Pancreatic Cyst-Gastrostomy 
Paula Marincola Smith and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Pancreatic pseudocysts are round or oval-
shaped collections of amylase- and lipase-rich 
pancreatic fluid, within the pancreatic tissue or 
immediately surrounding the pancreas. Pseudocysts 
are filled with simple pancreatic fluid without any 
solid components and are lined with a thick, 
fibrinous capsule. Importantly, the wall of the 
pseudocyst does not contain epithelial tissue, 
distinguishing it from a true cyst.  
Pancreatic 
pseudocysts 
occur 
due 
to 
disruption of the pancreatic duct, resulting in leakage 
and accumulation of pancreatic juice. There is often 
associated hemorrhagic fat necrosis. As a result of 
the intense inflammation that occurs when pancreatic 
enzymes 
encounter 
intraabdominal 
structures, 
pancreatic pseudocysts are lined by a thick capsule 
of fibrosed granulation tissue. 
Pancreatic pseudocysts often occur as the 
consequence of acute pancreatitis, but can also occur 
after chronic pancreatitis, because of iatrogenic 
injury (after instrumentation or surgery,) or after 
pancreatic trauma. In the early phase (first 4 weeks) 
after duct disruption, the acute peripancreatic fluid 
collection lacks a well-defined capsule. About 1 in 3 
acute 
peripancreatic 
fluid 
collections 
will 
spontaneously resolve while the remaining 2/3 
organize into a pseudocyst within 4-6 weeks. While 
most pseudocysts are located in the lesser sac 
between the stomach and the pancreas, they can 
originate anywhere along the trajectory of the 
pancreatic duct. Pancreatic pseudocysts can also 
extend anywhere in the abdominal cavity, including 
the paracolic gutters and pelvis, and can be multiple.  
Abdominal CT scan with intravenous 
contrast is the imaging modality of choice to evaluate 
pancreatic pseudocysts. On CT scan, they appear as 
well-circumscribed round or oval peripancreatic 
fluid collections. The fluid is noted to be 
homogenous with low attenuation, and the cyst is 
often surrounded by a well-defined wall which 
enhances with intravenous contrast. The presence of 
non-liquified components within the cyst cavity 
should lead you to consider alternate diagnoses. 
While 
asymptomatic 
or 
incidentally- 
discovered pseudocysts do not require intervention, 
patients frequently present with symptoms of mass 
effect including pain, early satiety, gastric outlet 
obstruction, or biliary obstruction. In the setting of 
such symptoms that fail to resolve with conservative 
management, or in the case of secondary infection or 
cyst recurrence, intervention is indicated.  
It is important to remember that intervention 
should be avoided if possible until at least 6 weeks 
following an episode of acute pancreatitis for two 
main reasons. First, up to one third of acute 
pancreatic 
fluid 
collections 
will 
resolve 
spontaneously with only supportive care and 
symptomatic management, thus eliminating the need 
for further intervention. Second, all interventions for 
pancreatic pseudocyst rely on the presence of a thick, 
fibrinous wall. Intervention before this wall is mature 
leads to a higher chance of post-procedural leakage 
or other complications. 
Treatment 
options 
include 
open 
or 
laparoscopic internal drainage (cyst-gastrostomy or 
cyst-jejunostomy,) 
endoscopic 
drainage, 
or 
percutaneous drainage. Endoscopic drainage (often 
an 
endoscopic 
cyst-gastrostomy 
or 
cyst-
duodenostomy) may be difficult to access in a low-
resource setting due to lack of equipment and 
expertise. Percutaneous drainage should generally be 
avoided for pancreatic pseudocysts: persistent 
leakage from the pancreatic duct leaves the 
possibility 
of 
pancreatico-cutaneous 
fistula 
formation. Of note, it has been suggested that 
pancreatic pseudocysts that do not communicate 
with the main duct are at low risk of recurrence or 
fistula development after percutaneous drainage. 
Nonetheless, percutaneous management remains 
controversial, and we discourage a percutaneous 
approach in the absence of high-quality pre-
operative imaging (MRI/MRCP) to fully examine 
the integrity of the pancreatic duct. Remember, the 
pseudocyst was caused by leakage from the duct in 
the first place: if that leakage starts up again once the 
cyst is externally drained, the result is a pancreatico-
cutaneous fistula.  
Regarding open internal drainage procedures, 
the decision to proceed with cyst-gastrostomy versus 
cyst-jejunostomy is entirely anatomic. When the 
pancreatic pseudocyst is in the lesser sac directly 
Pancreatic Cyst-Gastrostomy 
Paula Marincola Smith and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
behind the stomach (the most common location,) a 
cyst-gastrostomy is a technically straightforward 
procedure. We describe this procedure here. When 
the pancreatic pseudocyst is located outside of the 
lesser sac (for instance, in case of a pseudocyst which 
arises from the head of the pancreas in the right 
hemiabdomen), a cyst-jejunostomy may be more 
technically feasible. This procedure is described 
elsewhere in the Manual. The general goal of both 
operations is similar: to marsupialize the cyst and 
create an anastomosis between the cyst wall and a 
hollow viscus (stomach or jejunum) in order to allow 
continual drainage of pancreatic fluid into the 
intestinal tract. This chapter will focus specifically 
on the cyst-gastrostomy, as this is the most common 
procedure performed. 
Consider also the etiology of the episode of 
pancreatitis. 
If 
it 
was 
gallstones, 
perform 
cholecystectomy at the same time as this procedure 
if it was not done before. Standard practice is to 
remove 
the 
gallbladder 
during 
the 
same 
hospitalization as the pancreatitis episode. If this was 
not done, it is appropriate to do it at this time.  
It is important to remember that the presence 
of a pancreatic cyst should lead you to consider 
alternative diagnoses including cystic lesions of the 
pancreas: 
• Serous cystadenoma  
• Mucinous cystic neoplasm  
• Side branch intraductal papillary mucinous 
neoplasm [IPMN]  
• Solid pseudopapillary neoplasm  
• Choledochal cyst  
• Mesenteric duplication cysts 
• Gastric duplication cysts.  
These alternate diagnoses have entirely 
different treatment algorithms which are not 
discussed here. 
To summarize, pancreatic pseudocysts have 
features that will allow you to differentiate them 
from these alternate diagnoses: 
• A regular/rounded appearance 
• Lack of any internal solid components,  
• High amylase and lipase levels (these require 
fluid sampling- body fluid amylase assays are 
often not available in resource-limited settings.) 
• History of pancreatitis or episode of severe 
abdominal pain suggestive of pancreatitis 
 
 
Pancreatic cyst-gastrostomy proceeds in the 
following steps:  
• Abdominal exploration 
• Anterior gastrotomy and aspiration of the 
pseudocyst through the posterior gastric wall to 
confirm pseudocyst position 
• Generous excision of a portion of the common 
wall of the posterior stomach and anterior 
pseudocyst 
• Suture placement along the circumference of the 
common wall 
• Placement of nasogastric tube 
• Closure of the anterior gastrotomy in two layers 
 
Steps: 
1. General anesthesia is induced. 
2. Upper midline laparotomy is performed. 
3. Abdominal exploration. Rule out signs of 
malignancy. Inspect the liver, omentum, and 
peritoneal surfaces both visually and by 
palpation. If peritoneal masses or nodules are 
detected, the diagnosis is much more likely to be 
malignancy (pancreatic, gastric, or colonic) with 
peritoneal 
metastasis. 
Explore 
the 
entire 
abdomen carefully, take adequate biopsies, and 
close.  
If, on the other hand, you find only enlarged 
lymph nodes without other unexpected findings, 
recall that often intraperitoneal lymph nodes are 
enlarged even without any pathology. If 
inspection does not reveal any unexpected 
pathology, proceed as planned. 
 
Pancreatic Cyst-Gastrostomy 
Paula Marincola Smith and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Begin with an upper midline incision, exposing the anterior 
wall of the stomach. Prior to proceeding with additional 
dissection, take this opportunity to survey the abdomen for 
signs of malignancy including metastatic spread. The liver, 
omentum, and the peritoneum should be visually inspected and 
palpated for signs of metastatic disease. If masses or nodules 
concerning for malignancy are identified, they should be 
biopsied prior to proceeding further. 
 
4. Palpate for the pseudocyst through the stomach 
in order to plan your gastrostomy. 
5. Make a generous longitudinal gastrotomy in the 
anterior wall over the palpable cystic mass. This 
incision should ideally be in the mid-body of 
stomach, taking care to avoid injury to blood 
vessels on the greater curve. Next use a self-
retaining (Weitlaner or similar) retractor to hold 
open the edges of the anterior stomach wall. 
6. Using a sterile finder needle and syringe, aspirate 
the pseudocyst through the posterior wall of 
stomach to confirm position once again. Fluid 
should return as thin, dark pancreatic fluid. 
Return of thick fluid or mucous should lead you 
to reconsider your working diagnosis and 
operative approach. 
 
 
Following anterior longitudinal gastrotomy, a self retraining 
retractor holds the gastric wall aside. A sterile finder needle 
and syringe are used to aspirate the cyst through the posterior 
wall of the stomach. You should easily aspirate thin, dark 
pancreatic fluid. Return of thick fluid or mucous should lead 
you to reconsider your working diagnosis. 
 
7. Use diathermy to make a circular incision 
through the common posterior stomach and 
anterior pseudocyst wall. Make sure to have a 
functioning suction device on hand to allow swift 
decompression of the cyst cavity and to avoid 
gross spillage of pancreatic fluid and enzymes 
into the abdominal cavity.  
 
Pancreatic Cyst-Gastrostomy 
Paula Marincola Smith and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Use diathermy to open the common posterior gastric/anterior 
cyst wall. An assistant can insert a retractor into the cyst with 
one hand while operating the suction with the other, to keep the 
opening visible to the surgeon. 
 
8. Following decompression, excise a circular 
portion of this common wall to create a common 
window, no less than 3cm in diameter. Larger 
windows are preferable if possible. You should 
be able to see the inside of the cyst cavity easily 
through this defect. Submit the common wall for 
pathology.  
 
 
 
Excise a circular portion of the common wall (posterior 
stomach/anterior cyst), at least 3cm in diameter, to create a 
common window between the stomach and pseudocyst cavity. 
Use diathermy and go slowly, the inflammatory tissue of the 
pseudocyst wall will bleed copiously.  
 
9. Suture the wall of the posterior gastrotomy to the 
cyst wall circumferentially with a running 
locking absorbable suture (2-0 Vicryl or PDS) for 
hemostasis and to avoid possible leakage. Take 
care to make full-thickness bites on both layers, 
ensuring large bites of serosa and small bites of 
mucosa with each bite of stomach. 
 
 
For hemostasis and to secure the stomach to the pseudocyst, 
suture the wall of the posterior gastrostomy to the anterior cyst 
wall circumferentially in a locking manner to promote 
hemostasis. Absorbable suture such as 2-0 Vicryl or PDS 
should be used. 
 
10. Close the anterior gastrotomy in 2 layers, taking 
care not to narrow the pre-pyloric area or injure 
the greater curve vessels. Absorbable suture 
should be used on the inner layer (Vicryl or PDS.) 
Take full-thickness bites with large bites of 
serosa and small bites of mucosa, to avoid 
bulging of mucosa. The outer layer can be closed 
in either an interrupted or running fashion, taking 
care to fully “bury” and cover the primary suture 
line with seromuscular bites. Either absorbable or 
non-absorbable (silk) suture can be used for the 
second layer. 
 
Pancreatic Cyst-Gastrostomy 
Paula Marincola Smith and Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The anterior gastrotomy should be closed in two layers, taking 
care to avoid narrowing the pre-pyloric area or creating an 
iatrogenic injury to the greater curve vessels. 
 
11. Place a nasogastric tube intraoperatively and 
manually confirm placement in the stomach prior 
to closing the abdomen. Leave the nasogastric 
tube in situ overnight to avoid gastric distention. 
Start clear liquids by mouth on the morning of 
post-operative day one. 
 
Pitfalls 
• Recurrence of the cyst: excised portion of 
common wall was too small, limiting the 
capacity of the cyst fluid to adequately drain into 
the gastrointestinal tract. 
• Bleeding from common wall: Make sure to 
carefully inspect the cyst cavity. The excised 
portion of common wall should be large enough 
to 
allow 
adequate 
visual 
inspection 
for 
hemostasis. A running locking suture is typically 
utilized to promote hemostasis as this area is 
typically very well-vascularized. Additional 
sutures may need to be used to achieve 
hemostasis.  
• Undiagnosed malignancy: review for signs of 
possible malignancy on preoperative history and 
physical exam as well as imaging, and visually 
inspect/manually palpate for signs of malignancy 
or metastatic spread upon abdominal entry. If the 
cyst is found to contain mucinous or gelatinous 
debris during surgery, convert to subtotal 
gastrectomy and distal pancreatectomy, if 
possible. Try to preserve the fundus of stomach 
as a reservoir. The short gastric arteries are the 
primary blood supply to the fundus of the 
stomach, so they should be preserved during 
subtotal gastrectomy.  
• Malnutrition/poor wound healing: many patients 
with symptomatic pancreatic pseudocysts are 
malnourished at the time of their operation for a 
combination of reasons (mass effect from the 
pseudocyst itself, history of acute or chronic 
pancreatitis, concurrent alcohol or substance 
abuse.) Consider early feeding, nutritional 
supplementation, and monitoring for re-feeding 
syndrome, when appropriate. See Nutrition in the 
Surgical Patient.  
 
 
Paula Marincola Smith, MD, PhD 
Vanderbilt University Medical Center 
Tennessee, USA 
 
Richard Davis MD, FACS, FCS(ECSA)  
AIC Kijabe Hospital  
Kenya  
 
March 2023 
