Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video)

Preliminary report on a new, fully covered, metal stent designed for the treatment of pancreatic fluid collections

BACKGROUND

Endoscopic transluminal treatment of pancreatic fluid collections (PFC) has been reported as an effective alternative approach to surgical treatment. A wide, short stent with an anti-migration system has been developed.

OBJECTIVE

To evaluate a newly developed, fully covered, self-expandable metal stent (FCSEMS) customized for cystogastrostomy.

DESIGN

Retrospective case series.

SETTING

Tertiary-care academic medical centers and affiliated hospitals.

PATIENTS

Nine patients who underwent endoscopic treatment of PFCs (5 with pseudocysts and 4 with walled-off pancreatic necrosis).

INTERVENTION

Stent deployment after endoscopic US-guided puncture. Irrigation and necrosectomy were performed at the discretion of the endoscopist.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success rate, complications, and removability.

RESULTS

The FCSEMS was inserted successfully in all cases (9/9, 100%). Clinical success was achieved in 7 of 9 cases (77.8%). No early complications associated with the procedure were observed. Late complications were observed in 2 cases (bleeding and asymptomatic migration). The FCSEMS was removed without any complications in all 6 cases where it was attempted after the procedure had been completed (100%).

LIMITATIONS

This was a retrospective evaluation of a small number of cases. The FCSEMS was always inserted via the transgastric route. Follow-up duration was short.

CONCLUSION

The endoscopic approach that uses this new FCSEMS is feasible for the treatment of PFCs. However, further evaluation is required.

EUS-guided endoscopic necrosectomy and temporary cystogastrostomy for infected pancreatic necrosis with self-expanding metallic stents

Pancreatic pseudocyst with infected necrotic tissue is associated with necrotizing pancreatitis and carries a high rate of complications and death. Open cystogastrostomy with removal of necrotic material and necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Endoscopic cyst drainage with necrosectomy is an alternative and less invasive technique. We report a case of endoscopic ultrasound-guided cystogastrostomy with a fully covered 15-mm-diameter self-expandable metal stent and staged endoscopic necrosectomy through the stent. This is the first case, so far, to use this technique with complete removal of necrotic material without any complications.

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting, May 7th, 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7^th, 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.

Transmural endoscopic necrosectomy of infected pancreatic necroses and drainage of infected pseudocysts: a tailored approach

OBJECTIVE

Transmural endoscopic drainage and necrosectomy have become favored treatment modes for infected pancreatic pseudocysts and necroses. In this analysis, we summarize the outcome of 40 patients with complicated course of acute pancreatitis after endoscopic treatment.

MATERIAL AND METHODS

From January 2006 through May 2011, 40 patients of our department with complicated pancreatitis were included in this retrospective analysis. All patients underwent endosonographic transgastric puncture followed by wire-guided insertion of one or more double pigtail stents. Patients with extensive necroses were treated repeatedly with transgastric necrosectomy. Treatment success was determined by clinical, laboratory, and radiological parameters.

RESULTS

Nine patients had interstitial pancreatitis (IP) with pancreatic pseudocysts. Thirty-one patients had necrotizing pancreatitis (NP) with acute pancreatic necroses (n = 4) or walled-off pancreatic necrosis (n = 27). All patients with IP and nine patients with NP had pseudocysts without solid material and underwent transgastric drainage only. In this group major complications occurred in 11.1% and no mortality was observed. Twenty-two NP patients were treated with additional repeated necrosectomy. In patients with localized peripancreatic necroses (n = 10) no need of surgery or mortality was observed, major complications occurred in 10%. In patients with extensive necroses reaching the lower abdomen (n = 12), three needed subsequent surgery and three died.

CONCLUSIONS

Transgastric endoscopy is an effective minimally invasive procedure even in patients with advanced pancreatic necroses. Complication rate is low particularly in patients with sole pseudocysts or localized necroses. The extent of the fluid collections and necroses is a new predictive parameter for the outcome of the patients.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in “one step”, EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

A kit for eus-guided access and drainage of pancreatic pseudocysts: efficacy in a porcine model

OBJECTIVE

Transluminal pseudocyst drainage with currently available tools remains technically challenging, time consuming and limited to fluid collections adherent to the GI tract. Multiple tools and steps are still required to achieve pseudocyst drainage. We evaluated a novel kit to facilitate endoscopic ultrasonography (EUS)-guided access, drainage and rapid decompression in a porcine model.

METHODS

The kit consists of the NAVIX access device and the AXIOS stent delivery system. The NAVIX contains an inner trocar for puncture and an outer dual balloon catheter for anchorage and dilation. The AXIOS stent is a fully covered dual flanged stent. Both are inserted through the working channel of a curved linear array echoendoscope. In a porcine model, a gallbladder was used as a proxy for a pseudocyst.

RESULTS

Six Yorkshire pigs underwent this procedure successfully without complication and 3 of them were kept alive. After a 4-week implantation period, the AXIOS stents were removed easily using a snare and the 3 animals were observed for an additional 4 weeks. The stents were well-tolerated by the stomach and gallbladder tissues, as confirmed by weekly endoscopic inspection, gross necropsy and histopathology.

CONCLUSION

EUS-guided transluminal access and drainage of the porcine gallbladder was technical feasible using a novel kit. This kit has the potential to simplify, streamline, and improve the safety of pancreatic pseudocyst drainage.

Endoscopic necrosectomy for walled-off pancreatic necrosis

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.

Treatment of Pancreatic Abscess with Endoscopic Ultrasound-guided Placement of a Covered Metal Stent Following Failed Balloon Dilation and Endoscopic Necrosectomy

For the management of pancreatic abscess, endoscopic ultrasound (EUS)-guided puncture and drainage has become recognized as a safer and more effective alternative to surgery. Typically, a double-pigtail plastic stent is placed for drainage. When an abscess is complicated by infected necrosis, endoscopic evacuation is essential. However, endoscopic evacuation carries a high risk of hemorrhage and needs to be performed daily to be effective. We describe EUS-guided endoscopic evacuation and placement of a fully covered metal stent following two failed evacuations. Patient recovery time was excellent, and no complications occurred.

Endoscopic ultrasound-guided biliary drainage

Objective

To demonstrate a comprehensive review of published articles regarding endoscopic ultrasound (EUS)-guided biliary drainage.

Materials and Methods

Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews.

Results

EUS-guided hepaticogastrostomy, coledochoduodenostomy and choledoantrostomy are advanced biliary and pancreatic endoscopy procedures, and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is the coledochoduodenostomy or choledochoantrostomy in distal lesions. Both procedures must be performed only after unsuccessful ERCPs. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian.

Conclusion

Hepaticogastrostomy and coledochoduodenostomy or choledochoantrostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy. Advanced echo-endoscopy should currently be performed under a rigorous protocol in educational institutions.

Covered self expandable metallic stent with flared plastic one inside for pancreatic pseudocyst avoiding stent dislodgement

Endoscopic ultrasound-guided drainage has recently been recommended for increasing the drainage rate of endoscopically managed pancreatic fluid collections and decreasing the morbidity associated with conventional endoscopic trans-mural drainage. The type of stent used for endoscopic drainage is currently a major area of interest. A covered self expandable metallic stent (CSEMS) is an alternative to conventional drainage with plastic stents because it offers the option of providing a larger-diameter access fistula for drainage, and may increase the final success rate. One problem with CSEMS is dislodgement, so a metallic stent with flared or looped ends at both extremities may be the best option. An 85-year-old woman with severe co-morbidity was treated with percutaneous approach for a large (20 cm) pancreatic pseudocyst with corpuscolated material inside. This approach failed. The patient was transferred to our institute for EUS-guided transmural drainage. EUS confirmed a large, anechoic cyst with hyperechoic material inside. Because the cyst was large and contained mixed and corpusculated fluid, we used a metallic stent for drainage. To avoid migration of the stent and potential mucosal growth above the stent, a plastic prosthesis (7 cm, 10 Fr) with flaps at the tips was inserted inside the CSEMS. Two months later an esophagogastroduodenoscopy was done, and showed patency of the SEMS and plastic stents, which were then removed with a polypectomy snare. The patient experienced no further problems.

Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos)

BACKGROUND

Tubular plastic and metal stents have inherent shortcomings when used for transenteric drainage of fluid collections.

OBJECTIVE

To evaluate a novel lumen-apposing, self-expandable metal stent for EUS-guided drainage of pancreatic pseudocysts and the gallbladder.

DESIGN

Retrospective case series.

SETTING

Tertiary-care academic medical center.

PATIENTS

This study involved 15 patients (median age 54 years) with symptomatic pancreatic pseudocysts who underwent 12 transgastric and 3 transduodenal pseudocyst drainage procedures. Five patients (median age 69.5 years) with acute cholecystitis underwent 4 cholecystoduodenostomies and 1 cholecystogastostomy.

INTERVENTION

Stent deployment under EUS guidance, passage of an endoscope through the stent lumen for pseudocystoscopy or cholecystoscopy, transenteric endoscopy-guided interventions including biopsy, necrosectomy, and stone removal.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success.

RESULTS

All stents were successfully deployed without complication, with a median time to removal of 35 days. All pseudocysts resolved after a single drainage procedure. One stent migrated into the stomach, and the remaining 14 were found to be patent at the time of removal. There was no pseudocyst recurrence during the 11.4-month median follow-up period. One gallbladder stent remains indwelling and fully patent at 12 months. Resolution of acute cholecystitis was observed immediately after stent implantation. No recurrence of symptoms was observed during a median follow-up period of 9 months.

LIMITATIONS

Retrospective study, small sample size, lack of control patients.

CONCLUSION

Transenteric drainage of pancreatic pseudocysts and the gallbladder by using a novel, lumen-apposing, metal stent was accomplished with high technical and clinical success in this pilot observational study. Further studies are warranted.

Endoscopic management of pancreatic pseudocysts

Techniques of endoscopic pseudocyst management continue to evolve, but the principles of proper patient selection and careful consideration of the available therapeutic options remain unchanged. Endoscopic management is considered first-line therapy in the treatment of symptomatic pseudocysts. Clinicians should be vigilant in the evaluation of all peripancreatic fluid collections to exclude the presence of a pancreatic cystic neoplasm and avoid draining an immature collection. Expectant management with periodic observation should be considered for the minimally symptomatic patients, even after the traditional 6 weeks of maturation. Further, symptoms, complications, and expansion on serial imaging should prompt intervention by endoscopic, surgical, or percutaneous methods. Pseudocysts should only be punctured when the wall has had sufficient time to mature and after pseudoaneurysm has been ruled out by careful imaging. Small to moderately sized pseudocysts (< 4–6 cm) that communicate with the pancreatic duct are good candidates for endoscopic transpapillary stenting. For larger lesions requiring transmural drainage, EUS guidance is preferable, but good results can be achieved with ENL. EUS may be particularly useful in permitting drainage in patients with suspected perigastric varices or if an endoscopically visible bulge is not apparent. Necrosis is a significant factor for a worse outcome; aggressive debridement with nasocystic or percutaneous endoscopic gastrostomy-cystic catheter lavage plus manual endoscopic techniques for clearing debris should be used. Endoscopic failure, especially in cases with significant necrosis, should be managed operatively. Percutaneous drainage is a good option for immature infected pseudocysts or in patients who are not optimal candidates for other procedures. Close cooperation between endoscopists, surgeons, interventional radiologists, and other healthcare providers is paramount in successfully managing these patients.

Endoscopic management of peri-pancreatic collections

Endotherapy of peripancreatic fluid collections is an increasing utilized procedure in interventional endoscopy. The aim of this paper is to provide a general overview of the topic, highlighting the indications, technique, and important management issues relating to endoscopic management of the various forms of peri-pancreatic fluid collections.

Stent-in-stent through a side hole to prevent biliary metallicstent migration

The covered self-expandable metallic stent (SEMS) has been developed to overcome the problem of tissue in­growth, However, stent migration is a well-known com­­plication of covered SEMS placement. Use of a double pigtail stent to lock the movement of the SEMS and prevent migration has been advised by many ex­perts. Unfortunately, in our case this technique led to an in­cidental upward migration of the SEMS. We used APC to create a side hole in the SEMS for plastic stent insertion as stent-in-stent. This led to a successful pre­ven­tion of stent migration.

EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study

OBJECTIVES

Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) with plastic stents has been introduced as an alternative to percutaneous transhepatic biliary drainage (PTBD) in cases of biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. Although self-expandable metallic stents with a larger diameter might offer long-lasting patency compared with plastic stents, to date, EUSBD with one-step placement of a fully covered self-expandable metal stent (FCSEMS) has not been evaluated. We conducted this study to determine the feasibility and usefulness of EUSBD with one-step placement of FCSEMS.

METHODS

A prospective feasibility study on EUSBD with one-step placement of FCSEMS was carried out in 14 patients with malignant biliary obstruction who were candidates for alternative techniques for biliary decompression because of unsuccessful ERCP.

RESULTS

The technical and functional success rate was 100% (14/14). Nine patients were treated using the intrahepatic approach. The remaining five patients were treated using the extrahepatic approach. With the intrahepatic approach, two patients showed self-limited pneumoperitoneum. With the extrahepatic approach, no patients had pneumoperitoneum. No bile peritonitis or cholangitis was observed after the procedure in any of the patients treated using the intra- or extrahepatic approach. During follow-up periods (median 6 months), one case of re-intervention (7%, 1/14) necessitated by distal stent migration was observed.

CONCLUSIONS

EUSBD with one-step placement of an FCSEMS may be feasible, safe, and effective as an alternative to PTBD in cases of malignant biliary obstruction when ERCP is unsuccessful. Prospective randomized trials of EUSBD with plastic stent vs. EUSBD with FCSEMS may be needed.

Endoscopic necrosectomy of organized pancreatic necrosis: a currently practiced NOTES procedure

BACKGROUND

Endoscopic necrosectomy is now an established minimally invasive method for treatment of organized pancreatic necrosis.

METHODS

Review of methods and results of endoscopic treatment of pancreatic necrosis.

RESULTS

Reports by multiple groups have demonstrated favorable results of endoscopic necrosectomy. The mortality of critically ill patients undergoing endoscopic treatment in several series is approximately 10%. Some patients will eventually also require surgery for situations such as complete pancreatic duct disruption, but even in these cases endoscopic necrosectomy is useful because pancreatic surgery can often be delayed until the patient is stable.

CONCLUSIONS

Endoscopic necrosectomy will likely assume an increasing role in the treatment of pancreatic necrosis. This should result in reduced morbidity and mortality in these critically ill patients.