Endoscopic Ultrasound Directed Pseudocyst Drainage Without the Use of Fluoroscopy: A Case Series

Abstract

Introduction: Endoscopic drainage of pancreatic pseudocysts is usually performed using fluoroscopy and a therapeutic duodenoscope. Endoscopic ultrasound (EUS) is often used to choose the puncture site and avoid penetrating a vessel. However, fluoroscopy and EUS equipment are typically in separate rooms making transport of EUS equipment difficult and cumbersome. Also, availability of a fluoroscopy suite can be an issue at many institutions. The aim of this study was to evaluate the technical feasibility and safety of EUS directed pseudocyst drainage without the use of fluoroscopy. Methods: Patients referred for pseudocyst drainage to one endosonographer between July 2005 and June 2015 were managed by cyst drainage using EUS guidance without the use of fluoroscopy. Technical success rate and complications were reviewed. In addition, previous attempts at drainage were recorded.17 procedures were performed using the Olympus GF-UC140P echoendoscope; 6 procedures were performed using Pentax therapeutic echoendoscope, 21 procedures were performed using Olympus therapeutic echoendoscope. In each case initial puncture was made using a 19G needle and fluid was aspirated. A .035 wire was passed through the needle into the cyst. The tract was dilated over the wire using a 4.5 to 6F graduated dilator; In 24 patients balloon dilation was then performed to 8 or 10 mm. 2 to 4 double pigtail stents were placed. Either 7Fx3cm or 5cm double pigtail stents were used. In 18 patients a 10 mmx4cm fully covered self expandable metal stent was placed (8 Wallflex & 10 Viabil stents). An ERCP trained nurse was required for the procedure. All procedures were performed only with a linear echoendoscope. Results: A total of 44 patients were managed with this technique. The procedure was unsuccessful in 1 of 44 patients due to difficulty with sedation. 5 patients had previous failed attempts at cyst drainage by ERCP experts using fluoroscopy and a therapeutic duodenoscope. EUS guided drainage was successful in all 5 of these patients. There were 4 complications: 1 patient had delayed bleeding requiring transfusion; this patient was known to have varices in the pseudocyst. 1 patient had stent migration into the cyst; this was removed at a later date without any untoward consequences. In 2 patients, one of the stents slipped out of the cyst; this was removed without any complications. Conclusion: EUS directed pseudocyst drainage without the use of fluoroscopy appears technically feasible and safe.