Pediatr Radiol (1990) 20:590-593
Pediatric Radiology 9
1990
Percutaneous transgastric drainage of the lesser sac in children G. M. A m u n d s o n 1,*, R. B. T o w b i n 3,*, D. L. M u e l l e r 1 a n d C. G. E S e a g r a m 2 1 Department for Diagnostic Imaging, and 2 Division of Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada, and 3 Department of Radiology, Children's Hospital Medical Center, Cincinnati, Ohio, USA Received: 25 January 1990; accepted: 10 April 1990
Abstract. In four children (5-14 years old), lesser sac fluid collections (3 pseudocysts and i abscess) were externally drained using a p e r c u t a n e o u s transgastric approach. With ultrasound or C T guidance and fluoroscopic monitoring, a s h e a t h e d needle is inserted t h r o u g h the s t o m a c h into the lesser sac fluid collection, the catheter is exchanged, secured in place and c o n n e c t e d to external drainage. All four fluid collections were complications of pancreatitis (3 acute post-traumatic, 1 post-surgical). All four fluid collections were successfully drained without n e e d for surgical intervention. T h e r e were no m a j o r complications. T h r e e m i n o r complications o c c u r r e d as a result of reinsertion of catheters; transient gastric venous bleeding, hematuria, and bleeding into the pseudocyst. P e r c u t a n e o u s transgastric drainage can be p e r f o r m e d successfully in children, and provides an alternative to surgical intervention of lesser sac fluid collections. D r a i n a g e early in the course of pancreatic pseudocysts m a y lessen the m o r bidity, potential mortality, and p r o l o n g e d hospitalization usually necessary for standard medical and surgical mana g e m e n t of these patients.
A c u t e pancreatitis in children is most c o m m o n l y due to blunt a b d o m i n a l t r a u m a f r o m an accident or abuse. O t h e r causes include drugs, infection, congenital biliary a n o m alies, and familial or idiopathic disease [1-5]. Lesser sac fluid collections (pseudocyst, abscess, h e m o r r h a g e ) are frequent complications of pancreatitis and m a y occur in up to 35% of children [3]. These fluid collections m a y be life threatening or cause morbidity and p r o l o n g e d hospitalization. Pancreatic abscesses have required p r o m p t surgical drainage since there is an extremely high mortality without treatment; pancreatic pseudocysts often require surgical d e c o m p r e s s i o n into the s t o m a c h (cystogastrostomy) or j e j u n u m (cystojejunostomy) after m a t u r a t i o n of the cyst wall (4-7 weeks) [6-8]. In view of the recent reports of successful percutaneous drainage of lesser sac fluid collections by various
routes [9-19], p e r c u t a n e o u s transgastric drainage ( P T G ) was p e r f o r m e d in four children as an alternative to surgery. T h e p u r p o s e of this report is to d o c u m e n t the success of this technique in three children with post-traumatic pancreatic pseudocysts and o n e child with a lesser sac abscess.
Methods Over a 15 month period, 3 boys and 1 girl, ranging in age from 5 to 14 years, underwent percutaneous drainage of lesser sac fluid collections at two different children's hospitals. Although several approaches can be used [12-13], we elected the transgastric route for drainage of the lesser sac [14-19]. Indications for PTG drainage in the 3 children with pancreatic pseudocysts were: increase in size of the pseudocyst, persistently elevated serum amylase and lipase, and prolonged fever, abdominal pain, and malaise. In the patient with a pancreatic abscess, drainage was performed because of persistent fever and leukocystosis.
Technique I
All four patients received intravenous antibiotics for at least 24 h prior to the procedure. After defining the location and extent of the lesser sac fluid collection by sonography or computed tomography (CT), the inferolateral margin of the left lobe of the liver is marked on the skin. The transverse colon may be outlined with oral contrast given 4 to 6 h prior to drainage or via a contrast enema. Either general anesthesia or sedation with intravenous pentobarbital sodium (Nembutal, Abbott Laboratories, North Chicago, IL) and fentanyl citrate (Sublimaze, Janssen Pharmaceutica, Inc, Piscataway, NJ) may be used [20]. A nasogastric tube is placed, and under fluoroscopic guidance, the stomach distended with air. Intravenous glucagon (0.25-0.5 mg) may be given to impede gastric emptying. The entrance site is chosen on the anterior abdominal wall over the body of the stomach, inferior to the costal margin and lateral to the rectus abdominus muscles. Following injection of local anesthesia, a skin incision is made with a # 11 scalpel blade and an 18F sheathed needle is inserted into the distended stomach, avoiding the left lobe of the liver and transverse colon. Under sonographic or fluoroscopic guidance, the sheathed needle is then pushed through the posterior wall of the stomach into the lesser sac fluid collection. Fluid is with-
* Currentaddress:DepartmentofRadiology, Children'sHospitalof
Michigan, 3901 Beaubien Boulevard, Detroit, Michigan 48201, USA
i Modified from Nunez et al.
G. M. Amundson et al.: Lesser sac drainage in children
591
Fig. l a, h. Case 1. Pancreatic pseudocyst, a Transverse sonogram: lesser sac pseudocyst (P) with wedged defect in body of pancreas (white arrow) associated with dilatation of the distal pancreatic duct (black arrow). b Right lateral decubitus view of abdomen: contrast outlines dependent portion of large pseudocyst with PTG drainage tube placed within it Fig.2a, b. Case 2. Pancreatic pseudocyst, a Transverse sonogram: the pancreas is enlarged and inhomogeneous with a tear in the body (arrow). P = developing pseudocyst, small arrowheads = head of pancreas, and large arrowhead = splenic vein. b Transverse sonogram one month later. A large lesser sac pseudocyst with early septation
(arrows) Fig. 3a, b. Case 4. Lesser sac abscess, a CT demonstrates hypodense lesser sac abscess with an irregular, slightly thickened wall (arrows). Note that it is completely surrounded by other organs and lies adjacent to the posterior wall of the stomach (S). b CT following catheter placement and drainage. Catheter traverses opacified stomach into abscess bed drawn for gram stain, culture, and enzyme analysis. The sheath is exchanged for a stiff guidewire (0.036 or 0.038 inch Amplatz superstiff guidewire or heavy duty guide wire), the tract is dilated, and a drainage catheter inserted. If a trocar technique is used, the trocar is removed and the catheter positioned in the fluid collection. The position of the catheter may be confirmed by contrast injection. The catheter is then secured to the abdominal wall and connected to gravity or mild negative pressure (Hemovac) drainage.
Case reports Case I J.S., a 5-year-old girl admitted three days following a handle-bar injury to her epigastrium. Initial abdominal sonography revealed pancreatitis with an associated splenic contusion and flee intraperitoneal fluid. Three days later sonography demonstrated a wedged defect in the body of the pancreas with a developing pseudocyst (Fig. 1 a). Over the next two weeks there was progressive enlargement of the pseudocyst associated with persistently elevated pancreatic enzymes and continued patient morbidity. Fourteen clays following the formation of the pseudocyst, a # 6.0 French pigtail catheter was inserted into the pseudocyst using a PTG approach (Fig. lb). Most of the fluid was removed at the time of catheter insertion, but
over the next week the pseudocyst continued to enlarge with frequent catheter blockages and intermittent drainage. One week later a # 8.3 French pigtail catheter was inserted and the # 6.0 French catheter removed. Over the next three weeks the patient had multiple exacerbations of pancreatitis. Although drainage was adequate at times; there was a gradual increase in the size of the pseudocyst. Thirty-four days following the initial catheter placement, the drainage tube was removed with thought toward operative cystogastrostomy. However, there was prompt drainage of the pseudocyst fluid into the stomach. The serum amylase and lipase rapidly returned to normal; with institution of normal feeding, there was no evidence of recurrent pancreatitis or pseudocyst formation. Follow-up sonography one month later demonstrated persistent dilatation of the distal pancreatic duct but no recurrence of the pseudocyst. She has been clinically well without recurrence for more than 2 years.
Case 2 J. T., a 9-year-old boy admitted one day following a handle-bar injury to his epigastrium. Abdominal sonography performed two days later demonstrated pancreatitis, a laceration of the body of the pancreas, a developing pseudocyst, and free intraperitoneal fluid (Fig.2a). Despite medical management, over the next four weeks the pseudocyst progressively increased in size, with persistent elevation of
592 serum amylase and lipase (Fig.2b). Twenty-seven days following formation of the pseudocyst, a # 8.3 French pigtail catheter was placed using a PTG approach. All the fluid was immediately drained. The catheter was left in place for 16 days, then removed after the pancreatic enzyme values returned to normal and oral feeding was successfully instituted. Follow-up examination has shown no recurrence and the patient is clinically well 2 years later.
G. M. Amundson et al.: Lesser sac drainage in children
K. B., a 10-year-old boy admitted three weeks following a handle-bar injury to his epigastrium. A surgical cystogastrostomy had been performed at another hospital two weeks following the injury. However, upon institution of oral feeding, the pancreatitis and pseudocyst recurred, and the patient was transferred because of increasing abdominal pain, fever, and an enlarging palpable abdominal mass. Abdominal sonography confirmed the pancreatitis, ascites, and pseudocyst in the lesser sac. Over the next three days the pseudocyst increased in size with the patient spiking fevers. An # 8.3 French catheter was inserted into the fluid collection using the PTG approach. Most of the fluid was immediately drained, but the pseudocyst did not completely resolve with continuing drainage of 40-60 cc of fluid per day. Two weeks later the catheter was replaced with a # 10 French pigtail catheter which was transgastrically inserted into the pseudocyst using a trocar technique. All the fluid was immediately evacuated without reaccumulation. The patient showed immediate clinical improvement with a gradual return of pancreatic enzymes to normal levels over the next six weeks. Following a trial of oral feeding without reaccumulation of the pseudocyst sonographically, or clinical symptomatology, the catheter was removed. The patient is clinically well without recurrence 2 years later.
ters. In patient 1, the 6F catheter was replaced with an 8.3F catheter; in patient 3, the 8.3F catheter was replaced with a 10F pigtail catheter before adequate drainage could be accomplished. Tube dislodgement did not occur in any child. Contrast was injected into the lesser sac collections in patients 1 and 4, but not in patients 2 and 3. The initial P T G drainages were p e r f o r m e d using intravenous sedation; however, in the two patients requiring catheter exchanges, general anesthesia was employed. T h e r e were no major complications and all patients were cured without surgical intervention. Three minor complications occurred: in patient 1, upon insertion of the second (8.3F) catheter, there was transient bleeding into the stomach which did not require treatment. Following the procedure, there was transient gross hematuria, presumably due to renal t r a u m a incurred during guide wire manipulation and catheter placement in this large pseudocyst (Fig. 1 b). Patient 3 had minor bleeding into the pseudocyst during placement of the 10F catheter, which cleared without further therapy. In the 3 patients with pseudocysts, the drains were left in place until: (1) the pancreatic enzyme elevation had returned to normal, (2) there was no recurrence of the fluid collection or sonographic evidence of pancreatitis, (3) there was no further drainage, and (4) a trial of oral feeding was successful with no reaccumulation of fluid or elevation of pancreatic enzymes. No patient was discharged with a drain in place.
Case 4
Discussion
R.W., a 14-year-old male with longstanding chronic renal failure treated with hemodialysis, presented with persistent fever and abdominal pain. Four years previously he had developed a pancreaticocutaneous fistula, complicating a left nephrectomy with concurrent pancreatitis. CT demonstrated a fluid collection of the lesser sac (Fig. 3a). The fluid collection was completely surrounded by other organs, but was adjacent to the posterior wall of the stomach. An # 8.3 French pigtail catheter was placed through the stomach and 8 cc's of purulent fluid withdrawn (Fig. 3 b). The patient improved rapidly and the catheter was removed three days later due to lack of drainage.
Pancreatitis in u n c o m m o n in childhood, however, when present it may be associated with significant morbidity and/or mortality. In most reported pediatric series, the etiology of pancreatitis is related to trauma, which may be accidental or a result of child abuse, or due to congenital or acquired biliary tract disease. Conditions such as sickle cell anemia, steroid therapy, systemic disease such as mumps, and congenital biliary anomalies are the most frequently precipitating causes [1-6]. Pancreatitis may result in numerous complications such as pseudocyst formation, hemorrhage, abscess, or necrosis. Pseudocysts develop about twice as often in children with traumatic pancreatitis c o m p a r e d with non-traumatic causes [1, 3, 6]. The effect of these fluid collections is variable and may be life threatening or result in prolonged hospitalization. In the past, surgery has been the mainstay of management, however, interventional techniques have b e c o m e a viable alterative which m a y be used either to temporize in patients too ill for surgery or to effect a cure. Pancreatic pseudocysts may resolve spontaneously [5, 21, 22]; however, if signs and symptoms persist, some form of drainage is usually necessary. Jaffe and colleagues [19] have reported their experience with percutaneous drainage of seven post-traumatic pseudocysts in children. Using either CT or ultrasound guidance they utilized the transabdominal route in five and the transgastric route in two patients. However, they preferred an approach which avoids the stomach. Conversely, we think the transgastric route is optimal for drainage of lesser sac fluid collections.
Case 3
Results The four lesser sac fluid collections were successfully drained using the P T G approach. In patient 4 the abscess was localized with CT, the catheter inserted using fluoroscopy and was left in place for 3 days. In the 3 children with pancreatic pseudocysts, the catheter placement was monitored with ultrasound and fluoroscopy; drainage time was 16, 34, and 59 days, respectively. The time from injury to development of the pseudocysts ranged from 3 to 12 days. Medical therapy prior to P T G drainage was 5 days in the child with the lesser sac abscess and ranged from 17 to 28 days in the children with pseudocysts. Patient 3 had an unsuccessful surgical cystogastrostomy p e r f o r m e d prior to the percutaneous drainage. In two patients the catheters initially were too small to adequately drain the pseudocyst and were subsequently replaced with larger cathe-
G. M. Amundson et al.: Lesser sac drainage in children
In our four patients the transgastric route was advantageous since it was the most direct route for drainage and it minimized the change of cutaneous fistula formation
[181. In addition, the percutaneous approach appears to have several advantages over surgical drainage: (1) The child can be treated earlier in the course of the illness, potentially modifying its severity, (2) transgastric drainage can be performed prior to cyst wall maturation, and (3) the length and cost of hospitalization may be reduced. However, proof of this speculation requires a greater pediatric experience. As a result of our experience with the transgastric approach, we have learned that: (1) Gastric puncture is best performed with a sheathed needle or trocar system to avoid wire exchanges, (2)if a Seldinger approach is utilized, overdilating the tract by 2F makes catheter insertion easier, (3) use of the Amplatz superstiff wire eases drain insertion, and (4) the largest diameter catheter possible ( > 8.3F) should be placed to avoid future catheter exchanges. In our series, minor complications occurred at the time of catheter reinsertion due to difficulties passing it over the guide wire through the posterior gastric wall. We believe that the PTG approach should be considered when there is a lesser sac fluid collection which requires drainage. It has potential advantages over the cutaneous, transhepatic, transplenic, and transenteric routes in many instances and may minimize the potential for formation of a cutaneous fistula and reduce the chance of bleeding and sepsis. However, further experience is necessary to support this premise. Nevertheless, the PTG approach can be performed successfully for drainage of pseudocysts in the pediatric population and should be an alternative to surgical decompression.
Acknowledgements. The authors would like to thank J.Hutchings and K. Mukavetz for their secretarial assistance.
References 1. Ziegler DW, Long JA, Philippart AI, Klein MD (1988) Pancreatitis in childhood. Experience with 49 patients. Ann Surg 207: 257 2. Tam PKH, Saing H, Irving IM, Lister J (1985) Acute pancreatitis in children. J Pediatr Surg 20:58 3. Coleman BG, Arger PH, Rosenberg HK, Mulhern CB, Ortega W, Stauffer D (1983) Gray-scale sonographic assessment ofpancreatitis in children. Radiology 146:145 4. Fleischer AC, Parker R Kirchner SG, James AE Jr (1983) Sonographic findings of pancreatitis in children. Radiology 146:151
593 5. Slovis TL, VonBerg V J, Mikelic V (1980) Sonography in the diagnosis and management of pancreatic pseudocysts and effusions in childhood. Radiology 135:153 6. Synn AY, Mulvihill SJ, Fonkalsrud EW (1987) Surgical management of pancreatitis in childhood. J Pediatr Surg 22:628 7. Bradley EL III, Clements LJ Jr, Gonzalez AC (1979) The natural history of pancreatic pseudocysts: a unified concept of management. Am J Surg 137:135 8. Shatney CH, Lillehei RC (1981) The timing of surgical treatment of pancreatic pseudocysts. Surg Gynecol Obstet 152:809 9. Karlson KB, Martin EC, Fankuchen EI, Mattern RF, Schultz RW, Casarella WJ (1982) Percutaneous drainage of pancreatic pseudocysts and abscesses. Radiology 142:619 10. Gerzof SG, Johnson WC, Robbins AH, Spechler SJ, Nasbeth DC (1984) Percutaneous drainage of infected pancreatic pseudocysts. Arch Surg 119:888 11. Torres WE, Evert MB, Baumgartner BR, Bernardino ME (1986) Percutaneous aspiration and drainage of pancreatic pseudocysts. AJR 147:1007 12. Mueller PR, Ferrucci JT, Simeone JF, Butch RJ, Wittenberg J, White M, Brown AS (1985) Lesser sac abscesses and fluid collections: drainage by transhepatic approach. Radiology 155:615 13. van Sonnenberg E, Wittich GR, Casola G, Brannigan TC, Karnel F, Stabile BE, Varney RR, Christensen RR (1989) Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience in 101 cases. Radiology 170:757 14. Bernardino ME, Amerson JR (1984) Percutaneous gastrocystostomy: a new approach to pancreatic pseudocyst drainage. AJR 143:1096 15. Ho CS, Taylor B (1984) Percutaneous transgastric drainage for pancreatic pseudocyst. A JR 143:623 16. Kuligowska E, Olsen WL (1985) Pancreatic pseudocysts drained through a percutaneous transgastric approach. Radiology 154:79 17. Nunez D Jr, Yrizarry JM, Russell E, Sadighi A, Casillas J, Leuera JJ Jr, Hutson DG (1985) Transgastric drainage of pancreatic fhiid collections. AJR 145:815 18. Matzinger FRK, Ho C-S, Yee AC, Gray RR (1988) Pancreatic pseudocysts drained through a percutaneous transgastric approach: further experience. Radiology 167:431 19. Jaffe RB, Arata JA Jr, Matlak ME (1989) Percutaneous drainage of traumatic pancreatic pseudocysts in children. A JR 152:591 20. Towbin RB, B all WS Jr (1988) Pediatric interventional radiology. In: Oh KS, Bender TM (eds) Radiologic Clinics of North America. WB Saunders, Philadelphia, p 419 21. Bradley EL III, Clements LJ (1975) Spontaneous resolution of pancreatic pseudocysts: implications for timing of operative intervention. Am J Surg 129:23 22. Sarti DA (1977) Rapid development and spontaneous regression of pancreatic pseudocysts documented by ultrasound. Radiology 125:789
G. M. Amtmdson, M. D. Department of Radiology Children's Hospital of Michigan 3901 Beaubien Boulevard Detroit, Michigan 48201 USA
Pediatric Radiology 9
1990
Percutaneous transgastric drainage of the lesser sac in children G. M. A m u n d s o n 1,*, R. B. T o w b i n 3,*, D. L. M u e l l e r 1 a n d C. G. E S e a g r a m 2 1 Department for Diagnostic Imaging, and 2 Division of Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada, and 3 Department of Radiology, Children's Hospital Medical Center, Cincinnati, Ohio, USA Received: 25 January 1990; accepted: 10 April 1990
Abstract. In four children (5-14 years old), lesser sac fluid collections (3 pseudocysts and i abscess) were externally drained using a p e r c u t a n e o u s transgastric approach. With ultrasound or C T guidance and fluoroscopic monitoring, a s h e a t h e d needle is inserted t h r o u g h the s t o m a c h into the lesser sac fluid collection, the catheter is exchanged, secured in place and c o n n e c t e d to external drainage. All four fluid collections were complications of pancreatitis (3 acute post-traumatic, 1 post-surgical). All four fluid collections were successfully drained without n e e d for surgical intervention. T h e r e were no m a j o r complications. T h r e e m i n o r complications o c c u r r e d as a result of reinsertion of catheters; transient gastric venous bleeding, hematuria, and bleeding into the pseudocyst. P e r c u t a n e o u s transgastric drainage can be p e r f o r m e d successfully in children, and provides an alternative to surgical intervention of lesser sac fluid collections. D r a i n a g e early in the course of pancreatic pseudocysts m a y lessen the m o r bidity, potential mortality, and p r o l o n g e d hospitalization usually necessary for standard medical and surgical mana g e m e n t of these patients.
A c u t e pancreatitis in children is most c o m m o n l y due to blunt a b d o m i n a l t r a u m a f r o m an accident or abuse. O t h e r causes include drugs, infection, congenital biliary a n o m alies, and familial or idiopathic disease [1-5]. Lesser sac fluid collections (pseudocyst, abscess, h e m o r r h a g e ) are frequent complications of pancreatitis and m a y occur in up to 35% of children [3]. These fluid collections m a y be life threatening or cause morbidity and p r o l o n g e d hospitalization. Pancreatic abscesses have required p r o m p t surgical drainage since there is an extremely high mortality without treatment; pancreatic pseudocysts often require surgical d e c o m p r e s s i o n into the s t o m a c h (cystogastrostomy) or j e j u n u m (cystojejunostomy) after m a t u r a t i o n of the cyst wall (4-7 weeks) [6-8]. In view of the recent reports of successful percutaneous drainage of lesser sac fluid collections by various
routes [9-19], p e r c u t a n e o u s transgastric drainage ( P T G ) was p e r f o r m e d in four children as an alternative to surgery. T h e p u r p o s e of this report is to d o c u m e n t the success of this technique in three children with post-traumatic pancreatic pseudocysts and o n e child with a lesser sac abscess.
Methods Over a 15 month period, 3 boys and 1 girl, ranging in age from 5 to 14 years, underwent percutaneous drainage of lesser sac fluid collections at two different children's hospitals. Although several approaches can be used [12-13], we elected the transgastric route for drainage of the lesser sac [14-19]. Indications for PTG drainage in the 3 children with pancreatic pseudocysts were: increase in size of the pseudocyst, persistently elevated serum amylase and lipase, and prolonged fever, abdominal pain, and malaise. In the patient with a pancreatic abscess, drainage was performed because of persistent fever and leukocystosis.
Technique I
All four patients received intravenous antibiotics for at least 24 h prior to the procedure. After defining the location and extent of the lesser sac fluid collection by sonography or computed tomography (CT), the inferolateral margin of the left lobe of the liver is marked on the skin. The transverse colon may be outlined with oral contrast given 4 to 6 h prior to drainage or via a contrast enema. Either general anesthesia or sedation with intravenous pentobarbital sodium (Nembutal, Abbott Laboratories, North Chicago, IL) and fentanyl citrate (Sublimaze, Janssen Pharmaceutica, Inc, Piscataway, NJ) may be used [20]. A nasogastric tube is placed, and under fluoroscopic guidance, the stomach distended with air. Intravenous glucagon (0.25-0.5 mg) may be given to impede gastric emptying. The entrance site is chosen on the anterior abdominal wall over the body of the stomach, inferior to the costal margin and lateral to the rectus abdominus muscles. Following injection of local anesthesia, a skin incision is made with a # 11 scalpel blade and an 18F sheathed needle is inserted into the distended stomach, avoiding the left lobe of the liver and transverse colon. Under sonographic or fluoroscopic guidance, the sheathed needle is then pushed through the posterior wall of the stomach into the lesser sac fluid collection. Fluid is with-
* Currentaddress:DepartmentofRadiology, Children'sHospitalof
Michigan, 3901 Beaubien Boulevard, Detroit, Michigan 48201, USA
i Modified from Nunez et al.
G. M. Amundson et al.: Lesser sac drainage in children
591
Fig. l a, h. Case 1. Pancreatic pseudocyst, a Transverse sonogram: lesser sac pseudocyst (P) with wedged defect in body of pancreas (white arrow) associated with dilatation of the distal pancreatic duct (black arrow). b Right lateral decubitus view of abdomen: contrast outlines dependent portion of large pseudocyst with PTG drainage tube placed within it Fig.2a, b. Case 2. Pancreatic pseudocyst, a Transverse sonogram: the pancreas is enlarged and inhomogeneous with a tear in the body (arrow). P = developing pseudocyst, small arrowheads = head of pancreas, and large arrowhead = splenic vein. b Transverse sonogram one month later. A large lesser sac pseudocyst with early septation
(arrows) Fig. 3a, b. Case 4. Lesser sac abscess, a CT demonstrates hypodense lesser sac abscess with an irregular, slightly thickened wall (arrows). Note that it is completely surrounded by other organs and lies adjacent to the posterior wall of the stomach (S). b CT following catheter placement and drainage. Catheter traverses opacified stomach into abscess bed drawn for gram stain, culture, and enzyme analysis. The sheath is exchanged for a stiff guidewire (0.036 or 0.038 inch Amplatz superstiff guidewire or heavy duty guide wire), the tract is dilated, and a drainage catheter inserted. If a trocar technique is used, the trocar is removed and the catheter positioned in the fluid collection. The position of the catheter may be confirmed by contrast injection. The catheter is then secured to the abdominal wall and connected to gravity or mild negative pressure (Hemovac) drainage.
Case reports Case I J.S., a 5-year-old girl admitted three days following a handle-bar injury to her epigastrium. Initial abdominal sonography revealed pancreatitis with an associated splenic contusion and flee intraperitoneal fluid. Three days later sonography demonstrated a wedged defect in the body of the pancreas with a developing pseudocyst (Fig. 1 a). Over the next two weeks there was progressive enlargement of the pseudocyst associated with persistently elevated pancreatic enzymes and continued patient morbidity. Fourteen clays following the formation of the pseudocyst, a # 6.0 French pigtail catheter was inserted into the pseudocyst using a PTG approach (Fig. lb). Most of the fluid was removed at the time of catheter insertion, but
over the next week the pseudocyst continued to enlarge with frequent catheter blockages and intermittent drainage. One week later a # 8.3 French pigtail catheter was inserted and the # 6.0 French catheter removed. Over the next three weeks the patient had multiple exacerbations of pancreatitis. Although drainage was adequate at times; there was a gradual increase in the size of the pseudocyst. Thirty-four days following the initial catheter placement, the drainage tube was removed with thought toward operative cystogastrostomy. However, there was prompt drainage of the pseudocyst fluid into the stomach. The serum amylase and lipase rapidly returned to normal; with institution of normal feeding, there was no evidence of recurrent pancreatitis or pseudocyst formation. Follow-up sonography one month later demonstrated persistent dilatation of the distal pancreatic duct but no recurrence of the pseudocyst. She has been clinically well without recurrence for more than 2 years.
Case 2 J. T., a 9-year-old boy admitted one day following a handle-bar injury to his epigastrium. Abdominal sonography performed two days later demonstrated pancreatitis, a laceration of the body of the pancreas, a developing pseudocyst, and free intraperitoneal fluid (Fig.2a). Despite medical management, over the next four weeks the pseudocyst progressively increased in size, with persistent elevation of
592 serum amylase and lipase (Fig.2b). Twenty-seven days following formation of the pseudocyst, a # 8.3 French pigtail catheter was placed using a PTG approach. All the fluid was immediately drained. The catheter was left in place for 16 days, then removed after the pancreatic enzyme values returned to normal and oral feeding was successfully instituted. Follow-up examination has shown no recurrence and the patient is clinically well 2 years later.
G. M. Amundson et al.: Lesser sac drainage in children
K. B., a 10-year-old boy admitted three weeks following a handle-bar injury to his epigastrium. A surgical cystogastrostomy had been performed at another hospital two weeks following the injury. However, upon institution of oral feeding, the pancreatitis and pseudocyst recurred, and the patient was transferred because of increasing abdominal pain, fever, and an enlarging palpable abdominal mass. Abdominal sonography confirmed the pancreatitis, ascites, and pseudocyst in the lesser sac. Over the next three days the pseudocyst increased in size with the patient spiking fevers. An # 8.3 French catheter was inserted into the fluid collection using the PTG approach. Most of the fluid was immediately drained, but the pseudocyst did not completely resolve with continuing drainage of 40-60 cc of fluid per day. Two weeks later the catheter was replaced with a # 10 French pigtail catheter which was transgastrically inserted into the pseudocyst using a trocar technique. All the fluid was immediately evacuated without reaccumulation. The patient showed immediate clinical improvement with a gradual return of pancreatic enzymes to normal levels over the next six weeks. Following a trial of oral feeding without reaccumulation of the pseudocyst sonographically, or clinical symptomatology, the catheter was removed. The patient is clinically well without recurrence 2 years later.
ters. In patient 1, the 6F catheter was replaced with an 8.3F catheter; in patient 3, the 8.3F catheter was replaced with a 10F pigtail catheter before adequate drainage could be accomplished. Tube dislodgement did not occur in any child. Contrast was injected into the lesser sac collections in patients 1 and 4, but not in patients 2 and 3. The initial P T G drainages were p e r f o r m e d using intravenous sedation; however, in the two patients requiring catheter exchanges, general anesthesia was employed. T h e r e were no major complications and all patients were cured without surgical intervention. Three minor complications occurred: in patient 1, upon insertion of the second (8.3F) catheter, there was transient bleeding into the stomach which did not require treatment. Following the procedure, there was transient gross hematuria, presumably due to renal t r a u m a incurred during guide wire manipulation and catheter placement in this large pseudocyst (Fig. 1 b). Patient 3 had minor bleeding into the pseudocyst during placement of the 10F catheter, which cleared without further therapy. In the 3 patients with pseudocysts, the drains were left in place until: (1) the pancreatic enzyme elevation had returned to normal, (2) there was no recurrence of the fluid collection or sonographic evidence of pancreatitis, (3) there was no further drainage, and (4) a trial of oral feeding was successful with no reaccumulation of fluid or elevation of pancreatic enzymes. No patient was discharged with a drain in place.
Case 4
Discussion
R.W., a 14-year-old male with longstanding chronic renal failure treated with hemodialysis, presented with persistent fever and abdominal pain. Four years previously he had developed a pancreaticocutaneous fistula, complicating a left nephrectomy with concurrent pancreatitis. CT demonstrated a fluid collection of the lesser sac (Fig. 3a). The fluid collection was completely surrounded by other organs, but was adjacent to the posterior wall of the stomach. An # 8.3 French pigtail catheter was placed through the stomach and 8 cc's of purulent fluid withdrawn (Fig. 3 b). The patient improved rapidly and the catheter was removed three days later due to lack of drainage.
Pancreatitis in u n c o m m o n in childhood, however, when present it may be associated with significant morbidity and/or mortality. In most reported pediatric series, the etiology of pancreatitis is related to trauma, which may be accidental or a result of child abuse, or due to congenital or acquired biliary tract disease. Conditions such as sickle cell anemia, steroid therapy, systemic disease such as mumps, and congenital biliary anomalies are the most frequently precipitating causes [1-6]. Pancreatitis may result in numerous complications such as pseudocyst formation, hemorrhage, abscess, or necrosis. Pseudocysts develop about twice as often in children with traumatic pancreatitis c o m p a r e d with non-traumatic causes [1, 3, 6]. The effect of these fluid collections is variable and may be life threatening or result in prolonged hospitalization. In the past, surgery has been the mainstay of management, however, interventional techniques have b e c o m e a viable alterative which m a y be used either to temporize in patients too ill for surgery or to effect a cure. Pancreatic pseudocysts may resolve spontaneously [5, 21, 22]; however, if signs and symptoms persist, some form of drainage is usually necessary. Jaffe and colleagues [19] have reported their experience with percutaneous drainage of seven post-traumatic pseudocysts in children. Using either CT or ultrasound guidance they utilized the transabdominal route in five and the transgastric route in two patients. However, they preferred an approach which avoids the stomach. Conversely, we think the transgastric route is optimal for drainage of lesser sac fluid collections.
Case 3
Results The four lesser sac fluid collections were successfully drained using the P T G approach. In patient 4 the abscess was localized with CT, the catheter inserted using fluoroscopy and was left in place for 3 days. In the 3 children with pancreatic pseudocysts, the catheter placement was monitored with ultrasound and fluoroscopy; drainage time was 16, 34, and 59 days, respectively. The time from injury to development of the pseudocysts ranged from 3 to 12 days. Medical therapy prior to P T G drainage was 5 days in the child with the lesser sac abscess and ranged from 17 to 28 days in the children with pseudocysts. Patient 3 had an unsuccessful surgical cystogastrostomy p e r f o r m e d prior to the percutaneous drainage. In two patients the catheters initially were too small to adequately drain the pseudocyst and were subsequently replaced with larger cathe-
G. M. Amundson et al.: Lesser sac drainage in children
In our four patients the transgastric route was advantageous since it was the most direct route for drainage and it minimized the change of cutaneous fistula formation
[181. In addition, the percutaneous approach appears to have several advantages over surgical drainage: (1) The child can be treated earlier in the course of the illness, potentially modifying its severity, (2) transgastric drainage can be performed prior to cyst wall maturation, and (3) the length and cost of hospitalization may be reduced. However, proof of this speculation requires a greater pediatric experience. As a result of our experience with the transgastric approach, we have learned that: (1) Gastric puncture is best performed with a sheathed needle or trocar system to avoid wire exchanges, (2)if a Seldinger approach is utilized, overdilating the tract by 2F makes catheter insertion easier, (3) use of the Amplatz superstiff wire eases drain insertion, and (4) the largest diameter catheter possible ( > 8.3F) should be placed to avoid future catheter exchanges. In our series, minor complications occurred at the time of catheter reinsertion due to difficulties passing it over the guide wire through the posterior gastric wall. We believe that the PTG approach should be considered when there is a lesser sac fluid collection which requires drainage. It has potential advantages over the cutaneous, transhepatic, transplenic, and transenteric routes in many instances and may minimize the potential for formation of a cutaneous fistula and reduce the chance of bleeding and sepsis. However, further experience is necessary to support this premise. Nevertheless, the PTG approach can be performed successfully for drainage of pseudocysts in the pediatric population and should be an alternative to surgical decompression.
Acknowledgements. The authors would like to thank J.Hutchings and K. Mukavetz for their secretarial assistance.
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G. M. Amtmdson, M. D. Department of Radiology Children's Hospital of Michigan 3901 Beaubien Boulevard Detroit, Michigan 48201 USA
