EUS-guided Pseudocyst Drainage Research Articles

Inadvertent double puncture of the stomach and duodenum during EUS-guided pseudocyst drainage: Caution against puncturing from the gastric antrum.

Inadvertent double puncture of the stomach and duodenum during EUS-guided pseudocyst drainage: Caution against puncturing from the gastric antrum.

Transesophageal EUS-Guided Pseudocyst Drainage: Is the Juice Worth the Squeeze?

Gastroenterology Medicine & Research Transesophageal EUS-Guided Pseudocyst Drainage: Is the Juice Worth the Squeeze? Joshua B French MD1, Swati Pawa MD1 Raymond B Dyer MD2 and Rishi Pawa MD1* 1Department of Medicine, Division of Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA 2Department of Radiology, Wake Forest School of Medicine, Winston Salem, NC, USA *Corresponding author:Rishi Pawa MD, Department of Medicine, Division of Gastroenterology, USA Submission: November 27, 2019;Published: December 06, 2019 DOI: 10.31031/GMR.2019.04.000581 ISSN 2637-7632Volume4 Issue2

Diagnostic and therapeutic role of endoscopic ultrasound in children’s pancreaticobiliary disorders

Background and Objectives:The diagnostic role of endoscopic ultrasound (EUS) in children has been demonstrated only recently. Data on the technique’s therapeutic indications remain scarce. We evaluated diagnostic and interventional EUS indications, safety, and impact in children with pancreaticobiliary disorders.Patients and Methods:We retrospectively reviewed our single pediatric center experience covering a 14-year period.Results:Between January 2000 and 2014, 52 EUS procedures were performed on 48 children (mean age 12 years) with pancreaticobiliary disorders for suspected biliary obstruction (n = 20/52), acute/chronic pancreatitis (n = 20), pancreatic mass (n = 3), pancreatic blunt trauma (n = 7), and ampullary adenoma (n = 2). Positive impact of EUS was observed in 51/52 procedures (98%), precluding using endoscopic retrograde cholangiopancreatography (ERCP) (n = 9), focusing on endotherapy (n = 21), or reorienting therapy toward surgery (n = 7). EUS-guided fine needle aspiration was carried out on 12 patients. Thirteen therapeutic EUS procedures were conducted, nine of which were combined EUS-ERCP procedures (three EUS-guided pseudocyst drainage, one EUS-guided transgastric biliary drainage of a metastatic rhabdomyosarcoma).Conclusions:We report on a large pediatric EUS series for diagnostic and therapeutic pancreaticobiliary disorders, showing a significant impact of diagnostic EUS and affording insights into novel EUS and combined EUS-ERCP therapeutic applications. We suggest considering EUS as a diagnostic and therapeutic tool in the management of pediatric biliopancreatic diseases.

A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy.

There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.

Endoscopic ultrasound with or without fine-needle aspiration has a meaningful impact on clinical care in the pediatric population.

Background and Objectives:The safety and utility of endoscopic ultrasound (EUS) for the evaluation and management of gastrointestinal (GI) tract disorders among adults has been established. The literature on safety and efficacy in a pediatric referral population (under 21 years of age) is limited. We hypothesized that EUS is safe and useful in the pediatric population. We reviewed the pediatric EUS experience at a single tertiary-care system. We describe the indications, findings, safety, technical success rate, and impact on clinical outcomes.Patients and Methods:All patients 21 years of age or younger referred for EUS between 5, 2007 and 11, 2012 were identified from our electronic medical record databases. Retrospective chart review was then conducted to document demographics, procedure indications, procedure type (diagnostic or therapeutic), type of anesthesia used, EUS findings, and the clinical impact of EUS on the subsequent management of the patients.Results:Seventy EUS procedures were attempted in 58 patients during the study. Of these, two EUS procedures were aborted due to inadequate moderate sedation and 68 were successfully completed. The median age at initial endoscopy was 18 years (range 6–21 years), 50% were male and 65% were Caucasian. Four patients underwent EUS-guided pseudocyst drainage. Among the remaining 54 patients, the indications for EUS were the evaluation of GI mucosal/submucosal lesions (n = 14), acute or recurrent pancreatitis (n = 10), localization of suspected insulinoma (n = 8), evaluation of pancreatic abnormalities seen on prior imaging (n = 6), surveillance of tumors or evaluation of luminal lesions in hereditary syndromes (n = 6), abdominal pain of suspected pancreatobiliary origin (n = 5), and other rare indications (n = 5). Fine-needle aspiration was performed in 13 (9 diagnostic, 4 therapeutic) and trans-gastric fine-needle contrast injection of the pancreatic duct was performed in one patient without any complications. Sedation (data available for 66 procedures) included general endotracheal anesthesia in 38 (57%), monitored anesthesia care (MAC) in 19 (29%), and moderate sedation in 9 (14%). There were 4 minor intra-procedural anesthesia-related complications (laryngospasm in 2 and hypoxemia from airway obstruction and secretions in 2) in MAC and general endotracheal anesthesia (GA) cases, and 1 postprocedural complication (fever after pseudocyst drainage). EUS can achieve the diagnostic or therapeutic goal and ruled out suspected pathology in 88% of cases precluding need for additional testing.Conclusions:(1) EUS in the pediatric population is technically successful and efficacious. (2) Therapeutic and diagnostic EUS impacted clinical care decisions. (3) There is a low risk of immediate significant complications. (4) The overall efficacy and safety support the performance of EUS in a pediatric population by experienced endoscopists.

EUS-guided pseudocyst drainage through a gastric pouch by use of a lumen-apposing metal stent in a patient with Roux-en-Y anatomy.

EUS-guided pseudocyst drainage through a gastric pouch by use of a lumen-apposing metal stent in a patient with Roux-en-Y anatomy.

PWE-157 EUS Guided Trans-Gastric Pancreatic Pseudocyst Drainage- Does Standard Use of Fluoroscopy Just Complicate Things?: Abstract PWE-157 Table 1

Introduction Endoscopic pancreatic pseudocyst drainage is effective and associated with lower morbidity and mortality compared to surgical or percutaneous methods. EUS guidance is now the gold standard intervention due to a higher success rate and lower complication rate compared to blind puncture with fluoroscopic assistance. Many centres still use fluoroscopic guidance with EUS for all cyst-gastroscopy procedures. We present single centre experience of EUS guided pseudocyst drainage and complication rates comparing complication rates with and without fluoroscopic assistance. Methods All EUS guided trans-gastric and trans-duodenal pseudocyst and acute pancreatic fluid collections drainage procedures from 2010 to January 2016 were included. Demographics, use of fluoroscopy and initial success of drainage with stent placement were recorded. All procedures were performed with midazolam and fentanyl sedation without endotracheal tube insertion. Standard trans-gastric drainage was attempted if there was good luminal/gastric wall apposition (cyst distance Results 71 procedures were performed in 68 patients (mean age 50.8, SD 16.1). Immediate drainage was achieved in 69/71 (97.1%) of cases (2 procedures were abandoned due to bleeding). 2 procedures used fully covered metal stents, the remainder used two plastic stents. 2 procedures were performed via the duodenum due to cyst position. 9 patients experienced complications. Although the complications in the fluoroscopy group were more frequent there was no significant statistical difference in complication rates on comparing the two groups (p = 0.25). Conclusion Although fluoroscopy could be helpful in certain circumstances, the routine additional use of fluoroscopy does not reduce complications for EUS guided trans-gastric drainage of pancreatic pseudocysts. Disclosure of Interest None Declared

Diagnostic and Therapeutic Roles of Endoscopic Ultrasound in Pediatric Pancreaticobiliary Disorders.

The diagnostic role of endoscopic ultrasound (EUS) in children has only recently been demonstrated, and that also to a lesser extent than in adults. Data on the technique's therapeutic indications remain scarce. We therefore sought to evaluate diagnostic and interventional EUS indications, safety, and impact in children with pancreaticobiliary disorders. We retrospectively reviewed our single pediatric center records, covering a 14-year period. From January 2000 to January 2014, 52 EUS procedures were performed in 48 children (mean age: 12 years; range: 2-17 years) with pancreaticobiliary disorders for the following indications: suspected biliary obstruction (n = 20/52), acute/chronic pancreatitis (n = 20), pancreatic mass (n = 3), pancreatic trauma (n = 7), and ampullary adenoma (n = 2). EUS was found to have a positive impact in 51 of 52 procedures, enabling us to avoid endoscopic retrograde cholangiopancreatography (ERCP) (n = 13 biliary; n = 6 pancreatic), focusing instead on endotherapy (n = 7 biliary; n = 14 pancreatic) or reorienting therapy toward surgery (n = 7). EUS-guided fine-needle aspiration was carried out on 12 patients for pancreatic tumor (n = 4), pancreatic cyst fluid analysis (n = 4), autoimmune pancreatitis (n = 2), and suspicion of biliary tumor (n = 2). A total of 13 therapeutic EUS procedures (11 children) were conducted, including 9 combined EUS-ERCP procedures (7 children, mean age: 8 years, range: 4-11 years), 3 EUS-guided pseudocyst drainage (2 children), and 1 EUS-guided transgastric biliary drainage. Our study reports on a large pediatric EUS series for diagnostic and therapeutic pancreaticobiliary disorders, demonstrating the impact of diagnostic EUS and affording insights into novel EUS and combined EUS-ERCP therapeutic applications. We suggest considering EUS as a diagnostic and therapeutic tool in the management of pediatric pancreaticobiliary diseases.

206 EUS-Guided Pseudocyst Drainage: Prospective Evaluation of Early Removal of Fully Covered Self Expandable Metal Stents With Pancreatic Ductal Stenting in Selected Patients

206 EUS-Guided Pseudocyst Drainage: Prospective Evaluation of Early Removal of Fully Covered Self Expandable Metal Stents With Pancreatic Ductal Stenting in Selected Patients

EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self-expandable metal stents with pancreatic ductal stenting in selected patients

EUS-guided pseudocyst drainage with fully covered self-expandable metal stents (FCSEMSs) was recently described. The appropriate period for stent removal is not known. To assess the safety and efficacy of EUS-guided FCSEMS placement for 3 weeks, along with pancreatic ductal stenting in selected patients. Prospective, single-center evaluation. Tertiary referral center. Symptomatic pseudocysts in the body and tail region of the pancreas. EUS-guided transgastric placement of FCSEMS. MRCP was performed after 3 weeks. Patients with a suspected pancreatic duct leak underwent ERCP and plastic stent placement. The FCSEMSs were removed at 3 weeks. Success of FCSEMS placement, adverse events, and recurrence rate. Forty-seven patients met the eligibility criteria. Technical and functional success was achieved in 43 patients (intention to treat, 91.48% and 95.34% patients [per protocol, 41/43, respectively]). Adverse events occurred in 2 patients (cyst infections, 4.6%). Follow-up of 42 patients at 3 weeks was performed. MRCP detected a ductal leak in 3 patients (7.1%) and a disconnected duct in 2 patients (4.7%). ERCP and stenting were successful in all 3 patients with a ductal leak. During a median follow-up of 306 days in 42 patients, 2 recurrences (4.7%) were detected, both in patients with disconnected duct. Multivariate analysis showed that pancreatic ductal leak or disconnection was an independent factor affecting pseudocyst resolution at 3 weeks (P = .0001). Single-center study. Short-term placement of FCSEMSs with pancreatic ductal stenting in selected patients appears safe and effective for the treatment of pseudocysts.

Application of Endoscopic Ultrasonography in the Diagnosis and Treatment of Lower Gastrointestinal Disease

Application of Endoscopic Ultrasonography in the Diagnosis and Treatment of Lower Gastrointestinal Disease

Endoscopic ultrasound-guided drainage of pancreatic pseudocysts.

Pancreatic pseudocysts are fluid collections in the peripancreatic tissues associated with acute or chronic pancreatitis. Endoscopic ultrasound (EUS)-guided drainage has become an established indication, having better results as compared to percutaneous drainage, nonguided endoscopic drainage, or surgical drainage. The aim of this review is to assess critically the current literature concerning EUS-guided pseudocyst drainage and to review the place of the procedure in the clinical decision management algorithms of these patients.

Single-step EUS-guided pancreatic pseudocyst drainage: An assessment of efficacy, safety, long-term follow-up, and technical feasibility

Single-step EUS-guided pancreatic pseudocyst drainage: An assessment of efficacy, safety, long-term follow-up, and technical feasibility

Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent

BackgroundHemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.Case presentationWe report a case of an immediate internal spurting arterial bleeding precipitated during EUS-guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self-expandable metal stent through mechanical hemostasis.ConclusionIn an unusual situation of bleeding from collateral circulation near the pseudocyst wall during pseudocyst drainage, the placement of an expandable metal stent proved to be useful.

Outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts by using combined endoprosthesis and a nasocystic drain

The presence of debris within a pseudocyst may impair success of endoscopic drainage. To compare the clinical outcomes and adverse-event rates of EUS-guided pseudocyst drainage with and without a nasocystic drain for the management of pancreatic pseudocysts with viscous solid debris-laden fluid. Retrospective study. Single, tertiary-care referral center. Consecutive patients with pancreatic pseudocysts managed by EUS-guided drainage: those with solid debris who underwent drainage via nasocystic drains alongside stents (n = 63) and those with solid debris who underwent drainage via transmural stents only (n = 24). Drainage via nasocystic drains alongside stents or drainage via transmural stents only. The primary outcomes were short-term success and long-term success of the procedures. The secondary outcomes were procedure-related adverse events and reintervention. The patients with viscous solid debris-laden fluid whose pseudocysts were drained by both stents and nasocystic tubes had a 3 times greater short-term success rate compared with those who had drainage by stents alone (P = .03). On 12-month follow-up, complete resolution of pseudocysts with debris drained via stents alone was less (58%) compared with those with debris who underwent drainage via nasocystic drains alongside stents (79%; P = .059). The rate of stent occlusion was higher in cysts with debris drained by stents alone (33%) compared with those drained via nasocystic drains alongside stents (13%; P = .03). Retrospective design; limited sample size. In patients with pseudocysts with viscous debris-laden fluid, EUS-guided drainage by using a combination of a nasocystic drain and transmural stents improves clinical outcomes and lowers the stent occlusion rate compared with those who underwent drainage via stents alone.

Endosonography-guided transmural drainage of pancreatic pseudocysts using an exchange-free access device: initial clinical experience

Endosonography (EUS)-guided transmural pseudocyst drainage is a multistep procedure currently performed with different "off-the-shelf" accessories developed for other applications. Multiple device exchanges over-the-wire is time consuming and risks loss of wire access. This report describes the technical feasibility and outcomes for EUS-guided drainage of pancreatic fluid collections using a novel exchange-free device developed for translumenal therapy. Between April and November 2010, 14 patients (9 men; mean age, 49.9 years) with pancreatic fluid collection (mean size, 102 mm) underwent 16 EUS-guided drainage procedures using the exchange-free access device at a single tertiary care center. The trocar of the exchange-free device was used to gain pseudocyst access. The dual-balloon catheter then was advanced over the trocar, followed by inflation of the (first) anchor balloon. Cyst contents were sampled, and contrast was injected to define the pseudocyst anatomy. The first guidewire was inserted into the cyst cavity. The cystenterostomy tract was dilated to 10 mm with the (second) dilation balloon, followed by a second guidewire insertion. The exchange-free access device was removed, leaving the two guidewires in place for two double-pigtail stents. The procedure was technically successful for all the patients. No acute procedure-related complications occurred. Late complications included a symptomatic leak in a patient who underwent drainage of a pancreatic uncinate pseudocyst from the second duodenum, a self-limited transfusion-dependent bleed after transbulbar drainage, and symptomatic pseudocyst infection. Pseudocyst access, cystenterostomy tract dilation, and placement of two guidewires for dual stent drainage are technically feasible using an exchange-free access device. The device has the potential to standardize, simplify, and streamline EUS-guided pseudocyst drainage with a single instrument. Comparative studies with alternative tools and methods for pseudocyst drainage are warranted.

Combined EUS-Guided Abdominal Cavity Drainage and Cystogastrostomy for the Ruptured Pancreatic Pseudocyst

Background. Endoscopic-Ultrasonography- (EUS-) guided puncture and drainage of pancreatic pseudocyst is currently one of the most widely accepted nonsurgical treatments. To date, this technique has only been used for pancreatic pseudocysts adhesive to the gastric wall. This study introduces the technique of EUS-guided pseudocyst drainage and additional EUS-guided peritoneal drainage for the ruptured pseudocyst. Methods. Transmural puncture and drainage of the cyst were performed with a 19 G needle, cystotome, and 10 Fr endoprosthesis. Intraperitoneal drainage was performed with a nasobiliary catheter when rupture of pseudocyst occurred. The entire procedure was guided by the echoendoscope. Results. A total of 21 patients, 8 men and 13 women, with a mean age of 36 years, were included in this prospective study. All of the pseudocysts were successfully drained by EUS. Peritoneal drainage was uneventfully performed in 4 patients. There were no severe complications. Complete pseudocyst resolution was established in all patients. Conclusion. The technique of EUS-guided transmural puncture and drainage, when combined with abdominal cavity drainage by a nasobiliary catheter, allows successful endoscopic management of pancreatic pseudocysts without adherence to gastric wall.

Endoscopic Biliary Access

Endoscopic Biliary Access

Endoscopic ultrasound (EUS)-guided pseudocyst drainage as a one-step procedure using a novel multiple-wire insertion technique (with video)

The EUS 2008 working group considered the development of equipment and methods to minimize the need for exchanging accessories and to facilitate insertion of multiple transmural stents during endoscopic ultrasound (EUS)-guided pseudocyst drainage as an important advance for therapeutic EUS. The authors aimed to describe their experience with EUS-guided pseudocyst drainage using a novel multiple-wire insertion technique facilitated by the double-lumen biliary cytology brush catheter. The study enrolled 10 symptomatic patients undergoing EUS-guided pseudocyst drainage. The EUS-guided pseudocyst drainage was performed as a one-step procedure using graded catheter and balloon dilation of the cystgastrostomy tract and a novel multiple-wire insertion technique facilitated by a modified double-lumen biliary cytology brush catheter. The main outcome measured was technical success. In this study, 10 patients with 11 pseudocysts underwent a EUS-guided pseudocyst using the novel multiple-wire insertion technique. Technical success, defined as successful achievement of access and drainage of pseudocysts, was achieved in all cases (100 %) with no procedural complications. Clinical success was achieved in all cases with complete resolution of pseudocysts. The novel method of using a modified double-lumen biliary cytology brush catheter allows for a simple and safe one-step EUS-guided drainage of pseudocysts.

Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications.

Pancreatic cystic lesions are being detected with an increasing frequency. Endoscopic ultrasound (EUS) provides both diagnostic and therapeutic means for pancreatic cystic lesions. Detailed imaging and EUS-guided fine-needle aspiration provide additional information on pancreatic cystic lesions. EUS-guided pseudocyst drainage has advantages over conventional drainage modalities. EUS-guided cyst ablation is a promising therapeutic modality.