Drainage Of Pancreatic Fluid Collections Research Articles

EUS-guided stent removal in buried lumen-apposing metal stent syndrome: a case series.

Background and AimsLumen-apposing metal stents (LAMSs) play an increasing role in transgastric and transduodenal drainage of pancreatic fluid collections and allow novel EUS-guided interventions. Alongside the main adverse events of bleeding and occlusion, LAMSs can be overgrown by mucosa, which leads to the inability to visualize the stent in endoscopy.MethodsWe describe a series of 4 cases of buried LAMSs that were removed under EUS guidance for identification of the stent followed by removal with rat-tooth forceps.ResultsThe median in situ time of the LAMSs in the reported 4 cases was 53 days. All stents could no longer be visualized endoscopically when drainage of necrosis was complete. All 4 buried LAMSs could be identified by EUS and were removed successfully with forceps. In 1 case, balloon dilation of the stent tract was performed before stent removal. No adverse events were observed after the procedure.ConclusionsBuried stent syndrome is a rare adverse event of LAMSs. Here we describe a safe and effective approach for stent identification and removal without prior mucosal dissection.

3162 Through the Scope Retrieval of a Migrated AXIOS Stent

INTRODUCTION: Endoscopic drainage of pancreatic fluid collections (PFC) is widely accepted modality of therapy due to its less invasive nature, shorter recovery time, lower cost and complication rates. Lumen apposing covered self-expandable metallic stents (LACSEMS) are increasingly utilized in the management of PFC. LACSEM have excellent safety profile and adverse effects are generally low. Rare migration of these LACSEMS has been described, noted at follow up, both in to the enteral lumen as well in to the cyst cavity. We here by present a case of AXIOS stent migration in to PFC that was successfully retrieved. CASE DESCRIPTION/METHODS: A 33 year-old Caucasian male with H/O ETOH related pancreatitis presented with 3 months of intermittent nausea and vomiting with nearly 100-pound weight loss. CT abdomen showed a 24 × 21 × 14 cms PFC causing GOO (Figure 1). Under EUS guidance, a 15 × 10 mm hot AXIOS stent (Xlumena Inc., Mountain view, CA, USA) was deployed by transgastric approach in to the cyst but the stent migrated in to the cavity. A second 15 × 10 mm hot AXIOS stent was successfully placed in to the cyst (Figure 2). The lumen of the AXIOS stent in good position was dilated to 15 mm using a wire guided CRE balloon. Large amount of necrotic material was visualized in the cyst cavity. Through the stent necrosectomy was performed. The migrated stent within the cyst was localized by fluoroscopy. Under endoscopic and fluoroscopic guidance, attempt at grabbing the migrated stent with forceps and removal through the stent in good position was unsuccessful. Few days later, migrated stent removal was attempted again. A therapeutic scope was advanced through the AXIOS in good position in to the WON cavity. The migrated stent was grabbed with a Rat-Tooth forceps and was pulled in to the working channel and successfully removed through the scope (Figure 3). DISCUSSION: In our case, the AXIOS stent migrated in to the WON cavity at the time of initial deployment necessitating a second AXIOS stent placement. Immediate removal of the migrated stent was not pursued due to risk of dislodging the second stent in good position. Subsequently, after endoscopic necrosectomies and improved WON size, the migrated stent was removed by intubating the WON with a therapeutic gastroscope through the AXIOS stent in good position and pulling the migrated stent in to the working channel of the gastroscope. To the best of our knowledge, retrieval of a migrated LACSEMS inside a WON through the scope via an AXIOS stent has not been previously described.

2134 Drainage of a Mediastinal Abscess After Esophagectomy Using a Lumen-Apposing Metal Stent

INTRODUCTION: Endoscopic ultrasound (EUS) is an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy1. Therapeutic EUS has found a role in management of pancreatic fluid collections, biliary and pancreatic duct drainage, and drainage of mediastinal and intra-abdominal abscesses and collections1. We present a case of a mediastinal abscess drainage after esophagectomy using a Lumen-apposing metal. To our knowledge, this is the second case using a Lumen-apposing metal stent for mediastinal collections2. CASE DESCRIPTION/METHODS: Case Summary: This is a case of a 75-year-old man with esophageal adenocarcinoma s/p transhiatal esophagectomy complicated by recurrent pleural effusions, ischemic colitis requiring right hemicolectomy and end ileostomy who presented to the ED from rehab because of abnormal lab findings of hypernatremia and leukocytosis. During his hospital stay, the patient developed persistent fevers and leukocytosis. A CT scan of the chest revealed a large posterior mediastinal collection adjacent to the gastric pull-through that coursed inferiorly into the peritoneum. The collection measured 8 cm × 4.1 cm x 12 cm in size and was presumed to be the source of infection. The case was discussed amongst the surgical oncologist, thoracic surgeon, interventional radiologist, and advanced endoscopists. Options for drainage included repeat surgery, percutaneous drain placement, and endoscopic drainage. The consensus opinion was to drain the collection internally by endoscopic ultrasound. The patient underwent a successful EUS-guided abscess drainage with a lumen apposing metal stent. The patient drastically improved after internal drainage with the lumen apposing metal stent. Fevers and leukocystosis resolved. Follow-up CT scan of the chest 10 days later demonstrated a resolution of the mediastinal collection. DISCUSSION: Conclusion: Although developed for drainage of pancreatic fluid collections, this case demonstrates that lumen apposing metal stents can be safely used to drain mediastinal collections. Our literature review identified one other case that utilized a lumen-apposing metal stent to drain a mediastinal abscess2. This stent seems to be useful and safe for mediastinal drainage. We recommend a multidisciplinary discussion with surgeons and radiologists when dealing with large mediastinal collections that require drainage.

934 Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections Using AXIOS Electrocautery Enhanced Delivery System a Retrospective Experience at a Large Quaternary Care Center

INTRODUCTION: Pancreatic fluid collections (PFC) are common complications of acute pancreatitis, surgery, or trauma. Many PFC reabsorb spontaneously but the remainder create cystic structures filled with fluid and/or with necrotic debris. Since the development of lumen apposing metal stents (LAMS) first line treatment of PFCs are with EUS guided drainage. However, despite the high technical and clinical success of the commonly used Electrocautery Enhanced AXIOS LAMS (EEAL), outcome data is still scarce. METHODS: An IRB approved, retrospective chart review, was performed on EUS-guided drainage of PFC using EEAL at a large quaternary care, teaching hospital. Specific procedural data including technical success rate, adverse events, and length of stay were collected. Descriptive statistics were then used to report outcomes. RESULTS: A total of 43 EEAL were used in the treatment of pancreatic pseudocysts (41.9%) and walled off pancreatic necrosis (65.1%). LAMS were placed successfully in 100% of procedures and required revisions in 28.6% of patients. Adverse events occurred in 16.3% of interventions: 2 bleeding events (4.7%), 3 stent migrations (7%), 1 pigtail stent occlusion (2.4%) and 1 spontaneous pancreatic fistula formation (2.4%). Only 2 patients (4.8%) required subsequent surgical resection. The average hospital stay after the procedure was 6.79 days (median of 3 days) and stents were ultimately removed on average at 24.68 days. CONCLUSION: This study demonstrated 100% technical success rate. Of the recorded adverse events after EEAL use in drainage of PFC most were subclinical and minor. Importantly, only two patients required further surgical intervention to obtain desired outcome. Furthermore, length of stay was particularly low with median hospital stay of 3 days. Ultimately, this study highlights how EEAL provides high value care by providing an efficient intervention in a cost-feasible length of time. Further ongoing prospective studies will help determine the utility of EEAL in the practice setting.

1691 Lumen-Apposing Metal Stent Assisted ERCP in Stenosis Associated With Silastic Ring in Vertical Banded Gastroplasty

INTRODUCTION: Lumen-apposing metal stent is being increasingly used for transmural drainage of pancreatic fluid collections (PFC). More recently, certain off label uses for LAMS are being explored1 such as benign gastrointestinal strictures, gastrojejunostomy, and gastro-gastrostomy. Here we present a case of LAMS-assisted ERCP for stenosis in a patient with silastic ring vertical banded gastroplasty. CASE DESCRIPTION/METHODS: An 82yo F with h/o breast cancer and diabetes mellitus type 2 was referred for EUS guided biopsy of a pancreatic head mass identified on CT scan of the abdomen, performed during evaluation of abdominal pain. The patient had normal liver enzymes. An EUS was planned for biopsy of pancreatic mass. At the time of the procedure, a benign-appearing, severe, intrinsic stenosis was found in the gastric body. An echoendoscope could not be advanced across this mid-gastric body stenosis, despite balloon dilation to 15mm. No significant mucosal disruption was seen. It was suspected that the stenosis was due to adhesions related to the silastic ring. A 15 mm × 10 mm LAMS was deployed across the stenosis to facilitate EUS. LAMS was dilated to 15 mm with balloon dilation under fluoroscopic guidance. An EUS scope could not be advanced despite dilation of LAMS to 15 mm. A duodenoscope could not be advanced, either. The plan was made to repeat EUS in 48 hrs. However, the patient developed obstructive jaundice, and an ERCP was planned instead. LAMS was removed prior to ERCP due to mild resistance to passage of the scope. This was done to prevent stent dislodgement. Following LAMS removal, a duodenoscope could be advanced across the stenosis with minimal resistance. An ERCP was successfully performed, which revealed a tight distal biliary stricture. Brush cytology was performed using a large caliber brush. A biliary stent was placed. Her immediate post-ERCP course was uncomplicated. She had normalization of her liver function tests. Final cytology results revealed pancreatic adenocarcinoma. DISCUSSION: ERCP is a challenging procedure in patients with previous bariatric surgery due to anatomical variations. LAMS have a high success rate for the drainage of PFCs. Many new off-label indications are being identified for LAMS, and the early results are promising1. We present an off-label use for LAMS placement, for facilitating ERCP in patients with stenosis related to silastic ring vertical banded gastroplasty. Watch the video: http://bit.ly/2LuZ2Mo.

1386 Narrow Tunnel, Zero Visibility: Role of Lumen-Apposing Metal Stent in the Treatment of Short Luminal Stricture Prior to Endoscopic Retrograde Cholangiopancreatography Procedure

INTRODUCTION: Managing short-segment benign gastrointestinal (GI) strictures can be challenging if they become refractory to conventional endoscopic therapies. Even though lumen-apposing metal stents (LAMS) are approved for access to and drainage of pancreatic fluid collections, endoscopists are using it in off label manner to treat these short GI luminal strictures. Here we present a patient with short duodenal stricture who was treated with LAMS, resulting in improvement of duodenal patency to accomplish ERCP. CASE DESCRIPTION/METHODS: 69-year-old male with signs of obstructive jaundice (choledocholithiasis) could not get ERCP due to a large duodenal ulcer and associated duodenal stricture. He underwent percutaneous biliary drainage (PTC), treated with antibiotics and later internalization of biliary plastic stent through interventional radiology. Three months later, follow up endoscopy showed healed duodenal ulcer but persistent duodenal stricture. CT revealed proximal migration of the biliary stent. Esophagogastroduodenoscopy was done and under endoscopic and fluoroscopic guidance, a 20 mm LAMS was placed across the duodenal stricture (measured to be <1 cm) with its Distal flange of LAMS was deployed first followed by proximal flange successfully. Two weeks later, the site was found to be patent with the LAMS intact. LAMS was removed with rat tooth forceps without any complication and ERCP was accomplished easily through improved duodenal lumen. Migrated biliary stent was removed and duct was cleared of stones and sludge followed by placement of 10 mm by 60 mm fully covered biliary metal stent and treatment with antibiotics. DISCUSSION: Our case represents another success story of treatment of short GI luminal stricture with LAMS in a patient who required ERCP and eventually had it after duodenal stricture treatment. The short length and wide flanges make LAMS potentially an attractive alternative treatment for short GI luminal stricture without any significant complications and better patient tolerance. Long term data and efficacy still needs to be studied. However, it is likely to continue to substitute as an alternative to traditional endoscopic option for short GI luminal stricture.

25 Very High Rates of Pancreatic Fluid Collections in Patients With the Triad of Hypertriglyceridemia-Induced Acute Pancreatitis and Diabetes Ketoacidosis

INTRODUCTION: The triad of hypertriglyceridemia (HTG) induced acute pancreatitis (AP) coexisting with diabetes ketoacidosis (DKA) has been reported. Patients with the triad are a special subgroup of AP patients that may need different management due to potential life-threatening conditions presenting all at once. Outcomes of pancreatic fluid collections (PFCs) in this population has not yet been studied. We sought to investigate AP mortality, morbidity and PFC outcomes in patients with the triad. METHODS: We perform a cohort study of a prospectively maintained database of patients admitted with AP at a tertiary center in the last 15 years. We strictly included patients who met AP diagnosis by Revised Atlanta Classification. Study groups were: AP-only vs. HTG-AP + DKA, AP + DKA, and HTG-AP. Primary outcome was inpatient mortality, morbidity (SIRS, ICU, AKI, ARDS), severity of AP and complication of AP. Multivariable logistic regression models were constructed using STATA software version 9.4. RESULTS: Over two thousand patients were reviewed, of whom 124 patients had the triad (HTG-AP, DKA), 100 had HTG-AP only (triglyceride levels >1,000 mg/dL), 67 had AP + DKA and we included 101 with AP-only (control) for the analysis. Patients with HTG-AP + DKA had higher rates of PFCs 59% compared to AP-only 22%, HTG-AP 29% and AP + DKA 20% (P < 0.001). HTG-AP + DKA were more likely to have acute peripancreatic fluid collections (APFC) 46% compared to AP-only 17%, HTG-AP 19% and AP + DKA 13% (P < 0.001). HTG-AP were more likely to have pseudocysts 11% compared to AP-only 4%, HTG-AP + DKA 4%, and AP + DKA 2% (P = 0.06). No difference in PFC drainage was found (P = 0.97). Patients with AP+DKA were more likely to develop AKI 63% compared to AP-only 8%, HTG-AP + DKA 34% and HTG-AP 33% (P < 0.001). HTG-AP patients were more likely to have ARDS 25% compared to AP-only 2%, AP + DKA 10% and HTG-AP + DKA 17% (P < 0.001). HTG-AP were more likely to require enteral tube feeding and total parenteral nutrition (Table 1). No difference inpatient mortality was found. CONCLUSION: Patients with the triad of HTG-AP + DKA have significantly higher rates of pancreatic fluid collections. But PFCs seems to resolve in its own as there was not difference in interventions for the PFCs. Less aggressive strategy for PFCs management in this patient population can be followed.

2132 Perivesicular Abscess Drainage With Axios Stent

INTRODUCTION: Pelvic abscesses can occur as sequelae of surgery and are associated with significant morbidity and mortality. The treatment of choice for these abscesses is immediate initiation of broad-spectrum antibiotics and drainage of the collection. We propose that lumen-apposing self-expanding metal stents (LAMS) are a safe treatment option for drainage of pelvic abscesses. LAMS were originally designed for transmural pancreatic fluid collection drainage however have been successfully used for drainage of various extra-luminal fluid collections. CASE DESCRIPTION/METHODS: The patient is an obese 34-year-old female with a PMHx of IDDM, and HTN who had recently underwent ex-lap for a large non-malignant pelvic mass. On POD #5, the patient developed a fever and repeat CT revealed a multiloculated pelvic abscess measuring 5.8 × 4.2 cm. IR was unable to drain the collection in this location between bladder and rectum. Rectal EUS was performed and revealed a septated fluid collection viewed best using 7.5 mHz ultrasound at 10 cm from the anal verge. A 2 cm margin was observed between the abscess and the urinary bladder. A 2 mm margin was seen between the rectal wall and the abscess wall. A 19-gauge non-core needle was used to access the fluid collection which appeared purulent. A 15 mm AXIOS stent was then deployed using the same technique employed with pseudocyst drainage. Drainage was successful. 9 days after placement, the stent was removed using a cold snare. No bleeding resulted from stent pull. The defect was then clipped closed with a 15 mm over the scope clip. The patient tolerated the procedure well, experienced complete resolution of the abscess. DISCUSSION: Manvar et al suggest that EUS-guided LAMS drainage of pelvic abscesses is more efficacious and has a more favorable safety profile when compared to EUS-guided drainage with catheters and plastic stents. It is an efficient and safe alternative for the management of intra-abdominal and pelvic collections. This case demonstrated the novel use of a lumen-apposing self-expanding metal stent for peri-rectal abscess drainage. Although more evidence is needed for its off-label use, we conclude that it should be strongly considered as a viable treatment option if not the initial treatment modality for collections located in the pelvis.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades

BackgroundEndoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic fluid collections (PFCs) due to the better experience and significant progress using newer stents and access devices during last decade. This study aimed to evaluate the role of the evolving experience and possible influence of new technological devices on the outcome of patients evaluated for PFCs and submitted to EUS-guided drainage during two different periods: the early period at the beginning of experience when a standardized technique was used and the late period when the increased experience of the operator, combined with different stents quality were introduced in the management of PFCs. MethodsWe retrospectively analyzed the clinical data of a cohort of 91 consecutive patients, who underwent EUS-guided drainage of symptomatic PFCs from October 2001 to September 2017. Demographic, therapeutic results, complications, and outcomes were compared between early years’ group (2001–2008) and late years’ group (2009–2017). ResultsEndoscopic treatment was successfully achieved in 55.6% (20/36) of patients in the early years’ group, and in 96.4% (53/55) in the late years’ group. Eighteen patients (12 in early years’ and 6 in the late year's group) required additional open surgery. Procedural complications were observed in 5 patients, 4 in early years’ and 1 in late years’ group. Mortality was registered in two patients (2.2%), one for each group. ConclusionsDuring our long-term survey using EUS-guided endoscopic drainage of PFCs, significantly better outcomes in term of improved success rate and decrease complications rate were observed during the late period.

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

Endoscopic Ultrasonography-Guided Versus Percutaneous Drainage for the Recurrent Pancreatic Fluid Collections.

BackgroundUltrasonography-guided percutaneous drainage for pancreatic fluid collections is associated with a high recurrence rate and endoscopic ultrasonography (EUS)-guided drainage is a valuable approach. Our aim was to compare the efficacy and safety of percutaneous and EUS-guided drainage for the recurrent pancreatic fluid collections.Material/MethodsA retrospective analysis of percutaneous-guided and EUS-guided procedures for pancreatic fluid collections drainages at a single tertiary care center between February 2017 and May 2018 was performed. Treatment success, adverse events, recurrence, need for surgery, length of hospital stays, and number of follow-up computed tomography (CT) scan were assessed.ResultsA total of 119 pancreatic fluid collections treated with initial percutaneous drainage were included in this study and 35 patients had recurrent pancreatic fluid collections. Recurrent patients were classified based on drainage method: EUS-guided drainage (18 patients) and the second percutaneous drainage (17 patients). EUS-guided drainage revealed a shorter length of hospital stays (P<0.001), less re-intervention (P=0.047), fewer number of follow-up CT scans (P=0.006) compared with the initial percutaneous drainage. Furthermore, we also compared the clinical outcomes between the EUS-guided drainage and the second percutaneous drainage for the recurrent PFC after initially failed percutaneous drainage. EUS-guided drainage showed higher clinical success (P=0.027), shorter length of hospital stays (P<0.001), less re-intervention (P=0.012), fewer number of follow-up CT scan (P<0.001) and less recurrence P=0.027) compared to the second percutaneous drainage procedure.ConclusionsEUS-guided drainage is an effective and appropriate method to treat the recurrent pancreatic fluid collections after initially failed percutaneous drainage procedure, with the advantage of higher clinical success, shorter length of hospital stays, less re-intervention, fewer number of follow-up CT scan and less recurrence compared to the percutaneous drainage.

Lumen-Apposing Metal Stents for Benign Gastrointestinal Strictures

Lumen-apposing metal stents (LAMS) are approved for the access and drainage of pancreatic fluid collections (PFCs), including pseudocysts and

EUS-guided drainage of pancreatic fluid collections using lumen apposing metal stents: An international, multicenter experience

IntroductionLumen apposing metal stents (LAMS) have been used increasingly for drainage of pancreatic fluid collections (PFC). We present an international, multicenter study evaluating the safety and efficacy of LAMS in PFCs. MethodsConsecutive patients undergoing LAMS placement for PFC at 12 international centers were included (ClinicalTrials.gov NCT01522573). Demographics, clinical history, and procedural details were recorded. Technical success was defined as successful LAMS deployment. Clinical success was defined as PFC resolution at three-month follow-up. Results192 patients were included (140 males (72.9%), mean-age 53.8 years), with mean follow-up of 4.2 months ± 3.8. Mean PFC size was 11.9 cm (range 2–25). The median number of endoscopic interventions was 2 (range 1–14). Etiologies for PFC were gallstone (n = 82, 42.7%), alcohol (n = 50, 26%), idiopathic (n = 26, 13.5%), and other (n = 34, 17.7%). Technical success was achieved in 189 patients (98.4%). Clinical success was observed in 125 of 135 patients (92.6%).Adverse events included bleeding (n = 11, 5.7), infection (n = 2, 1%), and perforation (n = 2, 1%). Three or more endoscopy sessions were a positive predictor for PFC resolution and the only significant predictor for AEs. ConclusionLAMS has a high technical and clinical success rate with a low rate of AEs. PFC drainage via LAMS provides a minimally invasive, safe, and efficacious procedure for PFC resolution.

Disconnected Pancreatic Duct in Children With Walled OFF Necrosis: Impact on Outcomes of Endoscopic Drainage.

Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed.

Clinical outcomes of endoscopic management of pancreatic fluid collections in cirrhotics vs non-cirrhotics: A comparative study.

BACKGROUNDEndoscopic management of symptomatic pancreatic fluid collections (PFCs) using self-expandable metal stents (SEMS) placement has emerged as an innovative therapeutic approach with excellent efficacy, safety, and relatively few adverse outcomes. However, their use has not been studied in patients with cirrhosis. Cirrhotics tend to be considered less than optimal candidates due to concern for portal hypertension and coagulopathy related complications.AIMTo compare the efficacy and safety of using SEMS for drainage of symptomatic PFCs in cirrhotic vs non-cirrhotic patients.METHODSWe conducted a retrospective comparative analysis of patients with symptomatic PFCs [pancreatic pseudocyst (PP) or walled-off necrosis (WON)] who underwent endoscopic ultrasound (EUS)-guided placement of fully covered self-expandable metals stents or lumen-apposing self-expandable metal stents. All patients were followed clinically until resolution of PFCs or death. Definition: (1) Technical success was defined as successful placement of SEMS; and (2) Clinical success was defined as complete resolution of the PFCs without additional interventions including interventional radiology or surgery. Number of procedures performed per patient, number of patients who achieved complete resolution of the PFCs without additional interventions and procedure related adverse events were recorded.RESULTSFrom January 2012 to December 2017, a total of 88 patients underwent EUS-guided drainage of symptomatic PFCs. Of these, 58 non cirrhotic patients underwent plastic stent insertion for management of PFC and 30 patients, 5 with cirrhosis and 25 without cirrhosis, underwent EUS-guided transmural drainage with SEMS, including 18 (60%) PP and 12 (40%) WON. Technical success was achieved in all 30 patients. Clinical success was achieved in 60% cirrhotic patients and 92% non-cirrhotics (P = 0.12). Procedure-related adverse events were 60% in cirrhotic and 28% non-cirrhotic (P = 0.62). Moreover, fatal adverse events were statistically more common in cirrhotics compared with non-cirrhotics (0 vs 40%; P = 0.023). Successful stent removal following resolution of the PFC, was 60% in cirrhotics and 80% in non-cirrhotics (P = 0.57). Post-procedure length of hospitalization was 18.6 ± 20.3 d in cirrhotics and 5.6 ± 13.7 d in non-cirrhotics (P = 0.084).CONCLUSIONEUS-guided management of PFC using SEMS placement has a high technical and clinical success rate in non-cirrhotics. However, in cirrhotics caution must be exercised given the high morbidity and mortality as evidenced by our cohort, particularly for the endoscopic debridement of WONs. Larger, multicenter studies are warranted to further characterize the risk profile and outcomes in these patients.

Su1213 DOUBLE GUIDEWIRE TECHNIQUE USING A DOUBLE LUMEN CANNULA FOR INTERVENTIONAL EUS

There are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement for EUS-guided drainage of pancreatic fluid collections (PFC). However, this technique can provide advantages other than multiple drainage placement during interventional EUS, such as scope stabilization, support for stone extraction or device insertion.

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial.

Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP. Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications. Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention. Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.

Endoscopic management of pancreatic fluid collections.

Pancreatic fluid collections (PFCs) are common complications of acute pancreatitis. Asymptomatic collections do not require drainage while symptomatic or infected collections should be drained. Drainage can be performed surgically, percutaneously, or endoscopically. Recent studies have shown that endoscopic drainage of PFCs is equivalent or superior to surgical or percutaneous drainage, with less complications. Advances in tools and technology coupled with increasing expertise in management of PFCs has resulted in minimally invasive endoscopic drainage, by endosonographic guidance, being the preferred approach. New larger diameter lumen apposing metal stents (LAMS) have simplified the process of drainage. LAMS have also made performing direct endoscopic necrosectomy for walled-off necrosis (WON) easier. Technique, duration, frequency, and tools used for direct endoscopic necrosectomy are variable. Performing PFC drainage requires adequate and fundamental knowledge of diagnostic and basic therapeutic EUS.

Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management

The development of endoscopic ultrasound (EUS)-guided drainage techniques and lumen-apposing metal stents (LAMS) has markedly reduced the complication rate of endoscopic transmural drainage of pancreatic collections and made these procedures safer and more effective. Despite its improved safety profile, various types of complications, some even life-threatening, can occur after EUS-guided drainage of pancreatic fluid collections. Stent maldeployment/migration, bleeding, gastrointestinal perforation, and air embolism are important complications of EUS-guided drainage of pancreatic collections. Delayed complications weeks after the procedure, such as bleeding and buried LAMS due to the presence of prolonged indwelling transmural stents, have also been described. Careful patient selection, with proper assessment of the size, solid necrotic content and location of the collection, as well as an in-depth understanding of various risk factors that predict complications, are important for a safer and more effective endoscopic transmural drainage. For a better clinical outcome, it is important for the endoscopist to know about various complications of EUS-guided drainage of pancreatic collections, as well as their appropriate management strategies.

Anchoring lumen-apposing metal stent with coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: any benefit?

Background:Anchoring double-pigtail plastic stents (DPSs) within lumen-apposing metal stents (LAMSs) has been proposed to prevent adverse events during endoscopic drainage of pancreatic fluid collections (PFCs). We sought to compare the outcomes of patients who received LAMSs alone and those who received both LAMSs and anchoring DPSs for drainage of PFCs.Methods:A retrospective study was conducted at the University of Kentucky. Patients with PFCs who underwent endoscopic ultrasound-guided drainage using LAMSs, with or without DPSs, between January 2016 and March 2018 were included. Categorical data were analyzed using chi-square tests, and continuous variables using 2-sample t-tests. Adverse events were defined according to the American Society for Gastrointestinal Endoscopy’s Lexicon. The primary outcome was to evaluate the efficacy (PFC resolution), and safety (adverse events) of LAMSs with or without DPSs used to drain PFCs.Results:Fifty-seven patients with PFCs were treated by 2 experienced endoscopists over 26 months. Twenty-one (37%) patients received LAMSs alone, and 36 (63%) received LAMSs plus DPSs. Forty-three patients had walled-off pancreatic necrosis, and 14 patients had pancreatic pseudocyst. Clinical success (resolution of PFCs) was achieved in 15 patients (71.4%) in the LAMSs alone group, and 21 patients (58.3%) with LAMSs plus DPSs (P=0.32). In patients with LAMSs alone, 6 patients (28.6%) had adverse events, while in those with LAMSs plus DPSs, 14 (38.9%) patients had adverse events (P=0.43).Conclusion:No significant difference was identified in fluid resolution or adverse events between patients with LAMSs alone and those with LAMSs plus DPSs.