Use of a transparent cap for endoscopic drainage of a pancreatic pseudocyst.

scope cap in difficult cases has been de− scribed [1]. The use of this device to facil− itate endoscopic access to a pancreatic pseudocyst prior to drainage has not been reported before. We report the case of a 47−year−old man with abdominal pain 3 months after acute biliary pancreatitis. CT scan showed a 12−cm pseudocyst in the pancreatic body and in close contact (< 1 cm) with the posterior gastric wall with no collat− eral veins. Endoscopic ultrasound (EUS) showed typical pseudocyst findings and the optimal puncturing site was marked with a forceps. Using a therapeutic duo− denoscope, a small incision (triple−lumen needle knife) was made, but severe bleeding occurred (l" Fig. 1). Adrenaline 1 :10 000 (5 ml) was injected without success. We changed to a therapeutic gas− troscope equipped with a transparent cap. This gave a better view of the active bleeding, and after application of two he− moclips the bleeding stopped (l" Fig. 2). Noticing the appropriate and stable posi− tion obtained with the transparent cap against the posterior gastric wall, we decided to continue. Two centimeters from the hemoclips another small inci− sion was made with a triple−lumen nee− dle knife, and using this catheter the gas− tric wall was punctured (l" Fig. 3), lead− ing the guide wire into the pseudocyst (l" Fig. 4). Frequently, the best gastric compression site is in a difficult position for endoscopic drainage, and a freehand incision or puncturing technique may misdirect placement of the guide wire. However, we found that using the trans− parent cap a stable endoscopic position can be obtained and cutting and/or punc− turing can be carried out with more con− fidence. After leading the guide wire into the cyst we changed to a duodenoscope; tract dilatation was carried out and two 10−Fr double pigtail stents were inserted. We consider that the transparent cap can be a very useful accessory to maintain the position of the endoscope in cases of diffi− cult pancreatic pseudocyst access.