Use of Lumen-Apposing Stents for the Treatment of Postsurgical Fluid Collections: A Case Series and a Review of Literature

Comprehensive analysis of adverse events associated with transmural use of LAMS in patients with liver cirrhosis: International multicenter study

Background and study aims Endoscopic ultrasound (EUS)-guided transmural (TM) deployment of lumen-apposing metal stents (LAMS) is considered relatively safe in non-cirrhotic patients and is cautiously offered to cirrhotic patients. Patients and methods This was a retrospective, multicenter, international matched case-control study to study the safety of EUS-guided TM deployment of LAMS in cirrhotic patients. Results Forty-three cirrhotic patients with model for end-stage liver disease score 12.5 ± 5, with 23 having ascites and 16 with varices underwent EUS-guided TM LAMS deployment, including 19 for pancreatic fluid collection (PFC) drainage, 13 gallbladder drainage, six for endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), three for EDGI, one for endoscopic ultrasound-directed transenteric ERCP, and one postsurgical collection drainage. Technical failure occurred in one LAMS for PFC drainage. Clinical failure was encountered in another PFC. Nine adverse events (AEs) occurred. The most common AE was LAMS migration (3), followed by non-bleeding mucosal erosion (2), delayed bleeding (2), sepsis (1), and anesthesia-related complication (pulseless electrical activity) (1). Most AEs were graded as mild (6), followed by severe (2), and moderate (1); the majority were managed conservatively. On univariable comparison, risk of AE was higher when using a 20 × 10 mm LAMS and the absence of through-the-LAMS plastic stent(s). Conditional logistic regression of matched case-control patients did not show any association between potential predicting factors and occurrence of AEs. Conclusions Our study demonstrated that mainly in patients with Child-Pugh scores A and B cirrhosis and despite the presence of mild-to-moderate ascites in over half of cases, the majority of AEs were mild and could be managed conservatively. Further studies are warranted to verify the safety of LAMS in cirrhotic patients.

Endoscopic ultrasound-guided drainage of a pelvic abscess - An alternative use of lumen-apposing metallic stents

The use of lumen-apposing metal stent is well defined for endoscopic ultrasound-guided drainage of pancreatic collections (e.g. WON). However, it is not yet a well-established approach in the management of postsurgical collections. We present an alternative application of LAMS for EUS drainage of pelvic abscess, showing that it is a safe and minimally invasive technique, with excellent clinical results. This technique should be considered as a drainage alternative in these scenarios due to its lower morbidity and mortality, opening a new era in the approach to these lesions.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Futuristic Developments and Applications in Endoluminal Stenting

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.

Management of infected post-pancreatic resection fluid collections under endoscopic ultrasound guidance using lumen apposing metal stent: A case series and review of the literature

Backgrounds/Aims

Post-operative pancreatic fistulas (POPF) and fluid collections (POPFC) remain significant sources of morbidity and mortality after pancreatic resections. There remains a paucity of literature describing endoscopic ultrasound (EUS) guided drainage of POPFC using a Hot AXIOS™ lumen apposing metal stent (LAMS).

Methods

We conducted a retrospective study, encompassing all consecutive patients with POPFC managed using Hot AXIOS™ LAMS at our institution between January 2017 and December 2019. Primary outcome measures were technical and clinical success. Secondary outcome measures were adverse events and recurrence rates.

Results

Five patients underwent EUS guided drainage using Hot AXIOS™ LAMS during the study period. Mean age of patients was 67.8 ± 2.16 years. The majority (60.0%) of patients were males. Median duration of symptom onset after surgery was 9 days. All patients presented with abdominal pain. Median size of the collection measured on computed tomography was 91 mm. Median interval time between symptom onset and EUS drainage was 30 days. Two patients required percutaneous drainage prior to EUS guided drainage. Technical and clinical success were achieved for all patients. No adverse events were observed. Median duration of follow-up was 90 days. No recurrence of collection occurred during the follow-up period.

Conclusions

EUS guided drainage of POPFC using Hot AXIOS™ LAMS is a safe and effective treatment modality with technical and clinical success rates of 100% in our experience.

Endoscopic ultrasound-guided pelvic abscess drainage: a report of 2 cases and literature review

BACKGROUND

Drainage is essential for source control of the infection in a pelvic abscess. The purpose of this study was to report 2 cases of endoscopic ultrasound (EUS)-guided drainage of the pelvic abscess and review the literature of different modalities of EUS-guided drainage of pelvic abscess.

CASE PRESENTATION

A 60-year-old male developed a pelvic abscess 1 month after laparoscopic complete tumor resection. An abdominal CT showed a mass shadow (about 7.1 cm × 5.1 cm) in the right pelvic region. Another case was an 85-year-old male who developed a pelvic abscess 3 days after recurrent tumor resection of multiple organs. The CT showed pelvic effusion and gas accumulation (approximately 6.5 cm × 4.2 cm), and the intestinal tube above the small intestinal anastomosis was dilated with effusion. A 19G-A puncture needle was used to puncture the abscess. An 8-mm cylindrical balloon was inserted, followed by a 10 Fr-3 cm double pigtail stent and an 8.5 Fr drainage tube. After EUS-guided drainage of pelvic abscess, the symptoms disappeared without recurrence.

CONCLUSIONS

EUS-guided drainage is an effective and safe method for treating pelvic abscesses as long as the drainage modality is appropriately selected based on the etiology, size, and mucus viscosity of the abscess.

Endoscopic Drainage of Giant Pancreatic Pseudocysts Using Both Lumen-Apposing Metal Stent and Plastic Stent: A Report of Two Cases and Review of the Current Literature

Introduction

A pancreatic pseudocyst (PP) with major diameter equal to 10 cm or more is called a giant pseudocyst. The ideal management for giant PPs is controversial. Endoscopic drainage is an alternative nonsurgical approach for PP management. Only a few cases of giant PPs were reported to be managed by endoscopic drainage. Case Presentation. We reported two cases of giant PPs following an episode of acute pancreatitis. Both were resolved following endoscopic cystogastrostomy using metallic and double-pigtail stents with excellent outcomes. There was no history of recurrence or complications on follow-up. In addition, we extensively reviewed all available literature studies of giant pancreatic pseudocyst presentation, management, and complications. We summarized all reported cases and presented them in a comprehensive table.

Conclusion

The endoscopic cystogastrostomy approach is cost saving, can avoid surgical complications, and offers an early hospital discharge.

Authors' response to "Straight plastic stents in tumors at the hepatic hilum and related duodenal perforation"

We appreciate the interesting comments from García Cano et al. regarding the complications derived from the use of plastic prostheses in hilar tumors. Indeed, most of the published case reports on duodenal perforations secondary to migrated biliary prostheses occurred with plastic stents, which may be related to the entrapment phenomenon described.