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Double-channel fistulotome for endoscopic drainage of pancreatic pseudocyst
Double-channel fistulotome for endoscopic drainage of pancreatic pseudocyst Gregory L. Knecht, MD Richard A. Kozarek, MD
Endoscopic management of selected patients with pancreatic pseudocysts has shown considerable promise and success.! A variety of endoscopic instruments have been utilized to gain access to the pseudocyst cavity. We describe a new device that simplifies and expedites this technique. CASE REPORT
A 51-year-old man with a prior history of alcoholism presented with a 2-week history of epigastric abdominal pain. He denied abdominal trauma, prescription drug use, familial pancreatitis, hyperlipidemia, or prior symptoms of biliary tract disease. He suffered one prior episode of alcoholic pancreatitis 3 years before this admission. He denied recent alcohol consumption. Vital signs were normal. Physical examination revealed epigastric tenderness but no mass. Significant presenting lab values included WBC, 16,000; alkaline phosphatase, 134 (normal, <110), and serum amylase, 804 (normal, <85). ERCP demonstrated pancreatic ductal disruption at the juncture of head and body with filling of a retrogastric pseudocyst and changes of chronic pancreatitis. An abdominal ultrasound demonstrated a thin-walled pancreatic pseudocyst 5 X 8 cm posterior to gastric antrum. Gallbladder and bile ducts were normal. In spite of bowel rest and supportive care, the patient demonstrated increasing abdominal pain, a rapidly expanding epigastric mass and progressive respiratory distress. CT scan 6 days later documented an enlarged thin-walled 12cm pseudocyst posterior to the gastric antrum. There was less than 1 cm between the gastric lumen and the pseudocyst cavity. Because of the lack of pseudocyst maturity, surgery was felt ill-advised. With progressive respiratory distress, pain, and fear of pseudocyst rupture, endoscopic transgastric drainage was believed to be necessary and appropriate. A cyst puncture instrument was devised through modification of a double-channel, 7 French sphincterotome (model PTG 30-7; Wilson-Cook Medical Inc., Winston Salem, N. C.). The distal portion of the catheter was transected at an angle at the proximal exit site of the cutting wire. The braided wire was then cut, allowing 4 mm to extend beyond the tip of the catheter, thus creating a double-channel, retractable, needle knife, or "fistulotome" (Fig. 1). A JFITI0 endoscope (Olympus Corporation of America, Lake Success, N. Y.) was used first to visualize the maximal point of antral compression by the cyst and the exposed diathermic wire of the fistulotome was used to create a small burn hole directly into the cyst cavity. A copious gush of Received January 3, 1991. Accepted February 7, 1991. From the Department of Medicine, Sacred Heart General Hospital, Eugene, Oregon and Department of Medicine, Section of Therapeutic Endoscopy, Virginia Mason Clinic, Seattle, Washington. Reprint requests: Gregory L. Knecht, MD, 677 E. 12th, Suite 500, Eugene, Oregon, 97401. 356
cloudy fluid heralded cyst entry, immediately obscuring endoscopic view. The 0.035-inch guidewire, placed through the second channel of the fistulotome, was quickly advanced into the cyst cavity securing cyst access. The needle knife wire of the fistulotome was then withdrawn from the catheter, allowing placement of a second 0.025-inch guidewire into the cyst cavity. The double-channel catheter was then withdrawn, leaving the two guidewires in place. A 10 French, 5-cm long, double-pigtail stent was then advanced into the cyst cavity using a guiding catheter and the 0.035-inch guidewire. The 0.025-inch guidewire was then used to place a 6 French nasocyst catheter. Careful fluoroscopic monitoring was utilized during the entire procedure. A total of 850 ml of cyst fluid was aspirated via the endoscope during the procedure. The patient showed dramatic clinical improvement. The nasocyst drainage catheter was used for culture and radiographic cystography and showed progressive decline in fluid output. The nasocyst catheter was removed 10 days after insertion, and a second 10 French double-pigtail stent was placed alongside the first stent to enhance long-term decompression. Four weeks later, follow-up ultrasound showed complete resolution of the cyst cavity, and both stents were uneventfully removed. Unfortunately, the pseudocyst recurred due to continued duct disruption documented by follow-up ERCP. Attempted pancreatic stenting to bridge the duct disruption failed. Surgical cystoenterostomy, combined with lateral pancreaticojejunostomy has led to complete clinical recovery, (4-month post-operative follow-up).
DISCUSSION
A variety of endoscopic instruments have been recommended to gain direct endoscopic access to pancreatic pseudocysts, including the pre-cut sphincterotome, standard needle knife, exposed end of a polypectomy snare, and lasers. 2- 6 Depending upon the anatomy of the cyst and the presence of pancreatic duct disruption, stents placed into the pancreatic duct
Figure 1. Modified Wilson-Cook wire-guided sphincterotome (PTG 30-7); 0.035-inch guidewire exits top channel. Retractable (transected) diathermic wire exits bottom channel. GASTROINTESTINAL ENDOSCOPY
through the major or minor papilla have also been used successfully5,7,8 and may complement, and even obviate, transmucosal drainage as described. We feel the optimal instrument for direct transmucosal access must address several important, potential pitfalls when utilizing this method of therapy. 1. Since the gastric and duodenal mucosa are quite vascular and since bleeding has been observed as a major complication from this procedure,2-4 the described concept of a small burn hole (for stenting), instead of an extended cut, will likely lessen this complication. 2. The visual field is commonly obscured by cyst fluid immediately upon cyst entry, and it is therefore extremely important to be able to quickly advance a guidewire into the cyst cavity before the catheter itself has a chance to dislodge. If the catheter does dislodge before guidewire access is secured, the original burn hole is quite difficult to find secondary to the large volume of escaping fluid and re-entry may be difficult due to a rapidly decompressing cyst. The second channel of the described instrument allows for immediate guidewire access and addresses this most important problem. 3. If there are uncertainties regarding the nature of the cyst after initial puncture, cystography to define the anatomy of the cyst or its relationship to other structures, is of value. The second channel of the described device can be conveniently and immediately used for contrast injection. 4. The ability to place two guidewires before catheter removal from the cyst is a significant convenience for the placement of either a nasocyst catheter plus a stent, or two stents. The nasocyst catheter is helpful in allowing day to day monitoring of cyst output, irrigation, fluid sampling for culture, and sequential cystography to monitor cyst size. Two stents allow a larger cystoenterostomy and less chance of stent occlusion. A somewhat similar cyst-puncture device has been described by Cremer et al.,9 in which a diathermic needle catheter is utilized for cyst puncture followed by a 10 French diathermic sleeve passed over the catheter. Cutting current is applied to the diathermic sleeve to enlarge the fistula. Although neither author of this report has used this device, our instrument would appear to be somewhat simpler in design and may be easier to use. In addition, the immediacy of guidewire placement, as well as the ability to place two guidewires simultaneously, would appear to be an advantage. Enlarging the fistula, after the initial small
VOLUME 37, NO, 3, 1991
burn hole, was not necessary for stent placement in this patient. Since even large cystoenterostomies can spontaneously close with surprising rapidity, reliance on one or two stents for cyst drainage, rather than the endoscopic cystostomy itself, may be the preferred method of drainage. More comparative data are clearly needed, however, before a firm recommendation can be made. It is to be stressed that the application of this instrument and technique should be reserved for those patients in whom the anatomical relationship of the pseudocyst to gut wall can be clearly defined by CT or ultrasound. In addition, proper endoscopic orientation to, and visualization of, a mucosal bulge are essential. The manufacturer of the sphincterotome utilized in this report does not recommend the simultaneous use of cautery with an in-dwelling guidewire in the second channel. However, a prototype instrument, nearly identical to the one described in this report, that would allow concomitant cautery with in-dwelling guidewire, has been developed and may be available soon for general use. ACKNOWLEDGMENTS The authors are grateful for the assistance of Betty Kang, Barbara Adler, Gene Evans, Kate Brown, and JoAnna Hatch.
REFERENCES 1. Barkin JS, Shakir AH. Changing concepts in the management
of pancreatic pseudocysts. Gastrointest Endosc 1989;35:62-3. 2. Kozarek RA, Brayko CM, Harlan J, Sanowski RA, Cintora I, Kovak A. Endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 1985;31:322-7. 3. Cremer M, Deviere J, Engelholm L. Endoscopic management of cysts and pseudocysts in chronic pancreatitis: long-term follow-up after 7 years of experience. Gastrointest Endosc 1989;35:1-9. 4. Sahel J, Bastid C, Pellat B, Shurgers P, Sarles H. Endoscopic cystoduodenostomy of cysts of chronic calcifying pancreatitis; a report of 20 cases. Pancreas 1987;2:447-53. 5. Huibregtse K, Schneider B, Vrij AA, Tytgat GNJ. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endose 1988;34:9-15. 6. Buchi KN, Bowers JH, Dixon JA. Endoscopic pancreatic cystogastrostomy using the Nd:YAG laser. Gastrointest Endosc 1986;32:112-4. 7. Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and pseudocyst. Gastroenterology (in press). 8. Kozarek RA, Patterson DJ, Ball TJ, Traverso LW. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis. Ann Surg 1989;209:261-6. 9. Cremer M, Deviere J, Baize M, Matos C. New device for endoscopic cystoenterostomy. Endoscopy 1990;22:76-7.
357
Endoscopic management of selected patients with pancreatic pseudocysts has shown considerable promise and success.! A variety of endoscopic instruments have been utilized to gain access to the pseudocyst cavity. We describe a new device that simplifies and expedites this technique. CASE REPORT
A 51-year-old man with a prior history of alcoholism presented with a 2-week history of epigastric abdominal pain. He denied abdominal trauma, prescription drug use, familial pancreatitis, hyperlipidemia, or prior symptoms of biliary tract disease. He suffered one prior episode of alcoholic pancreatitis 3 years before this admission. He denied recent alcohol consumption. Vital signs were normal. Physical examination revealed epigastric tenderness but no mass. Significant presenting lab values included WBC, 16,000; alkaline phosphatase, 134 (normal, <110), and serum amylase, 804 (normal, <85). ERCP demonstrated pancreatic ductal disruption at the juncture of head and body with filling of a retrogastric pseudocyst and changes of chronic pancreatitis. An abdominal ultrasound demonstrated a thin-walled pancreatic pseudocyst 5 X 8 cm posterior to gastric antrum. Gallbladder and bile ducts were normal. In spite of bowel rest and supportive care, the patient demonstrated increasing abdominal pain, a rapidly expanding epigastric mass and progressive respiratory distress. CT scan 6 days later documented an enlarged thin-walled 12cm pseudocyst posterior to the gastric antrum. There was less than 1 cm between the gastric lumen and the pseudocyst cavity. Because of the lack of pseudocyst maturity, surgery was felt ill-advised. With progressive respiratory distress, pain, and fear of pseudocyst rupture, endoscopic transgastric drainage was believed to be necessary and appropriate. A cyst puncture instrument was devised through modification of a double-channel, 7 French sphincterotome (model PTG 30-7; Wilson-Cook Medical Inc., Winston Salem, N. C.). The distal portion of the catheter was transected at an angle at the proximal exit site of the cutting wire. The braided wire was then cut, allowing 4 mm to extend beyond the tip of the catheter, thus creating a double-channel, retractable, needle knife, or "fistulotome" (Fig. 1). A JFITI0 endoscope (Olympus Corporation of America, Lake Success, N. Y.) was used first to visualize the maximal point of antral compression by the cyst and the exposed diathermic wire of the fistulotome was used to create a small burn hole directly into the cyst cavity. A copious gush of Received January 3, 1991. Accepted February 7, 1991. From the Department of Medicine, Sacred Heart General Hospital, Eugene, Oregon and Department of Medicine, Section of Therapeutic Endoscopy, Virginia Mason Clinic, Seattle, Washington. Reprint requests: Gregory L. Knecht, MD, 677 E. 12th, Suite 500, Eugene, Oregon, 97401. 356
cloudy fluid heralded cyst entry, immediately obscuring endoscopic view. The 0.035-inch guidewire, placed through the second channel of the fistulotome, was quickly advanced into the cyst cavity securing cyst access. The needle knife wire of the fistulotome was then withdrawn from the catheter, allowing placement of a second 0.025-inch guidewire into the cyst cavity. The double-channel catheter was then withdrawn, leaving the two guidewires in place. A 10 French, 5-cm long, double-pigtail stent was then advanced into the cyst cavity using a guiding catheter and the 0.035-inch guidewire. The 0.025-inch guidewire was then used to place a 6 French nasocyst catheter. Careful fluoroscopic monitoring was utilized during the entire procedure. A total of 850 ml of cyst fluid was aspirated via the endoscope during the procedure. The patient showed dramatic clinical improvement. The nasocyst drainage catheter was used for culture and radiographic cystography and showed progressive decline in fluid output. The nasocyst catheter was removed 10 days after insertion, and a second 10 French double-pigtail stent was placed alongside the first stent to enhance long-term decompression. Four weeks later, follow-up ultrasound showed complete resolution of the cyst cavity, and both stents were uneventfully removed. Unfortunately, the pseudocyst recurred due to continued duct disruption documented by follow-up ERCP. Attempted pancreatic stenting to bridge the duct disruption failed. Surgical cystoenterostomy, combined with lateral pancreaticojejunostomy has led to complete clinical recovery, (4-month post-operative follow-up).
DISCUSSION
A variety of endoscopic instruments have been recommended to gain direct endoscopic access to pancreatic pseudocysts, including the pre-cut sphincterotome, standard needle knife, exposed end of a polypectomy snare, and lasers. 2- 6 Depending upon the anatomy of the cyst and the presence of pancreatic duct disruption, stents placed into the pancreatic duct
Figure 1. Modified Wilson-Cook wire-guided sphincterotome (PTG 30-7); 0.035-inch guidewire exits top channel. Retractable (transected) diathermic wire exits bottom channel. GASTROINTESTINAL ENDOSCOPY
through the major or minor papilla have also been used successfully5,7,8 and may complement, and even obviate, transmucosal drainage as described. We feel the optimal instrument for direct transmucosal access must address several important, potential pitfalls when utilizing this method of therapy. 1. Since the gastric and duodenal mucosa are quite vascular and since bleeding has been observed as a major complication from this procedure,2-4 the described concept of a small burn hole (for stenting), instead of an extended cut, will likely lessen this complication. 2. The visual field is commonly obscured by cyst fluid immediately upon cyst entry, and it is therefore extremely important to be able to quickly advance a guidewire into the cyst cavity before the catheter itself has a chance to dislodge. If the catheter does dislodge before guidewire access is secured, the original burn hole is quite difficult to find secondary to the large volume of escaping fluid and re-entry may be difficult due to a rapidly decompressing cyst. The second channel of the described instrument allows for immediate guidewire access and addresses this most important problem. 3. If there are uncertainties regarding the nature of the cyst after initial puncture, cystography to define the anatomy of the cyst or its relationship to other structures, is of value. The second channel of the described device can be conveniently and immediately used for contrast injection. 4. The ability to place two guidewires before catheter removal from the cyst is a significant convenience for the placement of either a nasocyst catheter plus a stent, or two stents. The nasocyst catheter is helpful in allowing day to day monitoring of cyst output, irrigation, fluid sampling for culture, and sequential cystography to monitor cyst size. Two stents allow a larger cystoenterostomy and less chance of stent occlusion. A somewhat similar cyst-puncture device has been described by Cremer et al.,9 in which a diathermic needle catheter is utilized for cyst puncture followed by a 10 French diathermic sleeve passed over the catheter. Cutting current is applied to the diathermic sleeve to enlarge the fistula. Although neither author of this report has used this device, our instrument would appear to be somewhat simpler in design and may be easier to use. In addition, the immediacy of guidewire placement, as well as the ability to place two guidewires simultaneously, would appear to be an advantage. Enlarging the fistula, after the initial small
VOLUME 37, NO, 3, 1991
burn hole, was not necessary for stent placement in this patient. Since even large cystoenterostomies can spontaneously close with surprising rapidity, reliance on one or two stents for cyst drainage, rather than the endoscopic cystostomy itself, may be the preferred method of drainage. More comparative data are clearly needed, however, before a firm recommendation can be made. It is to be stressed that the application of this instrument and technique should be reserved for those patients in whom the anatomical relationship of the pseudocyst to gut wall can be clearly defined by CT or ultrasound. In addition, proper endoscopic orientation to, and visualization of, a mucosal bulge are essential. The manufacturer of the sphincterotome utilized in this report does not recommend the simultaneous use of cautery with an in-dwelling guidewire in the second channel. However, a prototype instrument, nearly identical to the one described in this report, that would allow concomitant cautery with in-dwelling guidewire, has been developed and may be available soon for general use. ACKNOWLEDGMENTS The authors are grateful for the assistance of Betty Kang, Barbara Adler, Gene Evans, Kate Brown, and JoAnna Hatch.
REFERENCES 1. Barkin JS, Shakir AH. Changing concepts in the management
of pancreatic pseudocysts. Gastrointest Endosc 1989;35:62-3. 2. Kozarek RA, Brayko CM, Harlan J, Sanowski RA, Cintora I, Kovak A. Endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 1985;31:322-7. 3. Cremer M, Deviere J, Engelholm L. Endoscopic management of cysts and pseudocysts in chronic pancreatitis: long-term follow-up after 7 years of experience. Gastrointest Endosc 1989;35:1-9. 4. Sahel J, Bastid C, Pellat B, Shurgers P, Sarles H. Endoscopic cystoduodenostomy of cysts of chronic calcifying pancreatitis; a report of 20 cases. Pancreas 1987;2:447-53. 5. Huibregtse K, Schneider B, Vrij AA, Tytgat GNJ. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endose 1988;34:9-15. 6. Buchi KN, Bowers JH, Dixon JA. Endoscopic pancreatic cystogastrostomy using the Nd:YAG laser. Gastrointest Endosc 1986;32:112-4. 7. Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and pseudocyst. Gastroenterology (in press). 8. Kozarek RA, Patterson DJ, Ball TJ, Traverso LW. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis. Ann Surg 1989;209:261-6. 9. Cremer M, Deviere J, Baize M, Matos C. New device for endoscopic cystoenterostomy. Endoscopy 1990;22:76-7.
357