Endoscopic Ultrasound (EUS) Guided Pancreatic Pseudocyst Drainage and Placement of Stent

This leaflet describes why you are having an Endoscopic Ultrasound (EUS) Guided Pancreatic Pseudocyst Drainage and what it involves. Please read this leaflet carefully before coming for the procedure so that you can ask any questions you may have when you attend. You will be asked to sign the consent form after you have had a chance to ask questions.

What is Endoscopic Ultrasound (EUS) Guided Pancreatic Pseaudocyst Drainage?

You have been advised to have an EUS. This is a procedure that allows an Endoscopist (a consultant trained to do EUS) to see inside your oesophagus (gullet or food pipe), stomach and duodenum (small intestine) and the organs outside it (liver, pancreas, gall bladder, kidneys, adrenal glands, lymph glands, blood vessels and nerves) using an EUS endoscope. (See diagram below).

An EUS endoscope (a thin, flexible tube with a bright light and a small ultrasound probe on the end), will be passed through your mouth and down into your stomach and small bowel. Once the EUS endoscope is in position, ultrasound waves are used to see the area and structures deeper in the chest and abdomen. Your Doctor has requested to carry out EUS as this will allow the fluid collection around the pancreas to be seen and guide the placement of the stent between the fluid collection and the stomach or the duodenum (beginning of the small bowel).

If you are an in-patient, you may need further treatments to help remove the fluid and infected tissue. This will be explained to you in more detail before the procedure. You will need to have a blood test before the procedure to check that your blood is clotting properly.

What is pancreatic pseudocyst?

A pancreatic pseudocyst is a fluid filled collection that has formed as a result of pancreatitis (inflammation of the pancreas gland). This can occur in both acute (short-term) and chronic (long-term) pancreatitis.

Who is this procedure for?

This procedure is only for patients with symptoms of abdominal (tummy) pain, nausea (feeling sick), vomiting or weight loss that is caused by having a pancreatic Pseudocyst.

Why am I having this procedure?

Your Doctor has referred you for this procedure because you have displayed some of the above symptoms and they have not been helped by standard treatment.

What are the risks and possible complications?

Like all procedures, EUS guided Pancreatic Pseudocyst drainage procedures have some side effects or complications.

These include:

• Damage to your teeth or bridgework – The EUS endoscope can occasionally cause damage to your teeth or bridgework. This is rare and a mouth guard is used to lower the risk.

• Aspiration – As you are sedated, if your stomach contains food or drink, it can leak into your lungs. This can affect your breathing and cause an infection .This is why you must not eat or drink for 6 hours before the procedure. Aspiration of fluid drained from Pseudocyst can also occur into your lungs. Your Doctor will try to prevent this by suctioning out all of the fluid from the stomach during the procedure.

• Bleeding – If any bleeding happens during your procedure, steps will be taken to stop it. You may need a blood transfusion, radiological intervention (procedure carried out under X-rays) or rarely, an operation. This can happen in between 1 to 12 patient in every 100.

• Perforation – (a hole or tear in the gullet or stomach) – this can happen to 5 patients in every 100. If this happens, this will need treatment with fluids, antibiotics and sometimes surgery.

• Pancreatitis – (inflammation of the pancreas glands leading to abdominal pain, vomiting and fever) – This is rare. If this happens, you would need to stay in hospital for a few days to receive intravenous fluids and pain relief. This can happen to 1 patient in every 100.

• Infection – This can happen to 20 in every 100 patients. To prevent this from happening, you will be administered a single dose of intravenous antibiotics prior to the procedure and 3 days of oral antibiotics following the procedure. If an infection occurs, it is usually treated with antibiotics intravenously (into a vein) or orally (by mouth) as required.

• Stent Migration (movement) – There is a risk that the stent could migrate from its position (move) internally (inside your body). This can happen to 20 in every 100 patients.

• Stent Occlusion (blockage) – There is a risk that the stent could become blocked, preventing drainage of fluid collection. Further endoscopic procedures may be carried out to unblock the stent .This can happen to 17 patients in every 100 patients.

• Adverse effects of conscious sedation – (a drug which should make you feel comfortable and relaxed) – This can occasionally cause problems with your breathing, heart rate and blood pressure. Careful monitoring (checking) by a fully trained endoscopy nurse will make sure that they are identified and treated quickly.

• Procedure related mortality (death) – Severe complications are rare 1 in 250, but may require emergency admission, repeat endoscopic procedure, surgery, blood transfusion or in extremely rare circumstances, result in death.

Are there any other procedures that can be done instead?

In the past, surgical operations were required to drain the fluid collections but now we can drain the collection using a less invasive endoscopic camera test. However, in very rare instances, an operation might still be required.

You do not have to have any procedures you do not want, but the Doctor who has requested the treatment has advised this is best for you. Your Consultant has recommended this procedure as being the best option.

What will happen before my procedure?

You will be admitted to the Endoscopy Unit at North Tees on the morning of your procedure, unless your appointment letter states otherwise. You will usually be advised to stay in hospital overnight so please be prepared for this. It might be useful to pack a bag with night clothes and toiletries or anything else you think you might need but please do not bring anything valuable into hospital.

What will I need to do to prepare for my procedure?

It is very important you follow the instructions given into this leaflet to make sure your oesophagus (food pipe), stomach and duodenum (intestine, gut) are empty. This will allow the Endoscopist to get a clear view and make sure no areas are hidden.

You must stop eating or drinking at least 6 hours before your procedure. This is very important and you must follow the instructions, nothing means nothing at all.

If you forget and you do eat or drink anything, you must tell your Doctor or Nurse, as your procedure may need to be delayed for your safety. This is because when you are sedated, if your stomach contains food or drinks and you vomit (throw up), it could get into your lungs, affect your breathing and cause an infection and other complications.

If you are taking any medication to thin your blood or if you are unsure, you must contact the Endoscopy Unit as soon as you get your appointment.

This medication includes anticoagulants such as Warfarin, Apixaban, Dabigatran, Rivaroxban amongst others, or antiplatelet medications such as Aspirin, Clopidogrel, Ticagrelor, Dipyridamole amongst others. This will be discussed with you at your pre-assessment appointment.

You can continue to take Aspirin if you are already doing so, but you must stop taking this on the morning of your procedure.

If you have diabetes, you should contact the Endoscopy Unit for advice about your medication.

Can I be sedated for the procedure?

The procedure is usually carried out using conscious sedation. Sometimes the procedure is carried out using deep sedation with the help of an anaesthetist. The effect of sedation will stay with you for at least 24 hours so it is important you follow this advice. There must be a responsible adult to take you home and look after you for the first 24 hours after your procedure. This is because the effects of the sedation will affect your judgement.

For the first 24 hours after sedation:

• You must not go back to work
• You must not drive a car, ride a bicycle or motorcycle. It is an offence to drive while unfit to do so because of drugs and it will probably invalidate your insurance policy
• You must not supervise children
• You must not make important decisions or sign any legal documents
• You must not operate machinery or electrical appliances
• You must not go near open flames or sources of high heat
• You must not drink alcohol
• You must not take sleeping tablets, tranquilisers or any drugs other than those prescribed for you by your GP
• You must not lock the toilet or bathroom door in case you need any help
• You must not smoke.

What will happen when I arrive for my appointment?

When you arrive at the Endoscopy Unit, you will be advised by the endoscopy Nurse of an approximate time you should be ready to go home. There is limited space in the Unit, so only in special cases will someone be allowed to stay with you, for example, adults with special needs.

A Nurse will call you though to the unit. They will check your personal details and ask you a few questions about your health. They will also check your blood pressure and pulse and explain the procedure and risks to you. This is to make sure you understand everything before you sign the consent form. You should tell the Nurse if you have had any allergies or reactions to drugs or other procedures in the past. You should also tell your Nurse about any previous endoscopy procedures you may have had.

Please bring with you a list of medications (drugs) you are currently taking. This includes medicines prescribed by your Doctor or those you have bought yourself. Although it is likely you will be staying in the hospital after the procedure, you will still be asked for a contact telephone number of the relative or friend who will take you home and stay with you on discharge.

You will be taken to a comfortable waiting area to wait your turn. We operate a list system. This means you will be seen when it is your turn and not the time given for you to arrive at the unit. Before your examination, if you have any worries or questions, please talk to your Nurse or Endoscopist.

What should I do on the day of my procedure?

On the day of your procedure, it is important that:

• You should not smoke
• Long hair should be tied back for comfort
• You avoid bringing valuables with you
• You wear loose fitting clothing
• False teeth, glasses and hearing aids may be removed in the Endoscopy room.

When it is time for your procedure, a Nurse will take you into the examination room.

What will happen during my procedure?

Before your procedure begins, you will be asked to remove any false teeth, if you have them. A local anaesthetic will be sprayed on to the back of your throat to numb the area.

You will be given a sedative drug before the examination starts. This is called conscious sedation. You will still be awake but should feel more comfortable and relaxed.

This involves injecting medication (drugs) through a cannula (a fine tube) inserted into a vein in the back of your hand or arm using a small fine needle.

In the examination room, you will then be asked to lie down on a trolley on your left side. Your pulse, blood pressure and oxygen levels in your blood will be checked before and during your procedure. A Nurse will make sure you are comfortable and your privacy and dignity will be maintained at all times through the procedure.

You will be given extra oxygen to breathe through a soft plastic tube that goes in your nose. A small plastic guard will be put gently between your teeth to protect them. Do not worry, this is all routine and is not painful.

The Endoscopist will then pass the EUS scope through your mouth, into your stomach and then into your duodenum (gut). Air will be passed through the tube to inflate your stomach so that your endoscopist can see all parts of your stomach wall. This can cause “windy” discomfort. The pancreatic Pseudocyst drainage and stent placement will then be carried out.

During the procedure, any extra saliva will be cleared from your mouth using a fine suction tube. When the procedure is over, the air and the EUS camera are removed quickly and easily.

We routinely take photographs or videos of your insides during this procedure. These are used to help in your investigations and treatment. The procedure may take up between 45 to 60 minutes to be completed.

What happens to the pictures taken during my procedure?

The pictures taken during your procedure will be kept as part of your healthcare record. These may sometimes be used anonymously for training or research. If hospital staff want to use any of your pictures for any other purposes, for example, in an article to be published (printed) in a professional magazine or book, they will ask for your permission first before this happens.

What will happen after the procedure?

You will be taken to the recovery area where you will be able to rest on a trolley until the immediate effects of the sedation have worn off. You will be given some fluids through the intravenous cannula (drip) to prevent hypotension (low blood pressure).

You will usually have to stay in hospital overnight for observation.

Should I take any special precautions after the procedure?

You might feel slightly more under the weather for the first 24 to 48 hours after your procedure. We recommend that you get plenty of rest during this time. Because of the sedation given for the procedure, you will not be able to drive or operate heavy machineries for the next 24 hours.

What follow up is planned for my procedure?

A copy of the report will go to your referring team who will continue to manage your symptoms.

When will I be told about the outcome of my procedure?

Before you leave the unit, your Nurse or Endoscopist will explain the outcome of your procedure to you. A copy of your report will be sent to your GP within 24 hours. If you are an in-patient, the Doctor responsible for your care will discuss the outcome of the procedure with you on the ward.

Contact Numbers

If you need further advice, or have any problems, please contact the Unit where you are to have your examination.

University Hospital of North Tees Endoscopy Unit

Telephone: 01642 624387

Opening hours: 8:00am to 7:00pm (Monday to Friday) and 8:00am to 2:00pm (Saturday)

Emergency Department

If you start to experience any significant pain, please attend the Emergency Department.
24 hours a day, 7 days a week.
Telephone: 01642 382899

Further information is available from:

NHS Choices

Telephone: 111 (when it is less urgent than 999).

Calls to this number are free from landlines and mobile phones or via the website.

References

Adverse events associated with EUS and EUS-guided Procedures, Nauzer Forbes, Nayantara Coelho-Prabhu, Mohammad A. Al-Haddad et al, ASGE Standards of Practice Committee, Gastrointestinal Endoscopy Volume 95, No. 1, 2022 2.

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