Cùng một loại hệ thống thoát nước nội bộ cũng có thể được thực hiện sau khi endosonography để xác định một khu vực thủng không có tàu hoặc trực tiếp thông qua một echoendoscope như mô tả của Giovannini et al. | PART I to also insert nasocystic external temporary drainage this allows the inside of the cavity to be flushed regularly and the washing liquid to be aspirated thereafter. The same kind of internal drainage can also be performed after endosonography for determining a zone of puncture devoid of vessels or directly through an echoendoscope as described by Giovannini et al. The same principle has also been described using a combination of percutaneous and endoscopic methods the stent between stomach and cyst being delivered over an echo-guided percutaneous catheter and correctly positioned using the gastroscope. Such internal endoscopic drainage has a morbidity evaluated at around 10 mainly due to perforation or hemorrhage. Recurrence is often observed which should prompt another endoscopic intervention consisting of an exchange of stents with careful washing of the inside of the cyst. Sometimes enlargement of the communication has to be performed. Eventually cystoscopies endoscopic examination of the inside of a cystic cavity can be performed. Of the last 16 patients we have treated using this kind of endoscopic approach direct cystogastrostomy has been performed five times. One case was complicated by a hemorrhage that was treated endoscopically by injection of local vasoactive agent. The mean size of the cavities was over 18 cm. Another patient had to be operated on because of recurrence and massive infection after the first endoscopic procedure. The other three patients healed completely after four endoscopic procedures as described earlier. The second endoscopic approach is cystoduodenos-tomy which is very similar to but easier and safer than cystogastrostomy it necessitates a well-defined bulging of the cyst into the second or third part of the duodenum Fig p. 144 . The surgeon can also perform this kind of communication in the third part of the duodenum with the help of an echoendoscope. The technique is absolutely identical to that used through the .
