CC BY 4.0 · Endoscopy 2024; 56(S 01): E356-E357
DOI: 10.1055/a-2299-2253
E-Videos

Difficult management of pancreatic pseudocyst drainage in a 4-year-old child

1   Gastroenterology, Shanghai Childrenʼs Medical Center, Shanghai Jiatong University, Shanghai, China
,
Zhaohui Deng
1   Gastroenterology, Shanghai Childrenʼs Medical Center, Shanghai Jiatong University, Shanghai, China
,
Sheng Ding
1   Gastroenterology, Shanghai Childrenʼs Medical Center, Shanghai Jiatong University, Shanghai, China
› Institutsangaben

Gefördert durch: The Science and Technology Commission of Shanghai Municipality of China 22Y11921800
 

    A 4-year-old boy with acute lymphoblastic leukemia had recurrent pancreatitis with pancreatic pseudocyst formation following asparaginase chemotherapy. At 6 months after stent drainage of the pancreatic duct, computed tomography (CT) revealed an enlarged pancreatic pseudocyst ([Fig. 1]).

    Zoom Image
    Fig. 1 Computed tomography (CT) showed an enlarged pancreatic pseudocyst at 6-month follow-up after stent drainage of the pancreatic duct in a 4-year-old child.

    However, the massive pseudocyst compressed the gastric lumen, which was relatively small due to the patient’s young age, which led to difficulty in selecting a puncture site. Finally, the junction of the esophagus and cardia was selected for puncture. The puncture tract was expanded using an 8-mm dilation catheter. The intention was that, for drainage, two double-pigtail stents (7 Fr, 7 cm), were to be deployed from the esophagus, with their ends eventually coiling in the gastric lumen at the cardia.

    However as the first stent was being placed, straightforward release of the pigtail end was precluded by the small space available. When its guidewire was withdrawn, the entire stent slid into the pseudocyst because of esophageal compression and inertial coiling of the stent.

    Removal of the stent from the pseudocyst lumen was challenging. The puncture site was identified using a gastroscope with a transparent cap (Olympus; diameter 9.2 mm). A foreign body forceps was advanced through the dilated puncture channel into the lumen of the pseudocyst, under fluoroscopic guidance and along the second of the guidewires that had been inserted for stent placement. The stent was successfully removed and replaced by a 7-Fr curved transnasal pancreaticobiliary drain ([Video 1]).

    Challenging management of pancreatic pseudocyst drainage in a 4-year-old child.Video 1

    On CT re-examination at 1 week post-procedure, the pseudocyst was markedly smaller ([Fig. 2]; 20.9 × 16.3 × 21.6 mm). On endoscopic ultrasonography at 2 weeks post-procedure, the lumen was completely drained of cystic fluid and presented as an empty cavity; the cyst was 26 × 11 mm ([Fig. 3]). Subsequently, the transnasal pancreaticobiliary drain was removed, no complications (e.g., esophagopleural fistula) were observed on postoperative follow-up, and pancreatic enzymes returned to normal levels.

    Zoom Image
    Fig. 2 CT at 1 week after start of external nasobiliary drainage showed shrinking of the pseudocyst to 20.9 × 16.3 × 21.6 mm.
    Zoom Image
    Fig. 3 Endoscopic ultrasound after 2 weeks of drainage showed shrinking of the pseudocyst to approximately 26 × 11 mm.

    The small lumen of the digestive tract in children is a major challenge in endoscopic treatment. Puncture and drainage at the gastroesophageal junction are feasible in special cases. In this case successful drainage was achieved at this site, albeit suggesting that external drainage may be more appropriate for a puncture site near the esophagus.

    Endoscopy_UCTN_Code_CPL_1AL_2AD

    E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).

    This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.


    #

    Conflict of Interest

    The authors declare that they have no conflict of interest.

    Correspondence

    Sheng Ding, MD
    Department of Gastroenterology, Shanghai Children’s Medical Center
    1678 Dongfang Road
    Shanghai
    China   

    Publikationsverlauf

    Artikel online veröffentlicht:
    24. April 2024

    © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

    Georg Thieme Verlag KG
    Rüdigerstraße 14, 70469 Stuttgart, Germany

    Zoom Image
    Fig. 1 Computed tomography (CT) showed an enlarged pancreatic pseudocyst at 6-month follow-up after stent drainage of the pancreatic duct in a 4-year-old child.
    Zoom Image
    Fig. 2 CT at 1 week after start of external nasobiliary drainage showed shrinking of the pseudocyst to 20.9 × 16.3 × 21.6 mm.
    Zoom Image
    Fig. 3 Endoscopic ultrasound after 2 weeks of drainage showed shrinking of the pseudocyst to approximately 26 × 11 mm.