Laparoscopic Roux-en-Y Drainage of a Pancreatic Pseudocyst
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MINIMALLY INVASIVE PANCREATIC SURGERY (MG HOUSE, SECTION EDITOR)
Laparoscopic Roux-en-Y Drainage of a Pancreatic Pseudocyst Ankit D. Patel • Nathaniel W. Lytle Juan M. Sarmiento
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Published online: 17 March 2013 Ó Springer Science+Business Media New York 2013
Abstract Minimal changes have been made in regard to management of pancreatic pseudocysts, and drainage remains the treatment of choice for large (more than 6 cm), symptomatic, and persistent pseudocysts. Laparoscopic techniques have been increasingly employed with success and continue to be favored when possible. Laparoscopic Roux-en-Y cystjejunostomy is an appropriate and effective drainage procedure, especially when cystgastrostomy cannot be performed. We review the literature and describe the technique in this review. Keywords Pancreatic pseudocyst Pancreas Laparoscopic surgery Roux-en-Y cystjejunostomy Drainage Postoperative care Follow-up care
Introduction Pancreatic pseudocysts have classically been described as organized collections of enzyme-rich fluid that persist after an episode of acute pancreatitis, an exacerbation of chronic pancreatitis, or pancreatic trauma. In 1979, Bradley et al. [1] published the first study examining the natural history of pancreatic pseudocysts and found that in 54 patients A. D. Patel N. W. Lytle Emory Endosurgery Unit, Emory University Hospital, 1364 Clifton Road, NE. H-124, Atlanta, GA 30322, USA e-mail: [email protected] N. W. Lytle e-mail: [email protected] J. M. Sarmiento (&) Department of Surgery, Emory University Hospital, 1364 Clifton Road, NE. H-124, Atlanta, GA 30322, USA e-mail: [email protected]
under serial observation, the risk of complications from an untreated pseudocyst increased significantly after a 7-week period of observation. This risk of complications, such as cyst rupture, abscess formation, jaundice, and hemorrhage from untreated pseudocysts, was far greater than the risk of operative treatment. Therefore, for the next decade, pseudocysts that had not resolved by 6 weeks underwent operative therapy with the goal of performing internal drainage. However, surgical outcomes during this period of enteric-pseudocyst drainage remained relatively high, with an overall mortality of 7 % and morbidity exceeding 40 % [2]. Enteric-pancreatic drainage for any pseudocyst was the dominant treatment until the early 1990s, when two studies suggested that the risk of complication from a pseudocyst was related directly to the size of the lesion. Pseudocysts at that time were identified and followed by computer tomography, and Yeo et al. [3] as well as Vitas and Sarr [4] found that the observation of asymptomatic pseudocysts less than 6 cm in size infrequently resulted in complications. In the study of Vitas and Sarr, seven patients with pseudocysts larger than 10 cm were successfully managed by observation. As a result of these studies, an expectant approach to the management of asymptomatic, small pancreatic pseudocysts was adopted. However, a general observation was that a large pseudo
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