Minimally Invasive Open Cystogastrostomy for Giant Pancreatic Pseudocyst in Pediatric Patients

Abstract

Open cystogastrostomy is the standard treatment for the operative management of pancreatic pseudocysts. We describe our technique of minimally invasive open cystogastrostomy for giant pediatric pancreatic pseudocyst. Preoperative incision marking on the most prominent part of the pseudocyst was done by ultrasound guidance. A transverse incision of approximately 3-4 cm was made, and a minilaparotomy was performed. Stay sutures were applied on the anterior wall of the stomach. The anterior wall was exteriorized; transverse gastrotomy was performed, and superior and inferior flaps were made. Deaver's retractor was placed inside the lumen, and cystogastrostomy was completed. We employed this technique in five male patients without any complications. All patients were allowed clear liquids on postoperative day 4 or 5; and gradually shifted to a soft diet. The mean duration of postoperative stay was 7 days. The size of the scar ranged from 3 to 5 cm. All patients were doing well on follow-up. Our technique of minimally invasive open cystogastrostomy is a viable option for pancreatic pseudocyst in pediatric patients.

Keywords: Cystogastrostomy; minimally invasive; open; pancreatic; pediatric; pseudocyst; trauma.

Figure 1

Contrast-enhanced computed tomography (CECT) with both oral and intravenous contrast images of patients: (a) Axial section image (case A) showing a large 16.7 cm × 9.6 cm sized cyst in relation to the body of pancreas with 3 mm wall thickness. It is present in the lesser sac, pushing the stomach (nasogastric tube in situ) antero-laterally and causing displacement of the portal vein. It extends into the splenic hilum. (b) Coronal section image (case A) of the cyst in the supracolic compartment and extending into the paracolic compartment. The cyst is abutting the porta hepatis and pushing the stomach superolaterally. (c) Axial section images (case B) of a large (8.2 cm × 11.2 cm) sized, well-defined hypodense cystic lesion with internal echoes and septations in relation to the tail and body of the pancreas. The cyst is thick walled and abutting the celiac axis and superior mesenteric artery; encasement of the splenic artery is present. (d) Coronal section image (case C) of the cyst shows a large well-defined thin-walled (3 mm) cyst (15 cm × 10 cm × 9 cm) in close relation to the body of the pancreas) The cyst is pushing the bowel loops inferiorly, and transverse colon antero-superiorly. Clinical photographs of the patients with pseudocysts of the pancreas: (e) epigastric lump with nasogastric tube palpable per-abdominally. (f) Inset image showing a large epigastric lump causing bulging of the upper abdominal wall. (g) A 4-year-old boy with a large epigastric lump causing bulging of the anterior abdominal wall; the site marking of the incision site has been performed under ultrasound guidance. (h) Inset ultrasound image shows a large cystic lesion (11.1 cm × 8.4 cm) in the epigastrium having a cyst wall of 2.6 mm, arising in relation to the body of the pancreas. (i) Postoperative photograph shows a small scar with staples in place

Figure 2

Intraoperative photographs show (a) traction sutures on the edges of superior and inferior flaps of the stomach wall and stay sutures on the posterior wall. Langenbach’s retractors were placed inside the gastric lumen and the contents of the cyst were sucked with a suction cannula; (b) Cystogastrostomy completed and hemostasis checked. (c) Contents of cyst (>1500 mL) in suction apparatus. (d) Intraoperative photographs show (d) closure of the anterior gastric wall and (e) sheath closure