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INDICATIONS

Pseudocysts of the pancreas are not an uncommon sequela of acute pancreatitis, chronic pancreatitis, and blunt abdominal trauma with resulting traumatic pancreatitis. Pancreatic pseudocysts should be suspected when symptoms remain after the initial episode of pancreatitis has resolved. A palpable mass may be detected in the upper abdomen, most frequently in the midepigastrium or the left upper quadrant. These cysts do not have an epithelial lining, as do true pancreatic cysts. Pancreatic pseudocysts are found most commonly in the body and tail of the pancreas but also may be found in the neck and head of the pancreas. Ultrasonography, computed tomography scans, and retrograde cannulation of the pancreatic duct with injection of dye and x-ray opacification (endoscopic retrograde cholangiopancreatography [ERCP]) may demonstrate a pseudocyst. Films of the chest and abdomen may demonstrate elevation of the left hemidiaphragm with or without basilar atelectasis or pleural effusion. Treatment of cysts that do not regress spontaneously consists most often of internal drainage via the stomach, duodenum, or jejunum. External tube drainage with subsequent fistula may be rarely indicated. A preferential option used by some gastroenterologists is the creation of a cystogastrotomy endoscopically. In this technique, a cystogastrotomy is made and a stent placed to drain the pseudocyst into the stomach. The procedure requires stent removal at a later date but avoids an operation.

The ideal time to drain these pseudocysts internally is 6–8 weeks after their appearance, when the cyst is intimately attached to the surrounding structures and the surrounding inflammatory reaction is quiescent. At this time, the cyst wall is strong enough for the technical anastomosis. External tube drainage of the cyst may be necessary if the cyst wall is friable or if the patient is septic or has a rapidly expanding pseudocyst. In all cases, the interior of the cyst should be thoroughly examined and the cyst wall biopsied to rule out malignancy. Externally drained cysts usually close spontaneously, but pancreatic fistulas can occur. Cysts may resolve gradually, particularly those associated with stones in the common duct and acute pancreatitis. In general, patency of the ampulla and the proximal pancreatic duct may be established by ERCP prior to any operative procedure in selected patients.

PREOPERATIVE PREPARATION

It is most important that these patients be in satisfactory metabolic condition before surgery. Accordingly, deficiencies in electrolytes, red cell mass, serum protein, or prothrombin levels are corrected preoperatively, and total parenteral nutrition should be considered.

ANESTHESIA

General anesthesia with intratracheal intubation is satisfactory.

POSITION

Patients are placed in a comfortable supine position as close to the operator’s side as possible. The knees are flexed on a pillow. Moderate elevation of the head of the table facilitates exposure. Facilities for operative pancreatic cystogram as well as cholangiogram should be available.

OPERATIVE PREPARATION

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