Infected pancreatic pseudocyst drainage and necrosectomy by endoscopic per-oral transgastric approach

Abstract

Open surgery with external drainage represents the treatment of choice in case of infected pancreatic pseudo cyst but may result in a pancreatic external fistula difficult to heal. Endoscopic internal drainage with stent avoids the risk of pancreatic fistula but may have a lower success rate and may require multiple stent replacements. The authors present the case of a 52 years old male patient with acute severe necrotizing alcoholic pancreatitis that developed, as local complication, a 7 cm diameter pancreatic pseudo cyst in the body of the pancreas that persisted 6 for weeks after the onset and later became infected. The diagnosis was set upon the clinical signs of infection, enhanced dynamic intravenous contrast CT scan and endoscopic ultrasonography. The patient was submitted to transgastric endoscopic drainage considering the fact that the pseudocyst was bulging into the stomach. Endoscopic ultrasound was use to choose an avascular window structure in the walls of the pseudocyst. After needle-knife puncture and guide wire introduction, a balloon dilator was inserted and an orifice of 1.5 cm was created through which a turbulent fluid and tissue debris were removed. The endoscope was then inserted in the cavity to check for residual debris and fluid and the cavity was rinsed with abundant saline and povidone-iodine. Healing of the residual cavity was followed by endoscopy and CT scan at 1 month, showing an important reduction in size. No hemorrhagic or septic complication occurred during the endoscopic procedure and during the follow-up interval. In cases of infected pancreatic pseudocyst, transgastric endoscopic cystgastrostomy may be a better solution for the patients that the classical external drainage performed by any other approach.