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Simon Campbell and Anthony Mee Beware: the locking drain!
Simon Campbell and Anthony Mee, 31 January 2005
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Abstract

Percutaneous drainage remains an important radiological intervention in the management of pancreatic pseudocysts. While approximately 50% of pseudocysts are managed in this way there is a paucity of reports of potential complications with this procedure.

We describe the case of a 57-year-old lady with a pancreatic pseudocyst that was managed by percutaneous drainage. This case report highlights an unusual complication resulting directly from the use of a locking type drain. Lack of experience with this particular type of drain resulted in fragments of the drain becoming sheared off and retained within the pancreatic cavity - resulting in further infective complications.

The use of locking drains is becoming more common in radiological departments. This report reinforces the need for such drains to be removed by experienced staff and preferably from a member of the radiological team if possible.

Case report

A 57-year-old lady presented with severe necrotizing pancreatitis necessitating a 5-week admission to ITU. A CT scan revealed a large communicating pseudocyst and because of an ongoing fever and raised inflammatory indices, the cyst was drained percutaneously. A locking 8F catheter (Boston Scientific) was placed into the pseudocyst with good drainage over the next 10 days.

While still on ITU, the drain was removed by a member of the ITU staff because of drain blockage. A further 8F locking catheter was re-inserted into the pseudocyst because of ultrasonographic evidence of a persisting fluid collection. The patient made a good recovery and the patient was discharged to await cholecystectomy.

One month later she represented to the surgeons with abdominal pain and fever (amylase <30, WCC 24x106, normal LFTs). A repeat CT scan revealed remaining fluid within the pancreatic bed but also a foreign body within the region of the tail of the pancreas. There was also evidence of dilatation of the common bile duct (13mm). At ERCP a fistula below the papilla was noted. The lower end of the bile duct was narrowed with proximal dilatation (consistent with surrounding inflammatory tissue) but there were no filling defects. The gallbladder was thickened with filling defects.

Cannulation of the pancreatic duct revealed only the remnant of the pancreatic head while cannulation of the fistula entered the necrotic area, but in addition, fragments of a pigtail catheter were clearly seen on X-ray (Figure 1).

On withdrawal of the scope from the papilla, the fragment could be seen eroding through the duodenal wall, proximal to the papilla. This was removed by snare and retrieved. The patient made an unremarkable recovery.

Figure 1 ERCP image revealing pigtail remnants (arrows).

Figure 2 shows the locking pigtail catheter and the retrieved fragment adjacent to it. The pigtail catheter is inserted as per any normal drainage catheter, but after insertion, the thread is pulled tight to "pigtail" the catheter to prevent it being dislodged from the drainage site.

Figure 2 Locking pigtail catheter with retrieved fragment of old catheter.

Discussion

The optimal management for chronic unresolved and or infected pancreatic pseudocyts (PP) remains controversial. There are 3 main interventions available: surgical drainage (debridement and external drainage), radiological percutaneous drainage (RPD), and internal drainage by endoscopic cystgastrostomy or cystduodenostomy or endoscopic transpapillary drainage.

More recently, RPD has become the primary mode of treatment in many medical centres across the world [1]. Several studies to date have reported favourable success rates with RPD, with up to 90% of pseudocysts being successfully drained in this manner [2,3]. This is superior to single-step needle aspiration where results are often disappointing - approximately 30% success rate. RPD was compared with internal drainage by Adams et al. [4] in 92 patients with symptomatic pancreatic pseudocysts over a 27-year period. They concluded that RPD was an effective first line management when compared to internal surgical drainage with a significantly lower mortality rate in the former group (p<0.05).

Local complications of RPD such as catheter blockage, external pancreatic fistula formation and drain track infection are relatively common (occurring in up to 38% of patients). This should be balanced by the obvious benefits such as low mortality of the procedure, avoidance of major surgery and the ability to perform more extensive drainage procedures without violating the operative area. Other smaller series have reported similar complications - with drain track infection being the most common complication [3,4,5].

To date, this is the first case report that has described drain disruption with subsequent retention of RPD remnants as a complication following drainage removal from a pancreatic pseudocyst. It remains unclear whether the corrosive action of pancreatic juices may have played a role in weakening the drain before it was removed. The fact that there are no previous reports of this type of complication suggests that this is an unlikely explanation.

With the increasing use of locking type RPD catheters, this report highlights the increasing importance of identifying the type of drainage catheter that has been inserted before their removal and thorough inspection of the catheter after removal to ensure complete removal has been achieved. Responsibility also falls in the hands of the operator who has initially inserted the drain and to make it clear what type of drain has been inserted as well as written instructions of how to remove the drain if this job is to be delegated to other medical staff.

Removal without appropriate "unlocking" can be extremely uncomfortable for the patient and can lead to the breakage of the drain by the cutting action of the taut thread acting as a cheesewire on the distal tip. Subsequent retention of fragments can become a nidus to further infection (as in this case) and further complicate recovery. Medical and nursing staff responsible for drain removal should be familiar with their use and potential pitfalls.

This article was first published on GastroHep.com on 31 January 2005.

Authors

Dr Simon Campbell
Dr Anthony Mee
Royal Berkshire Hospital, London Road, Reading, Berks., RG1 5AN, UK

Contact information

Dr S Campbell
Department of Gastroenterology, Royal Berkshire Hospital, Reading, Berks., RG51 5AN, UK
Phone +44 (0)1189-875-111
simoncampbell@hotmail.com

References

  1. Spivak H, Galloway JR, Amerson JR et al. Management of pancreatic pseudocyts. J Am Coll Surg 1998; 186(5): 507-511.
  2. VanSonnenberg E, Wittich GR, Casola G et al. Complicated pancreatic inflammatory disease: diagnostic and therapeutic role of interventional radiology. Radiology 1985; 155(2): 335-340.
  3. Fataar S. Percutaneous drainage of pancreatic pseudocysts: technique and problems. Australas Radiol 1990; 34(4): 334-338.
  4. Adams DB, Anderson MC. Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst. Ann Surg 1992; 215(6): 571-576.
  5. VanSonnenberg E, Wittich GR, Casola G et al. Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience of 101 cases. Radiology 1989; 170: 757-761.

 
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