Advances in Endoscopic Procedures: Large Pancreatic Fluid Collection Drained Utilizing Endoscopic Cystgastrostomy

Abstract

Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) can result in the formation of fluid-filled pseudocysts communicating with the pancreas, a complication which occurs in 20-40% of patients. Advances in both interventional radiology and endoscopy have made it possible to perform therapeutic, non-invasive cystgastrostomy. We report a case of pancreatic pseudocyst treated endoscopically via cystgastrostomy with drainage of an extremely large amount of fluid. A 54-year-old alcoholic man with a recent hospitalization for acute pancreatitis presented to an outside facility after experiencing abdominal distention associated with generalized weakness for 2 weeks. Upon transfer to our institution for further management of a large fluid collection found on CT (> 22 cm), endoscopic ultrasound (EUS) showed it to be a large pseudocyst. Laboratory results were significant for a Hgb of 8.0 g/dL, MCV of 78 fL, INR of 1.4, and an albumin of 2.9 g/dL. Cystgastrostomy via EUS utilizing a lumen apposing metal stent drained 4.75 L of fluid. After a hospital course complicated by MRSA pneumonia, the patient was transferred to a long-term acute care facility. EGD with necrosectomy was performed 2 weeks later, but he was then hospitalized for continuing fevers, undergoing laparotomy with necrosectomy and closure of gastrostomy with drain placement. The patient was transferred to a skilled nursing facility for continued management 6 weeks later. Cautery assisted Lumen Apposing Metal Stents (LAMS), while not familiar to many physicians, offers a safe, cost effective, method of drainage of pancreatic pseudocysts. It has a similar success rate when compared to surgical or interventional radiology approaches, specifically when the patient has progressed clinically to pseudocyst containing necrotic debris. In our patient, the size of the cyst and the severity of his pancreatitis made initial surgery a difficult proposition due to potential morbidity, and IR drainage unfavorable due to possible fistula formation. Over time, pseudocysts can spontaneously resolve if the circumstances are right. The size and amount of fluid present in this pseudocyst made our patient an unlikely candidate for spontaneous resolution of his pseudocyst, thus making drainage an acceptable option. Endoscopic guided cystgastrostomy, when available, is quickly becoming the preferred method of fluid drainage.Figure: Endoscopic ultrasound showing fluid consistent with a pancreatic pseudocyst.Figure: Endoscopic view of the gastric lumen as fluid (arrow) is being drained via a lumen apposing metal stent.