Introduction Current accepted practice for EUS-guided stent insertion for drainage of pancreatic pseudocysts (PP) involves placement of two or more double-pigtail stents.1 There has been little work into whether a single stent would provide an equal outcome without increasing complications. Rates of successful drainage without surgical or percutaneous intervention are 88–64% with complication rates at 32–14%.2 We present a case series comparing outcomes of single stent insertion against these.
Methods Retrospective analysis of cases, identified by searching the electronic endoscopic database, in a DGH providing tertiary HPB and EUS service between August 2005 and December 2011 was performed. All procedures were performed by the same experienced endoscopist. All patients had a radiographically proven PP and received a single 7 cm 7Fr double-pigtail stent with prophylactic antibiotics.
Results 24 patients underwent cystogastrostomy. 1 patient died from unrelated causes in the days post-procedure, therefore is not included in the analysis. 20 of 23 patients (86.9%) were successfully drained without any surgical or percutaneous intervention. One patient had a pre-existing infected PP, only recognised on fluid analysis after the procedure, required laparotomy for excision and surgical cystogastrostomy. With hindsight more than one stent may have resulted in a better outcome. There were two procedure related complications (8.6%). One suffered pneumoperitoneum 2 days post-procedure. Emergency surgery revealed the pancreatic lesion to actually be a mucinous cystadenoma, despite radiographically and endoscopically (including pre-stent insertion aspirate) behaving as a PP. This misdiagnosis and complication was unavoidable due to this unusual behaviour. The other patient developed sepsis 26 days post-procedure, and had a CT guided drain. Culture of aspirated cyst fluid revealed candida, possibly a post-insertion complication or an incidental finding; patient responded to fluconozole. Two further patients were re-admitted with pyrexia 3 and 5 days respectively post-procedure. They improved with antibiotics, required no intervention, and imaging revealed PP improvement.
Conclusion This data suggests that efficacy and complication rates for single-stented EUS-guided cystogastrostomy in simple PP are comparable with data from studies using two or more stents. This would result in shorter procedure time and reduced risks from insertion thereby improving patient safety, and reduced costs. Single stenting is not recommended for infected or complex PP.
Competing interests None declared.
References 1. Seewald S, Ang TL, Teng KC, et al. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc 2009;21(Suppl 1):S61–5.
2. National Institute of Clinical Excellence. Endoscopic Transluminal Drainage of Pancreatic Pseudocyst and Pancreatic Necrosectomy—Overview. 2011.