Drainage Of Pancreatic Fluid Collections Research Articles

A novel lumen-apposing metal stent for endoscopic drainage of symptomatic pancreatic fluid collections: a retrospective study.

Previous studies showed that lumen-apposing metal stent (LAMS) provides a feasible route to perform direct endoscopic necrosectomy. However, the high risk of bleeding and migration induced by the placement of LAMS attracted attention. The aim of this study was to evaluate the safety and effectiveness of a novel LAMS. In this retrospective study, we enrolled patients with symptomatic pancreatic fluid collections (PFCs) to perform EUS-guided drainage with a LAMS in our hospital. Evaluation variables included technical success rate, clinical success rate, and adverse events. Thirty-two patients with a mean age of 41.38 ± 10.72 years (53.1% males) were included in our study, and the mean size of PFC was 10.06 ± 3.03 cm. Technical success rate and clinical success rate reached 96.9% and 93.8%, respectively. Stent migration occurred in 1 patient (3.1%), and no stent-induced bleeding occurred. The outcomes of using LAMS in 10 patients with pancreatic pseudocyst and 22 patients with walled-off necrosis were comparable. Compared with pancreatic pseudocyst, walled-off necrosis needed more direct endoscopic necrosectomy times to achieve resolution (P = 0.024). Our study showed that the novel LAMS is effective and safe for endoscopic drainage of PFCs with a relatively low rate of adverse events. Further large-scale multicenter studies are needed to confirm the present findings.

Lumen-apposing metal stents versus traditional self-expanding metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis.

Endoscopic drainage has become the preferred treatment for pancreatic fluid collections (PFCs). There is still a lack of reliable evidence to prove which metal stent is the best choice for endoscopic ultrasound (EUS)-guided drainage of PFCs. In this study, we aimed to evaluate the efficacy and safety of lumen-apposing metal stents (LAMS) compared to traditional self-expanding metal stents (SEMS) in meta-analysis. We systematically searched PubMed, Embase, Web of Science, and Cochrane Library up to July 15, 2023. Relevant publications that compared LAMS with traditional SEMS for drainage of patients' PFCs under EUS-guidance were included. This meta-analysis assessed endpoints using Review Manager 5.3 and Stata 14.0 statistical software. Nine citations comprising 707 patients with PFCs were included. The clinical success rate of LAMS tended to be higher than that of SEMS (RR = 1.07, 95%CI [1.00, 1.15], P = 0.05). LAMS had a lower technical success rate (RR = 0.97, 95%CI [0.94, 0.99], P = 0.02) and faster procedure time (minutes) (MD = - 24.29, 95%CI [- 25.59, - 22.99], P < 0.00001) compared to SEMS. In addition, LAMS had fewer overall adverse events (RR = 0.64, 95%CI [0.48, 0.87], P = 0.004). For specific adverse events, LAMS had fewer migration (RR = 0.37, 95%CI [0.19, 0.72], P = 0.003), occlusion (RR = 0.43, 95%CI [0.22, 0.82], P = 0.01) and infection (RR = 0.38, 95%CI [0.20, 0.70], P = 0.002). There was no significant difference in bleeding and perforation between the two stents. For hospital stay (days), LAMS group was similar to SEMS group (MD = - 3.34, 95%CI [- 7.71, - 1.03], P = 0.13). Regarding recurrence, LAMS group was fewer than SEMS group (RR = 0.41, 95%CI [0.21, 0.78], P = 0.007). Compared to traditional SEMS, LAMS has a higher clinical success rate, faster procedure time, fewer adverse events, similar hospital stay and lower recurrence rate in EUS-guided drainage of PFCs. LAMS is a good choice with a high technical success rate over 95%, and using a shorter length or "one-step" operation can further improve it. Richer placement experience is required for LAMS placement under EUS-guidance.

Does endoprosthesis design impact bleeding risk when using lumen-apposing metal stents for drainage of pancreatic fluid collections?

Does endoprosthesis design impact bleeding risk when using lumen-apposing metal stents for drainage of 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 (&lt;48 hours) or late (&gt;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.

Early versus delayed EUS-guided drainage for postoperative pancreatic fluid collections: a systematic review and meta-analysis.

Postoperative pancreatic fluid collections (POPFCs) are common adverse events (AEs) after pancreatic surgery and may need interventions. Endoscopic ultrasound (EUS)-guided drainage for POPFCs is increasingly reported, but its appropriate timing has not been fully elucidated. The aim of this meta-analysis was to evaluate treatment outcomes of POPFCs according to the timing of EUS-guided drainage. Using PubMed, Embase, Web of Science, and the Cochrane database, we identified clinical studies published until December 2022 with data comparing outcomes of early and delayed EUS-guided drainage for POPFCs. We pooled data on AEs, mortality, and technical and clinical success rates, using the random-effects model. From 1415 papers identified in the initial literature search, we identified 6 retrospective studies, including 128 and 107 patients undergoing early and delayed EUS-guided drainage for POPFCs. The threshold of early and delayed drainage ranged from 14 to 30days. Distal pancreatectomy was the major cause of POPFCs, ranging from 44 to 100%. The pooled odds ratio (OR) for AEs was 0.81 (95% confidence interval [CI] 0.40-1.64, P = 0.55) comparing early to delayed drainage. There was no procedure-related mortality. Technical success was achieved in all cases and a pooled OR of clinical success was 0.60 (95% CI 0.20-1.83, P = 0.37). POPFCs can be managed by early EUS-guided drainage without an increase in AEs.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections with two different dedicated metal stents: a nationwide, multicentre, propensity score-matched comparison

Endoscopic ultrasound-guided drainage of pancreatic fluid collections with two different dedicated metal stents: a nationwide, multicentre, propensity score-matched comparison

S113 Endoscopic vs Percutaneous Drainage for Post-Operative Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis

S113 Endoscopic vs Percutaneous Drainage for Post-Operative Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis

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.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management.

The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment. To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance. We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms "lumen apposing metal stent", "LAMS", "endoscopic ultrasound" and "choledochoduodenostomy" or "gallbladder" or "pancreatic fluid collections". We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy. The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC. LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.

Impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic drainage of pancreatic fluid collections.

To study the impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFC). Patients undergoing EUS-guided PFC drainage and treated using lumen-apposing metal stents (LAMS) or plastic endoprostheses constituted the study cohort. The primary outcome was the presence of systemic inflammatory response syndrome (SIRS) after index intervention. Secondary outcomes were persistent organ failure, new onset organ failure, duration of hospitalization, and treatment success. In all, 303 patients were treated using LAMS (n = 247) or plastic stents (n = 56). At 48 h postintervention, the presence of SIRS (25.0 vs. 14.2%, P = 0.047), new onset SIRS (10.0 vs. 1.8%, P = 0.017), and new organ failure (5.4 vs. 0.4%, P = 0.003) were significantly higher in the plastic stent cohort compared to LAMS. On multivariable logistic regression analysis, the use of plastic stents (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.0, P = 0.014), patients receiving high-acuity care (OR 5.1, 95% CI 2.5-10.4, P < 0.001) and the presence of ≥33% of necrosis (OR 4.5, 95% CI 2.0-10.0, P < 0.001) were significantly associated with the presence of SIRS or new organ failure. While there was no significant difference in treatment success (96.4 vs. 95.5%, P = 0.77), duration of hospitalization was significantly longer for the plastic stent cohort (mean [standard deviation] 12.5 [17.8] vs. 7.9 [10.1] days, P = 0.009). Use of plastic stents as compared to LAMS was associated with a higher proportion of SIRS and new organ failure that prolonged hospital stay. Therefore, placement of LAMS is recommended in sick patients and those with ≥33% necrosis to minimize inflammatory response.

A Chinese prospective multicenter cohort study evaluating EUS-guided drainage of pancreatic fluid collections using the Hot AXIOS system.

The Hot AXIOS system, which features a cautery-enhanced lumen-apposing metal stent, facilitates EUS-guided transmural drainage of pancreatic fluid collection (PFC). We aimed to evaluate the safety and efficacy of stents in a multicenter Chinese cohort. Thirty patients from nine centers with a single pancreatic pseudocyst (PP) or walled-off necrosis (WON) who underwent EUS-guided transgastric or transduodenal drainage with the novel stent were prospectively enrolled. We included 15 (50%) patients with PPs and 15 (50%) with WONs. The mean diameter of the PFCs was 11.06 ± 3.56 cm. Stent placement was technically successful in all patients (100%), whereas clinical success was achieved in 93.3% of patients (28/30). Clinical success was defined as the alleviation of clinical symptoms combined with at least a 50% reduction in PFC diameter within 60 days after surgery. 73.3% (22/30) of AXIOS stents were removed after reaching clinical success in the 1st month of follow-up. A total of 14 (46.7%) PFC-associated infections occurred (4 pre- and 10 postoperation), which recovered within 1 week after treatment. Other complications included three (10%) partially or fully blocked stents and two (6.7%) stent migrations. Regarding the fully opened stent without blocking, complete remission of PFCs within 1 month was independently predicted by a previous pancreatitis attack > 6 months prior (adjusted odds ratio: 11.143; 95% confidence interval: 1.108-112.012; P = 0.041). EUS-guided drainage of PFCs using the Hot AXIOS system is safe and efficient. Regarding completely patent stents, a previous pancreatitis attack > 6 months prior predicts a greater chance of achieving 100% remission of PFCs within 1 month of AXIOS treatment.

Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach?

Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4 weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation.

Current uses of electro-cautery lumen apposing metal stents in endoscopic ultrasound guided interventions.

The electro-cautery lumen apposing metal stent (EC-LAMS) is a newly developed device that integrates the electro-cautery cyctotome with the one-step metal stent delivery and releasing system in recent years. LAMS was first designed to complete the drainage of pancreatic fluid collection under endoscopic ultrasound guidance, and the technological innovation of EC-LAMS has made more off-labeled indications of endoscopic intervention for gastrointestinal diseases realized, such as abdominal fluid drainage, bile duct, or gallbladder drainage through stomach or duodenum, gastrointestinal anastomosis, and the establishment of fistulous channel for further endoscopic operation when necessary. The unique feature of this metal stent is that it has the design of a saddle shape and a large lumen, and can almost connect the adjacent structures to minimize the risk of perforation and leakage. Compared with traditional LAMS, EC-LAMS, an advanced integrated device, can greatly simplify the endoscopic process, shorten the procedure time and reduce the technical difficulty, thus it can help endoscopists complete more complex endoscopic interventions. In this review, we discuss the state of art with regard to EC-LAMS and its endoscopic process, current indications, outcomes, adverse events, and future application prospects.

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.

S1075 Early (&lt;4 Weeks) vs Standard (≥ 4 Weeks) Endoscopic Drainage of Pancreatic Walled-Off Fluid Collections: A Systematic Review and Meta-Analysis

Introduction: Previous studies have demonstrated that the ideal time for drainage of walled off pancreatic fluid collections is 4-6 weeks after its development. However, some pancreatic collections, including pancreatic walled-off necrosis (WON), require earlier drainage. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. The aim of this study was to evaluate clinical outcomes and safety of endoscopic ultrasound (EUS) - guided drainage of pancreatic fluid collections < than 4 weeks after its development compared to ≥4 weeks after its development. Methods: Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception through June 2022 in accordance with PRISMA and MOOSE guidelines. Outcomes of interest included technical success defined as successful endoscopic placement of LAMS, clinical success defined as reduction in cystic collection size, and procedure-related adverse events. A random effects model was used for analysis and results were expressed as odds ratio (OR) along with 95% confidence interval (CI). Results: A total of 6 studies (630 patients) were included in our final analysis where 182 patients (28.9%) were enrolled in the early drainage cohort and 448 (71.1%) patients in the standard drainage cohort. Age ranges were similar between groups. Alcohol was the main driver of acute pancreatitis. Infection was the most common indication for pancreatic drainage (42.6%). The mean fluid collection size was 143.4 ± 18.8 mm for the early cohort vs 128 ± 19.7 mm for the standard cohort. Most fluid collections were located in the body of the pancreas (86.7%). Overall, technical success favored standard drainage over early drainage (OR 0.01; 95% CI 0.00 – 0.15; P=0.001). Clinical success also favored standard drainage over early drainage (OR 0.46; 95% CI 0.16 – 1.32; P=0.03). With regards to adverse events, there was no statistically significant difference in overall adverse events (OR 0.76; 95% CI 0.42 – 1.39; P=0.56) or mortality (OR 1.14; 95% CI 0.29 – 4.48; P=0.23). Hospital stay was longer for patients undergoing early drainage compared to standard drainage (23.7 vs 16.0 days, respectively). (Figure) Conclusion: Compared to early drainage (< 4 weeks), endoscopic drainage of pancreatic fluid collections is significantly more efficacious when performed at least 4 weeks after development, with a shorter hospital length of stay. Therefore, pancreatic fluid collections should ideally be drained 4 weeks after development.Figure 1.: Forrest plot showing pooled rates of clinical success.

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.

S2845 Inadvertent Treatment of a Vertical Banded Gastroplasty Stricture With a LAMS for Two Years

Introduction: Lumen-apposing metal stents (LAMS) are innovative endoscopic devices representing the next significant advancement in stent technology. LAMS have demonstrated success, most notably with improving drainage of pancreatic fluid collections. Other clinical indications for using LAMS include biliary drainage, gastroenterostomy, or the managment of luminal tract strictures. The stent has a larger lumen diameter than previously created stents as well as a unique “dumbbell” shape to limit migration. Studies have demonstrated advantages such as shorter procedure times and overall reduced repeat endoscopic procedures. As LAMS has gained notoriety, there have been increasing studies demonstrating potential complications of the device. Most common consequences of LAMS include bleeding, biliary stricture, and buried LAMS syndrome. As the anatomical design has decreased migration risk, prompt removal is recommended to prevent buried LAMS syndrome, where the stent is embedded in the wall of the gastric mucosa and can eventually not be visualized endoscopically. In this case, we will present a patient with an endoscopically placed LAMS, which was successfully removed with minimal complications after two years in place. Case Description/Methods: Our patient is a 68 year old female with a Vertical Banded Gastroplasty Stricture. She had required multiple repeat endoscopies for dilation therapy but the stricture was refractory to dilation, as a result, she underwent LAMS placement Due to the onset of the COVID pandemic, patient was lost to follow up. On a repeat EGD two years after placement, the stent remained in its original location. There were signs of mild gastric tissue overgrowth at the right lateral side of the LAMS. The stent was then removed easily with no signs of bleeding. After removal, the stricture remained dilated as the scope could be passed without difficulty. Over course of COVID she ate better than she had in years. (Figure) Discussion: LAMS have demonstrated significant success in a variety of endoscopic interventions. Their potential complications are well documented in various studies. This case is unique in regards to the length of time in which the LAMS remained in position. From a literature review, no study has demonstrated a LAMS in place as long as two years for stricture management. More remarkable is the lack of complications from the stent such as no bleeding with removal and no true buried LAMS syndrome as there was minimal tissue overgrowth.Figure 1.: LAMS on endoscopic evaluation two years after placement.

S75 Safety and Efficacy of Endoscopic Drainage of Pancreatic Fluid Collections Performed by Early Career Advanced Endoscopists: A Multicenter Experience

S75 Safety and Efficacy of Endoscopic Drainage of Pancreatic Fluid Collections Performed by Early Career Advanced Endoscopists: A Multicenter Experience

S1164 Lumen-Apposing Metal Stents for Pancreatic Fluid Collections Reduce 90-Day Readmission Rates

Introduction: Management of symptomatic mature pancreatic fluid collections (PFCs) such as pancreatic pseudocysts or walled-off necrosis now involve the use of lumen-apposing metal stents (LAMS) under endoscopic ultrasound (EUS) guidance. LAMS appear to be superior compared to traditional plastic stents however require close follow up. Numerous studies have shown a benefit of LAMS for short-term (e.g., 4-week) outcomes. However, there is a lack of data evaluating longer term outcomes. Our aim was to investigate 90-day readmission rates after LAMS placement over an 8-year period. Methods: We identified all patients ≥ 18 years who underwent deployment of a LAMS from 01/01/2014 to 06/01/2021 at our urban, safety net hospital. We subsequently collected demographic data, cyst characteristics, and stent information. Follow-up upper endoscopies and imaging were examined to determine stent removal date and assess for complications. Hospital admission rates 90 days before and after stent placement were collected. Admissions were stratified into gastrointestinal (GI)-related or other. Results: We identified 27 patients who underwent LAMS for drainage of mature PFCs. Of these, 18 were simple pancreatic pseudocysts (PP), 6 walled-off necrosis (WON), and 3 mixed collections. Mean age was 52.1 ± 11.0 years, 66.7% male, 66.7 % non-white, and 59.3% reported alcohol use. The average collection was 6.6 ± 2.0 cm. Stents were removed in 81.5% of patients at a median of 37.5 days. 7.4% were lost to follow up, and 22.2% of patients had stent complications during follow-up: 2 bleeding, 2 stent migration, and 2 stent occlusions. Patients on average had 1.00 ± 0.20 hospital admissions in the 90 days prior to stent placement vs 0.48 ± 0.17 admissions 90 days after placement (mean difference 0.52 ± 0.17, p< 0.05). Of these patients, 64.7% of pre-stent hospitalizations were due to GI complaints vs 22.2% of post-stent hospitalizations (p< 0.05). Neither cyst size nor time to stent removal were significantly related to complications. Conclusion: LAMS for the management of mature pancreatic fluid collections were effective at reducing 90-day readmission rates especially in the setting of GI-related complaints. Although there was a delay in LAMS removal with a median of 38 days, it did not appear to translate into higher complication rates. Perhaps an extended use of LAMS beyond 4 weeks may prove to be safe and efficacious, however larger studies are required.

S11 Short- and Long-Term Outcomes of Necrotizing Pancreatitis After Endoscopic, Percutaneous and Surgical Management

Introduction: Pancreatic fluid collections (PFCs) are a common complication of necrotizing acute pancreatitis (NAP) and are a significant cause of morbidity and mortality. Multiple intervention approaches are utilized in a step-up fashion for the management of symptomatic PFC in patients with NAP. The aim of this study is to analyze the short- and long-term clinical outcomes in these patients treated endoscopically, percutaneously, or surgically. Methods: This retrospective cohort study was conducted in a large tertiary center. Patients with NAP complicated by PFC were selected for possible inclusion. Short-term (<90 days) and long-term (>90 days) clinical outcomes including mortality were compared between three groups; the first group was defined as patients who underwent endoscopic ultrasound-guided drainage alone or in combination with percutaneous drainage, and the second group are patients who underwent surgery only and the third group is patients who underwent percutaneous drainage alone. Results: A total of 637 patients with NAP complicated by PFC on imaging were included, of those; 318 patients underwent an intervention for management of PFC from 2009 to 2019 with a median follow-up time of 17 months. Group 1 had 229 patients, group 2 had 30 patients and group 3 had 59 patients. Patients in groups 2 and 3 had longer hospital stays (18 and 19 days, respectively, P < 0.05), were more likely to be transferred to ICU (33% and 24%, respectively, P < 0.05) and had severe pancreatitis at the time of presentation (57% and 59%, respectively, P < 0.05). Patients in group 1 were more likely to present with recurrent episodes of AP (74%, P < 0.05). Alcoholic pancreatitis was the most common etiology overall and in group 1 39%, P < 0.05. The infected collection was the most common indication for drainage overall, and in group 3 (64%, P < 0.05). Transfer to ICU was lower in group 1 (14%, P < 0.05). 90-day mortality was lower in group 1 with 5.2% (P < 0.05). No difference was noted in long-term complications between the different groups. Conclusion: Endoscopic management alone or in combination with percutaneous drainage of symptomatic PFC in patients with necrotizing acute pancreatitis leads to a shorter hospital stay, and lower mortality when compared to percutaneous drainage alone or surgery. There was no difference in the long-term complications including chronic pancreatitis, EPI, new-onset DM, and chronic abdominal pain across these groups. A multidisciplinary approach is recommended in NAP. Table 1. - Patient Characteristics, Short- and Long-Term Complications Characteristics Overall (N=318) Intervention Modality Endoscopy Alone or Endoscopy+IR/PERC (N=229) Surgery Alone (N=30) IR/PERC Alone (N=59) p-value Body Mass Index, Median (IQR) 26 (23-32) 26 (23-30) 27 (23-32) 32 (26-36) < 0.001 Severe Acute Pancreatitis on Presentation, n (%) 103 (32) 51 (22) 17 (57) 35 (59) < 0.001 Occurrence, n (%) < 0.001 First 98 (31) 58 (25) 12 (40) 28 (47) Recurrent 216 (68) 170 (74) 17 (57) 29 (49) Chronic 4 (1.3) 1 (0.4) 1 (3.3) 2 (3.4) Alcoholic Pancreatitis, n (%) 104 (33) 90 (39) 4 (13) 10 (17) < 0.001 Multiple Pancreatic and Peripancreatic Fluid Collections, n (%) 180 (57) 129 (57) 10 (33) 41 (69) 0.005 PFC Size on CT Scan, Median (IQR) 89 (56-128) 78 (50-112) 120 (89-138) 126 (82-158) < 0.001 Retroperitoneal PFC with Pelvic Extension, n (%) 55 (17) 29 (13) 6 (20) 20 (34) < 0.001 Drain Indication Abdominal Pain, n (%) 89 (28) 71 (31) 13 (43) 5 (8.5) < 0.001 Infected Collection, n (%) 102 (32) 50 (22) 14 (47) 38 (64) < 0.001 Gastric Outlet Obstruction, n (%) 35 (11) 32 (14) 1 (3.3) 2 (3.4) 0.023 Length of Hospital Stay, Median (IQR) 10 (6-22) 8 (5-18) 18 (10-29) 19 (11-38) < 0.001 Transferred to ICU, n (%) 65 (20) 32 (14) 11 (37) 22 (37) < 0.001 90-Day Mortality, n (%) 26 (8.2) 12 (5.2) 3 (10) 11 (19) 0.004 Long-Term Complications Pancreatic Fistula, n (%) 0.10 Internal Fistula 31 (86) 20 (83) 1 (50) 10 (100) External Fistula 5 (41) 4(17) 1 (50) 0 (0) New Chronic Pancreatitis, n (%) 36 (12) 28 (12) 2 (6.9) 6 (11) 0.8 Chronic Abdominal Pain, n (%) 25 (7.9) 19 (8.3) 2 (6.7) 4 (6.8) >0.9 New-Onset Diabetes, n (%) 50 (16) 32 (14) 7 (23) 11 (19) 0.3 Exocrine Insufficiency, n (%) 17 (5.3) 11 (4.8) 2 (6.7) 4 (6.8) 0.6 Pancreatic Cancer, n (%) 5 (1.6) 4 (1.7) 0 (0) 1 (1.7) >0.9 Duodenal Ulceration, n (%) 16 (5.0) 14 (6.1) 1 (3.3) 1 (1.7) 0.5 Abdominal Thrombosis, n (%) 78 (25) 63 (28) 3 (10) 12 (20) 0.079 Abdominal Pseudoaneurysm, n (%) 21 (6.6) 18 (7.9) 0 (0) 3 (5.1) 0.3 Biliary Tract Stricture, n (%) 67 (21) 53 (23) 4 (13) 10 (17) 0.3 Figure 1.: PFC Interventions Frequency Per Year