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Endoscopic transmural drainage of pancreatic pseudocysts: technical challenges in the resource poor setting.

Cawich SO, Murphy T, Shah S, Barrow P, Arthurs M, Ramdass MJ, Johnson PB - Case Rep Gastrointest Med (2013)

Bottom Line: We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers.Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware.Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine, Trinidad and Tobago.

ABSTRACT
Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options, the requirement for specialized equipment, technical expertise, and consumables limits the options available in low resource settings. We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers. Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware. Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

No MeSH data available.


Related in: MedlinePlus

Immediate abdominal decompression (a) after 3700 mL of turbid pancreatic fluid was drained from the cyst (b).
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fig6: Immediate abdominal decompression (a) after 3700 mL of turbid pancreatic fluid was drained from the cyst (b).

Mentions: An endoscopic cystogastrostomy was attempted in the endoscopy suite under conscious sedation with intravenous Propofol. The procedure was performed in the left lateral decubitus position with noninvasive monitoring. Intravenous ceftriaxone was administered as prophylaxis at induction. A side viewing duodenoscope (Olympus TJF-140, Olympus America, Central Valley, PA, USA) was advanced into the stomach. With insufflation the area of extrinsic gastric compression was identified on the posterior wall. Endoscopic ultrasound (EUS) was not available so the stomach was aspirated while the endoscope remained in situ. This facilitated simultaneous transabdominal ultrasound (Figure 2) to confirm that the endoscope tip was at an appropriate area for puncture. A triple lumen needle knife sphincterotome (Micro-knife XL, Boston Scientific Co., Marlborough, MA, USA) was advanced through the working channel of the scope and used to create a 1-2 cm incision in the gastric mucosa (Figure 3(a)) with bipolar electrocautery (force FX, Valleylab, Boulder, CO, USA). Entry into the cyst was confirmed by a gush of clear pancreatic fluid returning (Figure 3(b)). A 480 cm flexible 0.035′′ guidewire (Hydra Jagwire, Boston Scientific Co., Marlborough, USA) was advanced through the incision. The needle knife catheter was removed leaving the guidewire across the incision within the pseudocyst cavity. A 6–8 mm controlled radial expansion biliary dilating balloon (CRE Wireguided Balloon Dilator, Boston Scientific Microvasive, Natick, MA, USA) was railroaded over the guidewire (Figure 4(a)) and inflated to dilate the transmural tract to 16 mm (Figure 4(b)). The dilating balloon was inflated on three separate occasions for 20 seconds to ensure adequate dilation of the incision. The dilating balloon was removed with the guidewire left in place. A double pigtail 10 F × 5 cm plastic stent (C-flex Biliary; Boston Scientific, Spencer, IN, USA) was then advanced over the guidewire and deployed with the proximal end in the gastric lumen and the distal end within the pseudocyst cavity. Ultrasound was repeated to confirm drain placement within the cavity and the gastric placement was confirmed at endoscopy and subsequently with plain radiographs (Figure 5). Approximately 3700 mL of turbid pancreatic fluid was removed from the cyst, resulting in immediate abdominal decompression (Figure 6).


Endoscopic transmural drainage of pancreatic pseudocysts: technical challenges in the resource poor setting.

Cawich SO, Murphy T, Shah S, Barrow P, Arthurs M, Ramdass MJ, Johnson PB - Case Rep Gastrointest Med (2013)

Immediate abdominal decompression (a) after 3700 mL of turbid pancreatic fluid was drained from the cyst (b).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3860138&req=5

fig6: Immediate abdominal decompression (a) after 3700 mL of turbid pancreatic fluid was drained from the cyst (b).
Mentions: An endoscopic cystogastrostomy was attempted in the endoscopy suite under conscious sedation with intravenous Propofol. The procedure was performed in the left lateral decubitus position with noninvasive monitoring. Intravenous ceftriaxone was administered as prophylaxis at induction. A side viewing duodenoscope (Olympus TJF-140, Olympus America, Central Valley, PA, USA) was advanced into the stomach. With insufflation the area of extrinsic gastric compression was identified on the posterior wall. Endoscopic ultrasound (EUS) was not available so the stomach was aspirated while the endoscope remained in situ. This facilitated simultaneous transabdominal ultrasound (Figure 2) to confirm that the endoscope tip was at an appropriate area for puncture. A triple lumen needle knife sphincterotome (Micro-knife XL, Boston Scientific Co., Marlborough, MA, USA) was advanced through the working channel of the scope and used to create a 1-2 cm incision in the gastric mucosa (Figure 3(a)) with bipolar electrocautery (force FX, Valleylab, Boulder, CO, USA). Entry into the cyst was confirmed by a gush of clear pancreatic fluid returning (Figure 3(b)). A 480 cm flexible 0.035′′ guidewire (Hydra Jagwire, Boston Scientific Co., Marlborough, USA) was advanced through the incision. The needle knife catheter was removed leaving the guidewire across the incision within the pseudocyst cavity. A 6–8 mm controlled radial expansion biliary dilating balloon (CRE Wireguided Balloon Dilator, Boston Scientific Microvasive, Natick, MA, USA) was railroaded over the guidewire (Figure 4(a)) and inflated to dilate the transmural tract to 16 mm (Figure 4(b)). The dilating balloon was inflated on three separate occasions for 20 seconds to ensure adequate dilation of the incision. The dilating balloon was removed with the guidewire left in place. A double pigtail 10 F × 5 cm plastic stent (C-flex Biliary; Boston Scientific, Spencer, IN, USA) was then advanced over the guidewire and deployed with the proximal end in the gastric lumen and the distal end within the pseudocyst cavity. Ultrasound was repeated to confirm drain placement within the cavity and the gastric placement was confirmed at endoscopy and subsequently with plain radiographs (Figure 5). Approximately 3700 mL of turbid pancreatic fluid was removed from the cyst, resulting in immediate abdominal decompression (Figure 6).

Bottom Line: We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers.Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware.Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine, Trinidad and Tobago.

ABSTRACT
Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options, the requirement for specialized equipment, technical expertise, and consumables limits the options available in low resource settings. We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers. Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware. Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

No MeSH data available.


Related in: MedlinePlus