A 48-year-old woman with chronic ethylic pancreatitis presented with new onset of
fever, dysphagia, and elevated inflammatory parameters. Computed tomography revealed
a large cystic supradiaphragmatic paraesophageal structure and two small retroperitoneal
cysts near the pancreatic body. Transesophageal endosonographic fine-needle aspiration
showed pus and an elevated amylase level. The diagnosis of an infected pancreatic
pseudocyst was made. Consequently, a 10 Fr double-pigtail catheter and a 7 Fr nasocystic
tube were inserted transesophageally. Infection was treated with intravenous penicillin
according to antimicrobial resistance of the detected Streptococcus anginosus.
During a second intervention 2 weeks later, using a 10 Fr digital endoscope (SpyScope-DS;
Boston Scientific, Marlborough, Massachusetts, USA), we were able to locate and pass
the transhiatal fistula of the pancreatic pseudocyst after balloon dilation to reach
the caudally located smaller part of the pancreatic pseudocyst. After several unsuccessful
attempts, a 0.035 inch guidewire was passed under visual guidance through the pancreatic
pseudocyst and into the pancreatic duct ([Fig. 1], [Video 1]). The wire was then advanced via the ampulla of Vater into the duodenum and extracted
orally. By holding the guidewire tightly at both ends, we were able to support the
difficult and precise placement of a 5 Fr, 13 cm plastic stent into the pancreatic
duct, via the thoracic and abdominal part of the pancreatic pseudocyst. The proximal
end was placed visually in the small abdominal cystic part and the distal end was
located in the duodenum. The nasocystic tube and double-pigtail catheter were removed
and the esophagocystic access was closed using two hemoclips. Subsequently, both the
thoracic and the abdominal part of the pancreatic pseudocyst collapsed totally and
the patient recovered completely. The stent was replaced transpapillarily 3 months
later and completely removed 2 months thereafter. The patient continues to be asymptomatic.
Fig. 1 Fluoroscopy showing the mediastinal pseudocyst with a caudally located smaller pseudocyst
and its connection to the pancreatic duct.
Video 1: Successful drainage of a large pancreatic pseudocyst located in the mediastinum
and abdomen using a 10 Fr digital endoscope.
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