Teaching Case

A 56-year-old male presented with severe acute pancreatitis, which responded well to conservative treatment and medical treatment with zidovudine (AZT).

A patient with systemic lupus erythematosus (SLE) presented to our hospital with severe acute pancreatitis, which responded well to conservative treatment and zidovudine (AZT) administration. The patient was then followed up with imaging tests to monitor the evolution of peripancreatic fluid collections. After six weeks, the patient had still vague abdominal pain but no fever. His WBC count was found to be normal. In order to evaluate the pancreas, a multidetector spiral CT scan was performed: the CT scan demonstrated the presence of three giant mature pseudocysts adjacent to the stomach. We decided to perform a percutaneous pseudocystogastrostomy in order to relieve the pseudocysts.

We used the ultrasound (US) technique to detect the pseudocysts and the level where they were adherent to the gastric wall in two cases. A CT procedure was used for the lesion located in the tail of the pancreas. Under local anaesthesia, moderate analgesia, and gastric hypotension, the three cysts were punctured with a 5F sheathed needle under US or CT guidance by traversing the anterior and posterior wall of the stomach which was partially distended with 200–300 ml of water. The cysts were opacified by replacing several ml of cystic fluid with an equal quantity of water soluble contrast medium. Under fluoroscopy, a 10F pig-tail drainage catheter was inserted deeply into the pseudocysts and an external drainage was established. We left the external drainage for a week and performed catheter flushing twice a day with sterile saline in order to eliminate intracystic debris. In order to establish an internal drainage and obtain a pseudocygastrostomy we did not exchange the 10F catheter with a stent as has been described by other authors. As matter of fact, the procedure is usually performed by replacing the external-internal drainage catheter, over a guide-wire, with a double pig-tail stent. In our opinion, this technique makes the whole procedure more complex and may lead to the risk of losing access to the cyst when the exchange guide-wire is placed in a well-drained and collapsed cavity. To simplify the procedure, we transformed the internal-external catheter into a permanent internal drainage catheter. We cut the proximal end of the catheter at the level of the patient’s skin, inserted a stiff guide-wire, and by using a 10F pusher we pushed the catheter deeply into the stomach. The satisfactory position of the cut end of the catheter within the stomach was checked under fluoroscopy with lateral views. At this point, the pig-tail of the catheter remained within the cystic cavity, while the long proximal portion remained hanging into the stomach. The pseudocystogastrostomy catheters were removed endoscopically after five months in two cysts, while in the third cyst, the stent had dislodged itself into the stomach after three months and was passed out of the body with the stool. The patient was followed up with routine CT and US studies. A complete resolution of the cysts and clinical success was demonstrated. No complication or recurrence was observed. So far we have used this technique in 42 patients with a success rate of 92% (unpublished data).