4696 Role of endosonography for endoscopic therapy of pancreatic pseudocysts. results of a prospective study.

Abstract

Background: Bleeding and perforation are the most frequent complications in endoscopic treatment (ET) of PPC. The absence of GI- wall impression by the PPC is a major obstacle for non transpapillary ET. The aim of this study is to evaluate, wether success and safety of endoscopic drainage of PPC and selection of patients can be improved by EUS diagnosis and EUS guided treatment. Methods: From march 1992 till november 1999 a total of 86 patients with suspicion of PPC (54M;32F), mean age 49 years (r:11-98), who were referred for ET, were evaluated. All patients had upper GI endoscopy to detect impression of the GI wall and gastric varices. EUS was performed in all cases with the GF-UM 20 (Olympus) echoendoscope, for EUS guided drainage the FG-32UA (Pentax) was used. EUS evaluation included assessment of a circumscribed fluid collection, distance between the PPC and the wall of the GI tract and collateral circulation (CC) with dilated veins in the GI wall and / or between GI wall and PPC. Endoscopic transgastric or transduodenal drainage were performed with or without prior EUS assisted marking of the GI wall or under direct EUS guidance. Results: 17 patients were not suitable for endosopic treatment due to diffuse necrosis without circumscribed cyst (n=12), distance to the PPC more than 1 cm (n=4), cystic tumor (n=1). In the group of patients considered for ET (n=69) a bulging of the GI wall was present in 39 cases. CC was detected in 13 cases of those with a bulging and in 14 patients without impression of the GI wall. ET was performed in 24 cases without further EUS assistance, in 26 after EUS assisted marking and in 19 patients EUS guided. 48 patients had transgastric, 17 transduodenal and 4 combined transgastric and transduodenal drainage. ET was successful in 96% (66/69) of all cases. Procedure related complications occured in 6% (4/69) of cases; bleeding (n=2), perforation (n=2). All complications were managed endoscopically. There was no procedure related mortality. Conclusion: EUS is crucial for selection of patients with PPC for endoscopic drainage. With EUS assisted or EUS guided drainage also patients with PPC without bulging of the GI wall and those with CC can safely be treated by endoscopy. When an impression of the GI wall due to the PPC is absent, EUS guided drainage should be preferred. EUS improves the selection of patients and clearly enlarges the number of patients suitable for ET. Therefore EUS evaluation / EUS guided treatment should be recommended for patients with PPC, when ET is considered.