Therapeutic Success of Endoscopic Ultrasound-Guided Drainage of Pancreatic Pseudocysts in a Pediatric Population

Abstract

Background: Endoscopic drainage has become established as the primary therapy for pancreatic pseudocysts (PC) in adults. Endoscopic ultrasound (EUS) has improved the safety and efficacy of transmural drainage by identification of blood vessels, wall thickness and most optimal site for cyst puncture. However, the management of symptomatic PC among children is less clear regarding the role of EUS. Aim: The aim of this study was to evaluate the success and safety of linear EUS-guided drainage of symptomatic pancreatic PC in children. Methods: Children who presented to our institution between 1/2004 and 8/2008 with symptomatic PC were included. All patients had pancreatic cysts noted on CT imaging. EUS was performed with the curvilinear array Olympus endoscope (GFUC140-P or GFUCT140) and either 19- or 22-guage Cook aspiration needles. Antibiotic prophylaxis was administered prior to endoscopy. PC was confirmed by the appearance on CT and/or EUS, fluid aspiration with histology and in certain cases elevated fluid amylase and low fluid CEA levels. Complete aspiration of smaller cysts was attempted. In other cysts, one to two 10 Fr double pig-tailed plastic stents were placed for 8 weeks and removed after resolution of the PC. Results: The group included 9 patients age <18years (4-17years), (6 females, 3 males). Etiologies of pancreatitis and PC included biliary stones (2), trauma (2), idiopathic (3), familial (1), and divisum (1). Indications for therapy included fever (2), pain (5) and impaired oral intake (2). In the initial cases, EUS served as a salvage therapy for failed ERCP (2), then a combined modality (2), and finally the primary modality to treat pancreatic cysts (5). Cysts larger than 5 cm required EUS-guided cyst-gastrostomy with placement of transmural stents while smaller cysts could be successfully aspirated alone. One patient (familial pancreatitis) had initial success with cyst drainage but developed a second PC during recurrent pancreatitis 8 months later which necessitated surgical intervention for hemosuccus pancreaticus. The remaining 8 patients (89%) had complete resolution of symptoms without recurrence. In 3 of 9 patients, infected cysts were present and were treated successfully with EUS-guided transmural stent placement. Conclusions: EUS drainage of pancreatic PC is safe with durable symptom relief in a pediatric population. Cysts smaller than 5cm can be aspirated successfully without stent placement. Infected cysts can be managed effectively with transmural stents. This series demonstrates that the need for ERCP has diminished over time as the use of EUS-guided PC drainage has evolved into the primary modality.