Endoscopic-Ultrasonography- (EUS-) guided pancreatic pseudocyst puncture and drainage are a widely accepted nonsurgical intervention [
Recent advances in understanding of the pathophysiology of pancreatic pseudocysts (PPs) allow the selection of optimal candidates for minimally invasive treatment approaches [
A review of the literature indicates that this paper is the first to demonstrate the use of combined EUS-guided pseudocyst drainage for ruptured pancreatic pseudocyst and to provide an evaluation of the safety and effectiveness of this method.
Inclusion criteria for this study are as follows: (1) pancreatic pseudocyst without adherence to gastric wall confirmed by CT and EUS; (Figures
(a) CT shows a large cyst in the upper abdominal area. (b) EUS shows the cyst wall was 3 mm. The wall was not adhered to the gastric wall, as relative movement was observed. (c) After the needle puncture, cyst (red arrow) fluid will leak into the omental bursa. After cystotome dilation and stent placement, fluid leak (green arrow) begins to increase. (d) A large collection of fluid, measuring 3 cm, is seen below the cyst. (e) Transmural approach by a cystotome. (f) Intraperitoneal drainage by a 7 Fr nasobiliary catheter. (g) Drainage catheters seen on X-ray. (h) Pancreatic pseudocyst size is diminished, as confirmed by CT.
Longitudinal echoendoscope (PENTAX EG3830UT, Pentax Corporation, Japan) with a working channel of 3.8 mm accessible to a 10 Fr stent is used. Echo-Tip Ultra needle (19-G, Wilson-Cook Medic, USA) with a lumen of 0.8 mm in diameter is fitted to a 0.035 inch guidewire. Cystotome (10-Fr, Wilson-Cook Medic) is used to dilate the tract and create a large fistula. A nasobiliary drainage catheter (7-Fr, Wilson-Cook Medic) is used for peritoneal drainage or infected cyst drainage. A double pigtail stent (10 Fr, Endo-Flex GmbH, Germany) facilitates the cyst drainage.
The patient candidate for our study is following the steps shown in the chart in Figure
The patient candidate for our study is following the steps in chart.
If the cyst is ruptured with a large amount of fluid rush into the abdominal cavity, EUS-guided abdominal cavity drainage is introduced (Figures
A total of 86 patients with pancreatic pseudocyst treated at Shengjing hospital between May 2005 and June 2011 were enrolled in this study. 21 patients (13 women, 8 men) with pancreatic pseudocyst without adherence to gastric wall were selected for this procedure (Table
Patient characteristics in this study.
Patients details | |
---|---|
Patients, total | 21 |
Male : Female | 8 : 13 |
Age, mean, years (range) | 36 (10–45) |
Location of cyst | |
Head | 2 |
Body | 18 |
Tail | 1 |
The distance from the cyst to the gastric wall, cm | 2.1 (1.5–3) |
Diameter of cyst, cm | 7.6 (7–10) |
Cause of the cyst | |
Trauma | 3 |
Severe pancreatitis | 16 |
Postoperative | 2 |
All patients resumed regular diets after three days. Within one week of treatment, there was a reduction in cyst diameter of at least 50% in 19/21 patients, as measured by abdominal CT scan. Cysts in both of the patients in whom reduction of cyst diameter was less than 50% had an etiology of trauma.
4 patients had cyst ruptured, with intraperitoneal drainage kept for 3 days, and the gastric decompression tube for 2 days. No further infections were found in these patients.
Cyst infection was found in 2 patients in our study. EUS-guided secondary dilation of fistula was performed with an additional 10 Fr stent placement.
Stents were to be removed by endoscopy once cyst diameter was <3 cm, as measured by CT or EUS; this goal was achieved in 18 patients at 3-month followup. In the three remaining patients, stents were removed at six-month followup. At one year, no recurrence was found in any of the patients.
There were no severe procedure-related complications resulting from this technique; no bleeding, no perforation, no pneumoperitoneum. The postprocedure fever that developed in 2 patients was successfully managed by a secondary EUS-guided dilation. Results are reviewed in Table
Patients results of EUS-guided cystogastrostomy.
Patient details | |
---|---|
Completely recovery | 21 |
Cyst rupture during the procedure | 4/21 |
Symptoms after EUS drainage | |
Fever | 1 |
Abdominal pain | 0 |
Others | 0 |
Decompression tube in place, days | 2-3 |
Postoperative hospital stay, days | 4–10 (4.3) |
A pancreatic pseudocyst is a collection of pancreatic fluid occurring within the pancreas or adjacent to it and surrounded by nonepithelialized tissue. It can occur after an episode of acute pancreatitis, trauma, or surgery, or in the setting of chronic pancreatitis. The cysts result from liquefaction of necrotic pancreatic tissue or from pancreatic duct obstruction or disruption [
Management options available for pancreatic pseudocysts include endoscopic, radiologic (percutaneous), surgical (open surgery or Laparoscopic drainage), and conservative (medical) treatment [
During the past decade, it has gradually been recognized that echoendoscopic treatment is a preferred approach in management of pancreatic pseudocysts [
Pseudocysts may be classified according to anatomic location in relation to the omental bursa. Pseudocysts inside the omental bursa often have a common wall with the GI tract, and retroperitoneal perforation is rare when there is close apposition of the pseudocyst to the gastric wall. EUS-guided cystoenterostomy in this type of cyst usually has a low risk of complications and short recovery period. Over the past ten years, there have been numerous reports of successful treatment by this method, and it has become the recommended therapy for these cysts.
The other type of pseudocyst is located without adherence to gastric wall. This type of cyst usually has a wall that is separate from the gastric wall. Relative motion between the cyst wall and the gastric wall may be seen during EUS, particularly if the patient is instructed to take a deep breath. These cysts may be situated 2 cm or further from the GI wall as shown in our study. A transmural approach may cause cyst rupture or large leak of cyst fluid, resulting in ascites or infection. We think adequate drainage was effective to reduce the risk of infection. So, needle path dilation by cystotome or balloon was needed even they may have the higher risk of cyst rupture. Simple EUS-guided drainage of these ruptured cysts is usually not adequate. In the past, drainage by transpapillary placement of a stent in the pancreatic duct was considered if the cyst wall was behind omental bursa, but, as noted above, this approach has limited efficacy due to the smaller diameter of the stent.
This study proposes that cysts without adherence to gastric wall can be safely and effectively drained by EUS-guided cystoenterostomy accompanied by nasobiliary tube drainage of the abdominal cavity. To demonstrate this, the technique and the results of the procedure in 21 patients have been reported.
For surgeons, abdominal drainage for peritoneal infection or fistula in the abdominal cavity has been a routine [
The main complications expected of this therapy are hemorrhage and infection. Hemorrhage can be avoided by using color Doppler for the detection and avoidance of interposing vessels during the puncture. Some studies are considered performing the povidone-iodine washing of gastrointestinal mucosa to prevent the infection [
The technique of EUS-guided transmural drainage of pancreatic pseudocysts without adherence to gastric wall combined with drainage of the abdominal cavity by a nasobiliary catheter allows for successful endoscopic management with a low risk of complications. This should lead to expanded application of EUS-guided pancreatic pseudocyst drainage.
Results from larger series will be necessary to learn more about this procedure and its ultimate role in the treatment of pancreatic pseudocysts without adherence to gastric wall.