Pancreatic pseudocyst drainage guided by endoscopic ultrasound

Figure 1 Images of a 14 cm diameter pseudocyst in a patient with an alcoholic chronic pancreatitis. A: CT; B: Endoscopic ultrasonography (EUS) with doppler, the pseudocyst can be seen in close contact with the gastric wall without intervening vessels.

Figure 2 Approach to drain the pseudocyst. A: In this fluoroscopic image the linear array echoendoscope is inside the gastric lumen in a stable and straightened position, with the needle coming out of the working channel; B: EUS image with linear array echoendoscope in which the needle can be seen inside the cyst once the puncture has been made; C: The guidewire is inserted through the needle and curled inside the cyst cavity; D: With deflation of the balloon dilator the pseudocyst contents spurts through the fistula into the gastric lumen; E: Fluoroscopic view of the first double pigtail stent inserted through the fistula connecting the gastric lumen and the cyst cavity (Dimensions of the stent: 5 cm long and 10 F diameter); F: Three double pigtail stents can be seen draining the cyst contents into the gastric lumen; G: The three double pigtail stents are placed transmurally. The gastric and cyst lumen can easily be seen on the X-ray image.

Figure 3 In this case, a large cyst of 18 cm in diameter with a horseshoe morphology going down bilaterally as far as the pelvic cavity can be seen on the CT scan.

Figure 4 The same patient as previus images. A: The patient was treated with placement of three transmural double pigtail stents, and a thinner nasocystic drainage catheter because of dense cyst contents; B: The pseudocyst has disappeared after 4 wk with the stents. One of the stents has migrated and the other two can be seen communicating between the gastric lumen and the collapsed cyst cavity. Both stents were retrieved uneventfully and the patient remains asymptomatic 6 mo later.