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Comparison of surgical outcome between conventional laparoscopic cystogastrostomy method and plication of the edge of anterior gastrotomy in patients with pancreatic pseudocyst: A retrospective study at two tertiary care centres
Prabhas Naik1, Manash Ranjan Sahoo1, Jyotirmay Nayak2
1 Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 SCB Medical College and Hospital, Cuttack, Odisha, India
|Date of Submission||02-Sep-2020|
|Date of Decision||29-Oct-2020|
|Date of Acceptance||23-Nov-2020|
|Date of Web Publication||03-Feb-2021|
Manash Ranjan Sahoo,
Professor & Head, Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
Background: In retro-gastric Pancreatic pseudocyst (PP) Laparoscopic cystogastrostomy (LCG) is an established procedure of drainage.
Aims and Objectives: To compare surgical outcome between laparoscopic cysto-gastrostomy conventional method and plication of the edge of anterior gastrotomy in patients of pancreatic pseudocyst.
Materials and Methods: Twenty six patients were underwent LCG from 2010-2020 by a single surgeon. Both the conventional LCG group Group-1(Gr-1) and the plication group Group-2 (Gr-2) where plication of edge of anterior gastrostomy was performed, contained 13 patients each.
Results: The numbers of male/female in Gr-1 was 9/4 and that in Gr-2 was 10/3 (P = 1). Mean ages of patients were 45.3 ± 10.4 years (range 23-60) in Gr-1 and 48.0 ± 12.3 years (range 27-65) in Gr-2. Etiological factors were alcohol (46.1% in Gr-1, 53.8% in Gr-2), gallstone disease (38.4% in Gr-1,15.3% in Gr-2), trauma (15.3% in each groups), idiopathic cause (15.3% in Gr-2). The cyst size was 9.0 ± 1.5 cm in Gr-1and 8.9 ± 2.1cm in Gr-2. The mean operative time in Gr-1 (107.6 ± 12.5 minutes) was longer than Gr-2 (97 ± 1 3.6 minutes) (P = 0.06). The size of cystogastric anastomosis in Gr-1 was 4.6 ± 0.7 cm and that in Gr-2 was 4 ± 0.8 cm (P = 0.04). The intra-operative blood loss in Gr-1 and Gr-2 were 101.9 ± 21.7ml and 78.4 ± 30.7 ml respectively. There was a significant change in intraoperative blood loss and stoma size in Gr-2. The postoperative complications were managed conservatively. No recurrence over a period of 18 months of follow-up.
Conclusion: Plication of edges of anterior gastrostomy result in reduction in operative time, smaller anastomosis without complication and less intra-operative blood loss.
Keywords: Anterior gastrotomy, cystogastrostomy, plication, pseudocyst
|How to cite this URL:|
Naik P, Sahoo MR, Nayak J. Comparison of surgical outcome between conventional laparoscopic cystogastrostomy method and plication of the edge of anterior gastrotomy in patients with pancreatic pseudocyst: A retrospective study at two tertiary care centres. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 15]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=308675
| ¤ Introduction|| |
Pancreatic pseudocyst (PP) is a localised collection of fluid surrounded by a wall of fibrous tissue without a true epithelium. It commonly develops due to pancreatic ductal disruption caused by acute or chronic pancreatitis. The prevalence of PP ranges from 6% to 18.5% in acute pancreatitis and 20% to 40% in chronic pancreatitis.,, PP can be managed conservatively, percutaneous or endoscopic drainage, or surgically depending on the size of the cyst, duration of symptoms and/or the presence of complications. The surgical intervention may include total excision, internal or external drainage. In recent years, laparoscopic internal drainage such as cystogastrostomy (CG), cystojejunostomy (CJ) and cystoduodenostomy is preferred depending on the size and location of the cyst.
Here, we present a retrospective, comparative study to determine how plication of edge of anterior gastrostomy (AG) during the procedure of laparoscopic anterior CG (LCG) gives better result over the conventional (non-plication) procedure of LCG.
| ¤ Materials and Methods|| |
Sixty-two patients with PP were operated between 2010 and 2020 by a single surgeon in two tertiary care academic institutes (2010–2018 and 2018–2020). Out of the 62 patients, 26 underwent LCG, 21 underwent laparoscopic CJ, 10 underwent open procedure (7 CJ and 3 CG) and 5 underwent external drainage. The 26 patients who underwent LCG were divided into two groups. The Group-1 (Gr-1) contained 13 patients, where conventional LCG had been done. The Group-2 (Gr-2) also had 13 patients where the edge of the AG was plicated.
PP was diagnosed by clinical and radiological examinations (ultrasound, computed tomography scan and magnetic resonance cholangiopancreatography). Demographic data such as age, gender, aetiology and radiological findings (size, number and location) of the study groups were collected. In all cases in the study groups, it was single PP, located in the retro-gastric region adhered to the posterior wall of the stomach. All patients were planned for surgery with a minimum interval of 2 months after the incidence of their aetiological factors.
The operative time, stoma size of CG, intraoperative blood loss and post-operative complications between the two surgical groups were compared.
All patients were operated under general anaesthesia with the patient in a modified lithotomy position, that is the operating surgeon standing between the legs of the patient, the first assistant holding the camera on the right side of the patient and the second assistant standing on the left side of the patient. The monitor was placed at the head end of the patient. Pneumoperitoneum was created using a Veress needle. The port position (a 10-mm camera port and two 5-mm working ports) is shown in [Figure 1]a. A 5-cm gastrostomy of the anterior stomach wall was performed by a harmonic scalpel [Figure 1]b. An appropriate-sized posterior CG was planned so that adequate drainage and debridement of necrotic tissues could have been done. All the fluid contents inside the cyst were aspirated, necrotic tissues were debrided and a sample of pseudocyst wall was sent for pathological analysis. Cystogastric anastomosis was performed with two continuous interlocking sutures of ethilon (nylon) 48-mm needle [Figure 2]a running in opposite direction, that is one starting from 3 o'clock position to 9 o'clock position and another from 9 o'clock to 3 o'clock position to avoid purse string effect and better haemostasis. The tip of a nasogastric tube was placed inside the cyst.
|Figure 1: Intraoperative image showing position of the port (a), anterior gastrostomy (b), bite taken from the anterior gastrostomy (c), plication of the edge of anterior gastrostomy without tension (d)|
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|Figure 2: Intraoperative image showing cystogastric anastomosis with ethilon 48-mm needle (a), closure of the anterior gastric wall (b)|
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In Gr-2 also, most of the steps were similar to that of Gr-1 except that we had added a step after AG, that is plicating the edge of the AG with the stomach wall to improve visibility and exposure. A seromuscular bite was taken from the greater curvature side till it includes the edge of the gastrotomy [Figure 1]c and tied without tension [Figure 1]d. Three to four such plicating sutures were taken on both sides of the gastrotomy. This made the posterior stomach wall exposed and kept the gastrostomy open during the rest of the procedure. After CG, the plicated sutures were removed and AG was closed in a running continuous suture [Figure 2]b. An abdominal drain was placed and all ports were closed.
In most of the patients, the post-operative course was uneventful. The complications are presented in [Table 1] and were managed conservatively. The nasogastric tube was removed on post-operative day (POD)-1 and the drain was removed on POD-3. Oral liquid was started on POD-1. All patients were discharged on POD-5 to POD-7. Follow-up ultrasound was done in 3, 6, 12 and 18 months in all patients, showing no recurrence.
Data processing and analysis was done using SPSS Statistics version 25.0 (Statistical Production and Service Solution for Windows, IBM Corp., Armonk, New York, USA). Normally distributed quantitative data were analysed using Student's t-test and represented as mean (standard deviation). Skewed continuous variables represented as median (interquartile range) were analysed using Mann–Whitney U-test. Qualitative data were analysed using Pearson's Chi-square test and Fisher's exact test and were expressed in frequency (proportion). Differences were considered statistically significant when P < 0.05.
| ¤ Results|| |
Details of the patient characteristics included in our study are summarised in [Table 2]. In both the groups, there was a male predominance: 69.2% in Gr-1 and 76.9% in Gr-2. The mean ages of the patients were 45.3 ± 10.4 years (range 23–60) in Gr-1 and 48.0 ± 12.3 years (range 27–65) in Gr-2. Alcohol was the main aetiological factor in both groups (46.1% in Gr-1 and 53.8% in Gr-2). Other aetiological factors associated were gallstone disease (38.4% in Gr-1 and 15.3% in Gr-2), and trauma (15.3% in both the groups). Besides this, 15.3% of the patients in Gr-2 had idiopathic causes. In Gr-1, the cyst size was 9.0 ± 1.5 cm (range 7–11.5 cm), and in Gr-2, it was 8.9 ± 2.1 cm (range 6.5–13 cm).
The comparative surgical outcome is presented in [Table 1]. The operative time in Gr-2 (97 ± 13.6 min) was less than that of Gr-1 (107.6 ± 12.5 min), with P = 0.06. The size of cystogastric anastomosis in Gr-2 (4 ± 0.8, range 3–5 cm) was smaller than that of Gr-1 (4.6 ± 0.7, range 4–6 cm), P = 0.04, which is statistically significant. There was a significant reduction in intraoperative blood loss, in Gr-2 (78.4 ± 30.7 ml, range 40–150 ml) than in Gr-1 (101.9 ± 21.7 ml, range 75–150 ml), with P = 0.03. The complication in Gr-1 included haematemesis, chest infection and abdominal distension and that in Gr-2 included chest infection, as shown in [Table 1]. None of the cases were converted to open procedure and the mortality is zero.
| ¤ Discussion|| |
In our study, the surgical outcome in Gr-2 is better in terms of less operative time, need for small anastomosis and less intraoperative blood loss. There was no major complication in either group with a zero recurrence rate in a follow-up period of 18 months.
The important aetiological factors in both the groups were alcohol, gallstone disease, trauma and idiopathic cause. According to Walt et al., the associated factors for PPs are alcohol (70%), biliary tract disease (8%), blunt trauma (5%), penetrating trauma (1%) and idiopathic cause (16%). In various published articles, alcohol has been reported to be the main aetiological factor for PP., Spontaneous resolution of PP occurs in up to 85% of cases. Cyst size >6 cm, beyond 6 weeks of duration, is more likely to persist and may develop complications.
In the study, the cyst size was >6 cm in all cases and operated after a minimum period of 2 months after the incidence of aetiological factors, which gave the cyst wall adequate time to mature. LCG with anterior approach is very much convenient for retrogastric PP. The cystogastric anastomosis could be done by using a suture or a stapler. We preferred suture over stapler anastomosis as there is more chance of leak in cystoenteric anastomosis using stapler. Again, the inflammatory capsule may be very thick and getting a good haemostasis after crushing and stapling may be difficult, hence some surgeons practice to take a haemostatic suture even after stapler anastomosis. Hence, to avoid the risk of anastomotic leak and bleeding, we had done suture anastomosis in all cases. In most of the cases, we had used nylon with a 48-mm half-circle-round body needle. Performing anastomosis with 48-mm needle was more comfortable in taking bites on the posterior stomach wall and the thick wall of the cyst together.
While doing LCG in Gr-1, after AG, there was a bulge over the posterior wall of the stomach due to compression of the cyst, keeping the AG wound open [Figure 1b]. After aspiration of the cystic fluid, the cyst collapsed and both the edges of AG tend to fall over the wound. Effort was required to retract the edges of the AG while doing necrosectomy and cystogastric anastomosis. Again, while doing anastomosis, we were cautious not to take bite in the anterior wall of the stomach. Even surgeons performing stapler anastomosis are also attentive not to pick up the anterior wall of the stomach while firing the stapler. Hence, to overcome these problems, we just plicated both the edges of anterior gastrotomy to improve visibility and exposure, as described in the surgical technique, and got a comparable result in Gr-2.
With better surgical access and exposure, the operating time decreased to 97 ± 13.6 min in Gr-2 as compared to 107.6 ± 12.5 min in Gr-1. Although the data were statistically not significant (P = 0.06), the surgeon felt more comfortable in doing the procedure in Gr-2. The average operating time in the study by Šileikis et al. was 145 ± 37.6 min. The median operating time by Khaled et al. was 62 min, ranging between 25 and 350 min.
A small CG is associated with early closure and recurrence of PP. In a study by Atabek et al., there was recurrence of PP with a CG of size 1.5 cm. According to Hauters et al., a size of 2 cm of CG is associated with early closure and secondary infection of PP. Hence, a wide CG is required to minimise the risk of early stoma closure and recurrence. However, to date, there are no precise criteria to define a wide CG. The stomach wall was highly vascular, and also in some cases, the author had encountered pulsatile bleeding during cutting the cyst wall, which was difficult to manage. Large CG refers to more muscle cutting, more risk of bleeding and also increased chances of infections. In our experience, an anastomotic stoma sized 3 cm or more is enough with a zero recurrence rate and without major post-operative complications. This is also supported by few published articles., The result in the size of the stoma in our study was also statistically significant (P = 0.04).
The intraoperative blood loss was 78.4 ± 30.7 ml in Gr-2 as compared to 101.9 ± 21.7 ml in Gr-1 (P = 0.03). In a study by Aljarabah and Ammori, the mean operative blood loss was 89 ml, which ranged from 30 to 350 ml. The reduction of intraoperative blood loss in Gr-2 indicates that working in a well-exposed surgical field leads to better haemostasis. Again, during plication of edge in the greater curvature side, there is a chance of injury to the right gastro-epiploic vessels. However, in our study, we had not faced this problem.
In our study, the post-operative complications were haematemesis, abdominal distension and chest infection, as shown in Table 1, and were managed conservatively. There was no major complication such as bleeding, anastomotic leak or infection.
There are few limitations to our study. As this is a retrospective study, few data such as thickness of cyst wall were not available in the initial part. Thickness of the cyst wall was the factor for the use of the 48-mm needle in the anastomosis in our study. We had performed a cystogastric anastomosis sized 3 cm in 5 out of 26 patients (19.2%) without any complication and recurrence. However, we feel that the sample size is not large enough to document a minimum ideal size for cystogastric anastomosis.
| ¤ Conclusions|| |
Plication of margins of AG increases access, visibility and exposure during surgery and a better outcome in the form of reduction in operative time, smaller anastomosis without complication and less intraoperative blood loss.
- Surgical outcome is better in a well-exposed surgical field, which is the basic principle of surgery that can be easily achieved by plication during anterior CG
- A 3-cm CG anastomosis is sufficient for adequate drainage without recurrence, avoiding the need for a larger anastomosis
- In suture anastomosis, there is a good control on bleeding
- In a thick cystic wall, the anastomosis can be comfortably done with a 48-mm needle.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]