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Single-step EUS-guided drainage of a pancreatic pseudocyst with a modified guidewire as a cystotome

Open AccessPublished:November 02, 2020DOI:https://doi.org/10.1016/j.vgie.2020.10.002

      Abbreviation:

      PPC (pancreatic pseudocyst)
      In EUS-guided drainage of pancreatic pseudocysts (PPCs), the cystogastrostomy tract is usually established using a cystotome with a guidewire, and a stent or nasocystic catheter is implanted. However, cystic fluid leakage could occur before implantation. Therefore, we modified a guidewire (Fusion LoopTip, Cook Medical, Bloomington, Ind, USA) with a loop tip as a cystotome (Fig. 1A) by shearing its terminal coating, bending it, and plugging it into an electrosurgical unit (VIO 200 S, Erbe, Tübingen, Germany) (Fig. 1B). The loop tip was sleeved onto the inserted guidewire, and a nasocystic catheter was inserted next to the loop tip (Fig. 1C). Thus, the cystogastrostomy tract was established, and the nasocystic catheter was implanted simultaneously. This new 1-step EUS-guided drainage is easier to perform and reduces the risk of leakage.
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      Figure 1Illustrations of a modified guidewire. A, Diagrammatic sketch of modification steps and the process of connections. B, The modified guidewire with a loop tip as a cystotome was plugged into an electric source. C, The loop tip was sleeved on to the inserted guidewire, and a nasocystic catheter was inserted next to the loop tip.
      A 69-year-old man with a history of chronic pancreatitis was referred to our hospital for severe abdominal distention and vomiting. CT revealed multiple pancreatic calcifications and a large tension pseudocyst in the pancreatic head that compressed adjacent organs (Fig. 2). EUS-guided drainage was performed: A 19-gauge EUS-FNA needle (ECHO-HD-19-A, Cook) was punctured into the PPC, and 40 mL of cystic fluid was aspirated. Next, a guidewire (VDK-ZGW-88-460-A, JIUHONG, Changzhou, China) was inserted into the cyst cavity through the needle and coiled inside it (Fig. 3), and the needle was withdrawn. The loop tip of the modified guidewire then was sleeved onto the inserted guidewire, and a 7F nasocystic catheter was placed next to the loop tip.
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      Figure 2CT showing a large pseudocyst in the pancreatic head.
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      Figure 3A 19-gauge EUS-FNA needle was punctured into the pancreatic pseudocyst.
      As the loop tip approached the gastric wall, a cutting current was used to establish the cystgastrostomy trace, and the nasocystic catheter was implanted simultaneously (Fig. 4). Finally, the inserted guidewire was withdrawn, and the modified guidewire subsequently fell off and was withdrawn (Fig. 5). This single-step EUS-guided drainage of PPC was a safe and effective treatment (Video 1, available online at www.giejournal.org).
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      Figure 4A cutting current was used to establish the cystgastrostomy trace when the loop tip approached the gastric wall. Simultaneously, a nasocystic catheter was implanted.
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      Figure 5The nasocystic catheter was successfully implanted.

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data