Double-pigtail Plastic Stents Research Articles

The Efficacy and Safety of EUS-Guided Gallbladder Drainage as a Bridge to Surgery for Patients with Acute Cholecystitis.

This study aimed to compare the efficacy and safety of endoscopic ultrasound-guided gallbladder drainage and percutaneous transhepatic gallbladder drainage as a bridge to surgery in patients with acute cholecystitis unfit for urgent cholecystectomy. This retrospective study included 46 patients who underwent cholecystectomy following endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) or percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis in NTT Tokyo Medical Center. We surveyed 35 patients as the EUS-GBD group and 11 patients as the PTGBD group, and compared the rate of technical success of the cholecystectomy and periprocedural adverse events. A 7-F, 10-cm double pigtail plastic stent was used for ultrasound-guided gallbladder drainage. The rate of technical success of cholecystectomy was 100% in both groups. Regarding postsurgical adverse events, no significant difference was noted between the two groups (EUS-GBD group, 11.4%, vs. PTGBD group, 9.0%; p = 0.472). EUS-GBD as a BTS seems to be an alternative for patients with AC because it can ensure lower adverse events. On the other hand, there are two major limitations in this study--the sample size is small and there is a risk of selection bias.

Clinical outcomes of permanent stenting with endoscopic ultrasound gallbladder drainage.

Endoscopic ultrasound gallbladder drainage (EUS-GBD) is gaining attention as a treatment method for cholecystitis. However, only a few studies have assessed the outcomes of permanent stenting with EUS-GBD. Therefore, we evaluated the clinical outcomes of permanent stenting using EUS-GBD. This was a retrospective, single-center cohort study. The criteria for EUS-GBD at our institution are a high risk for surgery, inability to perform surgery owing to poor performance status, and inability to obtain consent for emergency surgery. EUS-GBD was performed using a 7-Fr double-pigtail plastic stent with a dilating device. The primary outcomes were the recurrence-free rate of cholecystitis and the late-stage complication-avoidance rate. Secondary outcomes were technical success, clinical success, and procedural adverse events. A total of 41 patients were included in the analysis. The median follow-up period was 168 (range, 10-1,238) days. The recurrence-free and late-stage complication-avoidance rates during the follow-up period were 95% (38 cases) and 90% (36 cases), respectively. There were only two cases of cholecystitis recurrence during the study period. EUS-GBD using double-pigtail plastic stent was safe and effective with few complications, even in the long term, in patients with acute cholecystitis.

Removal of an impacted migrated biliary stent with cholangioscopy: lights, camera, action.

A 50-year-old woman was referred for removal of an internally migrated biliary stent. Fluoroscopy showed the migrated biliary stent and cholecystectomy clips ([Fig. 1]). She underwent endoscopic retrograde cholangiopancreatography (ERCP) and a biliary balloon was passed over the guidewire. Balloon sweeping was done; however, on sweeping, fresh blood was noticed emerging through the papilla. The procedure was therefore abandoned and a 7-Fr, 10-cm double-pigtail plastic stent (DPPS) was placed alongside the migrated stent. On day 3, the patient presented with severe anemia and hypotension. Contrast-enhanced computed tomography angiography (CTA) showed a right hepatic artery pseudoaneurysm, with an adjacent hematoma. She underwent conventional angiography and angioembolization with cyanoacrylate ([Fig. 2]).

Troubleshooting the migration of a double-pigtail plastic stent into a pelvic abscess (with videos).

The usefulness of EUS pelvic abscess drainage (EUS-PAD) for treating pelvic abscesses (PA) has recently been reported;[1] however, the procedure is often difficult to perform due to limited working space and field of view of that particular anatomical location. During EUS-related drainage, stent placement must be confirmed by both endoscopic and fluoroscopic images, to avoid risk of occurrence of misplacement.[2] A 70-year-old Japanese female with morbid obesity presented with PA secondary to a perforated appendicitis. Abdominal computed tomography revealed size of the PA to be125.3 mm that had originated from the appendix through the retroperitoneum [Figure 1a-c]. EUS-PAD was performed using a convex EUS scope. The abscess was punctured through the rectum using a 19-gauge needle [Figure 1d]. Two guidewires were inserted and coiled in the cavity, and the puncture tract was dilated using an 8-mm balloon dilator. Since the endoscope was inserted through a narrow and short space, it could easily shift position and slip out of the body. Due to the patient’s high obesity, the radiographic permeability was low, which made placing the double-pigtail plastic stent (DPPS) difficult. The DPPSs placement was finally performed, but under poor both endoscopic and fluoroscopy image. During placement of the second DPPS, it was observed that the first DPPS had strayed into the PA cavity [Figure 1e and Video 1]. After two DPPSs were placed incompletely, we proceeded to reposition the first DPPS that had migrated to the wrong position. After we dilated the puncture site using an 8-mm balloon dilator, a 5.8-mm endoscope was inserted into the cavity. The position of the migrated DPPS could be confirmed and its pigtail edge was re-inserted into the rectum using a 1.8-mm-diameter retrieval net [Figure 2]. No complications with the EUS-PAD procedures were encountered, and the patient’s symptoms improved gradually thereafter [Video 2]. Here, we present a procedure for dealing with an erroneously migrated DPPS during EUS-PAD. Additionally, the technique of direct insertion and drainage using a thin endoscope into the PA cavity, which was performed to retrieve the stray DPPS, may be useful in aggressive treatments of PA.Figure 1: Abdominal computed tomography revealed a pelvic abscess (a) with an air bubble of 125.3 mm that originated from an appendiceal perforation (b) and traversing the retroperitoneum (c; arrowhead). Endoscopic-ultrasound pelvic abscess drainage using a convex endoscopic-ultrasound scope. The abscess (outlined with asterisks) was punctured using a 19-gauge needle through the rectum (d). The first DPPS strayed into the pelvic cavity during the placement of the second DPPS (e; arrowhead). DPPS: Double-pigtail plastic stentFigure 2: Replacement of the migrated DPPSs following incomplete placement of two DPPSs. An esophagogastroduodenoscopy scope was inserted to place a guidewire into the PA cavity, and the puncture tract dilated using an 8-mm balloon dilator (a). Subsequent insertion of a 5.8-mm endoscope into the abscess cavity (b). A large amount of purulent fluid in the PA cavity, and the surface of the cavity with effusion, erythema, and purulent fluid (c). After aspiration of sufficient purulent fluid, the migrated DPPS was identified (d; arrow). DPPS: Double-pigtail plastic stent, PA: Pelvic abscesses {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_8datqvv1"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 2","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_hvyt4t8t"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Endoscopic management of food impaction following endoscopic ultrasound-guided gallbladder drainage using lumen-apposing metal stent.

A 61-year-old man was referred to our center for severe acute cholecystitis. Given his serious comorbidities (previous dissection of an aortic aneurysm with residual disease awaiting surgical reintervention; stage 3b chronic kidney disease; alcohol-related liver disease), the patient underwent transgastric endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a 10 × 10 mm lumen-apposing metal stent (LAMS) ([Fig. 1]). In the following months the patient experienced two episodes of food impaction of LAMS, which were treated endoscopically with placement of two double-pigtail plastic stents coaxially through the LAMS. Then, 3 months after the procedure, the patient was admitted for a third recurrence of acute cholecystitis. Computed tomography revealed a distended gallbladder, 19 cm in the long axis and completely occupied by food ([Fig. 2]). After a multidisciplinary evaluation, surgery was again excluded, and an endoscopic attempt was performed.

Intermediate- to long-term outcomes of endoscopic transpapillary gallbladder stenting in patients with gallstone-related disease: a 10-year single-center experience.

Endoscopic transpapillary gallbladder stenting (ETGS) can be a bridging therapy to elective cholecystectomy or a permanent gallbladder drainage method in patients with symptomatic gallbladder disease who are awaiting cholecystectomy or are unfit for surgery, respectively. We evaluated the intermediate- to long-term outcomes of ETGS in these groups. We retrospectively reviewed 234 patients (acute cholecystitis = 147), who were unfit for surgery (n = 50) or had deferred cholecystectomy (n = 184) and who underwent ETGS between 2012 and 2021. A 7-Fr, 15-cm, double-pigtail plastic stent was placed for ETGS without scheduled stent exchange. Biliary event-free rates (i. e. cholecystitis and cholangitis) were determined at 6 months, 1 year, and ≥ 2 years. Technical and clinical success rates were 84.6 % (198/234) and 97.4 % (193/198), respectively. Kaplan-Meier analysis (n = 193) showed a biliary event-free rate of 99 % (95 %CI 0.95-1.00) at 6 months, 92 % (95 %CI 0.87-0.97) at 1 year, and 76 % (95 %CI 0.65-0.93) at ≥ 2 years, during a median follow-up period of 564 days (range 200-3001 days). ETGS is an effective biliary drainage method that should be considered in selected cases with common bile duct stone where cholecystectomy could not be performed or was deferred. The biliary event-free rates of ≥ 76 % up to ≥ 2 years further support the use of ETGS in these patient groups.

Safety and Efficacy of Lumen-Apposing Metal Stents With and Without Coaxial Plastic Stents for Pancreatic Fluid Collections

Background and AimsPancreatic fluid collections (PFCs) are common complications of acute pancreatitis and can cause pain, difficulty feeding, and infection. Endoscopic ultrasound-guided drainage has become the standard of care, with lumen-apposing metal stents (LAMSs) replacing double pigtail plastic stents (DPPSs) as the preferred device. Coaxial placement of DPPSs through LAMSs is hypothesized to lower the risks of adverse events related to LAMSs. We conducted a retrospective study to evaluate the safety and efficacy of this strategy. MethodsWe conducted a retrospective study of consecutive patients with PFCs undergoing endoscopic cystgastrostomy with LAMSs and DPPSs or LAMSs alone at two U.S. academic tertiary care centers from January 2016 until November 2022. Propensity scoring and an adjusted logistic regression model were used for analysis. ResultsWe included 68 patients with an average follow-up of 189 days. The most common etiology of pancreatitis was gallstones (35.3%), most PFCs were walled-off necrosis (61.8%), and the mean size was 14.7 cm (SD ± 5.9 cm). Overall clinical success was 88.2%, without significant differences between LAMSs and DPPSs vs LAMSs alone (95.7% vs 84.4%; P = 0.18; aOR = 4.6; 95% CI, 0.5-41.4). We found no statistically significant differences in rates of LAMS occlusion (aOR = 0.47; 95% CI, 0.09-2.5), infection (aOR = 1.03; 95% CI, 0.17-6.2), bleeding (aOR = 0.4; 95% CI, 0.03-5), or stent migration (aOR = 0.42; 95% CI, 0.04-4.1) between the 2 groups. ConclusionThis retrospective cohort study found no statistically significant differences in the safety or efficacy of cystgastrostomy with LAMSs and DPPSs vs LAMSs alone. Larger, prospective trials comparing these strategies are needed.

Efficacy and safety of endoscopic ultrasound guided drainage of pseudocysts and walled-off necrosis after failure of percutaneous drainage.

Endoscopic Ultrasound (EUS) represents the gold standard for initial drainage of pancreatic fluid collections (PFC) due to various etiologies. However, data concerning salvage EUS drainage after initial percutaneous drainage are limited. The purpose of our study was to evaluate the clinical outcomes and safety of EUS-guided drainage of pancreatic collections after failure of percutaneous drainage. This retrospective study was conducted in a single, tertiary university center from August 2013 to January 2020. Indication was pancreatic collection after acute pancreatitis with PFC requiring EUS-guided drainage after failure of percutaneous drainage. Twenty-two patients with PFC after acute pancreatitis were included (mean age 64.1 ± 11.3years) of which 4/22 (18.2%) had pancreatic pseudocyst and 18/22 (81.8%) presented with a walled-off necrosis. Seventy-six interventions were performed among the 22 patients. Lumen-Apposing Metal Stent (LAMS) were used in 5/22 (22.7%) and double pigtail plastic stents in 17/22 (77.3%) of interventions with a median number intervention of 3 per patient (range 1 to 7). Technical success rate was 98.7% (75/76) with an overall clinical success of 81.8% (18/22). Procedure related adverse events rate was 9.1% (2/22) including one bleeding and one pancreatic fistula. Two non-procedure related deaths were observed. EUS-guided pancreatic collection drainage is clinically effective and safe after clinical/technical failure of radiological percutaneous management.

Technical and Clinical Outcomes of Using a Single Wide-Caliber Double-Pigtail Stent for Endoscopic Ultrasound-Guided Pancreatic Pseudocyst Drainage: A Multicenter Prospective Study

Introduction: Endoscopic ultrasound (EUS)-guided pancreatic cysto-gastrostomy/duodenostomy is the current accepted practice for management of symptomatic pancreatic pseudocysts with insertion of two or more double-pigtail (DP) stents. There is no much work on the efficacy of using a single wide-caliber DP stent, aiming to decrease the time, complications, and accessories used in the procedure. Aim of the Work: The aim of this study was to assess technical and clinical outcomes of using a single wide-caliber DP stent in EUSguided pancreatic pseudocyst drainage. Methodology: This multicenter prospective study included 57 patients, from which the 35 patients with symptomatic pancreatic pseudocysts enrolled. Patients with cysts with multiple septations (7 cases) or cyst with >30% necrosis (8 cases) of the cyst content and patients with generalized ascites (4 cases) or patients with major comorbidities (3 cases) were excluded. Patients were followed up within 1 month and 6 months after stent placement to assess complete resolution or a decrease in the sizes of cysts with clinical symptomatic improvement. Results: From 57 patients, 35 patients (19 females/16 males, median age 40 years) with a symptomatic pancreatic pseudocyst were referred for EUS-guided drainage. All used stents were 10 Fr DP plastic stents. The median duration of the whole procedure was 16 min. Technical success was achieved in all cases. Clinical success was encountered in 32 patients (91.4%) without re-accumulation on follow-up. Minor adverse events were encountered in 3 patients (8.6%) including post-procedure abdominal pain (1 case) and fever (2 cases). Conclusion: We suggest that using a wide-caliber single-pigtail stent for EUS-guided cystogastrostomy is safe and effective with short procedure time, with reduced risks from the insertion of another stent(s).

Continuation of common bile duct clearance with gallbladder stenting after duodenal perforation with subsequent treatment for tension pneumoperitoneum and pneumothorax.

An 88-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) because of septic cholangitis with acute calculous cholecystitis. Unfortunately, incidental duodenal perforation (Stapfer classification type 1) [1] occurred during duodenoscope intubation by our trainee endoscopist. Gastroscopy with a transparent cap revealed a linear 4-cm defect with active oozing at the duodenal apex ([Video 1]). Perforation closure was attempted with preceding guidewire insertion into the downstream duodenal lumen ([Fig. 1]) to prevent accidental luminal closure [2]. The first traumatic type over-the-scope clip (OTSC, 12/6t; Ovesco) was deployed by suction on the lacerating tissue at the caudal side of the defect ([Fig. 2]). However, the defect did not close completely; therefore, a second OTS clip was deployed using twin graspers to appose the edges of the defect. Contrast enterography revealed no intraperitoneal leakage ([Fig. 3]). Immediately after closure, ERCP with stones removal and transpapillary gallbladder stenting with a double-pigtail plastic stent to prevent recurrent cholecystitis was successfully performed. At almost 40 minutes before completion of the procedure, the patient developed marked abdominal distension, hypotension, and desaturation. Tension pneumoperitoneum with right pneumothorax was confirmed by fluoroscopy ([Fig. 4]). Emergency needle decompression was performed using an 18 G needle to release the tension pneumoperitoneum, and the patient was then intubated. Her abdomen gradually softened with an improvement in oxygen saturation. At 4 hours later, plain radiography showed no free air ([Fig. 5]). The patient was extubated and resumed oral intake the following day.

S2892 A Novel Application of Double-Pigtail Plastic Stents for Endoscopic Treatment of Stenoses and Anastomotic Leaks Following Bariatric Surgery: Endoluminal Placement to Facilitate Gastrointestinal Flow

Introduction: Transmural double pigtail plastic stents (DPPS) for treatment of anastomotic leaks have shown high success rates ( >75%), while being well-tolerated and cost-effective. For example, DPPS can be endoscopically deployed across staple-line leaks following laparoscopic sleeve gastrectomy (LSG), often combined with dilation of distal sleeve stenoses or kinks. The rationale for this combination treatment is to promote internal drainage AND intraluminal flow. However, there may also be a beneficial role for endoluminal DPPS placement in the treatment of complex anastomotic leaks and luminal stenoses. We present a series of four patients with complicated post-bariatric anatomy successfully managed with endoluminal DPPS placement. Case Description/Methods: Patient 1: 50-year-old female POD5 from LSG and duodenal switch presented with symptomatic gastric sleeve stenosis. Dilation was considered too high-risk. Two 10Fr x 12cm DPPS were endoscopically placed spanning the stenosis, pylorus, and duodenal-ileal anastomosis with instant symptom relief. DPPS were removed on POD65 with continued symptom resolution. Patients 2 and 3: 67-year-old and 70-year-old females POD12 and 14, respectively, from duodenal switch with duodeno-ileal anastomotic leak and stricture. Two 7Fr x 3cm DPPS were deployed across the leak site. A third 10Fr x 3cm DPPS was placed across the anastomosis. All stents were removed on POD45 and POD65, respectively, following leak resolution. Patient 4: 34-year-old female POD3 from complex gastric bypass reversal and duodenal switch complicated by large staple line leak proximal to stenosis. A 10Fr x 3cm DPPS was placed across the leak site. A 10Fr x 9cm DPPS was placed across the gastric stenosis and duodenal-ileal anastomosis. Serial dilation of stenosis began on POD45. All stents were removed on POD95 with resolution of leak and stenosis. Discussion: Transluminal DPPS placement across anastomotic leaks is an effective, well-tolerated, and cost-effective treatment option. This case series suggests that intraluminal DPPS placement may also be clinically beneficial by promoting GI flow and ultimately diverting away from the leak site. Intraluminal DPPS can be used singly or in combination with transluminal DPPS. Applicable scenarios include newly post-operative gastric sleeve stenoses or kinks where dilation is too high-risk and duodenal anastomotic leaks with concomitant anastomotic stricture (where metal stent placement would be challenging and dilation likewise risky). (Figure)Figure 1.: a) Endoscopic image of moderate stenosis of the mid gastric sleeve POD 5 precluding safe dilation; b) two intraluminal DPPS traversing sleeve stricture with symptom resolution ; c) improved sleeve stenosis and continued symptom resolution following DPPS removal

S1088 Comparison of Safety of Lumen Apposing Metal Stents With or Without Coaxial Plastic Stent Placement for the Management of Pancreatic Fluid Collections

Introduction: Lumen opposing metal stents (LAMS) allow for safe and effective endoscopic drainage of pancreatic fluid collections (PFCs). LAMS, however, have been associated with bleeding within the cavity and pseudoaneurysm formation. Placement of a coaxial double pigtail plastic stent (DPPS) may theoretically reduce this risk and that of symptomatic stent occlusion. The aim of this study is to compare the safety of LAMS alone versus LAMS with coaxial DPPS placement (LAMS/DPPS) for the management of PFCs. Methods: Patients who underwent LAMS placement for management of a PFC between Sep 2019 and Feb 2022 were retrospectively identified from a tertiary care center procedural data base. Cases were categorized as LAMS or LAMS/DPPS. Demographics, clinical characteristics, and outcomes were compared between the two cohorts. The primary outcome was the rate and type of adverse events between the groups. Secondary outcomes included clinical success rates and time to clinical success. Results: 185 unique patients were identified; 83 (44.9%) with LAMS drainage alone and 102 (55.1%) LAMS/DPPS. There were no significant differences in age, sex, PFC etiology, PFC type, size, or paracolic extension (Table). DPPS with 7Fr or 10Fr diameters were utilized with a median length of 4.0 cm (IQR 4.0-7.0). There were no significant differences in rates of clinical success, need for early necrosectomy, number of endoscopies, or number of necrosectomies. However, stent dwell time was significantly longer in the LAMS only group (69 vs. 35 days, p=0.017). Overall, AE rates were the same in the two cohorts (15.7%, vs. 15.7%, p=0.825). Bleeding occurred in 2 (2.4%) and 9 (8.8%) cases in the LAMS and LAMS/DPPS groups, respectively (p=0.067), with 4 confirmed cases of pseudoaneurysm bleeding (1 LAMS and 3 LAMS/DPPS, p=0.220). There were no differences in the rate of clinically significant stent occlusion (2.4% LAMS vs. 2.9% LAMS/DPPS, p=0.825) or migration (3.6% LAMS vs. 1.0% LAMS/DPPS, p=0.220). Incidental DPPS migration was noted in 12 (11.8%) cases, but all patients were asymptomatic. Conclusion: The safety profile of LAMS was similar to LAMS/DPPS in this cohort. The incidence of bleeding and occlusion was low overall and not significantly impacted by the presence of a DPPS. Randomized studies are needed to further elucidate the role of coaxial DPPS in drainage of PFCs. Table 1. - Baseline clinical characteristics and outcomes of patients who underwent placement of either lumen opposing metal stent (LAMS) alone or LAMS with coaxial double pigtail plastic stent (LAMS/DPPS) placement BASELINE CHARACTERISTICS LAMSN = 83 LAMS/DPPSN=102 P Value Age, y, median (IQR) 55.0 (45.5 – 65.0) 56.5 (42.8 – 65.0) 0.760 Female 22 (26.5) 41 (40.2) 0.051 Collection Type Walled-off necrosis Pseudocyst 64 (77.1)21 (25.3) 80 (78.4)22 (21.6) 0.550 Maximum diameter of dominant collection, cm, median (IQR) 12.0 (7.9 – 18.4) 11.0 (7.8 – 15.0) 0.098 Multiple collections 30 (36.6) 51 (50.0) 0.068 Paracolic extension 32 (38.6) 34 (33.3) 0.461 OUTCOMES LAMS dwell time, d, median (IQR) 69.0 (31.0 – 131.0) 35.0 (21.0 – 65.5) 0.017 Clinical success 63 (75.9) 71 (69.6) 0.341 Total therapeutic endoscopies, no., median (IQR) 2 (1 – 3) 3 (2 – 4) 0.216 Total necrosectomies, no., median (IQR) 1 (0 – 2) 1 (0 – 2) 0.976 Unplanned early necrosectomy 12 (14.6) 16 (15.7) 0.843 Incidental stent migration LAMS DPPS 1 (1.2)N/A 1 (0.9)12 (11.8) 0.883 Adverse Events LAMS Occlusion LAMS Migration Bleeding Infection 13 (15.7)2 3 26 16 (15.7)3194 0.9960.8250.2200.0670.322 Data reported as no. (%) unless indicated.

S2870 Successful Use of EUS-Guided Choledochoduodenostomy With LAMS in a Post-Liver Transplant Patient With Recurrent Choledocholithiasis and Cholangitis

Introduction: Biliary complications, like anastomotic stricture and cholangitis, are seen in 10-15% of orthotopic liver transplants (OLT). OLTs often require multiple endoscopic retrograde cholangiopancreatoscopy (ERCP) for recurrent disease. Endoscopic ultrasound guided choledochoduodenostomy (EUS-CD) has been effective in treatment of malignant distal biliary obstruction after failed ERCP; however, there are limited reports regarding EUS-CD in OLTs. We present a case of successful EUS-CD with lumen apposing metal stents (LAMS) in an OLT with recurrent cholangitis secondary to benign anastomotic stricture refractory to management with ERCP. Case Description/Methods: A 61-year old female with 3 OLTs (1996 and twice in 2008) for autoimmune hepatitis presented with recurrent cholangitis secondary to anastomotic biliary stricture in the setting of duct mismatch with a dilated common hepatic bile duct to 3 cm. She had recurrent choledocholithiasis measuring 3 cm despite prior mechanical and electrohydraulic lithotripsy with cholangioscopy confirmed clearance. As a result, she had undergone a total of 26 prior ERCP treatments (2012-2021). She underwent an EUS-CD with LAMS for definitive treatment. 2-weeks later, an upper endoscope was traversed through the LAMS to perform lithotripsy of remaining choledocholithiasis. At this time, the patient remains free of cholangitis for the past 8 months. (Figure) Discussion: Biliary complications, like anastomotic stricture and recurrent cholangitis, are a common occurrence in OLTs. With use of various ERCP techniques, obstructions can be removed or ameliorated. Timely treatment of cholangitis is imperative as the mortality rate is high (10-30%). With each cholangitis episode and subsequent ERCP, the cumulative procedural risk and mortality increases. EUS-CD has been demonstrated to be effective in treatment for malignant distal biliary obstruction after failed ERCP. Our patient had previously undergone 26 ERCPs and additionally was on Warfarin for pulmonary embolism putting her at very high risk for complications with additional future endoscopic procedures. This represents a case of successful use of EUS-CD with LAMS in a patient post-OLT with a significant distal common bile duct stricture which had been refractory to traditional management via ERCP. Long term studies are indicated to see if this can provide durable benefit.Figure 1.: 1A. MRI imaging demonstrating a large 3 cm choledocholithiasis within the dilated CBD, which formed as a result of bile stasis. 1B. CT coronal view demonstrating successful deployment of LAMS to complete EUS-CD. 1C. Fluoroscopic view of the standard upper scope traversing through the LAMS for definitive lithotripsy and dredging of remaining choledocholithiasis. 1D. Endoscopic view of the final LAMS placement with double pigtail plastic stents.

S2878 When One Stent Fails, Another One to the Rescue: A Novel Approach to Managing Small Post-Op Gastric Leaks Following Laparoscopic Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a commonly used procedure in the surgical management of Obesity. However, post-op complications such as gastric leaks and their sequelae pose challenges. We present a case of a novel alternative in managing a small contained post-op gastric leak, which was difficult to define radiographically but was visible endoscopically causing the patient symptoms. Case Description/Methods: A 47 year old female with history of prior LSG, hiatal hernia, pernicious anemia presented for revision of her LSG for continued weight gain and hernia repair for dyspepsia. Surgery was uneventful but on post-op day 25 she developed fever (101.5 F), tachycardia (HR125), BP 131/74, RR 18, Sat 96%. Suspecting gastric leak, CT scan was performed which showed only extraluminal bubbles (Panel 1). Despite a negative upper GI series she was placed on prophylactic antibiotics and 3 days later an EGD performed confirmed the presence of pus 3-4 cm below GE junction consistent with an anastomotic leak. (Panel 2). A therapeutic 23 x 150 mm fully covered esophageal metal stent was placed , however 6 days later she developed nausea, vomiting and left upper quadrant pain. Abdominal x-ray showed distal migration of the esophageal stent confirmed by subsequent EGD (Panel 3). At that point, the stent was removed and a 7 Fr x 7 cm plastic double pigtail stent was placed into the abscess cavity for drainage of purulent fluid (Panel 4) into the stomach. Successful drainage of the abscess was achieved and confirmed by repeat EGD on post-op day 83 indicating normal gastric mucosa. The pigtail stent was subsequently removed. The patient has since been asymptomatic. Discussion: Endoscopic stenting has been widely used to manage post-op LSG gastric leak by closing off the cavity and draining extra-luminally. However, its migration causes significant patient discomfort, allows persistent fluid collection and abscess formation, delays healing and prolongs hospital stay. We propose a novel technique of mimicking a transgastric pseudocyst drain using a double pigtail plastic stent as an effective method of treating a small post-op LSG gastric leak after esophageal stent migration. In our patient, this technique hastened recovery, and decreased morbidity- related outcomes and hence this technique can be considered as future first line treatment.Figure 1.: (1) CT Ab/Pelvis arrowhead notes extraluminal bubbles near the GE Junction (arrowhead) (2) EGD showing white fluid (pus) 3 – 4 cms below the EG junction consistent with post-op LSG gastric leak (3) EGD showing increased pus anterior to tip of migrated stent (arrowhead) (4) Placement of double pigtail for successful drainage of purulent material.

S1795 Portobiliary Fistula on Single Operator Cholangioscopy

Introduction: Portobiliary fistula formation is an exceedingly rare complication following endoscopic retrograde cholangiopancreatography (ERCP), with a scarcity of cases reported in scientific literature. Patients may present with ensuing—often fatal—gastrointestinal hemorrhage with challenges in diagnosis and management as a result. Case Description/Methods: We present a case of 78-year-old male who was found to have opacification of vascular structures on intraoperative cholangiography during laparoscopic cholecystectomy. This was concerning for the development of a biliary-vascular fistula. The patient had recently undergone ERCP with biliary stent placement at an outside facility for choledocholithiasis. Gastroenterology was consulted for endoscopic evaluation. An ERCP was performed. Selective biliary cannulation was achieved, and contrast was injected to identify an irregularity in the distal common bile duct with upstream dilatation up to 13 mm. No clear contrast extravasation was noted in the biliary tree. The biliary tree was then swept using a 15 mm extraction balloon with successful removal of gallstones and sludge. Despite multiple contrast injections, extravasation was not seen, as previously noted on intraoperative cholangiography. Therefore, single operator cholangioscopy was introduced and advanced to the hilum of the common hepatic duct. Examination revealed a small defect in the common bile duct communicating with a thrombosed vascular structure, likely a branch of the portal vein (Figure). After a multidisciplinary discussion with surgery service, a fully covered 10 mm by 8 cm metallic stent was placed across the defect, anchored by a second 7 French by 10 cm double-pigtail plastic stent, with trans-papillary drainage. Discussion: We present a novel approach for the identification and management of portobiliary fistulas. Our case demonstrates the utility of biliary stents in the management of this disease. Our patient tolerated the procedure well with no post-operative complications.Figure 1.: Portobiliary Fistula on Single Operator Cholangioscopy.

S1718 Delayed Gastrointestinal Hemorrhage From Visceral Artery Pseudoaneurysm in Necrotizing Pancreatitis After LAMS Removal

Introduction: Delayed bleeding from visceral artery pseudoaneurysm (PA) formation is an uncommon complication of lumen-apposing metal stent (LAMS) placement. Risk factors for gastrointestinal bleeding (GIB) in patients with LAMS remain largely undefined. We report a case of delayed GIB due to rupture of a splenic artery PA 16 months after LAMS removal. Case Description/Methods: A 34-year-old female with a history of severe necrotizing pancreatitis presented to our hospital with massive hematemesis. 23 months prior to presentation, she underwent uncomplicated placement of a 15x10 mm LAMS and 2 7 Fr x 4 cm double pigtail plastic stents for drainage of walled-off pancreatic necrosis. She was briefly lost to follow-up and returned for LAMS removal 5 months later. Contrast was injected into the residual cyst cavity and contrast filling was noted of what appeared to be a splenic vessel without active bleeding (Figure A). CT angiogram showed no PA but proximity of the splenic hilar vasculature to the LAMS (Figure B). The LAMS was successfully removed 2 months later without complication. On presentation, she was tachycardic but normotensive. Laboratory studies were notable for hemoglobin 8.8 g/dL (baseline 14 g/dL). Upper endoscopy showed brisk bleeding in the proximal gastric body near the area of prior LAMS. Her bleeding was refractory to endoscopic hemostatic maneuvers, and she underwent emergent mesenteric angiography. Angiography revealed active arterial extravasation arising from the inferior segmental branch of the splenic artery ( Figure C) which was successfully embolized with no further bleeding. Discussion: Visceral artery PA development after LAMS placement is thought to occur due to friction of the inner flange against regional vasculature surrounding the necrotic cavity as it collapses. Close anatomical proximity of LAMS to regional vasculature increases the risk of PA development. In our case, the LAMS was placed near the rich vascular supply of the splenic hilum. Most reported bleeding events related to LAMS have occurred within 8 weeks of placement. Our case is notable for the prolonged delay between LAMS removal and bleeding presentation. Adherent scar tissue between the gastric wall and vasculature could potentially cause delayed PA development after LAMS removal. This case reinforces that high clinical suspicion for PA bleeding is necessary for patients who have previously undergone distant LAMS removal who present with massive GIB.Figure 1.: (A) Fluoroscopic image of contrast injection into residual cyst cavity demonstrating opacification of likely splenic vasculature; (B) Coronal images demonstrating the proximity of the LAMS to the vasculature of the splenic hilum (yellow arrow); (C) Super-selective angiography demonstrating active extravasation into the lateral aspect of the stomach from a pseudoaneurysm (White arrow) involving an inferior segmental branch of the splenic artery.

Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives.

Background and study aims Therapeutic EUS (t-EUS) is increasingly being adopted in clinical practice in tertiary referral centers; however, little is known about radiation exposure (RE) metrics and diagnostic reference limits for it. Methods Kerma-area product (KAP [Gy·cm 2 ]), Air Kerma and fluoroscopy time were retrospectively evaluated for all consecutive t-EUS procedures performed in San Raffaele Institute between 2019 and 2021. For EUS-guided choledochoduodenostomies (EUS-CDS) and gastroenterostomies (EUS-GE), an equal number of endoscopic retrograde cholangiopancreatographies (ERCPs) plus metal stenting and duodenal stents were included respectively for comparison. Results Data from 141 t-EUS procedures were retrieved (49 % pancreatic cancer, 38 % peripancreatic fluid collections). EUS-CDS (N = 44) were mainly performed fluoroless, while ERCPs required a significantly higher RE (KAP = 25 [17–55], P < 0.0001). Fluid collection drainage (EUS-FCD) with lumen apposing metal stents (LAMS, N = 26) were performed fluoroless, while EUS-FCD with double-pigtail plastic stents (DPPS, N = 28) required higher RE (KAP = 23 [13–45]). EUS-guided gallbladder drainage (EUS-GBD, N = 6) required scarce RE (KAP = 9 [3–21]) for coaxial DPPS placement. EUS-GE (N = 27) required higher RE than duodenal stenting (KAP = 44 [28–88] versus 29 [19–46], P = 0.03). EUS-guided hepaticogastrostomies (EUS-HGS, N = 10) had the highest RE among t-EUS procedures (KAP = 81 [49–123]). Procedure complexity or intervening complications were evaluated and resulted in higher RE within each procedure. Conclusions t-EUS procedures have different RE ( P < 0.000001). EUS-CDS, EUS-GBD, and EUS-FCD with LAMS can be performed with no-to-mild radioscopy, unlike standard alternatives. However, radioscopy remains essential in case of technical difficulties or complications. EUS-GE and EUS-HGS involve a high RE. Endoscopists involved in t-EUS might experience RE higher than category standards, which indicates a need for increased awareness and personalized preventive measures.

Comparison of lumen-apposing metal stents versus double-pigtail plastic stents for infected necrotising pancreatitis

ObjectiveLumen-apposing metal stents (LAMS) are believed to clinically improve endoscopic transluminal drainage of infected necrosis when compared with double-pigtail plastic stents. However, comparative data from prospective studies are very limited.DesignPatients...

Management of pancreatic fluid collections.

Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).

Microbial Spectra and Clinical Outcomes from Endoscopically Drained Pancreatic Fluid Collections: A Descriptive Cohort Study.

Pancreatic pseudocyst (PC) and walled-off necrosis (WON) are dreaded complications of acute pancreatitis. Standard therapy consists of endoscopic ultrasound-guided transmural placement of stents to expedite resolution through internal drainage of fluids or necrotic material. Either double pigtail plastic stents (DPPS) or lumen-apposing metal stents (LAMS), or a combination of both, are available for this purpose. The objective of this study was to examine the impact of different stent types on infection rates in addition to clinical outcome measures such as periprocedural adverse events. We conducted a retrospective study comprising 77 patients who had undergone endoscopic drainage for PC or WON in a pancreatitis tertiary referral center. Analysis revealed that both bacterial and fungal infections occurred more frequently in patients treated with LAMS with or without DPPS compared to DPPS only. The use of antibiotics and antimycotics followed the same pattern. Furthermore, a prolonged length of hospital stay and a higher likelihood of transfer to an intermediate care unit were observed in patients with LAMS with or without DPPS. These differences were eliminated if only WON patients were analyzed. Our data imply that the clinical course is primarily influenced by the complexity of the pancreatic fluid collection (PFC) itself rather than the stent type. Prospective large-scale cohort studies are mandatory to underpin these findings.