Pancreatitis is rare in children, although the incidence is reported to be increasing (1). The aetiology can be ascribed to both medical (infections, drugs, genetic predisposition) and surgical conditions (eg, blunt abdominal trauma, choledochal malformation, gallstones, pancreas divisum, and so on). Pancreatic pseudocysts can arise as a complication in both chronic and acute pancreatitis, although this may take some weeks to evolve.
Pancreatic pseudocysts can often be managed conservatively, particularly if they are small (<6 cm) and asymptomatic (2); however, once maturation occurs (typically >4–6 weeks), resolution is less likely and symptoms often become intolerable (3). Furthermore, complications may arise such as infection, haemorrhage, and even rupture (4). Active management of pseudocysts includes percutaneous drainage; however, this is generally reserved for unstable patients, immature and infected cysts due to a reportedly higher failure rate and risk of fistula formation (5,6). Internal drainage is a treatment option and can be achieved by transpapillary stenting, open/laparoscopic/endoscopic cyst gastrostomy, or Roux loop cyst-jejunostomy (7–11).
The aim of the present study was to review the use of endoscopic cyst gastrostomy (E-CG) as a treatment option for children with established pancreatic pseudocysts.
We reviewed case-notes of all of the children referred to our tertiary paediatric surgical centre during a recent 10-year period (January 2001–December 2010) for a diagnosis of pancreatic pseudocyst. All had undergone thorough investigation and imaging (ultrasound, computed tomography, magnetic resonance cholangiopancreatography), and any underlying abnormal pancreaticobiliary anatomy was identified. All of the endoscopic procedures described were performed by a single endoscopist (P.H.).
Our experience with acute endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct stenting for trauma has been reported previously and includes 2 of the children described here (7).
All of the endoscopic procedures were performed under general anaesthesia using a paediatric 11-mm side-viewing endoscope (Olympus, JF 240, Olympus UK Ltd). Typically, the pseudocyst was seen to bulge directly into posterior aspect of the stomach and was punctured using an endoscopic cystotome CST10 (Cook Medical, Bloomington, IN), followed by a guidewire and then a Zimmon double pigtailed biliary stent (7–10 Fr) (Cook Medical). Dilatation of the tract was not usually required. Sometimes an additional pigtail stent was left to ensure adequate drainage. Placement of a pancreatic duct stent (Zimmon 5–7 Fr, Cook Medical) was also used in some cases in conjunction with E-CG. Clinical follow-up in all of the cases was accompanied by serial ultrasonography. All data are quoted as median (range).
Seven children (5 males) underwent E-CG with a median age at presentation of 11.7 (8.2–15.8) years. Demographic details, aetiology, and clinical details are shown in Table 1. The median time from onset injury/insult to pseudocyst diagnosis was 4 (2–9) weeks. The median pseudocyst size at presentation was 12 × 8 × 10 cm. All of the patients treated were symptomatic with abdominal pain, symptoms of gastric outlet obstruction, or in case no. 5 an acute bleed into the pseudocyst. Three children (no. 1, 3, 4) underwent an ERCP and pancreatic duct stent placement as their initial intervention, but all required E-CG due to reaccumulation at 4 (2–4) weeks following stenting despite 1 patient having a repeat ERCP and stent placement in the interim.
Four patients (no. 2, 3, 4, 7) had uncomplicated resolution of pseudocyst following E-CG. One patient (no. 6) was admitted from her local hospital following 8 weeks of abdominal pain and underwent a primary E-CG. This patient had undergone a duodenoduodenostomy as a neonate for a duodenal web. Unfortunately, the single pigtail stent slipped out of the pseudocyst and into the duodenum after 15 days. A repeat E-CG and pancreatic duct stenting were successful and all of the stents were removed 6 weeks later.
One patient (no. 1) underwent an initial ERCP and stent placement followed by E-CG 2 weeks later. Ultrasound scan surveillance showed resolution of the pseudocyst and stents were removed at 8 weeks post E-CG; however, recurrent symptoms and cyst reaccumulation (9 × 5 × 10 cm) occurred 8 weeks later, and he subsequently went on to have a successful open cyst gastrostomy, with no recurrence.
One patient (no. 5) presented with gastric outlet obstruction secondary to a huge pseudocyst (Fig. 1A). This was aspirated (2-L blood/pancreatic fluid) to alleviate symptoms in the first instance and then an open cyst gastrostomy performed. Three weeks later, the pseudocyst had reaccumulated. An endoscopy showed the cyst gastrostomy to be patent, but rescue E-CG and ERCP and stenting were performed 3 weeks later (Fig. 1B and C). At the time of ERCP the pancreatic duct was found to be tortuous containing multiple stones. A magnetic resonance cholangiopancreatography performed 2 months following removal of all stents showed complete resolution of the pseudocyst and a mildly dilated pancreatic duct (Fig. 1D). The child is presently asymptomatic but under close observation.
All of the stents were removed endoscopically at 8 (6–40) weeks, and there has been no recurrence at median follow-up of 18 (5–108) months. Case no. 3 went on to have a successful laparoscopic cholecystectomy to treat his gallstone disease.
Pancreatic pseudocysts are a well-recognised complication of pancreatitis and pancreatic trauma, although their natural history of pseudocysts is uncertain. Spontaneous resolution has been reported to occur in 25% to 50% (4,10,12,13); however, some clearly persist and intervention is then required if they become symptomatic.
The earliest case of successful E-CG in adults was reported by Kozarek et al (14) from Arizona in 1985. This was followed over a decade later with the first paediatric case report by Falchetti et al in 1998 (15). E-CG has been reported previously from other centres (9–11,16,17), although in most numbers were small and experience limited. There are 2 comparable series to our own. Sharma and Maharshi from Jaipur, India (9) present 9 children acquired during a 10-year period with a mean age of about 10 years within which 8 pseudocysts were caused by trauma. In contrast to our practice, they also attempt to place nasocystic drainage tubes as an adjunct to facilitate irrigation of the cyst cavity (predominantly turbid/thick cystic fluid). We have not attempted this and insertion of 2 pigtail stents seems adequate to ensure complete cyst drainage. Avoidance of external drainage tubes appears preferable in children because they are unpleasant and can all too easily be pulled out. More recently, Jazrawi et al (17) describe their experience in 10 children with a similar mean age of 11 years and a much more heterogenous group of underlying diagnoses. They preferred to use endoscopic ultrasound and aspiration to localise their collections, something that we have not found necessary.
The nature of underlying aetiology does not seem to predict those that need intervention. Teh et al (12) attribute trauma as a cause in 46% of their series of pseudocysts, but only 45% of these required intervention compared with 92% of non–trauma-related pseudocysts. In our previous report, only 2 of 15 trauma-related pancreatic injury cases developed a pseudocyst. This may reflect the benefit of early transpapillary stenting (our standard care) in such cases.
In all our patients, the pseudocyst wall could be visualised bulging into the stomach on endoscopy, facilitating puncture and drainage. In cases in which a bulge is not seen, endoluminal ultrasound has been used to minimise the risks of bleeding and failure of stenting (17). Alternatively, if the cyst bulges into the wall of the duodenum, then an endoscopic cyst-duodenostomy can be equally as effective (9,11). Some pseudocysts, of course, have no anatomical relation with the stomach or duodenum and therefore cannot be accessible using this technique. For these, open cyst-jejunostomy using a Roux loop appears to be the favoured solution.
Recurrence of pseudocysts is a problem reported in most series (18–20). Reaccumulation occurred in one of our series at about 8 weeks following stent removal. This was the first patient in our series managed by E-CG and we would now rather repeat the E-CG than resort to definitive open surgery. We continue to advise serial ultrasonography to track the development of recurrent collections and pre-empt symptoms if possible.
E-CG lends itself to a quicker recovery as reflected in our brief median hospital stay. Nonetheless, we appreciate that the first 2 cases in the series spent 23 and 13 days in hospital, respectively. This may reflect to some extent our learning curve with this procedure, but with increasing experience and prophylactic antibiotics before intervention, the hospital stay postprocedure has been reduced. It is safe and a minimally invasive effective method of treating pancreatic pseudocysts in children with few reported complications (18,20) and should now be considered as a first-line intervention in those centres with access to experienced upper gastrointestinal endoscopists.
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