Digestive Endoscopy (2009) 21 (Suppl. 1), S82–S86 doi:10.1111/j.1443-1661.2009.00875.

CURRENT STATUS AND FUTURE PERSPECTIVE OF INTERVENTIONAL EUS

EUS-GUIDED PANCREATIC PSEUDOCYST DRAINAGE

Ichiro Yasuda,1 Keisuke Iwata,2 Tsuyoshi Mukai,2 Takuji Iwashita1 and Hisataka Moriwaki1
1
First Department of Internal Medicine, Gifu University Hospital, Gifu, and 2Department of Gastroenterology,
Gifu Municipal Hospital, Gifu, Japan

Background: Endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS-PPD) has recently become popular.
However, this technique has not yet been standardized, and the available instruments have not been sufficiently developed.
Therefore, it is difficult to determine the treatment strategy and the choice of devices.
Aims: To evaluate the current status of EUS-PPD.
Methods: Between May 2001 and February 2008, EUS-PPD was attempted in 26 patients. Initially, an external drainage was
placed, which was replaced with an indwelling tube in cases where the discharge continued more than 2 weeks.The early and
late outcomes of EUS-PPD were retrospectively analyzed.
Results: Placement of a naso-cystic drainage was successful in 24 (92%) of the 26 patients. Insertion of the drainage tube
failed in other 2 patients due to a thickened cystic wall. The pseudocyst was completely resolved after the placement in 23
patients, while the remaining patient underwent a surgical operation. Discharge of the cystic fluid was stopped and the
naso-cystic tube was removed in 12 patients after a median duration of 14.5 days. In the remaining 11 patients, it was
replaced with indwelling tubes due to continuous discharge after 2 weeks. Thereafter, the indwelling tubes were removed in
all cases after a median duration of 4 months. Recurrence of the pseudocyst occurred in 4 patients during a median follow-up
period of 48 months. All 15 patients without cystic infection were successfully treated by EUS-PPD, and 9 (60%) of them
were treated by only an external drainage. On the other hand, one patient (11%) failed treatment by EUS-PPD and 5
patients (56%) required subsequent internal drainage among the 9 patients with cystic infection.
Conclusions: Endoscopic ultrasound-guided pancreatic pseudocyst drainage is a promising treatment for a pancreatic
pseudocyst. However, the insertion of the tube is difficult in cases with a thickened cystic wall. Infected pseudocysts are often
difficult to treat by only short-term external drainage, thus additional treatments should be considered at an early stage.

Key words: EUS, EUS-guided drainage, pancreatic pseudocyst.

INTRODUCTION PATIENTS AND METHODS

Endoscopic drainage of pancreatic pseudocysts has been Patients
attempted since the 1980s.1–2 Initially, the puncture was
Between May 2001 and February 2008, EUS-PPD was
attempted blindly through the gastric or duodenal wall.
attempted in 26 patients with pancreatic pseudocysts at Gifu
Therefore, it was possible only in cases where the cyst
University Hospital and at Gifu Municipal Hospital, Gifu,
bulged into the gastric or duodenal lumen. On the other
Japan. The early and late outcomes were retrospectively
hand, endoscopic ultrasound-guided pancreatic pseudocyst
reviewed. Patients with organized pancreatic necrosis
drainage (EUS-PPD) was first introduced in 1992.3 In this
containing significant solid debris were excluded from this
method, the puncture can be performed under real-time
study because the outcomes and the treatment strategy were
EUS image guidance, and the procedure became more
different from that for pseudocysts.4,5
reliable and much safer. After that, it has been widely
The indication for EUS-PPD were: (i) symptomatic; (ii)
employed and is currently popular worldwide. However, the
resistant to conservative treatments such as fasting and the
technique has not been well established, and questions and
administration of antibiotics and protease inhibitors; and (iii)
difficulties remain in determining the treatment strategy
the cystic wall was in contact with the gastric or duodenal
and the choice of devices. Therefore, the current study
wall on CT images. If the patients with pancreatic pseu-
evaluated the current status of EUS-PPD, and discussed the
docysts met the criteria, endoscopic retrograde cholangio-
current issues on this method.
pancreatography (ERCP) was performed first. In cases
where communication of the pseudocyst with the pancreatic
duct was confirmed by the pancreatography, transpapillary
Correspondence: Ichiro Yasuda, First Dept. of Internal Medicine, drainage was performed first.
Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan. Email:
YASUDAIC@aol.com Patients were excluded if they demonstrated a bleeding
tendency or if images, including EUS images, raised suspicion
Received 2 February 2009; accepted 26 February 2009. that the cyst might be neoplastic.
© 2009 The Authors
© 2009 Japan Gastroenterological Endoscopy Society
EUS-GUIDED PSEUDOCYST DRAINAGE
a b
Fig. 1. Endoscopic ultrasonography(EUS)-guided pancreatic pseudocyst drainage. The puncture site was determined based on
the EUS image (A). After the initial puncture, a 0.035-inch guidewire was inserted sufficiently through a 19-gauge needle into the
cyst (B). After dilation of the puncture tract, a 7-Fr. pigtail-type nasobiliary drainage tube was inserted into the cyst over the
guidewire (C).
Procedures
An electronic linear scanning video echoendoscope (GF-
UCT240 or -UC240P, Olympus, Tokyo, Japan) was connected
with ultrasonographic equipment (SSD-5000, Aloka, Tokyo,
Japan). After the patient was sedated, the echoendoscope
was advanced into the stomach (or further into the duode-
num if the cyst was located in the pancreatic head). The cyst
was carefully observed to ensure that no mural nodules or
tumorous lesions were being overlooked, and then the punc-
ture site was determined (Fig. 1A). The gastric wall needed to
be in contact with the cystic wall at the site, and power-
Doppler imaging was used to ensure that there were no
interposed vessels on the puncture line. The initial puncture
was achieved with a 19-gauge needle (EchoTip, COOK,
Winston-Salem, NC, USA) guided by real-time EUS
imaging. After withdrawal of the inside needle stylet, a
0.035-inch guidewire (Jagwire, Boston-Scientific, Natick,
MA, USA) was inserted through the needle into the cyst.
When fluoroscopic imaging confirmed the guidewire was
sufficiently inserted, the needle was then withdrawn, while
leaving the guidewire (Fig. 1B). Next, a 7 Fr. biliary dilation
catheter (Soehendra dilator, COOK) was inserted, and
dilated the puncture tract. If it was difficult to insert the
dilation catheter, a conventional polypectomy snare (SD-7P,
Olympus) was used as previously reported.6 After dilation of
the puncture tract, a 6- or 7-Fr. pigtail-type nasobiliary drain-
age tube was inserted into the cyst over the guidewire. The
guidewire was then removed, and as much cystic fluid as
possible was aspirated via the drainage tube. The tip of the
drainage tube position was confirmed by injecting a small
amount of contrast medium into the cyst. Then the echoen-
doscope was removed and the drain was fixed at an adequate
position (Fig. 1C).
Collected cystic fluid was subjected to a routine cytological
examination and cultured. After the procedure the patients
were observed carefully and were given a blood examination
after 2 hr and the next morning. Prophylactic antibiotic treat-
ment was given routinely from the morning of the perfor-
mance day for at least 3 days. Fasting was maintained for a
few days after removal of the drain.
S83
c
If the cyst was completely resolved and discharge also
stopped, the naso-cystic tube was removed after 2 weeks. In
the case that the cyst was resolved but discharge continued,
the external drainage was replaced with a 7- or 8.5-Fr.
indwelling pigtail stent after 2 weeks. If the cyst did not
resolve or the symptoms continued, then other treatment
options such as percutaneous drainage and a surgical opera-
tion were considered.
RESULTS
The baseline characteristics of the 26 patients that underwent
EUS-PPD are shown in Table 1.They included of women and
22 men, with a median age of 56.5 years (ranging from 29 to
79). The etiologies of the pancreatic pseudocysts were alco-
holic in 16 cases, idiopathic in 7, post-operative in 2, and
post-traumatic in one case. The cysts were located in the
pancreatic head in one case, in the body in 8, in the body to
the tail in 6, and in the tail in 11. The median largest diameter
of the cysts was 8 cm (ranging from 5.5 to 21 cm). All patients
had complained of abdominal pain, and 11 patients also had
fever. The median duration from the first detection of the
cysts to the drainage was 7.5 weeks (ranging from 2 to
24 weeks).
Early outcomes of EUS-PPD
The puncture was attempted transgastric in 25 patients and
transduodenal in one patient. The median thickness of the
cystic and gastric/duodenal walls was 5 mm (ranging from 4
to 10 mm). Placement of a naso-cystic drainage was success-
ful in 24 (92%) of the 26 patients. In the remaining 2 cases, the
insertion of the naso-cystic drainage failed due to a thickened
cystic wall (10 mm in both cases). Percutaneous drainage was
performed in those 2 patients (Table 2).
The clinical symptoms were resolved in 23 of the 24
patients in whom a naso-cystic tube was successfully placed
after a median duration of 1 day (ranging from 1 to 7 days).
However, fever continued even after the drainage and the
cystic lumen was also retained in one patient. Moreover, a
© 2009 The Authors
© 2009 Japan Gastroenterological Endoscopy Society
S84 I YASUDA ET AL.

Table 1. Baseline characteristics of the patients that underwent recurred 1–6 months after the removal of the naso-cystic
EUS-guided pancreatic pseudocyst drainage or indwelling tube. Among them, one patient underwent a
surgical operation. However, the remaining 3 patients
Total number of patients 26 are observed conservatively, because they don’t have any
Age (year, median, range) 56.5 (26–79) symptoms so far.
Gender
Women 4
Men 22 Comparison between infected and non-infected cyst
Etiology
Alcoholic 16 All 15 patients without a cystic infection were successfully
Idiopathic 7 treated by EUS-PPD, and 9 (60%) of them were treated by
Post-operative 2 only external drainage (Figs 1,2). On the other hand, one
Post-traumatic 1 patient (11%) failed treatment by EUS-PPD and 5 patients
Location of the cyst
(56%) required subsequent internal drainage in the 9
Head 1
Body 8 patients with cystic infection (Table 4)
Body-Tail 6
Tail 11
Largest diameter of the cyst 8 (5.5–21) DISCUSSION
(cm, median, range)
Observation period until drainage 7.5 (2–24)
There have been several reports of classic transgastric or
(week, median, range) transduodenal approaches using conventional endoscopes,
Thickness of the cystic wall 5 (4–10) but it had several limitations. First, it could be used when a
(mm, median, range) bulging lesion appears endoscopically.1,2,7 Second, since
Infected pseudocyst 11 the puncture was a ‘blind’ approach, blood vessels could be
damaged or a bulging lesion could be mistaken for compres-
Data are number of patients unless otherwise stated. sion by another organ such as the gallbladder or colon.There-
fore, the risks of bleeding and perforation were significant,
Table 2. Early outcomes of EUS-guided pancreatic pseudocyst and their incidence was reported to range from 6% to
drainage 24%.2,5,7,8 On the other hand, EUS can easily find and distin-
guish the lesion even if it does not bulge into the gastric
Failed Procedure 2 (8%) lumen. In addition, the real-time image can show the punc-
Successful procedure 24 (92%) ture needle lengthwise during the whole puncture process
Resolution of the cyst 23 and color-Doppler function is helpful for avoiding the
External drainage only 12 interposed vessels on the puncture line. Therefore, the
Subsequent internal drainage 11 EUS-guided transmural puncture is much more reliable and
Retained the cyst 1 safer than the previous conventional method.
The first successful case of EUS-PPD was reported by
Data are number of patients.
Grimm et al. in 1992.3 However, the echoendoscope had only
a small instrumental channel (diameter of 2 mm) without an
elevator control for accessories. Therefore, the initial needle
pseudoaneurysm of the cystic wall ruptured in the patient, puncture and subsequent drainage tube insertion were not
and he underwent a surgical resection of pancreatic tail easy, and it was necessary to switch to a duodenoscope with a
and spleen. The pseudocyst was completely resolved in the larger channel in order to place the drainage tube. Since that
remaining 23 patients. Discharge of the cystic fluid stopped in time, the echoendoscope has been improved, and the current
12 patients, thus the naso-cystic tube was removed after a models have a relatively large working channel (2.8–3.7 mm)
median duration of 14.5 days (ranging from 7 to 24). In the as well as an elevator. The resolution of the EUS image also
remaining 11 patients, discharge from naso-cystic tube con- became more precise and the color-Doppler function is much
tinued, thus the tube was replaced with an indwelling tube better than before. Now a naso-cystic drain or an indwelling
after a median duration of 14 days (ranging from 7 to 31). stent can be placed without exchanging the endoscopes.
Any serious complications related to the procedure did not Instruments and methods have also been somewhat
occur in any patients during and after the procedure. improved. The initial puncture is usually made by either a
conventional FNA needle or an electrocautery needle. The
simple puncture using a conventional FNA needle seems
Follow-up results
easier and safer,8 but the subsequent insertion of a drainage
Thereafter, the indwelling tubes were removed in all 11 cases tube over a guidewire is often difficult especially in cases with
after a median duration of 4 months (ranging from 2 to a thick and hard cystic wall.Therefore, a polypectomy snare is
12 months). In a median follow-up period of 48 months used to enlarge the tract for such cases,6 but it is still occasion-
(ranging from 6 to 85 months), recurrence of pseudocyst was ally difficult. Special ‘one-step’ drainage systems have also
observed in 4 patients. The detailed data are shown in been reported.9–12 In those reports, an endoprosthesis
Table 3. All patients had alcoholic chronic pancreatitis and (7–8.5 Fr) is inserted into the cyst after initial puncture by a
continued abuse of alcohol. The previous treatment was needle and without the exchange of endoscopes, catheters or
naso-cystic drainage and following internal drainage in 3 guidewires. Although those techniques seem easier and more
cases, and only external drainage in one case. The cyst convenient than earlier approaches, they are not yet popular.
© 2009 The Authors
© 2009 Japan Gastroenterological Endoscopy Society
EUS-GUIDED PSEUDOCYST DRAINAGE S85

Table 3. Characteristics of the 4 patients with pancreatic pseudocyst recurrence

Age/Gender Etiology Infection Previous treatment Duration to recurrence Treatment

37/M Alcoholic None External → Internal 1 mo Surgical operation

drainage (4 mo)
29/M Alcoholic None External → Internal 3 mo Conservative
drainage (5 mo)
61/M Alcoholic + External drainage only 6 mo Conservative
26/F Alcoholic + External → Internal 5 mo Conservative
drainage (2 mo)
M, Male; F, Female; mo, months.

a b c

Fig. 2. A 61-year-old male with alcoholic chronic pancreatitis (same case to Figure 1). Computed tomography images show a huge
pancreatic pseudocyst (A, B). The pseudocyst was completely resolved after the placement of a naso-cystic drainage (C).

Table 4. Comparison of early outcomes between patients with
non-infected and infected pseudocysts
Outcomes Non-infected Infected
(n = 15) (n = 9)
Successful resolution 15 (100%) 8 (89%)
By only external drainage 9 (60%) 3 (33%)
By subsequent internal drainage 6 (40%) 5 (56%)
Failed resolution 0 1 (11%)
Data are number of patients.
The devices may not have achieved satisfactory levels of safety
and convenience. Another accessory, the cystotome (Wilson
Cook,Winston Salem, NC, USA) has also been invented.13 It is
a modified needle knife sphincterotome that consists of an
inner wire with a needle tip, a 5 Fr inner catheter, and a 10 Fr
outer catheter equipped with a diathermy ring at its distal tip.
It has become relatively popular in Western countries, but it is
not yet available in Japan.
Naso-cystic drainage is initially placed because an external
drainage has several advantages over endoprostheses. It can
monitor the volume and character of the discharge in real
time.Abdominal computed tomography (CT) was performed
if the discharge stopped. In cases where the cystic lumen is
completely resolved, the treatment can be completed by
pulling back and removing the tube. If the cystic lumen is
retained,the tube may be obstructed.In such case,the tube can
be washed away by sterile saline. These results indicate that
more than half of the patients without a cystic infection were
successfully treated by only the placement of a naso-cystic
tube for a median duration of 2 weeks. On the other hand,
treatment with external drainage alone failed in most of the
patients with infected pseudocysts. Previous studies also
reported that the treatment results seemed unsatisfactory and
recurrence was more likely in infected cases.14–15 Therefore,
other or additional treatments should be considered for the
patients with infected pseudocysts. One option is the simulta-
neous insertion of multiple stents. Placement of more than one
stent ensures a wider drainage opening with less chance of
stent occlusion, and this appears to provide better drainage.16
Another option is the combined placement of one or two
double-pigtail stents and a naso-cystic tube after balloon dila-
tion of the puncture tract.The naso-cystic tube is also available
for aggressive irrigation using saline solution.5,17
Drainage for longer than 6 weeks seems to be associated
with a more favorable outcome.16 However, there were four
recurrent cases, and their duration of drainage was mostly
longer than 6 weeks.
A strategy for the treatment of pancreatic pseudocysts was
established based on the results of the present study. Only a
naso-cystic drainage is placed for patients without cystic
infection. However, additional treatments such as dilation of
the puncture site using a large balloon and multiple stenting
are considered for patients with cystic infection from the
beginning. EUS-PPD for pseudocysts with a thickened was
difficult with the current equipment, thus new devices and
techniques are required.
CONFLICT OF INTEREST
No conflict of interest has been declared by I Yasuda, K
Iwata, T Mukai, T Iwashita or H Moriwaki.
© 2009 The Authors
© 2009 Japan Gastroenterological Endoscopy Society
S86
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© 2009 The Authors
© 2009 Japan Gastroenterological Endoscopy Society