One Step Endoscopic Drainage of Pancreatic Pseudocysts: Use of a New Therapeutic Echo Endoscope

Abstract

Background: Different methods have been proposed for pancreatic pseudocysts (PPC) drainage. We describe our experience in endoscopic drainage of PPC with a one step technique using a new therapeutic echo endoscope with a linear curved array transducer, a 3.7 mm working channel and an elevator (Olympus GF-UCT140-AL5). Methods: 12 patients (8 men, 4 women; mean age 53.9, range 28-77) were referred from October 2002 to October 2003 for endoscopic pseudocyst drainage. The mean size of the pancreatic cysts was 11.2 cm (6.5-25 cm). Either monitored anesthesia with Propofol or general anesthesia was used to sedate the patients. The Olympus GF-UCT140-AL5 was passed into the stomach; the optimal localization of the puncture site was determined. Color Doppler was used to rule out gastric varices and large vessels. Under real time ultrasound guidance a 19 gauge FNA needle (EchoTip, Wilson-Cook) was then inserted into the pseudocyst. A 0.025″ Jagwire (Boston Scientific) was passed through the needle under fluoroscopy and coiled into the pseudocyst. A Needle Knife (HPC-3) was introduced over the wire. Under EUS and endoscopic guidance an electrosurgical puncture was performed using the Needle Knife. The tract was dilated with a 10 mm balloon followed by the placement of 1 to 3 10-Fr double pigtail stents. The stents were removed in 1 to 3 months after the resolution of the cyst. Results: Drainage was not attempted on 2 patients due to large gastric varices on the first and a malignant mass in the cyst of the second, both diagnosed only by EUS. Drainage was attempted on 10 patients; placement of the 10-Fr double pigtail stents was successful in 9 patients. In one case drainage could not be achieved. In one other patient with a large cyst and internal debris surgery was required for a cyst infection that did not resolve with endoscopic management. 8/10 patients had complete resolution of their symptoms and cysts. One patient required 2 procedures due to the presence of debris in the cyst. There were no significant bleeding or other complications noted. Conclusion:In our experience EUS is essential prior to endoscopic drainage of PPC as it affected the clinical management of 2/12 patients. Endoscopic drainage of PPC using the new therapeutic echo endoscope with EUS guided wire placement and puncture allows a safe one step procedure without exchanging scopes.