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Pseudocyst Drainage Complications
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Written by Dr Sebastian Zeki
MCQs for this page
Pseudocyst Drainage Complications
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Complications of Endoscopic Drainage
(most common- more likely if co-existing necrosis- incidence
up to 50%)- can get abscess formation
Due to:
Stent malfunction / loculation after transmural drainage.
Techniques to avoid infection:
a)Intense endoscopic debridement
b)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 antibiotics
Treatment:
Most infections can be dealt with with 1 additional endoscopy- surgery can be
avoided
Percutaneous 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.
Perforation
Perforation 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 stenting
Endoscopically 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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