Splenic pseudocyst as result of pancreatic ductal leak is not uncommon. Endoscopic
drainage of splenic pseudocyst is generally not preferred because of risk of bleeding
and difficult location to access endoscopically. Percutaneous drainage (PCD) and surgery
are associated with high morbidity and can result into fistula formation. In this
case report, we have demonstrated endoscopic ultrasound (EUS)-guided drainage of splenic
pseudocyst communicating with pancreatic duct (PD).
A-35-year-old male who was suffering with recurrent acute pancreatitis for the last
4 years now presented with complaint of left upper quadrant pain and fever for 15
days. His laboratory evaluation showed leukocytosis and raised serum amylase and lipase.
Magnetic resonance cholangiopancreatography (MRCP) showed increased size of pseudocyst
compared with previous computed tomography (CT) scan and mildly dilated irregular
PD communicating with splenic pseudocyst (100 × 112 mm) ([Fig. 1A–C]). On MRCP, pseudocyst was visualized within splenic capsule rather than in splenic
bed ([Fig. 2A, B]). As there was high risk of fistula with PCD, EUS-guided drainage of splenic pseudocyst
was performed. EUS-guided drainage of pseudocyst was performed with curvy-linear echoendoscope
(UCT-180; Olympus ltd, Tokyo, Japan) in left lateral position under propofol sedation
([Video 1]). Collection was accessed from cardia and with 19-gauge (EZ shot 2, Olympus, Tokyo,
Japan) needle. After puncturing collection dark brown color fluid was aspirated. Through
the needle 0.025 guidewire (VisiGlide, Olympus corporation, Tokyo, Japan) was coiled
into cavity and needle was then removed. Over the guidewire 6 Fr cystotome (Endo-flex
GmbH Dusseldorf, Germany) was passed and tract was dilated and 7Fr 7CM double pig
tail stent (Cook Medical, Bloomington, IN, USA) was deployed ([Fig. 3A–D]). Postprocedure CT showed significant reduction in size of collection. Plastic stent
was preferred over the metal stent considering the puncture point in cardia and location
of the pseudocyst, that is, splenic intracapsular to prevent subsequent complications
(perforation and bleeding). Subsequently, he underwent endoscopic retrograde cholangiopancreatography.
Initially PD cannulation was attempted via major papilla with a guidewire. Over the
guidewire major papilla sphincterotomy (CleverCut 2, Olympus, Tokyo, Japan) was done;
however, on further pushing guidewire was repeatedly getting curved and came out through
minor papilla. Sphincterotome was then exchanged with needle knife and over the guidewire
minor papilla papillotomy was performed. Initial guidewire was then withdrawn from
major papilla and PD cannulation was done through minor papilla with tapered tip cannula.
Guidewire was placed deep into the PD via minor papilla and pancreatogram was taken.
Pancreatogram showed partial pancreas divisum with normal diameter PD and leak from
tail region. Minor papilla sphincterotomy done and pancreatic stent (5Fr 12 cm single
pigtail, Cook Medical, Bloomington, IN, USA) placed across the leak ([Fig. 4A–C]). Postprocedure patient was stable and discharged on oral antibiotics. On telephonic
conversation with him, he was asymptomatic and both PD stent and cystogastric stent
were removed at 3 months after resolution of collection at his primary care center.
