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Drainage of peripancreatic-fluid collections: is EUS really necessary?

2007; Elsevier BV; Volume: 66; Issue: 6 Linguagem: Inglês

10.1016/j.gie.2007.06.028

1097-6779

Enrique Vázquez-Sequeiros,

Gastrointestinal disorders and treatments

EUS allows puncture of a pancreatic pseudocyst regardless of location, and, once access has been gained with the needle and a guidewire has been advanced and curled inside the cyst, drainage should be possible.Pancreatic pseudocysts are a relatively common complication of both acute and chronic pancreatitis. This type of pancreatic-fluid collection may be differentiated from other pancreatic cystic lesions according to their clinical presentation, lesion morphology, and fluid analysis.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar Although not all experts agree on which lesions should be drained, most pancreatologists and therapeutic endoscopists will consider pseudocyst drainage when the patient is symptomatic or when the cyst measures more than 6 cm after 6 weeks of follow-up.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar Traditionally, such patients with complicated pancreatitis have been referred for surgical therapy. However, recent, less-invasive drainage techniques performed under radiology, endoscopy, or EUS guidance have attempted to reduce the morbidity and costs associated with surgical techniques.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Endoscopic drainage of pancreatic pseudocysts may be performed by using a transpapillary or transmural approach (transgastric and transduodenal) for stent placement.4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar The blindness of the endoscopic technique, which entirely relies upon bulging of the pseudocysts in the gastric or duodenal wall, may lead to severe complications, including bleeding or perforation. This has meant that its use is restricted to experts in therapeutic endoscopy with long-standing experience.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 5Kozarek R.A. Brayko C.M. Harlan J. et al.Endoscopic drainage of pancreatic pseudocysts.Gastrointest Endosc. 1985; 31: 322-327Abstract Full Text PDF PubMed Scopus (200) Google Scholar, 6Monkemuller K.E. Baron T.H. Morgan D.E. Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique.Gastrointest Endosc. 1998; 48: 195-200Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar With the advent of linear echoendoscopes in the last few decades, an EUS-guided technique was developed to resolve these theoretical limitations of the blind endoscopic approach.7Giovannini M. Pesenti C. Rolland A.L. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echoendoscope.Endoscopy. 2001; 33: 473-477Crossref PubMed Scopus (267) Google Scholar, 8Sriram P.V. Kaffes A.J. Rao G.V. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.Endoscopy. 2005; 37: 231-235Crossref PubMed Scopus (80) Google Scholar, 9Seewald S. Groth S. Omar S. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm.Gastrointest Endosc. 2005; 62: 101-104Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar The growing number of endosonographers who perform EUS-guided FNA makes it easier at present to gain access, under EUS control, to the pancreatic pseudocyst. It is important to note that the EUS echoendoscope allows direct US visualization of the fluid collection, so an entry point can be selected from the stomach or the duodenum and avoid vascular structures.7Giovannini M. Pesenti C. Rolland A.L. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echoendoscope.Endoscopy. 2001; 33: 473-477Crossref PubMed Scopus (267) Google Scholar, 8Sriram P.V. Kaffes A.J. Rao G.V. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.Endoscopy. 2005; 37: 231-235Crossref PubMed Scopus (80) Google Scholar, 9Seewald S. Groth S. Omar S. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm.Gastrointest Endosc. 2005; 62: 101-104Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar After puncturing the pseudocyst under EUS guidance, the rest of the procedure is similar to that of the standard endoscopic approach, and EUS imaging is no longer required.There are several reasons that justify the use of EUS before draining a pancreatic cyst. First, it is not infrequent that a cyst in the pancreas documented on a CT of patients with an episode of pancreatitis is not a “true” pseudocyst but a cystic tumor, which should not be drained. This was well shown in a study, published in this month's issue of Gastrointestinal Endoscopy, by Varadarajulu et al,10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar who diagnosed 5 cystic tumors in a series of 63 patients (8%). CTs and magnetic resonance imaging (MRI) are excellent imaging techniques for identifying the presence of cystic lesions in the pancreas, but, in a large number of cases, they do not allow one to determine the nature of the lesions.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar The higher resolution of EUS endoscopes, compared with CTs or MRIs, serves to identify certain morphologic features not seen with other imaging techniques, such as septation; thickness of the septum; the presence of irregularities, internal intramural projections, debris in the cyst fluid; communication with the main pancreatic duct; the size of the cyst; or the presence of a central scar, while also offering the possibility of obtaining cyst fluid for analysis. The overall accuracy of EUS endoscopes to differentiate among different types of pancreatic cysts exceeds 80%.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar Second, through the use of EUS, we can assess, at the time of drainage, the type of pseudocyst we are attempting to drain. EUS identification of solid debris within the lesion will modify the treatment strategy toward a more aggressive approach, including a wider hole in the gastric or duodenal wall, placement of a larger number of stents and a nasocystic irrigation catheter, and endoscopic debridement. Conversely, if no debris is identified on an EUS examination, a more conservative approach (1-2 regular stents) can be applied. Finally, EUS may help the physician determine if there are any intervening vessels in the puncture area (eg, collateral circulation) to avoid accidental puncture and will also show beforehand the distance between the cyst and the gut wall. With this information, the risks of bleeding (as high as 6% and sometimes life threatening) and perforation can be effectively reduced.2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 8Sriram P.V. Kaffes A.J. Rao G.V. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.Endoscopy. 2005; 37: 231-235Crossref PubMed Scopus (80) Google ScholarAlthough endoscopic drainage of pancreatic pseudocysts was originally described some decades ago and there have since been multiple publications on this subject (mostly uncontrolled and retrospective studies), today there is still a lack of consensus as to which is the best drainage technique.5Kozarek R.A. Brayko C.M. Harlan J. et al.Endoscopic drainage of pancreatic pseudocysts.Gastrointest Endosc. 1985; 31: 322-327Abstract Full Text PDF PubMed Scopus (200) Google Scholar, 11Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Thus, a survey conducted among the American Society for Gastrointestinal Endoscopy members (including both U.S. and non-U.S. endoscopists) revealed a wide variety of practices used for pancreatic pseudocyst drainage.11Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar The results of the survey disclosed that most experts preferred the transgastric route for drainage (65% of them), along with placement of 1 to 5 stents per patient for 2 to 30 weeks. Interestingly, predrainage EUS imaging of the pancreatic pseudocyst was only undertaken by 70% of U.S. endoscopists and by 59% of non-U.S. endoscopists (most at teaching academic centers). More importantly, however, direct EUS-guided drainage of pseudocysts was only performed by 56% of U.S. and 43% of non-U.S. endoscopists. The lesson to be learned from these results is that no consensus has been reached on the subject, and perhaps that, although desirable, many institutions presently lack adequate EUS equipment and experts in the field for EUS-guided pseudocyst drainage.The past decade has witnessed a boom in EUS, with more and more hospitals adding this useful tool to their endoscopic armamentarium. The growing number of EUS units and experts available at most academic and even private institutions, suggests that in the near future we will be able to offer most patients EUS guidance for pseudocyst drainage. However, I do believe that further efforts still need to be made to train more gastroenterologists to be autonomous and proficient in this technique and to acknowledge them as experts in EUS-guided pseudocyst drainage through incentives for performing this type of procedure.Because EUS assistance for drainage of pancreatic-fluid collections may not be widely available and may be technically challenging, in the study discussed here, Varadarajulu et al10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar attempted to identify certain patient and pancreatic-fluid–collection characteristics associated with technical and clinical success when performing a blind endoscopic approach for pancreatic pseudocyst drainage. These investigators designed a prospective study in which they meticulously followed the standards of clinical practice in patients with a pancreatic pseudocyst. In pseudocysts that were symptomatic or that measured more than 6 cm, they initially performed an ERCP, obtained a pancreatogram, and, when possible, drained the cyst by the transpapillary route. If transpapillary drainage was not possible, then blind endoscopic transmural drainage was attempted by the standard technique. Finally, the classic EUS-guided technique was used to drain the pancreatic pseudocyst when neither the transpapillary nor the blind endoscopic transmural technique was possible. It should be stressed that the physicians who performed the drainage procedures were well-trained therapeutic endoscopists and endosonographers with extensive experience in pancreatic-pseudocyst drainage, which unfortunately is not the situation at all other institutions where these procedures are performed. The investigators also defined a priori, according to the accepted definitions created by expert committees, the pancreas head, body, and tail. They also made a clear definition of what they considered technical success, treatment success, and treatment failure. In addition, Varadarajulu et al10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar defined what was understood as a complication and systematically followed patients to identify these complications.The limitations of the blind endoscopic approach to pseudocyst drainage were well revealed in the study by Varadarajulu et al.10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar By using their state-of-the-art approach to pseudocyst drainage, 23 of the 53 patients (43%) included in the study eventually required EUS guidance for pseudocyst drainage after failure of the initial procedure. More importantly, the EUS-guided approach was successful in all the patients in whom the blind approach had previously failed.10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar This is certainly the feeling that most endosonographers have in clinical practice. EUS allows us to puncture a pancreatic pseudocyst regardless of location, and, once we have gained access with the needle and a guidewire has been advanced and curled inside the cyst, drainage should be possible.We should highlight the fact that, in this prospective study, Varadarajulu et al10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar attempted blind internal endoscopic drainage of all pancreatic pseudocysts, yet were only able to do so if bulging of the pseudocyst occurred and if this did not compress the gastric or duodenal wall. These findings indicate that when EUS-guided drainage is not available, a blind endoscopic approach can be used to drain most bulging pseudocysts located in the head and body of the pancreas, 81% and 85% of cases, respectively. However, as previously mentioned, nonbulging cysts are more difficult to treat and those located in the tail of the pancreas seem only amenable for drainage under EUS guidance (0% technical success for the blind approach). A review of the literature indicates a 95% success rate for the EUS-guided approach, and, as shown in this study, the blind approach only achieves drainage in 57% of cases, and in 0% of pseudocysts in the pancreatic tail.2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 11Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar When blind pseudocyst drainage was technically possible, treatment was successful, as defined by the investigator, in 90% of them.The limited sample size of the study prevented the investigators from demonstrating a statistically significant difference between the treatment options (the blind vs the EUS-guided approach). However, it should be noted that the only clinically meaningful episode of bleeding occurred with the blind endoscopic approach. Given that, in patients with pancreatic pseudocysts, portal hypertension caused by compression or thrombosis of the splenic vein is not infrequent, and pseudocysts may also be associated with aneurysms of the splenic artery, a guided (EUS in this case) approach will always be safer than a blind one. Although relatively rare, major complications, such as massive bleeding or even death, have been described for the blind endoscopic approach, owing to perforation of a splenic artery aneurysm during the drainage manoeuvres.The above information is particularly useful for gastroenterologists who pursue endoscopic drainage of a pseudocyst but who lack the valuable help of an echoendoscope. Bulging pseudocysts located in the head and body of the pancreas may be “safely” drained, without the need for EUS guidance. However, if EUS is available, a blind approach does not seem to be the first and safest option to drain a pancreatic pseudocyst.In summary, although the blind approach may be successfully used to drain some pseudocysts at specific sites in the pancreas, the risks of misdiagnosis, technical failure, and complications support the use of the EUS-guided method for the treatment of this type of lesion. At present, it would seem wise to refer the patient to an institution in which EUS is available to minimize risks. I believe the answer to the question “Is EUS really necessary for drainage of peripancreatic fluid collections?” is reasonably clear. We should try to offer our patients the best therapeutic option available for cure, and, at present, this option is undoubtedly the EUS-guided approach. EUS allows puncture of a pancreatic pseudocyst regardless of location, and, once access has been gained with the needle and a guidewire has been advanced and curled inside the cyst, drainage should be possible.Pancreatic pseudocysts are a relatively common complication of both acute and chronic pancreatitis. This type of pancreatic-fluid collection may be differentiated from other pancreatic cystic lesions according to their clinical presentation, lesion morphology, and fluid analysis.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar Although not all experts agree on which lesions should be drained, most pancreatologists and therapeutic endoscopists will consider pseudocyst drainage when the patient is symptomatic or when the cyst measures more than 6 cm after 6 weeks of follow-up.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar Traditionally, such patients with complicated pancreatitis have been referred for surgical therapy. However, recent, less-invasive drainage techniques performed under radiology, endoscopy, or EUS guidance have attempted to reduce the morbidity and costs associated with surgical techniques.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Endoscopic drainage of pancreatic pseudocysts may be performed by using a transpapillary or transmural approach (transgastric and transduodenal) for stent placement.4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar The blindness of the endoscopic technique, which entirely relies upon bulging of the pseudocysts in the gastric or duodenal wall, may lead to severe complications, including bleeding or perforation. This has meant that its use is restricted to experts in therapeutic endoscopy with long-standing experience.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 5Kozarek R.A. Brayko C.M. Harlan J. et al.Endoscopic drainage of pancreatic pseudocysts.Gastrointest Endosc. 1985; 31: 322-327Abstract Full Text PDF PubMed Scopus (200) Google Scholar, 6Monkemuller K.E. Baron T.H. Morgan D.E. Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique.Gastrointest Endosc. 1998; 48: 195-200Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar With the advent of linear echoendoscopes in the last few decades, an EUS-guided technique was developed to resolve these theoretical limitations of the blind endoscopic approach.7Giovannini M. Pesenti C. Rolland A.L. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echoendoscope.Endoscopy. 2001; 33: 473-477Crossref PubMed Scopus (267) Google Scholar, 8Sriram P.V. Kaffes A.J. Rao G.V. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.Endoscopy. 2005; 37: 231-235Crossref PubMed Scopus (80) Google Scholar, 9Seewald S. Groth S. Omar S. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm.Gastrointest Endosc. 2005; 62: 101-104Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar The growing number of endosonographers who perform EUS-guided FNA makes it easier at present to gain access, under EUS control, to the pancreatic pseudocyst. It is important to note that the EUS echoendoscope allows direct US visualization of the fluid collection, so an entry point can be selected from the stomach or the duodenum and avoid vascular structures.7Giovannini M. Pesenti C. Rolland A.L. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echoendoscope.Endoscopy. 2001; 33: 473-477Crossref PubMed Scopus (267) Google Scholar, 8Sriram P.V. Kaffes A.J. Rao G.V. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.Endoscopy. 2005; 37: 231-235Crossref PubMed Scopus (80) Google Scholar, 9Seewald S. Groth S. Omar S. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm.Gastrointest Endosc. 2005; 62: 101-104Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar After puncturing the pseudocyst under EUS guidance, the rest of the procedure is similar to that of the standard endoscopic approach, and EUS imaging is no longer required. EUS allows puncture of a pancreatic pseudocyst regardless of location, and, once access has been gained with the needle and a guidewire has been advanced and curled inside the cyst, drainage should be possible. EUS allows puncture of a pancreatic pseudocyst regardless of location, and, once access has been gained with the needle and a guidewire has been advanced and curled inside the cyst, drainage should be possible. There are several reasons that justify the use of EUS before draining a pancreatic cyst. First, it is not infrequent that a cyst in the pancreas documented on a CT of patients with an episode of pancreatitis is not a “true” pseudocyst but a cystic tumor, which should not be drained. This was well shown in a study, published in this month's issue of Gastrointestinal Endoscopy, by Varadarajulu et al,10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar who diagnosed 5 cystic tumors in a series of 63 patients (8%). CTs and magnetic resonance imaging (MRI) are excellent imaging techniques for identifying the presence of cystic lesions in the pancreas, but, in a large number of cases, they do not allow one to determine the nature of the lesions.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar The higher resolution of EUS endoscopes, compared with CTs or MRIs, serves to identify certain morphologic features not seen with other imaging techniques, such as septation; thickness of the septum; the presence of irregularities, internal intramural projections, debris in the cyst fluid; communication with the main pancreatic duct; the size of the cyst; or the presence of a central scar, while also offering the possibility of obtaining cyst fluid for analysis. The overall accuracy of EUS endoscopes to differentiate among different types of pancreatic cysts exceeds 80%.1Brugge W.R. Lewandrowski K. Lee-Lewandrowski E. et al.Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study.Gastroenterology. 2004; 126: 1330-1336Abstract Full Text Full Text PDF PubMed Scopus (1095) Google Scholar, 2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar Second, through the use of EUS, we can assess, at the time of drainage, the type of pseudocyst we are attempting to drain. EUS identification of solid debris within the lesion will modify the treatment strategy toward a more aggressive approach, including a wider hole in the gastric or duodenal wall, placement of a larger number of stents and a nasocystic irrigation catheter, and endoscopic debridement. Conversely, if no debris is identified on an EUS examination, a more conservative approach (1-2 regular stents) can be applied. Finally, EUS may help the physician determine if there are any intervening vessels in the puncture area (eg, collateral circulation) to avoid accidental puncture and will also show beforehand the distance between the cyst and the gut wall. With this information, the risks of bleeding (as high as 6% and sometimes life threatening) and perforation can be effectively reduced.2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 3Vazquez-Sequeiros E. Wiersema M.J. The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states.Curr Gastroenterol Rep. 2000; 2: 125-132Crossref PubMed Scopus (13) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 8Sriram P.V. Kaffes A.J. Rao G.V. et al.Endoscopic ultrasound guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.Endoscopy. 2005; 37: 231-235Crossref PubMed Scopus (80) Google Scholar Although endoscopic drainage of pancreatic pseudocysts was originally described some decades ago and there have since been multiple publications on this subject (mostly uncontrolled and retrospective studies), today there is still a lack of consensus as to which is the best drainage technique.5Kozarek R.A. Brayko C.M. Harlan J. et al.Endoscopic drainage of pancreatic pseudocysts.Gastrointest Endosc. 1985; 31: 322-327Abstract Full Text PDF PubMed Scopus (200) Google Scholar, 11Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Thus, a survey conducted among the American Society for Gastrointestinal Endoscopy members (including both U.S. and non-U.S. endoscopists) revealed a wide variety of practices used for pancreatic pseudocyst drainage.11Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar The results of the survey disclosed that most experts preferred the transgastric route for drainage (65% of them), along with placement of 1 to 5 stents per patient for 2 to 30 weeks. Interestingly, predrainage EUS imaging of the pancreatic pseudocyst was only undertaken by 70% of U.S. endoscopists and by 59% of non-U.S. endoscopists (most at teaching academic centers). More importantly, however, direct EUS-guided drainage of pseudocysts was only performed by 56% of U.S. and 43% of non-U.S. endoscopists. The lesson to be learned from these results is that no consensus has been reached on the subject, and perhaps that, although desirable, many institutions presently lack adequate EUS equipment and experts in the field for EUS-guided pseudocyst drainage. The past decade has witnessed a boom in EUS, with more and more hospitals adding this useful tool to their endoscopic armamentarium. The growing number of EUS units and experts available at most academic and even private institutions, suggests that in the near future we will be able to offer most patients EUS guidance for pseudocyst drainage. However, I do believe that further efforts still need to be made to train more gastroenterologists to be autonomous and proficient in this technique and to acknowledge them as experts in EUS-guided pseudocyst drainage through incentives for performing this type of procedure. Because EUS assistance for drainage of pancreatic-fluid collections may not be widely available and may be technically challenging, in the study discussed here, Varadarajulu et al10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar attempted to identify certain patient and pancreatic-fluid–collection characteristics associated with technical and clinical success when performing a blind endoscopic approach for pancreatic pseudocyst drainage. These investigators designed a prospective study in which they meticulously followed the standards of clinical practice in patients with a pancreatic pseudocyst. In pseudocysts that were symptomatic or that measured more than 6 cm, they initially performed an ERCP, obtained a pancreatogram, and, when possible, drained the cyst by the transpapillary route. If transpapillary drainage was not possible, then blind endoscopic transmural drainage was attempted by the standard technique. Finally, the classic EUS-guided technique was used to drain the pancreatic pseudocyst when neither the transpapillary nor the blind endoscopic transmural technique was possible. It should be stressed that the physicians who performed the drainage procedures were well-trained therapeutic endoscopists and endosonographers with extensive experience in pancreatic-pseudocyst drainage, which unfortunately is not the situation at all other institutions where these procedures are performed. The investigators also defined a priori, according to the accepted definitions created by expert committees, the pancreas head, body, and tail. They also made a clear definition of what they considered technical success, treatment success, and treatment failure. In addition, Varadarajulu et al10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar defined what was understood as a complication and systematically followed patients to identify these complications. The limitations of the blind endoscopic approach to pseudocyst drainage were well revealed in the study by Varadarajulu et al.10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar By using their state-of-the-art approach to pseudocyst drainage, 23 of the 53 patients (43%) included in the study eventually required EUS guidance for pseudocyst drainage after failure of the initial procedure. More importantly, the EUS-guided approach was successful in all the patients in whom the blind approach had previously failed.10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar This is certainly the feeling that most endosonographers have in clinical practice. EUS allows us to puncture a pancreatic pseudocyst regardless of location, and, once we have gained access with the needle and a guidewire has been advanced and curled inside the cyst, drainage should be possible. We should highlight the fact that, in this prospective study, Varadarajulu et al10Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar attempted blind internal endoscopic drainage of all pancreatic pseudocysts, yet were only able to do so if bulging of the pseudocyst occurred and if this did not compress the gastric or duodenal wall. These findings indicate that when EUS-guided drainage is not available, a blind endoscopic approach can be used to drain most bulging pseudocysts located in the head and body of the pancreas, 81% and 85% of cases, respectively. However, as previously mentioned, nonbulging cysts are more difficult to treat and those located in the tail of the pancreas seem only amenable for drainage under EUS guidance (0% technical success for the blind approach). A review of the literature indicates a 95% success rate for the EUS-guided approach, and, as shown in this study, the blind approach only achieves drainage in 57% of cases, and in 0% of pseudocysts in the pancreatic tail.2Jacobson B.C. Baron T.H. Adler D.G. et al.The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory collections of the pancreas.Gastrointest Endosc. 2005; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 4Baron T.H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.Gastrointest Endosc Clin N Am. 2003; 13: 743-764Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 11Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar When blind pseudocyst drainage was technically possible, treatment was successful, as defined by the investigator, in 90% of them. The limited sample size of the study prevented the investigators from demonstrating a statistically significant difference between the treatment options (the blind vs the EUS-guided approach). However, it should be noted that the only clinically meaningful episode of bleeding occurred with the blind endoscopic approach. Given that, in patients with pancreatic pseudocysts, portal hypertension caused by compression or thrombosis of the splenic vein is not infrequent, and pseudocysts may also be associated with aneurysms of the splenic artery, a guided (EUS in this case) approach will always be safer than a blind one. Although relatively rare, major complications, such as massive bleeding or even death, have been described for the blind endoscopic approach, owing to perforation of a splenic artery aneurysm during the drainage manoeuvres. The above information is particularly useful for gastroenterologists who pursue endoscopic drainage of a pseudocyst but who lack the valuable help of an echoendoscope. Bulging pseudocysts located in the head and body of the pancreas may be “safely” drained, without the need for EUS guidance. However, if EUS is available, a blind approach does not seem to be the first and safest option to drain a pancreatic pseudocyst. In summary, although the blind approach may be successfully used to drain some pseudocysts at specific sites in the pancreas, the risks of misdiagnosis, technical failure, and complications support the use of the EUS-guided method for the treatment of this type of lesion. At present, it would seem wise to refer the patient to an institution in which EUS is available to minimize risks. I believe the answer to the question “Is EUS really necessary for drainage of peripancreatic fluid collections?” is reasonably clear. We should try to offer our patients the best therapeutic option available for cure, and, at present, this option is undoubtedly the EUS-guided approach. DisclosureThe author has no financial or economic interest related with opinions stated in this article. The author has no financial or economic interest related with opinions stated in this article.