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home - Pancreas - Pancreatic Masses and Cysts - Pseudocyst Drainage Complications Written by Dr Sebastian Zeki

Pseudocyst Drainage Complications

Complications of Endoscopic Drainage (most common- more likely if co-existing necrosis- incidence up to 50%)- can get abscess formationDue to: Stent malfunction / loculation after transmural drainage.Techniques to avoid infection:a)Intense endoscopic debridementb)Transmural puncture+ tract dilation + multiple stents if pseudocyst > 6 cm in size or contains thick fluid or debris.c)Nasocystic catheter for lavage can avoid stent occlusion + prevent loculation by keeping the pseudocyst fluid thin so that it drains easily.d) Use peri-procedural antibioticsTreatment:Most infections can be dealt with with 1 additional endoscopy- surgery can be avoidedPercutaneous draingage if a single loculation is noted in the periphery of the gland or if inaccessible to an endoscopic approach.Surgery remains the mainstay for multiloculated infected necrosis or acutely ill patients who are unable to delay drainage for pseudocyst maturation Techniques to avoid bleeding:-Get EUS guidance.-Use hydrostatic balloon dilation of the tract with or without a small diathermic puncture to extend tracts.-If bleeding, use 1:10,000 adrenaline followed by endoscopic coagula-tion or haemostatic clipping; embolization or surgery is rarely needed.-Use pigtail stents to avoid stent migration, perforation, and haemor-rhage. PerforationPerforation is more likely when cyst> 1cm from the intestinal lumen as a puncture could result in leakage of pseudocyst contents and/or pneumoperitoneum.In the absence of EUS, puncture is not attempted if a visible endoscopic bulge is probed by the extended 8 mm HBAN-22 needle but not entered.Perforation can be managed conservatively but may require emergency surgery.Either direct puncture under EUS guidance or endoscopic needle localization may help reduce the risk by leaving the needle in place to secure the pseudocyst and endoscope. Ductal alterations after transpancreatic stentingEndoscopically placed pancreatic duct stents may induce ductal changes similar morphologically to those of chronic pancreatitis but clinical significance is unclear and 60% resolve over time.Stent migration problems can be reduced with a double pigtail stents as less migration. Infection Written by Dr Sebastian Zeki

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