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Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts
Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts Jeroen M. Jansen, MD, Agaath Hanrath, RN, Eric A. Rauws, MD, PhD, Marco J. Bruno, MD, PhD, Paul Fockens, MD, PhD Amsterdam, The Netherlands
Background: Endoscopic drainage of pancreatic pseudocysts and abscesses has been shown to be an effective treatment modality. A major determinant for successful cyst resolution is the insertion of multiple endoprostheses and/or placement of a nasocystic drain, which require repeated entries of a catheter into the pseudocyst to reintroduce the guidewire. Objective: We describe a novel and easy technique to prevent the need for repeated access into the pseudocyst, thereby facilitating the placement of multiple endoprostheses by using a commercially available guiding system for stent introduction. Design: Case series. Setting: Academic Medical Center, The Netherlands. Patients: Eight consecutive patients with symptomatic pancreatic pseudocysts after acute pancreatitis. Interventions: Intracystic wire exchange for the insertion of multiple stents in endoscopic treatment of pancreatic pseudocysts by using an echoendoscope. Main Outcome Measurements: Feasibility of intracystic wire exchange and complications. Results: No guidewire access to the pseudocyst was lost. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established in all patients. Conclusions: The endoscopic appliance of multiple stents becomes easier when using intracystic wire exchange for transgastric pancreatic pseudocyst drainage.
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.02.016
pancreatic pseudocysts.4,11,12,13 Recently, Cahen et al4 reported the results of a retrospective study on the longterm outcome of endoscopic drainage, with almost 75% success rate. Placement of multiple endoprostheses was found to be predictive of a more successful outcome of long-term cyst resolution.4 Multiple endoprostheses ensure a wider gastro/duodenocystostomy opening for improved drainage, with less chance of stent clogging. A pseudocyst can be drained with or without EUS guidance, the latter procedure having the advantage of avoiding intervening vessels and the possibility to drain nonbulging cysts. The pseudocyst can be punctured with a needle knife, a cystotome, or a 19-gauge needle. After ensuring an adequate diameter of the gastro/duodenocystostomy opening, for which balloon dilation is sometimes indicated, endoprostheses and/or a nasocystic drain are inserted over a guidewire. The placement of multiple endoprostheses requires repeated entries of the pseudocyst to reintroduce a guidewire. This is time consuming and, in some cases, technically demanding because of changes in local anatomy once the cyst is drained.
www.giejournal.org
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 157
Pancreatic pseudocyst formation is a well-known complication of pancreatitis, occurring up to 10% to 20% in acute pancreatitis and 20% to 40% in chronic pancreatitis.1-4 In acute pancreatitis, the majority of peripancreatic-fluid collections resolve spontaneously. In chronic pancreatitis, however, cysts rarely regress if they are larger than 6 cm in diameter.5-7 Indications for drainage of pancreatic pseudocysts are persistent symptoms, rapid increase in size, infection, or biliary obstruction.4 Before contemplating drainage, it is preferable that there is an observation period of 6 weeks, because many pseudocysts resolve spontaneously.8-10 Drainage can be established by surgical, radiologic, or endoscopic techniques. No randomized trials have been published to compare these different treatment modalities. Nowadays, endoscopic drainage is widely used and has been proven to be a safe and effective treatment for
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts
In this article, we describe a novel application of intracystic wire exchange for the insertion of multiple stents, without the need for reentering the pseudocyst, by using a commercially available guiding catheter for stent placement.
Jansen et al
Capsule Summary What is already known on this topic d
PATIENTS AND METHODS
Successful pancreatic pseudocyst resolution requires the insertion of multiple endoprostheses and/or placement of a nasocystic drain, requiring repeated catheter entries.
What this study adds to our knowledge
For endoscopic drainage of pancreatic pseudocyst, patients were placed in a prone position. Routinely, midazolam and/or fentanyl was given, and an oblique-viewing therapeutic echoendoscope was used (GF-UCT140; Olympus Medical System Europe, Hamburg, Germany). Prophylactic antibiotics were administered. Under EUS guidance, the cyst was punctured with a 10F cystotome (Wilson Cook, Limerick, Ireland) or a 19-gauge EUS needle (Cook EchoTip; Wilson Cook). After entering the pseudocyst, the content was aspirated, and contrast medium was injected to confirm position of the needle inside the pseudocyst by fluoroscopy. The first guidewire (Met-35-480; Wilson Cook) was advanced into the pseudocyst through the inner catheter of the cystotome or the 19-gauge needle. This first guidewire never left the pseudocyst during the drainage procedure. The 10F outer catheter of the cystotome was advanced over the first guidewire up to the level of the gut wall while retracting the inner catheter or the 19-gauge needle. Then, coagulation current was applied to introduce the 10F outer catheter of a cystotome into the pseudocyst. Next, the inner catheter of the cystotome was removed and a second guidewire (Hydra Jagwire ST, 0.35/450; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass), with a different color from the first guidewire, was introduced through the outer catheter of the cystotome, alongside the first guidewire. After checking by fluoroscopy that both guidewires were well advanced into the cyst, the 2 wires were locked by a wire-locking device on the endoscope. The first guidewire was used for placing a double-pigtail stent (Fig. 1A). The second guidewire could be used for a second stent or a nasocystic drain. More than 2 endoprostheses can be inserted by using the intracystic wire exchange method. With this technique, 1 guidewire was always kept in position and was used to reintroduce a second guidewire before the next endoprosthesis was inserted. For this procedure, an Oasis guiding catheter (Oasis; Wilson Cook), which consists of a 9F lumen to allow passing a 0.0035-inch guidewire, was used. This guiding catheter contains a side hole at 2.5 cm from the distal tip of the catheter and has a radiopaque marker at this point. The guidewire is inserted through the distal tip of the Oasis guiding catheter and exits the catheter lumen after 2.5 cm through the side hole (Fig. 1B). The guiding catheter was advanced into the pseudocyst until it reached the opposite wall of the cyst. Subsequently, the guidewire was slowly pulled back, under radiologic guidance, until it disengaged 158 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 1 : 2007
d
Intracystic wire exchange was used to drain pancreatic pseudocysts in 8 consecutive patients, without complications or loss of pseudocyst access.
from the guiding catheter (intracystic wire exchange) (Fig. 2A and B). Then, the stylet of the guiding catheter was removed and replaced by a second guidewire, which was advanced into the pseudocyst. Once the second guidewire entered the pseudocyst, the guiding catheter was removed and, effectively, 2 guidewires were in place without the need to recannulate the gastro/duodenocystostostomy opening (Fig. 1C and D). This procedure could be repeated endlessly and placement of endoprostheses and a nasocystic drain was only limited by the size of the opening in the pseudocyst (Fig. 1E).
RESULTS Since April 2006, 8 consecutive patients (5 men and 3 women; mean age 51 years; range, 19-64 years) who underwent transgastric endoscopic drainage of a symptomatic pancreatic pseudocyst were included. All patients developed pseudocysts after an episode of acute pancreatitis. The mean time interval between the acute pancreatitis and drainage procedure was 8.4 months (range, 2-24 months). Indications for drainage was pain in 4 patients, increase in size of the pseudocyst in 3 patients, and jaundice from compression of the common bile duct in 1 patient (Table 1). Pseudocyst drainage was performed under US guidance to identify the optimal drainage site. Pseudocyst access was established by using the cystotome or the 19-gauge needle, and multiple double-pigtail endoprostheses were placed by using the intracystic wire exchange method. In each patient, routinely, 3 stents were placed without the need for reentry of the pseudocyst. In case of the presence of debris in the pseudocyst, the patients, in addition, received a nasocystic drain, and the procedure was repeated after 2 to 3 days for endoscopic debridement. At no time was guidewire access to the pseudocyst lost. The mean number of drainage procedures carried out was 2.5 (range, 1-4). The endoprostheses were extracted after 6 weeks, if the pseudocysts had collapsed. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established all patients. www.giejournal.org
Jansen et al
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts
Figure 1. A, Endoscopic picture, showing the placement of a double-pigtail endoprosthesis when using 1 of the 2 guidewires and a second guidewire in situ. B, A guiding catheter is advanced over the second guidewire. C and D, An intracystic wire exchange is performed, resulting in the presence of 2 guidewires alongside the first pigtail endoprosthesis. E, Results after 4 intracystic exchanges with 4 double-pigtail endoprostheses and 2 guidewires inside a pseudocyst.
Treatment of pancreatic pseudocysts can be effectively performed by endoscopic drainage in the majority of patients. In 6% to 30%, however, endoscopic treatment fails,
and surgery is indicated.4,11,12,14 Factors that determine treatment success are placement of multiple endoprostheses, location of a pseudocyst in the head of the pancreas (preferentially drained via the bulbus or the duodenum), and duration of drainage longer than 6 weeks.4,15 The
www.giejournal.org
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 159
DISCUSSION
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts
Jansen et al
Figure 2. Radiologic image, showing an intracystic exchange. One endoprosthesis is present in situ, together with the guiding catheter, which contains 2 guidewires. A, The guidewire before leaving the side port. B, The guidewire after leaving the side port of the guiding catheter at the site of the radiopaque marker (Zintracystic wire exchange).
TABLE 1. Patients and pseudocyst characteristics
Cyst no.
Debris
Distance cyst-stomach, mm
13
1
No
Unknown
Cystotome
1
Pain
17
1
No
Unknown
Cystotome
1
5 wk
Pain
20
1
Yes
10
Cystotome
4
60
10 mo
Pain
14 and 10
2
Yes
8 and 8
Cystotome
6
5
60
2y
Growth
9.5
1
Yes
5
19-gauge needle
1
6
56
8 mo
Growth
Unknown
2
No
2 and 3
Cystotome
2
7
59
8 mo
Growth
17
1
Yes
4
19-gauge needle
4
8
50
2 mo
Cholestasis
8
1
Yes
Unknown
19-gauge needle
2
Patient no.
Age, y
Time interval*
Indication drainage
1
64
Unknown
Pain
2
19
2 mo
3
44
4
Cyst size, cm
Entry method
Sessions (nr)
nr, Number of drainage procedures. *Time between pancreatitis and pseudocyst drainage.
outcome also differs according to the type of pseudocyst. Successful drainage is more favorable in chronic pancreatitis (92%) compared with acute pancreatitis (74%) or pancreatic necrosis (72%).16 In the latter case, aggressive endoscopic management is mandatory, with placement of multiple endoprostheses, including a nasocystic drain and frequent reinterventions for evacuation of solid debris.16 Wilson Cook recently introduced the Fusion system for ERCP procedures. This system features the so-called intraductal exchange technology by which a guidewire can dis-
engage from the catheter within the bile duct or the pancreatic duct. This allows for placement of multiple plastic stents and eliminates the necessity of an exchange outside the endoscope and repeated cannulations for reentering the ductal system. When using this same principle, we hereby report our initial experience with the technique of intracystic wire exchange to drain pancreatic pseudocysts in 8 consecutive patients. All procedures went without complications, including technical complications, and at no time was access to the pseudocyst lost. The placement of a second guidewire through the
160 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 1 : 2007
www.giejournal.org
Jansen et al
cystotome and subsequent use of the intracystic wire exchange method secures access to the pseudocyst at all time and avoids the need for repetitive entries, thereby making it a simple, easy, and efficient technique for the drainage of pancreatic pseudocysts.
DISCLOSURE None of the authors have any disclosures to make.
REFERENCES 1. Beckingham IJ, Krige JE, Bornman PC, et al. Long term outcome of endoscopic drainage of pancreatic pseudocysts. Am J Gastroenterol 1999;94:71-4. 2. Barthet M, Bugalo M, Moreira LS, et al. Management of cysts and pseudocysts complicating chronic pancreatitis. A retrospective study of 143 patients. Gastroenterol Clin Biol 1993;17:270-6. 3. Baillie J. Pancreatic pseudocysts (Part I). Gastrointest Endosc 2004;59: 873-9. 4. Cahen D, Rauws E, Fockens P, et al. Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment. Endoscopy 2005;37:977-83. 5. Gouyon B, Levy P, Ruszniewski P, et al. Predictive factors in the outcome of pseudocysts complicating alcoholic chronic pancreatitis. Gut 1997;41:821-5. 6. Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992;111:123-30. 7. Beebe DS, Bubrick MP, Onstad GR, et al. Management of pancreatic pseudocysts. Surg Gynecol Obstet 1984;159:562-4.
www.giejournal.org
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts 8. Yeo CJ, Bastidas JA, Lynch-Nyhan A, et al. The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet 1990;170:411-7. 9. Lehman GA. Pseudocysts. Gastrointest Endosc 1999;49:S81-4. 10. Adkisson KW, Baron TH, Morgan DE. Pancreatic fluid collections: diagnosis and endoscopic management. Semin Gastrointest Dis 1998;9: 61-72. 11. Azar RR, Oh YS, Janec EM, et al. Wire-guided pancreatic pseudocyst drainage by using a modified needle knife and therapeutic echoendoscope. Gastrointest Endosc 2006;63:688-92. 12. Kruger M, Schneider AS, Manns MP, et al. Endoscopic management of pancreatic pseudocysts or abscesses after an EUS-guided 1-step procedure for initial access. Gastrointest Endosc 2006;63:409-16. 13. Giovannini M, Bernardini D, Seitz JF. Cystogastrotomy entirely performed under endoscopic guidance for pancreatic pseudocysts: results in six patients. Gastrointest Endosc 1998;48:200-3. 14. Vosoghi M, Sial S, Garrett B, et al. EUS-guided pancreatic pseudocyst drainage: review and experience at Harbor-UCLA Medical Center. MedGenMed 2002;4:2. 15. Binmoeller KF, Seifert H, Walter A, et al. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42: 219-24. 16. 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.
Received October 10, 2006. Accepted February 1, 2007. Current affiliations: Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Reprint requests: Jeroen M. Jansen, MD, Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 161
Background: Endoscopic drainage of pancreatic pseudocysts and abscesses has been shown to be an effective treatment modality. A major determinant for successful cyst resolution is the insertion of multiple endoprostheses and/or placement of a nasocystic drain, which require repeated entries of a catheter into the pseudocyst to reintroduce the guidewire. Objective: We describe a novel and easy technique to prevent the need for repeated access into the pseudocyst, thereby facilitating the placement of multiple endoprostheses by using a commercially available guiding system for stent introduction. Design: Case series. Setting: Academic Medical Center, The Netherlands. Patients: Eight consecutive patients with symptomatic pancreatic pseudocysts after acute pancreatitis. Interventions: Intracystic wire exchange for the insertion of multiple stents in endoscopic treatment of pancreatic pseudocysts by using an echoendoscope. Main Outcome Measurements: Feasibility of intracystic wire exchange and complications. Results: No guidewire access to the pseudocyst was lost. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established in all patients. Conclusions: The endoscopic appliance of multiple stents becomes easier when using intracystic wire exchange for transgastric pancreatic pseudocyst drainage.
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.02.016
pancreatic pseudocysts.4,11,12,13 Recently, Cahen et al4 reported the results of a retrospective study on the longterm outcome of endoscopic drainage, with almost 75% success rate. Placement of multiple endoprostheses was found to be predictive of a more successful outcome of long-term cyst resolution.4 Multiple endoprostheses ensure a wider gastro/duodenocystostomy opening for improved drainage, with less chance of stent clogging. A pseudocyst can be drained with or without EUS guidance, the latter procedure having the advantage of avoiding intervening vessels and the possibility to drain nonbulging cysts. The pseudocyst can be punctured with a needle knife, a cystotome, or a 19-gauge needle. After ensuring an adequate diameter of the gastro/duodenocystostomy opening, for which balloon dilation is sometimes indicated, endoprostheses and/or a nasocystic drain are inserted over a guidewire. The placement of multiple endoprostheses requires repeated entries of the pseudocyst to reintroduce a guidewire. This is time consuming and, in some cases, technically demanding because of changes in local anatomy once the cyst is drained.
www.giejournal.org
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 157
Pancreatic pseudocyst formation is a well-known complication of pancreatitis, occurring up to 10% to 20% in acute pancreatitis and 20% to 40% in chronic pancreatitis.1-4 In acute pancreatitis, the majority of peripancreatic-fluid collections resolve spontaneously. In chronic pancreatitis, however, cysts rarely regress if they are larger than 6 cm in diameter.5-7 Indications for drainage of pancreatic pseudocysts are persistent symptoms, rapid increase in size, infection, or biliary obstruction.4 Before contemplating drainage, it is preferable that there is an observation period of 6 weeks, because many pseudocysts resolve spontaneously.8-10 Drainage can be established by surgical, radiologic, or endoscopic techniques. No randomized trials have been published to compare these different treatment modalities. Nowadays, endoscopic drainage is widely used and has been proven to be a safe and effective treatment for
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts
In this article, we describe a novel application of intracystic wire exchange for the insertion of multiple stents, without the need for reentering the pseudocyst, by using a commercially available guiding catheter for stent placement.
Jansen et al
Capsule Summary What is already known on this topic d
PATIENTS AND METHODS
Successful pancreatic pseudocyst resolution requires the insertion of multiple endoprostheses and/or placement of a nasocystic drain, requiring repeated catheter entries.
What this study adds to our knowledge
For endoscopic drainage of pancreatic pseudocyst, patients were placed in a prone position. Routinely, midazolam and/or fentanyl was given, and an oblique-viewing therapeutic echoendoscope was used (GF-UCT140; Olympus Medical System Europe, Hamburg, Germany). Prophylactic antibiotics were administered. Under EUS guidance, the cyst was punctured with a 10F cystotome (Wilson Cook, Limerick, Ireland) or a 19-gauge EUS needle (Cook EchoTip; Wilson Cook). After entering the pseudocyst, the content was aspirated, and contrast medium was injected to confirm position of the needle inside the pseudocyst by fluoroscopy. The first guidewire (Met-35-480; Wilson Cook) was advanced into the pseudocyst through the inner catheter of the cystotome or the 19-gauge needle. This first guidewire never left the pseudocyst during the drainage procedure. The 10F outer catheter of the cystotome was advanced over the first guidewire up to the level of the gut wall while retracting the inner catheter or the 19-gauge needle. Then, coagulation current was applied to introduce the 10F outer catheter of a cystotome into the pseudocyst. Next, the inner catheter of the cystotome was removed and a second guidewire (Hydra Jagwire ST, 0.35/450; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass), with a different color from the first guidewire, was introduced through the outer catheter of the cystotome, alongside the first guidewire. After checking by fluoroscopy that both guidewires were well advanced into the cyst, the 2 wires were locked by a wire-locking device on the endoscope. The first guidewire was used for placing a double-pigtail stent (Fig. 1A). The second guidewire could be used for a second stent or a nasocystic drain. More than 2 endoprostheses can be inserted by using the intracystic wire exchange method. With this technique, 1 guidewire was always kept in position and was used to reintroduce a second guidewire before the next endoprosthesis was inserted. For this procedure, an Oasis guiding catheter (Oasis; Wilson Cook), which consists of a 9F lumen to allow passing a 0.0035-inch guidewire, was used. This guiding catheter contains a side hole at 2.5 cm from the distal tip of the catheter and has a radiopaque marker at this point. The guidewire is inserted through the distal tip of the Oasis guiding catheter and exits the catheter lumen after 2.5 cm through the side hole (Fig. 1B). The guiding catheter was advanced into the pseudocyst until it reached the opposite wall of the cyst. Subsequently, the guidewire was slowly pulled back, under radiologic guidance, until it disengaged 158 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 1 : 2007
d
Intracystic wire exchange was used to drain pancreatic pseudocysts in 8 consecutive patients, without complications or loss of pseudocyst access.
from the guiding catheter (intracystic wire exchange) (Fig. 2A and B). Then, the stylet of the guiding catheter was removed and replaced by a second guidewire, which was advanced into the pseudocyst. Once the second guidewire entered the pseudocyst, the guiding catheter was removed and, effectively, 2 guidewires were in place without the need to recannulate the gastro/duodenocystostostomy opening (Fig. 1C and D). This procedure could be repeated endlessly and placement of endoprostheses and a nasocystic drain was only limited by the size of the opening in the pseudocyst (Fig. 1E).
RESULTS Since April 2006, 8 consecutive patients (5 men and 3 women; mean age 51 years; range, 19-64 years) who underwent transgastric endoscopic drainage of a symptomatic pancreatic pseudocyst were included. All patients developed pseudocysts after an episode of acute pancreatitis. The mean time interval between the acute pancreatitis and drainage procedure was 8.4 months (range, 2-24 months). Indications for drainage was pain in 4 patients, increase in size of the pseudocyst in 3 patients, and jaundice from compression of the common bile duct in 1 patient (Table 1). Pseudocyst drainage was performed under US guidance to identify the optimal drainage site. Pseudocyst access was established by using the cystotome or the 19-gauge needle, and multiple double-pigtail endoprostheses were placed by using the intracystic wire exchange method. In each patient, routinely, 3 stents were placed without the need for reentry of the pseudocyst. In case of the presence of debris in the pseudocyst, the patients, in addition, received a nasocystic drain, and the procedure was repeated after 2 to 3 days for endoscopic debridement. At no time was guidewire access to the pseudocyst lost. The mean number of drainage procedures carried out was 2.5 (range, 1-4). The endoprostheses were extracted after 6 weeks, if the pseudocysts had collapsed. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established all patients. www.giejournal.org
Jansen et al
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts
Figure 1. A, Endoscopic picture, showing the placement of a double-pigtail endoprosthesis when using 1 of the 2 guidewires and a second guidewire in situ. B, A guiding catheter is advanced over the second guidewire. C and D, An intracystic wire exchange is performed, resulting in the presence of 2 guidewires alongside the first pigtail endoprosthesis. E, Results after 4 intracystic exchanges with 4 double-pigtail endoprostheses and 2 guidewires inside a pseudocyst.
Treatment of pancreatic pseudocysts can be effectively performed by endoscopic drainage in the majority of patients. In 6% to 30%, however, endoscopic treatment fails,
and surgery is indicated.4,11,12,14 Factors that determine treatment success are placement of multiple endoprostheses, location of a pseudocyst in the head of the pancreas (preferentially drained via the bulbus or the duodenum), and duration of drainage longer than 6 weeks.4,15 The
www.giejournal.org
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 159
DISCUSSION
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts
Jansen et al
Figure 2. Radiologic image, showing an intracystic exchange. One endoprosthesis is present in situ, together with the guiding catheter, which contains 2 guidewires. A, The guidewire before leaving the side port. B, The guidewire after leaving the side port of the guiding catheter at the site of the radiopaque marker (Zintracystic wire exchange).
TABLE 1. Patients and pseudocyst characteristics
Cyst no.
Debris
Distance cyst-stomach, mm
13
1
No
Unknown
Cystotome
1
Pain
17
1
No
Unknown
Cystotome
1
5 wk
Pain
20
1
Yes
10
Cystotome
4
60
10 mo
Pain
14 and 10
2
Yes
8 and 8
Cystotome
6
5
60
2y
Growth
9.5
1
Yes
5
19-gauge needle
1
6
56
8 mo
Growth
Unknown
2
No
2 and 3
Cystotome
2
7
59
8 mo
Growth
17
1
Yes
4
19-gauge needle
4
8
50
2 mo
Cholestasis
8
1
Yes
Unknown
19-gauge needle
2
Patient no.
Age, y
Time interval*
Indication drainage
1
64
Unknown
Pain
2
19
2 mo
3
44
4
Cyst size, cm
Entry method
Sessions (nr)
nr, Number of drainage procedures. *Time between pancreatitis and pseudocyst drainage.
outcome also differs according to the type of pseudocyst. Successful drainage is more favorable in chronic pancreatitis (92%) compared with acute pancreatitis (74%) or pancreatic necrosis (72%).16 In the latter case, aggressive endoscopic management is mandatory, with placement of multiple endoprostheses, including a nasocystic drain and frequent reinterventions for evacuation of solid debris.16 Wilson Cook recently introduced the Fusion system for ERCP procedures. This system features the so-called intraductal exchange technology by which a guidewire can dis-
engage from the catheter within the bile duct or the pancreatic duct. This allows for placement of multiple plastic stents and eliminates the necessity of an exchange outside the endoscope and repeated cannulations for reentering the ductal system. When using this same principle, we hereby report our initial experience with the technique of intracystic wire exchange to drain pancreatic pseudocysts in 8 consecutive patients. All procedures went without complications, including technical complications, and at no time was access to the pseudocyst lost. The placement of a second guidewire through the
160 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 1 : 2007
www.giejournal.org
Jansen et al
cystotome and subsequent use of the intracystic wire exchange method secures access to the pseudocyst at all time and avoids the need for repetitive entries, thereby making it a simple, easy, and efficient technique for the drainage of pancreatic pseudocysts.
DISCLOSURE None of the authors have any disclosures to make.
REFERENCES 1. Beckingham IJ, Krige JE, Bornman PC, et al. Long term outcome of endoscopic drainage of pancreatic pseudocysts. Am J Gastroenterol 1999;94:71-4. 2. Barthet M, Bugalo M, Moreira LS, et al. Management of cysts and pseudocysts complicating chronic pancreatitis. A retrospective study of 143 patients. Gastroenterol Clin Biol 1993;17:270-6. 3. Baillie J. Pancreatic pseudocysts (Part I). Gastrointest Endosc 2004;59: 873-9. 4. Cahen D, Rauws E, Fockens P, et al. Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment. Endoscopy 2005;37:977-83. 5. Gouyon B, Levy P, Ruszniewski P, et al. Predictive factors in the outcome of pseudocysts complicating alcoholic chronic pancreatitis. Gut 1997;41:821-5. 6. Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992;111:123-30. 7. Beebe DS, Bubrick MP, Onstad GR, et al. Management of pancreatic pseudocysts. Surg Gynecol Obstet 1984;159:562-4.
www.giejournal.org
Intracystic wire exchange in endoscopic drainage of pancreatic pseudocysts 8. Yeo CJ, Bastidas JA, Lynch-Nyhan A, et al. The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet 1990;170:411-7. 9. Lehman GA. Pseudocysts. Gastrointest Endosc 1999;49:S81-4. 10. Adkisson KW, Baron TH, Morgan DE. Pancreatic fluid collections: diagnosis and endoscopic management. Semin Gastrointest Dis 1998;9: 61-72. 11. Azar RR, Oh YS, Janec EM, et al. Wire-guided pancreatic pseudocyst drainage by using a modified needle knife and therapeutic echoendoscope. Gastrointest Endosc 2006;63:688-92. 12. Kruger M, Schneider AS, Manns MP, et al. Endoscopic management of pancreatic pseudocysts or abscesses after an EUS-guided 1-step procedure for initial access. Gastrointest Endosc 2006;63:409-16. 13. Giovannini M, Bernardini D, Seitz JF. Cystogastrotomy entirely performed under endoscopic guidance for pancreatic pseudocysts: results in six patients. Gastrointest Endosc 1998;48:200-3. 14. Vosoghi M, Sial S, Garrett B, et al. EUS-guided pancreatic pseudocyst drainage: review and experience at Harbor-UCLA Medical Center. MedGenMed 2002;4:2. 15. Binmoeller KF, Seifert H, Walter A, et al. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42: 219-24. 16. 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.
Received October 10, 2006. Accepted February 1, 2007. Current affiliations: Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Reprint requests: Jeroen M. Jansen, MD, Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 161