Walled Off Research Articles

2119 Acute Post-Operative Drainage With a Lumen-Apposing Metal Stent (LAMS)

INTRODUCTION: Peripancreatic fluid collections may occur following pancreatic resection and are traditionally managed by percutaneous surgical drains. Endoscopic management of these peripancreatic fluid collections is increasingly utilized and there is growing experience in this realm. CASE DESCRIPTION/METHODS: A 54-year-old woman with a history of resectable adenocarcinoma of the pancreatic tail (T1a) who received FOLFIRINOX neoadjuvant therapy and was transitioned to Gemcitabine/Abraxane, presented for surgical management. She initially underwent laparoscopic, hand-assisted distal pancreatectomy and splenectomy. She tolerated surgery with no immediate complications. On postoperative day #4, she developed moderate abdominal pain. Computed tomography (CT) demonstrated an irregularly-shaped, hypodense fluid collection measuring 7.5 × 6.5 × 8.3 cm about the pancreatic tail, concerning for pancreatic duct leak. The decision was made to perform endoscopic drainage under endoscopic ultrasound guidance. On postoperative day 6, EUS demonstrated a 7 × 4 cm septated collection in the postoperative bed in the region of the distal pancreas (Figure A). The acute collection had not yet become walled off based on CT and EUS. The common wall between the stomach and cyst was interrogated utilizing color Doppler and an ideal puncture sight was determined. An electrocautery enhanced lumen apposing metal stent (LAMS) was advanced into the cyst and a 10 × 10 mm LAMS was placed with flanges in close approximation to the fluid collection and stomach wall through cystgastrostomy (Figure B). An additional 7 Fr by 4 cm soft double pigtail stent was then placed coaxial to the LAMS to maintain patency. At follow-up, two weeks later, her abdominal symptoms had resolved. Her interval scan demonstrated a significantly decreased pancreatic tail collection and transgastric LAMS. At postoperative day 10, cross sectional imaging demonstrated complete resolution of her fluid collection, and endoscopy was performed with uneventful LAMS removal (Figure C). DISCUSSION: This case demonstrates a patient with an acute postoperative peripancreatic fluid collection after distal pancreatectomy which was successfully treated six days postoperatively with transgastric cystgastrostomy using a LAMS. While traditional management in the acute postoperative setting has been percutaneous drain placement, further study is needed to evaluate the safety and efficacy of minimally invasive, endoscopic methods of postoperative drainage.

2 Hydrogen Peroxide-Assisted Endoscopic Necrosectomy vs. Standard Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis: A Multi-Center Retrospective Comparative Study

INTRODUCTION: Endoscopic necrosectomy has emerged as the preferred treatment modality for walled off pancreatic necrosis (WON). Standard endoscopic necrosectomy can be tedious and time consuming, employs sharp instruments in vascular cavities, and does not provide for microdebridement. Hydrogen peroxide (H2O2) lavage has been reported in small series; however, there have been no comparative studies on its safety and efficacy in the management of WON. METHODS: We performed a retrospective chart review of all cases undergoing endoscopic transmural management of WON at 9 major medical centers in the US from November 2011 to August 2018. Cystogastrostomies were performed using lumen apposing metal stents (LAMS). Patients who underwent cystogastrostomy without necrosectomy were excluded. Clinical success was defined as resolution of the WON by imaging within 6 months, without requiring non-endoscopic drainage procedures or surgery. RESULTS: A total of 296 patients underwent cystgastrostomy and 206 patients underwent one or more necrosectomies. Clinical success was achieved in 171/192 (89.1%) of those with follow-up data at 6 months. In terms of patients, 122 (59.2%) patients had at least one H2O2 necrosectomy (H2O2 group), and 84 (40.8%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group (n = 107 (95.5%) vs 63 (79.7%), P < 0.001). On multivariate logistic regression, the use of hydrogen peroxide (OR 17.4, 95% CI: 2.9–103, P = 0.002) was associated with higher clinical success rates (Table 2). During a mean follow up of 278 days, 29 complications occurred: bleeding (n = 18), perforation (n = 5), respiratory complication (n = 3), and sepsis (n = 3). One death was presumed to be procedure related (splenic pseudoaneurysm rupture day 8; standard necrosectomy group). A total of 394 necrosectomies were performed. Comparing necrosectomy procedures with and without H2O2 (n = 209 vs 185), there was no difference in procedure time (72.5 ± 39.6 vs 72 ± 44.2, P = 0.936), post-procedural bleeding (8 vs 10, P = 0.45), perforation (3 vs 2, P = 1), infection (1 vs 2, P = 0.6) or overall complication rate (n = 15 (7.1%) vs 14 (7.6%), P = 1) (Table 3). CONCLUSION: In this multicenter retrospective cohort study, H2O2 necrosectomy appeared to be safe and effective with a higher clinical success rate and equivalent rates of bleeding, perforation, death, and overall complications relative to standard necrosectomy.

1684 Paging Dr. MacGyver: A Novel Approach to Redeploying a Dislodged AXIOS Stent During a Pancreatic Necrosectomy

INTRODUCTION: Although multiple modalities exist for managing walled off and infected pancreatic necrosis, EUS-guided transmural drainage is often favored due to its minimally invasive and highly effective nature. The AXIOS stent has demonstrated clear superiority over double pigtail and fully covered self-expanding metal stents in this setting. Although the radial force from its wide luminal diameter and its dumbbell shape helps secure the stent in place, stent migration and dislodgement can still occur. Here, we present a case of stent dislodgement during a pancreatic necrosectomy, which was salvaged by stent extraction and endoscopic re-deployment using a stone extraction balloon catheter sheath. CASE DESCRIPTION/METHODS: A 68-year-old woman with a medical history notable for prior acute pancreatitis presented to the ED with abdominal pain, nausea, and vomiting. CT Abdomen revealed a large pancreatic fluid collection with surrounding necrosis. She was admitted to the SICU for management of necrotizing pancreatitis, and underwent cystgastrostomy with an AXIOS stent on day 14 of admission. During her necrosectomy one week later, the previously placed AXIOS stent was accidentally displaced into the stomach. The displaced stent was grasped with a rat tooth forceps and removed from the patient. One end of the extracted AXIOS stent was stretched so that it became thin enough to be inserted into an empty stone extraction balloon catheter sheath. The other end was then back-loaded into the larger channel of a double-channel gastroscope. The scope was then re-introduced and advanced into the pancreatic cyst cavity. A rat tooth forceps was inserted into the instrument channel and used to advance the back-loaded stent forward, re-deploying the stent under endoscopic guidance only, such that it again traversed the cystic cavity and stomach. The stent was then adjusted into its desired position using rat tooth forceps. DISCUSSION: As Interventional Endoscopy’s technologies continue to evolve, it will become increasingly important for the skilled endoscopist to understand the mechanics of the tools being used, and trouble shoot these technologies as unforeseen complications arise. The novel method for AXIOS stent re-deployment described here not only demonstrates this understanding, but also serves as an example of a cost saving recourse for dislodged AXIOS stent re-deployment. Indeed, in an era of cost-conscious care, one must trouble shoot in a manner that is both clinically effective and financially efficient. Watch the video: http://bit.ly/2O2RYbW.

2652 Primary Malignant Peripheral Nerve Sheath Tumor of Small Bowel and Colon Presenting With Metastases to Bone, Lung, Liver, Spleen, and Brain

INTRODUCTION: Malignant Peripheral Nerve Sheath Tumor (MPNST) is a rare diagnosis, with an incidence of 1:100,000 per year and 4–10% of soft tissue sarcoma, contains properties both neural crest cells and mesenchymal cells. Gastrointestinal MPNSTs are rare disease conditions with only 10 cases reported worldwide in the literature. CASE DESCRIPTION/METHODS: A 71-year old Portuguese male, presented with 8-week history of abdominal pain, anorexia with 20Ib weight loss. Vital signs were normal. On physical examination, a firm, tender, fixed abdominal mass in the RLQ was palpated. CT scan of the abdomen showed a 10 cm necrotic mass on the right side of the abdomen with communication to the small bowel was detected with a suggestion of a walled off perforation. Colonoscopy revealed a flattening of the terminal ileum suggesting an extrinsic compression. Biopsy of tumor consisting of mixed spindle and pleomorphic cells with focal rhabdoid features, high grade nuclear features and brisk mitotic activity. A week later, he presented with symptoms of small bowel obstruction, the CT scan at this time showed a 8 cm left sided abdominal mass with communication to the small bowel with dilation of the jejunum suggesting a new partial obstruction in addition. The patient underwent a palliative debulking of the tumor. Multiple large obstructive masses were found in the Ligament of Treitz,significant portion of the small bowel, right colon, left upper quadrant and omentum. For palliation purposes, these masses were resected and anastomosis was performed. Gross examination of the surgical specimens revealed grayish-tan cystic masses filled with brownish tan hemorrhagic material. Histology of the masses were similr to previous mass. On immunohistochemistry, showed patchy weak S100 immunoreactivity and focal BCL-2 and Neuron Specific Enolase stain immunoreactivity. Ki-67 proliferation index was 70%. The pathologic diagnosis of MPNST was established. He developed multiple bone, pulmonary, liver, splenic and hemorrhagic brain metastases. He died under hospice care within six months of his initial presentation. DISCUSSION: MPNST, occurs mostly in association with Neurofibromatosis Type 1 (8–13%). The tumor typically originates from the nerve sheaths of the major nerves in the extremities (40%), trunk/ retroperitoneal (38%) and head and neck region (21%). However, recent case reports have also documented MPNST of the liver, thyroid gland, skin, eighth cranial nerve and rarely the greater omentum without a history of radiation or NF1.

Hierarchy within female ACG fandom in China

This case study focuses on a Chinese female-oriented ACG fan community, 3n5b, with an eye to studying how this community creates a sense of exclusivity and hierarchy through the discourses of copyright infringement, fan labor, and quality membership. Through controlling the distribution of rare resources, 3n5b creates high demand for their manga scanlation, and this demand is translated to a highly restricted membership. Membership is valuable because it is closely related to individual member's social and cultural capital, as well as their access to forum resources. Well-behaved members can slowly gain entry into more restricted forums, while members who violate forum rules are punished with loss of forum status or even membership revocation. This hierarchy seeks to raise the forum's overall quality and to wall off unwanted members, but it also replicates offline power relations that inevitably place people of lower social status at a disadvantage.

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.

Surgical Challenges in Management of Transected Pancreatic Duct in Blunt Trauma

Isolated blunt pancreatic injury with ductal involvement is rare following a motor vehicle collision, but correlates with significant morbidity and mortality. We reported a 15-year-old male who presented to emergency department after sustained motor vehicle collision. Post trauma, he appeared drowsy but hemodynamically stable. Abdominal examination was unremarkable but FAST scan was positive and he was subjected for CECT abdomen and showed pancreatic laceration at the body with suspicious of pancreatic duct injury. He was planned for emergency exploratory laparotomy and intra-operatively noted pancreatic head laceration with transected pancreatic duct. The case proceeded with ligation of pancreatic duct cephalic stump, and distal pancreaticogastrostomy. Post operatively, the patient recovered well and he was discharged home on day 6 post operatively. Upon follow up visit, he was asymptomatic with repeated ultrasonography of abdomen showed no evidence of intra-abdominal collection. Discussion: Pancreatic injuries with ductal disruption are of special significance. Apart from bleeding, the leak of enzyme rich of pancreatic juice incites vigorous inflammatory cascade that lead to catastrophic changes in patient metabolism and its sequelae including pancreatic necrosis, peripancreatic abscess, pseudocyst, enteric fistulae and organ failures. In a hemodynamically stable patient, CECT abdomen is the investigation of choice to detect pancreatic duct involvement. Pancreatic injury with ductal involvement require surgical management to prevent the complication of pancreatic enzyme leak. Non operative measure is found to be useful in selected patient. The criteria for nonoperative group are stable hemodynamically, a controlled leak wall off like pseudocyst, absent associated injury or pancreatic necrosis. Non-operative strategy requires multidisciplinary involvement with excellent nutritional support, expert endoscopist and interventional radiologist.

Experiences with endoscopic ultrasound-guided drainage of walled off pancreatic necrosis with lumen apposing metal or plastic stents

Experiences with endoscopic ultrasound-guided drainage of walled off pancreatic necrosis with lumen apposing metal or plastic stents

Definitive treatment of walled off necrosis – case report

Background: Walled off necrosis (WON) is defined as a mature collection of pancreatic or peripancreatic necrosis with a well defined wall. Diagnosis is made after 4 weeks to the onset of necrotising pancreatitis. Minimally invasive approaches currently are reported to be associated with less morbidity and mortality with similar success rates than surgery alone. We report a case of a walled of necrosis which was treated through an endoscopic approach. Methods: We report the case of a 48 year old woman, admitted on May 2017 with severe acute pancreatitis (respiratory and renal disfunction). Admission computed tomography (CT) - pancreatic and peri pancreatic necrosis compromising pancreatic body and tail (Figure 1). Patient had a good response to initial intensive care treatment. On first month of follow up patient begun with epigastric pain and fullness postprandial sensation. Magnetic resonance (MRI) - pancreatic collection of approximately 5 inches occupying body and tail with a thin wall. Interior is liquid and has detritus. (Figure 2) Medical treatment is proposed and patient is discharged. Symptoms do not decrease and 3 months after onset of pancreatitis, a trans gastric endoscopic approach of the WON is performed. (Figure 3). Results: Endoscopic cystogastrostomy was performed to manage WON. A yo-yo stent to maintain its lumen for programmed endoscopic drainages. Endoscopic trans gastric necrosectomy was done in three opportunities. Symptoms decreased and a new CT scan was made 2 months after treatment, this showed no elements of WON nor pancreatic tissue alterations. (Figure 4) Laparoscopic cholecystectomy was done 2 months after to complete integral treatment of this pathology. No complications were registered during or after both procedures. Conclusion: WON is an evolutive complication of necrotising pancreatitis. Minimally invasive approaches, particularly endoscopic access has shown to be the procedure with less morbidity and mortality than other procedures. Laparoscopic cholecystectomy completes treatment, avoiding new complications.

Clinical and Magnetic Resonance Imaging Characteristics of Postfenestration Optic Nerve Sheath Pseudomeningoceles.

The clinical significance of postoperative pseudomeningocele formation following optic nerve sheath fenestration (ONSF) has not been fully characterized. A literature review identifies 9 previously published cases the authors believe demonstrate pseudomeningocele formation and approximately 19 other similar findings that were either transient or less defined blebs. This study was undertaken to more clearly define the clinical, radiographic, and histopathologic features associated with this entity. Sixteen-year, single-center, retrospective chart review of all ONSF cases performed by 2 surgeons. Clinical data, intracranial pressure, radiographic imaging, and histopathology of clinically detected pseudomeningoceles after ONSF were reviewed. Eighty-six eyes in 57 patients underwent ONSF (28 unilateral, 12 bilateral sequential, 17 bilateral simultaneous). Forty-nine of 57 patients had elevated intracranial pressure preoperatively (41 idiopathic intracranial hypertension, 4 venous thrombosis, 2 meningitis, 1 arteriovenous malformation, and 1 sarcoid). In 32 patients undergoing postoperative imaging, 4 eyes (4.7%) in 4 patients developed well-defined pseudomeningoceles, of which 3 were symptomatic and 2 required surgical revision. Each pseudomeningocele developed in the setting of elevated preoperative intracranial pressure (350, 360, 430, 500 mm H20). Magnetic resonance imaging and/or computed tomography revealed sharply demarcated fluid-filled sacs adjacent to the optic nerve. The contents of these sacs were hypointense on T1-weighted imaging, hyperintense on T2-weighting, variably enhanced with contrast, and hypointense on fluid attenuated inversion recovery, and were thus consistent with cerebrospinal fluid. Histopathologic analysis of one of these outpouchings demonstrated an acellular, fibrocollagenized lining consistent with pseudomeningocele. Three eyes in 3 additional patients had less well-defined findings on imaging interpreted as bleb-like or cyst-like change. Pseudomeningoceles following ONSF may be asymptomatic or may cause symptomatic orbital mass effect and rarely visual loss, amendable to surgical excision. Post-ONSF pseudomeningoceles are identified on computed tomography or magnetic resonance imaging to occur at the locations of fenestration sites and contain cerebrospinal fluid communicating with the subdural space that may act as a "filtration" bleb in some cases. Imaging findings may represent a spectrum spanning intraorbital cerebrospinal fluid leakage, partial walling off of bleb, or fully developed cysts. Resection of optic nerve pseudomeningoceles is considered in symptomatic cysts or eyes with papilledema that fails to improve.

Discontinuation of proton pump inhibitor use reduces the number of endoscopic procedures required for resolution of walled-off pancreatic necrosis.

Background and Objectives:Endoscopic drainage/debridement of symptomatic walled off necrosis (WON) using lumen-apposing metal stents (LAMS) is both safe and effective. While endoscopic management of WON is the standard approach to treatment, the ideal concomitant medical therapy remains unclear. The purpose of this study was to further elucidate the effect of proton pump inhibitor (PPIs) therapy on the technical and clinical success of endoscopic treatment of WON.Methods:Two hundred and seventy-two patients in 8 centers with WON managed by endoscopic drainage using LAMS were evaluated. Patients were followed for at least 6 months following treatment. The patients were divided into two groups: Those that used PPIs continuously during the therapy and those not on PPIs continuously during the interval of therapy. Outcomes included but were not limited to technical success, clinical success, number of procedures performed, and adverse events.Results:From 2013 to 2016, 272 patients underwent WON drainage with successful transmural LAMS placement. The two groups were split evenly into PPI users and non-PPI users, and matched in regards to demographics, etiology of pancreatitis, WON size, and location. There was no difference in the technical success between the two groups (100% vs. 98.8%, P = 1), or in clinical success rates (78.7% vs. 77.9%). There was a significant difference in the required number of direct endoscopic necrosectomies to achieve clinical success in the PPI vs. non-PPI group (3.2 vs. 4.6 respectively, P < 0.01). There were significantly more cases of stent occlusion in the non-PPI group vs. PPI group (9.5% vs. 20.1% P = 0.012), but all other documented adverse events were not significantly different.Conclusion:Discontinuing PPIs during endoscopic drainage and necrosectomy of symptomatic WON appears to reduce the number of endoscopic procedures required to achieve resolution. Continuous PPI results in higher rates of early stent occlusion.

Natural course of asymptomatic walled off pancreatic necrosis

IntroductionThere is paucity of data on natural course of asymptomatic walled off necrosis (WON). ObjectiveTo study the natural course as well as outcome of conservative management in patients with asymptomatic WON. MethodsRetrospective analysis of prospectively maintained data base of patients with asymptomatic WON presenting to us 4–6 weeks after an episode of acute necrotising pancreatitis (ANP). ResultsForty three patients (37 M; mean age: 38.2 ± 10.4 years) with asymptomatic WON were studied. The size of WON ranged from 5 to 16 cm (mean 8.2 ± 2.2 cm). The site of WON was head, body and tail in 5 (11%), 34 (79%) and 4 (10%) patients respectively. Thirty of 43 patients (70%) patients did not have any complications during the expectant management period of 3 weeks–32 months with 13 (30%) patients having spontaneous resolution within 6.2 ± 3.4 months. Thirteen (30%) patients became symptomatic or developed complication within 3.2 ± 1.3 months. These were refractory pain (n = 7), infection (n = 4), spontaneous rupture into gastrointestinal tract (n = 5; stomach in 3, duodenum in 1 and colon in 1 patient respectively) and bleeding from splenic artery pseudoaneursym in 1 patient. ConclusionsMajority of patients with asymptomatic WON have an uneventful clinical course. However, one third patients will develop symptoms/complications requiring interventional treatment.

Hydrogen Peroxide-Assisted Endoscopic Necrosectomy

Pancreatic inflammation can result in varying degrees of transient and permanent pancreatic parenchymal or ductal injury. Pancreatic necrosis and pseudocyst formation may occur and can require endoscopic or surgical intervention. Hydrogen peroxide-assisted necrosectomy is an endoscopic technique for irrigation of walled off pancreatic collections to chemically debride solid components. An 84-year-old male with a medical history of gallstone pancreatitis post cholecystectomy complicated by sepsis, pseudocyst (17.2 cm x 9 cm) and end organ damage, experienced gram negative bacteremia from pseudocyst infection 4 weeks after his bout of pancreatitis. The patient underwent cystgastrostomy with endoscopic ultrasound, aspiration of purulent material, and lumen opposing (Axios) stent placement. Several necrosectomies were required due to the presence of solid necrotic material within the pseudocyst. The initial necrosectomy successfully cleared the stent of solid material and aspirated purulent fluid. Upon re-inspection at a 2 week interval, solid material was visualized and lavage of the pseudocyst with 2 weeks of enterally ingested “coca-cola” was attempted. A third inspection of the stent revealed re-occlusion with solid debris. Intra-procedurally, 120mL of 1.5% hydrogen peroxide solution lavage with mechanical debridement resulted in near complete evacuation of the pseudocyst cavity. The stent was removed and a 10 French x 7 cm pigtail was left to enable further drainage of the cavity. Patient's symptomatology resolved and repeat imaging confirmed collapse of the pseudocyst to 2.3 by 1.2 cm. The pigtail stent was removed and the patient remains asymptomatic. The use of hydrogen peroxide during pancreatic pseudocyst necrosectomy appears to aid in the chemical dissolution of solid necrotic material and facilitate resolution of pancreatic collections. We encourage scrupulous utilization of this technique as an aide during necrosectomies to collect further data on its absolute utility during endoscopic management of pancreatic pseudocycts.2112_A Figure 1. Endoscopic view of pancreatic pseudocyst through the lumen opposing stent visualizing extensive necrotic debris prior to lavage with a 1.5% solution of hydrogen peroxide.2112_B Figure 2. Endoscopic view of cystgastrostomy with solid necrotic debris extruding through the lumen opposing stent prior to debridement with a 1.5% solution of hydrogen peroxide.2112_C Figure 3. Endoscopic view of pancreatic pseudocyst through the lumen opposing stent visualizing successful debridement of solid necrotic material using a 1.5% solution of hydrogen peroxide.

Internal Migration of Lumen-Apposing, Fully Covered Self-Expanding Metal Stent Used for Walled off Pancreatic Necrosis: An Approach for Retrieval

Internal Migration of Lumen-Apposing, Fully Covered Self-Expanding Metal Stent Used for Walled off Pancreatic Necrosis: An Approach for Retrieval

Spontaneous gastric fistulation during the course of acute necrotizing pancreatitis: a case report

Introduction: Acute pancreatitis is a common surgical condition with significant morbidity and mortality. Pancreatic pseudocysts and walled off pancreatic necrosis (WOPN) are late sequele of pancreatitis. Spontaneous perforation or fistulation of such collections into a hollow viscus is a rare complication of pancreatitis. The most commonly reported site is the transverse colon, though such fistulation can involve all levels of the alimentary tract. Method: We describe a rare case of spontaneous gastric fistulation of a WOPN with subsequent improvement in the patient's clinical condition and successful conservative management. Case report: A 52 year old Chinese male presented on day 29 after a bout of severe necrotizing alcoholic pancreatitis with worsening pain and sepsis. Imaging confirmed the presence of an infected walled off pancreatic necrosis abutting and inseperable from the posterior gastric wall and duodenum. The patient was treated initially with percutaneous drainage and a step wise approach with an aim for VARDS. On day 38 of pancreatitis, there was a sudden change in drain fluid character to copious amounts of clear gastric fluid. CT and fluoroscopic imaging confirmed the presence of spontaneous fistulation into the stomach. Patient was treated conservatively for as a controlled fistula with rapid clinical improvement, hence avoiding any further surgical intervention. Conclusion: Though prompt surgical intervention may be required in cases of infected necrotic collections, the rare instances of spontaneous perforation into the duodenum or stomach results in transient drainage of the infected collection and subsequent clinical improvement.

Acute necrotising pancreatitis – early management in the district general hospital and tertiary hepato-pancreatico-biliary unit

Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.

Justifying Intervention in Walled Off Necrosis (WON)

Justifying Intervention in Walled Off Necrosis (WON)

Single incision laparoscopic surgery flank necrosectomy: A novel approach to extra-pancreatic walled off necrosis

Single incision laparoscopic surgery flank necrosectomy: A novel approach to extra-pancreatic walled off necrosis

870 OOPS, THE LUMEN-APPOSING METAL STENT (LAMS) MISDEPLOYED! STAY CALM. NOW LET’S RESCUE IT

Reasons for misdeployment of a lumen-apposing metal stent (LAMS) include: Unfamiliarity with the stent, difficult scope position, patient movement and a lack of sufficient space in the lumen being targeted. Consequence of an unaddressed, misdeployed stent can be serious. We present 5 locations and techniques of rescuing misdelpoyed LAMS. Case 1: 56 year old male with severe acute pancreatitis with infected walled off necrosis, undergoing endoscopic necrosectomy. During LAMS deployment, distance of the collection (11mm from duodenum) and patient movement, resulted in duodenal flange almost completely misdeploying into the collection. The last of the tines of the LAMS was grasped with a forcep and repositioned with gentle traction. Case 2: 45 year old male with metastatic pancreatic cancer and a 3rd bout of cholecystitis undergoing cholecystoduodenostomy. Due to patient coughing, the duodenal flange misdeployed into the peritoneum. Unable to reposition this with a forcep, the LAMS was pulled out and access lost. However, using a papillotome and guidewire through the duodenal perforation, access was regained and a new LAMS was placed. Case 3: 38 year old female with Roux-en-Y gastric bypass with choledocholothiasis undergoing EUS-tansgastric fistula for ERCP. The Gastric pouch flange misdeployed in the peritoneum. Balloon dilation allowed us to visualize the LAMS and push it into the gastric remnant. A new LAMS was then deployed allowing for an ERCP. Case 4: 68 year old male with locally advanced pancreatic mass and positive FNA at EUS with a gastric outlet obstruction precluding ERCP, undergoing EUS choledochoduodenostomy. Due to the small bile duct (12mm), the biliary flange misdeployed in the retroperitoneum. After reconstraining the LAMS and redeploying the second time, the LAMS double punctured the bile duct. It was removed and rescued with a 10mm x 10cm biliary FCSEMS. Case 5: 72 year old male admitted with recurrent gastric outlet obstruction post-Whipple, despite dilations, steroids, and stents elected to undergo EUS-gastroenterostomy. After guidewire access into the jejunum, the LAMS was advanced, but instead of penetrating the jejunum, it was pushed it away and deployed in the peritoneum. The LAMS was removed and the gastric perforation closed with an over-the-scope clip. None of the 5 patients needed surgery and were discharged between 1 and 3 days. Prior to procedure, written consent to use a LAMS off-label and a surgeon on standby for a gastroenterostomy should be done. Recognize whether the perforation is on one or both lumenal sides and how can we seal the leak. If spillage of luminal contents has occurred, how will this be managed? Admit the patient, watch for adverse events and communication with providers involved in the patient’s care should follow.

449 - Natural Course of Asymptomatic Walled off Pancreatic Necrosis: A Long Term Prospective Follow up Study

449 - Natural Course of Asymptomatic Walled off Pancreatic Necrosis: A Long Term Prospective Follow up Study