Endoscopic ultrasound (EUS) guided pancreatic collection or pseudocyst drainage

Pancreatic collections and pseudocysts are fluid filled sacs that can develop around the pancreas following an attack of severe acute pancreatitis or as a result of chronic pancreatitis. Sometimes these can also contain solid material, often due to dead fragments of pancreas (‘necrotic tissue’). This will affect what type of treatment is best for drainage.

Collections and pseudocysts can cause symptoms of abdominal pain, nausea, vomiting and weight loss, and can become infected and cause fevers which can make patients very unwell.

If the collection or pseudocyst is causing symptoms or has become infected and requires drainage, endoscopic ultrasound guided drainage is considered to be the preferred treatment. The collection or pseudocyst has to be situated close to the stomach or the first part of the small bowel (duodenum) however for this procedure to be used.

Endoscopic ultrasound (EUS) guided pancreatic collection or pseudocyst drainage involves the insertion of a stent (a flexible plastic or metal tube) to drain the liquid or solid (‘necrotic’) material into the stomach or duodenum (the first part of the small bowel).

The endoscope (a long flexible tube) is passed through the mouth to reach the stomach and duodenum.

At the tip of the endoscope is a small ultrasound probe that uses sound waves to produce images of the organs inside the body. This enables us to identify a suitable position to place the stent and drain the collection into the stomach or duodenum.

It has been shown in clinical trials (research that tests the effects of new treatments) that EUS-guided pancreatic collection and pseudocyst drainage is a safe and effective means of treatment.

In particularly large necrotic pancreatic collections, the insertion of a metallic flexible stent also allows for a ‘necrosectomy’, which is a procedure where the endoscope is passed through the stent into the collection and various tools are used to remove the dead tissue that might make you more unwell.

If the stent inserted is metallic this will be removed approximately six weeks after insertion. This can be replaced with plastic stents if there are ongoing signs of a collection that requires longer drainage.

It is important that metal stents are not left in too long as they can become stuck in position which could cause problems in the long term. If you have not heard about your appointment to remove the stent at six weeks after insertion, please contact our Pancreatobiliary Clinical Nurse Specialist on 07967 760146.

All treatments and procedures have risks, and we will talk to you about the specific risks of EUS-guided pancreatic collection and pseudocyst drainage.

Uncommon complications which can occur during any EUS procedure include chest infections, damage to or perforation (a hole) in the wall of the oesophagus, stomach or duodenum, allergy to sedative medication, bleeding and damage to teeth.

There are also specific risks which can occur during or after EUS-guided pancreatic collection and pseudocyst drainage, such as problems placing the stent, the stent migrating (falling out from the position it was placed in), or difficulty removing it.

Problems that may happen straight away

There is a risk of bleeding from the stent as it goes through the wall of the stomach or duodenum: this can occur in approximately 1 in every 12 procedures (8%). You would need to stay in hospital after the procedure to be observed, and if the bleeding is severe, then a blood transfusion or a procedure to stop the bleeding, using X-rays to guide equipment inserted into the groin and through blood vessels to seal the leaking blood vessel may be required. This is known as an ‘interventional radiology’ procedure.

There is also a risk of the endoscope or stent making a hole in the lining of the stomach, duodenum or the oesophagus. The risk of this is in approximately 1 in every 25 procedures (4%). If this occurs you may need a further endoscopy procedure to treat this, or in the rare case an operation can be needed to close the hole.

There is a small chance that the stent may be placed in the wrong place in approximately 1 in every 30 procedures (3%). If this happens you may need a percutaneous drain (placement of a drainage tube through your abdominal wall) or an operation performed by a surgeon in operating theatres to remove the stent and make any necessary repairs.

Problems that may happen later

In approximately 1 in every 10 (10%) procedures the stent can become blocked. This would lead to recurrence of symptoms (abdominal pain, vomiting or fevers). If this happens you would need to return to hospital for a further endoscopy procedure to unblock the stent.

There is also a risk that the stent may lead to some bleeding around the collection. The symptoms of bleeding would include passing blood in vomit, or very black sticky stool. You may also develop symptoms of low blood pressure with dizziness and a fast heart rate. If these develop it is important to return to hospital to be assessed. This may require surgery or interventional radiology to treat.

Patients with pancreatic collections can be very sick and any procedure in this condition carries risks. Any of the complications of endoscopic ultrasound guided drainage outlined can usually be treated with further endoscopies, surgery or by interventional radiology, but on very rare occasions can result in death.

The main alternative to EUS-guided pancreatic collection and pseudocyst drainage is the placement of one or more drainage tubes through your abdominal wall (percutaneous drainage). Other treatment options include surgery to drain the material within the collection.

EUS-guided drainage procedures have, however, been shown in clinical trials to be a better and safer option for patients with pancreatic collections and pseudocysts.

Since X-rays are sometimes taken during the procedure, please tell us if there is any possibility you may be pregnant.

We will need to know about all the medications you take, in particular blood thinners, such as clopidogrel, ticagrelor, prasugrel, warfarin, heparin, rivaroxaban, apixaban, edoxaban or dabigatran, which may need to be stopped or adjusted up to one week before the procedure.

If you take clopidogrel or other blood thinners it may be necessary to check with your Cardiologist (or other specialist) to be sure that these can be stopped before your procedure.

If you are a diabetic and take insulin, it is important that you continue taking your insulin, but it is suggested that you reduce your dose on the day and night before the procedure. If you are concerned about how to manage this, then contact your local Diabetes nurse for advice. Remember to check your blood sugar regularly while fasting

If you are taking tablets for your diabetes, please do not take them on the day of the procedure until after the procedure has been done. Please bring your diabetic tablets or insulin to the hospital with you if you are not already in hospital.

Please continue to take any other medication (including laxatives). If you are in hospital when the procedure is being done, then doctors on the ward will manage your medicines for you.

You should not eat anything for six hours before the appointment. You may drink water only up until four hours before the procedure (your usual prescription medicines can still be taken after that with a sip of water).

Patients often need to remain in hospital (either at University College Hospital or returning to your local hospital if you are already an inpatient there) to be monitored after the procedure is completed. If you are being admitted to the ward in University College Hospital overnight following the procedure you will need to bring an overnight bag.

Pre-assessment clinic

If you are attending the appointment as from home (not an inpatient transfer from another hospital) then you will be contacted by the anaesthetic team prior to your appointment. This appointment will go through your medical background and medications to be certain it is safe to undergo the anaesthetic for the procedure.

(If you are attending as an inpatient from another hospital this will not take place. The local anaesthetic team may review your case and provide this information directly to the University College Hospital team.)

When you arrive at University College Hospital, please come to the 2nd Floor of the Podium and report to the Endoscopy Unit Reception. From there a nurse will take you to ‘Admissions’, check your personal details and check your blood pressure, and you will be asked to change into a hospital gown. Before your EUS-GJ we will discuss the procedure further, as part of the consent process (see below).

Sometimes due to emergencies and other circumstances your appointment may be delayed or postponed. We try our best to see everyone on time but please understand that delays can occur, and we ask for your patience in these circumstances.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please speak with a senior member of staff again.

The procedure is done in the Endoscopy Department and is performed by a specially trained team led by a Gastroenterologist. The procedure is done either under sedation (you are given a drug to make you sleepy but are not fully asleep) delivered by the doctor doing the procedure or with an anaesthetist putting you to sleep with a full anaesthetic. You will spend up to 45 minutes in the procedure room.

The procedure is performed using a thin flexible tube containing a miniature camera (endoscope) with an ultrasound probe on the end. The endoscope is put in your mouth and passed down your oesophagus to your stomach or duodenum. Using ultrasound guidance, a special type of stent (a ‘lumen-apposing metal stent’) or one or more plastic stents is placed into the pancreatic collection or pseudocyst through the wall of either your stomach or duodenum.

These stents create an opening between the collection and the stomach or duodenum. This allows the contents to flow out of the collection and into the stomach or bowel, which should usually lead to a rapid improvement in the symptoms.

As described earlier, sometimes, if there is solid necrotic (dead) tissue within the collection, a further procedure called a necrosectomy may be required following the initial stent insertion to clear this tissue. This involves passing an endoscope into the collection and using various tools to remove the necrotic pancreatic tissue into the stomach or duodenum. This carries a small risk of triggering bleeding which can require emergency surgery or emergency interventional radiology.

You may wake up with some pain in your abdomen. We will prescribe pain medication if required. If your pain is severe or it worsens, then the doctors may check to see if there has been a complication, and so may request a CT (computerized tomography) scan.

If you are taking blood thinning medication, we will tell you when you can restart the medication following your procedure. This information will also be provided in your discharge paperwork.

Depending on how the procedure goes you will be able to resume eating and drinking later that day. The instructions on when it is safe to do this will be explained to you after the procedure.

The evidence we have tells us that this is a safe procedure. However, the following symptoms might suggest a complication:

• severe persistent abdominal pain
• light-headedness or fainting
• shivering or fever
• vomiting of blood
• passing of blood or black tar-like stools
• feeling generally very unwell.

If you have any problems, please contact the Pancreatobiliary Clinical Nurse Specialist in the first instance (contact details below).

If you have a problem outside of office hours which cannot wait until the next day, please contact the hospital switchboard and ask to be put through to the on-call Gastroenterology Registrar (see below). In an emergency, please visit your nearest Accident and Emergency Department.

Endoscopy Booking Team (Monday to Friday 09:00-17:00)
Direct line: 020 3456 7022
Switchboard: 08451 555 000 / 020 3456 7890 ext. 67022
E-mail: uclh.endoscopy@nhs.net

Endoscopy Recovery (Monday to Friday 09:00-17:00)
Direct line: 020 3447 3282
Switchboard: 08451 555 000 / 020 3456 7890 ext. 73282

Hepatobiliary Pathway Co-Ordinator (Monday to Friday 09:30-17:30)
Direct line: 020 3447 9229
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 79229

Pancreatobiliary Clinical Nurse Specialist (Monday to Friday 09:00-17:00)
Direct line: 07967 760146 / 07811 785093

On-call Gastroenterology Registrar (out of hours emergencies only)
Switchboard: 0845 155 5000 / 020 3456 7890

Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London, NW1 2BU