The treatment focus of psedo pancreatic cyst is shifting slowly in to minimally invasive procedures and the scientific data is assuring it's long standing future with good results.

1. Laparoscopic Management Of
Pseudocyst Pancreas
Dr.Varun Raju.Thirumalagiri
D.N.B ( Surgery) FMAS,FIAGES,FALS (HPB)
H.O.D Surgery – ST Hospital
Course director Laparoscopic surgery –IMA-AMS
Senior Consultant Laparoscopic ,G.I ,General & Bariatric Surgeon
TVR LAPAROSCOPY CENTER
Hyderabad

2. Revised Atlanta Classification -2016
Interstitial edematous pancreatitis (IEP)
Acute peripancreatic fluid collections (APFCs)
Acute necrotic collections (ANCs)
walled-off necrosis (WON)
WOPN can occur in locations similar to those
of pseudocysts; however, WOPN requires
intervention more often for systemic
symptoms or failure to thrive, recurrent fevers,
or infection.

3. Pseudocyst .Axial CT image obtained 6 weeks
after onset of gallstone pancreatitis shows a
large homogeneous fluid collection in the
lesser sac (*) with no non liquefied
components and a thick enhancing wall
(arrows), findings that are consistent with
pseudocyst.

4. Indications
Beyond 6 weeks
– Size not a criteria
– Symptoms are very important
– Progressively increasing in size after 6 weeks
6 cm more likely to need intervention
Complications- Jaundice, GOO, Infection and bleeding
Wall maturity
6-7 mm wall thickness
Well defined collection with a well defined wall
More important CJ than CG

5. TIMING OF THE DRAINAGE
• A pseudocyst that occurs
after an episode of alcohol related pancreatitis has
to be observed
for 4 to 6 weeks
with regular follow up and ultrasound examinations of
the abdomen.
• After 6 weeks,
observation should continue if the size of the cyst is
less than 6cm and the patient is asymptomatic or if
there is decrease in size.

6. Selection ■ Cystogastrostomy
• Adherent to the posterior wall of the stomach,
i.e., the posterior wall of the stomach forms
the anterior wall of the pseudocyst

7. Contraindications ■ Cystogastrostomy
• Pseudocyst in the head or tail of the pancreas not
adherent to stomach, or a pseudocyst that
bulges through the transverse mesocolon only
partially adherent to the stomach
• When the surgeon is not entirely certain that
the cystic mass is a pseudocyst of the pancreas
• Grossly infected pseudocysts

9. Laparoscopic Cysto-Gastrotomy
Operative procedure
• With the transgastric approach, access to the posterior gastric wall
is established through an anterior gastrostomy.
• A needle is introduced to confirm the location of the PPC and to
sample the fluid.
• The ultrasonically activated scalpel is used to create a stoma *4–5
cm in size between the adherent posterior gastric wall and the
anterior wall of the PPC.
• Hemostatic sutures were placed between the posterior gastric
wall and the anterior cyst wall/ Stapler is used .
• The cyst cavity was examined and all the necrotic material is
debrided followed by irrigation through a nasogastric tube
previously placed within the cyst.
• Intracorporeal sutures were used to close the anterior
gastrostomy.
• The peritoneal cavity is lavaged and a drainage tube placed

10. Video

11. Advantages of Lap.Cysto Gastrostomy
• wider stoma (for adequate drainage), possibility
of necrosectomy,low postoperative infection
and recidivation rates.
• Al though laparoscopic management has been
reported with very encouraging results, long-
term follow-up has still to show equivalence to
open surgery
Aghdassi A, Mayerle J, Kraft M, et al. Diagnosis and treatment ofpancreatic
pseudocysts in chronic pancreatitis. Pancreas 2008;36: 105-12.

12. Selecting■Cystojejunostomy
• A pseudocyst not adhering to the posterior
gastric wall in any location in the pancreas
*head, *body, or *tail or Pseudocysts that
bulge through the *transverse meso colon
• Multiple pseudoscyts

13. ■ Cystojejunostomy: Contra indications
• Pseudocysts more amenable to
cystogastrostomy or cysto duodenostomy
• Immature wall
• Infected and sepsis – external drainage better

14. Laparoscopic Cysto-jejunostomy
• Laparoscopic cystojejunostomy is performed with three or four
ports in a similar fashion as for laparoscopic cystogastrostomy.
• Patient Position- modified lithotomy position with legs split apart.
• Surgeon Position- Stands in between the legs,Camera surgeon on
left side,1st assistant on right side
• Port Position- 5 mm port at Rt hypochondrium.
• 10 mm port above the umbilicus and Rt Hypochondrium.
• Gastocolic ligament is divided (depending on cyst position).
• Pseudocyst defined.
• Roux-en-y jejunal loop is brought out through the mesenteric
window and cystojejunostomy performed.
• Window closed , Jejuno-jejunostomy done.
• A drainage tube is kept in the left paracolic gutter.

15. VIDEO

16. CYSTOJEJUNOSTOMY-AN IDEAL TREATMENT FOR PANCREATIC PSEUDOCYST LOCATED
DISTANT TO THE STOMACH
C Palanivelu, MS, MCh, FACS, P Sethilnathan, MS, R Parthasarathi, MS, P Praveen Raj,
MS, Vp Nalankilli, MS, S Sumonth, MS. GEM Hospital & Research Centre, Coimbatore,
INDIA.
• Conclusion :- Laparoscopic cystojejunostomy
is a good procedure for pancreatic
pseudocysts not in apposition of stomach or
the duodenum. It is safe,effective and allows
patient an early resumption of their normal
activities

17. Laparoscopic Cystojejunostomy For Pseudocyst Of Pancreas: Which One is
Better Suture Or Stapler?
Manash Ranjan Sahoo*
Department of Surgery, S.C.B Medical College, Cuttack, Odisha, India
Published June 30, 2015. Pancreatic Disorders & Therapy
• Conclusion
This trial found that laparoscopic suture cystojejunostomy
is a safe and feasible procedure and gives superior results
in regards to safety of anastomosis and its resultant
morbidity.
Suture cystojejunostomy is also comparable and in some
parameters better than stapler cystojejunostomy.

18. VIDEO

19. Indication ■ Cystoduodenostomy
• A pseudocyst of the head of the pancreas
anatomically placed so that only a
cystoduodenostomy is possible

21. Post procedure follow-up
• A fixed analgesia protocol with intravenous non-
• narcotic(ketorolac tromethamine 30 mg) is used twice
daily.
• An opioid (Pethidine hydrochloride 50 mg) added
when the pain cannot be tolerable.
• Tube will be removed on the first postoperative day
and oral diet will be started after the bowels moved.
• During postoperative follow-up, the patients are
evaluated by clinical examination and ultrasound of the
abdomen after 15 days, 1 month, 3 months, 6 months,
and yearly thereafter.

22. Primary success
• Primary success was defined as clinical or radiographic cyst
resolution after the index intervention.
• Overall success is defined as clinical or radiographic cyst resolution
at the last clinical follow-up assessment regardless of the number
of trial or methods of intervention.
• Length of hospital stay is defined as the time from the day of
treatment to the day of discharge.
• Treatment failure was defined as conversion from one to another
modality or repeated intervention
Zhao X, Feng T, Ji W. Endoscopic versus surgical treatmentfor pancreatic pseudocyst. Dig Endosc
2016;28:83–89

23. Re-intervention
• Re-intervention was defined as the need for repeat intervention due to
persistent symptoms in association with a residual pseudocyst that was not
less than half of the original size on follow-up imaging.
• Recurrence was defined as new-onset abdominal pain in the presence of a
pancreatic fluid collection on CT imaging after complete resolution.
• Postoperative morbidity and mortality included all complications or deaths
that developed within 30 days of intervention
• Varadarajulu S, Bang JY, Sutton BS, Trevino JM, ChristeinJD, Wilcox CM. Equal efficacy of endoscopic
and surgicalcystogastrostomy for pancreatic pseudocyst drainage in arandomized trial.
Gastroenterology 2013;145:583–590
• Dindo D, Demartines N, Clavien P-A. Classification ofsurgical complications: A new proposal with evaluation ina
cohort of 6336 patients and results of a survey. Ann Surg2004;240:205

24. Median operating time
• The median operating time of laparoscopic drainage wass ignificantly
shorter than that of open drainage.
• There are no available data in the literature regarding the operative time
of endoscopic drainage, whereas the operative time ranged from 60 to 305
minutes (mean, 152) for the laparoscopic drainage.
Aljarabah M, Ammori BJ. Laparoscopic and endoscopicapproaches for drainage of pancreatic
pseudocysts: A sys-tematic review of published series. Surg Endosc 2007;21:1936–1944

25. Hospital stay
• A recent meta analysis reported that the endoscopic group experienced an
evidently shorter length of hospital stay than did the surgical group.
• Also a recent systemic review revealed that the mean postoperative
hospital stay was 5.7 days(range, 2–32 days), in laparoscopy
versus 4.5 to 5 days in endoscopy.

26. Recurrence rate
• A recent meta-analysis reported the overall
recurrence rate was 3.1% in the endoscopic
group and 3.2% in the surgical group with no
statistical significance.11
Zhao X, Feng T, Ji W. Endoscopic versus surgical treatment for pancreatic
pseudocyst. Dig Endosc 2016;28:83–89

27. Open Vs Laparoscopy
• In a systematic review of the literature, laparoscopic
drainage was associated with low morbidity, rapid
recovery,and recurrence rates comparable to those reported
by open surgery
Hamza N, Ammori BJ. Laparoscopic drainage of pancreaticpseudocysts: a methodological approach. J
Gastrointest Surg2010; 14: 148-55
Kurnicki J, Świątkiewicz J, Wrzesińska N, et al. Laparoscopic treat-ment of a huge mesenteric
pseudocyst – case report. Video-surgery Miniinv 2011; 6: 167-72

28. Open Vs Laparoscopy
• Although laparoscopic management has been
reported with very encouraging results, long-
term follow-up has still to show equivalence
to open surgery
Aghdassi A, Mayerle J, Kraft M, et al. Diagnosis and treatment ofpancreatic
pseudocysts in chronic pancreatitis. Pancreas 2008;36: 105-12

29. Ref. Design Studyduration Follow-up duration1 Interventions Sample size Pseudocyst defined
Inclusion criteria or
indicationsfor
intervention
Varadarajulu et al[8]
(United States)
Single center RCT Jan 2009-Dec 2009 24
EUS vs open
cystogastrostomy
20:20 Yes
Pseudocyst > 6 cm and
adjacent to stomach
History of acute or chronic
pancreatitis
Persistent pain
Complications of
pseudocyst
Melman et al[9] (United
States)
Single center retrospective Mar 1999-Aug 2007 9.5
EUS vslaparoscopic vsope
n cystogastrostomy
45:16:22 Yes Symptomaticpseudocyst
Varadarajulu et al[10]
(United States)
Single center retrospective Jul 2005-Jun 2007 24
EUS vs Open
cystogastrostomy
20:10 Yes NA
Park et al[11] (South
Korea)
Single center RCT Jan 2004-Dec 2007 25 - 27 EGD ± R-EUS vsEUS 29:31 Yes
Symptomaticpseudocyst >
4 wk
Varadarajulu et al[12]
(United States)
Single center RCT May 2007-Oct 2007 NA EGD vs EUS 15:15 Yes
Symptomaticpseudocyst >
4 wk
Kahaleh et al[13] (United
States)
Single center retrospective 2000-2005 11 EGD vs EUS 53:46 Yes NA
Morton et al[14] (United
States)
National multicenter
retrospective
Jan 1997-Dec 2001 NA
Percutaneous vsSurgical
drainage
8121:6409 Yes NA
Heider et al[15] (United
States)
Single center retrospective 1984-1995 NA
Percutaneous vsSurgical
drainage
66:66 Yes NA
Adams et al[16] (United
States)
Single center retrospective 1965-1991 NA
Percutaneous vsSurgical
drainage
52:42 No
Percutaneous drainage:
Symptomatic pseudocyst >
5 cm without PD dilation
Lang et al[17] (United
States)
Single center retrospective Jan 1978-Jun 1988 NA
Percutaneous vsSurgical
drainage
12:14 Yes Wall thickness < 3 mm
World J Gastrointest Endosc. Mar 25, 2016;
8(6): 310-318
Published online Mar 25, 2016. doi:
10.4253/wjge.v8.i6.310
Systematic review comparing endoscopic,
percutaneous and surgical pancreatic
pseudocyst drainage

30. Endoscopic ultrasound vs surgical
drainage of pancreatic pseudocysts
Ref. Sample size Size (cm)
Clinical
success
Hospital
stay (d)
Reinterventi
on
Mortalities
Adverse
events
Bleeding
Intra-
abdominal
infection
Varadarajulu
et al[8]
EUS: 20
10.5 (9-
14.9)1
95% 2 (1-4)13 5% 0 0 0 0
Open: 20
11 (8.4-
14.5)1
100% 6 (5-9)1 5% 0 2% 1 0
Melman et
al[9]
EUS: 45 9.1 (0.4) 51.1%2 3.9 (0-25)2 - 0 15.6% 2.2% 0
Lap: 16 10.4 (0.5) 87.5% 6.9 (3-23)2 - 0 25% 12.5% 0
Open: 22 9.5 (0.8) 81.2% 10.8 (4-82)2 - 0 22.7% 0 0
Varadarajulu
et al[10]
EUS: 20 9.8 95% 2.6 (1-11)23 0 0 0 0 0
Open: 10 8.9 100% 6.5 (4-20)2 10% 0 0 0 0

31. Percutaneous vs surgical drainage of
pancreatic pseudocysts.
Ref. Sample size Size (cm)1
Clinical
success
Hospital stay
(d)1
Reinterventio
n
Mortalities
Adverse
events
Bleeding
Intra-
abdominal
infection
Morton et
al[14]
Perc: 8121 - - 21 (22)2 5.9%2 - 9.64%2 6.8%2
Surg: 6409 - - 15 (15) 2.8% - 8.96% 4.54%
Heider et
al[15]
Perc: 66 8.2 (1.1) 42% 45 (5) 50% 9.1% 64%2 9.1% 45.5%
Surg: 66 7.4 (1.3) 88% 18 (2) 12% 0 27% 4.5% 15.2%
Adams et
al[16]
Perc: 52 - - 36.7 9.5% 2 7.7% 1.9% 1.9%
Surg: 42 - - 39.8 19.2% 7.1% 16.7% 4.8% 4.8%
Lang et al[17] Perc: 26 - 76.9% - 11.5% 3.8% 3.8% 3.8% 0
Surg: 26 - 73.1% - 23.1% 3.8% 0 0 0
Systematic review comparing endoscopic, percutaneous and surgical pancreatic
pseudocyst drainage
Anthony Yuen Bun Teoh, Vinay Dhir, Zhen-Dong Jin, Mitsuhiro Kida, Dong Wan Seo, Khek
Yu Ho

32. Conclusion
• Treatment of PPC is in an era of re - evaluation.
• Relatively new and minimally invasive techniques have been introduced as alternatives to the standard
conventional open surgical management.
• Endoscopic procedures have been increasingly used with excellent results.
• Laparoscopic approach, although difficult, appears to be promising.
• However, large-scale comparative studies of the three different therapeutic modalities are highly
recommended.
• ~50% of pancreatic pseudocysts regress spontaneously
• Treatment is indicated for complicated or symptomatic pseudocysts or chronic pseudocysts >5cm
• Need to exclude malignancy
• Transpapillary drainage favoured for communicating Pseudocysts
• Endoscopic and laparoscopic approaches have comparable results with lower morbidity and mortality
compared with open surgery

33. •Thank you !
Website- www.drvarunraju.com
Phone - 9866159160