Sequential therapy with combined trans-papillary endoscopic naso-pancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts

Abstract

Background: Endoscopic retrograde pancreatic drainage (ERPD) and stent implantation has become the major treatment method for pancreatic pseudocysts. However, it is associated with a high recurrence rate and infection.

Aim: To manage pancreatic pseudocysts by sequential therapy with endoscopic naso-pancreatic drainage (ENPD) combined with ERPD and evaluate the treatment outcome.

Methods: One hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed. There were 152 cases of intubation via the duodenal papilla, of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD (two-step procedure). The success rate of the procedure, incidence of complications (infection, bleeding, etc.), recurrence, and length and cost of hospitalization were compared between the two groups.

Results: The incidence of infection was significantly higher in the ERPD group (12 cases) than in the two-step procedure group (2 cases). Twelve patients developed infection in the ERPD group, and anti-infection therapy was effective in five cases but not in the remaining seven cases. Infection presented as fever and chills in the two-step procedure group. The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group (P < 0.05). Similarly, the recurrence rate was significantly higher in the ERPD group (19 cases) than in the two-step procedure group (0 cases).

Conclusion: Sequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.

Keywords: Endoscopic nasobiliary drainage; Endoscopic retrograde cholangiopancreatography; Endoscopic retrograde pancreatic drainage; Endoscopic ultrasonography trans-gastric puncture drainage of the pancreas; Endoscopy; Pancreatic pseudocyst.

Figure 1

Process of pancreatic duct stenting for pancreatic pseudocysts. A: Location of the pancreatic pseudocyst shown by computed tomography; B and C: Location of the pancreatic pseudocyst shown by magnetic resonance cholangiopancreatography (orange arrow) using the T2 weighted image sequence (B) and balanced turbo field echo sequence (C); D: Successful duodenal intubation followed by a guide wire inserted into the pancreatic duct (white arrow); E: Pancreatic duct and cyst shown by imaging (orange arrow); F: Pancreatic duct stenting (blue arrow).

Figure 2

Sequential therapy of pancreatic pseudocysts using the two-step procedure (endoscopic naso-pancreatic drainage combined with endoscopic retrograde pancreatic drainage sequential therapy). A and B: Location of the pancreatic pseudocyst shown by computed tomography (CT) (orange arrow); C and D: Location of the pancreatic pseudocyst shown by magnetic resonance cholangiopancreatography (orange arrow) using the T2 weighted image sequence (C) and balanced turbo field echo sequence (D); E: Successful duodenal papilla intubation followed by a guide wire into the pancreatic duct (white arrow); F: Pancreatic pseudocyst shown by imaging of the guide wire into the pancreatic duct (orange arrow); G: Naso-pancreatic duct placed in the pancreatic pseudocyst (yellow arrow is the naso-pancreatic duct, and black arrow is the biliary stent); H: Abdomen of the patient before naso-pancreatic duct placement (blue arrow); I: Changes in the abdomen 3 h after naso-pancreatic duct placement (blue arrow); J: Pancreatic pseudocyst shown by CT 1 wk after naso-pancreatic duct placement (orange arrow); K: Pancreatic pseudocyst shown by guide wire and radiography after removal of the naso-pancreatic duct via endoscopic retrograde cholangiopancreatography (orange arrow); L: Placement of the pancreatic duct stent after removal of the naso-pancreatic duct (purple arrow).

Figure 3

Three cyst types (Xinqiao classification) based on the relationship between the pancreatic pseudocyst and the splenic vein (the orange line on the horizontal axis is the splenic vein plane, and the white line on the vertical axis indicates the distance between the cyst and the splenic vein plane). Type I: Pancreatic pseudocyst above the splenic vein plane; Type II: Pancreatic pseudocyst located partially above the splenic vein and partially within 3 cm below the splenic vein; Type III: Pancreatic pseudocyst located below the splenic vein (greater than 3 cm or the entire cyst is below the splenic vein).

Figure 4

Flow diagram of patient enrollment. ERPD: Endoscopic retrograde pancreatic drainage.