Transmural Drainage of Cystic Peripancreatic Lesions with a New Large-Channel Echo Endoscope

• Introduction
• Patients and Methods
• Results
• Discussion
• References

Background and Study Aims: The availability of a new large-channel echo endoscope led us to develop a new needle-stent device for endoscopic puncture and drainage of pancreatogenic cystic lesions. The purpose of this study was to examine whether endoscopic ultrasound (EUS)-guided one-step 10-F puncture and drainage with the new equipment could be feasible and successful. The use of the technique and the short-term outcome in our first four patients are described and discussed.

Patients and Methods: Cystic lesions were drained using the new technique in four patients. All the patients had symptomatic peripancreatic lesions, one with intrahepatic and one with intrasplenic extension. Punctures were carried out using a new echo endoscope with a 3.7 mm working channel and an Albarran lever. The 10-F transmural stents were placed over a 1 mm stainless steel needle and a 6-F Teflon catheter using a special assembly designed for controlled one-step placement and stent release.

Results: Puncture and drainage were technically successful in two patients. In one patient, the 10-F component failed to pass the cystic wall. Drainage was successful in the same session using a 7-F one-step device. In one patient, no stent was placed, but the 1 mm needle was used for diagnostic tissue sampling during the procedure because of the suspicious cyst morphology. Surgical resection revealed a ganglioneuroma.

Conclusions: The new echo endoscope allows endoscopic interventions for peripancreatic cystic lesions under excellent endoscopic and EUS control. The Albarran lever was reliable and helpful for optimal direction of the needle. The new echo endoscope combined with special needle-stent devices was effective and safe for diagnosis and therapy in the first four cystic lesions. Cystic tumors must always be considered as a differential diagnosis in patients with apparently pancreatitis-induced cystic lesions.

Introduction

Transmural endoscopic puncture and drainage of cystic peripancreatic lesions has become widely accepted during recent years as a less invasive alternative to surgical therapy [1] [2] . Guidance by endoscopic ultrasound has enabled the puncture of cysts which did not bulge into the intestinal lumen and allowed safe puncture even in difficult anatomical situations, under direct visual control [3] [4] [5] . Several types of needle for endoscopic transmural punctures have been developed [6] [7] [8] . More recently, one-step transmural drainage, using a new 3.2 mm channel echo endoscope and special puncture devices, has been described [9] [10] . Although we have successfully treated pancreatic abscesses using 7-F transmural stents [10], longitudinally scanning echo-endoscopes with larger working channels allowing passage of 10-F equipment were expected to facilitate retroperitoneal interventions and treatment of infected lesions [11]. We here describe one-step puncture and drainage of cystic lesions in four patients using a new longitudinally scanning echo endoscope with a 3.7 mm working channel and an Albarran lever. For this purpose, we have constructed a new needle-stent device allowing controlled placement of transmural 10-F plastic stents.

Patients and Methods

Transmural puncture and drainage were carried out in four patients with symptomatic peripancreatic cysts. Detailed patient data are listed in Table [1]. In all patients endoscopic therapy was preceded by abdominal ultrasound imaging.

All procedures were performed using a new large-channel echo endoscope with a curved array electronic longitudinal scanner (GF UCT-140 AL5, attached to the Aloka SSD 5500 ultrasound unit; Olympus, Hamburg, Germany). This new instrument had a 3.7-F working channel, an Albarran lever, a longitudinal 180° ultrasound image, combined with a 100° angled endoscopic image. Gastroscopic orientation was obtained during the first endoscopic ultrasonography (EUS) examination using the video endoscopic function of the echo endoscope. The cystic lesions were located and the optimal puncture sites determined using the longitudinally scanning ultrasound function of this instrument, generally in the 10-MHz setting. Sonographic coupling was obtained in all cases without a balloon by minimizing intraluminal air and by direct contact of the transducer with the intestinal surface. All punctures were carried out under direct EUS guidance with some endoscopic control during the terminal phase when the stent was released. Fluoroscopy was available during all procedures but was not used in any of them.

The puncture needles were of 1 mm stainless steel and had a blunted mandrel as described previously [10]. This design was modified as follows (Figure [1]). The needle was in a 6-F Teflon catheter with a tapered tip which fitted snugly around the needle, with 5 mm of the needle tip left free for puncture. This ensemble was loaded with a 10-F Teflon pusher and a 10-F Teflon stent, which had two sideholes and four flaps. The stents were 6 cm in length and connected to the pusher as described (Figures [1] and [2 E, F]). An easily removable piece of protective Teflon tube was used to prevent damage of the working channel when the device was introduced. Punctures were carried out, without diathermy, with the sharp needle tip after retraction of the mandrel. After the needle had reached the cystic lumen, which was visualized sonographically (Figure [3 C]), it was advanced in order to introduce first the 6-F catheter and then the 10-F stent into the cystic lumen. Optimal positioning and function of the stent were verified during the therapeutic procedure first by endoscopic ultrasound, then by direct endoscopic control.

All procedures were performed with the patients under intravenous propofol sedation [12]. Informed consent was obtained from all patients before the interventions.

Results

The punctures were technically successful at the first attempt in three patients and without procedure-related complications in all patients (for details see Table [1]). In one patient (patient 3) it was impossible to advance the 10-F stent into the cystic lumen with reasonable force, although the needle and the 6-F catheter had been passed through the fibrous wall of the cyst. Because he had splenic vein thrombosis and large gastric varices with previous bleeding (Figures [2 C - F]), a vigorous attempt at 10-F drainage was avoided. Instead, in this patient a 7-F stent was placed using a one-step procedure as described previously [10], without difficulties, and 2 days later, this stent was replaced by a 10-F stent over a guide wire.

Patient 4 was referred for drainage of a cyst that had persisted for more than 3 months. The clear and highly viscous aspirate after EUS-guided puncture (Figure [4 A]) was suspicious for a mucinous pancreatic tumor. Surgery was therefore recommended and no draining procedure was performed. The cytopathological report on the aspirate described few nondiagnostic cells and mucus. On open surgery, a nonpancreatic cystic tumor was enucleated without difficulty, next to the pancreatic head (Figures [4 B, C]). Based on neuronal cells in its wall, it was diagnosed as a ganglioneuroma. There were no features of malignancy.

Discussion

Whenever cystic lesions are adjacent to the gastric or duodenal wall, EUS-guided puncture and drainage seem to be possible, with little risk of procedure-related complications and good short-term success [4] [5] . Large-channel echo endoscopes allow placement of 10-F stents as a first therapeutic procedure without considerable risk of complications. These conclusions, however, are still based on relatively small numbers of patients and need further confirmation. In one case, penetration of a very thick fibrous wall succeeded only with a 7-F stent. In some instances it is expected that fenestration by balloon dilation or diathermy devices such as needle knives or special catheters would be required.

We found that the possibility of still being able to aspirate any sort of liquid (e. g., bile or blood) was advantageous in the new instrument tested here. Also, the Albarran or elevator lever proved to be durable and very helpful, even with our very stiff needle assembly including a steel mandrel and 6- and 10-F Teflon material. The capability of precisely steering the direction of the needle even after entering the tissue is essential in patients with variceal intra- and extragastric veins to avoid bleeding (patient 3) and to obtain aspiration cytology samples from small or distant lesions (patient 4).

Although in patients 1 and 2, punctures of intrahepatic and intrasplenic abscesses were suspected to carry a considerable risk of procedure-induced bleeding, we recommended endoscopic therapy. Expectant management seemed inappropriate in both patients, and the surgical option was always available. After the positive outcome in both patients, we feel that the EUS-guided therapeutic approach might become the therapy of choice in such cases. The rare case of a cystic ganglioneuroma, in addition to adding a new entity to the differential diagnoses of pancreatic pseudocysts, once again alerted us to always bear in mind the possibility of cystic tumors when we drain cystic peripancreatic lesions.

During recent years, we have successfully treated by transmural and transpapillary drainage not only typical pseudocysts with clear liquid contents, but also many abscesses with viscous and putrid discharge. In the latter it was often necessary to place nasocystic tubes for flushing the abscess cavity. Our experience with 7-F and now with 10-F drainage, without any nasocystic tube, encourages us to omit these awkward devices in future in the treatment of peripancreatic cystic lesions. The persisting symptomless pseudocyst in the splenic hilum of patient 2 was managed according to the principle of only treating symptomatic lesions. Because of the excellent clinical success we do not consider this outcome to be a failure of endoscopic treatment.

In summary, the improving quality of available echo endoscopes has led to the successful endoscopic treatment of even complex pancreatic and peripancreatic lesions. The improved quality of the ultrasound component of these instruments, which has long been awaited by EUS-oriented gastroenterologists, should increase the safety of interventions and facilitate diagnostic accuracy, e. g. in sorting out patients with “pseudo-pseudocyst”, who have cystic pancreatic tumors and need surgical treatment.

References

• 1 Sahel J, Bastid C, Pellat B, et al. Endoscopic cystoduodenostomy of cysts of chronic calcifying pancreatitis: a report of 20 cases.  Pancreas. 1987;  2 447-453
  CrossrefPubMedSearch in Google Scholar
• 2 Cremer M, Deviere J. Endoscopic management of pancreatic cysts and pseudocysts.  Gastrointest Endosc. 1986;  32 367-368
  Search in Google Scholar
• 3 Grimm H, Binmoeller K F, Soehendra N. Endosonography-guided drainage of a pancreatic pseudocyst.  Gastrointest Endosc. 1992;  38 170-171
  CrossrefPubMedSearch in Google Scholar
• 4 Binmoeller K F, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts.  Gastrointest Endosc. 1995;  42 219-224
  Search in Google Scholar
• 5 Giovannini M, Bernardini D, Seitz J F. Cystogastrotomy entirely performed under endosonography guidance for pancreatic pseudocyst: results in six patients.  Gastrointest Endosc. 1998;  48 200-203
  CrossrefPubMedSearch in Google Scholar
• 6 Cremer M, Deviere J, Baize M, Matos C. New device for endoscopic cystoenterostomy.  Endoscopy. 1990;  22 76-77
  Thieme ConnectPubMedSearch in Google Scholar
• 7 Knecht G L, Kozarek R A. Double-channel fistulotome for endoscopic drainage of pancreatic pseudocyst.  Gastrointest Endosc. 1991;  37 356-357
  CrossrefPubMedSearch in Google Scholar
• 8 Binmoeller K F, Seifert H, Soehendra N. Endoscopic pseudocyst drainage: a new instrument for simplified cystoenterostomy.  Gastrointest Endosc. 1994;  40 112
  PubMedSearch in Google Scholar
• 9 Vilmann P, Hancke S, Pless T, et al. One-step endosonography-guided drainage of a pancreatic pseudocyst: a new technique of stent delivery through the echo endoscope.  Endoscopy. 1998;  30 730-733
  Thieme ConnectPubMedSearch in Google Scholar
• 10 Seifert H, Dietrich C, Schmitt T, et al. Endoscopic ultrasound-guided one-step transmural drainage of cystic abdominal lesions with a large-channel echo-endoscope.  Endoscopy. 2000;  32 255-259
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.  Lancet. 2000;  356 653-655
  Search in Google Scholar
• 12 Wehrmann T, Kokabpick S, Lembcke B, et al. Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study.  Gastrointest Endosc. 1999;  49 677-683
  PubMedSearch in Google Scholar

H. Seifert, M.D.

Medizinische Klinik II der Universität
Zentrum der Inneren Medizin

Theodor-Stern-Kai 7
60590 Frankfurt
Germany


Fax: + 49-69-63016247

Email: seifert@em.uni-frankfurt.de

References

• 1 Sahel J, Bastid C, Pellat B, et al. Endoscopic cystoduodenostomy of cysts of chronic calcifying pancreatitis: a report of 20 cases.  Pancreas. 1987;  2 447-453
  CrossrefPubMedSearch in Google Scholar
• 2 Cremer M, Deviere J. Endoscopic management of pancreatic cysts and pseudocysts.  Gastrointest Endosc. 1986;  32 367-368
  Search in Google Scholar
• 3 Grimm H, Binmoeller K F, Soehendra N. Endosonography-guided drainage of a pancreatic pseudocyst.  Gastrointest Endosc. 1992;  38 170-171
  CrossrefPubMedSearch in Google Scholar
• 4 Binmoeller K F, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts.  Gastrointest Endosc. 1995;  42 219-224
  Search in Google Scholar
• 5 Giovannini M, Bernardini D, Seitz J F. Cystogastrotomy entirely performed under endosonography guidance for pancreatic pseudocyst: results in six patients.  Gastrointest Endosc. 1998;  48 200-203
  CrossrefPubMedSearch in Google Scholar
• 6 Cremer M, Deviere J, Baize M, Matos C. New device for endoscopic cystoenterostomy.  Endoscopy. 1990;  22 76-77
  Thieme ConnectPubMedSearch in Google Scholar
• 7 Knecht G L, Kozarek R A. Double-channel fistulotome for endoscopic drainage of pancreatic pseudocyst.  Gastrointest Endosc. 1991;  37 356-357
  CrossrefPubMedSearch in Google Scholar
• 8 Binmoeller K F, Seifert H, Soehendra N. Endoscopic pseudocyst drainage: a new instrument for simplified cystoenterostomy.  Gastrointest Endosc. 1994;  40 112
  PubMedSearch in Google Scholar
• 9 Vilmann P, Hancke S, Pless T, et al. One-step endosonography-guided drainage of a pancreatic pseudocyst: a new technique of stent delivery through the echo endoscope.  Endoscopy. 1998;  30 730-733
  Thieme ConnectPubMedSearch in Google Scholar
• 10 Seifert H, Dietrich C, Schmitt T, et al. Endoscopic ultrasound-guided one-step transmural drainage of cystic abdominal lesions with a large-channel echo-endoscope.  Endoscopy. 2000;  32 255-259
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.  Lancet. 2000;  356 653-655
  Search in Google Scholar
• 12 Wehrmann T, Kokabpick S, Lembcke B, et al. Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study.  Gastrointest Endosc. 1999;  49 677-683
  PubMedSearch in Google Scholar

H. Seifert, M.D.

Medizinische Klinik II der Universität
Zentrum der Inneren Medizin

Theodor-Stern-Kai 7
60590 Frankfurt
Germany


Fax: + 49-69-63016247

Email: seifert@em.uni-frankfurt.de