contrast-enhanced computed tomography of the abdomen (sagittal view) showing retropancreatic pancreatic pseudocyst

The patient underwent laparoscopic loop cystojejunostomy with laparoscopic cholecystectomy simultaneously.

Case 3

A 50-year-old female patient admitted with complaints of upper abdominal pain and fullness. Five months before the admission, she had a history of mild gallstone pancreatitis, and a laparoscopic cholecystectomy was done at that time. On admission, she was vitally stable, and blood investigations, including CBC, LFT, lipase and amylase were within the normal range. CECT abdomen revealed a walled off pseudocyst (6.4 cm × 8.4 cm × 6.7 cm; HU 15; wall thickness 3.1 mm) posterior to the body of the pancreas. MRCP showed oedematous pancreas with PP posterior to body of the pancreas (6 cm × 8.4 cm × 6.5 cm) with no communication with MPD. UGI endoscopy with EUS showed no bulge into the stomach or dilated veins and no evidence of pseudoaneurysm. Laparoscopic loop cystojejunostomy was done.

Case 4

A 65-year-old male patient had a history of alcohol-induced acute pancreatitis 4 months back for which he was admitted and treated conservatively. Now presented with upper abdominal pain and distension. On physical examination, he had significant abdominal distension and tenderness in the upper abdomen. His blood investigations were normal except for elevated amylase (261 U/L) and lipase (216 U/L). CECT of the abdomen revealed atrophic pancreas with calcific deposits, a pseudocyst (measuring 8.5 cm × 6 cm × 5 cm; HU 15; wall thickness 2.5 mm) anterior to the body and tail of the pancreas. UGI endoscopy with EUS showed no bulge into the stomach or dilated veins and no evidence of pseudoaneurysm. The patient underwent laparoscopic loop cystojejunostomy.

RESULTS

Of these 4 patients, one had concomitant cholecystectomy. Mean surgical time was 78 min, and average blood loss was 75 ml.

Postoperative period for all patients was uneventful. Postoperative CECT abdomen and MRCP (on the 7th day and 1–3 months follow-up) showed no leak, no reflux of contrast into the pseudocyst cavity and no recurrence or residual cyst. All patients are asymptomatic at the mean follow-up period of 16 months (ranging from 12 months to 24 months) [Table 1].

Table 1

Follow-up Status of each case

Serial number of cases	CECT abdomen on follow-up	MRI abdomen on follow-up
1	No leak, no reflux of contrast into the pseudocyst cavity	No recurrence or residual cyst
2	No leak, no reflux of contrast into the pseudocyst cavity	No recurrence or residual cyst
3	No leak, no reflux of contrast into the pseudocyst cavity	No recurrence or residual cyst
4	No leak, no reflux of contrast into the pseudocyst cavity	No recurrence or residual cyst

DISCUSSIONS

The natural history of a PP is unpredictable. It may be asymptomatic or may present with a variety of symptoms such as pain, early satiety, upper gastrointestinal bleeding, nausea and vomiting. The maturation period of PPs is reported to be approximately 2–6 weeks. During this period, spontaneous resolution is expected in 33% of PP. However, a substantial number of persistent cysts require treatment owing to the potential complications such as infection, haemorrhage, cyst rupture and compression of viscera.[8]

The treatment of PP has traditionally been surgical.[4589] Laparoscopic approach is now well accepted for the surgical management of PP. Adequate internal drainage and concomitant debridement of necrotic tissue within the pseudocysts with minimal morbidity can be achieved by laparoscopic cystogastrostomy or cystojejunostomy.[910]

Cystojejunostomy is an option where the cyst is not in apposition of the stomach wall/duodenum, and consequently, cystogastrostomy/cystoduodenostomy is not an option. Laparoscopic Roux-en-Y cystojejunostomy is a standard modality for the internal drainage of PP; however, loop cystojejunostomy is also an option which was described in a German literature but has not become popular due to some scepticism regarding the risk of leak and reflux of intestinal contents in the cyst.[57]

It was said that in loop cystojejunostomy, effective diversion from the alimentary tract is not there, and the contents of the biliary tree may also flow freely into the pseudocyst cavity. In addition, if there is an anastomotic leak, the loop cystojejunostomy would yield a greater morbidity as it is in continuity with the alimentary track.[56] However, in our limited experience with four patients, we have not found either leak or the reflux of any content/contrast spilling into the pseudocyst cavity. All of them had effective drainage of the pseudocyst with none showing recurrence. Further multicentre studies with larger sample size are required to validate these findings.

CONCLUSION

Laparoscopic loop cystojejunostomy for PP is a sparsely used procedure. It can be safely performed with simpler technique with no complications. Although with four patients it's too early to claim promising results, this just opens the door of further exploration of this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.