Interventional Endoscopic Ultrasonography

Exclusion of the presence of vasculature in the path of the needle using color Doppler ultrasound.

Puncture the pseudocyst under EUS-guidance using a 19-gauge fine needle aspiration (FNA) needle and insertion of a 0.035 inch guidewire through the needle and coiling of the guidewire within the pseudocyst under fluoroscopic guidance.

Sequential dilation of the tract under fluoroscopic guidance by first passing a 4.5 or 5 Fr ERCP cannula over the guidewire, followed by further dilatation using a 6 or 8 mm over–the–wire biliary balloon dilator.

Following dilation, insertion of two 7 or 10 Fr double pigtail stents within the pseudocyst under fluoroscopic guidance.

Insertion of additional stents and a 7 or 10 Fr nasocystic drainage catheters in all patients with pancreatic abscess or necrosis for periodic flushing and evacuation of the cystic contents.

Removal of the nasocystic catheter and all but one of the drainage stents.

Under radiologic guidance, dilatation of the tract with a balloon up to 18 mm.

Introduction of a therapeutic gastroscope from the dilated tract into the cavity (Fig. 1a).

Use of a Dormia basket, a Roth net and/or a snare to remove necrotic tissue (Fig. 1b).

Re-insertion of pigtail stents and nasocystic catheter into the cavity.

Visualization of extrahepatic bile duct from the duodenal bulb using a convex array echoendoscope with the long/pushing position (Fig. 2a).

Under EUS guidance, insertion of a needle knife or a 19-gauge needle transduodenally into the bile duct.

After removal of a stylet, bile aspiration and injection of contrast medium into the bile duct for cholangiography (Fig. 2b).

Insertion of a 450 cm long, 0.035-inch guidewire into the outer sheath.

If necessary, use of a biliary catheter or papillary balloon dilator for dilatation of the duodenocholedochal fistula.

Insertion of a 5-Fr to 10-Fr biliary plastic stent or self-expandable metallic stent through the choledochoduodenostomy site into the extrahepatic bile duct (Fig. 2c,d).