Description:

The treatment of pancreatic pseudocysts has historically been managed by surgeons; however, endoscopic drainage of pancreatic pseudocysts by expert endoscopists has become an accepted alternative to surgery when an intervention is indicated. Its advantage over percutaneous drainage is the ability to place multiple internal drains with minimal patient discomfort through one puncture site and the avoidance of the development of a pancreaticocutaneous fistula.

Today, I will be presenting a case of a 37 year-old male with no significant past medical history who developed acute pancreatitis after vacationing in the Bahamas. His pancreatitis was complicated by the formation of a pancreatic pseudocyst. the patient was treated with conservative therapy and had a peripherally inserted central catheter placed for the administration of central parenteral nutrition. He later presented at our institution six weeks after his initial diagnosis of acute pancreatitis with symptoms of worsening nausea and vomiting and was found to have an elevated white blood cell count. Computed tomography demonstrated an enlarging pseudocyst measuring 27 cm with a mature wall that was displacing the transverse colon and stomach. Because of his poor nutritional status, he was deemed a poor surgical candidate and was referred for endoscopic drainage of his pseudocyst.

Endoscopy revealed a large pseudocyst bulge in the gastric antrum resulting in a narrowed pylorus with gastric outlet obstruction.

ERCP was able to be performed and demonstrated no evidence of extravasation of contrast to suggest a pancreatic duct leak or communication of the main pancreatic duct with the pseudocyst.

The endoscope was withdrawn into the stomach and the most inferior portion of the convex bulge was chosen to access the pseudocyst. A needle-knife was used to incise the pseudocyst resulting in prompt drainage of a steady stream of grayish thick liquid.

A guidewire was then passed into the cyst cavity as the cyst contents continued to drain.

The puncture site was then dilated using an 18mm CRE balloon over the guidewire resulting in the creation of a large cyst gastrostomy and dramatic drainage of pseudocyst fluid. A total of 4,700 cc of fluid was drained.

to keep the cystgastrostomy patent, a 30 french (10mm x 8cm) fully covered self expanding metal stent was deployed across the cystgastrostomy. During the procedure, there was a noticeable improvement in the shape of the stomach. Following the procedure the patient had instant relief of his symptoms.

A repeat CT performed 1 day after his procedure showed marked improvement in the size of the pseudocyst with the stent in place. the patient was started on a regular diet and was discharged from the hospital.

A followup CT 1 month later showed that the pseudocyst was even smaller in size, but there was a considerable amount of organized debris in the pseudocyst. the patient was referred back for endoscopic treatment.

Repeat endoscopy demonstrated an occluded stent that had partially migrated into the stomach, but was still bridging the cystgastrostomy. the stent was removed with a snare and the pseudocyst was careful inspected and generously irrigated with saline mixed with gentamycin. the cyst was entered and the walls of the cyst cavity appeared healthy with mild bleeding indicating the viability of the tissue. the necrotic debris was partially debrided using a variety of techniques. A Roth net was used grab necrotic debris and transfer it to the stomach.

A tripod retriever was later used to grasp necrotic tissue and extract the debris from the patient.

Another metal stent was placed at the end of the procedure to ensure adequate drainage from the cyst cavity.

This case highlights the usefulness of endoscopic drainage of pancreatic pseudocysts. the large size of the pseudocyst and obvious location allowed for the cyst to be drained without the guidance of endoscopic ultrasound. our patient had an immediate relief in symptoms after drainage. Furthermore, endoscopic management obviated the need for surgery, particularly with the patient's poor nutritional status. in expert hands, endoscopic drainage of pancreatic pseudocysts is an acceptable alternative to surgery to optimize patient outcomes.

Contributed by:

Vinay Chandrasekhara, M.D.,