African Journal of Paediatric Surgery About APSON | PAPSA  
Home About us Editorial Board Current issue Search Archives Ahead Of Print Subscribe Instructions Submission Contact Login 
Users Online: 590Print this page  Email this page Bookmark this page Small font size Default font size Increase font size 
 
 


 
CASE REPORT Table of Contents   
Year : 2010  |  Volume : 7  |  Issue : 3  |  Page : 194-196
Ultrasound-guided endoscopic transgastric drainage of a post-traumatic pancreatic pseudocyst in a child


1 Department of Pediatric Surgery, Penteli General, Athens, Greece
2 P & A Kuriakou, Children's Hospital, Athens, Greece

Click here for correspondence address and email

Date of Web Publication18-Sep-2010
 

   Abstract 

Despite of a number of techniques in the armentarium of the paediatric surgeon, the management of pancreatic pseudocysts remains a challenge. We report on a case of a 5-year-old child with a post-traumatic pancreatic pseudocyst who was successfully treated with endoscopic ultrasound-guided transgastric approach. Endoscopic ultrasound-guided transgastric drainage of a pancreatic pseudocyst is effective and safe in children.

Keywords: Pseudocyst, pancreas, ultrasound

How to cite this article:
Theodoros D, Nikolaides P, Petousis G. Ultrasound-guided endoscopic transgastric drainage of a post-traumatic pancreatic pseudocyst in a child. Afr J Paediatr Surg 2010;7:194-6

How to cite this URL:
Theodoros D, Nikolaides P, Petousis G. Ultrasound-guided endoscopic transgastric drainage of a post-traumatic pancreatic pseudocyst in a child. Afr J Paediatr Surg [serial online] 2010 [cited 2019 Nov 21];7:194-6. Available from: http://www.afrjpaedsurg.org/text.asp?2010/7/3/194/70426

   Introduction Top


Pancreatic pseudocysts (PPC) are not common in children and usually are secondary to blunt abdominal trauma. [1] Their management still remains a challenge for the paediatric surgeon. Traditionally the management of PPC is carried out by surgical procedures such as cyst gastrostomy or enterostomy. [2] Other modalities include percutaneous drainage under US guidance [3] and laparoscopic approach. [4] Endoscopic cystogastrostomy, either ultrasound-guided or no, is a relatively new technique in the treatment of PPC. On reviewing the literature, we could find 11 cases till now. [5],[6],[7],[8],9[],[10],[11],[12]

We report a case of post-traumatic pseudocyst successfully treated with endoscopic ultrasound-guided transgastric drainage.


   Case Report Top


A 5-year-old boy was admitted in Emergency Department after an accidentally injury to the abdomen in the bed. On examination, the upper abdomen was mild distended and tender with guarding. His vital signs were normal and standard serum tests showed blood amylase 1194 mg/dl, lipase 5954 mg/dl and normal liver function test. An ultrasound examination of the abdomen with attention to the right upper quadrant revealed the presence of loculated fluid collection in the hilum of the liver measuring 2 x 5cm [Figure 1]. Management of the child included nil per mouth, total parental nutrition poor in lipids, antibiotics and rest. The patient had an uneventful course and discharged from the hospital on the day 15 with normal amylase levels and a normal ultrasound. After one and a half month, the patient was readmitted in the hospital with the complain of pain in the epigastrium. Serum tests showed blood amylase level of 830 mg/d, lipase 3610 mg/dl and urine amylase 2718 mg/dl. An ultrasound showed a fluid collection in the lesser sac measuring 6 cm. A magnetic resonance cholangiopagreatography (MRCP) showed a pancreatic cyst in the attachment with the choledochal duct, the stomach and the duodenum [Figure 2]. On the fourth day of hospitalization, endoscopic transgastric drainage of the cyst was decided under general anaesthesia. Under general anaesthesia, a flexible gastroscopy was performed. The PPC was visualized under Doppler ultrasound guidance and a puncture was performed in the posterior wall of the stomach by using a diathermy needle knife in the most prominent site of the bulge. A guide wire was then inserted through the needle into the pseudocyst cavity and the knife was withdrawn. A double pigtail 8Fr stent was inserted into the cyst cavity over the guide wire. The cyst resolved almost immediately. Postoperative period was uneventful and the patient was discharged on the day 3. The stent was removed after 3 months of endoscopic procedure. Patient is doing well at 24 months follow-up without any recurrence and follow-up with ultrasound revealed pancreas to be normal.
Figure 1 :Ultrasound showing a PPC in the hilum of the live measuring 2 x 5 cm

Click here to view
Figure 2 :Magnetic resonance cholangiopagreatography (MRCP) showing a pancreatic cyst in the attachment with the choledochal duct, the stomach and the duodenum

Click here to view



   Discussion Top


A PPC is usually a complication of blunt abdominal trauma in 56% of cases in children. [10] Many of them will resolve spontaneously with conservative treatment. The size of the cyst is a good predictor of outcome: cysts less than 4 cm in size will resolve in 90% of cases, while those with size greater than 6 cm have only 20% to be resolved.

The current management for PPCs in children is predicated on adult techniques and includes open, percutaneous, laparoscopic and endoscopic drainage. Surgical cystogastrostomy is the standard method of treatment for PPC, [13] with short hospitalization and low risk of recurrence. Percutaneous drainage is a less invasive method frequently performed in the past, but there is a risk of a pancreato-cutaneous fistula, [9] which may require a major reconstructive operation. Thus, percutaneous drainage is reserved for immature or infected cysts and unstable patients [9] Laparoscopic approach is an alternative new technique to open cystogastrostomy for the minimally invasive management of PPCs in the paediatric population. However, only three cases are referred in the literature, [4],[14],[15] and therefore, more studies are needed to establish their effectiveness.

Endoscopic transmural drainage of PPC began in 1980 and most reports are referred to the adults. [10] The most important prerequisites for successful outcome include a cyst situated in direct apposition to either the stomach or duodenum, a visible bulge in the gastrointestinal lumen and a cyst wall less than 1 cm thick. [9] The complications of endoscopic drainage of PPCs include recurrence, stent occlusion, stent dislodgment, technical failure to drain the cyst, bleeding, gallbladder puncture, intestinal perforation, infection, stent leak and recurrence of PPC. [10],[16] It is important to stent all the cystenterostomies to avoid recurrence [9] and use a double pigtail stent to avoid dislodgment. [11]

This case shows that endoscopic ultrasound-guided transgastric drainage of PPC is an effective and safe approach in children.


   Acknowledgement Top


To Dr. Zavras Nikolaos, lecture of Pediatric Surgery, Attikon Hospital, Athens, Surgery Division, Pediatric Surgery Department.

 
   References Top

1.Cooney DR, Crosfeld JL. Operative management of pancreatic pseudocyst in infants and children: A review of 75 cases. Ann Surg 1975;182:590-6.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Poston GJ, Williamson RC. Surgical management of acute pancreatitis. Br J Surg 1990;77:5-12.  Back to cited text no. 2  [PUBMED]    
3.Burnweit C, Wesson D, Stringer D, Filler R. Pecutaneous drainage for traumatic pseudocysts in children. J Trauma 1990;30:1273-7.  Back to cited text no. 3  [PUBMED]    
4.Seitz G, Warmann SW, Kirschner HJ, Haber HP, Schaefer JW, Fuchs J. Laparoscopic cystojejunostomy as a treatment option for pancreatic pseudocysts in children-a case report. J Pediatr Surg 2006;41;e33-5.  Back to cited text no. 4      
5.Patty I, Kalaoui M, Al-Shamali M, Al-Hassan F, Al-Naqeeb B. Endoscopic drainage for pancreatic pseudocyst in children. J Pediatr Surg 2001;36:503-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Bridoux-Henno L, Dabadie A, Rambeau M, Gall EL, Bretagne JF. Successful endoscopic drainage of a pancreatic pseudocyst in a 17 month old boy. Eur J Pediatr 2004;163:482-4.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Al-Shanafey S, Shun A, Williams S. Endoscopic drainage of pancreatic pseudocysts in children. J Pediatr Surg 2004;39:1062-5  Back to cited text no. 7      
8.Haluszka O, Campbell A, Horvath K. Endoscopic management of pancreatic pseudocystin children. Gastrointest Endosc 2002;55:128-31.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Breckon V, Thomson SR, Hadley GP. Internal drainage of pancreatic pseudocysts in children using an endoscopically placed stent. Pediatr Surg Int 2001;17:621-3.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Kimble RM, Cohen R, Williams S. Successful endoscopic drainage of a post traumatic pancreatic pseudocyst in a child. J Pediatr Surg 1999;34:1518-20.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Falchetti D, Ubertazzi M, Torri F, Salucci P, Alberti D, Caccia G. Endoscopic cure of pancreatic pseudocyst in a child. J Pediatr Gastroenterol Nutr 1998;27:446-8.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Budhiraja S, Sood A, Gill CS. Endoscopic cystogastrostomy. Indian J Pediatr 2008;75:398-9.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Ford EG, Hardin WD Jr, Mahour GH, Woolley MM. Pseudocysts of the pancreas in children. Am Surg 1990;56:384-7.  Back to cited text no. 13  [PUBMED]    
14.Saad DF, Gow KW, Cabbabe S, Heiss KF, Wulkan ML. Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts in children. J Pediatr Surg 2005;40:e13-7.  Back to cited text no. 14      
15.Makris KI, St Peter SD, Tsao KJ, Ostlie DJ. Laparoscopic intragastric stapled cystgastrostomy of pancreatic pseudocyst in a child. J Laparoendosc Adv Surg Tech A 2008;18:771-3.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42:219-24.  Back to cited text no. 16  [PUBMED]    

Top
Correspondence Address:
Dionysis Theodoros
Department of Pediatric Surgery, Penteli General Children's Hospital, Athens
Greece
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.70426

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
 
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
    Introduction
    Case Report
    Discussion
    Acknowledgement
    References
    Article Figures

 Article Access Statistics
    Viewed3411    
    Printed162    
    Emailed0    
    PDF Downloaded147    
    Comments [Add]    

Recommend this journal