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In addition to the conventional open techniques of internal drainage of pancreatic pseudocysts, several centers have accomplished laparoscopic drainage procedures\ • 1 • At present, the experience is limited to small series, and comparisons cannot be made with standard internal drainage techniques.

A small proportion of pseudocysts are best treated by pancreatic resection. Most commonly, this operation involves distal pancreatectomy for pseudocysts located in the body or tail of the gland. Peripancreatic and peripseudocyst inflammation can make distal pancreatectomy a technically challenging procedure in this setting. After distal pancreatectomy, a Roux-en-Y pancreaticojejunostomy to the remnant pancreas may be required to decompress an obstructed or abnormal proximal pancreatic duct. In a few patients with symptomatic pseudocysts in the head of the pancreas associated with an inflammatory mass, excisional therapy may require pancreaticoduodenectomy. In this case, pylorus-preserving pancreaticoduodenectomy is the procedure of choice. Less commonly performed procedures, such as duodenum-preserving head of the pancreas resection, may be applicable in some patients.

External drainage of a pancreatic pseudocyst through an operative approach is indicated when gross infection is found at the time of operation or when an immature, thin-walled pseudocyst is encountered that will not allow for safe internal drainage. When the pseudocyst is initially aspirated, purulent material is retrieved. At this time, the pseudocyst is packed off from the remaining abdominal viscera with moist packs, and the pseudocyst cavity is opened with the electrocautery device. The contents of the pseudocyst cavity are then completely evacuated, and the pseudocyst cavity is closely inspected to ensure adequate hemostasis. Then, at least one closed suction-drainage catheter is placed into the cavity and is brought out through the abdominal wall. Appropriate antibiotic therapy should be instituted, and follow-up CT scans are obtained to ensure that the pseudocyst is entirely drained. External drainage may lead to the development of pancreaticocutaneous fistulas, most of which heal spontaneously as long as the proximal pancreatic duct is not obstructed. Total parenteral nutrition and octreotide therapy (50 to 250 pg subcutaneously three times per day) may assist in the closure of a persistent pancreaticocutaneous fistula.

Figure 4-5a Cystojejunostomy for a pancreatic pseudocyst. A, Schematic of a sagittal section showing the final anatomy.

Figure 4-5a Cystojejunostomy for a pancreatic pseudocyst. A, Schematic of a sagittal section showing the final anatomy.

Figure 4-5b B, Aspiration of a portion of the pseudocyst contents through the transverse mesocolon.

Figure 4-5c C, Creation of the posterior outer layer of the anastomosis, using interrupted

silk sutures.

Figure 4-6a Cystogastrostomy for a pancreatic pseudocyst. A, An anterior gastrotomy is performed. B, Aspiration of a portion of the pseudocyst contents through the posterior gastric wall. Inset shows sagittal section anatomy.

Figure 4-6b C, A posterior gastrotomy creates a communication between the pseudocyst and the stomach. D, Biopsy of the pseudocyst wall. E, A running locking suture is used for hemostasis and to maintain apposition of the pseudocyst wall to the posterior wall of the stomach. F, Closure of the anterior gastrotomy. (From Cameron, J.L.: Atlas of Surgery, Vol. 1. Toronto, B.C. Decker, 1990, p. 381, with permission.)

Figure 4-8 Cholangiogram of a patient with a long distal common bile stricture caused by chronic pancreatitis.

Figure 4-9 Cholangiogram of a patient with a pancreatic pseudocyst, showing extrinsic compression of the common bile duct. Arrows show a narrowed distal common bile duct.

Figure 4-10 Upper gastrointestinal series of a patient with chronic pancreatitis, showing a stricture at the junction of the first and second portions of the duodenum.

Figure 4-11 Chest radiograph of a patient with chronic massive pancreatic pleural effusion. (From Cameron, J.J., Kieffer, R.S., Anderson, W.J., et al.: Internal pancreatic fistulas: Pancreatic ascites and pleural effusions. Ann. Surg., 184:587, 1976, with permission.)

Figure 4-12 Four computed tomography scan images showing extensive pancreatic ascites in a young female patient with alcoholism. The small bowel loops float centrally, and ascitic fluid fills the abdomen.

Figure 4-13 An endoscopic retrograde cholangiopancreatogram from the patient with pancreatic ascites whose computed tomography scan is shown in Figure 4-12 . Contrast extravasates from the proximal pancreatic duct into the peritoneal cavity. The visualized portion of the extrahepatic biliary tree is normal.

Figure 4-14 A and B, A patient with a pancreatic duct disruption and pancreatic ascites treated by anastomosing a Roux-en-Y jejunal loop to the duct leak. (From Cameron, J.J., Brawley, R.K., Bender, H.W., et al.: The treatment of pancreatic ascites. Ann. Surg., 170:668, 1969, with permission.)

TABLE 4-5 -- Clinical Features Distinguishing Biliary Obstruction Caused by Pancreatic Carcinoma from Chronic Pancreatitis

Feature

Pancreatic Carcinoma

Chronic Pancreatitis

History and physical examination

Persistent jaundice

Intermittent jaundice

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