Pseudocyst Resolution in Two Shakes of a LAMS Tail

Abstract

Pancreatic pseudocysts (PPs) develop in approximately 10%-26% of acute pancreatitis cases and 20%-40% of chronic pancreatitis cases. Endoscopic ultrasound-guided cystogastrostomy is the preferred approach to drain pseudocysts. In 2013, the Food and Drug Administration approved a new, lumen-apposing, fully-covered, selfexpanding metal stent (LAMS) which has been used successfully in transmural PP drainage (AXIOS; Xlumena, Mountain View, CA). The LAMS has lumen-apposing ability and a wide diameter allowing for robust drainage and endoscope passage. A recent multi-center retrospective study showed high rates of success in LAMS placement and subsequent resolution of PPs with low major complication rates. The current literature has only discussed high technical success rates utilizing the LAMS in patients presenting with a single PP. We describe a patient who required placement of two LAMSs for drainage of two separate PPs simultaneously. A 71-year-old male with history of recent cholecystectomy presented with sharp, stabbing back and epigastric pain with nausea and vomiting. His lipase was greater than 6000 U/L with elevated liver enzymes and leukocytosis. Abdominal CT revealed acute interstitial pancreatitis, and the patient was subsequently diagnosed and treated for necrotizing pancreatitis. Four weeks later, the patient presented with severe abdominal pain, and a CT showed a 7.2 x 12.5 cm PP closely abutting the lesser curvature of the stomach. Cystogastrostomy was performed and a 15 x 10 mm AXIOS LAMS was placed [Figure 1, 2]. 5 days later, the patient experienced another episode of abdominal pain, and another CT showed resolution of the stented PP as well as a new 5.9 x 6.0-cm x 11.9-cm PP along the lateral margin of the stomach. Cystogastrostomy was again performed and a second 15 x 10 mm LAMS was placed through the second PP while leaving the first LAMS in place [Figure 3]. Repeat CT one month later demonstrated resolution of both PPs. Both stents were removed without complication using a standard snare. Placement of the two LAMSs was well-tolerated by the patient and resulted in the complete resolution of his two PPs. LAMS have been highly successful in treating single pancreatic pseudocysts. Multiple PPs, however, have been reported to occur in up to 18.5% of patients presenting with PPs and can be difficult to treat. Additional research in simultaneous placement of multiple AXIOS LAMSs to treat multiple PPs is warranted.Figure 1Figure 2Figure 3