Cystogastrostomy

Endoscopic cystogastrostomy treatment

Endoscopic cystogastrostomy Endoscopic cystogastrostomy is a procedure of minimum invasiveness and endoscopic surgery intended to drain a pancreatic pseudocyst or a walled-off pancreatic necrosis (WON) into the stomach. It works in reducing the symptoms of pain, nausea, vomiting and infection brought about by fluid accumulation around the pancreas.

What is Endoscopic Cystogastrostomy?

It is an endoscopic drainage procedure, in which a connection (stoma) is established between the pancreatic cyst and the stomach wall with the use of an endoscope. This will enable the contents of the cyst (fluid, pus or necrotic matter) to drain into the stomach where they may be naturally expelled through the digestive tract.

Procedure Steps

Preparation

• The patient is subjected to sedation or general anaesthesia.
• The endoscope (a camera-fitted flexible tube) is pushed down the mouth into the stomach.

Identification of the cyst

• Endoscopic ultrasound (EUS) is a method that is employed in locating the cyst and determining its contents and wall thickness.
• Doppler imaging makes sure that there are no large blood vessels between the stomach and a cyst.

Development of cystogastrostomy

• The cyst is punctured by means of a needle or cystotome into the stomach wall.
• To hold the pathway in place, a guidewire is placed.

Stent placement

• To ensure the cyst and the stomach are connected, metal or plastic stents (in most cases lumen-apposing metal stents, LAMS) are implanted.
• During days or weeks, the cyst fluid is emptied into the stomach.

Post-procedure monitoring

• Complications are monitored in the patient.
• The imaging to be used is follow-up to achieve total cyst drainage prior to stent removal (typically after 46 weeks).

Indications

Endoscopic cystogastrostomy indicates:

• Pancreatic pseudocysts that are more than 6 cm big or which last over 6 weeks.
• Walled-off necrosis of the pancreas (WON)

Symptomatic cysts causing:

• Abdominal pain or bloating
• Gastric outlet obstruction
• Infection or the development of abscess.
• Biliary obstruction

Advantages

• Least invasive (no incision opening in the abdomen)
• Shorter recovery as compared to open surgery.
• Shorter hospital stay
• High success rate (80–95%)
• Reduced chances of development of complications than surgical drainage.

Laparoscopic cystogastrostomy surgery

Laparoscopic cystogastrostomy is a minimum invasive surgery that is performed to drain a pancreatic pseudocyst or walled-off pancreatic necrosis (WON) into the stomach. It forms an opening that is permanent between the back of the stomach and the pseudocyst, through which the contents of the cyst will drain into the digestive system.

The procedure is usually opted to be used when endoscopic drainage is either not available or it has been unsuccessful.

What is Laparoscopic Cystogastrostomy?

Laparoscopic cystogastrostomy is the laparoscopic development of a cyst-stomach junction with the use of small incisions and a camera-directed procedure. It will cause a direct and controlled drainage of the pancreatic fluid collection to the stomach to relieve pain and pressure among other symptoms caused by the cyst.

Procedure Steps

Anaesthesia & Preparation

• General anaesthesia is provided to the patient.
• Carbon dioxide gas is pumped into the abdomen to create space over which the procedure is to be done.

Laparoscopic Access

• The abdomen is incised by 3-4 small cuts.
• Laparoscope (camera) and surgery tools are inserted.

Locating the Pseudocyst

• The pancreatic pseudocyst which is attached to the back wall of the stomach is identified by the surgeon.
• The stomach wall and cyst wall are brought together.

The development of the Cystogastrostomy

• A cut is done on the stomach and the cyst.
• The two holes are cut off to create a stoma (connection).
• This is then sutured or stapled to provide secure drainage.

Drainage and Cleaning

• The fluid (or pus) in the cyst flows into the stomach.
• It is debrided in case of necrosis (dead tissue).

Closure

• The instruments are withdrawn, and the abdominal little incisions are sutured.

Factors Affecting Cost of cystogastrostomy in India

These are the major determinants that influence the cost of cystogastrostomy (endoscopic / laparoscopic / open) in India:

Type of Procedure / Technique

• It could be endoscopic cystogastrostomy, laparoscopic, or open. Minimally invasive ones tend to be more costly in terms of specialized equipment / technology / expertise.
• Image guidance (e.g. Endoscopic Ultrasound, intraoperative ultrasound or CT) is costly.

Infrastructure and Type of Hospital

• Centres with multi-specialty / super-specialty (NABH accreditation, advanced ICU, high-end OT) are more expensive.
• Accessibility to sophisticated devices (robotics, special stents, high-end laparoscopic tools) increase the prices.

Location / City

• Metro cities (Delhi, Mumbai, Bangalore, Hyderabad) are associated with higher charges in hospitals, rent, staff expenses, etc. that translate into higher surgical prices than those in the tier-2 / tier-3 cities.
• Hospital operating costs and room/bed charges are also influenced by cost of living and real estate.

Surgeon & Specialist Fees

• Age and popularity of the surgeon (more experienced / reputed surgeons are more expensive).
• Seniority, specialization (HPB -hepato-pancreato-biliary surgeons), education in advanced endoscopic or laparoscopic drainage.

Preoperative Workup

• Imaging (CT, MRI, Ultrasound, Endoscopic ultrasound) to evaluate the cyst and its contents (fluid, necrosis, etc.), wall thickness, attachment to blood vessels, and so on.
• Laboratory tests, blood tests, cross-match, etc.
• Anaesthesia consultation.

Intraoperative Factors

• The size, location, complexity of the cyst (how thick the wall is, how adherent, is there that of infected necrosis)
• Extent of necrosis / debridgement (walled-off necrosis) will prolong operating time and potentially increment equipment, drains.
• The use of stents or drains (type of stent, metal or plastic), their quantity. Foreign / specialized equipment is expensive.

Consumables and Implants

• Stent, drain, stapler, suture, graft, any prosthetic.
• Consumables use: sterilization, single-use devices, medical grade disposable.

Anaesthesia and OT Charges

• General or regional / sedation.
• Time of operation and use time of OT. Long surgeries cost more.
• Surveillance, anaesthesia assistant staff, anaesthetic drugs.

Hospital Stay / Room Type

• Length of stay: length of stay in the hospital after surgery, ICU (when necessary).
• Room type: shared ward or private room or deluxe / luxury room.
• Aftercare: physiotherapy, nurse to patient ratio.

Post-surgical Management and Surgery follow-up

• Treatment (antibiotics, analgesics).
• Follow-up imaging to determine cyst resolution.
• Endoscopic / imaging follow-up and removal of stents where necessary.
• Treatment of complications (bleeding, infection) becomes more expensive.

Complications 

• In case of complications (bleeding, infection, perforation, re-operation), they are a big cost.
• Extra ICU or extra surgery / interventions.

Factors within the patient / comorbidities

• Special monitoring or prolonged care may be needed by age, general health, comorbid diseases (e.g., diabetes, heart disease) etc.
• The procedure and postoperative recovery may be complicated by the condition of coagulation status, nutritional status.

Miscellaneous Factors

• Administrative fees, taxes.
• Disposables / medicines Price is generally going to fluctuate based on the imports and the local products used by the hospital.
• Radiology and diagnostic tests performed in privately-owned laboratories vs in hospital.

Best hospitals for cystogastrostomy in India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Top gastro surgeons for cystogastrostomy in India

• Dr. Paritosh S Gupta
• Dr. M A Mir
• Dr. Randhir Sud
• Dr. Arvind Kumar Khurana
• Dr. Pradeep Chowbey

Conclusion

Cystogastrostomy, endoscopic, laparoscopic, or open surgery, is a very effective therapy of the pancreatic pseudocysts and walled-off pancreatic necrosis. Procedure selection varies based on the size, location, complexities and condition of the patient. Endoscopic cystogastrostomy is less invasive, faster to heal and is used in easy to reach cysts. Laparoscopic cystogastrostomy is a little bit more invasive but it enables one to see the cyst directly, drain it effectively, and is suited to the complex or infected cysts. In very complex cases or in case of failure of minimally invasive methods, it is open surgery.

Cystogastrostomy treatment in India GetWellGo

GetWellGo is regarded as a leading supplier of healthcare services. We help our foreign clients choose the best treatment locations that suit their needs both financially and medically.

We offer:

• Complete transparency
• Fair costs.
• 24 hour availability.
• Medical E-visas
• Online consultation from recognized Indian experts.
• Assistance in selecting India's top hospitals for Cystogastrostomy treatment.
• Expert gastroenterologist with a strong track record of success
• Assistance during and after the course of treatment.
• Language Support
• Travel and Accommodation Services
• Case manager assigned to every patient to provide seamless support in and out of the hospital like appointment booking
• Local SIM Cards
• Currency Exchange
• Arranging Patient’s local food

FAQ

1, What is the duration of the process?

• Endoscopic: ~30–60 minutes
• Laparoscopic: ~1.5–3 hours
• Open surgery: 24 hours based on complexity.

2. Is it painful?

• This is done under the influence of sedation or general anaesthesia, thus the procedure is not very painful. There can be the presence of postoperative pain, which can be dealt with by painkillers, most of the time.

3. What is the recovery time?

• Endoscopic: 1-3 days in hospital, normal activity in about one week.
• Laparoscopic: hospital stays 3-5 days, normal activity 1-2 weeks.
• Open surgery: Patient stays 7-10 days, normal activity in 4-6 weeks.

4. Does the cyst reoccur following the procedure?

• Recurrence is uncommon particularly when cyst is empty in every aspect and any ductal obstruction of the pancreas is tackled.