Introduction: One of the problems with the endoscopic treatment of pseudocysts is placement of
multiple stents. Re-entry into the pseudocyst after placement of a first stent can
be particularly cumbersome.
Aim: To develop a technique in which re-entry into the pseudocyst is not necessary by
simultaneous placement of multiple guidewires.
Procedure: We have developed two techniques to place multiple guidewires.
The first technique uses the 10Fr cystotome (Cook). After the pseudocyst has been
accessed with the tip, the needle is removed. The first wire is then placed through
the sheath of the needle. After the 10Fr outer sheath of the cystotome has been advanced
into the cyst, the inner catheter is removed and a second wire can be placed. Now
the outer sheath is also removed and two wires are in place inside the pseudocyst.
The second technique uses the guiding catheter of an 9Fr Oasis system (Cook), to perform
an intracystic exchange (I.C.E.). For this technique the Oasis catheter is loaded
over the first centimeters of the wire and exits the port 2.5cm from the distal end.
The Oasis catheter is advanced into the pseudocyst. Subsequently the wire is pulled
back under radiological guidance until it leaves the Oasis guiding catheter (I.C.E.)
Now the stylet of the Oasis catheter is removed and replaced by a second wire, which
is also advanced into the cyst. Once the second wire has also entered the cyst, the
Oasis guiding catheter can be removed by pulling it out of the endoscope. Two wires
are now appearing side-by-side from the cystogastrostomy. It is now possible to place
two stents or to repeat the procedure to place more wires.
Conclusion: Using either the 10Fr cystotome or the 9Fr Oasis guiding catheter in combination
with an intra-cystic exchange, it is now possible to place multiple stents without
the need to re-enter the pseudocyst.
