All the following surgical procedures are appropri¬ate for a patient who-has a pseudocyst of the head of the pancreas EXCEPT (AIIMS Nov 2011)
|D||removal of the involved segment of the pancreas|
|E||simple external drainage|
a. Internal drainage can be accomplished either endoscopically (by transpapillary drainage, cystogastrostomy, or cystoduodenostomy) or surgically (by cystogastrostomy, cystoduodenostomy, or Roux-en-Y cystojejunostomy).
b. The approach chosen depends primarily on the locally available expertise as well as the location of the pseudocyst, but endoscopic drainage may be preferable in poor surgical risk patients.
c. Pseudocysts that are directly adjacent to either the stomach or duodenum can be safely drained endoscopically if there are no intervening vessels.
d. After endoscopic ultrasound and preliminary aspiration of the cyst fluid to confirm the diagnosis and exclude intervening vessels, endoscopic drainage is achieved by making an incision into the pseudocyst through the wall of the stomach or duodenum.
e. To facilitate decompression, the opening is relatively large, and a pigtail catheter may be placed.
f. Transpapillary drainage might be more appropriate for patients with pancreatic head pseudocysts whose CT and endoscopic ultrasound suggest that incising into the pseudocyst could be hazardous.
g. At the time of endoscopic retrograde cholangiopancreatography (ERCP), a stent is passed into the pseudocyst through the papilla of Vater.
h. By excluding pancreatic juice from the pseudocyst, this bridging intraductal stent may permit the duct disruption to heal and the pseudocyst to resolve without drainage.
i. Surgical internal drainage of pseudocysts is usually accomplished by creating either a Roux-en-Y cysto-jejunostomy, a side-to-side cystogastrostomy, or a side-to-side cystoduodenostomy.
j. The former is usually accomplished by directly anastomosing a defunctionalized Roux-en-Y limb of jejunum to the opened pseudocyst.
k. Surgical cystogastrostomy (or cystoduodenostomy) has traditionally been accomplished by laparotomy and anterior gastrotomy (or lateral duodenotomy).
l. A generous incision is then made through the posterior wall of the stomach (or medial wall of the duodenum) into the pseudocyst.