Pseudocyst drainage

Traditional indication is pseudocyst >6cm present for more than 6 weeks
Spontaneous resolution of asymptomatic pseudocysts expected in 60%

True indications are
1.Symptomatic (pain, fullness, weight loss, nausea)
2.Enlarging (of any size, but this is controversial)
3.Infected (confirm by gram stain and culture)

Open drainage: procedure of choice if neoplasm suspected, infected, recurrent or failure of other means

1.Position the patient supine.
2.Upper midline incision (or rooftop).
3.Conduct a laparotomy. If the GB is still present, perform a cholecystectomy and cholangiogram.
4.Explore the lesser sac by incising the gastrohepatic omentum or through lesser curvature and examining the posterior surface of the stomach. If the psuedocyst (>5cm) is densely adherent then cystogastrostomy is the procedure of choice.


Transgastric cystgastrostomy: esp for the most common cyst which is body and tail lesions

Anterior incision in gastric wall (6-7cm) corresponding to cyst and parallel to blood supply
Grab margins of gastrotomy with Babcocks
Aspirate cyst
Incise through posterior gastric wall into cyst and excise an ellipse 3-6cm in length (send for frozen section)
Suture cyst through posterior gastric wall (ensure full thickness bites of cyst wall and stomach)
For a more inferiorly pointing cyst perform a roux-en-Y cystojejunostomy. Other options include cystoduodenostomy and distal pancreatectomy.
Lavage and close

?NGT through into cyst

Other methods
Percutaneous: If infected, place catheter. High rates of recurrence and failure
Endoscopic: Transmural or Transpapillary (if communicaiton with pancreatic duct) No ablility to biopsy so contraindicated if suspicious for neoplasm)