TGF-UC180J Forward-viewing EUS scope
Forward-viewing ultrasound gastrovideoscope pioneers new opportunities in EUS-guided treatment
Title: Pseudocyst Drainage in a Paediatric Patient
Author: Dr Johannes Wittmann
Hospital: Mater Hospital Brisbane
Presentation and Background
A 5-year-old female child was injured during an accident at a farm in central Queensland resulting in a crush injury to the abdomen and left torso. Significant organ trauma resulted requiring surgery and she developed pancreatitis and a large pseudocyst around the tail and body of pancreas and compressing the stomach. To provide nutritional support, nasoenteric feeding was used for five months but the pseudocyst continued to remain large restricting oral intake.
The child expressed the wish to be able to resume normal oral intake but had been coping well with the nasoenteral tube. Surgical opinion recommended internal drainage by EUS due to the extensive trauma and adhesions from the original injury. The patient was referred to Brisbane four months after the original accident.
The child was of a normal size for a five year old and the oesophagus was not deemed likely to allow a therapeutic linear echoendoscope to pass due to the long, non-bending ultrasound transducer tip and blind insertion with the side viewing optics. The forward viewing therapeutic linear echoendoscope from Olympus (TGF-UC180J-FV) was able to be passed into the oesophagus due to the much shorter tip with better angulation control and forward viewing optics allowing improved manoeuvrability in the hypopharynx, particularly important in such a young patient.
Despite the better intubation and handling of the scope and forward viewing optics, the instrument was only just able to be passed through the normal-for–age small calibre oesophagus with resistance.
Drainage of the pancreatic pseudocyst located in the lesser sac (and well seen on the forward viewing linear EUS imaging) was undertaken using a 10Fr cystotome to puncture the cyst cavity. The diathermy effect was easily seen on EUS imaging and confirmed deep cyst entry.
Once the needle knife was exchanged for a 0.035” stiff biliary wireguide, the gastrostomy tract was further enlarged by using the cystotome 10Fr cone shaped conductor. The cystotome was then exchanged for a fully covered 10mm diameter Nagi through the scope lumen apposing metal stent (LAMS). All of these manoeuvers were able to be monitored on ultrasound and visual control with the Forward viewing EUS tip giving enough distance to avoid blocking the optics even while EUS imaging control was maintained. This was in contrast to the normal side viewing linear EUS scope optics that requires de-angulation of the scope transducer tip away from the imaged pseudocyst to establish endoscopic image control. Being able to see the striped biliary wireguide and accessory passage endoscopically made the accessory exchanges easier and faster and reduced need for image intensifier time.
The Nagi stent was able to be inserted and deployed confidently under EUS imaging control and simultaneous visual control alone using the forward viewing scope. A good technical result was achieved and pseudocyst drained rapidly. Over the following days, the patient recovered fully and was able to tolerate oral intake again. The only side effect from the procedure was self-limiting central chest pain and some odynophagia resulting from oesophageal discomfort on the second day following the procedure. The LAMS was removed endoscopically after 4 weeks using a standard gastroscope and grasping forceps.
Images and case study provided by Dr Johannes Wittmann