Infected pancreatic pseudocysts are serious complications of acute
and chronic pancreatitis [1]
[2]
[3]. Endoscopic vacuum-assisted therapy (EVAT) is a reliable
treatment for abscesses that are accessible endoscopically [4]
[5]. We report the first case in
which EVAT was used in the treatment of an infected pancreatic pseudocyst.
A 28-year-old woman was admitted with a severe inflammatory response
syndrome (SIRS) due to a 20 cm infected pancreatic pseudocyst. We
performed endoscopic ultrasound-guided transgastric puncture, dilated the
transgastric access by balloon catheter (Olympus Medical Systems, Hamburg,
Germany), and drained the pseudocyst using three 10-Fr double-pigtail
endoprotheses (Medi-Globe, Achenmühle, Germany) and a nasocystic tube
(PBD-21Z; Olympus, Tokyo, Japan).
Over the next 6 days, 1500 mL normal saline per 24 hours was
continuously injected into the cyst via the nasocystic tube. On the second and
fifth days after the initial drainage, we again dilated the transgastric access
to 14 mm using a balloon catheter, intubated the cyst with the endoscope
(GIF Q180, Olympus, Tokyo, Japan), and removed infected fluid and tissue in a
Dormia basket (Endoflex, Voerde, Germany; [Fig. 1]).
Fig. 1 Endoscopic image of the
infected pancreatic pseudocyst at the beginning of treatment with infected
tissue in a Dormia basket, which was transferred into the stomach.
The cyst was therefore cleaned and the SIRS resolved; however, 7
days after the initial drainage, the pseudocyst had still not completely
collapsed ([Fig. 2]).
Fig. 2 Endoscopic image of the
infected pancreatic pseudocyst, 7 days after initial drainage and removal of
the necrotic tissue, prior to the commencement of endoscopic vacuum-assisted
therapy (EVAT).
We removed all the endoprotheses, dilated the access to 16 mm
and started EVAT following insertion of the Endo-SPONGE system (B. Braun,
Melsungen, Germany). The size of the sponge was adjusted according to the local
topography and placed into the cyst by means of a grasping forceps and guide
wire (Jagwire; Boston Scientific, Miami, USA; [Figs. 3] and [4]).
Fig. 3 Image of the
Endo-SPONGE, 40 mm in length and 14 mm in diameter.
Fig. 4 Endoscopic image of the
sponge in situ with the visible end in the stomach wall, the yellow-black guide
wire inside the suction tube for guidance during implantation, and the grasping
forceps.
The suction tube was extended with a nasogastric tube and secretions
were continuously evacuated with a suction of 120 mm Hg (16 kPa).
All procedures were performed whilst the patient was under conscious sedation
with midazolam and propofol.
The Endo-SPONGE system was replaced on the third day. The wall of
the cyst had become very well supplied with blood and demonstrated reddish
granulation tissue without signs of infection ([Fig. 5]).
Fig. 5 Endoscopic image showing
the visible guide wire and the inner cystic wall with clean granulation tissue
on the third day of endoscopic vacuum-assisted therapy (EVAT).
Throughout the period the patient received antibiotics and oral
nutrition. On the seventh day, EVAT was completed by extracting the sponge
without re-intubation of the cyst in order to maintain the cyst in its
collapsed state. The gastrocystic fistula was closed by metallic clips
(Olympus; [Fig. 6]).
Fig. 6 Endoscopic image of the
stomach showing the gastrocystic fistula closed by metallic clips.
No complications occurred during or within 8 weeks of therapy.
In our opinion EVAT has the potential to become a new standard
therapy for complicated infected pancreatic pseudocysts, because no further
drainage of the cyst was necessary and the treatment of the infected pancreatic
pseudocyst was completed during a single hospital stay.
Endoscopy_UCTN_Code_TTT_1AS_2AD
