Endoscopic ultrasound‐guided drainage of pancreatic pseudocysts using a large‐channel echoendoscope and a conventional polypectomy snare

Abstract

Background: Endoscopic drainage of pancreatic pseudocysts is becoming common. Recent techniques using endoscopic ultrasound (EUS) have made the procedure safer and easier. However, bleeding related to the procedure is sometimes still experienced and placement of the tube is also sometimes difficult in cases where the cystic wall is thick and hard. We describe a new technique of EUS‐guided drainage using a large‐channel echoendoscope, a conventional polypectomy snare and a high‐frequency current generator with automatic controls. We also evaluate this technique's utility. Methods: Between May 2001 and December 2002, EUS‐guided drainage was attempted in consecutive patients with symptomatic pancreatic pseudocysts that had resisted conservative treatments. The EUS device was a recently introduced large‐channel linear scanning echoendoscope. A puncture was made with a 19 G needle under EUS guidance and a 0.035 inch guidewire was passed through the puncture and into the pseudocyst. Then, a conventional polypectomy snare was used to enlarge the puncture tract with the new current generator, and a 7 Fr pigtail‐type nasocystic drain was placed. Results: The drainage was successful and insertion of the drain was easy in all 13 patients included in the study. No complications related to the procedure, such as bleeding and perforation, were observed. The clinical symptoms resolved after the procedure in all patients. In nine patients, the cyst completely disappeared and the discharge also stopped, allowing the tube to be removed after a mean of 15 days. The median follow‐up period for these nine patients was 4 months and no recurrence has been observed. In two other patients, the cysts shrank but did not disappear completely 4 weeks or more after the procedure. Since both of these patients had had previous cystic infections, they were given surgical operations. In the remaining two cases, the cystic lumen completely disappeared but the discharge continued for 4 weeks, so we replaced the 7 Fr nasobiliary tube with a 10 Fr internal drainage tube. Conclusion: This method is an easy and effective treatment for pancreatic pseudocysts. It may also reduce the risk of bleeding related to the procedure.

Eus‐guided Pancreatic Pseudocyst Drainage

“…The simple puncture using a conventional FNA needle seems easier and safer, 8 but the subsequent insertion of a drainage tube over a guidewire is often difficult especially in cases with a thick and hard cystic wall. Therefore, a polypectomy snare is used to enlarge the tract for such cases, 6 but it is still occasionally difficult. Special ‘one‐step’ drainage systems have also been reported 9–12 .…”

“…biliary dilation catheter (Soehendra dilator, COOK) was inserted, and dilated the puncture tract. If it was difficult to insert the dilation catheter, a conventional polypectomy snare (SD‐7P, Olympus) was used as previously reported 6 . After dilation of the puncture tract, a 6‐ or 7‐Fr.…”

“…If it was difficult to insert the dilation catheter, a conventional polypectomy snare (SD-7P, Olympus) was used as previously reported. 6 After dilation of the puncture tract, a 6-or 7-Fr. pigtail-type nasobiliary drainage tube was inserted into the cyst over the guidewire.…”

Eus‐guided Drainage of Pancreatic Pseudocysts, Abscesses and Infected Necrosis

“…Other authors have reported introducing either the 10Fr outer catheter of a cystotome, 14 or a 10Fr Soehendra biliary dilator, 15 into the pseudocyst cavity over the single guide‐wire inserted at the initial EUS‐guided puncture, followed by insertion of a second guide‐wire through these catheters. Sequential transmural stent and drainage catheter placement can then be performed without a loss of access to the pseudocyst cavity.Other techniques based on the above mentioned principles have been reported 16–18 …”