Pancreatic Pseudocysts At Atypical Locations- Endoscopic Management

Abstract

Endoscopic drainage of single abdominal pancreatic pseudocyst is well reported. Data is scarce on endoscopic management of pseudocyst at atypical locations. Aim: To study efficacy of endoscopic transpapillary nasopancreatic drain placement alone in management of pancreatic pseudocyst at atypical locations. Methods: Over 4 years, 9 patients (19-50 years, 7 M) with symptomatic pseudocysts at atypical locations communicating with pancreatic duct as visualized on endoscopic retrograde pancreatography (ERP), were treated by attempted endoscopic transpapillary nasopancreatic drain placement. An informed consent was obtained, intravenous midazolam and hyoscine butyl bromide administered and ERP performed. Pancreatic duct selectively cannulated and pancreatogram obtained. A 5F/7F nasopancreatic drain (NPD) was placed across/near site of pancreatic duct disruption over a 0.025/0.035 inch hydrophilic guide wire through major or minor papilla. Therapeutic success was defined as symptomatic improvement with radiological resolution on computed tomography (CT) scan and healing of ductal disruption. Therapeutic failure was defined as persistence of pseudocyst at eight weeks after NPD placement or need for surgical or radiological intervention. Results: All 9 patients had abdominal pain on presentation. Other symptoms were early satiety (3), abdominal lump (2), fever (1) and jaundice (1). Eight patients had underlying chronic pancreatitis (Alcohol-4 [associated pancreas divisum: 1], Idiopathic-4 [associated pancreas divisum: 1]) and one patient had pseudocyst as sequelae of gall stone pancreatitis. Size of pseudocysts ranged from 2 to 13 cms. Location of pseudocysts was: mediastinal (3), intrahepatic (3), and intrasplenic (3). On ERP, all patients had partial disruption of pancreatic duct and NPD could be placed across disruption in 8/9 (88.8%) patients. The site of ductal disruption was head, body and tail in 1(11%), 5 (55.5%) and 3 (33.3%) patients respectively. In one patient, in whom deep cannulation of pancreatic duct could not be achieved because of stricture in head region, only pancreatic sphincterotomy was performed and pseudocyst resolved at 6 weeks. One patient developed fever, 5 days after procedure that was successfully treated by antibiotics. NPD got blocked in 1 patient 12 days after procedure and it was successfully opened by aspiration. Pseudocysts resolved in all patients in 4-8 weeks with no recurrence on follow up of 5-52 months. Conclusion: Pancreatic pseudocysts with ductal communication at atypical locations can be effectively treated with endoscopic transpapillary nasopancreatic drain placement, especially when ductal disruption can be bridged.