Tuesday, September 8, 2015

Introduction of Interventional Radiology in Rwanda part 2

Jeffrey Forris Beecham Chick, MD, MPH

Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115

Email: jchick@partners.org

Today we performed the first ever ultrasound-guided catheter drainage in Rwanda. The patient was a 2-year-old female with elevated amylase and lipase and a cystic mass arising adjacent to the pancreas thought to represent a pseudocyst or benign cyst from pancreatic injury. Although pancreatic pseudocysts are common in adults with alcoholism and pancreatitis, they are rare in young children and the entire radiology team was uncertain why the child developed such a cyst in the first place. These cystic masses are surgically resected in Rwanda, however, there was only one visiting pediatric surgeon in Rwanda and these procedures carry a high morbidity and mortality. We were hoping to drain the cyst completely by inserting a catheter rather than relegating the child to surgical intervention. It was time. Several pediatricians, nurses, and families watched as we prepared for the procedure. A pediatrician provided conscious sedation with ketamine as we were now doing routinely in Rwanda. After the child was sedated, we identified the cystic fluid collection using ultrasound and advanced a drainage catheter into it. As we advanced the catheter, an abundance of clear yellow fluid came spilling out in and around the catheter. We aspirated all the fluid we could obtain, over 800 mL, sutured the catheter in place, and used the ultrasound to confirm that the collection had resolved completely. We sent the fluid for amylase and lipase in an attempt to confirm that the cyst was indeed the proposed pseudocyst. Unfortunately, 2 days later, we learned that the laboratories in Rwanda are unable to analyze any fluid, other than blood, for amylase and lipase. Moreover, we discovered that the catheter had been inadvertently pulled back to the skin while the child was playing during the day and that it was no longer draining any fluid. Due to the concern that it would become infected we removed the catheter. While we had successfully placed and drained the majority of the collection, we had failed to drain it completely, and it seems as if the child will likely need a second catheter placed or undergo surgical intervention in the future. We plan to discuss our case with the surgical team.

A: Pre-procedural computed tomography image demonstrating a unilocular cystic mass adjacent to a normal appearing pancreas concerning for a pancreatic pseudocyst.

B: Pre-procedural ultrasound image confirming the large peripancreatic cystic mass.

C: Intra-procedural photograph showing continuous monitoring during ketamine anesthesia as well as creation of an incision prior to catheter placement.

D: Intra-procedural ultrasound image demonstrating the advancement of the catheter into the collection.

E: Computed tomography image obtained two days after the placement of the catheter demonstrating a residual peripancreatic collection with the catheter retracted to the skin surface and no longer functioning.

F: Repeat ultrasound image, prior to consideration of placing a second catheter, demonstrating the new septated appearance of the collection.

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