EUS-guided Transgastric Drainage Research Articles

Mediastinal extension of a progressively enlarging pseudocyst treated by EUS-guided transgastric drainage in a child: A rare case report (with video).

Mediastinal extension of a progressively enlarging pseudocyst treated by EUS-guided transgastric drainage in a child: A rare case report (with video).

S1727 Endoscopic Ultrasound-Guided Transgastric Drainage of an Infected Biloma After Cholecystectomy: A Case Report

Introduction: A biloma is a well-defined collection of bile outside the biliary tree typically caused by iatrogenic disruption of a bile duct. Percutaneous drainage is the traditional treatment modality with surgery reserved for refractory cases. Endoscopic ultrasound (EUS) guided transenteric drainage has emerged as a suitable alternative. We present a case of an infected post-cholecystectomy biloma treated using EUS-guided drainage with a transgastric LAMS. Case Description/Methods: A 57-year-old female presented with fevers, abdominal pain, nausea, and vomiting following a laparoscopic cholecystectomy for acute cholecystitis 12 days prior. Labs noted a leukocytosis with normal liver chemistries. CT scan of the abdomen showed a peripherally enhancing gas and fluid collection in the subhepatic space measuring 14.5 x 7 x 8 cm, resulting in a mass effect on the antrum and proximal duodenum. Gastroenterology was consulted for the management of suspected bile leak and infected biloma. Endoscopic retrograde cholangiography (ERC) revealed a bile leak with contrast extravasation from the cystic duct stump. This was treated with biliary sphincterotomy and placement of a 10 Fr x 7 cm plastic biliary stent. Same session EUS demonstrated a large fluid collection abutting the antrum with a well-defined wall. EUS-guided drainage of the biloma was performed using a 15 x 10 mm electrocautery enhanced LAMS via a transgastric approach. Approximately 1 L of purulent fluid was evacuated from the cavity. A subsequent CT scan confirmed the correct positioning of the LAMS with marked cavity decompression (Figure). The patient’s symptoms resolved. Endoscopy with LAMS removal and placement of 2 10 Fr x 4 cm double pigtail stents (DPT) was performed 1 week later. CT 1 week after DPT placement noted near-complete resolution of the fluid collection. Six weeks after the index procedure, ERC showed resolution of the cystic duct leak and the biliary stent was removed. Both DPTs were removed 2 weeks later. The patient has remained well clinically. Discussion: EUS-guided transenteric biloma drainage is a safe and effective alternative to percutaneous drainage. Initial cases were performed using plastic stents but more recently, transduodenal drainage with a LAMS was reported. Endoscopic drainage also enables same session identification and treatment of the culprit bile leak which is essential to prevent biloma recurrence. Our case is the first reported EUS-guided transgastric drainage of an infected biloma using a LAMS.Figure 1.: A. CT scan illustrating a large subhepatic fluid and gas-containing collection (Black arrow) with resultant gastric outlet obstruction (red arrow). B. Successful placement of a transgastric lumen apposing metal stent (LAMS) into the biloma cavity with immediate drainage of purulent fluid. C. Post-drainage CT scan demonstrating biloma cavity decompression and appropriate positioning of the LAMS (green arrow).

Interventional endoscopy in hepatico-pancreatico-biliary disease

Interventional endoscopy in hepatico-pancreatico-biliary disease Abstract. Interventional endoscopy has undergone an exciting evolution in recent years, especially in the treatment of hepatico-pancreatico-biliary disease. However, novel endoscopes have also improved diagnostics through direct visualization of the biliary tract and the pancreatic duct, including targeted biopsy-sampling of suspicious endoluminal lesions. The use of cholangioscopy also allows for lithotripsy of complex gallstones under direct visualization. In patients with malignant biliary obstruction, endosonography(EUS)-guided insertion of novel lumen-apposing metal stents allow for extraanatomical access to intra- or extrahepatic bile ducts, if traditional transpapillary stent insertion fails. Especially in patients with altered anatomy e. g., after surgery, EUS-guided transgastric drainage may be the most sensible approach. Using similar techniques, EUS-guided drainage of the pancreatic duct is also possible. Local tumor therapy may be achieved with novel endoscopic retrograde cholangiography-guided catheter-based radiofrequency ablation and photodynamic therapy. In chronic pancreatitis, similar to biliary disease, methods of endoluminal diagnosis, lithotripsy, and transgastric drainage may also be applied. This article provides an overview of novel endoscopic techniques and methods that are available in hepatico-pancreatico-biliary disease.

EUS-guided Transgastric Drainage to Manage a Postoperative Pancreatic Fistula After Distal Pancreatectomy and Splenectomy in Recurrent Ovarian Cancer: A Case Report

Postoperative pancreatic fistula after distal pancreatectomy represents the most frequent procedure-related complication; however, a standard treatment is currently not available. We herein report a case of postoperative pancreatic fistula after distal pancreatectomy and splenectomy in a patient affected by a platinum-sensitive ovarian cancer recurrence. The 59-year-old patient developed a pancreatic fistula on postoperative day 4. An endoscopic transgastric double-pigtail drainage was placed on postoperative day 13. The patient was discharged after 5 days and referred to adjuvant medical treatment. A month later, computed tomography revealed complete resolution of the fistula, the drainage was removed, and the patient continued chemotherapy. She recovered uneventfully at a 3-month follow-up. EUS-guided drainage is a viable option in the management of postoperative pancreatic fistula, which can lead to a rapid resolution of peripancreatic fluid collections and to initiation of adjuvant chemotherapy with the slightest delay in ovarian cancer patients.

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

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.

Endoscopic ultrasonography-guided transgastric drainage of pancreatic fluid collections with a novel lumen-apposing metal stent

Objective To evaluate the efficacy and safety of a novel lumen-apposing metal stent(LAMS) in endoscopic ultrasonography(EUS)-guided transgastric drainage of pancreatic fluid collections(PFC). Methods A retrospective study of 46 patients was performed who underwent EUS-guided transgastric drainage of PFC with placement of LAMS from September 2015 to April 2017. Clinical data were reviewed and follow-up data were obtained by telephone and outpatient contact. Results A total of 49 LAMS were placed in 46 patients (2 LAMS were placed in 3 patient respectively for multiport access). The operation success rate was 95.9%(47/49), complications occurred in 14 patients(31.8%), including 2 severe complications (delayed hemorrhage and peritonitis). Additional intervention was performed in 10 patients(22.7%). The mean hospital stay was 6 days (1-40 days) and patients were followed for a mean time of 18.4 months (9-28 months). Treatment success was achieved in 40 patients(90.9%). Stent removal was performed after a mean time of 59.4 days (20-142 days), and recurrence rate was 10%(4/40) during the follow-up period. Conclusion Drainage of PFC using LAMS with special design is effective and relatively safe. Key words: Stents; Endosonography; Pancreatic fluicl collection; Drainage

EUS-guided transgastric drainage of a peripancreatic collection containing an arterial bypass graft

A 63-year-old man was admitted with aortic dissection and acute thrombosis of the superior mesenteric artery in May 2013. After urgent surgical arterial bypass, he experienced postoperative mesenteric ischemia, pancreatitis, and bleeding, requiring 2 additional surgical interventions. Subsequently, he experienced pancreaticocutaneous fistula and abdominal sepsis; after a lengthy hospital stay, he was discharged in September. One day after discharge he was readmitted for fever related to Pseudomona and Serratia spp infection of a peribypass collection, which was treated with percutaneous drainage twice, and 4 courses of antibiotics for recurrent bacteriemia until April 2014, when recurrence of the peribypass collection was diagnosed. Because of the patient’s unacceptable surgical risk, EUS-guided transgastric drainage of the collection with the arterial bypass floating inside (Fig. 1) was completed (Video 1, available online at www.giejournal. org). A double pigtail stent was inserted, followed by a nasocystic catheter for continuous lavage during 1 week. After 4 weeks, a CT scan confirmed resolution of the collection, and the transgastric double-pigtail stent was retrieved uneventfully. He has been asymptomatic except for an episode of fever, which resolved with antibiotics without recurrence of fluid collection during 9 months of follow-up.

Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video)

Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays. To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays. Retrospective, single-center study. Academic tertiary care center. Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs. EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution. Clinical success, number of repeat interventions, and length of hospital stay. Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events. Small, retrospective study. The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.

Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs. To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections. Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database. Single, academic, tertiary referral center. Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified. CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD) MAIN OUTCOME MEASURES: Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery. PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1-5] in the PD group and two [range 1-5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2-87] in the PD group versus 57 [range 32-217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer. Retrospective, nonrandomized study and small numbers. EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.

A case of spontaneous biloma successfully treated by EUS-guided transgastric drainage

A case of spontaneous biloma successfully treated by EUS-guided transgastric drainage

EUS Guided Transmural Pseudocyst Drainage Using Non-Thermal Technique

EUS guided transmural drainage is emerging as the leading treatment modality of symptomatic pancreatic pseudocysts. The aim of this study is to describe our centre's experience with EUS-guided transgastric drainage using track dilatation technique.

EUS-guided transgastric drainage of caudate lobe liver abscesses.

Pyogenic liver abscess is a rare but serious condition resulting in significant morbidity and mortality if left untreated. The first line treatment for hepatic abscess is the transcutaneous or surgical approach with an 80-100% success rate. However, these modalities are associated with numerous risks including bleeding, biliary peritonitis, fistula formation, and patient discomfort. The caudate lobe is anatomically difficult to access percutaneously. Given its proximity to the stomach, a transgastric approach to drainage is feasible. We report two consecutive patients who underwent EUS-guided transgastric drainage of a caudate lobe abscess.

Endoscopic therapy of a splenic abscess: definitive treatment via EUS-guided transgastric drainage

Splenic complications of pancreatitis are exceedingly rare, occurring in only 2.2% of cases. Patients typically present in a dramatic fashion and often need an urgent procedure to prevent overwhelming infection or hemorrhage. Historically, the procedures involve surgery (distal pancreatectomy and splenectomy) or percutaneous drainage. Walter Reed Army Medical Center. A patient with acute or chronic pancreatitis presented with pleuritic chest pain and fever up to 105 degrees F (40.6 degrees C). A CT of the abdomen and the pelvis demonstrated a splenic abscess. Because of the technical inability to perform transpapillary drainage, EUS-guided transgastric drainage resolved the splenic abscess. This is the first reported case of a splenic abscess treated definitively with endoscopic therapy. In the face of a worsening clinical picture and reported morbidities up to 79% with surgical and percutaneous drainage procedures, endoscopic therapies should be considered in the management of splenic complications of pancreatitis.