Laparoscopic Roux-en-Y pancreatic cyst-jejunostomy

Robotic-assisted sleeve gastrectomy with simultaneous Roux-en-Y cystojejunostomy in a patient with sever obesity and a pancreatic pseudocyst: a case report

Introduction

We tried to apply a new surgical method to treat obesity combined with pancreatic pseudocyst and achieved satisfactory results.

Case and presentation

We report a case of a severely obese patient with pancreatic pseudocyst who underwent robotic-assisted sleeve gastrectomy, while the pseudocyst was incised and cyst-jejunostomy was performed. The operation was successful, and the patient was discharged on the 8th day after the procedure. There were no complications during the perioperative period. After 12 months of follow-up examinations, the patient's pancreatic pseudocyst disappeared. Additionally, there was a significant decrease in body weight, body mass index, and other indicators. As a result, obesity and related metabolic diseases were completely relieved.

Conclusions

This case summarizes and presents the experience of using robotic bariatric surgery for the treatment of pancreatic pseudocyst. This case report indicates that this surgical procedure is both safe and effective for patients with pancreatic pseudocyst who also have obesity and related metabolic diseases.

Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach

INTRODUCTION

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution.

RESULTS

Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years.

CONCLUSION

Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.

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.

Systematic Review of Endoscopic Cyst Gastrostomy

Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents.

Endoscopic Management of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.

Laparoscopic versus open cystgastrostomy for pancreatic pseudocysts: a case-matched comparative study

BACKGROUND

Cystgastrostomy is the commonest method of internal drainage of pancreatic pseudocysts (PPs). While large and persistent retrogastric pancreatic pseudocysts are amenable to laparoscopic cystgastrostomy, the potential benefits of this minimally invasive laparoscopic approach over open surgery remain to be demonstrated. The aim of this study was to compare the outcomes of the laparoscopic and open approaches for cystgastrostomy.

METHODS

Patients who underwent laparoscopic cystgastrostomy (LCG) were matched on a 3:1 basis to those who underwent open cystgastrostomy (OCG) according to age, sex distribution, and size of pseudocyst. The outcomes of the two approaches were compared on an intention-to-treat basis. Data shown represent medians.

RESULTS

A total of 54 patients underwent cystgastrostomy (35 LCG, 19 OCG) between 1997 and 2011. The final case matched cohort consisted of 40 patients (12 female and 28 male) of which 30 underwent LCG (two converted to open surgery) and 10 underwent OCG. The laparoscopic and open groups were comparable for age (55 vs. 59 years, P = 0.80), sex distribution, and size of pseudocyst (10 vs. 13 cm, P = 0.51). The laparoscopic approach had a significantly shorter operating time (62 vs. 95 min, P = 0.035) and carried a significantly lower risk of postoperative morbidity (10% vs. 60%, P = 0.024) and shorter postoperative hospital stay (6.2 vs. 11 days, P = 0.038). There was one operative death after OCG (10%).

CONCLUSION

The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a shorter operating time, smoother and more rapid recovery, and a shorter hospital stay compared with open surgery. The laparoscopic approach should be considered the preferable approach where expertise is available.

[Therapy of pancreatic pseudocysts: endoscopy versus surgery]

Pancreatic pseudocysts are frequent complications following acute and chronic pancreatitis as well as abdominal trauma. They originate from enzymatic and/or necrotizing processes within the organ involving the surrounding tissues through inflammatory processes following pancreatic ductal lesion(s). Pseudocysts require definitive treatment if they become symptomatic, progressive, larger than 5 cm after a period of more than 6 weeks and/or have complications. Cystic neoplasms must be excluded before treatment. Endoscopic interventions are commonly accepted first line approaches. Should these fail or not be feasible surgical procedures have been well established and show comparable results. In summary, pancreatic pseudocysts require a reliable diagnostic approach with a multidisciplinary professional management involving gastroenterologists and surgeons.

Minimally invasive treatment of pancreatic disease

Minimally invasive surgery has been widely accepted as an alternative to conventional open surgery in many gastrointestinal fields and is now considered the standard of care in bariatric surgery as well as oncologic surgery of the colon and stomach. Despite the advancements in laparoscopic surgery instrumentation and technique, the anatomic relationships of the pancreas and the need for complex reconstructions have slowed similar progress in management of pancreatic disease. However, numerous recent studies show promising results in laparoscopic management of pancreatic pseudocyst, necrosis, and benign and malignant pancreatic neoplasms. We present the current status of clinical application of minimally invasive techniques for the treatment of complicated pancreatitis, chronic pancreatitis, and pancreatic neoplasms, and provide a review of the relevant literature. Present day and probable future developments, such as the use of robotics, natural orifice techniques, and major vascular reconstruction are also presented.

Open cystogastrostomy, retroperitoneal drainage, and G-J enteral tube for complex pancreatitis-associated pseudocyst: 19 patients with no recurrence

INTRODUCTION

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.

MATERIALS AND 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.

CONCLUSION

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.

Laparoscopic drainage of pancreatic pseudocysts: a methodological approach

BACKGROUND

This paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts (PPs) based on an anatomical classification.

METHODS

We adopted the laparoscopic approach in "all comers" who had PPs requiring surgical drainage. The recipient organ for drainage (e.g., cystgastrostomy, cystjejunostomy, or cystduodenostomy) and method of access (e.g., transgastric, endogastric, exogastric or lesser sac, and infracolic) were decided based on preoperative computed tomography (CT) and intraoperative findings. The results shown represent median (range).

RESULTS

Between 2001 and 2009, 30 laparoscopic drainage procedures for PPs were performed in 28 consecutive patients. The surgical approach included transgastric (n = 17) or endogastric (n = 3) cystgastrostomy for large retrogastric PPs (n = 20), exogastric cystgastrostomy for small perigastric PPs (n = 4), cystduodenostomy (n = 1) under ultrasound guidance, cystjejunostomy for infracolic PPs (n = 4), and one external drainage. The operative time was 118 (25-300) min. There was one conversion to laparotomy (3.3%), low morbidity (3.3%), and no mortality. The postoperative hospital stay was 2 (1-7) days. At a follow-up of 15 (1-48) months, PPs recurred in two patients (7.1%) and were drained by laparoscopic cystgastrostomy.

CONCLUSION

CT findings and laparoscopic exploration demonstrate the anatomical characteristics of PPs and enable successful planning and execution of their laparoscopic drainage.

Should all distal pancreatectomies be performed laparoscopically?

Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.

Pancreatic pseudocysts: observation, endoscopic drainage, or resection?

BACKGROUND

Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis. They are diagnosed with imaging studies and can be treated successfully with a variety of methods: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, laparoscopic surgery, or open pseudocystoenterostomy.

METHODS

Relevant publications that appeared from 1975 to 2008 were retrieved from the MEDLINE, PubMed and EMBASE databases for this review.

RESULTS

Endoscopic pseudocyst drainage has a high success rate (79.2%) and a low complication rate (12.9%). Percutaneous drainage is mainly used for the emergency treatment of infected pancreatic pseudocysts. Open internal drainage and pseudocyst resection are surgical techniques with high success rates (>92%), but also higher morbidity (16%) and mortality (2.5%) than endoscopic treatment (mortality 0.7%). Laparoscopic pseudocystoenterostomy, a recently introduced procedure, is probably similar to the endoscopic techniques with regard to morbidity and mortality.

CONCLUSIONS

An interdisciplinary approach is best suited for the safe and effective stage-specific treatment of pancreatic pseudocysts. The different interventional techniques that are currently available have yet to be compared directly in randomized trials.

Surgical therapy of pancreatic pseudocysts

BACKGROUND

Pancreatic pseudocysts are a common complication associated with acute and chronic pancreatitis. Fifteen percent and 40% of patients diagnosed with either acute or chronic pancreatitis, respectively, develop pseudocysts (Grace and Williamson, Br J Surg, 80:573-581, 1993). The treatment of pancreatic pseudocysts has evolved since the early 1980s, and changes in management have lead to an improved understanding of the pathophysiology of pseudocysts as well as necessary treatment paradigms.

CONCLUSIONS

It has become evident that not all pseudocysts are equal. Pseudocysts arising in the setting of acute pancreatitis have a different pathophysiologic basis than those arising from chronic pancreatitis. Moreover, even those pseudocysts that arise in acute pancreatitis exhibit unique features. Pseudocysts that develop from a mild episode of pancreatitis, complicated by pancreatic duct disruption, differ significantly from those developed as a consequence of severe acute necrotizing pancreatitis with severe distortion of the pancreatic parenchyma or pancreatic duct. This review will focus on the surgical therapy of pancreatic pseudocysts in the context of the underlying pathophysiology and alternative nonoperative therapies.

Primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts

BACKGROUND

Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts.

METHODS

Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis.

RESULTS

There were no significant differences (p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m(2)), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1-40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher (p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy (n = 13), percutaneous drainage (n = 3), and repeat endoscopic drainage (n = 6).

CONCLUSIONS

Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.

Operative and nonoperative management of pancreatic pseudocysts

The management of pancreatic pseudocysts has changed greatly over the last decade. As laparoscopic and endoscopic techniques continue to evolve, their use in the treatment of pseudocysts has gained acceptance, whereas the role of percutaneous drainage has become more limited. The literature on laparoscopic, endoscopic, and percutaneous management of pancreatic pseudocyst is reviewed here and, based on these data, a treatment algorithm is suggested.

Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series

BACKGROUND

The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PPs) are the current minimally invasive management options. This article reviews the evidence available on their effectiveness.

METHODS

A computerized search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from 1974 to 2005.

RESULTS

A total of 118 and 569 patients featured, respectively, in 19 and 25 reports underwent 118 and 583 laparoscopic and endoscopic drainage procedures, respectively. Pancreatic pseudocysts were considerably larger in the laparoscopic series (mean, 13 vs. 7 cm; p < 0.0001). The success rates for achieving resolution of the PPs in the laparoscopic and endoscopic series were 98.3% and 80.8% respectively, with morbidity rates of 4.2% and 12% and mortality rates of 0% and 0.4%, respectively. During follow-up period (mean, 13 vs 24 months; p < 0.0001), PPs recurred for 2.5% of the patients in the laparoscopic series and 14.4% of the patients in the endoscopic series, and the reintervention rates were 0.9% and 11.8%, respectively.

CONCLUSIONS

The laparoscopic and endoscopic approaches to internal drainage of PPs are safe. Although laparoscopic drainage appears to carry a higher success rate and lower rates of morbidity and recurrence, the heterogeneity of the published reports and the varied follow-up periods limit direct comparisons. Data from longer follow-up periods and randomized comparative trials are needed.

Laparoscopic pancreatic resection: the past, present, and future

Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism, and neoplasms of the pancreas; e.g., insulinoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, etc. Laparoscopic pancreatic resections with an en bloc lymph node dissection have also been performed for invasive carcinomas. The long-term results after laparoscopic resections for invasive pancreatic cancer, however, are still not well defined. Laparoscopic distal pancreatectomies with or without spleen preservation may benefit patients with reduced postoperative pain, shorter hospital stay, a quicker recovery to normal activity, and better cosmetic appearances based on retrospective analyses of collective series and case reports. Prospective randomized controlled trials are needed to validate these benefits. In contrast, laparoscopic proximal pancreatectomies with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy and laparoscopic duodenum-preserving pancreatic head resection are technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences by highly skilled endoscopic surgeons. To justify the performance of laparoscopic proximal pancreatectomies, it is mandatory to demonstrate the potential clinical benefits and safety of these complicated procedures.

Minimally invasive treatment of pancreatic disease

Although open surgical procedures remain the standard for both benign and malignant diseases of the pancreas, in recent years a wide variety of surgical procedures performed on the pancreas have been completed laparoscopically. This article reviews the application of minimally invasive surgery to the management of both benign and malignant diseases of the pancreas.

Minimally invasive surgery of the pancreas in progress

BACKGROUND

Laparoscopic pancreatic surgery should be considered as an advanced laparoscopic procedure and should be performed only in institutions with experience in pancreatic surgery by a team with advanced laparoscopic skills.

AIM

This review discusses the current status of the laparoscopic approach for inflammatory pancreatic diseases and for benign-appearing pancreatic tumors.

RESULTS

Laparoscopic surgery has been shown to be beneficial in patients with inflammatory tumors located in the body-tail of the pancreas for chronic pancreatitis. Furthermore, patients with pancreatic pseudocysts may be managed with laparoscopic internal drainage (to the stomach, duodenum, or jejunum). Also, laparoscopic or retroperitoneoscopic necrosectomy has been used with success in patients with necrotizing pancreatitis. At present, laparoscopic surgery has proven to be beneficial in patients with cystic pancreatic neoplasms and neuroendocrine pancreatic tumors.

CONCLUSIONS

The laparoscopic pancreatic approach was recently shown to be feasible and safe. Laparoscopy may contribute to reduced operation time and perioperative blood loss, and reduces surgical stress because of developments in devices, improvements in procedures, and advanced techniques.