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DOI: 10.1055/s-0032-1306793
Successful drainage of recurrent pancreatic pseudocyst via a transpapillary and transpancreatic approach, using a conventional cystotome
A 54-year-old patient was previously admitted to our hospital in 2010 with a history of biliary necrotizing pancreatitis and pancreatic fluid collection with necrotic debris projecting into the tail of the pancreas. We carried out endoscopic ultrasound-guided (EUS) transgastric drainage of the superinfected necrotic area. The patient was discharged and 6 months later the pigtails were removed after complete resolution of the fluid collection. After another 6 months, transabdominal ultrasound showed a large pseudocyst at the same site without any signs of inflammation. The diagnosis was confirmed by computed tomography (CT) ([Fig. 1]). EUS revealed a large stenosis in the pancreatic duct and there was suspicion of a fistula in relation to the pseudocyst. Transgastric access for pseudocyst drainage was impeded by the presence of multiple varices because of splenic vein thrombosis. We therefore chose a transpapillary approach for draining the pseudocyst (diameter 10 cm).
Endoscopic retrograde pancreatography (ERP) confirmed the presence of filiform stenosis in the pancreatic main duct and a prestenotic communication into the pseudocyst ([Fig. 2]). While a guide wire passed through the stenosis, neither an ERCP cannula nor a biliary dilatation catheter could be passed across it. After taking informed consent, another attempt was made to place the guide wire again via the stenosis into the pancreatic pseudocyst ([Fig. 3]). A cystotome was placed in the stenosis and moved under blended current into the pseudocyst ([Fig. 4]). A nasocystic tube was placed, which spontaneously drained 500 mL of clear cystic fluid ([Fig. 5]). A follow-up CT scan revealed rapid and complete resolution of the pseudocyst, and 4 days later the patient had was discharged with a 17-cm, 7-F Amsterdam stent. There were no signs of discomfort or inflammation. This case demonstrates that access to a pancreatic pseudocyst for transpapillary drainage through a stenosed duct can be gained with a cystotome under blended current, so long as the guide wire is safely placed inside the pseudocyst.
Endoscopy_UCTN_Code_TTT_1AR_2AI
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Competing interests: None