Gaining competence in rarely performed interventional procedures is difficult. We
present here a pig model for endoscopic drainage of pancreatic pseudocysts and describe
its preparation and the procedure. Endoscopic drainage of pancreatic pseudocysts through
the wall of the gastrointestinal tract is a challenging procedure for any endoscopist
because of the need to cross the peritoneal cavity [1]. The caseload of many endoscopy centres is usually relatively small and may only
amount to five to 20 procedures per year, and the opportunities for teaching and learning
are limited. We considered that the Erlangen Active Simulator for Interventional Endoscopy
(EASIE) model for endoscopic retrograde cholangiopancreatography designed by Hochberger
and Maiss might be suitable [2]. This model consists of a pig esophagus, stomach and duodenum with the ligamentum
hepatoduodenale, the whole biliary system and the liver, lying in a plastic box; it
does not have a pancreas because the pig pancreas does not drain via the main papilla.
We placed the gallbladder next to the anterior duodenal wall and fixed it with four
sutures, as shown in Figure [1], mimicking a pancreatic head cyst with duodenal bulging. We had filled the biliary
system via the papillary route earlier with water mixed with blue dye for better bulging
and better visualization of the draining fluid. The correct site for puncturing can
either be detected through the bulging region or during endoscopic ultrasound; alternatively,
it may be located at the centre of the four sutures when the stitches have penetrated
the whole thickness of the gastrointestinal wall. A neutral electrode was placed beneath
the model. We used a TJF-160R endoscope (Olympus Co., Tokyo, Japan) and the 10-Fr
Cremer pseudocyst drainage set in two instances. The set consists of a needle-knife
and a coaxial conic-tip cutting device. The intervention ends with the placement of
a double-pigtail stent using the Seldinger technique (Figure [2], [3]). On both occasions the simulation worked well. The only problem was that after
enlargement of the duodenobiliary fistula the duodenum lost almost all the inflated
air. A device with a smaller diameter (e. g. 8 Fr) may work better.
Figure 1 In order to simulate a pancreatic head cyst with duodenal bulging, the gallbladder
was placed next to to the anterior duodenal wall and fixed using four stitches. These
photographs show the first two stitches (a) and the third and fourth stitches (b).
Figure 2 A double-pigtail stent was placed using the Seldinger technique. This fluoroscopic
view shows the guide wire placed into the gallbladder.
Figure 3 The duodenum and gallbladder are opened after the procedure, demonstrating the correct
positioning.
Attachment of a prefilled gallbladder to the duodenum in the EASIE model with sutures
appears to create a valuable hands-on model for endoscopic pancreatic pseudocyst drainage.
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