Endoscopy 2017; 49(S 01): E81
DOI: 10.1055/s-0043-100189
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Into the mediastinum and out of the papilla: minimally invasive endoscopic therapy in two body cavities with one instrument

Bernhard Magdeburg
1   Department of Medicine, GZO – Zurich Regional Health Center, Wetzikon, Switzerland
,
Daniela B. Husarik
2   Institute of Radiology, GZO – Zurich Regional Health Center, Wetzikon, Switzerland
,
Thomas Greuter
1   Department of Medicine, GZO – Zurich Regional Health Center, Wetzikon, Switzerland
› Institutsangaben
Weitere Informationen

Corresponding author

Bernhard Magdeburg, MD
Gastroenterology and Hepatology
GZO – Zurich Regional Health Center
8610 Wetzikon
Switzerland   
Fax: +41-44-9341199   

Publikationsverlauf

Publikationsdatum:
31. Januar 2017 (online)

 

    A 48-year-old woman with chronic ethylic pancreatitis presented with new onset of fever, dysphagia, and elevated inflammatory parameters. Computed tomography revealed a large cystic supradiaphragmatic paraesophageal structure and two small retroperitoneal cysts near the pancreatic body. Transesophageal endosonographic fine-needle aspiration showed pus and an elevated amylase level. The diagnosis of an infected pancreatic pseudocyst was made. Consequently, a 10 Fr double-pigtail catheter and a 7 Fr nasocystic tube were inserted transesophageally. Infection was treated with intravenous penicillin according to antimicrobial resistance of the detected Streptococcus anginosus.

    During a second intervention 2 weeks later, using a 10 Fr digital endoscope (SpyScope-DS; Boston Scientific, Marlborough, Massachusetts, USA), we were able to locate and pass the transhiatal fistula of the pancreatic pseudocyst after balloon dilation to reach the caudally located smaller part of the pancreatic pseudocyst. After several unsuccessful attempts, a 0.035 inch guidewire was passed under visual guidance through the pancreatic pseudocyst and into the pancreatic duct ([Fig. 1], [Video 1]). The wire was then advanced via the ampulla of Vater into the duodenum and extracted orally. By holding the guidewire tightly at both ends, we were able to support the difficult and precise placement of a 5 Fr, 13 cm plastic stent into the pancreatic duct, via the thoracic and abdominal part of the pancreatic pseudocyst. The proximal end was placed visually in the small abdominal cystic part and the distal end was located in the duodenum. The nasocystic tube and double-pigtail catheter were removed and the esophagocystic access was closed using two hemoclips. Subsequently, both the thoracic and the abdominal part of the pancreatic pseudocyst collapsed totally and the patient recovered completely. The stent was replaced transpapillarily 3 months later and completely removed 2 months thereafter. The patient continues to be asymptomatic.

    Zoom Image
    Fig. 1 Fluoroscopy showing the mediastinal pseudocyst with a caudally located smaller pseudocyst and its connection to the pancreatic duct.
    Video 1: Successful drainage of a large pancreatic pseudocyst located in the mediastinum and abdomen using a 10 Fr digital endoscope.

    Qualität:

    Endoscopy_UCTN_Code_TTT_1AS_2AC


    #

    Competing interests

    Dr. Magdeburg is a medical consultant for Boston Scientific.


    Corresponding author

    Bernhard Magdeburg, MD
    Gastroenterology and Hepatology
    GZO – Zurich Regional Health Center
    8610 Wetzikon
    Switzerland   
    Fax: +41-44-9341199   


    Zoom Image
    Fig. 1 Fluoroscopy showing the mediastinal pseudocyst with a caudally located smaller pseudocyst and its connection to the pancreatic duct.