S2506 Use of the Pediatric Gastroscope for Endoscopic Decompression of a Right Hydronephrosis Caused by a Peripancreatic Fluid Collection in a Patient With Severe Acute Pancreatitis

Abstract

Introduction: Peri-pancreatic fluid collections can cause symptoms by compressing adjacent organs. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The treatment of such complication requires drainage of the collection with placement of stents between the cavity and the lumen. Case Description/Methods: A middle-aged man developed gallstone pancreatitis complicated by a large peri-pancreatic fluid collection (pancreatic pseudocyst). Four months later, he developed a right hydronephrosis caused by compression of the right ureter by the fluid collection surrounding it. He therefore underwent EUS guided cyst-gastrostomy with placement of a 20x10mm AXIOS stent and two plastic stents in the direction of the ureteral compression. In a second procedure two weeks later the XP190N pediatric gastroscope was passed through the AXIOS stent into the cavity and into the tract leading to the ureteral compression. This allowed for placement of a wire under fluoroscopic and endoscopic guidance with deployment of two plastic biliary stents. Total decompression of the ureter and resolution of the hydronephrosis ensued. Discussion: The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection, pain, or compression of adjacent organs may require intervention. Treatment may include endoscopic or percutaneous catheter drainage, and later endoscopic or surgical necrosectomy. Endoscopic drainage is now the preferred approach. This case highlights the use of the XP190N pediatric gastroscope to guide deployment of a wire through a narrow fistulous tract inside the peripancreatic cavity; this allows for deployment of stents to decompress the obstruction of the right ureter. Usage of the pediatric gastroscope in this case afforded multiple advantages including enhanced navigation capabilities due to its smaller size and excellent optics; dye was directly flushed trough the channel of the scope, thus affording fluoroscopic guidance. Also, a small snare was used for necrosectomy and removal of debris. Finally, the wire was placed into the desired position for precise stents deployment. The armamentarium of dedicated endoscopic equipment for treatment of peri-pancreatic fluid collections is limited, therefore, the pediatric gastroscope should be kept in mind for use in selected cases.Figure 1.: Upper left: Peripancreatic fluid collection. Upper right: Passage of a pediatric gastroscope through the AXIOS stent with wire placement in the peri-ureteral space. Lower left: Two plastic stent deployed for decompression of the ureteral obstruction. Lower right: Total resolution of the obstruction of the right ureter.