Differential treatment and early outcome in the interventional endoscopic management of pancreatic pseudocysts in 27 patients

Abstract

Aim: Pancreatic pseudocysts (PPC) as a complication of pancreatitis are approached only in the case of abdominal pain, infection, bleeding, and compression onto the gastrointestinal tract or biliary tree.

Methods: From 02/01/2002 to 05/31/2004, all consecutive patients with symptomatic PPC who underwent an interventional endoscopic approach were evaluated in this pilot case-series study: Group (Gr.) I-Primary percutaneous (external), ultrasound-guided drainage. Gr. II-Primary EUS-guided cystogastrostomy. Gr. III-EUS-guided cystogastrostomy including intracystic necrosectomy.

Results: (="follow up": n = 27): Gr. I (n = 9; 33.3%): No complaints (n = 3); change of an external into an internal drainage (n = 4); complications: (a) bleeding (n = 1) followed by 3 d at ICU, discharge after 40 d; (b) septic shock (n = 1) followed by ICU and several laparotomies for programmed lavage and necrosectomy, death after 74 d. Gr. II (n = 13; 48.1%): No complaints (n = 11); external drainage (n = 2); complications/problems out of the 13 cases: 2nd separate pseudocyst (n = 1) with external drainage (since no communication with primary internal drainage); infection of the residual cyst (n = 1) + following external drainage; spontaneous PPC perforation (n = 1) + following closure of the opening of the cystogastrostomy using clips and subsequently ICU for 2 d. Gr. III (n = 5; 18.5%): No complaints in all patients, in average two endoscopic procedures required (range, 2-6).

Conclusion: Interventional endoscopic management of pancreatic pseudocysts is a reasonable alternative treatment option with low invasiveness compared to surgery and an acceptable outcome with regard to the complication rate (11.1%) and mortality (3.7%), as shown by these initial study results.

Figure 1

EUS images of an infected pancreatic pseudocyst (abscess) prior (A) and after placement (B) of an external drainage.

Figure 2

EUS-guided drainage of a pancreatic pseudocyst after previous external drainage: (A) EUS image; (B) Subsequent fluoroscopy control image of correct placement of the drainage.

Figure 3

Endoscopy-guided cystogastrostomy via guide wire (A) and placement of an internal drainage (B).

Figure 4

Endoscopic images: (A) EUS-guided puncture after previous external drainage; (B) Balloon dilatation via guide wire.

Figure 5

Endoscopic view: (A) After EUS-guided placement of an internal drainage (external drainage previously); (B) Into the pseudocystic cavity showing necroses; (C) Showing necrosectomy; (D) Through the transgastrocystic opening into the necrosectomized pseudocystic cavity.