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Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement
of a covered self-expandable metal stent
BMC Gastroenterology 2013, 13:93 doi:10.1186/1471-230X-13-93
Adrian S¿ftoiu (adriansaftoiu@aim.com)
Lidia Ciobanu (ciobanulidia@yahoo.com)
Andrada Seicean (andradaseicean@yahoo.com)
Marcel Tant¿u (matantau@gmail.com)
ISSN 1471-230X
Article type Case report
Submission date 23 October 2012
Acceptance date 16 May 2013
Publication date 24 May 2013
Article URL http://www.biomedcentral.com/1471-230X/13/93
Like all articles in BMC journals, this peer-reviewed article can be downloaded, printed and
distributed freely for any purposes (see copyright notice below).
Articles in BMC journals are listed in PubMed and archived at PubMed Central.
For information about publishing your research in BMC journals or any BioMed Central journal, go to
http://www.biomedcentral.com/info/authors/
BMC Gastroenterology
© 2013 S¿ftoiu et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Arterial bleeding during EUS-guided pseudocyst
drainage stopped by placement of a covered self-
expandable metal stent
Adrian Săftoiu1,2
Email: adriansaftoiu@aim.com
Lidia Ciobanu3
Email: ciobanulidia@yahoo.com
Andrada Seicean3*
*
Corresponding author
Email: andradaseicean@yahoo.com
Marcel Tantău3
Email: matantau@gmail.com
1
Research Center of Gastroenterology and Hepatology Craiova, University of
Medicine and Pharmacy Craiova, Romania, Copenhagen, Denmark
2
Gastrointestinal Unit, Faculty of Health and Medical Sciences, Copenhagen
University, Copenhagen, Denmark
3
Regional Institute of Gastroenterology and Hepatology University of Medicine
and Pharmacy Cluj-Napoca, Romania, str. Croitorilor nr 19-21, Cluj-Napoca
400192, Romania
Abstract
Background
Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the
vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not
visible on color Doppler or even power Doppler EUS.
Case presentation
We report a case of an immediate internal spurting arterial bleeding precipitated during EUS-
guided pseudocyst drainage which stopped instantaneously by placement of a double flanged
covered self-expandable metal stent through mechanical hemostasis.
Conclusion
In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during
pseudocyst drainage, the placement of an expandable metal stent proved to be useful.
Keywords
Endoscopic ultrasound, Pancreatic pseudocyst, Upper gastrointestinal bleeding, Portal
hypertension
Background
Endoscopic ultrasound (EUS)-guided pseudocyst drainage is nowadays a routine procedure
performed in tertiary centers, with minimal morbidity and mortality. Initial procedures based
on one-step EUS-guidance were developed almost 15 years ago and they still represent the
standard of care in most advanced GI units [1,2]. During the years, EUS-guided procedures
for gastric or duodenal transmural drainage of pancreatic pseudocysts benefitted from a
certain number of technical improvements, although the technique still has a long learning
curve [3,4]. Despite the increased safety of transmural puncture based on the avoidance of
major vessels with increased use of EUS Doppler techniques, there are still immediate
complications consisting mainly of perforations and bleeding in about 1-2% of cases [5,6].
Nevertheless, if there is a careful selection of the patients, the EUS-guided drainage
procedure is considered safer as compared with surgical cyst-gastrostomy [7]. The case report
describes an immediate spurting arterial bleeding precipitated during EUS-guided pseudocyst
drainage which stopped instantaneously by placement of a double flanged covered self-
expandable metal stent.
Case presentation
We present the case of a 41 years old male with a long standing history of ethanol
consumption. His past medical history was significant for pancreatic disorders: he had two
episodes of acute pancreatitis induced by ethanol consumption. Four weeks before the
drainage procedure, he presented in the emergency department presenting with intense upper
abdominal pain, nausea and vomiting, induced again by heavy ethanol consumption.
Biological markers revealed elevated levels of blood and urine amylases (466 IU/L and 2397
IU/L) and leucocytosis. An emergency transabdominal ultrasound identified a large
pseudocyst located near the pancreatic tail, confirmed by the contrast-enhanced CT scan. No
other fluid collection or necrotic areas were revealed. Nevertheles, the CT scan indicated the
presence of the splenic vein thrombosis and the collaterals near the pancreatics tail region, as
well as in the gastric wall.
As the initial therapeutic option, we took into account the possibility of a transcutaneous
ultrasound-guided approach or an endoscopic approach by placing a stent using EUS-
guidance from the stomach. As an important collateral circulation developed as a
consequence of splenic vein thrombosis, after the inform consent was signed, our choice was
endoscopic stenting using an EUS-guided procedure with avoidance of major vessels through
the use of Doppler techniques. We used a therapeutic EUS scope with a large 3.8 mm channel
(Olympus GIF-UCT 140, Olympus, Tokyo, Japan) coupled with the corresponding
ultrasound system (Aloka Alpha10, Aloka, Tokyo, Japan). The pseudocyst was visualised
from the smaller gastric curvature and an area thought to be devoid of major vessels was
carefully selected by the use of color and power Doppler. Under EUS-guidance the
pseudocyst was punctured using the special device with a trocar and cutting blade (Navix,
Xlumena, Mountain View, California, USA). During the passage of the cutting blade through
the gastric wall a significant spurting (pulsatile) arterial bleeding started from the puncture
level inside the pseudocyst, being easily visible on the gray-scale mode (Figure 1, Additional
file 1: Movie S1), with minimal intragastric bleeding. A 0.035″ hydrophilic guidewire (Cook,
Limerick, Ireland) was placed through the 19 G trocar and coiled deeply inside the
pseudocyst. The procedure has been continued with both EUS-guidance, but also intermittent
radiological check-ups of the guidewire position inside the pseudocyst.
Figure 1 Significant spurting (pulsatile) arterial bleeding originating from the puncture
level inside the pseudocyst.
A special double flanged covered expandable stent of 10 mm in the saddle length (between
the two flanges) and 10 mm in diameter when expanded (Axios, Xlumena, Mountain View,
California, USA) was then uploaded on the guidwire. The stent is collapsed into a 10.8 Fr
delivery catheter system which adapts into the therapeutic channel of an EUS scope and then
expands separately for the distal and proximal flanges, without the ability of being collapsed
into the delivery catheter. The stent was then deployed from the distal part under EUS and
radiological guidance (Figure 2A-B), followed by deployment of the proximal part under
direct endoscopic guidance, using special manufacturers instructions and the steps provided
on the delivery system handle. As a consequence of stent deployment and pressure elicited on
the gastric and pseudocyst wall at the level of the fistula created during the EUS procedure,
the bleeding stopped instantaneously. The patient was then treated with a proton pump
inhibitor and large spectrum antibiotics (cefuroxime and metronidazol) for five days, with
fever of up to 38.3 degrees C, which decreased to normal after 24 hours.
Figure 2 Deployment of the stent under EUS and endoscopic guidance. A. Deployment of
the distal part of the stent under combined EUS and radiological guidance. B. Deployment of
the proximal part of the stent under direct endoscopic guidance.
After 4 weeks with ethanol abstinence, the patient returned for another episode of pain in the
upper abdomen and fever, associated with leucocytosis, but normal amylasemia. Although,
there were no collections visualised on ultrasound or contrast-enhanced CT scan, a decision
to remove the stent endoscopically was taken. The stent was easily snare and taken out, with
minimal bleding of the gastric wall which stopped after adrenaline injections (1 : 10 000) and
argon plasma coagulation. The pain immediately and the patient was discharged. There were
no episodes of bleeding or recurrent acute pancreatitis during a 6 months follow-up, and the
pseudocyst did not recurred.
Discussions
Bleeding during drainage of pancreatic pseudocysts is a severecomplication as it might occur
immediately [8] or delayed [9], leading to increased morbidity and even mortality. These are
due to prolongation of the period and an increased transfusion rate, as well as because of the
necessity of emergency surgical intervention. Moreover, the subgroup of patients with
complications after the drainage of pancreatic pseudocysts are the most prone to an increased
mortality. Hence, transcutaneous or endoscopic drainage of pancreatic pseudocysts were
replaced by EUS-guided drainage procedures which decrease significantly the risk of
bleeding [10]. Nevertheless, even with the use of real-time guidance during EUS, there are
still hemorrhagic complications in less than 1-2% of cases, because the vessels on the internal
wall of the pseudocyst might be compressed by the fluid and thus not visible on color
Doppler or even power Doppler EUS. In our case, the sudden spurting arterial bleeding was
most probably casused by the blade which extends in the tip of the 19G trocar, probably by
damaging concealed vessels at the internal wall of the pseudocyst, which were not visible
initially, but were probably decompressed during EUS-guided drainage, through initial
aspiration of the fluid, but also during exchange of the EUS accesories which probably lead
to leakage of the pseudocyst fluid.
Although single or multiple plastic stents, as well as nasocystic drainage catheters are used
for EUS-guided pseudocyst drainage, expandable stents were also considered as viable
alternatives as they keep open the tract created between the stomach and pseudoscyst cavity.
This is beneficial especially for the cases with large, infected pseudocysts or pancreatic
abscesses. Several articles already described the use of covered expandable metal stents for
the drainage of pancreatic pseudocysts, having the advantage of a large diameter with a
possible decrease in the reccurence rate [11]. There are however disadvantages which includ
stent migration and difficulty of insertion for large stents [12]. Even surgical approaches were
described, with the use of staplers applied transorally by minimal invasive NOTES
procedures, after an initial EUS-guided approach [13]. For our patient we chose a novel
metalic stent with double flanges, which have the intended advantage of preventing
migration, but also induce apposition of the pseudocyst wall and gastric/duodenal wall,
through the covered part, thus preventing leakage and decreasing the perforation risk [14,15].
However, due to the large diameter (10.8 Fr) of the delivery system, the insertion through the
gastric and pseudocyst wall might be difficult if a previous dilation of the initial tract is not
performed using baloon dilators and/or cautery devices (needle knife sphincterotome, hot
needle wires or cystotomes). Even under real-time EUS-guidance with use of color Doppler
techniques, the initial dilation of the tract before stent insertion can possibly cause significant
bleding at the level of the digestive tract wall or pancreatic pseudocyst wall collaterals which
might be compressed by the fluid inside the pseudocyst. Nevertheless, the advantage of a
covered expandable stent is exactly the possibility of stopping the bleeding through
mechanical hemostasis and this has been clearly demonstrated in our case report.
The use of metallic stents in order to control severe bleedings in the GI tract has been already
described in several articles. Thus, a review of preliminary reports suggested that self-
expandable covered metal stents might be considered useful and very effective to control
refractory acute variceal bleeding, being an alternative to the temporary control obtained by
Sengstaken-Blakemore baloon [16]. The stents used have a modified design (with atraumatic
edges and retrieval loops with gold markers at both stent ends) which allows them to be
extracted with a special system after a few days [17]. Covered self-expandable metallic
stenting was also described to be useful in post-sphincterotomy bleeding [18,19] or other GI
malignant tumors diffuse bleeding [20] or in case of the conventional endoscopic fluid
collection drainage [21], which does not stop after usual endoscopic treatment (injection,
coagulation, clipping, etc.). Our case presentation proved that the same approach is useful in
pseudocyst bleeding that occurs during EUS-guided drainage.
Conclusions
This case report shows a rare case of bleeding during the EUS drainage procedure of
pancreatic pseudocyst at the level of the pseudocyst wall. The double flanged covered self-
expandable metal stent proved its utility in such unusual cases with high risk for bleeding due
to colateral circulation.
Written informed consent was obtained from the patient for publication of this Case report
and any accompanying images. A copy of the written consent is available for review by the
Editor of this journal.
Abbreviations
EUS, Endoscopic ultrasound; CT scan, Computed tomography
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ASaftoiu did the EUS-guided pseudocyst drainage, LC, ASeicean and MT selected the
patient for the drainage and followed him up. All authors have been involved in drafting the
manuscript or revising it and have given final approval of the version to be published.
Acknowledgement
We are indebted to the medical staff which took part actively in the live demo, and especially
to Mr. Tom de Simio, Xlumena, Mountain View, California, USA. Devices used in the
procedure were kindly provided by Xlumena, both the Navix device and the Axios double
flanged stent.
References
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6. Ahn JY, Seo DW, Eum J, Song TJ, Moon SH, Park do H, Lee SS, Lee SK, Kim MH:
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versus surgical cyst-gastrostomy for management of pancreatic pseudocysts.
Gastrointest Endosc 2008, 68:649–655.
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ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts:
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9. Itoi T, Itokawa F, Sofuni A, Umeda J, Tsuchiya T: Late bleeding after EUS-guided
transjejunal drainage of a pancreatic pseudocyst in a Roux-en-Y patient. Dig Endosc
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10. Varadarajulu S, Christein JD, Wilcox CM: Frequency of complications during EUS-
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11. Belle S, Collet P, Post S, Kaehler G: Temporary cystogastrostomy with self-expanding
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72:1274–1278.
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covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy
bleeding. Endoscopy 2011, 43:369–372.
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H, Shindo Y, Goto H: Covered expandable metallic stent placement for hemostasis of
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Additional file
Additional_file_1 as AVI
Additional file 1: Movie S1. Significant spurting (pulsatile) arterial bleeding originating
from the puncture level inside the pseudocyst.
Figure 1
Figure 2
Additional files provided with this submission:
Additional file 1: 1927875018323026_add1.avi, 3790K
http://www.biomedcentral.com/imedia/2424294810027738/supp1.avi

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Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered selfexpandable metal stent

  • 1. This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent BMC Gastroenterology 2013, 13:93 doi:10.1186/1471-230X-13-93 Adrian S¿ftoiu (adriansaftoiu@aim.com) Lidia Ciobanu (ciobanulidia@yahoo.com) Andrada Seicean (andradaseicean@yahoo.com) Marcel Tant¿u (matantau@gmail.com) ISSN 1471-230X Article type Case report Submission date 23 October 2012 Acceptance date 16 May 2013 Publication date 24 May 2013 Article URL http://www.biomedcentral.com/1471-230X/13/93 Like all articles in BMC journals, this peer-reviewed article can be downloaded, printed and distributed freely for any purposes (see copyright notice below). Articles in BMC journals are listed in PubMed and archived at PubMed Central. For information about publishing your research in BMC journals or any BioMed Central journal, go to http://www.biomedcentral.com/info/authors/ BMC Gastroenterology © 2013 S¿ftoiu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
  • 2. Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self- expandable metal stent Adrian Săftoiu1,2 Email: adriansaftoiu@aim.com Lidia Ciobanu3 Email: ciobanulidia@yahoo.com Andrada Seicean3* * Corresponding author Email: andradaseicean@yahoo.com Marcel Tantău3 Email: matantau@gmail.com 1 Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy Craiova, Romania, Copenhagen, Denmark 2 Gastrointestinal Unit, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark 3 Regional Institute of Gastroenterology and Hepatology University of Medicine and Pharmacy Cluj-Napoca, Romania, str. Croitorilor nr 19-21, Cluj-Napoca 400192, Romania Abstract Background Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS. Case presentation We report a case of an immediate internal spurting arterial bleeding precipitated during EUS- guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self-expandable metal stent through mechanical hemostasis. Conclusion In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during pseudocyst drainage, the placement of an expandable metal stent proved to be useful.
  • 3. Keywords Endoscopic ultrasound, Pancreatic pseudocyst, Upper gastrointestinal bleeding, Portal hypertension Background Endoscopic ultrasound (EUS)-guided pseudocyst drainage is nowadays a routine procedure performed in tertiary centers, with minimal morbidity and mortality. Initial procedures based on one-step EUS-guidance were developed almost 15 years ago and they still represent the standard of care in most advanced GI units [1,2]. During the years, EUS-guided procedures for gastric or duodenal transmural drainage of pancreatic pseudocysts benefitted from a certain number of technical improvements, although the technique still has a long learning curve [3,4]. Despite the increased safety of transmural puncture based on the avoidance of major vessels with increased use of EUS Doppler techniques, there are still immediate complications consisting mainly of perforations and bleeding in about 1-2% of cases [5,6]. Nevertheless, if there is a careful selection of the patients, the EUS-guided drainage procedure is considered safer as compared with surgical cyst-gastrostomy [7]. The case report describes an immediate spurting arterial bleeding precipitated during EUS-guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self- expandable metal stent. Case presentation We present the case of a 41 years old male with a long standing history of ethanol consumption. His past medical history was significant for pancreatic disorders: he had two episodes of acute pancreatitis induced by ethanol consumption. Four weeks before the drainage procedure, he presented in the emergency department presenting with intense upper abdominal pain, nausea and vomiting, induced again by heavy ethanol consumption. Biological markers revealed elevated levels of blood and urine amylases (466 IU/L and 2397 IU/L) and leucocytosis. An emergency transabdominal ultrasound identified a large pseudocyst located near the pancreatic tail, confirmed by the contrast-enhanced CT scan. No other fluid collection or necrotic areas were revealed. Nevertheles, the CT scan indicated the presence of the splenic vein thrombosis and the collaterals near the pancreatics tail region, as well as in the gastric wall. As the initial therapeutic option, we took into account the possibility of a transcutaneous ultrasound-guided approach or an endoscopic approach by placing a stent using EUS- guidance from the stomach. As an important collateral circulation developed as a consequence of splenic vein thrombosis, after the inform consent was signed, our choice was endoscopic stenting using an EUS-guided procedure with avoidance of major vessels through the use of Doppler techniques. We used a therapeutic EUS scope with a large 3.8 mm channel (Olympus GIF-UCT 140, Olympus, Tokyo, Japan) coupled with the corresponding ultrasound system (Aloka Alpha10, Aloka, Tokyo, Japan). The pseudocyst was visualised from the smaller gastric curvature and an area thought to be devoid of major vessels was carefully selected by the use of color and power Doppler. Under EUS-guidance the pseudocyst was punctured using the special device with a trocar and cutting blade (Navix, Xlumena, Mountain View, California, USA). During the passage of the cutting blade through
  • 4. the gastric wall a significant spurting (pulsatile) arterial bleeding started from the puncture level inside the pseudocyst, being easily visible on the gray-scale mode (Figure 1, Additional file 1: Movie S1), with minimal intragastric bleeding. A 0.035″ hydrophilic guidewire (Cook, Limerick, Ireland) was placed through the 19 G trocar and coiled deeply inside the pseudocyst. The procedure has been continued with both EUS-guidance, but also intermittent radiological check-ups of the guidewire position inside the pseudocyst. Figure 1 Significant spurting (pulsatile) arterial bleeding originating from the puncture level inside the pseudocyst. A special double flanged covered expandable stent of 10 mm in the saddle length (between the two flanges) and 10 mm in diameter when expanded (Axios, Xlumena, Mountain View, California, USA) was then uploaded on the guidwire. The stent is collapsed into a 10.8 Fr delivery catheter system which adapts into the therapeutic channel of an EUS scope and then expands separately for the distal and proximal flanges, without the ability of being collapsed into the delivery catheter. The stent was then deployed from the distal part under EUS and radiological guidance (Figure 2A-B), followed by deployment of the proximal part under direct endoscopic guidance, using special manufacturers instructions and the steps provided on the delivery system handle. As a consequence of stent deployment and pressure elicited on the gastric and pseudocyst wall at the level of the fistula created during the EUS procedure, the bleeding stopped instantaneously. The patient was then treated with a proton pump inhibitor and large spectrum antibiotics (cefuroxime and metronidazol) for five days, with fever of up to 38.3 degrees C, which decreased to normal after 24 hours. Figure 2 Deployment of the stent under EUS and endoscopic guidance. A. Deployment of the distal part of the stent under combined EUS and radiological guidance. B. Deployment of the proximal part of the stent under direct endoscopic guidance. After 4 weeks with ethanol abstinence, the patient returned for another episode of pain in the upper abdomen and fever, associated with leucocytosis, but normal amylasemia. Although, there were no collections visualised on ultrasound or contrast-enhanced CT scan, a decision to remove the stent endoscopically was taken. The stent was easily snare and taken out, with minimal bleding of the gastric wall which stopped after adrenaline injections (1 : 10 000) and argon plasma coagulation. The pain immediately and the patient was discharged. There were no episodes of bleeding or recurrent acute pancreatitis during a 6 months follow-up, and the pseudocyst did not recurred. Discussions Bleeding during drainage of pancreatic pseudocysts is a severecomplication as it might occur immediately [8] or delayed [9], leading to increased morbidity and even mortality. These are due to prolongation of the period and an increased transfusion rate, as well as because of the necessity of emergency surgical intervention. Moreover, the subgroup of patients with complications after the drainage of pancreatic pseudocysts are the most prone to an increased mortality. Hence, transcutaneous or endoscopic drainage of pancreatic pseudocysts were replaced by EUS-guided drainage procedures which decrease significantly the risk of bleeding [10]. Nevertheless, even with the use of real-time guidance during EUS, there are still hemorrhagic complications in less than 1-2% of cases, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS. In our case, the sudden spurting arterial bleeding was
  • 5. most probably casused by the blade which extends in the tip of the 19G trocar, probably by damaging concealed vessels at the internal wall of the pseudocyst, which were not visible initially, but were probably decompressed during EUS-guided drainage, through initial aspiration of the fluid, but also during exchange of the EUS accesories which probably lead to leakage of the pseudocyst fluid. Although single or multiple plastic stents, as well as nasocystic drainage catheters are used for EUS-guided pseudocyst drainage, expandable stents were also considered as viable alternatives as they keep open the tract created between the stomach and pseudoscyst cavity. This is beneficial especially for the cases with large, infected pseudocysts or pancreatic abscesses. Several articles already described the use of covered expandable metal stents for the drainage of pancreatic pseudocysts, having the advantage of a large diameter with a possible decrease in the reccurence rate [11]. There are however disadvantages which includ stent migration and difficulty of insertion for large stents [12]. Even surgical approaches were described, with the use of staplers applied transorally by minimal invasive NOTES procedures, after an initial EUS-guided approach [13]. For our patient we chose a novel metalic stent with double flanges, which have the intended advantage of preventing migration, but also induce apposition of the pseudocyst wall and gastric/duodenal wall, through the covered part, thus preventing leakage and decreasing the perforation risk [14,15]. However, due to the large diameter (10.8 Fr) of the delivery system, the insertion through the gastric and pseudocyst wall might be difficult if a previous dilation of the initial tract is not performed using baloon dilators and/or cautery devices (needle knife sphincterotome, hot needle wires or cystotomes). Even under real-time EUS-guidance with use of color Doppler techniques, the initial dilation of the tract before stent insertion can possibly cause significant bleding at the level of the digestive tract wall or pancreatic pseudocyst wall collaterals which might be compressed by the fluid inside the pseudocyst. Nevertheless, the advantage of a covered expandable stent is exactly the possibility of stopping the bleeding through mechanical hemostasis and this has been clearly demonstrated in our case report. The use of metallic stents in order to control severe bleedings in the GI tract has been already described in several articles. Thus, a review of preliminary reports suggested that self- expandable covered metal stents might be considered useful and very effective to control refractory acute variceal bleeding, being an alternative to the temporary control obtained by Sengstaken-Blakemore baloon [16]. The stents used have a modified design (with atraumatic edges and retrieval loops with gold markers at both stent ends) which allows them to be extracted with a special system after a few days [17]. Covered self-expandable metallic stenting was also described to be useful in post-sphincterotomy bleeding [18,19] or other GI malignant tumors diffuse bleeding [20] or in case of the conventional endoscopic fluid collection drainage [21], which does not stop after usual endoscopic treatment (injection, coagulation, clipping, etc.). Our case presentation proved that the same approach is useful in pseudocyst bleeding that occurs during EUS-guided drainage. Conclusions This case report shows a rare case of bleeding during the EUS drainage procedure of pancreatic pseudocyst at the level of the pseudocyst wall. The double flanged covered self- expandable metal stent proved its utility in such unusual cases with high risk for bleeding due to colateral circulation.
  • 6. Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Abbreviations EUS, Endoscopic ultrasound; CT scan, Computed tomography Competing interests The authors declare that they have no competing interests. Authors’ contributions ASaftoiu did the EUS-guided pseudocyst drainage, LC, ASeicean and MT selected the patient for the drainage and followed him up. All authors have been involved in drafting the manuscript or revising it and have given final approval of the version to be published. Acknowledgement We are indebted to the medical staff which took part actively in the live demo, and especially to Mr. Tom de Simio, Xlumena, Mountain View, California, USA. Devices used in the procedure were kindly provided by Xlumena, both the Navix device and the Axios double flanged stent. References 1. Vilmann P, Hancke S, Pless T, Schell-Hincke JD, Henriksen FW: One-step endosonography-guided drainage of a pancreatic pseudocyst: a new technique of stent delivery through the echo endoscope. Endoscopy 1998, 30:730–733. 2. Giovannini M, Bernardini D, Seitz JF: Cystogastrotomy entirely performed under endosonography guidance for pancreatic pseudocyst: results in six patients. Gastrointest Endosc 1998, 48:200–203. 3. Seewald S, Thonke F, Ang TL, Omar S, Seitz U, Groth S, Zhong Y, Yekebas E, Izbicki J, Soehendra N: One-step, simultaneous double-wire technique facilitates pancreatic pseudocyst and abscess drainage (with videos). Gastrointest Endosc 2006, 64:805–808. 4. Lopes CV, Pesenti C, Bories E, Caillol F, Giovannini M: Endoscopic-ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts and abscesses. Scand J Gastroenterol 2007, 42:524–529. 5. Ardengh JC, Coelho DE, Coelho JF, de Lima LF, dos Santos JS, Módena JL: Single-step EUS-guided endoscopic treatment for sterile pancreatic collections: a single-center experience. Dig Dis 2008, 26:370–376.
  • 7. 6. Ahn JY, Seo DW, Eum J, Song TJ, Moon SH, Park do H, Lee SS, Lee SK, Kim MH: Single-step EUS-Guided transmural drainage of pancreatic pseudocysts: analysis of technical feasibility, efficacy, and safety. Gut Liver 2010, 4:524–529. 7. Varadarajulu S, Lopes TL, Wilcox CM, Drelichman ER, Kilgore ML, Christein JD: EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc 2008, 68:649–655. 8. Park DH, Lee SS, Moon SH, Choi SY, Jung SW, Seo DW, Lee SK, Kim MH: Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009, 41:842–848. 9. Itoi T, Itokawa F, Sofuni A, Umeda J, Tsuchiya T: Late bleeding after EUS-guided transjejunal drainage of a pancreatic pseudocyst in a Roux-en-Y patient. Dig Endosc 2011, 23(Suppl 1):51–53. 10. Varadarajulu S, Christein JD, Wilcox CM: Frequency of complications during EUS- guided drainage of pancreatic fluid collections in 148 consecutive patients. J Gastroenterol Hepatol 2011, 26:1504–1508. 11. Belle S, Collet P, Post S, Kaehler G: Temporary cystogastrostomy with self-expanding metallic stents for pancreatic necrosis. Endoscopy 2010, 42:493–495. 12. Tarantino I, Di Pisa M, Barresi L, Curcio G, Granata A, Traina M: Covered self expandable metallic stent with flared plastic one inside for pancreatic pseudocyst avoiding stent dislodgement. World J Gastrointest Endosc 2012, 4:148–150. 13. Pallapothu R, Earle DB, Desilets DJ, Romanelli JR: NOTES(®) stapled cystgastrostomy: a novel approach for surgical management of pancreatic pseudocysts. Surg Endosc 2011, 25:883–889. 14. Binmoeller KF, Shah J: A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections. Endoscopy 2011, 43:337–342. 15. Itoi T, Binmoeller KF, Shah J, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Moriyasu F: Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012, 75:870–876. 16. Escorsell A, Bosch J: Self-expandable metal stents in the treatment of acute esophageal variceal bleeding. Gastroenterol Res Pract Epub 2011:910986. 17. Hubmann R, Bodlaj G, Czompo M, Benkö L, Pichler P, Al-Kathib S, Kiblböck P, Shamyieh A, Biesenbach G: The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006, 38:896–901. 18. Shah JN, Marson F, Binmoeller KF: Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding. Gastrointest Endosc 2010, 72:1274–1278.
  • 8. 19. Itoi T, Yasuda I, Doi S, Mukai T, Kurihara T, Sofuni A: Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding. Endoscopy 2011, 43:369–372. 20. Hasegawa N, Kato K, Morita K, Kuroiwa M, Shinkai M, Hayashi T, Kamioka T, Otagiri H, Shindo Y, Goto H: Covered expandable metallic stent placement for hemostasis of colonic bleeding caused by invasion of gallbladder carcinoma. Endoscopy 2003, 35:178– 180. 21. Akbar A, Reddy DN, Baron TH: Placement of fully covered self-expandable metal stents to control entry-related bleeding during transmural drainage of pancreatic fluid collections (with video). Gastrointest Endosc 2012, 76:1060–1063. Additional file Additional_file_1 as AVI Additional file 1: Movie S1. Significant spurting (pulsatile) arterial bleeding originating from the puncture level inside the pseudocyst.
  • 11. Additional files provided with this submission: Additional file 1: 1927875018323026_add1.avi, 3790K http://www.biomedcentral.com/imedia/2424294810027738/supp1.avi