Background: Peripancreatic fluid collections (PFC) are a frequent complication following distal pancreatectomy (DP). Trans-papillary pancreatic stenting and percutaneous drainage are non-surgical management options with variable outcomes. Endoscopic trans-mural drainage by means of cyst-gastrostomy is feasible only when the PFC is large enough to causes luminal compression. However, endoscopic ultrasound (EUS) offers the potential to access PFC under direct sonographic visualization in patients without luminal compression. Aim: Evaluate the role of EUS in management of PFC following DP.
Methods: We prospectively collected data on all symptomatic patients referred for EUS-guided drainage of PFC following DP over a 3-yr period. Prior to EUS, all patients underwent contrast enhanced CT of the abdomen and ERCP. PFC was classified per Atlanta criteria. EUS-guided drainage was undertaken when trans-papillary pancreatic stenting failed or was ineffective. At EUS, the PFC were accessed trans-gastrically using a 19-gauge FNA needle and after passage of a 0.035 inch guidewire, sequential dilation of the trans-gastric tract was performed up to 8mm and 7Fr/10Fr double pigtail stents/drainage catheters were deployed. Technical success was defined as successful placement of stent/drain within the PFC. Treatment success was defined as resolution of clinical symptoms and fluid collection on follow-up CT at 6-weeks.
Results: Ten patients (6 Male, mean age 54.1yrs [range, 29-79]) underwent EUS-guided drainage of PFC (5 pseudocyst, 5 abscess) following DP. These were inclusive of referred patients from outside facilities and different subspecialties. Indications for DP were neuroendocrine tumor in 4, cyst neoplasm (3), splenectomy (2), and trauma (1). Eight of 10 patients had undergone prior trans-papillary pancreatic stenting; ERCP was unsuccessful in 2 patients. Mean size of the PFC (largest dimension) was 68mm (range, 40-110mm) and did not cause luminal compression in any patient. EUS-guided drainage was technically successful in 9 of 10 (90%) patients. Trans-gastric site for PFC drainage was gastric cardia in 5 patients, fundus (3) and lesser curvature (1). Mean procedural duration was 46 minutes (range, 18-95). Treatment was successful in 7 of 9 patients (78%): two patients with pancreatic abscess had persistent symptoms requiring surgical drainage. No procedural complications were encountered. One patient had recurrence of PFC after 8 months and was managed successfully by repeat EUS-guided drainage.
Conclusions: EUS-guided drainage is a safe, minimally invasive, and highly effective technique for management of PFC that develop following distal pancreatectomy.