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pic ulσasound Guided Drainage ofPerihepatic Fluid Collection after Laparoscopic Pylorus Preserving Pancreaticoduodenectomy.Eun Kwang Choi
Department이InlernalMedicine，Je띠NalionalUniversilySCh
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1of Medicine(ReceivedJanuBJy 25，2014; Revised .February 3. 2014; Accepted Febru81γ 8. 2014)
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Ab잉ract27 year old woman visiled ER due 10 severe epigastric pain who underwent laparoscopic pylorus preserving pancreaticoduodenectomy due to solid pseudopapillary tumor 3 years a90. CT scan showed loculated fluid collection in the perihepatic spaC8. The fluid collection W8Spunctured using a curvilinear echoendoscope followed by the placement 이two 7-Fr double pigtail plastic slents across the liver. There were na early or delayed complicalions and the procedure was effective in relie씨ng pain. Follow-up CT scan after 8 weeks showed completely resolved f1uidcolleclion. EUS guided drainage can be a
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easible way to resolve the symptom in patient with fluid col1ection after pancreatic resection. (J Med니’
e Sci 2014: 10(3)‘225-228)
Key Words : Endoscopic ulσasound (EUS) Guided Drainage，Postoperative F1uid Collection
Introduction
27 year old unmanied wom없1 visited emergency room
(ER) due to severe epigastric pain for 5 days. She underwent LPPPD due to s이id pseudopapillary tumor 3
CorresPOndence10: Eun KwangChoi IJeI며이me미of InternalM
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ne.JejuNa1io때I UnwersltySchool이M때icine，
15 Atan13"iji(Jeju승i，Je，ν-do. 690-767.RepUbl~이Korea
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k~에ej니nu.ac.krPostoperative f1uid collection remains a major cause of postoperative morbidity after pancreatic resectionll. T
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raditionally. peripancreatic nuid collections have been managed by percu벼neous or surgical drainage. Endoscopicultrasound (EUS) guided drainage has become a prornising therapy for panα-eatic pseudocysts. EUS has a1so been used successfully in drainage of peripancreatic fluid c이lections after pancreatic surgery .in sma11er numbers2l. To date. the rep
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dealing with EUS !!lιided dr.잉nage of postoperative f1uidcoUections is ωm잉dWe report a EUS guided drainage of perihepatic fluid collection after laparoscopic pylorus preserving pancreaticoduodenectomy (LPPPD). EUS gui야d ψainage c없
be an altemative way to resolve the 양mptom in patient
wiili :f1uidcollection after pancreatic resecti.on
years ago. She felt abdominal pain intennitten1Jy from 2 months ago. CT scan at that time demonstrated dilated main pancreatic duct due to pancreatico-j밍unosωmy (PJ)
site stricωre". EUS guided pancre뼈co-gastroswmy was
attempted at oU1er hospital but it WBS not successful due
to hard pancreatic tissue interrupting passage of dilating eatheter. She was recommended to perfonn operation for pJ site revision. but she dec1ined further operation because
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f the fear for the scar after laparotomy. She felt comfortable for two months after that time even though EUS guided pancreatico-gastrostomy was failedInitial vital sign at ER was stable except mild fever lnilial laboratory test showed leukocytosis (20，3001마)，
nonnal liver function test，and high lipase (336 ψL). CT scan showed loc띠ated fiuid collection in the perihepatic space pressing down tbe liver (Fig. 1). The f1uid colIection was visualized using a curvilinear echoendoscope (GF-UCT240-AL5; Olympus Medical Systems Co.，Tokyo，
Japan) 깨e fiuid collection was punctured with a 19 gauge Echotip~ 비tra need1e (Wilson-Cook Medical Inc..
Wmston-Salem. NC. USA) through the gastric wall after using Doppler ω avoid any intervening vessels (Fig. 2)‘Clear fluid was aspπated. A 0.035-inch guidewire was passed into the f1uid collection. The needle was withdrawn maintaining，U1e position of the guidewire，and a. dilating catheter (Oasis* One action stent introduction system. Cook Ireland Ltd.. Limerick. Ireland) was advanced over the guidewire. A 6 mm balloon 이lation .(Boston Scientific，
Case report
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Eun KwangChoi
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Fi밍lre 4 당ldα>::opicview of two double미밍밍1pla성ic s따1뻐，
Figure 3. Fluoro!효야c view of two guidewîreswithin the fluid
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Uectionfollowedby the placement of 7-Fγ double PigæiI pIastic앉잉lt aaoss the gastric w벼l외ld liver
Figure 1. lnitial CT scan양lOWed1
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ulared fluid collectionin thepe미lOpatic칙>aæ
Cork，lreland) was peñormed. One more guidewire was placed using Haber ramp catheter (Wilson-cook Medical Limerick. lreland) followed by the placement of a 7-Fr 4 cm and a 7-암 5 cm double pi와외1 plastic srent (Cook Ireland Ltrl.. Limerick. Ireland) across tbe liver (Fig. 3. 4 and 5) πlere were no early or delayed complications and the procedure was effective in re1ieving pain. The amylase
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f the fluîd was 27‘730 U1L. Follow-up CT scan afrer 8weeks showed completely resolved fluid collection (에g. 6)
F、믿Jre 2. EUS guided puncture of the ßuid
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Illectionwith a 19 gnu양 1뼈영1e thrrn때1야，e gn의ric w에l외1er using Dopplerto avoid잉W interveningve:용e1s
-Endos
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IpicUltrasoundGuided Drainage of PerihepaticFluid ColJccti.onafterl엉P암。scopic Pylorus PreservingPancreaticoduodenccromyFigure 5. F1uoros
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PIC씨ew of two double pig어il찌astic s떠lts，Ac
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mowedgrnents 「This research was supported by the 2013 scientific promotion pro망am funded byJ밍u National University
endoscopic transluminal drainageTl. Surgical drainage has been the rmal step to drainage of f1uid collections when other less invasive radiological or endoscopic techniques have failed. There are several reports that suggest high success rates with open surgical drainage; however，there was considerable morbidity and mortalit.y&J'l.Percutaneous drainage of symptomatic f1uid collection after pancreatic surgery has been shown to be effective10l’but the presence
of an external catheter may lead to cornpromise the patienf s quality of life with a risk of drainage site ÎJÛection. extern외fistuJa formation，and fluid and electroJνte losses
’"’.
In addition ，percutaneous catheters require monito디ng of fluid output，regular flushing of the eatheter，and m.ay require catheter changes. Also. some cases have been associated with fluid collections that may require prolonged drainage. on the other hand，the advantages of EUS guided drainage include obviating the need for an extern떠drainage. minimizing the risk of panα-eatic fistulas， and preventing f1uid and eleeσ"Olytelosses7l. In야니s case，the fluid collection was located just beneath the capsule of left lobe of liver. Because of this location，it seemed to be easier to drain with percut.aneous eatheter. But she is young woman who has the fear of the scar in her abdomen after operation or percut.aneous eatheter. we chose EUS guided drainage. EUS guided drainage was initially used for pancreatic pseud。양sts secondmγ
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acute pancreatitisl잉Multiple studies have shown that endoscopic drainage had a hi앙1 success rate and can achieve long-tenn resolution of the associated cyst with minimal complications
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RecentJy EUS guided drainage has also been used successfully in treating postoperative peripancreatic nuid collections Considering safef8. feasibiJif8 and success rate，EUS guided drainage can be a good alternative method to manage the postoperative Ouid collections. Similarly. there is a case report showing effective dr밍nage of liver abscess using EUSgιided metaJ stent insertion
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In conclusion. EUS guided drainage can be a feasible way to resolve the 양mptom in patient with fluid collection따'ter pancreatic resection. Larger prospective stu이es companng this technique with other conventional drainage are needed 10 validate 1he usefulness.
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흑; / /Figure 6. FollowlJll cr scan성lOWed
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mple엄ly reoolvedfluid C이lecüon..---_._----‘ ---~.._.._---_.-_.-.----_...
Discussion
i
까le reJX)rted맹ncreatic leak rate따용r뼈ncreatiαXIU여enectorny
ranges from 5% ω 20%""，P외1α-eatic fluid collec디。n may be
asymptomatic. but can lead to severe p밍n. gasσic outlet
。
bsσuction. fistulas. infection 뻐d sepsis잉 The principaltreatment is drainage of the f1uid within U1e abdominal caVl상’Common reasons for dr밍nage include abdominal
pain. signs of infection. and gastric out1et or biliary
。
bstructionðJ. The patient felt severe abdominal pain in this case. justifying the drainage of fluid coUeetionTherapy of fluid collections from pancreatic surgery has ranged from surgical drainage，percutaneous dr밍nage，and
-Eun K、"，ang Choi
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.R~erenCε
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