Description:
This is a case of a 40 year old male with chronic, relapsing pancreatitis secondary to alcohol use, who was referred for endoscopic pseudocyst drainage.
Following a flare of pancreatitis, the patient experienced persistent post-prandial abdominal pain, nausea and early satiety. A CT scan demonstrated interval development of a large, homogeneous pseudocyst in the head of the pancreas with partial obstruction of the duodenum.
Endoscopy was performed with a side-viewing duodenoscope and revealed extrinsic compression of the duodenal bulb. A sclerotherapy needle was used to puncture the duodenum at the site of maximal compression and injection of contrast confirms communication with the large cystic cavity.
A needle-knife papillotome was then used to incise the duodenal and pseudocyst walls using electrocautery. The needle is withdrawn and the catheter advanced into the cyst to serve as a conduit for guidewire placement. A .035” hydrophilic guidewire was advanced into the pseudocyst and can be seen coiling in the large cavity.
As the catheter is withdrawn, thin but turbid pseudocyst fluid can be seen streaming under pressure from the orifice.
The punctate cyst-duodenostomy was easily dilated using a pneumatic balloon. We chose an esophageal CRE balloon to dilate the opening serially from 8 mm to 10 mm in diameter.
As the balloon is deflated and the catheter withdrawn, a large volume of fluid is expelled from a gaping orifice and the previously-noted prominent bulge in the duodenum is no longer evident.
Conventionally, at this stage, one or more double-pigtail plastic stents would be placed across the cyst-duodenostomy to maintain patency and allow complete resolution of the pseudocyst. These stents are typically left for several months and often require replacement for premature occlusion.
In this case we opted to place a 10 mm fully-covered, self-expanding metal Viabil stent with intent to hasten the time to resolution of the pseudocyst and thereby avoid complications and need for repeated procedures. The stent is positioned and easily deployed across the cyst-duodenostomy. The pull-line deployment system allows for minimal movement of the stent catheter and, thereby, precise positioning. Initiation of deployment is seen as flowering of the proximal portion of the stent within the pseudocyst and progresses to eventual full deployment ending in the duodenum. Note the position of the anchoring fins on the underside of the stent, flush against the duodenal wall which serve to prevent inward migration.
The patient's symptoms promptly resolved after stent placement and a repeat CT done 4 weeks later revealed resolution of the large pseudocyst and a patent stent within an irregular parenchyma of the pancreatic head.
A repeat endoscopy was then performed for stent removal. The position of the stent remained unchanged however some debris can be seen within the stent lumen. A polypectomy snare was used to grasp the anchoring fin and one-third to one-half of the stent edge which subsequently collapses the mesh and allows removal of the stent through the working channel of the ERCP scope leaving a patent cyst-duodenosotmy. Note the whitish debris from within the pseudocyst cavity adherent to the outside of the stent. The cavity was gently irrigated with sterile saline and the scope withdrawn.
The patient maintained his well-being and a repeat CT scan performed 1 month after stent removal shows no evidence of recurrence of the pseudocyst.
Contributed By:
James Corasanti, MD, PhD, Buffalo General Hospital
