Robotic Cystogastrostomy for Giant Pancreatic Pseudocyst

Abstract

Introduction:

Pancreatic pseudocysts are complications of acute or chronic pancreatitis whose incidence ranges from 5.1% to 16%. ¹ Treatment options are conservative treatment, usually for small pancreatic pseudocyst, endoscopic drainage, or surgery. Endoscopic drainage is the current first step for pseudocysts but large pseudocysts with necrosis may not be amenable to adequate drainage with endoscopic stents. ^{2 , 3} Necrosis is a significant factor for adverse outcomes of endoscopic treatment. ⁴ Surgical cystogastrostomy offers the advantage of creating a wide communication that allows for future endoscopic maneuvers. The advantages of laparoscopic cystogastrostomy are well described in the literature. ⁵ Robotic assistance may facilitate this surgical procedure, but data on robotic approach are limited. ^{3 , 6} This video shows a robotic transgastric approach for the treatment of a giant pancreatic pseudocyst.

Case Presentation:

The patient is a 62-year-old woman with history of biliary pancreatitis, obesity, and appendectomy. In August 2019, she was diagnosed with acute biliary pancreatitis that was managed conservatively and she was discharged after 15 days. In September 2019, the patient was admitted with dyspepsia and heartburn. An MRI and a CT scan showed two pancreatic pseudocysts of 4 and 15 cm. The patient underwent conservative treatment, and follow-up scans at 5 months were planned. In October 2019, she was admitted with epigastric pain and vomiting and a CT scan confirmed the two pseudocysts. After discussion with the endoscopic team, we decided to surgically drain the largest cyst.

Materials and Methods:

The operation was conducted using a four-arm approach with the DaVinci^® Xi robotic system. Steps of the procedure were as follows: placement of robotic trocars as for a gastrectomy, incision of the anterior gastric wall, incision of the posterior gastric wall after having located the pseudocyst, verification of content of the pseudocyst with a needle, opening and drainage of the pseudocyst, execution of manual cystogastro anastomosis, placement of a nasogastric tube, closure of the anterior gastric wall with a double running suture, and cholecystectomy.

Results:

The patient tolerated the procedure well without postoperative complications. Operating time was 3.5 hours, estimated blood loss was negligible, and the nasogastric tube was removed on postoperative day (POD) 5. Oral intake was resumed on POD 6 with a specific diet for pancreatopaths. Follow-up CTs performed on POD 9 and POD 25 showed reduction of the pseudocyst and a CT performed after 5 months showed complete resolution. The patient underwent esophagogastroduodenoscopy (EGDS) with debridement on PODs 15, 22, and 29. Complete resolution of symptoms was observed on the POD 26. Length of hospital stay was 30 days.

Conclusion:

Robotic surgery enables a stable and wide communication between the stomach and the pseudocyst. This facilitates further endoscopic debridements of necrotic material. We believe the robotic approach offers more advantages in terms of mobility and precision, especially when performing this anastomosis.

Authors have not any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. The authors have nothing to disclose.

Runtime of video: 6 mins 35 secs

This is an original work that has never been presented elsewhere.

Patient Consent:

Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.