Endoscopic Transmural Drainage of Pancreatic Pseudocysts ...

Hindawi Publishing CorporationCase Reports in Gastrointestinal MedicineVolume 2013 Article ID 942832 6 pageshttpdxdoiorg1011552013942832

Case ReportEndoscopic Transmural Drainage ofPancreatic Pseudocysts TechnicalChallenges in the Resource Poor Setting

Shamir O Cawich1 Trevor Murphy2 Sundeep Shah3 Phillip Barrow3 Milton Arthurs2

Michael J Ramdass1 and Peter B Johnson3

1 Department of Clinical Surgical Sciences University of the West Indies St Augustine Campus St Augustine Trinidad and Tobago2Department of Medicine University of the West Indies Mona Campus Kingston Jamaica3 Departments of Surgery Radiology Anaesthesia and Intensive Care University of the West Indies Mona CampusKingston Jamaica

Correspondence should be addressed to Shamir O Cawich socawichhotmailcom

Received 26 September 2013 Accepted 23 October 2013

Academic Editors H Akiho and J Wig

Copyright copy 2013 Shamir O Cawich et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options the requirement for specializedequipment technical expertise and consumables limits the options available in low resource settings We describe the challengesexperienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriersDespite operating in a low resource environment endoscopic drainage of pancreatic pseudocysts can be incorporated into ourarmamentarium with minimal change to the existing hardware Careful patient selection by a dedicated multidisciplinary teamshould be observed in order to achieve good outcomes

1 Introduction

Disruption of the pancreatic ducts can produce an acute fluidcollection that matures to become surrounded by a fibrouscapsule due to the chronic inflammatory reactionThe result-ing pancreatic pseudocyst [1ndash3] may become complicated byhaemorrhage intestinal obstruction infection or rupture

When complications develop pseudocysts require someform of drainage [3 4] The traditional open surgicalapproach has now been superseded by less invasive optionssuch as percutaneous drainage [3] or endoscopic drainage [4]The advantages of these less invasive options are balanced bythe need for technical expertise specialized equipment andincreased cost Therefore these options are not universallyavailable in low resource settings in developing countries[3 5]

We report the challenges encountered in the low resourcesetting when performing endoscopic cystogastrostomy forpancreatic pseudocysts To the best of our knowledge this

is the first report of endoscopic cystogastrostomy from theAnglophone Caribbean

2 Report of a Case

A 14-year-old boy presented to the emergency departmenteight weeks after being kicked in the epigastrium during afootball match He reported getting worse and nonbiliousvomiting associated with an enlarging tender epigastricmass He could only tolerate small volumes of fluids orally

On presentation he was mildly dehydrated afebrile andanicteric There was upper abdominal distention associatedwith a firm epigastric mass The mass was tender on deeppalpation but there was no guarding or rebound tendernessBowel sounds were normal and a succussion splash wasnot presentThe respiratory and cardiovascular examinationswere normal

Liver function tests and serum amylase were normalAbdominal ultrasound revealed a 13 times 19 times 21 cm cystic

2 Case Reports in Gastrointestinal Medicine

Figure 1 Axial slice of a CT scan of a patient with a large pancreaticpseudocyst (PP) demonstrating its apposition onto the posteriorwall of the body of the stomach (S)

Figure 2 Gastroscope advanced into stomach to identify the area ofbulging at the posterior gastric wall Simultaneous transabdominalultrasound being performed to guide the endoscopist to the idealarea for puncture

mass occupying the entire lesser sac interposed betweenstomach and pancreas Multiphase computer tomographicscans confirmed the presence of a well-organized pancreaticpseudocyst displacing the stomach anteriorly and containedin a thick-walled mature capsule (Figure 1) Endoscopic ret-rograde pancreatography revealed no evidence of proximalstrictures and was unable to demonstrate the connectionbetween the ductal system and the pseudocyst

An endoscopic cystogastrostomy was attempted in theendoscopy suite under conscious sedation with intravenousPropofol The procedure was performed in the left lateraldecubitus positionwith noninvasivemonitoring Intravenousceftriaxone was administered as prophylaxis at inductionA side viewing duodenoscope (Olympus TJF-140 OlympusAmerica Central Valley PA USA) was advanced into thestomach With insufflation the area of extrinsic gastric com-pression was identified on the posterior wall Endoscopicultrasound (EUS) was not available so the stomach wasaspirated while the endoscope remained in situ This facili-tated simultaneous transabdominal ultrasound (Figure 2) toconfirm that the endoscope tip was at an appropriate areafor puncture A triple lumen needle knife sphincterotome(Micro-knife XL Boston Scientific Co Marlborough MAUSA) was advanced through the working channel of the

scope and used to create a 1-2 cm incision in the gastricmucosa (Figure 3(a)) with bipolar electrocautery (force FXValleylab Boulder CO USA) Entry into the cyst wasconfirmed by a gush of clear pancreatic fluid returning(Figure 3(b)) A 480 cm flexible 003510158401015840 guidewire (HydraJagwire Boston Scientific Co Marlborough USA) wasadvanced through the incision The needle knife catheterwas removed leaving the guidewire across the incisionwithin the pseudocyst cavity A 6ndash8mm controlled radialexpansion biliary dilating balloon (CREWireguided BalloonDilator Boston Scientific Microvasive Natick MA USA)was railroaded over the guidewire (Figure 4(a)) and inflatedto dilate the transmural tract to 16mm (Figure 4(b)) Thedilating balloon was inflated on three separate occasionsfor 20 seconds to ensure adequate dilation of the incisionThe dilating balloon was removed with the guidewire leftin place A double pigtail 10 F times 5 cm plastic stent (C-flex Biliary Boston Scientific Spencer IN USA) was thenadvanced over the guidewire and deployed with the prox-imal end in the gastric lumen and the distal end withinthe pseudocyst cavity Ultrasound was repeated to confirmdrain placement within the cavity and the gastric placementwas confirmed at endoscopy and subsequently with plainradiographs (Figure 5) Approximately 3700mL of turbidpancreatic fluid was removed from the cyst resulting inimmediate abdominal decompression (Figure 6)

The recovery period is uneventful and the patient wasnow able to tolerate a normal diet The patient remainedclinically well 6 months after stent removal (1 year afterdrainage) and the abdomen remained flat (Figure 7) Repeatultrasound 12 weeks after stent removal showed no evidenceof recurrence and the patient was discharged from followup

3 Discussion

Open surgical drainage was first described in 1882 [6] buthas become less popular over the past two decades as wewitness a shift toward less invasive drainage procedures [4 78] Laparoscopic drainage brings lower morbidity and fasterrecovery than open surgical drainage [8] but places an extrademand for specialized equipment and advanced laparo-scopic skill sets that are not universally available in manydeveloping countries To date there have been no reportsof laparoscopic pseudocyst drainage from the AnglophoneCaribbean

Percutaneous drainage is feasible but it has low long-term success rates that range from 42 [9] to 50 [10] withpercutaneous fistulae developing in 20 [7] to 40 [11] ofcases Therefore percutaneous external drainage is relegatedonly to high-risk patients patients with immature cyst wallsunsuitable for internal drainage and those with infected cysts[3]

Endoscopic drainage was first described in 1985 [12]and quickly gained popularity because it avoided the needfor general anaesthesia with relatively few complicationsWe performed a literature search in PubMed MEDLINESCOPUS SciELO and Cochrane databases seeking reportson endoscopic drainage of pancreatic pseudocysts published

Case Reports in Gastrointestinal Medicine 3

(a) (b)

Figure 3 (a) A needle knife papillotome punctures the most protuberant point on the gastric mucosa (b) entry into the cyst confirmed by agush of clear fluid returning

(a) (b)

Figure 4 A balloon dilator was railroaded over a guidewire (a) to dilate the transmural tract to 16mm (b)

in the past 5 years from June 2008 to June 2013 We excludedsmall studies with less than 15 drainage procedures Twelvestudies were identified reporting on EUS drainage in a totalof 532 patients [13ndash24] with good clinical outcomes technicalsuccess in 514 (966) cases clinical success in 500 (940)cases complications in 111 (209) cases and recurrence in46 (87) cases

Two types of endoscopic drainage exist transpapillaryand transmural Transpapillary drainage involves balloondilation and stenting at endoscopic retrograde pancreatogra-phy which should be done routinely to identify disruption orstenosis of the pancreatic ducts [7] Successful transpapillarydrainage requires a demonstrable communication betweenthe pseudocyst cavity and main duct to allow for completedrainage [4 7 25] Our patient was not a candidate for

transpapillary drainage as there was no demonstrable com-munication present

Transmural drainage can be done across the duodenalor gastric wall depending on pseudocyst location Theprerequisites for transmural endoscopic drainage includelt1 cm distance between the pseudocyst and intestinal wallon imaging a clear impression of the intestinal wall atendoscopy absence of varices absence of pseudoaneurysmsand exclusion of malignant lesions before treatment [26ndash28]

Many endoscopists now perform transmural drainageunder EUS guidance in order to avoid blood vessels [28ndash31] and select the optimal puncture site [32ndash37] As EUSwas not available in this low resource setting we utilizedtransabdominal ultrasound to guide the puncture site Byremoving the air interface from the insufflated stomach while


(a) (b)

Figure 5 Placement of the end of the pigtail stent within the gastric lumen Position confirmed on endoscopy (a) and on plan radiographs(b)

Figure 6 Immediate abdominal decompression (a) after 3700mLof turbid pancreatic fluid was drained from the cyst (b)

leaving the scope in situ we were able to visualize the scopeat transabdominal ultrasound and determine its relationshipto the pseudocyst cavity in order to avoid vessels and selectthe appropriate puncture site

There is still lack of consensus on the need for routineEUS during transmural drainage procedures During ourliterature searchwe encountered twoprospective randomizedtrials comparing EUS and non-EUS guided drainage ofpancreatic pseudocysts in a total of 90 patients [23 24]Overall 45 patients who had EUS guided drainage werecompared to 44who had conventional drainagewithout EUSTechnical success was better in EUS guided studies (956)than with conventional drainage without EUS (591) More-over the 18 patients who had failed conventional drainagewere crossed over into the EUS arm in both studies with100 success in these cases [23 24] Park et al [24] reportedthat EUS guided and conventional drainage procedures hadstatistically similar complication rates (7 versus 10) Weeagerly await the results of the ongoing Cochrane review

Figure 7 Abdomen remains flat one year after drainage

currently underway [38] designed to analyze the effectivenessof intramural endoscopic drainage with and without EUS

Although there is evidence in support of EUS there is stilldebate on whether it should be used routinely for transmuraldrainage Yusuf and Baron [39] carried out a survey of 266practicing gastroenterologists from the American Societyof Gastrointestinal Endoscopy They reported that 35 ofendoscopists who regularly perform transmural drainagedo not use EUS routinely only employing this modalityselectively [39] There seems to be consensus however thatEUS should be used in difficult cases where there is a smallwindow for entry [12 28] absent endoscopic bulge [39]unusual cyst location [12] or prior failed non-EUS guidedattempts [12 28]

Recent literature describes the use of a single stepapproach to transmural drainage where multiple drains areplaced using specialized echoendoscopes with large diameterworking channels [27 28 32ndash36] However in countries withlimited resources this type of specialized equipment is notusually available We had no access to EUS or specialized


echoendoscopes in this low resource setting In fact manyof the consumables used were received as donations fromcharity organizations The use of transabdominal ultrasoundin this manner may be a low cost alternative to EUS andechoendoscopes for transmural endoscopic drainage in theresource poor setting Although a drainage procedure canbe successful when performed by an experienced dedicatedmultidisciplinary team we acknowledge that careful patientselection should be exercised in the low resource setting

4 Conclusion

Despite operating in a low resource environment endoscopicdrainage of pancreatic pseudocysts can be incorporated intoour armamentarium with minimal change to the existinghardware Careful patient selection and a dedicated multidis-ciplinary team are required to achieve good outcomes

References

[1] E L Bradley III and C F Frey ldquoA clinically based classificationsystem for acute pancreatitis summary of the InternationalSymposium on Acute Pancreatitis Atlanta Ga September 11through 13 1992rdquo Archives of Surgery vol 128 no 5 pp 586ndash590 1993

[2] T L Bollen H C Van Santvoort M G Besselink et al ldquoTheAtlanta Classification of acute pancreatitis revisitedrdquo BritishJournal of Surgery vol 95 no 1 pp 6ndash21 2008

[3] M E C McFarlane ldquoThe role of percutaneous drainage in themodern management of pancreatic pseudocystsrdquo InternationalJournal of Clinical Practice vol 59 no 4 pp 383ndash384 2005

[4] D Cahen E Rauws P Fockens G Weverling K HuibregtseandM Bruno ldquoEndoscopic drainage of pancreatic pseudocystslong-term outcome and procedural factors associated with safeand successful treatmentrdquo Endoscopy vol 37 no 10 pp 977ndash983 2005

[5] S O Cawich M Abu-Hilal L K Simpson and N W PearceldquoTraining forHepatobiliary Surgery in themodern laparoscopicerardquoWest IndianMedical Journal vol 62 no S4 pp 24ndash25 2013

[6] J W Cannon M P Callery and C M Vollmer Jr ldquoDiagnosisand management of pancreatic pseudocysts what is the evi-dencerdquo Journal of the American College of Surgeons vol 209no 3 pp 385ndash393 2009

[7] MM Lerch A Stier UWahnscaffe and JMayerie ldquoPancreaticpseudocysts observation endoscopic drainage or resectionrdquoDeutsches Arzteblatt international vol 106 no 38 pp 614ndash6212009

[8] M Aljarabah and B J Ammori ldquoLaparoscopic and endoscopicapproaches for drainage of pancreatic pseudocysts a systematicreview of published seriesrdquo Surgical Endoscopy and OtherInterventional Techniques vol 21 no 11 pp 1936ndash1944 2007

[9] R Heider A A Meyer J A Galanko and K E BehrnsldquoPercutaneous drainage of pancreatic pseudocysts is associatedwith a higher failure rate than surgical treatment in unselectedpatientsrdquo Annals of Surgery vol 229 no 6 pp 781ndash789 1999

[10] A K Khanna S K Tiwary and P Kumar ldquoPancreatic pseudo-cyst therapeutic dilemmardquo International Journal of Inflamma-tion vol 2012 Article ID 279476 7 pages 2012

[11] M Dohmoto K Akiyama and Y Lioka ldquoEndoscopic andendosonographic management of pancreatic pseudocyst

a long-term follow-uprdquo Revista de Gastroenterologia del Peruvol 23 no 4 pp 269ndash275 2003

[12] R A Kozarek C M Brayko and J Harlan ldquoEndoscopicdrainage of pancreatic pseudocystsrdquo Gastrointestinal Endos-copy vol 31 no 5 pp 322ndash328 1985

[13] R P Voermans M C Veldkamp E A Rauws M J Brunoand P Fockens ldquoEndoscopic transmural debridement ofsymptomatic organized pancreatic necrosisrdquo GastrointestinalEndoscopy vol 66 no 5 pp 909ndash916 2007

[14] J C Ardengh D E Coelho J F Coelho L F Pereira de LimaJ S dos Santos and J L Pimenta Modena ldquoSingle-step EUS-guided endoscopic treatment for sterile pancreatic collectionsa single-center experiencerdquoDigestive Diseases vol 26 no 4 pp370ndash376 2009

[15] M Hocke U Will P Gottschalk U Settmacher and AStallmach ldquoTransgastral retroperitoneal endoscopy in septicpatients with pancreatic necrosis or infected pancreatic pseudo-cystsrdquo Zeitschrift fur Gastroenterologie vol 46 no 12 pp 1363ndash1368 2008

[16] S Varadarajulu A Tamhane and J Blakely ldquoGraded dilationtechnique for EUS-guided drainage of peripancreatic fluidcollections an assessment of outcomes and complications andtechnical proficiencyrdquoGastrointestinal Endoscopy vol 68 no 4pp 656ndash666 2008

[17] M Barthet G Lamblin M Gasmi V Vitton A Desjeux andJ-C Grimaud ldquoClinical usefulness of a treatment algorithm forpancreatic pseudocystsrdquoGastrointestinal Endoscopy vol 67 no2 pp 245ndash252 2008

[18] J P Talreja V M Shami J Ku T D Morris K Ellenand M Kahaleh ldquoTransenteric drainage of pancreatic-fluidcollections with fully covered self-expanding metallic stentsrdquoGastrointestinal Endoscopy vol 68 no 6 pp 1199ndash1203 2008

[19] I Yasuda K Iwata T Mukai T Iwashita and H Mori-waki ldquoEus-guided pancreatic pseudocyst drainagerdquo DigestiveEndoscopy vol 21 no 1 pp S82ndashS86 2009

[20] J Y Ahn D W Seo J Eum et al ldquoSingle-step EUS-Guidedtransmural drainage of pancreatic pseudocysts analysis oftechnical feasibility efficacy and safetyrdquo Gut and Liver vol 4no 4 pp 524ndash529 2010

[21] R Sadik E Kalaitzakis A Thune J Hansen and C JonsonldquoEus-guided drainage is more successful in pancreatic pseudo-cysts compared with abscessesrdquoWorld Journal of Gastroenterol-ogy vol 17 no 4 pp 499ndash505 2011

[22] U Will C Wanzar R Gerlach and F Meyer ldquoInterven-tional ultrasound-guided procedures in pancreatic pseudo-cysts abscesses and infected necrosesmdashtreatment algorithm ina large single-center studyrdquo Ultraschall in der Medizin vol 32no 2 pp 176ndash183 2011

[23] S Varadarajulu J D Christein A Tamhane E R Drelichmanand C M Wilcox ldquoProspective randomized trial comparingEUS and EGD for transmural drainage of pancreatic pseudo-cysts (with videos)rdquo Gastrointestinal Endoscopy vol 68 no 6pp 1102ndash1111 2008

[24] DH Park S S Lee S-HMoon et al ldquoEndoscopic ultrasound-guided versus conventional transmural drainage for pancreaticpseudocysts a prospective randomized trialrdquoEndoscopy vol 41no 10 pp 842ndash848 2009

[25] T H Baron G C Harewood D E Morgan and M R YatesldquoOutcome differences after endoscopic drainage of pancreaticnecrosis acute pancreatic pseudocysts and chronic pancreaticpseudocystsrdquoGastrointestinal Endoscopy vol 56 no 1 pp 7ndash172002


[26] E Christoforidis K Bluchos T Tsahalis K Tsalis and DBetsis ldquoEndoscopic drainage of pancreatic pseudocystsrdquoAnnalsof Gastroenterology vol 18 no 4 pp 445ndash450 2005

[27] S K Ahlawat A Charabaty-Pishvaian P G Jackson and NG Haddad ldquoSingle-step EUS-guided pancreatic pseudocystdrainage using a large channel linear array echoendoscope andcystotome results in 11 patientsrdquo Journal of the Pancreas vol 7no 6 pp 616ndash624 2006

[28] C Fabbri C Luigiano V Cennamo et al ldquoEndoscopicultrasound-guided transmural drainage of infected pancreaticfluid collections with placement of covered self-expandingmetal stents a case seriesrdquo Endoscopy vol 44 no 4 pp 429ndash433 2012

[29] P V J Sriram A J Kaffes G V Rao and D N Reddy ldquoEndo-scopic ultrasound-guided drainage of pancreatic pseudocystscomplicated by portal hypertension or by intervening vesselsrdquoEndoscopy vol 37 no 3 pp 231ndash235 2005

[30] M R Antillon R J Shah G Stiegmann and Y K ChenldquoSingle-step EUS-guided transmural drainage of simple andcomplicated pancreatic pseudocystsrdquo Gastrointestinal Endos-copy vol 63 no 6 pp 797ndash803 2006

[31] S Varadarajulu C M Wilcox A Tamhane M A EloubeidiJ Blakely and C L Canon ldquoRole of EUS in drainage ofperipancreatic fluid collections not amenable for endoscopictransmural drainagerdquo Gastrointestinal Endoscopy vol 66 no 6pp 1107ndash1119 2007

[32] M JWiersema ldquoEndosonography-guided cystoduodenostomywith a therapeutic ultrasound endoscoperdquo GastrointestinalEndoscopy vol 44 no 5 pp 614ndash617 1996

[33] M Giovannini D Bernardini and J-F Seitz ldquoCystogastro-tomy entirely performed under endosonography guidance forpancreatic pseudocyst results in six patientsrdquo GastrointestinalEndoscopy vol 48 no 2 pp 200ndash203 1998

[34] H Seifert C Dietrich T Schmitt W Caspary and TWehrmann ldquoEndoscopic ultrasound-guided one-step trans-mural drainage of cystic abdominal lesions with a large-channelecho endoscoperdquo Endoscopy vol 32 no 3 pp 255ndash259 2000

[35] H Seifert D Faust T Schmitt C Dietrich W Caspary andT Wehrmann ldquoTransmural drainage of cystic peripancreaticlesions with a new large-channel echo endoscoperdquo Endoscopyvol 33 no 12 pp 1022ndash1026 2001

[36] M Giovannini C Pesenti A-L Rolland V Moutardier andJ-R Delpero ldquoEndoscopic ultrasound-guided drainage of pan-creatic pseudocysts or pancreatic abscesses using a therapeuticecho endoscoperdquo Endoscopy vol 33 no 6 pp 473ndash477 2001

[37] A T Chan S J Heller J Van Dam D L Carr-Locke andP A Banks ldquoEndoscopic cystgastrostomy role of endoscopicultrasonographyrdquo American Journal of Gastroenterology vol 91no 8 pp 1622ndash1625 1996

[38] M S Sajid K Hutson T Worthington N Karanjia and KK Singh ldquoEndoscopic drainage with or without endo-ultra-sonography for pancreatic pseudocystrdquoCochrane Reviews 2012httpsummariescochraneorgCD009619endoscopic-drain-age-with-or-without-endo-ultrasonography-for-pancreatic-pseudocyst

[39] T E Yusuf and T H Baron ldquoEndoscopic transmural drainageof pancreatic pseudocysts results of a national and an interna-tional survey of ASGE membersrdquo Gastrointestinal Endoscopyvol 63 no 2 pp 223ndash227 2006


Figure 1 Axial slice of a CT scan of a patient with a large pancreaticpseudocyst (PP) demonstrating its apposition onto the posteriorwall of the body of the stomach (S)

Figure 2 Gastroscope advanced into stomach to identify the area ofbulging at the posterior gastric wall Simultaneous transabdominalultrasound being performed to guide the endoscopist to the idealarea for puncture

mass occupying the entire lesser sac interposed betweenstomach and pancreas Multiphase computer tomographicscans confirmed the presence of a well-organized pancreaticpseudocyst displacing the stomach anteriorly and containedin a thick-walled mature capsule (Figure 1) Endoscopic ret-rograde pancreatography revealed no evidence of proximalstrictures and was unable to demonstrate the connectionbetween the ductal system and the pseudocyst

An endoscopic cystogastrostomy was attempted in theendoscopy suite under conscious sedation with intravenousPropofol The procedure was performed in the left lateraldecubitus positionwith noninvasivemonitoring Intravenousceftriaxone was administered as prophylaxis at inductionA side viewing duodenoscope (Olympus TJF-140 OlympusAmerica Central Valley PA USA) was advanced into thestomach With insufflation the area of extrinsic gastric com-pression was identified on the posterior wall Endoscopicultrasound (EUS) was not available so the stomach wasaspirated while the endoscope remained in situ This facili-tated simultaneous transabdominal ultrasound (Figure 2) toconfirm that the endoscope tip was at an appropriate areafor puncture A triple lumen needle knife sphincterotome(Micro-knife XL Boston Scientific Co Marlborough MAUSA) was advanced through the working channel of the

scope and used to create a 1-2 cm incision in the gastricmucosa (Figure 3(a)) with bipolar electrocautery (force FXValleylab Boulder CO USA) Entry into the cyst wasconfirmed by a gush of clear pancreatic fluid returning(Figure 3(b)) A 480 cm flexible 003510158401015840 guidewire (HydraJagwire Boston Scientific Co Marlborough USA) wasadvanced through the incision The needle knife catheterwas removed leaving the guidewire across the incisionwithin the pseudocyst cavity A 6ndash8mm controlled radialexpansion biliary dilating balloon (CREWireguided BalloonDilator Boston Scientific Microvasive Natick MA USA)was railroaded over the guidewire (Figure 4(a)) and inflatedto dilate the transmural tract to 16mm (Figure 4(b)) Thedilating balloon was inflated on three separate occasionsfor 20 seconds to ensure adequate dilation of the incisionThe dilating balloon was removed with the guidewire leftin place A double pigtail 10 F times 5 cm plastic stent (C-flex Biliary Boston Scientific Spencer IN USA) was thenadvanced over the guidewire and deployed with the prox-imal end in the gastric lumen and the distal end withinthe pseudocyst cavity Ultrasound was repeated to confirmdrain placement within the cavity and the gastric placementwas confirmed at endoscopy and subsequently with plainradiographs (Figure 5) Approximately 3700mL of turbidpancreatic fluid was removed from the cyst resulting inimmediate abdominal decompression (Figure 6)

The recovery period is uneventful and the patient wasnow able to tolerate a normal diet The patient remainedclinically well 6 months after stent removal (1 year afterdrainage) and the abdomen remained flat (Figure 7) Repeatultrasound 12 weeks after stent removal showed no evidenceof recurrence and the patient was discharged from followup

3 Discussion

Open surgical drainage was first described in 1882 [6] buthas become less popular over the past two decades as wewitness a shift toward less invasive drainage procedures [4 78] Laparoscopic drainage brings lower morbidity and fasterrecovery than open surgical drainage [8] but places an extrademand for specialized equipment and advanced laparo-scopic skill sets that are not universally available in manydeveloping countries To date there have been no reportsof laparoscopic pseudocyst drainage from the AnglophoneCaribbean

Percutaneous drainage is feasible but it has low long-term success rates that range from 42 [9] to 50 [10] withpercutaneous fistulae developing in 20 [7] to 40 [11] ofcases Therefore percutaneous external drainage is relegatedonly to high-risk patients patients with immature cyst wallsunsuitable for internal drainage and those with infected cysts[3]

Endoscopic drainage was first described in 1985 [12]and quickly gained popularity because it avoided the needfor general anaesthesia with relatively few complicationsWe performed a literature search in PubMed MEDLINESCOPUS SciELO and Cochrane databases seeking reportson endoscopic drainage of pancreatic pseudocysts published


(a) (b)


(a) (b)








(a) (b)











4 Conclusion


References











































(a) (b)


(a) (b)








(a) (b)











4 Conclusion


References











































(a) (b)











4 Conclusion


References












































4 Conclusion


References










































Endoscopic Transmural Drainage of Pancreatic Pseudocysts ...

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