4698 Endoscopic intracystic treatment of pancreatic pseudocysts: a possible innovative technique in their management?

Abstract

Introduction: Endoscopic transmural drainage is a treatment modality of pancreatic pseudocysts when visible extrinsic compression of the gastric or duodenal wall and close apposition to the lumen are present. We describe a new technique based upon introduction of the endoscope into the pseudocyst in order to treat complications of drainage. Case 1: A 52-year-old man with chronic pancreatitis presented with a mature symptomatic pseudocyst located in the pancreatic head and bulging into the duodenum. Endoscopic transduodenal drainage was complicated by stent migration into the pseudocyst. A nasocystic catheter was inserted. Three days later the cystostomy tract was dilated with a 12 mm balloon until we were able to advance the endoscope into the pseudocyst. The stent was removed with a snare and cyst fluid was aspirated before endoscope withdrawal. Since ERCP revealed pseudocyst communication with the pancreatic duct, a transpapillary drainage was performed. The pseudocyst resolved with no recurrence after 3 months of follow-up. Case 2:Seven months following an episode of acute pancreatitis, a 54-year-old man presented with a mature symptomatic pseudocyst located in the pancreatic head, bulging into the duodenum and not communicating with the pancreatic duct. Uneventful endoscopic transduodenal drainage was performed. Two days later stent migration into the gut and pseudocyst infection were noticed. Antibiotics were started. After 12 mm balloon dilation of the cystostomy tract, the endoscope was advanced into the pseudocyst followed by aspiration or extraction of cyst fluid and debris. A nasocystic catheter was inserted. The catheter was irrigated twice under endoscopic view with saline passing together with cyst debris through the cystostomy into the duodenum, until only clear fluid was returning. Two weeks later an intracystic bleeding due to rupture of a pseudoaneurysm was treated by angiographic embolization. Further follow-up was uneventful with pseudocyst resolution after 3 months. Conclusion: Balloon dilation of a cystostomy tract followed by advancement of an endoscope into a pseudocyst can be safely performed in a mature pancreatic pseudocyst adjacent to the upper GI-tract. This new technique enabled us to treat complications of endoscopic transmural pseudocyst drainage for which surgery is usually carried out. It offers new perspectives in the endoscopic treatment of well-defined pseudocysts but needs further validation before it can be promoted as such.