Single-Scope EUS Guided Cyst Access, Debridement and Drainage Using a Novel Therapeutic Forward Viewing Echoendoscope

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Background: Despite reports of successful endoscopic cystgastrotomies, there remain technical limitations related to current CLA echoendoscopes - namely the oblique angle properties that result in a weakened transfer of force, difficult deployment of larger-bore accessories and its tunneling in the gastric wall. In addition, and most importantly, the technique requires the use an additional endoscope to perform cyst debridement with its potential loss of access during endoscope exchange. A novel therapeutic echoendoscope that shifts the endoscopic and ultrasound orientation from oblique to forward viewing has recently been prototyped. Methods: Phase I/II study of pancreatic cyst drainage using a forward viewing echoendoscope. A standardized approach of cyst drainage technique, including cyst localization, needle puncture under doppler ultrasound guidance, guidewire insertion, balloon dilation, cyst debridement and stent placement with or without nasocystic catheter, were used in order to study the technical advantages and disadvantages of the forward viewing endoscope. Patients were followed to assess symptom and cyst resolution. Our local Institutional Review Board approved the study. Results: Six consecutive patients who were referred for pancreatic cyst drainage were enrolled. The majority of patients were men (83%) with a mean age of 50 ± 20 years and had developed a cyst due to acute pancreatitis of various etiologies. The mean size of the cysts was 10 cm (range 6 to 12 cm) and they were located predominantly in the pancreatic body (83%). We gained cyst access using a 19-gauge needle followed by balloon dilation in 2 patients and with a Cystotome in 4. All cysts had successful stent drainage. Direct cystoscopy and debridement were achieved in 4 cases. Inability to directly enter the cyst with the echoendoscope occurred due to cyst location in the distal stomach in one case and inadequate cyst adherence to the stomach wall in the other. Conclusion: The forward viewing echoendoscope showed a number of promising mechanical advantages for pancreatic cyst drainage. Its most compelling feature was the ability to perform imaging and endoscopic interventions with the same instrument - for single scope ultrasound guided cyst access, debridement and stent drainage.