EUS-guided drainage of post-distal pancreatectomy collections using lumen apposing metal stent: a single center experience

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Introduction: Postoperative fluid collections (PoFC) are common complications after distal pancreatectomy. Symptoms related to PoFC include signs of infection, pain, dyspepsia and left-upper quadrant pressure sensation, although are more frequently asymptomatic radiological findings during post-operative routine controls. No recommendations exist regarding the management of PoFC. Endoscopic ultrasound (EUS) guided drainage of symptomatic PoFC allows to avoid reoperation, long-term percutaneous drainage and development of external pancreatic fistulas. Material and Methods: From January 2017 and December 2018, 92 consecutive distal pancreatectomies (24 of them spleen-preserving) were performed at our institution. All the patients who developed PoFC were included in the study. All the symptomatic PoFCs were drained using lumen apposing metal stents (LAMS; Hot-AXIOS, Boston Scientific, USA) Results: Fifteen patients (16%) developed PoFC at the resection margin of the pancreatic stump. All these patients had a PoPF (5 grade A and 10 grade B). Six of them were symptomatic and the complication was observed at CT scan within one month after discharge. Nine of them were asymptomatic and were observed at post-operative ultrasound scan follow-up. All the 6 patients with PoFC related symptoms underwent EUS-guided trans-gastric drainage using LAMS as first choice. Five out of six had an uneventful course. In one female patient, dislocation of the LAMS into the stomach occurred during endoscopic debridement 8 days after the procedure. An urgent laparotomy was necessary with open drainage and gastric suture with complete resolution of the condition. The other stents were removed after one month and no recurrence of collection were observed. Conclusions: Most of PoFCs are asymptomatic but whenever symptoms are present, the EUS guided drainage is feasible and safe and has a high success rate. When the collections are not completely accessible from the stomach or the duodenum, percutaneous or minimally invasive surgical approach should be preferred.