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Advanced techniques for drainage of peripancreatic fluid collections
Advanced techniques for drainage of peripancreatic fluid collections Stefan Seewald, MD, Tiing Leong Ang, MD, Nib Soehendra, MD Zurich, Switzerland, Singapore, Hamburg, Germany
THE PROBLEMS WITH CONVENTIONAL EUS-GUIDED DRAINAGE TECHNIQUES Conventional EUS-guided drainage of symptomatic pseudocysts involves needle puncture, guidewire insertion, balloon-catheter insertion and dilation, and placement of a transmural stent. A pseudocyst is ideal for endoscopic drainage if the pseudocyst is large and bulging, and is older than 6 weeks, such that the pseudocyst wall is adherent to the gastric or duodenal wall. Caution must be exercised when the pseudocysts are less than 6 weeks old or when ascites is present; this is because of the concern that the pseudocyst wall may not be adherent to the gastric or duodenal wall, thus increasing the risk of wall dehiscence and perforation during endoscopic drainage. With the use of EUS guidance, endoscopic drainage is feasible even for more complicated situations, such as nonbulging pseudocysts, multiple or septated pseudocysts, or pseudocysts that occur in patients with portal hypertension or varices. Nonetheless, difficulties may still arise during EUS-guided pseudocyst drainage. For instance, the tangential axis of the puncture and the limited ability of the available echoendoscopes to suction the copious fluid flowing out after the initial puncture may hinder endoscopic access to the pseudocyst cavity. Other problems include difficulty in puncturing pseudocysts situated high up at the cardia, and secondary infection of the pseudocyst because of inadequate drainage and an inability to remove necrotic tissue. When complicated pancreatic-fluid collections, such as abscesses and infected walled-off necrosis, are present, additional techniques and procedures are required for effective drainage.1 Several issues have to be considered: 1. Based on clinical experience, it is more effective to place multiple stents for drainage and also to provide continuous irrigation via a nasocystic catheter, especially in the context of infected fluid collections. With conventional EUS–guided techniques, repeated catheter and guidewire insertion into the cavity is necessary. This is often time consuming because of poor visibility from copious fluids gushing out after the initial stent placement and
DISCLOSURE: S. Seewald, T. L. Ang, and N. Soehendra disclosed no financial relationships relevant to this publication. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.12.035
S182 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
a tangential axis of puncture, and frequently requires changing to a duodenoscope. To overcome these difficulties, the concept of inserting multiple guidewires at the initial pseudocyst puncture was developed.2-4 2. The design of current therapeutic linear echoendoscopes could potentially hinder the process of endoscopic drainage, because of the oblique-viewing optics and a tangential axis of puncture. To address this issue, a prototype forward-viewing therapeutic linear echoendoscope was developed.5,6 3. In the presence of necrosis and purulent debris, endoscopic transmural necrosectomy is necessary to improve the treatment outcome.7-9
NEWER ADVANCED TECHNIQUES TO ACHIEVE INITIAL DRAINAGE Simultaneous double-wire technique To overcome the need to recannulate the pseudocyst cavity after the initial transmural stent placement, a prototype 3-layer puncture kit that, in 1 step, allowed the simultaneous insertion of 2 guidewires at the initial puncture was developed.1 This puncture kit consists of a 5F inner Teflon catheter inserted through an outer 8.5F Teflon catheter and a 22-gauge FNA needle, which is inserted through the inner catheter. By using the assembled kit with the needle protruding from the distal end of the catheter, the pseudocyst is punctured under EUS guidance by using electrocautery. The assembled inner and outer catheters are then pushed into the cavity. Once entry into the pseudocyst is confirmed by EUS and by aspiration of fluid, the needle and the 5F inner catheter are withdrawn, leaving behind the 8.5F outer catheter. Two 0.035-inch guidewires are simultaneously inserted into the pseudocyst cavity (Fig. 1), and a 8.5F double-pigtail stent, and a 7F nasocystic catheter or another stent, can be sequentially placed.
Sequential multiple wire techniques Intracystic wire-exchange technique. After the initial EUS-guided needle-knife puncture, a guidewire is inserted into the pseudocyst through the 5.5F inner catheter of the cystotome after withdrawing the needle-knife. The 10F outer catheter of the cystotome is then advanced over the guidewire into the pseudocyst by using electrocautery. A second guidewire can be introduced through the 10F outer catheter of the cystotome into the cavity, www.giejournal.org
Seewald et al
Advanced techniques
Figure 1. Simultaneous double-wire technique. Fluoroscopy, showing two 0.035-inch guidewires simultaneously introduced into the cyst cavity through the 8.5F outer catheter.
alongside the first guidewire after removal of the 5.5F inner catheter.3 Dilator-guided intracystic wire-exchange technique. After the initial guidewire insertion into the pseudocyst through a 19-gauge EUS-FNA needle, a wire-guided needle-knife (KD-441Q; Olympus Optical Co Ltd, Tokyo, Japan) is used to dilate the puncture site by using electrocautery. A 10F Soehendra dilator (Cook Endoscopy) is inserted over the guidewire into the cavity. Its entry is facilitated by its tapered tip, and a second guidewire can be inserted through the dilator alongside the first guidewire into the cavity.4 Theoretically, subsequent guidewires could be placed after initial drainage placement by reintroducing the 10F Soehendra biliary dilator or the 10F outer catheter of the cystotome over the second guidewire and introduction of another guidewire through the 10F dilator and/or catheter. This can be performed repeatedly.
Forward-viewing therapeutic echoendoscope By using the currently available oblique-viewing therapeutic echoendoscope, the angle of puncture is tangential (Fig. 2A and B). Puncturing at an angle may sometimes hamper successful completion of the procedure, because the force that is applied when introducing accessories through the working channel cannot be fully directed toward the puncture site because of the tangential axis. A prototype forward-viewing therapeutic echoendoscope has been developed by Olympus Optical Co Ltd. During the initial needle puncture and during the process of insertion of accessories, the axis of insertion is forward, parallel with the scanning axis (Fig. 3A and B). This facilitates forward transmission of force during the process of introducing accessories and inserting stents and catheters. The working channel of the prototype scope remains at 3.7 mm, www.giejournal.org
Figure 2. A, Endoscopic view from a conventional linear oblique echoendoscope, showing the axis of the puncture. B, EUS image from a conventional linear oblique echoendoscope, showing the axis of the puncture.
but the scanning range is smaller, at 90 . The scope has no elevator. In a pilot study, all cases were successfully drained without complications. In addition, there were cases that could only be punctured by using the forward-viewing scope.5 Based on our early experience, the use of a forward-viewing linear echoendoscope could be combined with a 1-step simultaneous double-wire technique that facilitated effective drainage.6
CONTINUOUS IRRIGATION AND ADJUNCTIVE ENDOSCOPIC DEBRIDEMENT When there is an infected pancreatic-fluid collection, continuous irrigation and adequate drainage is important. One can place multiple transmural stents and also irrigate the infected collection with 1 to 1.5 L saline solution daily via the nasocystic catheter. Once sepsis has resolved and there is no more purulent discharge from the nasocystic Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S183
Advanced techniques
Seewald et al
Figure 4. A, Endoscopic view during necrosectomy. B, Endoscopic view after necrosectomy.
Figure 3. A, Endoscopic view from a prototype forward-viewing linear echoendoscope, showing the axis of the puncture. B, EUS image from a prototype forward-viewing linear echoendoscope, showing the axis of the puncture.
catheter, the catheter may be removed. Upon resolution of the abscess, the internal stents are removed. In the presence of significant, thick, purulent material, necrosis and debris, adjunctive endoscopic debridement (Fig. 4A and B) is needed to improve the treatment success rate.7-9 In this situation, additional steps are required. Stepwise balloon dilation of the puncture site by using an endoscopic balloon dilator (eg, CRE balloon; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) is performed over a few days (up to 15–20 mm). When the opening is large enough, the nasocystic catheter is removed, a pediatric or even diagnostic or therapeutic gastroscope is inserted into the cavity, and endoscopic transmural debridement and necrosectomy is performed by using a saline solution lavage, Dormia baskets, and Roth Net retrieval nets (US Endoscopy, Ohio) every 1 to 2 days until all necrotic and purulent debris are removed, S184 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
which leaves behind pink granulation tissue within the cavity. To minimize the problem of perforation during endoscopic necrosectomy, one should ensure that the wall of infected collection is mature and is within 1 cm of the GI wall before performing endoscopic drainage. In addition, one needs to perform gradual balloon dilation of cystogastrostoma and/or enterostoma, avoid overinsufflation of air, and perform careful debridement to avoid bleeding and wall dehiscence. The possible use of carbon dioxide, rather than air insufflation, is an option that could be considered in the future.
REFERENCES 1. Seewald S, Ang TL, Teng KYK, et al. Innovation forum: EUS guided drainage of abdominal abscesses. Endoscopy 2009. In press. 2. Seewald S, Thonke F, Ang TL, et al. One-step, simultaneous doublewire technique facilitates pancreatic pseudocyst and abscess drainage (with videos). Gastrointest Endosc 2006;64:805-8. 3. Jansen JM, Hanrath A, Rauws EA, et al. Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 2007;66:157-61. 4. Ang TL, Teo EK, Fock KM. EUS-guided drainage of infected pancreatic pseudocyst: use of a 10F Soehendra dilator to facilitate a double-wire technique for initial transgastric access (with videos). Gastrointest Endosc 2008;68:192-4. 5. Voermans RP, Eisendrath P, Bruno MJ, et al. Initial evaluation of a novel prototype forward-viewing US endoscope in transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2007;66: 1013-7.
www.giejournal.org
Seewald et al 6. Seewald S, Ang TL, Omar S, et al. A novel forward viewing linear echoendoscope (Olympus XGIF-UCT160J-AL5) combined with a one-step, simultaneous double-wire technique facilitates EUS-guided pancreatic pseudocyst drainage [abstract]. Gastrointest Endosc 2007;65: AB196. 7. Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356: 653-5. 8. Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56:7-17.
www.giejournal.org
Advanced techniques
9. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm. Gastrointest Endosc 2005;62:92-100.
Center of Gastroenterology (S.S.), Klinik Hirslanden, Zurich, Switzerland, Division of Gastroenterology (T.L.A.), Changi General Hospital, Singapore, University Medical Center Hamburg-Eppendorf (N.S.), Hamburg, Germany. This article is from a meeting and has not undergone the GIE peer review process.
Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S185
THE PROBLEMS WITH CONVENTIONAL EUS-GUIDED DRAINAGE TECHNIQUES Conventional EUS-guided drainage of symptomatic pseudocysts involves needle puncture, guidewire insertion, balloon-catheter insertion and dilation, and placement of a transmural stent. A pseudocyst is ideal for endoscopic drainage if the pseudocyst is large and bulging, and is older than 6 weeks, such that the pseudocyst wall is adherent to the gastric or duodenal wall. Caution must be exercised when the pseudocysts are less than 6 weeks old or when ascites is present; this is because of the concern that the pseudocyst wall may not be adherent to the gastric or duodenal wall, thus increasing the risk of wall dehiscence and perforation during endoscopic drainage. With the use of EUS guidance, endoscopic drainage is feasible even for more complicated situations, such as nonbulging pseudocysts, multiple or septated pseudocysts, or pseudocysts that occur in patients with portal hypertension or varices. Nonetheless, difficulties may still arise during EUS-guided pseudocyst drainage. For instance, the tangential axis of the puncture and the limited ability of the available echoendoscopes to suction the copious fluid flowing out after the initial puncture may hinder endoscopic access to the pseudocyst cavity. Other problems include difficulty in puncturing pseudocysts situated high up at the cardia, and secondary infection of the pseudocyst because of inadequate drainage and an inability to remove necrotic tissue. When complicated pancreatic-fluid collections, such as abscesses and infected walled-off necrosis, are present, additional techniques and procedures are required for effective drainage.1 Several issues have to be considered: 1. Based on clinical experience, it is more effective to place multiple stents for drainage and also to provide continuous irrigation via a nasocystic catheter, especially in the context of infected fluid collections. With conventional EUS–guided techniques, repeated catheter and guidewire insertion into the cavity is necessary. This is often time consuming because of poor visibility from copious fluids gushing out after the initial stent placement and
DISCLOSURE: S. Seewald, T. L. Ang, and N. Soehendra disclosed no financial relationships relevant to this publication. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2008.12.035
S182 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
a tangential axis of puncture, and frequently requires changing to a duodenoscope. To overcome these difficulties, the concept of inserting multiple guidewires at the initial pseudocyst puncture was developed.2-4 2. The design of current therapeutic linear echoendoscopes could potentially hinder the process of endoscopic drainage, because of the oblique-viewing optics and a tangential axis of puncture. To address this issue, a prototype forward-viewing therapeutic linear echoendoscope was developed.5,6 3. In the presence of necrosis and purulent debris, endoscopic transmural necrosectomy is necessary to improve the treatment outcome.7-9
NEWER ADVANCED TECHNIQUES TO ACHIEVE INITIAL DRAINAGE Simultaneous double-wire technique To overcome the need to recannulate the pseudocyst cavity after the initial transmural stent placement, a prototype 3-layer puncture kit that, in 1 step, allowed the simultaneous insertion of 2 guidewires at the initial puncture was developed.1 This puncture kit consists of a 5F inner Teflon catheter inserted through an outer 8.5F Teflon catheter and a 22-gauge FNA needle, which is inserted through the inner catheter. By using the assembled kit with the needle protruding from the distal end of the catheter, the pseudocyst is punctured under EUS guidance by using electrocautery. The assembled inner and outer catheters are then pushed into the cavity. Once entry into the pseudocyst is confirmed by EUS and by aspiration of fluid, the needle and the 5F inner catheter are withdrawn, leaving behind the 8.5F outer catheter. Two 0.035-inch guidewires are simultaneously inserted into the pseudocyst cavity (Fig. 1), and a 8.5F double-pigtail stent, and a 7F nasocystic catheter or another stent, can be sequentially placed.
Sequential multiple wire techniques Intracystic wire-exchange technique. After the initial EUS-guided needle-knife puncture, a guidewire is inserted into the pseudocyst through the 5.5F inner catheter of the cystotome after withdrawing the needle-knife. The 10F outer catheter of the cystotome is then advanced over the guidewire into the pseudocyst by using electrocautery. A second guidewire can be introduced through the 10F outer catheter of the cystotome into the cavity, www.giejournal.org
Seewald et al
Advanced techniques
Figure 1. Simultaneous double-wire technique. Fluoroscopy, showing two 0.035-inch guidewires simultaneously introduced into the cyst cavity through the 8.5F outer catheter.
alongside the first guidewire after removal of the 5.5F inner catheter.3 Dilator-guided intracystic wire-exchange technique. After the initial guidewire insertion into the pseudocyst through a 19-gauge EUS-FNA needle, a wire-guided needle-knife (KD-441Q; Olympus Optical Co Ltd, Tokyo, Japan) is used to dilate the puncture site by using electrocautery. A 10F Soehendra dilator (Cook Endoscopy) is inserted over the guidewire into the cavity. Its entry is facilitated by its tapered tip, and a second guidewire can be inserted through the dilator alongside the first guidewire into the cavity.4 Theoretically, subsequent guidewires could be placed after initial drainage placement by reintroducing the 10F Soehendra biliary dilator or the 10F outer catheter of the cystotome over the second guidewire and introduction of another guidewire through the 10F dilator and/or catheter. This can be performed repeatedly.
Forward-viewing therapeutic echoendoscope By using the currently available oblique-viewing therapeutic echoendoscope, the angle of puncture is tangential (Fig. 2A and B). Puncturing at an angle may sometimes hamper successful completion of the procedure, because the force that is applied when introducing accessories through the working channel cannot be fully directed toward the puncture site because of the tangential axis. A prototype forward-viewing therapeutic echoendoscope has been developed by Olympus Optical Co Ltd. During the initial needle puncture and during the process of insertion of accessories, the axis of insertion is forward, parallel with the scanning axis (Fig. 3A and B). This facilitates forward transmission of force during the process of introducing accessories and inserting stents and catheters. The working channel of the prototype scope remains at 3.7 mm, www.giejournal.org
Figure 2. A, Endoscopic view from a conventional linear oblique echoendoscope, showing the axis of the puncture. B, EUS image from a conventional linear oblique echoendoscope, showing the axis of the puncture.
but the scanning range is smaller, at 90 . The scope has no elevator. In a pilot study, all cases were successfully drained without complications. In addition, there were cases that could only be punctured by using the forward-viewing scope.5 Based on our early experience, the use of a forward-viewing linear echoendoscope could be combined with a 1-step simultaneous double-wire technique that facilitated effective drainage.6
CONTINUOUS IRRIGATION AND ADJUNCTIVE ENDOSCOPIC DEBRIDEMENT When there is an infected pancreatic-fluid collection, continuous irrigation and adequate drainage is important. One can place multiple transmural stents and also irrigate the infected collection with 1 to 1.5 L saline solution daily via the nasocystic catheter. Once sepsis has resolved and there is no more purulent discharge from the nasocystic Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S183
Advanced techniques
Seewald et al
Figure 4. A, Endoscopic view during necrosectomy. B, Endoscopic view after necrosectomy.
Figure 3. A, Endoscopic view from a prototype forward-viewing linear echoendoscope, showing the axis of the puncture. B, EUS image from a prototype forward-viewing linear echoendoscope, showing the axis of the puncture.
catheter, the catheter may be removed. Upon resolution of the abscess, the internal stents are removed. In the presence of significant, thick, purulent material, necrosis and debris, adjunctive endoscopic debridement (Fig. 4A and B) is needed to improve the treatment success rate.7-9 In this situation, additional steps are required. Stepwise balloon dilation of the puncture site by using an endoscopic balloon dilator (eg, CRE balloon; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) is performed over a few days (up to 15–20 mm). When the opening is large enough, the nasocystic catheter is removed, a pediatric or even diagnostic or therapeutic gastroscope is inserted into the cavity, and endoscopic transmural debridement and necrosectomy is performed by using a saline solution lavage, Dormia baskets, and Roth Net retrieval nets (US Endoscopy, Ohio) every 1 to 2 days until all necrotic and purulent debris are removed, S184 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
which leaves behind pink granulation tissue within the cavity. To minimize the problem of perforation during endoscopic necrosectomy, one should ensure that the wall of infected collection is mature and is within 1 cm of the GI wall before performing endoscopic drainage. In addition, one needs to perform gradual balloon dilation of cystogastrostoma and/or enterostoma, avoid overinsufflation of air, and perform careful debridement to avoid bleeding and wall dehiscence. The possible use of carbon dioxide, rather than air insufflation, is an option that could be considered in the future.
REFERENCES 1. Seewald S, Ang TL, Teng KYK, et al. Innovation forum: EUS guided drainage of abdominal abscesses. Endoscopy 2009. In press. 2. Seewald S, Thonke F, Ang TL, et al. One-step, simultaneous doublewire technique facilitates pancreatic pseudocyst and abscess drainage (with videos). Gastrointest Endosc 2006;64:805-8. 3. Jansen JM, Hanrath A, Rauws EA, et al. Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 2007;66:157-61. 4. Ang TL, Teo EK, Fock KM. EUS-guided drainage of infected pancreatic pseudocyst: use of a 10F Soehendra dilator to facilitate a double-wire technique for initial transgastric access (with videos). Gastrointest Endosc 2008;68:192-4. 5. Voermans RP, Eisendrath P, Bruno MJ, et al. Initial evaluation of a novel prototype forward-viewing US endoscope in transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2007;66: 1013-7.
www.giejournal.org
Seewald et al 6. Seewald S, Ang TL, Omar S, et al. A novel forward viewing linear echoendoscope (Olympus XGIF-UCT160J-AL5) combined with a one-step, simultaneous double-wire technique facilitates EUS-guided pancreatic pseudocyst drainage [abstract]. Gastrointest Endosc 2007;65: AB196. 7. Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356: 653-5. 8. Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56:7-17.
www.giejournal.org
Advanced techniques
9. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm. Gastrointest Endosc 2005;62:92-100.
Center of Gastroenterology (S.S.), Klinik Hirslanden, Zurich, Switzerland, Division of Gastroenterology (T.L.A.), Changi General Hospital, Singapore, University Medical Center Hamburg-Eppendorf (N.S.), Hamburg, Germany. This article is from a meeting and has not undergone the GIE peer review process.
Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY S185