Pseudocysts of the pancreas (PP) are collections of pancreatic secretions that eventual include necrotic debris and blood and are walled by fibrous tissue, within or adjacent to the pancreas (1). Usually they are caused by blunt trauma (in approximately 55% of cases) or pancreatitis. Incidence is high during early school age, with boys affected twice as often as girls (2,3). Pancreatic pseudocysts, whatever their origin, may have spontaneous resolution, although they can raise a variety of complications, including infection, bleeding, fistulations, jaundice, and compression on adjacent structures (4,5). They also may cause chronic pain, probably related to their mass effect (1). Treatment is needed for symptomatic or large PPs. Surgical ablation or drainage has been traditionally considered the gold standard, although complete removal can be challenging and possibly harmful (6). Among draining procedures, internal drainage is superior to cystostomy in reducing infection and recurrence rates (7). During the past 2 decades, refinements in ultrasound (US) imaging and endoscopic techniques have improved diagnostic accuracy and promoted percutaneous transgastric internal draining procedures (8-10). Recently the same goal has been achieved endoscopically in adults (4,5).
A 4-year-old boy, who was affected by adrenogenital syndrome during replacement therapy was referred to our institution for a cystic mass in the upper abdomen, seen during routine investigation for recurrent episodes of epigastric pain. There was a vague history of abdominal blunt trauma.
At admission, the child had indistinct abdominal pain, mostly after meals, with no other gastrointestinal symptoms. He had never had jaundice. The abdomen was slightly tender, chubby, with no palpable mass. Laboratory data were at normal levels. Upper abdominal US and computed tomographic (CT) scan confirmed a thickwalled 7 × 6-cm cyst in the pancreatic head-body junction (Fig. 1). Otherwise, the pancreas was homogeneous and not enlarged, and there was no dilation of the pancreatic duct. Endoscopic retrograde cholangiopancreatography (ERCP) was considered an excessive method to use at that moment, although direct access to the cyst could have been both diagnostic and therapeutic. Internal drainage through the stomach was planned. Because the cyst was adjacent to the stomach, an endoscopic approach was tried first, after informed consent was received from the parents. With the patient under general anesthesia and the abdominal skin prepared as for a laparotomy, a pediatric videoduodenoscope (JF 200; Olympus; Lake Success, NY, U.S.A.) was introduced. There was no appreciable bulging of the cyst inside the stomach; therefore, the puncture site was selected with pre-operative US. A hole was made through both gastric and cyst walls with a sting papillotome (Pre-cut KD-10Q; Olympus) at the thinnest section of the diaphragm between both cavities. When a flow of a brownish fluid was observed, the sting was withdrawn and its sleeve pushed into the cyst: 80 ml with 19,450 Ul/ml of amylase content were evacuated, and the PP was outlined with contrast medium for confirmation (Fig. 2). The papillotome was then replaced by a guide wire on which a polyethylene double pig-tail stent (PDB-7Z; Olympus; the shortest, with 3 cm between the curls) was introduced into the PP. When the guide wire was removed, the opposite end of the double pig-tail stent drained freely into the stomach (Fig. 3).
No problems occurred during the whole procedure, and the child was allowed to eat normally the next day. The early postoperative period was uneventful; US showed a shrinking PP, and the boy was dismissed asymptomatic in a week with the stent in place. Subsequent US examinations performed every other week in the patient's town confirmed marked decrease in the PP's size.
The child was readmitted 3 months later. Ultrasound and CT scan showed the PP had completely disappeared. There was no evidence of the stent itself, which was eliminated spontaneously without significant discomfort. The internal remnants of the cystostomy were barely perceivable during gastroscopy. The child was still symptom free without recurrence after a 2-year follow-up.
The management of PP has changed with the times, mainly during the past decade. Former surgical management in children was described in 1922 and consisted of an external drainage procedure (11). In recent years, internal drainage procedures have become the preferred surgical approach because of their superior results, but they may carry complications and at times cause death (12-14). With the advent of US and CT techniques, percutaneous internal drainage has proved more feasible and attractive. This procedure has shown lower morbidity and mortality; its drawback is a slightly higher recurrence rate (6,13,15). Since 1985, there have been reports in adults of PP internal drainage using a stent put endoscopically into the first gastrointestinal tract, with further benefits manifested in less morbidity and mortality (4,5,16-18).
To our knowledge, this is the youngest patient reported with endoscopic pseudocystogastrostomy for PP. Modern endoscopes and tools, although designed for other purposes, allow such a procedure to be performed in children, rather than waiting, as we used to, for a miniaturization of adult instruments.
The main risks of the endoscopic approach include bleeding from puncture through an intramural vessel or leakage from entering the PP more than 10 mm away from the gastric lumen (17). Both eventualities can be avoided by a careful technique, but the procedure is best managed in a well-equipped surgical environment.
The PP in our case was cured in a short time, because it was not supplied by a large duct disruption. The technique of long-term PP cystostomy using a stent could be fairly effective also in provided PP, as it can induce the maturation of a permanent fistula (6,19).
The endoscopic procedure is less invasive and achieves the same results of surgical internal drainage. The technique is a worthy alternative to surgery for treatment of PP that impends on the stomach in children.
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