Management Of Pancreatic Fluid Collections Research Articles

Severe acute pancreatitis in the era of endoscopically placed lumen-apposing metal stents (LAMS): critical care outcomes from a large UK pancreatobiliary centre

Objectives1. Describe characteristics of patients with severe acute pancreatitis (SAP) requiring admission to Critical Care, including interventional management of pancreatic fluid collections.2. Quantify whether patients requiring drainage of collections via...

Coaxial plastic stent placement within lumen-apposing metal stents for the management of pancreatic fluid collections: a systemic review and meta-analysis.

Coaxial placement of double pigtail plastic stents (DPPS) through lumen-apposing metal stents (LAMSs) is commonly performed to reduce the risk of LAMS obstruction, bleeding, and stent migration when used for the drainage of pancreatic fluid collections (PFCs). A systematic review and meta-analysis were performed to compare the outcomes of LAMS alone and LAMS with coaxial DPPS placement in the management of PFCs. A systematic review was conducted to identify studies comparing LAMS and LAMS/DPPS for PFC drainage. Primary outcomes included the rate of clinical success, overall adverse events (AEs), bleeding, infection, occlusion, and stent migration. The pooled effect size was summarized using a random-effects model and compared between LAMS and LAMS/DPPS by calculating odds ratios (ORs). Nine studies involving 709 patients were identified (338 on LAMS and 371 on LAMS/DPPS). LAMS/DPPS was associated with a reduced risk of stent obstruction (OR, 0.59; p=0.004) and infection (OR, 0.55; p=0.001). No significant differences were observed in clinical success (OR, 0.96; p=0.440), overall AEs (OR, 0.57; p=0.060), bleeding (OR, 0.61; p=0.120), or stent migration (OR, 1.03; p=0.480). Coaxial DPPS for LAMS drainage of PFCs is associated with a reduced risk of stent occlusion and infection; however, no difference was observed in the overall AE rates or bleeding.

Role of imaging in evaluating the complications of endoscopic management of pancreatic fluid collections in acute pancreatitis.

Acute pancreatitis is associated with local and systemic complications. Pancreatic fluid collection (PFC) is the most common local complication. Infected or symptomatic PFCs need drainage. Endoscopic drainage (ED) is the first-line procedure for accessible PFCs adjacent to the stomach and duodenum. ED is performed under endoscopic ultrasound (EUS) guidance. The technical and clinical success rates of EUS-guided ED in well-encapsulated PFCs are high. ED of poorly encapsulated PFCs is associated with complications. Bleeding and perforation are the most common complications. Contrast-enhanced computed tomography is critical in planning ED and early detection and management of complications. With the increasing utilization of ED for PFC, the radiologist must be familiar with the ED techniques, types of stents, and the complications related to ED. In this review, we discuss the technical aspects of the ED as well as the imaging findings of ED-related complications.

Management of pancreatic fluid collections and pseudocysts

Management of pancreatic fluid collections and pseudocysts

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.

Analysis of adverse events with lumen apposing metal stents for drainage of pancreatic fluid collections

Abstract Background and study aims Innovations in endoscopic management of pancreatic fluid collections (PFCs) using lumen apposing metal stents (LAMS) have rendered it a preferred approach for drainage of PFCs. These advances have not come without concern for adverse events (AEs). We present our experience with LAMS for drainage of PFCs and analyze factors that contribute to LAMS-related AEs. Patients and methods From November 2015 to October 2021, a retrospective analysis was performed of patients undergoing endoscopic management of PFCs using LAMS. All AEs were classified as either early (<48 hours) or late (>48 hours). Univariate and multivariate analysis were performed using logistic regression to assess the relationship between independent variables and AEs. Results A total of 119 patients with symptomatic PFCs underwent endoscopic drainage with LAMS. There were 16 AEs (12.4%). These included systemic inflammatory response syndrome (SIRS) (n=2), stent occlusion (n=5), bleeding (n=7), and stent migration (n=2). Univariate analysis of risk of AEs showed that no variables approached statistical significance. Of the seven patients who developed bleeding, five had pseudoaneurysms following LAMS placement and underwent angioembolization by an interventional radiologist. The average time to bleeding was 9.3 days (standard deviation 7.3) with all bleeding events occurring within 3 weeks. In a multivariate model, pseudocysts and presence of paracolic gutter extension were associated with an increased risk of bleeding. Conclusions Endoscopists should be aware of the risk factors for LAMS-related bleeding and tailor their drainage strategy, including utilization of plastic stents for drainage of pseudocysts and adherence to a strict imaging interval and follow-up protocol.

Liver Biopsy and Pressure Hemodynamics: GI Perspective

AbstractEndoscopic ultrasound (EUS) has come a long way from mere diagnostic modality to performing interventional procedures like fine needle aspiration, gastric varices glue and coiling, and management of pancreatic fluid collection along with necrosectomy. Recently, EUS-guided biopsy of the liver has gained traction. This coupled with the ability to access the portal vein and measure portal pressure has made comprehensive liver evaluation possible using endoscopic route. In this review, we will discuss evolution and techniques of performing EUS-guided liver biopsy and portal pressure gradient. We will also compare the merits and demerits as compared with the other conventional techniques.

Lumen-apposing metal stents with or without coaxial plastic stent placement for the management of pancreatic fluid collections

Coaxial double-pigtail plastic stent (DPPS) placement is often performed within lumen-apposing metal stents (LAMSs) for drainage of pancreatic fluid collections (PFCs) to prevent adverse events (AEs) such as stent occlusion and bleeding. This study compares the safety and outcomes of LAMSs alone versus LAMSs with coaxial DPPSs for PFC management. Patients undergoing drainage of a PFC with LAMSs were retrospectively identified and categorized as LAMS or LAMS/DPPS based on initial drainage strategy. The AE rate, AE type, and clinical success were extracted by chart review. One hundred eighty-five individuals (83 LAMS, 102 LAMS/DPPS) were identified. No significant differences were found in rates of clinical success (75.9% LAMS vs 69.6% LAMS/DDPS, P= .34) or overall AEs (15.7% LAMS vs 15.7% LAMS/DPPS, P= .825). In this comparative single-center study, placement of a coaxial DPPS for drainage of PFCs with LAMSs did not affect rates of AEs or clinical success.

Pancreatic Fistulas: Current Evidence and Strategy-A Narrative Review.

Pancreatic fistulas are highly feared complications following surgery on or near the pancreas, abdominal trauma, or severe inflammation. These fistulas arise from leaks in the pancreatic ductal system, leading to various complications such as abscesses, delayed gastric emptying, and hemorrhage. Severe cases present with sepsis or organ failure, dramatically increasing mortality and morbidity. Risk factors include smoking, high BMI, male gender, age, and surgery-related factors like prolonged operation time and non-ligation of the main pancreatic duct. Therefore, treatment options and preventive measurements have become a hot topic in recent years. Studies have investigated the use of fibrin sealants, different closure methods, and less invasive surgical techniques. Treatment options consist of conservative measurements and the use of percutaneous drainage, prophylactic transpapillary stenting, and surgery in severe cases. As EUS has become widely available, transmural stenting started to influence the management of pancreatic fluid collections (PFCs). However, studies on its use for the management of pancreatic fistulas are lacking. Medical treatment options like somatostatin analogs and pasireotide have been investigated but yielded mixed results.

Management of Pancreatic Fluid Collections: An Evidence-based Approach.

Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.

Is Cystogastrostomy a Definitive Operation for Pancreatitis Associated Pancreatic Fluid Collections?

Pancreatic-enteric drainage procedures have become standard therapy for symptomatic pancreatic pseudocysts and walled-off pancreatic necrosis. The need for pancreatic resection after cyst-enteric drainage procedure in the event of recurrence is not well studied. This study aimed to quantify the percentage of patients requiring resection due to recurrence after surgical cystogastrostomy and identify predictors of drainage failure. A single-institution retrospective review was conducted to identify all patients undergoing surgical cystogastrostomy between 2012 and 2020. Demographic, disease, and treatment characteristics were identified. Failure of surgical drainage was defined as the need for subsequent pancreatic resection due to recurrence. Characteristics between failure and nonfailure groups were compared with identifying predictors of treatment failure. Twenty-four cystogastrostomies were performed during the study period. Three patients (12.5%) required a subsequent distal pancreatectomy after surgical drainage. There was no difference in comorbidities between drainage alone and failure of drainage groups. Mean cyst size seemed to be larger in patients that underwent drainage alone versus those that needed subsequent resection (15.2 vs 10.3cm, P =0.05). Estimated blood loss at initial operation was similar between groups (126 vs 166mL, P =0.36). Surgical pancreatic drainage was successful in the initial management of pancreatic fluid collections. We did not identify any predictors of failure of initial drainage. There was a trend suggesting smaller cyst size may be associated with cystgastrostomy failure. Resection with distal pancreatectomy for walled-off pancreatic necrosis and pancreatic pseudocysts can be reserved for cases of failure of drainage.

Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome.

Disconnected pancreatic duct syndrome (DPDS) is an important and common complication of acute necrotizing pancreatitis. Endoscopic approach has been established as the first-line treatment for pancreatic fluid collections (PFCs) with less invasion and satisfactory outcome. However, the presence of DPDS significantly complicates the management of PFC; besides, there is no standardized treatment for DPDS. The diagnosis of DPDS presents the first step of management, which can be preliminarily established by imaging methods including contrast-enhanced computed tomography, ERCP, magnetic resonance cholangiopancreatography (MRCP), and EUS. Historically, ERCP is considered as the gold standard for the diagnosis of DPDS, and secretin-enhanced MRCP is recommended as an appropriate diagnostic method in existing guidelines. With the development of endoscopic techniques and accessories, the endoscopic approach, mainly including transpapillary and transmural drainage, has been developed as the preferred treatment over percutaneous drainage and surgery for the management of PFC with DPDS. Many studies concerning various endoscopic treatment strategies have been published, especially in the recent 5 years. Nonetheless, existing current literature has reported inconsistent and confusing results. In this article, the latest evidence is summarized to explore the optimal endoscopic management of PFC with DPDS.

Evolution of interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.

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.

Feasibility and Safety of Bedside Percutaneous Catheter Drainage of Necrotic Pancreatic Fluid Collections in the Intensive Care Unit

Abstract Purpose Critically ill patients with acute pancreatitis (AP) require intensive care unit (ICU) admission. The management of pancreatic fluid collections (PFCs) in this group is challenging. We aimed to evaluate the feasibility and safety of bedside percutaneous ultrasound (USG)-guided interventions in necrotic PFC in ICU patients. Methods This retrospective study comprised consecutive patients with AP in the ICU who underwent bedside USG-guided interventions for necrotic PFC. Indications for intervention, technical success, clinical success, and complications were recorded. The site, number, and size of catheters were recorded. Clinical outcomes were assessed. Results Thirty-three patients (mean age, 38.1 years, 15 females) were included. All patients had nonresolving organ failure and were on mechanical ventilation. The mean pain to percutaneous catheter drainage (PCD interval was 42.2 days (range, 7–167 days). All the procedures were technically successful, and none of the patients required shifting to the interventional radiology suite for computed tomography guidance. PCD was clinically successful in 40% of the patients. There were no major complications. The mean length of hospital stay and ICU stay was 35 days (range, 6–69 days) and 13 days (range, 1–63 days), respectively. Six (17.1%) patients underwent necrosectomy. Sixteen (45.7%) patients died in the hospital. Conclusion USG-guided bedside PCD can be performed safely with high technical success in the ICU setting.

EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience

Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n= 16) and management of pancreatic fluid collections (n= 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n= 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n= 28) and EUS-guided cystgastrostomy (n= 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P= .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

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).

P-P36 AXIOS™ stents in the management of pancreatic fluid collections: case series from a single healthcare trust

Abstract Background This was a consecutive case-series of all pancreatic fluid collections (PFCs) managed with AXIOS™ stents in a 3 year period from a single healthcare trust, retrospectively analysed to determine the rate of technical success, clinical success and adverse events related to the procedure. Methods All patients in who underwent AXIOS stenting for PFCs in the Belfast Health and Social Care Trust between May 2016 and July 2019 were included, with a follow-up period of 1 year. Electronic care records (ECR) and Radiology reports were reviewed for each patient. PFCs were categorised into walled-of pancreatic necrosis (WOPN) and pseudocysts as per the revised Atlanta classification. The number of repeat procedures, endoscopic lavage +/- necrosectomy, the need for definitive surgery or any adverse events post-procedure were recorded. Results 45 patients were included in the study (21 male, 24 female). 17 patients (37.8 %) had WOPN and 28 (62.2 %) pancreatic pseudocysts. Median collection diameter on CT imaging was 12 cm (range 6.2 – 22 cm). The procedure was technically successful in 43 patients (95.6%), with stent mal-deployment in the remaining 2. Median duration for stenting was 29.5 days (Range 13 – 92). The procedure was clinically successful for 33 patients (73.3%). n = 8 (17.8%) of patients were re-admitted with sepsis following stent insertion requiring intravenous antibiotics. n = 16 (35.6%) patients required repeated endoscopic lavage +/- necrosectomy following stent blockage (n = 11 WOPN, n = 5 pseudocyst). n = 2 (4.4%) stents accidentally dislodged during lavage necessitating surgical removal. n = 4 (8.9%) patients required a second AXIOS stent within 45 days of removal, n = 2 (4.4%) required CT guided drainage and n = 8 (17.8%) ultimately required surgical intervention.The rate of adverse events post-procedure was 33.3%. Conclusions AXIOS stenting appears to be effective first-line in the “step-up” approach to managing PFCs. Despite some drawbacks, our study showed they were technically successful in 95.6% and clinically successful in 73.3% of cases, requiring no further intervention. For PFCs that do require surgery, AXIOS stenting may allow for a period of patient optimisation prior to definitive treatment.

TP6.1.6 The management of pancreatic fluid collections with AXIOS stenting in Belfast HSCT

Abstract Aims To assess the viability of using lumen-apposing self-expandable AXIOS stents, inserted under endoscopic ultrasound guidance, in the management of pancreatic fluid collections (PFCs) within the Belfast Health and Social Care Trust. Methods Data for all AXIOS stents inserted endoscopically between May 2016 and July 2019 were included. Electronic care records (ECR) and Radiology reports were reviewed for each patient. PFCs were categorised into walled-of pancreatic necrosis (WOPN) and pseudocysts, and the number of repeat procedures, OGDs with lavage, or the need for definitive surgery were recorded. The timeframe to surgery and whether PFCs recollected was also noted. Results 45 AXIOS stents were inserted for PFCs in the audit period. n = 17 (37.8%) were for WOPN, n = 28 (62.2%) for pseudocysts. Mean duration of stenting was 38 ± 19.7 days. n = 11 (35.6%) patients were readmitted for sepsis with stent in situ, and n = 16 (35.6%) required OGD and lavage for stent blockage (n = 11 WOPN; n = 5 pseudocyst). n = 2 (4.4%) stents accidentally dislodged during lavage necessitating surgical removal. n = 4 (8.9%) patients required a second AXIOS stent following removal, n = 2 (4.4%) required CT guided drainage and n = 8 (17.8%) ultimately required surgical intervention. Conclusions Despite some drawbacks, including the need for intermittent OGD and lavage to maintain patency, AXIOS stenting appears to be effective first-line management for PFCs. Our audit showed they were successful in 71% of cases, requiring no further intervention. In PFCs that do require surgical management, AXIOS stenting may represent an effective bridge to surgery allowing for patient optimization before definitive care.

The Role of Contrast-Enhanced Harmonic Endoscopic Ultrasound in Interventional Endoscopic Ultrasound

Over the last decades, contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) has emerged as an important diagnostic tool for the diagnosis and differentiation of several gastrointestinal diseases. The key advantage of CH-EUS is that the influx and washout of contrast in the target lesion can be observed in real time, accurately depicting microvasculature. CH-EUS is established as an evidence-based technique complementary to B-mode EUS to differentiate solid appearing structures, to characterize mass lesions, and to improve the staging of gastrointestinal and pancreatobiliary cancer. In the last few years, interest has increased in the use of CH-EUS in interventional procedures such as tissue acquisition, tumor ablation, biliary drainage, and the management of pancreatic fluid collections. The aim of this narrative review is to evaluate the available evidence and future expectations of CH-EUS in interventional EUS.