What are the steps of an open cystogastrostomy procedure?

Open Cystogastrostomy Procedure Steps

Open cystogastrostomy for pancreatic pseudocysts involves creating a surgical anastomosis between the pseudocyst and the stomach through a laparotomy, allowing internal drainage of the pseudocyst contents into the gastric lumen. 1

Preoperative Preparation

• Confirm pseudocyst maturity (typically 4-6 weeks from onset of pancreatitis) with a well-defined fibrous wall on CT or MRI imaging 1
• Administer prophylactic antibiotics with a first-generation cephalosporin or similar agent covering cutaneous organisms 1
• Optimize coagulation parameters: INR should be corrected to <1.5 and platelet count should be >50,000/μL 1
• Verify pseudocyst location is in contact with the posterior gastric wall, ideally with a broad area of adherence 1
• Ensure patent pancreatic duct via MRCP or ERCP when possible, as complete ductal disruption may lead to higher failure rates 1

Surgical Technique

Abdominal Access and Exposure

• Perform midline laparotomy to access the upper abdomen 1
• Mobilize the stomach to expose the anterior gastric wall adequately 2
• Enter the lesser sac by dividing the gastrocolic omentum to visualize the posterior gastric wall 3
• Identify the pseudocyst by palpation through the posterior gastric wall, confirming the area of maximal bulging 1

Creating the Cystogastrostomy

• Make an anterior gastrotomy incision in the body of the stomach, typically 6-8 cm in length 3, 4
• Aspirate the pseudocyst through the posterior gastric wall with a needle to confirm location and assess contents 1
• Create a posterior gastrotomy directly into the pseudocyst through the posterior gastric wall, making an opening of at least 4-6 cm to ensure adequate drainage 3, 4
• Send pseudocyst fluid for culture and amylase analysis 1
• Explore the pseudocyst cavity digitally or with suction to remove any debris, necrotic tissue, or septations that might obstruct drainage 1
• Obtain hemostasis of the cystogastrostomy margins using electrocautery or suture ligation of any bleeding vessels 5, 4

Anastomosis Formation

• Suture the pseudocyst wall to the posterior gastric wall using interrupted absorbable or non-absorbable sutures to create a secure, patent anastomosis 4
• Ensure the anastomosis is at least 4-6 cm in diameter to prevent premature closure and pseudocyst recurrence 5, 4
• Close the anterior gastrotomy in two layers using absorbable sutures 3, 4

Completion Steps

• Place a nasogastric tube for postoperative gastric decompression 1
• Consider placing a drain near the anastomosis site to monitor for leakage, though this is not universally required 1
• Close the abdominal wall in standard fashion 1

Postoperative Management

• Continue prophylactic antibiotics for 24-48 hours postoperatively 1
• Maintain nasogastric decompression until bowel function returns 1
• Advance diet gradually once gastric emptying is adequate 1
• Monitor for complications including bleeding, infection, anastomotic leak, or gastric outlet obstruction 1

Key Technical Considerations

The cystogastrostomy must be sufficiently large (≥4-6 cm) to prevent premature closure, which is a common cause of pseudocyst recurrence 5, 4. The pseudocyst should have a mature, well-defined wall before attempting drainage, typically requiring at least 4-6 weeks from the onset of pancreatitis 1.

Surgical drainage has superior outcomes compared to percutaneous approaches, with recurrence rates of only 2.5-5% and no pseudocyst recurrences reported in surgical series, compared to 14-32% cure rates with percutaneous drainage alone 1. Open surgical drainage is particularly indicated for pseudocysts with infracolic extension, those not amenable to endoscopic approaches, or when endoscopic drainage has failed 1.

Common Pitfalls and Prevention

• Inadequate anastomosis size: Create an opening of at least 4-6 cm to prevent premature closure and recurrence 5, 4
• Operating on immature pseudocysts: Wait at least 4-6 weeks for wall maturation to reduce bleeding risk 1
• Incomplete drainage of septated collections: Thoroughly explore and break down septations within the pseudocyst cavity 1
• Failure to control bleeding from cyst wall: Achieve meticulous hemostasis of the anastomotic margins to prevent postoperative hemorrhage 5
• Unrecognized pancreatic ductal disruption: Complete ductal disruption may require additional procedures such as Roux-en-Y cystojejunostomy instead of cystogastrostomy 1