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EUS-guided cystesophagostomy using a lumen-apposing metal stent for drainage of a pancreatic fluid collection in a pediatric patient

Open AccessPublished:April 04, 2018DOI:https://doi.org/10.1016/j.vgie.2018.03.002
      An 8-year-old boy was referred because of abdominal pain, dysphagia, and failure to thrive (weight loss/poor growth). He had made multiple visits to the emergency department over a 5-year period for abdominal pain of unclear etiology. His abdominal pain was thought to be related to constipation, and he was treated accordingly. His amylase/lipase levels were previously elevated but were nondiagnostic for acute pancreatitis. The results of colonoscopy and upper endoscopy were negative for any obvious cause. Magnetic resonance enterography demonstrated a bilobed fluid collection superior to the pancreas with a 3-cm × 3.5-cm component near the gastric body in continuity with a 6.5-cm × 5-cm component in the mediastinum (Fig. 1A). This was thought to be a pancreatic fluid collection (PFC) after an undiagnosed bout of acute pancreatitis. The PFC was consistent with a pseudocyst because minimal tissue necrosis was visualized. The patient subsequently received a diagnosis of hereditary chronic pancreatitis related to 2 mutations in the chymotrypsin C gene. We performed EUS-guided drainage of his PFC (Video 1, available online at www.VideoGIE.org).
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      Figure 1A, MRCP view demonstrating a bilobed pancreatic fluid collection extending across the diaphragm and into the mediastinum. B, Notable extrinsic compression in the distal esophagus from the mediastinal fluid collection. C, Complete resolution of the mediastinal fluid collection after removal of the lumen-apposing metal stent.
      Routine upper endoscopy showed extrinsic compression of the distal esophagus (Fig. 1B). An oblique-viewing, linear-array echoendoscope was used, and the fluid collection from the esophagus and stomach was examined. Transesophageal EUS-guided drainage was indicated because the abdominal component of the fluid collection was inaccessible owing to the intervening vasculature. Under direct EUS visualization, transesophageal puncture was performed with a 19-gauge FNA needle. Murky, tan-colored fluid was aspirated and sent for evaluation, the results of which were as follows: cytology, negative results; carcinoembryonic antigen, within normal limits; amylase, >7000 IU/L. A guidewire was coiled within the fluid collection, and a 4-mm biliary dilating balloon was used to dilate the tract. Ultimately, a 10-mm × 10-mm lumen-apposing metal stent (LAMS) was deployed to drain the collection. A10F × 4-cm double-pigtail plastic stent was placed within the LAMS. The patient was discharged with advice to advance gradually to a soft diet. All stents were removed 4 weeks later, and resolution of the PFC was demonstrated by cross-sectional imaging and injection of contrast material under fluoroscopy (Fig. 1C). The patient remains symptom free more than 1 month later.

      Disclosure

      Dr Law receives travel support from Taewoong. All other authors disclosed no financial relationships relevant to this publication.

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