Ultrasound-guided endoscopic drainage for the management of pancreatic pseudocysts: A case report

Abstract

BACKGROUND

The treatment strategy for pancreatic pseudocysts (PPC) is comprehensive and warrants multidisciplinary participation. However, at present, the treatment concepts for PPC are inconsistent. Moreover, the timing of interventional therapy is unclear, and complication management is insufficient. Therefore, the development of a multidisciplinary expert consensus on PPC is warranted. At present, endoscopic treatment is recommended for managing PPC in American Society for Gastrointestinal Endoscopy guideline and Chinese Consensus guidelines.

CASE SUMMARY

In this study, we present a rare case of PPC identified by endoscopy and imaging examination, and successfully managed by endoscopic and percutaneous drainage. In detail, an obese patient with a history of recurrent pancreatitis presents an irregular, elliptical cystic low-density shadow in the pancreatic region. Endoscopic ultrasound combined with double knife incision technique was used to endoscopic drainage, resulting in a favorable prognosis.

CONCLUSION

Ultrasound-guided endoscopic drainage for the management of PPC may provide additional insights to current clinical guidelines.

Key Words: Pancreatic fluid collection; Walled-off pancreatic necrosis; Pancreatic pseudocysts; Pancreatitis; endoscopy; Drainage; Case report

Core Tip: In this case, the patient underwent endoscopic window drainage for a pancreatic pseudocyst, utilizing ultrasound gastroscopy for the first time. The ultrasound gastroscopy facilitated accurate positioning, while the endoscopic submucosal dissection related technique was employed to incise the gastric wall and access the cyst, allowing for the drainage of cystic fluid. Subsequent dynamic re-examinations revealed a significant reduction in cyst size without any associated complications. During follow-up, the patient’s overall condition remained stable, and our institution has successfully performed four similar procedures without complications.

INTRODUCTION

Pancreatic fluid collection, a common complication of acute and chronic pancreatitis, manifests as pancreatic pseudocysts (PPCs) and walled-off pancreatic necrosis, a type of pancreatic cystic disease[1]. PPC represent a complication associated with both acute and chronic pancreatitis that usually develop four to six weeks from the onset of pancreatitis. Perforation of a pseudocyst is a rare lethal complication of PPCs, occurring in less than 3% of PPC cases[2]. Historically, surgical exploration has been the predominant method employed in the management of perforated pseudocysts. Nevertheless, recent literature indicates that both endoscopic ultrasonography-guided interventions and percutaneous drainage techniques represent feasible alternatives for the treatment of this condition[3].

Currently, the treatment concepts for PPC are inconsistent. The optimal timing of intervention is not yet clear, and strategies for managing complications are not well developed. Therefore, the development of a multidisciplinary expert consensus on PPC is warranted. At present, endoscopic treatment is recommended for managing PPC in American Society for Gastrointestinal Endoscopy guideline[4] and Chinese Consensus guidelines[5]. According to the latest guidelines, case series reported that PPCs were effectively managed through endoscopic cystogastrostomy decompression utilizing a lumen-apposing self-expandable metal stent (LAMS)[6]. In this study, we present a rare case of PPC identified by endoscopy and imaging examination, and successfully managed by endoscopic and percutaneous drainage.

CASE PRESENTATION

Chief complaints

This case report details the clinical management of a 36-year-old female patient who was admitted on September 6, 2024, presenting with a six-month history of upper abdominal discomfort.

History of present illness

The patient described intermittent sensations of fullness and discomfort in the upper abdomen, without significant abdominal pain, vomiting, or weight loss, and maintained a good appetite.

History of past illness

The patient’s medical history included multiple interventions for recurrent pancreatitis from 2019 to 2023. The patient presented with recurrent episodes of pancreatitis from 2019 to 2023, occurring at an approximate annual frequency. However, there were no indications of pancreatic necrosis. Therapeutic interventions, including fluid resuscitation, dietary fasting, and suppression of pancreatic juice secretion, were implemented at a local medical facility, resulting in clinical improvement. Notably, the patient experienced acute pancreatitis again with pancreatic necrosis in December 2023 and the computed tomography (CT) results from an external hospital in January 2024 indicated the presence of cysts.

Personal and family history

The patient reported no prior use of tobacco or alcohol, nor any long-term medication consumption, and denied any personal or familial history of specific genetic disorders.

Physical examination

Upon physical examination, the patient had a body mass index of 38.5, weighing 105 kg, and appeared in good spirits, with no signs of anemia or jaundice. The abdomen was soft, and no palpable masses were detected.

Laboratory examinations

Tumor markers and rheumatological markers, including immunoglobulin G4, were within normal limits.

Imaging examinations

Abdominal ultrasound revealed multiple echogenic clusters with acoustic shadows in the gallbladder, the largest measuring approximately 12 mm × 8 mm. The pancreas exhibited clear, non-echogenic changes, measuring approximately 231 mm × 135 mm × 109 mm. Auxiliary examinations included an enhanced CT scan of the upper abdomen, which revealed an irregular, elliptical cystic low-density shadow approximately 232 mm × 114 mm in size, located in the pancreatic region, with no significant dilation of the intrahepatic or extrahepatic bile ducts (Figure 1). Additionally, multiple gallstones were identified in the gallbladder. Magnetic resonance imaging findings confirmed the presence of a pancreatic cyst and gallstones.

Figure 1 Enhanced computed tomography scan of the upper abdomen. The computed tomography scan reveals the presence of an irregular elliptical cystic low-density shadow measuring approximately 232 mm by 114 mm in the region of the pancreas, which is not distinctly delineated from the surrounding pancreatic tissue. Notably, there is no significant dilation observed in the intrahepatic and extrahepatic bile ducts, nor in the common bile duct. Additionally, multiple gallstones are identified within the gallbladder.

MULTIDISCIPLINARY EXPERT CONSULTATION

The patient’s history of recurrent pancreatitis and gallstones led to a diagnosis of biliary pancreatitis, with surgical intervention planned for gallstone removal. However, due to the presence of a large pancreatic cyst and associated surgical risks, it was recommended that the cyst be addressed first through pseudocyst drainage. Following multidisciplinary discussions and informed consent from the patient, endoscopic treatment was performed under ultrasound guidance to facilitate the drainage of the PPC.

FINAL DIAGNOSIS

Biliary pancreatitis and PPCs.

TREATMENT

Under general anesthesia with endotracheal intubation, endoscopic ultrasound revealed a circular hypoechoic lesion in the body of the pancreas, with scattered areas of increased echogenicity (Figure 2). A 23G needle was utilized for puncture, yielding a coffee-like fluid. The puncture site was marked, and a Dual knife was employed to incise the gastric wall, exposing white, wall-like tissue. Upon aspiration with the puncture needle, a significant amount of coffee-like fluid was observed, prompting a deeper incision at the site, resulting in a substantial outflow of fluid (Figure 3). The endoscope was subsequently inserted into the cystic cavity to facilitate further aspiration, revealing a flocculent substance at the base. Hemostasis was achieved, and a gastric tube was placed (Figure 4).

Figure 2 Endoscopic ultrasound findings. Endoscopic ultrasound indicates a circular hypoechoic lesion surrounding the body of the pancreas, accompanied by scattered hyperechoic changes in certain areas. A puncture was performed using a Boco 23G needle, resulting in the extraction of a coffee-colored liquid.

Figure 3 The endoscopic treatment. The puncture site was marked, and an incision was made in the gastric wall using an electric knife, revealing a white, wall-like tissue exterior to the gastric wall. Upon aspiration with the puncture needle, the coffee-colored liquid was observed, prompting a deeper incision at this site, which resulted in a significant outflow of liquid.

Figure 4 A gastric tube was subsequently placed under endoscopic guidance. The gastroscope was introduced into the cystic cavity to aspirate the liquid, revealing flocculent material at the base of the cavity. Hemostasis was achieved, and a gastric tube was positioned.

OUTCOME AND FOLLOW-UP

Post-procedure imaging via CT scan, conducted eight hours after the endoscopic intervention, demonstrated complete resolution of the pancreatic cyst (Figure 5A). A follow-up CT scan on the sixth postoperative day indicated the reappearance of the cyst, albeit with a marked reduction in size compared to the initial presentation. Gastroscopy revealed an ulcer at the gastric wall incision site, without evidence of a fistula (Figure 5B). A nasointestinal tube was placed; however, the patient experienced intolerance to the procedure. Subsequent CT scans on the 13^th and 50^th days post-intervention confirmed a significant reduction in the size of the pancreatic cyst compared to the admission size, and the patient reported improvement in abdominal distension symptoms.

Figure 5 Postoperative computed tomography imaging. A: Computed tomography imaging conducted eight hours post-endoscopic intervention indicated no immediate complications; B: Follow-up gastroscopy performed six days postoperatively revealed the presence of ulcers on the gastric wall at the incision site, with no evidence of a fistula.

DISCUSSION

At present, the optimal timing for interventional therapy for PPC remains ambiguous, and the management of associated complications is inadequate. Consequently, there is a pressing need for the establishment of a multidisciplinary expert consensus regarding PPC[7,8]. Endoscopic intervention is recommended for PPCs that persist for over four weeks and exhibit a diameter of 6 cm or greater, as well as those associated with secondary compression symptoms, progressive swelling, infection, or concurrent pancreatic portal hypertension[5]. Treatment modalities for pseudocysts encompass percutaneous catheter drainage, laparoscopic surgical intervention, and Roux-en-Y anastomosis of the cyst to the jejunum, in addition to endoscopic retrograde cholangiopancreatography drainage[9,10]. Currently, the guidelines indicate a high quality of evidence and strong recommendation for endoscopic ultrasound-guided puncture drainage, advocating for the use of a LAMS. However, the placement of such stents is not without risks, which may include bleeding, displacement, detachment, and embedding[11].

In this case, the patient underwent endoscopic window drainage for a PPC, utilizing ultrasound gastroscopy for the first time. The ultrasound gastroscopy facilitated accurate positioning, while the endoscopic submucosal dissection related technique was employed to incise the gastric wall and access the cyst, allowing for the drainage of cystic fluid. Postoperative CT showed complete disappearance of the cyst, but it recurred 6 days later. We speculated that the causes for recurrence may be related to infection or incomplete drainage[12]. Subsequent dynamic re-examinations revealed a significant reduction in cyst size without any associated complications. During follow-up, the patient’s overall condition remained stable, and our institution has successfully performed four similar procedures without complications, which is similar to previous study[13]. The patient’s cyst and associated symptoms have markedly improved, thereby presenting a novel therapeutic approach for patients with similar conditions.

Recurrence is characterized as the emergence of a new pseudocyst, as detected through imaging techniques during follow-up assessments following a previously documented resolution. Previous studies have indicated instances of recurrence associated with the therapeutic interventions employed. However, no statistically significant differences in recurrence rates were observed between endoscopic drainage and laparoscopic surgery[14,15]. In addition, adverse events have been reported in the literature. A recent meta-analysis revealed an overall adverse event rate of 11.35% in the endoscopy cohort and 14.66% in the laparoscopy cohort[16]. Furthermore, a multicenter trial conducted by Teoh et al[17] indicates that the application of a novel self-approximating LAMS for the drainage of PPCs is both safe and effective, with a low incidence (6.8%) of stent-related adverse events associated with its use[17], which is also recommended by the 2024 American Society for Gastrointestinal Endoscopy guide[4]. However, some limitations should be noted. First, although tumor markers and rheumatological markers, including immunoglobulin G4, were within normal limits, we cannot confirm whether tumor or autoimmune pancreatitis was completely excluded due to the lack of pancreatic puncture pathology examination. Second, the follow-up was only up to 50 days after surgery, and the long-term efficacy was not evaluated.

CONCLUSION

In summary, we report a rare case with PPC which was successfully treated by ultrasound-guided endoscopic drainage.