Laparoscopic Cystogastrostomy in Children with Pancreatic Pseudocysts: A Preliminary Experience of Eight Cases.

Introduction: Pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) in children following acute pancreatitis are uncommon. The various modalities of therapy possible are conservative treatment, external drainage, endoscopic stenting, and internal surgical drainage procedures. There are no existing guidelines for the management of PPC in children. We evaluate the outcomes of laparoscopic cystogastrostomy (LCG) performed at our center. Materials and
Methods: Eight children (median age: 10 years) underwent LCG for large PPC (median size: 12.5 cm). There were seven patients with PPC and one with WON. Seven underwent LCG by a transgastric approach and one underwent LCG by a retrogastric approach.
Results: Seven out of the eight patients had complete resolution of symptoms and the PPC. The median follow-up period was 32 months (interquartile range: 9.5-55.5 months). There were no conversions. There was one patient with a WON who developed a recurrence.
Conclusion: LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, when indicated, is a safe approach with a comparable outcome. Copyright:

INTRODUCTION

Pancreatic pseudocysts (PPCs) result from collections of pancreatic secretions within the vicinity of the pancreas.[1] The Revised Atlanta Classification defines a PPC as an encapsulated collection of fluid surrounded by a well-demarcated inflammatory wall with minimal or absent necrosis, occurring at least 4 weeks after the onset of interstitial edematous pancreatitis.[2] This is in contradistinction to a walled-off necrosis (WON), which contains pancreatic or peripancreatic necrosis following necrotizing pancreatitis. Both these collections are encapsulated, lined by fibrous tissues and lack an epithelial lining.[3] The most common etiology in children is traumatic injury to the pancreas. The treatment options available for symptomatic PPC include endoscopic stenting and open/laparoscopic surgery, often determined by the expertise of the treating physician/surgeon. The aim of this study is to assess the various laparoscopic approaches and their outcomes in children with PPC/WON. We present a series of eight patients treated by laparoscopic cystogastrostomy (LCG).

MATERIALS AND METHODS

The medical records of children under 16 years of age who underwent laparoscopic drainage of PPC and WON secondary to acute pancreatitis between May 2012 and June 2020 were reviewed and included in the study [Figure 1]. Patients with PPC with features of chronic pancreatitis and those treated by open cystogastrostomy were not included in this review. The selected data obtained from the medical records included the clinical details of the patients, investigations, inpatient records, operative details, and postoperative follow-up and correspondences. As per institutional protocol, an Institutional Review Board approval was obtained for this retrospective study. After obtaining informed consent from the parents/guardians, LCG was performed. The outcomes studied were symptom and cyst resolution (ultrasound examination), estimated blood loss, blood transfusion, operative time, opioid requirement, postsurgery hospital stay, recurrence rate, morbidity, and mortality.

Figure 1

Patient selection flowchart

Laparoscopic transgastric cystogastrostomy (LTGC) was performed for seven patients by the coauthors using a technique described earlier in a video journal.[4] A brief description of the procedure is as follows: three 5 mm ports (umbilical and bilateral paraumbilical) were used. Percutaneous transgastric aspiration of the pseudocyst was initially done, using a 22G spinal needle under laparoscopic vision, to localize and confirm the position of the cyst. In very large cysts, partial decompression resulted in creating adequate working space. A longitudinal gastrotomy [Figure 2a] was performed on the anterior wall of the stomach just above the bulge of the pseudocyst by either cautery or harmonic scalpel. The posterior wall of the stomach and the adjoining pseudocyst were incised [Figure 2b] and entered, using a harmonic scalpel or cautery after confirmation by aspiration. An ellipsoid of the common wall about 2.5 cm in diameter was excised to maintain the cyst open [Figure 2c]. The margin of the pseudocyst wall and posterior wall of the stomach was sutured in five patients and was left unsutured in two children (at the surgeon's discretion), where Harmonic shears had been used to open into the cyst. This was done after confirming that the cyst wall and the posterior stomach wall were indeed fused together. The anterior gastrostomy was closed with 3-0 vicryl sutures [Figure 2d]. A brief video of this technique [Video 1] has been provided as supporting information.

Figure 2

Anterior transgastric cystogastrostomy. (a) Creation of anterior gastrotomy to access the bulging pancreatic pseudocyst. (b) Excising 2.5 cm ellipsoid of the adherent posterior gastric and pancreatic pseudocyst walls to create a cystogastrostomy using ultrasonic shears. (c) A view through the cystogastrostomy. (d) Closure of the anterior gastrotomy

Laparoscopic retrogastric cystogastrostomy (LRGC) was performed for one patient (symptomatic for 6 months) as the pseudocyst wall was not adherent to the stomach wall. This is described below: the port placement was similar to that of the LTGC approach and transgastric aspiration of the PPC was done to confirm the position. Inspection of the posterior aspect of the stomach revealed the absence of adhesions between the posterior wall of the stomach and the PPC. The stomach was hitched up in three areas along the greater curve [Figure 3a and b], serving to retract the stomach anteriorly while adequately exposing the anterior surface of the PPC after entering the lesser sac using Harmonic shears. The pseudocyst was opened into with Harmonic shears, and an ellipsoid of the wall of about 2.5 cm in diameter was excised. A separate gastrotomy was created on to the posterior stomach wall, proximate to the cystotomy site. The posterior cystogastrostomy was fashioned with 3-0 vicryl with continuous sutures for the posterior wall and interrupted sutures for the anterior wall [Figure 3c and d].

Figure 3

Posterior cystogastrostomy. (a) Laparoscopic view of the stomach and the pancreatic pseudocyst abutting onto the former. (b) Exposure of the lesser sac and the pancreatic pseudocyst by incising the greater omentum and retracting the greater curvature with transcutaneous hitching sutures. (c) Creation of a cystogastrostomy between the posterior stomach wall and the adjoining pancreatic pseudocyst. (d) Completed posterior cystogastrostomy

RESULTS

There were eight children: six boys and two girls (male: female = 3:1) with a median age of 10 years (interquartile range [IQR]: 2–11 years). The results are enumerated in Table 1. The chief presenting complaints were abdomen pain (n = 8) and abdomen distension (n = 5). The etiology of pancreatic pseudocyst were posttraumatic (n = 3), gallstone-induced pancreatitis (n = 2), and idiopathic (n = 3). They presented for surgery with a median of 8 weeks (IQR: 6–18 weeks) from the onset of symptoms.

Table 1

Demographics and clinical profile of patients operated with PPC/WON

Patient→Parameter↓	1	2	3	4	5	6	7	8	Median
Age (yrs)	10	5	10	15	11	2	1	10	10
Sex	M	F	M	F	M	M	M	M	-
Type	PPC	PPC	PPC	PPC	WON	PPC	PPC	PPC
Etiology	Post- traumatic	Post- traumatic	Post -traumatic	Gall stone induced	Gall stone induced	Idiopathic	Idiopathic	Idiopathic	-
Symptom duration (weeks)	8	8	8	4	28	10	3	26	8
Comorbidities	Nil	Nil	Nil	Diabetes mellitus	Nil	Developmental delay + GERD	Nil	Nil	-
Cyst location	Body	Body	Neck	Head + Body + Tail	Body + Tail	Tail	Body + Tail	Body + Tail	-
Max size (cm)	12	11.1	19	15	13.6	10.7	13	8	12.5
Uni/multilocular	Uni	Uni	Uni	Multi	Uni	Multi	Uni	Uni	Uni
Approach	Transgastric	Transgastric	Transgastric	Transgastric	Transgastric	Transgastric	Transgastric	Retrogastric	-
Number of ports	3	3	3	4	5	3	3	3	3
Additional procedures	-	-	-	Cholecystectomy	Cholecystectomy	-	-	-	-
Cyst entered by	Cautery- bipolar	Cautery- monopolar	Cautery- monopolar	Harmonic	Harmonic	Harmonic	Harmonic	Harmonic	-
Cystogastrostomy maturation	Suturing	Suturing	Suturing	Not sutured	Not sutured	Suturing	Suturing	Suturing	-
Operating time (min)	205	135	225	360	150	240	320	255	232
Blood loss (ml)	Minimal	Minimal	Minimal	Minimal	Minimal	Minimal	20	20	-
Time to discharge (days)	3	4	8	4	4	9	6	3	4
Post op Complication	Nil	Nil	Fever	Nil	Pain	Fever	Nil	Nil	-
Post op Recurrence	Nil	Nil	Nil	Nil	Yes	Nil	Nil	Nil	-
Follow up (months)	9	72	57	54	33	31	10	5	32

All PPCs had been diagnosed by both ultrasound abdomen and contrast-enhanced computed tomography (CT) scan of the abdomen. The cysts were located in the head (n = 1), neck (n = 1), body (n = 6), and tail (n = 5). There were six patients with a unilocular cyst; one patient with a bilocular cyst involving the head, body, and tail; and another patient with a multilocular cyst with 3 compartments.

One boy presented with a history of recurrence of the PPC following an endoscopic transmural cystogastrostomy stenting performed at another center. One girl had a posttraumatic pancreatic body transection, and one boy had gastroesophageal reflux for which an adjunctive feeding gastrostomy was done. Two patients had concurrent laparoscopic cholecystectomy for gallstone-induced pancreatitis. A LTGC was performed for seven patients, and a LRGC was performed for one patient.

The median operating time was 232 min (IQR: 178–288 min). This included three patients who underwent additional procedures, namely a cholecystectomy (n = 2) and a feeding gastrostomy (n = 1). The postoperative pain was minimal, with a median opioid requirement of only 1 day. The median time to initial feeding was 3 days (IQR: 2.5–4.5 days), and the median time to full feeds was 4 days (IQR: 3.5–5.5 days). The median time to discharge was at the end of the fourth postoperative day (IQR: 3.5–7 days). The two patients who stayed for 8 and 9 days postoperatively had mild fever which settled with antibiotic cover. One patient (with WON) presented 6 months postsurgery with a recurrence that was diagnosed on CT scan. He is presently awaiting surgery. The median postoperative follow-up was 32 months (IQR: 9.5–55.5 months). The overall success rate of LCG was 88% (7/8 patients).

DISCUSSION

PPCs are uncommon in children. Traumatic injuries causing PPC account for up to two-thirds of the cases, with nearly half occurring as a result of cycle handlebar injuries.[5] Other causes are gallstone-induced pancreatitis, familial pancreatitis, drug-induced pancreatitis, congenital malformations of the pancreatic duct, and idiopathic pancreatitis.[6] PPC may either resolve with conservative management or persist causing complications such as cyst rupture, bleeding into the cyst, infection, compressive symptoms, and fistulation.[1] PPCs that are more than 6-week duration and 6 cm in size have historically undergone intervention.[3]

External drainage has generally been reserved for surgically unfit patients, for those with an immature cyst wall, and in the presence of an infected PPC. This has been associated with an increased risk of failure and fistula formation.[7] Internal drainage is preferred in noninfected cases, which may be performed either endoscopically or surgically. Surgical drainage can be performed either by open or laparoscopic techniques. Laparoscopic drainage has been associated with fewer postoperative complications, shorter hospital stay, and lower hospitalization costs when compared to percutaneous or open surgical drainage.[8] In terms of success and complications between the different techniques, clinical equipoise is noted in adult trials with regard to length of hospital stay, cost of therapy, impact on physical/mental health, and superior outcomes.[9101112] Such randomized controlled trials are lacking in children.

Mixed results have been obtained for endoscopic transmural cystogastrostomy with or without transpapillary stenting in children.[713] Variable success in drainage has been achieved by substituting lumen apposing self-expanding endoscopic metal stents instead of the plastic version.[10] Recently, an image-guided cystogastrostomy modality has been described in children for internal drainage of PPC using covered, flanged self-expanding nitinol or biliary endoscopic stents via a preexisting gastrostomy tract or a percutaneous gastrostomy with good results, although risks of sepsis, peritonitis, and incomplete drainage have been reported.[14]

Although endoscopic drainage of PPC in children is a feasible option, our institution's practice has currently been primarily surgical, open or laparoscopic, due to the existing technical competencies.

Open surgical procedures such a cystogastrostomy and cystojejunostomy have been considered the gold standard for the treatment of nonresolving PPC.[6] Cystogastrostomy has classically been advocated in the presence of a solitary large PPC, which posteriorly abuts the stomach. LCG in children has traditionally been performed by the anterior approach using either a transgastric exposure or intragastric ports.[315] We have described the LTGC approach above. Laparoscopic cystojejunostomy has also been described in the management of large complicated PPC in children such as in communicating PPC or ones occurring in an atypical position.[16] In our series, one patient underwent an on-table needle aspiration of 1 L of cyst fluid under anesthesia to decompress the large cyst which initially precluded port placement. Successful laparoscopic drainage was achieved in two patients with multiple proximate pseudocysts. This resolution could theoretically be attributed to the presence of intraparenchymal channels of communication between the cysts.

A key factor in ensuring success in drainage of a PPC/WON is to ensure a permanent wide, watertight anastomosis. There were two patients in our study who underwent a suture-less cystogastrostomy via the LTGC approach using only the Harmonic shears to seal the anastomotic edges, a technique which has earlier been described by Yoder et al.[3] While this was successful in one patient with PPC, it resulted in a recurrence in the other with WON. The possible cause for this failure is that the stomatal opening fashioned solely with the Harmonic shears may have gradually stenosed completely, thus preventing complete drainage of the contents and causing a recurrence. This complication may have been avoided if a wider anastomotic diameter had been created and delayed absorbing sutures used to mature the anastomotic edges.

We have described our experience with the LRGC approach in a child with abdomen pain for 6 months having a large solitary retrogastric PPC. The preoperative CT scan and intraoperative assessment showed complete separation of the stomach from the PPC wall [Figure 4]. Furthermore, transgastric puncturing of the cyst to ascertain the position produced significant extravasation of the cyst fluid into the lesser sac. The PPC wall was clearly visualized, and a safe anastomosis was fashioned clear of proximate blood vessels. Although our case fulfilled the stipulated criteria for endoscopic intervention where a cyst to gastric lumen wall distance was <1 cm without intervening blood vessels,[17] we feel that such an attempt would have resulted in extravasation into the lesser sac.

Figure 4

Computed tomography abdomen images: Indications for an anterior and posterior approach in a pancreatic pseudocyst

LRGC with access via the lesser sac has been described in adults, whereby the posterior gastric wall is dissected from the anterior wall of the PPC;[18] however, this technique has not been reported in the management of PPC in children before. When compared to the LTGC approach, this technique avoids an anterior gastrotomy and suture line, aids in an enhanced vision of the PPC, and facilitates a greater anastomotic length to the cystogastrostomy, thus mitigating anastomotic stenosis.[19] Oida et al., while comparing the efficacy of the LRGC with open cystogastrostomy in an adult series of 28 patients, have demonstrated superior operative time, less blood loss, shorter postoperative hospitalization, and lesser recurrence with the retrogastric approach.[20]

The duration of surgery in this series is longer than the open surgery performed by the same authors for similar patients. This could be largely due to the learning curve of this procedure. In our study, there was one patient who developed recurrence of the pseudocyst and is awaiting a repeat surgery. The overall success of the outcomes in this study is comparable to that of a larger multicentric one with 13 children, where we report a PPC resolution rate of 88% as against 92%.[3] Thus, LCG offers all the benefits of minimal access surgery in children including excellent visualization, negligible blood loss, minimal pain, and early discharge to home.

CONCLUSION

LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, where indicated, is a safe approach with a comparable outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.