Transmural or transenteric endoscopic drainage procedures are performed through several endoscopic approaches through the stomach (endoscopic cystogastrostomy) or duodenum (endoscopic cystoduodenostomy).
Several prerequisites need to be fulfilled pursuant to endoscopic transmural drainage (Table 1). Ideally, the pseudocyst must be situated within the pancreatic head or body, and must be firmly adherent to the gastrointestinal tract to cause a visible impression on the gastric or duodenal wall at the time of endoscopy. Additionally, the distance between the pseudocyst and the adjacent gastric or duodenal wall should not exceed 1 cm on CT scan or endoscopic ultrasound (41-44).
Cystic neoplasms should be identified and managed appropriately. Cystic neoplasms managed inappropriately as pseudocysts may result in serious complications and compromise future surgical resection (21,45).
Pseudoaneurysms occur in approx 10% of pseudocysts (12,47,48) and represent an absolute contraindication to endoscopic intervention, unless arterial embolization has been accomplished first (6). Gastric varices in the setting of portal hypertension should be identified to minimize the risk of inadvertent puncture and hemorrhage (49).
duodenal pancreatic papilla duct
Pseudocyst communicating with main pancreatic duct
Straight pancreatic stent with single flange duodenal pancreatic papilla duct
Fig. 1. Transpapillary pancreatic pseudocyst drainage. A 5-7 French stent placed after pancreatic sphincterotomy.
1. Cysts must be allowed to mature prior to drainage
2. Assess for the presence of pseudoaneurysm
3. Rule out the presence of a cystic neoplasm
4. Identify gastric varices in the presence of portal hypertension
5. Identify debris within the pseudocyst
6. Outline the pancreatic duct by ERCP
7. The pseudocyst should be in close approximation to the gastric or duodenal wall
8. Utilize a transpapillary approach whenever feasible
9. Endoscopic needle localization should be used prior to puncture
Some authors advocate endoscopic needle localization (ENL) or needle aspiration of a pseudocyst prior to cyst puncture to reduce the risk of bleeding (50). Repeated bloody aspirate may represent inadvertent puncture of a blood vessel wall or pseudoaneurysm formation and should warrant further investigation prior to any attempt at drainage.
Pancreatic necrosis as demonstrated by contrast-enhanced CT might result in inadequate cyst evacuation, and subsequently increases the risk of infection, and should serve as a deterrent to, but not preclude endoscopic transmural drainage (51,52).
Endoscopic cystogastrostomies (ECG) and cystoduodenostomies (ECD) require the puncture of the gastric or duodenal wall at the point of an identifiable impression in the visceral lumen. A side-viewing endoscope is used and access into the cyst is achieved
Guidelines for Endoscopic Pancreatic Pseudocyst Drainage
with a diathermic needle. Once entry into the cyst is confirmed, a guidewire is inserted and the opening is enlarged to approx 3-50 mm. Balloon tract dilatation has been utilized to enlarge the opening to reduce the risk of bleeding. One or two 7-10 Fr stents are subsequently inserted into the cyst to maintain patency and are left in place for a mean period of 2-4 mo or until ultrasonographic confirmation of cyst resolution occurs (Fig. 2).
In a cumulative series of 50 patients who underwent endoscopic cystogastrostomy, successful pseudocyst drainage was achieved in 82 % of patients with a recurrence rate of 18%. Major complications included bleeding in 8%, and perforation in 8% of patients with no reported deaths. The collective incidence of bleeding requiring surgical intervention was 7%. Bleeding occurred at the time of gastrostomy enlargement with the sphincterotome. Small incisions and balloon dilatation of the gastrotomy tract have been recommended to reduce the risk of these complications (37,42-44).
Concurrently, in a series of 71 patients who underwent ECD, drainage was successful in 89% of patients with a reported recurrence rate of 6%, with a median follow-up of 9-48 mo. Complications were less frequent, with perforation in 4% and severe bleeding in 4%. All three patients that developed perforations were successfully managed with antibiotics. The overall incidence of bleeding requiring surgery was 3%. In two reported cases of bleeding, which resulted in one death, bleeding occurred as a result of a pseudoaneurysm (43). ECD confers the advantage of longer cystoduodenal fistula patency over ECG (41).
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