Endoscopic Transgastric Drainage Research Articles

SP4.6 - Endoscopic versus laparoscopic management of pancreatic pseudocyst - A systematic review and meta-analysis

Abstract Objective The aim of this meta-analysis is to compare the postoperative surgical outcomes of endoscopic versus laparoscopic management of pancreatic pseudocyst. Methods Two randomised control trials (RCTs) and four comparative trials reporting postoperative outcomes for patients undergoing treatment with endoscopic transgastric or transduodenal drainage versus laparoscopic cyst-gastrectomy or cyst-jejunostomy for the pancreatic pseudocyst were selected from medical electronic databases and meta-analysis was conducted by the guidelines of the Cochrane Collaboration using statistical software RevMan version 5.4. Results Two RCTs and four comparative trials on 401 patients reporting postoperative outcomes were included. In the random effect model analysis, the overall success rate [odds ratio (OR) 0.81, 95%, CI (0.38, 1.72), Z = 0.54, P = 0.59] was comparable between the two groups with no heterogeneity among the included studies. Adverse events after the procedure was also comparable between the two groups [OR 0.72, 95%, CI (0.34, 1.50), Z = 0.89, P = 0.37] with no heterogeneity among the included studies. Hospital stay was shorter in the endoscopic group [Mean difference -2.71, 95%, CI (-4.14, -1.27), Z = 3.69, P = 0.0002] with high statistical heterogeneity among the included studies. Conclusion The patients managed with endoscopic procedures had shorter hospital stay, but the incidence of adverse post-procedure outcomes and overall success rate were comparable between the two groups. Due to the paucity of the RCTs, a major multi-centre RCT is needed to strengthen the findings of this systematic review.

Safe and beneficial outcomes of pancreaticogastrostomy with endoscopic transgastric drainage for pancreatic fistula after pancreaticoduodenectomy

PurposesThe optimal surgical technique and perioperative management to prevent postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy have not yet been established. This study examined the perioperative outcomes of pancreaticogastrostomy with endoscopic transgastric drainage. MethodsWe performed a retrospective analysis of 191 patients who underwent pancreaticoduodenectomy between 2016 and 2023. They were divided into two groups: pancreaticojejunostomy group (n = 135) and pancreaticogastrostomy group (n = 56). We compared preoperative factors and postoperative outcomes. We performed endoscopic drainage only in the pancreaticogastrostomy group. ResultsPreoperative factors were similar between the two groups. Operative time [480 (404–542) vs. 382 (346–458) minutes], blood loss [505 (270–850) vs. 315 (145–535) g], pseudoaneurysm formation (7% vs. 0%), and postoperative hospital stay [28 (22–38) vs. 19 (17–24) days] were significantly lower in the pancreaticogastrostomy group. In the analysis of 41 patients with POPF, postoperative hospital stay [40 (23–108) vs. 27 (18–54) days] and hospital stay after POPF diagnosis [30 (10–99) vs. 15 (5–35) days] were significantly shorter in the pancreaticogastrostomy group. Endoscopic transgastric drainage was performed in 77% of patients in the pancreaticogastrostomy group, and drainage was successfully completed in all patients. ConclusionPancreaticogastrostomy with endoscopic transgastric drainage could be effective for the safe management of pancreaticoduodenectomy.

An effective endoscopic hand-suturing method for fistula closure after endoscopic transgastric drainage for walled-off necrosis

Video 1How to use an endoscopic hand-suturing device (video version).

A possible manifestation of pancreas divisum–pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report

BackgroundPancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.Case presentationThe patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.ConclusionIn children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.

Results of transgastric drainage of fluid collections and postnecrotic pancreas cysts in patients with acute pancreatitis

INTRODUCTION. The issues of treating patients with acute fluid collections and postnecrotic cysts are still relevant at the present time. Optimization of the tactics of treatment of patients at the early stages of the formation of postnecrotic cysts makes it possible to reduce the percentage of complications.The OBJECTIVE was to develop diagnostic criteria for the formation of a cyst capsule at the early stages of acute pancreatitis, to determine the optimal timing and options for transgastric drainage of cysts.METHODS AND MATERIALS. The results of treatment of 62 patients were analyzed. All patients underwent computed tomography with bolus contrast and endoscopic ultrasonography. There were 2 groups of patients who underwent surgical treatment in the early and late periods. The results of endoscopic transgastric drainage of postnecrotic pancreatic cysts were analyzed.RESULTS. Based on the analysis of the results of treatment of patients with postnecrotic pancreatic cysts and acute peripancreatic fluid collections, the data of multispiral computed tomography and endoscopic ultrasonography at the stages of cyst formation, options and optimal timing of endoscopic transgastric drainage were determined. Causes of complications accompanying this method were identified and analyzed. The technique of transgastric drainage has been improved, methods for the prevention of complications have been proposed.CONCLUSION. The obtained results make it possible to recommend diagnostic criteria and a treatment algorithm for use in clinical practice.

Subdiaphragmatic abscess due to penetration of a duodenal ulcer successfully treated with endoscopic transgastric drainage: a case report

BackgroundSubdiaphragmatic abscesses are sometimes caused by intraabdominal infections. We report a case of endoscopic ultrasound-guided transgastric drainage.Case presentationA 75-year-old Asian man was referred to our hospital for treatment for upper gastrointestinal bleeding. On admission, blood tests showed a marked inflammatory response, and abdominal computed tomography showed free air in the abdominal cavity and a left subdiaphragmatic abscess. Therefore, the patient was diagnosed with an intraabdominal abscess associated with a perforated duodenal ulcer. Because he did not have generalized peritonitis, fasting and antibiotic treatment were the first therapies. However, because of the strong pressure on the stomach associated with the abscess and difficulty eating, we performed endoscopic ultrasound-guided transgastric drainage. After treatment, the inflammatory response resolved, and food intake was possible. The patient’s condition remains stable.ConclusionsDrainage is the basic treatment for subdiaphragmatic abscesses; however, percutaneous drainage is often anatomically difficult, and surgical drainage is common. We suggest that our success with endoscopic ultrasound-guided transgastric drainage in this patient indicates that this approach can be considered in similar cases and that it can be selected as a minimally invasive treatment method.

EUS-guided Transgastric Drainage to Manage a Postoperative Pancreatic Fistula After Distal Pancreatectomy and Splenectomy in Recurrent Ovarian Cancer: A Case Report

Postoperative pancreatic fistula after distal pancreatectomy represents the most frequent procedure-related complication; however, a standard treatment is currently not available. We herein report a case of postoperative pancreatic fistula after distal pancreatectomy and splenectomy in a patient affected by a platinum-sensitive ovarian cancer recurrence. The 59-year-old patient developed a pancreatic fistula on postoperative day 4. An endoscopic transgastric double-pigtail drainage was placed on postoperative day 13. The patient was discharged after 5 days and referred to adjuvant medical treatment. A month later, computed tomography revealed complete resolution of the fistula, the drainage was removed, and the patient continued chemotherapy. She recovered uneventfully at a 3-month follow-up. EUS-guided drainage is a viable option in the management of postoperative pancreatic fistula, which can lead to a rapid resolution of peripancreatic fluid collections and to initiation of adjuvant chemotherapy with the slightest delay in ovarian cancer patients.

Management of biliary complications after adult-to-adult living donor liver transplantation. Initial experience in a latin american center

Presenter: Sergio Riveros MD | Pontificia Universidad Católica de Chile Background: Living donor liver transplantation (LDLT) is a complex therapeutic alternative that requires a specialized multidisciplinary team with the capacity to resolve complications. The number of anastomosed ducts has an impact on the rate of postoperative biliary complications, but the literature is still scarce. The objective of this study was to describe early and late postoperative biliary complications with a focus on therapeutic management in the initial experience of a LDLT program. Methods: Non-concurrent cohort study at a Pontificia Universidad Católica de Chile. All patients who underwent adult-to-adult LDLT were included from 2016 to 2020. Patients were divided into two groups according to the number of bile duct anastomoses (single duct, group A; and two or three ducts, group B). Demographic, perioperative, postoperative outcomes regarding early and late biliary complications (>2 months), treatment, major complications (Clavien-Dindo III-IV), mortality, and survival were evaluated and compared between groups. Results: single bile duct was anastomosed in 63.3% (n = 19), two bile ducts in 33.3% (n = 10) and three bile ducts in 3.3% (n = 1). Duct-to-duct (DD) anastomosis was performed in 56.7% (n = 17), hepaticojejunostomy (HJ) in 33.3% (n = 10) and combined in 10% (n = 3). Major complications were reported in 46.7% (n = 14), median length of postoperative stay was 15.5 days (7-46) and median follow-up 17 months (0.4-53.5). Overall graft and patient survival was 87% at 24 months. Group A (n = 19) had major complications in 21% (n = 4), early biliary complications in 15.8% (n = 3) and late biliary strictures in 26.7% (n = 4). None required percutaneous drainage, 5.3% surgical drainage (n = 1) and 10.5% re-anastomosis to a Roux-en-Y HJ (n = 2). They underwent ERCP in 26.7% (n = 4) and percutaneous transhepatic internal-external drainage in 6.7% (n = 1). Four patients (21.1%) had early mortality and one patient (6.7%) late mortality, all unrelated to biliary complications. Group B (n = 11) had major complications in 90.9% (n = 10), early biliary complications in 81.8% (n = 9) and late biliary strictures in 54.5% (n = 6). They required percutaneous drainage in 27.3% (n = 3), surgical drainage in 9.1% (n = 1), endoscopic transgastric drainage in 9.1% (n = 1), duct-to-duct reinforcement (n = 1) and re-anastomosis to Roux-en-Y HJ (n = 4). They underwent ERCP in 27.3% (n = 3) and percutaneous transhepatic internal-external drainage in 18.2% (n = 2). All patients are alive with 100% graft and patient survival. Conclusion: Living donor liver transplantation is a challenging treatment that requires a specialized high-volume center with the ability to rescue postoperative complications. The number of reconstructed ducts affects the rate of early biliary complications, without an impact on graft and patient survival. In our experience, patients with 2-3 graft bile ducts had a high rate of biliary complications, but with adequate management, all patients are alive with functioning grafts. Expertise in advanced endoscopy, interventional radiology, and complex reoperations are crucial to achieve excellent outcomes.

Endoscopic ultrasonography-guided transgastric drainage of pancreatic fluid collections with a novel lumen-apposing metal stent

Objective To evaluate the efficacy and safety of a novel lumen-apposing metal stent(LAMS) in endoscopic ultrasonography(EUS)-guided transgastric drainage of pancreatic fluid collections(PFC). Methods A retrospective study of 46 patients was performed who underwent EUS-guided transgastric drainage of PFC with placement of LAMS from September 2015 to April 2017. Clinical data were reviewed and follow-up data were obtained by telephone and outpatient contact. Results A total of 49 LAMS were placed in 46 patients (2 LAMS were placed in 3 patient respectively for multiport access). The operation success rate was 95.9%(47/49), complications occurred in 14 patients(31.8%), including 2 severe complications (delayed hemorrhage and peritonitis). Additional intervention was performed in 10 patients(22.7%). The mean hospital stay was 6 days (1-40 days) and patients were followed for a mean time of 18.4 months (9-28 months). Treatment success was achieved in 40 patients(90.9%). Stent removal was performed after a mean time of 59.4 days (20-142 days), and recurrence rate was 10%(4/40) during the follow-up period. Conclusion Drainage of PFC using LAMS with special design is effective and relatively safe. Key words: Stents; Endosonography; Pancreatic fluicl collection; Drainage

Energy expenditure and loss of muscle and fat mass in patients with walled-off pancreatic necrosis: A prospective study.

Ensuring adequate nutritional support in patients with walled-off pancreatic necrosis (WON) is challenging and weight loss is often considerable. The aim of this study was to evaluate resting energy expenditure (REE) and body composition in patients with WON. We prospectively included 18 patients (67% men; median age 63 y; 44% gallstones; 39% alcohol) with WON undergoing endoscopic transgastric drainage and necrosectomy. Patients were followed for 4 wk after admission. We assessed hand-grip strength, REE using indirect calorimetry, and body composition with dual-energy x-ray absorptiometry to assess the percentage change in muscle mass (MM) and fat mass (FM). Data are summarized using medians (range). At baseline, the median body mass index was 27.9 kg/m2 (17.7-35.6 kg/m2). Fifteen patients (83%) had infected WON. Eight patients (44%) received total or supplemental parenteral nutrition. The median percentage loss in MM was 0.31% and FM was 6.2%. The median REE was 6870 kJ (3255-8870 kJ) at baseline. Compared with the predicted REE, the measured REE was 1049 kJ higher (-3065 to 2126 kJ) at baseline and -951 kJ lower (-2600 to 3202 kJ) at 4 wk. The difference between the predicted and measured REE at baseline was correlated with the percentage loss in MM (P = 0.043) and FM (P = 0.026). Additionally, patients with infected WON had significantly higher REE (P = 0.003). In patients with WON, an increased REE appears to predict increased muscle and fat loss. Additional studies are necessary to evaluate if REE may be used to improve nutritional support.

Minimally invasive approach for the treatment of pancreatic pseudcyst. Transgastric drainage - where we are now?

Introduction. Minimally invasive approach for the treatment of acute pancreatitis (AP) and its complications has proven to reduce morbidity and mortality rate, length of hospitalization and costs of treatment, and improve quality of life of the patients. This approach for the AP has been implemented in developed countries, but in our region lags behind. In this case report we presented the successful endoscopic transgastric drainage of the large pancreatic pseudocyst (PPC) developed as a complication of AP. Case report. A 63-years old male patient was presented with nausea and vomiting as a consequence of the compressive effects of the PPC in the body and tail of the pancreas after episode of AP. On computed tomography (CT) scan, it was shown a cystic formation in the region of the pancreatic body and tail compressing stomach which was verified on upper endoscopy. Under fluoroscopy, using lateral duodenoscope, the biliary plastic prosthesis of 12 French and 8 cm of length was placed throughout posterior stomach wall into the PPC. The intervention was finished uneventfully, without complications. On CT scan performed 7 days after procedure, the reduction of the PPC size was significant and control CT scan one month after the procedure and removal of the prosthesis showed almost complete resolution of the PPC. Conclusion. Endoscopic transgastric drainage is safe and effective procedure for PPCs especially when the PPC has propulsion effects on stomach wall.

ЕNDOSCOPIC TRANSGASTRIC DRAINAGE OF LIQUID CONGESTIONS AND POST-NECROTIC CYSTS IN ACUTE PANCREATITIS

Aim. To develop methods of transgastric endoscopic drainage of liquid congestions and post-necrotic cysts in pancreatic necrosis and to estimate results of treatment. Material and Methods. Drainage of post-necrotic cysts and liquid congestions has been carried out in 60 patients. 34 patients underwent external drainage, 26 patients had EUS-assisted endoscopic transgastric drainage. Stages of postnecrotic cysts formation have been studied in 40 patients. Technique of endoscopic drainage included detection of cyst location relatively to gastric lumen using endosonography. The shortest trajectory between gastric lumen and cyst in avascular zone was chosen to apply cystogastroanastomosis. EUS-assisted cystogastrostomy was performed in 15 patients, in 5 cases cystogastrostomy was supplemented by stenting; 9 patients underwent transgastric puncture of cysts and liquid congestions, 5 of them had necrsequesterectomy. Results. External drainage was associated with external pancreatic fistula in 7 (18.9%) patients. External pancreatic fistula accompanied by hard-healing wound in the area of postoperative scar was observed in 3 (8%) patients. One patient (2.7%) suffered from external biliary fistula, 1 patient died due to multiple organ failure. There were no deaths after transgastric drainage. Conclusion. Transgastric drainage of post-necrotic cysts was not accompanied by deaths. If sequesters are present sanation of the cyst's cavity and stenting are necessary.

An unusual esophageal endoscopic appearance

A 44-year-old man, with medical history of chronic alcoholic intoxication and smoking, presented with suspicion of infected pancreatic necrosis, 5 weeks after severe acute alcoholic pancreatitis. The physical examination revealed asthenia, diffuse abdominal pain and fever (38.4 °C). Laboratory results showed elevated inflammatory markers, anemia (hemoglobin 8.5 g/dL) and malnutrition with hypoalbuminemia (25 g/L). Abdominal CT-scan showed a 8 cm walled-off pancreatic necrosis. A necrosis puncture was positive for Escherichia coli. Before initiation of treatment of the infection, the patient experienced melena. Upper gastrointestinal endoscopy (UGE) showed pale and necrotic esophageal mucosa with coffee-ground exudates, from 28 cm from dental arches (DA) to the gastro-esophageal junction (Fig. 1). Proton pump inhibitor has been introduced; then, treatment of the infected pancreatic necrosis was performed by endoscopic transgastric drainage and antibiotic. Three weeks later, dysphagia for solids occurred. A new upper endoscopy showed impassable esophageal stricture with inflammatory mucosa and fibrinous exudates. Balloon dilation was performed 3 times during 4 months whit good clinical efficacy. What is the diagnosis? Answer: Acute esophageal necrosis or “Black esophagus”. The acute esophageal necrosis (AEN) or “black esophagus” is a rare disease, with a low incidence, estimated about 0,2% in a prospective study, diagnosing 8 patients from 3900 UGE [[1]Ben Soussan E. Savoye G. Hochain P. Hervé S. Antonietti M. Lemoine F. et al.Acute esophageal necrosis: a 1-year prospective study.Gastrointest Endosc. 2002 Aug; 56: 213-217Abstract Full Text Full Text PDF PubMed Google Scholar]. A recent literature review including 112 cases, reported a mean age at diagnosis of 68 years; with a male to female ratio of 4:1 [[2]Day A. Sayegh M. Acute oesophageal necrosis: a case report and review of the literature.Int J Surg. 2010; 8 ([Epub 2009 Oct 1]): 6-14https://doi.org/10.1016/j.ijsu.2009.09.014Crossref PubMed Scopus (35) Google Scholar]. AEN occurred generally in patients with significant comorbidities including cardiovascular risk factors, cancer, chronic pulmonary disease, alcohol abuse or liver cirrhosis [[3]Gurvits G.E. Shapsis A. Lau N. Gualtieri N. Robilotti J.G. Acute esophageal necrosis: a rare syndrome.J Gastroenterol. 2007 Jan; 42 ([Epub 2007 Feb 16]): 29-38Crossref PubMed Scopus (155) Google Scholar]. Acute conditions are often associated including shock and hypotension, acute liver failure or infection. The main clinical presentation includes upper gastrointestinal bleeding (hematemesis or coffee ground vomit) occurring in two third of cases. Melena, epigastric pain, and dysphagia are less common. Endoscopic examination reveals diffuse necrotic mucosa affecting, in most cases, the lower third of the esophagus with respect of gastro-esophageal junction [[2]Day A. Sayegh M. Acute oesophageal necrosis: a case report and review of the literature.Int J Surg. 2010; 8 ([Epub 2009 Oct 1]): 6-14https://doi.org/10.1016/j.ijsu.2009.09.014Crossref PubMed Scopus (35) Google Scholar]. The mechanism of AEN remains unclear, probably multifactorial where hypoperfusion in patients with comorbidities seems the key factors. Associated gastric outlet obstruction could also increase lesions by prolonged esophageal acid reflux (cardia preserved) [1Ben Soussan E. Savoye G. Hochain P. Hervé S. Antonietti M. Lemoine F. et al.Acute esophageal necrosis: a 1-year prospective study.Gastrointest Endosc. 2002 Aug; 56: 213-217Abstract Full Text Full Text PDF PubMed Google Scholar, 2Day A. Sayegh M. Acute oesophageal necrosis: a case report and review of the literature.Int J Surg. 2010; 8 ([Epub 2009 Oct 1]): 6-14https://doi.org/10.1016/j.ijsu.2009.09.014Crossref PubMed Scopus (35) Google Scholar, 3Gurvits G.E. Shapsis A. Lau N. Gualtieri N. Robilotti J.G. Acute esophageal necrosis: a rare syndrome.J Gastroenterol. 2007 Jan; 42 ([Epub 2007 Feb 16]): 29-38Crossref PubMed Scopus (155) Google Scholar]. Reported mortality rate of 38% is probably overestimated because occurring in patients with acute and severe life-threatening failure. Mucosal healing is observed in the most of cases but stricture can occurred and is reported in less than 10% of cases, accessible to endoscopic dilatation [[2]Day A. Sayegh M. Acute oesophageal necrosis: a case report and review of the literature.Int J Surg. 2010; 8 ([Epub 2009 Oct 1]): 6-14https://doi.org/10.1016/j.ijsu.2009.09.014Crossref PubMed Scopus (35) Google Scholar].

幽門側胃切除術後に合併した腹腔内膿瘍に対して超音波内視鏡下経胃的ドレナージ術が奏功した2例

幽門側胃切除術後に合併した腹腔内膿瘍に対して超音波内視鏡下経胃的ドレナージ術が奏功した2例

腹腔鏡補助下幽門側胃切除後の腹腔内膿瘍に対して内視鏡的経残胃ドレナージが有効であった1例

腹腔鏡補助下幽門側胃切除後の腹腔内膿瘍に対して内視鏡的経残胃ドレナージが有効であった1例

脾臓sclerosing angiomatoid nodular transformationに対し腹腔鏡下脾臓・膵尾部摘出術施行後に生じた術後膵瘻に対し内視鏡下ドレナージを施行した１例

脾臓sclerosing angiomatoid nodular transformationに対し腹腔鏡下脾臓・膵尾部摘出術施行後に生じた術後膵瘻に対し内視鏡下ドレナージを施行した１例

Synchronous ovarian carcinoma detected on staging 18F-FDG PET/CT in a patient of esophageal carcinoma: A rare association

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas.

Effectiveness and safety of endoscopic ultrasound-guided transgastric or transpapillary drainage in treating pancreatic pseudocyst

To explore the effectiveness and safety of endoscopic transgastric or transpapillary drainage in treating pancreatic pseudocysts. The clinical data of 15 patients with pancreatic pseudocyst who underwent endoscopic ultrasound-guided transgastric or transpapillary drainage in the Chinese PLA General Hospital between June 2004 and February 2013 were retrospectively analyzed. Also, we reviewed the relevant Chinese literature in the China Academic Journal Network Publishing Database (from 1994 to 2012) and VIP China Science and Technology Journal Database (from 1989 to 2012) using the key words "pancreatic pseudocyst and drainage". Five literatures including 103 cases were enrolled. The data of 118 cases undergoing endoscopic drainage, included 94 cases with transgastric approach and 24 with transpapillary approach, entered the final analysis. The success rate was 94.9%, and cysts completely disappeared in 83.9% of the patients. The overall incidence of complications (bleeding, infection, and stent clogging or migration) was 19.5%. One patient lost to follow-up and only one case of recurrence was noted. Endoscopic transgastric or transpapillary drainage is safe and effective in treating the pancreatic pseudocysts and therefore can be a preferred therapeutic approach.

Endoscopic transgastric drainage of a gastric wall abscess after endoscopic submucosal dissection

A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer. Endoscopic submucosal dissection (ESD) was successfully performed for complete resection of the tumor. On the first post-ESD day, the patient suddenly complained of abdominal pain after an episode of vomiting. Abdominal computed tomography (CT) showed delayed perforation after ESD. The patient was conservatively treated with an intravenous proton pump inhibitor and antibiotics. On the fifth post-ESD day, CT revealed a gastric wall abscess in the gastric body. Gastroscopy revealed a gastric fistula at the edge of the post-ESD ulcer, and pus was found flowing into the stomach. An intradrainage stent and an extradrainage nasocystic catheter were successfully inserted into the abscess for endoscopic transgastric drainage. After the procedure, the clinical symptoms and laboratory test results improved quickly. Two months later, a follow-up CT scan showed no collection of pus. Consequently, the intradrainage stent was removed. Although the gastric wall abscess recurred 2 wk after stent removal, it recovered soon after endoscopic transgastric drainage. Finally, after stent removal and oral antibiotic treatment for 1 mo, no recurrence of the gastric wall abscess was found.

A Case Series of Successful Endoscopic Management of Pancreatic Pseudocysts after Failed Surgical Drainage

Purpose: Pseudocysts (PCs) of the pancreas are the most common lesion of the pancreas. PCs are a localized collection of fluid within the pancreas, which usually contain large quantities of amylase. Typically the PCs form from repeated bouts of pancreatitis, trauma, or pancreatic duct obstruction. In the last few decades, there has been an evolution of management and treatment of PCs. Initially a surgical approach was the mainstay of treatment with a fairly recent shift to endoscopic cystogastrostomy (CGY). Current practices recommend that the first line approach to the management of pancreatic PCs be endoscopic with surgery reserved for complicated necrotic PCs which are not amenable to endoscopic drainage. The four cases described here all had pancreatic PCs which were initially treated with surgical CGY of the PC. On follow-up, all PCs were persistent or recurred and a GI consultation was called for endoscopic CGY. Endoscopic transgastric pseudocyst drainage with transmural stenting was successfully performed in all four cases with complete resolution of the PCs. The first case is a 48-year-old male who developed a 10 × 10 cm PC following a bout of acute pancreatitis. The patient underwent endoscopic CGY and remained treated after 12 months without re-accumulation of the PC. In the second case, a 67-year-old male, with a history of alcoholic pancreatitis developed a 11 × 10 cm PC which was successfully treated with no recurrence of the PC at 8-month follow-up. In the third case, a 14-year-old boy s/p blunt abdominal trauma had a 10 × 12 cm PC successfully managed endoscopically without recurrence of the PC at 36 months. The final case is a 37-year-old male with alcoholic pancreatitis and a symptomatic 4 × 4.5 cm PC that was successfully treated endoscopically without recurrence at 12 months. Despite current literature suggesting surgical management of pancreatic pseudocysts as the “gold standard,” endoscopic therapy via endoscopic ultrasound guided transmural pseudocyst drainage is emerging as the method of choice due to its minimally invasive approach and safety and success profile when compared to surgery. The rate of resolution of PCs following endoscopic drainage range from 65-89% with no mortality reported to date. The most common complications being: infection (<50%), bleeding, and perforation (<3%). Additionally, endoscopic management allows for transpapillary stenting which may be needed if pancreatic duct disruption is a suspected etiology of pseudocyst formation. Surgical management of PCs is much more invasive and associated with higher morbidity; therefore, we suggest that surgical management be reserved for cases which are not amendable to endoscopic CGY.