Pigtail Stent Research Articles

787 The Hidden and The Lost: A Case of a Rare Complication from A Long-Lost Surgical Technique

Abstract Background Various operative techniques have been developed for liver transplant since the 1960's. Waddell-Calne technique for biliary reconstruction in orthotopic liver transplant (OLT) was one of the rare and now relatively obsolete techniques. The aim of our presentation is to describe a long-term complication of this lost technique and how it posed multiple diagnosis and management challenges after 35 years post-liver transplant. Case presentation Our case is on a 50-year-old lady with a history of OLT for end-stage liver failure secondary to type-1 autoimmune hepatitis. Peri and postoperative period were completely unremarkable. 35 years later, she presented with symptoms of recurrent cholangitis. Magnetic resonance cholangio-pancreaticography demonstrated biliary tree dilatation with choledocholithiasis and possible cholecystitis. Removal of the distal stones together with pig-tail stent insertion was achieved via endoscopic retrograde cholangio-pancreaticography, however, her biliary colic persisted. The background of OLT and grossly distorted anatomy on imaging posed a challenge for further surgery. Extensive tracing of the history back from 1985 and multicentre multidisciplinary discussion revealed that the Waddell-Calne technique was carried out for her OLT where a gallbladder conduit was used for the hepaticojejunal-anastomosis. Finally, excision of the gallbladder conduit and hepaticojejunostomy with long Roux-en-Y was able to perform successfully. Conclusions Waddle-Calne technique is rarely seen globally nowadays but should be considered as a possible cause of recurrent cholangitis in patients with a history of OLT a long time ago. We demonstrated that the knowledge of such a rare procedure, together with the multidisciplinary approach could enormously benefit the management of the case.

106 Stentolith As an Uncommon Complication of Loss to Follow Up After Endoscopic Biliary Stenting

Abstract Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, and the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration [2]. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months (1). However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith” [4]. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation [6]. Variation in formation has been described, with plastic stents developing circumferential stones [12-25], due to potential space between the wall and stent. Conclusions This highlights the importance of robust inter-disciplinary working; careful patient follows up and implementation of a mandatory registry at all hospitals for stented patients.

S1666 EUS Choledochoduodenostomy: A Novel Way to Treat Recurrent Malignant Biliary Obstruction in the Setting of an Existing Biliary and Duodenal Stent

Introduction: EUS-guided choledochoduodenostomy (EUS-CD) is an effective way to manage patients with malignant biliary obstruction and an inaccessible papilla. It involves creation of a fistula between the duodenal bulb and distal common biliary duct (CBD) using a lumen-apposing metal stent (LAMS). Data shows high technical and clinical success rates, with low adverse event rates and improved morbidity and mortality. Advantages of this approach include the ability to provide drainage to altered or inaccessible anatomy, and minimal invasiveness due to internalized drainage. We present a report of a patient with cholangitis due to recurrent biliary and gastric outlet obstruction (GOO) treated successfully with duodenal stenting and EUS-CD despite indwelling hardware. Case Description/Methods: A 71-year-old male with as history of locally invasive pancreatic adenocarcinoma presented with cholangitis and intolerance to oral intake. His prior course was complicated by GOO and biliary obstruction that required biliary fully covered self-expandable metal stent (FC-SEMS) and uncovered duodenal stent placement. Despite palliative chemotherapy, he presented 6 months later with cholangitis and imaging findings concerning for CBD stent occlusion, partial GOO and new ascites. Upper endoscopy showed significant stenosis within the duodenal stent that involved the major papilla, preventing conventional ERCP. The decision was made to evaluate for EUS biliary drainage. Presence of significant ascites precluded hepaticogastrostomy or gastrojejunostomy, however, there was an area superior to the indwelling biliary stent amenable to EUS-CDS. A 10mm x10mm LAMS was placed into the common hepatic duct with drainage of purulent fluid (Figure 1). Cholangiogram confirmed correct placement and excluded a leak. An uncovered duodenal stent was deployed through the indwelling duodenal stent and placement confirmed radiographically (Figure 1). The patient was discharged 2 days later with downtrending liver chemistries and tolerating oral intake. Discussion: Patients with combined malignant biliary and duodenal obstruction can be challenging to manage. Existing hardware complicates management even further. This case highlights the versatility of EUS biliary drainage allowing patient directed therapy with EUS-CDS in the setting of an existing biliary stent as an effective means of biliary drainage when ERCP was not possible.Figure 1.: A: occluded biliary stent B: LAMS with pigtail stents C: duodenal stent D: KUB showing stents in place.

Endoscopic ultra-sound (EUS) guided management of symptomatic pelvic collections: puncture-aspiration or drainage? Results from mono-centric retrospective experience with therapeutic algorithm

Background Pelvic collections may occur after surgery or in medical diseases. EUS transmural (TM) treatment has been shown as highly effective and safe, becoming an alternative to surgery or radiology. We aimed to assess the results of EUS management of pelvic collections. Methods Retrospective, single-center observational study conducted between 2004 and 2018. Patients with symptomatic collections treated by EUS-TM approach were enrolled. The procedures were performed with a therapeutic EUS-scope, following two possible options: puncture-aspiration-injection of antibiotics PAIA (group 1) or EUS-drainage by plastic double pigtail stents (DPS) with an ano-cavitary drain (ACD) or lumen-apposing metal Stent (LAMS) (group 2). The main objective was to assess the clinical effectiveness based on symptoms and collection resolution. Results Seventy-three patients were included. Mean age was 42.5 years [12–87]. 30 patients in group 1 (41%) underwent PAIA and 43 in group 2 (59%) underwent DPS ± ACD in 41 patients (95%) and LAMS in 2. The collection was postoperative in 58%. The mean size was 48.9 mm [8–120], 33 +/- 17 mm in group 1, compared to 67 ± 21 mm in group 2 (p < .0001). All the procedures were technically successful. Overall clinical success was 96% (93% in group 1 (28/30), 98% (42/43) in group 2). Failures occurred in 2 post sigmoiditis abscesses and 1 ileo-colic Crohn’s disease. No adverse event was reported. During the median follow-up of 7.5 years [4.4–8.9], no patient had recurrence. Conclusions EUS-TM with either PAIA or drainage depending on the collection size is confirmed to be highly effective and safe.

258 MANAGEMENT OF OESOPHAGO-GASTRIC LEAKS FOLLOWING MINIMALLY INVASIVE IVOR LEWIS OESOPHAGO-GASTRECTOMY USING DOUBLE PIGTAIL STENTS

Abstract Anastomotic leak following Ivor Lewis oesophago-gastrectomy is a major complication with high morbidity and mortality. We report our experience with three such cases where endoscopically deployed double pigtail stents (DPT) were used to help manage the leaks. Methods Three patients from October 1, 2019 to February 29, 2020 experienced leakage from the oesophago-gastric anastomosis following minimally invasive Ivor Lewis oesophago-gastrectomy. These occurred on post-operative day 9, day 29 and day 7 respectively. All cases were managed with endoscopic deployment of double pigtail stents along with other adjunctive measures. Results To date all patients remain alive, with sepsis under control. One of the patients had been able to have his double pigtail stent removed at six weeks and he has been able to commence adjuvant chemotherapy. Another patient had a follow-up contrast study one week after DPT insertion which showed no further contrast extravasation and was able to recommence oral intake. The third patient has a left empyema (managed conservatively with a combination of internal DPT and external pigtail drainage) which is gradually resolving. Conclusion Endoscopically deployed DPTs are a useful tool in the armamentarium for managing oesophago-gastric anastomotic leaks in selected patients following Ivor Lewis oesophago-gastrectomy. They are advantageous in that stent migration does not appear to be an issue, nor is there any problem with leakage around the stent. Patients are mostly able to restart oral intake soon after insertion of DPTs. This reduces the morbidity associated with these anastomotic leaks, and reduces the number of interventions needed.

Living on the EDGE: Canadian Experience With EUS-directed Transgastric ERCP (EDGE) in Patients With Roux-en-Y Gastric Bypass Anatomy.

IntroductionRoux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EDGE, is an endoscopic approach which involves accessing the excluded stomach to facilitate ERCP.ObjectiveThe objective of this study is to describe the results of EDGE procedures performed in Canada.MethodsData were collected from patient cases who had undergone an EDGE procedure across centers in Canada. All patients had a history of RYGB bariatric surgery. In each procedure, a 20-mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS guidance to allow access from the gastric remnant/proximal jejunum to the excluded stomach. Subsequently, during a separate procedure, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was replaced with a pigtail stent or APC was used to facilitate closure of the gastro-jejunal/gastro-gastric fistula.ResultsThe indication for EDGE in the seven included cases was for the treatment of choledocholithiasis (six) or gallstone pancreatitis (one). The technical success rate of the EDGE procedure in these cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all cases. There were no adverse events reported.ConclusionThe results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery.

PD35-10 ALLIUM URETERAL STENT FOR THE TREATMENT OF URETERAL STRICTURE AND FISTULA AFTER ABDOMINAL SURGERY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (PD35)1 Sep 2021PD35-10 ALLIUM URETERAL STENT FOR THE TREATMENT OF URETERAL STRICTURE AND FISTULA AFTER ABDOMINAL SURGERY Massimiliano Di Marco, Antonio Luigi Pastore, Yazan Al Salhi, Andrea Fuschi, Raniero Parascani, Matteo Sampalmieri, Alessia Fraioli, Cristina Avitabile, Saleh Abuorouq, Fabio Maria Valenzi, and Antonio Carbone Massimiliano Di MarcoMassimiliano Di Marco More articles by this author , Antonio Luigi PastoreAntonio Luigi Pastore More articles by this author , Yazan Al SalhiYazan Al Salhi More articles by this author , Andrea FuschiAndrea Fuschi More articles by this author , Raniero ParascaniRaniero Parascani More articles by this author , Matteo SampalmieriMatteo Sampalmieri More articles by this author , Alessia FraioliAlessia Fraioli More articles by this author , Cristina AvitabileCristina Avitabile More articles by this author , Saleh AbuorouqSaleh Abuorouq More articles by this author , Fabio Maria ValenziFabio Maria Valenzi More articles by this author , and Antonio CarboneAntonio Carbone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002039.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral injuries are well-known complications of abdominal surgery. The aim of the study is to evaluate the safety and feasibility of Allium ureteral prosthesis in patients with distal and upper ureteral injuries after abdominal surgery. METHODS: The Allium URS is a new-developed ureteral stent made of nickel-titanium (Nitinol) meant to automatically expand when inserted in a stricture in order to restore and preserve a larger caliber. Furthermore, the stent is coated with a biochemical co-polymer which prevents tissue ingrowth and incrustations. For this study 71 consecutive patients were enrolled. All of them had iatrogenic ureteral injury in the upper, mid and distal ureter after undergoing abdominal surgery. From these 71 patients, 21 underwent gynecologic surgery. The other 50 patients underwent abdominal surgery due to: ureteral stenosis caused by retroperitoneal lymph node metastasis (3pts 4,22%), uretero-cysto-anastomosis (4pts 5,63%), pyeloureteral junction stenosis (5pts 7,04%), colectomy (6pts 8,45%), ureteral obstruction due to bladder cancer (6pts 8,45%), bladder cuff excision (8pts 11,27%), ureteral stones (18 pts 25,36%). All of them were selected for positioning the allium prosthesis between January 2017 and December 2020. Ureteral leakage and stricture were diagnosed using intravenous pyelography. During the procedure the stent was inserted anterogradely or retrogradely with intraoperative x-ray guidance after dilation of the stricture. RESULTS: No major complications occurred during the stenting procedure. During the follow up (mean 36 months) 6 obstructions (8,45%) have been reported after 8 months caused by ureteral stones all successfully treated endoscopically with holmium laser. In addition, stent migration occurred in 10 patients (14,08%) within 3 months after its insertion, of which 5 were easily replaced and the other 5 were removed with the subsequent need of a robotic re-anastomosis. Among the 5 patients affected by pyeloureteral junction stenosis, 4 needed laparoscopic pyeloplasty due to stent migration. In 20 patients the stents were removed as planned after one year of indwelling time and remained asymptomatic in a follow-up period of up to 24 months. The removal of the left 31 stents is planned during the next 12 months. CONCLUSIONS: Due to its unique structure, the Allium stent resulted superior to the standard pigtail stents in the treatment of ureteral strictures. Stent migration was seen in 19.7% (14pts) of the patients, and mainly reported in patients with stricture of the upper ureter. The results of our study show that the use of Allium URS for the treatment of ureteral strictures is feasible, safe and effective. The relative ease of its insertion could encourage its use in a wide range of other indications. However, evaluating the results we do not recommend the use of Allium stent to treat pyeloureteral junction strictures because of its high risk of migration. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e593-e593 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Massimiliano Di Marco More articles by this author Antonio Luigi Pastore More articles by this author Yazan Al Salhi More articles by this author Andrea Fuschi More articles by this author Raniero Parascani More articles by this author Matteo Sampalmieri More articles by this author Alessia Fraioli More articles by this author Cristina Avitabile More articles by this author Saleh Abuorouq More articles by this author Fabio Maria Valenzi More articles by this author Antonio Carbone More articles by this author Expand All Advertisement Loading ...

Role of endoscopic ultrasonography in the management of peripancreatic collections.

Pancreatic fluid collections are surrounded by a wall of granulation tissue and may contain necrotic debris. They occur following a severe acute pancreatitis and most of the cases resolve spontaneously after several weeks. However, their management may lead to a very hard-to-treat condition, requiring a multidisciplinary approach. During the last decades we assisted to a change of paradigm involving Endoscopic Ultrasonography, from a pure diagnostic technique to an interventional-therapeutic one, allowing an effective, safe and less invasive approach than other existing treatment standards, historically consisting of surgical and percutaneous drainage. Treatment of pancreatic fluid collections is indicated if they become infected or symptomatic. Over the past years, exponential developments were done in interventional endoscopic approach, making it the first line suggested modality. The use of endoscopic ultrasound allows assessment of the collection, even when it is not directly bulging on gastrointestinal wall, creation of an internal fistulous tract, checking for surrounding vessels with the use of Doppler, and deployment of a stent avoiding the discomfort of external tubes. Several types of stent have been used for endoscopic drainage: plastic double pigtail stents, fully covered self-expanding metal stents and, more recently, lumen apposing metal stents, which are considered revolutionary because of their two-side flanges and wide and short internal channel, a new design that made easier direct endoscopic necrosectomy. This review aims to go through currently available literature on the diagnostic and therapeutic role of endoscopic ultrasonography to handle pancreatic fluid collections.

Endoscopic internal drainage and low negative-pressure endoscopic vacuum therapy for anastomotic leaks after oncologic upper gastrointestinal surgery.

Endoscopic internal drainage (EID) with double-pigtail stents or low negative-pressure endoscopic vacuum therapy (EVT) are treatment options for leakage after upper gastrointestinal oncologic surgery. We aimed to compare the effectiveness of these techniques. Between 2016 and 2019, patients treated with EID in five centers in France and with EVT in Göttingen, Germany were included and retrospectively analyzed using univariate analysis. Pigtail stents were changed every 4 weeks; EVT was repeated every 3-4 days until leak closure. 35 EID and 27 EVT patients were included, with a median (interquartile range [IQR]) leak size of 0.75 cm (0.5-1.5). Overall treatment success was 100 % (95 % confidence interval [CI] 90 %-100 %) for EID vs. 85.2 % (95 %CI 66.3 %-95.8 %) for EVT (P = 0.03). The median (IQR) number of endoscopic procedures was 2 (2-3) vs. 3 (2-6.5; P = 0.003) and the median (IQR) treatment duration was 42 days (28-60) vs. 17 days (7.5-28; P < 0.001), for EID vs. EVT, respectively. EID and EVT provide high closure rates for upper gastrointestinal anastomotic leaks. EVT provides a shorter treatment duration, at the cost of a higher number of procedures.

Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients.

Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents. A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

A136 LIVING ON THE EDGE: EUS-DIRECTED TRANSGASTRIC ERCP (EDGE) IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY

Abstract Background Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EUS-directed transgastric ERCP (EDGE), is an entirely endoscopic approach which involves accessing the excluded stomach to facilitate conventional ERCP. Objectives To describe the results of EDGE procedures performed in two centres in British Columbia. Aims To describe the results of EDGE procedures performed in two centres in British Columbia. Methods Data were collected from five patient cases who had undergone an EDGE procedure at Victoria General Hospital (4) or Vancouver General Hospital (1) in British Columbia from 2019 to 2020. All patients had a history of RYGB bariatric surgery. In each of the procedures, a 20 mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS-guidance to allow access from the gastric remnant or proximal jejunum to the excluded stomach. Subsequently, during a separate procedure 4 to 28 days later, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was removed 0 to 38 days later and replaced with a double pigtail stent to facilitate controlled closure of the gastro-jejunal or gastro-gastric fistula. Results Of the five cases included in the case series, 4 patients underwent EDGE for treatment of choledocholithiasis and one patient underwent the procedure for gallstone pancreatitis. The technical success rate of the EDGE procedure in the five cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all of the cases. There were no adverse events related to the EDGE procedure in these five cases. Conclusions The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery. Funding Agencies None

Incidental misplacement of a percutaneous nephrostomy tube in the inferior vena cava

Introduction. An isolated renal pelvis rupture is a rare type of blunt renal trauma that can occur mostly in patients with pre-existing hydronephrosis due to different causes. We presented a patient with the misplacement of a percutaneous nephrostomy tube during the treatment of isolated renal pelvis rupture in a patient with pre-existing hydronephrosis caused by post-irradiation ureteral stricture. Case report. A 36-year-old woman was referred to our institution by her gynaecologist for the treatment of a retroperitoneal urinoma. She had completed the irradiation treatment with concurrent cisplatin chemotherapy for a uterine malignancy one year ago. A computed tomography scan showed an isolated rupture of the left renal pelvis with the pre-existing hydronephrosis. A nephrostomy catheter was misplaced in the inferior vena cava during the percutaneous urinary drainage attempt. The patient underwent a laparotomy, renal pelvis suture and ureteroneocystostomy with an indwelling double pigtail stent. The percutaneous nephrostomy was removed during the same surgical procedure. Conclusion. Inadvertent injury of vascular structures is a possible complication of percutaneous nephrostomy under ultrasound guidance. It may have been possible to avoid the reported complication if the dilation of the nephrostomy tract over the guidewire had been performed under contrast-enhanced X-ray fluoroscopy.

Endoscopic management of anastomotic leak after esophageal or gastric resection for malignancy: a multicenter experience.

Background:Most anastomotic leaks after surgical resection for esophageal or esophagogastric junction malignancies are treated endoscopically with esophageal stents. Internal drainage by double pigtail stents has been used for the endoscopic management of leaks following bariatric surgery, and recently introduced for anastomotic leaks after resections for malignancies. Our aim was to assess the overall efficacy of the endoscopic treatment for anastomotic leaks after esophageal or gastric resection for malignancies.Methods:We conducted a multicenter retrospective study in four digestive endoscopy tertiary referral centers in France. We included consecutive patients managed endoscopically for anastomotic leak following esophagectomy or gastrectomy for malignancies between January 2016 and December 2018. The primary outcome was the efficacy of the endoscopic management on leak closure.Results:Sixty-eight patients were included, among which 46 men and 22 women, with a mean ± SD age of 61 ± 11 years. Forty-four percent had an Ivor Lewis procedure, 16% a tri-incisional esophagectomy, and 40% a total gastrectomy. The median time between surgery and the diagnosis of leak was 9 (6–13) days. Endoscopic treatment was successful in 90% of the patients. The efficacy of internal drainage and esophageal stents was 95% and 77%, respectively (p = 0.06). The mortality rate was 3%. The only predictive factor of successful endoscopic treatment was the initial use of internal drainage (p = 0.002).Conclusion:Endoscopic management of early postoperative leak is successful in 90% of patients, preventing highly morbid surgical revisions. Internal endoscopic drainage should be considered as the first-line endoscopic treatment of anastomotic fistulas whenever technically feasible.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series.

Aim:Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).Methods:All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.Results:Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).Conclusions:Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

The evolution of surgical treatment for chronic leak following sleeve

<h3>Background</h3> Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed. <h3>Objectives</h3> The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG. <h3>Setting</h3> University hospital, France. <h3>Methods</h3> Between January 2013–December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed. <h3>Results</h3> Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m² underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6–12 months in 6 cases; between 1–3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median=225 min). The hospital stay ranged from 5–30 days (mean = 12.67, median=11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded. <h3>Conclusions</h3> Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278–283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.

S0960 Evaluation of the Efficacy and Safety of Lumen Apposing Metal Stents for Peripancreatic Fluid Collection Drainage Without Double Pigtail Stent Placement: Our Experience in a Large Community Hospital

INTRODUCTION: Acute pancreatitis (AP) is sometimes accompanied by fluid collections and necrosis. These include acute pancreatic fluid collections (PFCs), pancreatic pseudocysts, acute necrotic collections (ANCs), and walled off pancreatic necrosis (WOPN). Indications for drainage of the PFCs include infection, bleeding, luminal obstruction, fistulization, and biliary obstruction. Currently endoscopic drainage is considered standard of care. Cautery enhanced lumen-apposing metal stents (LAMS) is a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections. Some endoscopists prefer placing double pigtail stents (DPS) within the LAMS, while others do not. Rationale for DPS within LAMS is to reduce potential adverse events like bleeding, stent occlusion & infections. We perform endoscopic drainage without placing DPS within the LAMS. We propose that placing DPS within LAMS does not decrease adverse events associated with LAMS placement. METHODS: We conducted a retrospective study of patients with cautery enhanced LAMS placed for pseudocyst or WOPN between January 1, 2017 and November 30, 2019. We evaluated the efficacy and safety of LAMS. Adverse events were categorized into two: early- occurring within 48 hours and late occurring after 48 hours. RESULTS: This study had 18 patients with the following characteristics: 10 males and 8 females; 8 Caucasians, 9 African Americans and 1 Hispanic; and the average age was 48 yrs. The clinical findings showed a similar etiology of pancreatitis for gallstones and alcohol. All LAMS deployed were 15mm in diameter. The average size of collection drained was 114.11 mm with an average duration of stent placement of approx. 52 days. Overall, 8 patients required necrosectomy. Of those that required a necrosectomy, 2 patients required 1 session, and 6 required multiple sessions. In all patients, only one early adverse event was found: Stent mal-deployment. None of the patients required re-intervention as there was complete/near complete resolution of PFC at 3 months follow-up. CONCLUSION: Successful resolution of pancreatic fluid collections may be achieved endoscopically. Our data suggest that deployment of LAMS reduces the rate of adverse events and reinterventions. The additional deployment of double pigtail stents through LAMS, as suggested by the Shamah et al. 2018 paper may not be needed. Further prospective, randomized study in a larger sample size is warranted to validate these results.Table 1

S3489 Double Pigtail Stents: A Simple Solution to Prevent Delayed Bleeding From the Lumen Apposing Metal Stents?

S3489 Double Pigtail Stents: A Simple Solution to Prevent Delayed Bleeding From the Lumen Apposing Metal Stents?

S0580 Endoscopic Vacuum Therapy for Upper Gastrointestinal Defects

INTRODUCTION: Endoscopic interventions have been successful in the closure of gastrointestinal perforations and post-operative leaks, issues that have traditionally been addressed surgically. Mechanical endoscopic closure has been reported with clips, stents, suturing, and fibrin glue. Endoscopic vacuum therapy (EVT) offers an alternate mechanism of closure via negative pressure that results in defect reduction, aspiration of infected fluid, and promotion of granulation tissue. We present our experience with EVT as it relates to spontaneous, iatrogenic, and post-operative upper GI tract perforations, leaks, and fistulas. METHODS: We retrospectively reviewed patients presenting with upper GI tract perforation, post-operative leak, or fistula that underwent EVT at one of five hospitals between 6/2018 and 5/2020. Data collected includes age, ethnicity, gender, BMI, Charlson comorbidity index, indication, defect size and location, duration of antibiotics, prior endoscopic therapies, time to EVT from diagnosis, sponge placement (intraluminal vs intracavitary), NG tube size, total days with EVT, number/interval of EV exchanges, and adjunctive endoscopic therapies. Technical success, degree of closure, hospital length of stay (LOS), and duration of follow up were analyzed. Student t-test and chi-squared analyses were performed. RESULTS: 15 patients underwent EVT with a technical success rate of 100%. There was an 80% closure rate with 9 patients achieving complete closure and 3 patients achieving partial closure. Two of three failures were patients with external fistulas compared to the 12 successes which were patients with post-operative leaks, perforations, and one enclosed fistula with a concomitant cutaneous wound vacuum (P < 0.02). There was a higher success rate with intraluminal compared to intracavitary placement of EVT (P < 0.006). The average LOS was shorter in those with successful EVT (P < 0.05). CONCLUSION: EVT is effective for closure of complex upper gastrointestinal defects, potentially obviating the need for surgical intervention and reducing the LOS. It appears less effective for external fistulas, likely because a complete vacuum seal is difficult to accomplish. Many patients (56%) required adjunctive endoscopic therapy such as double pigtail stents, over the scope clips, and percutaneous drains to achieve complete closure, suggesting that the optimal strategy is likely a tailored one. Larger studies are needed to make firm conclusions regarding optimal patient selection and methodologies for EVT.Table 1.: Demographic DataTable 2.: Endoscopic and Technical Variables

S0925 The Endoscopic Management of Stricture in Patients With Pancreaticoduodenectomy

INTRODUCTION: Stricture formation is a known post-pancreaticoduodenectomy (PD)-related adverse event (AE) and noted to be as high as 8.2% in the first 5 years. In this study, we assessed the safety and efficacy of ERCP for the treatment of choledochojejunostomy and pancreaticojejunostomy stricture. METHODS: We retrospectively evaluated patients with prior classic or pylorus-preserving PD who received ERCP from 01/13/06 to 01/16/19. ERCP reports were analyzed for stricture location, treatment for stricture, and stent characteristics. Outcomes included technical success rate—the ability to treat stricture with dilation or stent placement, and clinical success rate—a decrease in bilirubin to normal or 50% of peak value within 2 weeks. Statistical analysis was done using Stata/SE version 16.0. RESULTS: A total of 28 patients (75% male; median age 66 years, range 22–86 years) with prior PD received 66 ERCPs for biliary (25 patients received 63 ERCPs) and pancreatic (3 patients received 3 ERCPs) evaluation. All 3 ERCPs for pancreatic evaluation were unsuccessful. On hepatobiliary assessment, 16 patients had stricture on initial ERCP: choledochojejunostomy (n = 12), distal extrahepatic (n = 3) and hilar (n = 1). An additional 36 strictures were discovered on repeat ERCPs for a total of 52 strictures. Overall, the most common stricture location was at the choledochojejunostomy (n = 41), then the distal extrahepatic (n = 8), intrahepatic (n = 2), and hilar (n = 1). A total of 38 stents were placed: 33 plastic (86.8%), 3 uncovered metal (7.9%), and 2 covered metal (5.3%). More straight plastic stents (n = 23, 69.7%) were placed than double pigtail stents (n = 10, 30.3%), and the most common stent size was 10 Fr by 5 cm (n = 17, 44.7%). All strictures were treated with balloon dilation and subsequent stent placement when indicated. The technical success rate was 81.0% (51/63 ERCPs) and the clinical success rate was 76.2% (48/63 ERCPs). Procedure-related AEs occurred in 5/66 ERCPs (7.6%): 4 cases of self-resolving fever, 1 case of mild cholangitis. CONCLUSION: ERCP is a safe and effective modality for the management of post-PD-related stricture. The incidence of stricture formation was likely inflated in our population given the nature of a large tertiary cancer-center. Further technological advancements and improvements in technique are required for pancreatic intervention in post-PD patients.

S2352 A Tale of Two Stents: Rescue of a Migrated Lumen-Apposing Stent During EUS-Guided Cystogastrostomy

INTRODUCTION: Pancreatic pseudocysts are a common complication of pancreatitis. Both percutaneous and endoscopic therapeutic avenues have been developed for the drainage of symptomatic cysts. Surgical management is associated with higher rates of morbidity and, therefore, trans-gastric and trans-duodenal endoscopic drainage have become widely utilized treatments for the definitive management of pancreatic pseudocysts. Following tract creation and dilation, plastic pigtail stents, self-expanding metal stents, and now lumen-apposing covered self-expanding metal stents (LAMS) are used to maintain patency of the tract and allow for drainage of cysts. Though LAMS reduce the risk of stent migration, we report a case of a 28-year old female undergoing endoscopic ultrasound (EUS)-guided trans-gastric cystogastrostomy complicated by intra-procedural stent migration. CASE DESCRIPTION/METHODS: The patient had a two year history of abdominal pain that began after a cholecystectomy for gallstone disease. Computerized tomography (CT) imaging from May of 2019 demonstrated a large, thin-walled cyst within the head of the pancreas (Figure 1). The patient was scheduled to undergo EUS-guided drainage. A trans-gastric approach was utilized for tract creation. A 10 mm × 10 mm LAMS stent was deployed across the tract. The distal flange opened appropriately, however the proximal flange did not completely open. Because the tract was slightly longer than the length of the stent, while attempting to retract and reposition the stent, the proximal end migrated into the tract. To ensure maintained patency of the tract, a 10 mm × 80 mm covered metal biliary stent was placed inside of the LAMS stent to completely and securely bridge the cyst and the stomach. Final stent position was confirmed with fluoroscopy (Figure 2). The patient remained asymptomatic in the time between discharge and follow-up visit. The stents were removed without complication and no necrosis or bleeding was noted at the tract site. DISCUSSION: The use of lumen-apposing covered metal stents for pancreatic fluid collection drainage is a relatively novel technique offering a convenient, single step method of deployment. Though these large-lumen, dumbell-shaped devices reduce the risk of stent migration, we report a unique complication of the procedure in which, during stent deployment, one end of the LAMS stent migrated into the tract. Placement of a biliary metal stent proved to be an effective and safe rescue technique in this patient.Figure 1.: Large, thin-walled fluid-filled cyst in head of pancreas.Figure 2.: Fluoroscopic image demonstrating biliary metal stent contained within lumen-apposing metal stent bridging cyst to stomach.