VideoGIE



Transluminal drainage with a 20 mm cautery assisted lumen apposing metal stentThis is a 21-year-old female who initially presented with necrotizing pancreatitis due to alcohol. She also had a SMV thrombosis and was placed on anticoagulation. She was treated with supportive care and was ultimately discharged. However, she was readmitted afterward in hemorrhagic shock due to retroperitoneal bleeding. She underwent emergent exploratory laparotomy with evacuation of the hematoma. Her abdomen was left open and she underwent several washout procedures. However, she developed fevers and tachycardia prompting this CT scan which shows a large left abdominal fluid collection 6 weeks after her initial insult. Due to her frozen abdomen, surgical drainage was not feasible and we were asked to perform endoscopic transluminal drainage. Here you can see us targeting the collection under EUS. We identified a safe transgastric site away from intervening vessels or vessels that would be abutting the deployed stent and a site where the collection is adherent to the gastric wall with less than 1 cm distance. We initially access the collection with a 19-gauge needle and coil a wire into the collection. Now we are using the cautery-assisted LAMS deployment system to create the cystgastrostomy and deliver the stent. Given the size of the collection and large amount of necrosis, a larger 20-mm LAMS was chosen because it may be more advantageous.One difference noted during deployment of this 20-mm stent, compared with prior iterations, was the additional manipulation needed to ensure full deployment of the larger distal and proximal flanges. Here you can see the distal flange taking extra effort to fully open. We deploy the proximal flange within the endoscope channel and here you can see the proximal flange also requiring extra effort to deploy and push out of the channel. But ultimately it was successful and prompt drainage of brown fluid was seen.?The stent was then postdilated to 18 mm, which some institutions do not do out of concern for dislodgement, but we think that dilation after LAMS deployment may aid with initial drainage of purulent material improving immediate clinical response and possibly prevent early obstruction by solid debris. In our experience we have not noted significant adverse events related to immediate dilation.?A large amount of necrosis and/or clot was appreciated through the stent, but no active bleeding was seen. ?It is our practice to typically place a double-pigtail plastic stent through the metal stent to avoid complete collapse of the cavity. This theoretically can prevent back wall irritation from the stent and reduce the risk of bleeding.?This is a follow-up CT scan. In the interim, interventional radiology placed a percutaneous drain into the left retroperitoneal collection to facilitate further drainage in a “step-up” fashion 3 days after endoscopic drainage when the patient had clinical deterioration. ?Two weeks after transgastric stent placement, the patient underwent endoscopic necrosectomy through the 20-mm stent. ?Here you can see the prior plastic stent had migrated through the metal stent into the collection but was easily removed; however, it is something to note with these larger-diameter stents. ?We now proceed with extensive necrosectomy through the 20-mm stent. It did appear to allow for extra working space during the necrosectomy. A larger-diameter therapeutic upper endoscope can easily pass through the diameter of this stent possibly making it less likely to be dislodged during endoscopic necrosectomy. ?Now you can see a significant amount of necrotic material has been successfully removed from the cavity with just some small amount remaining.?To facilitate drainage of the collection along the left paracolic gutter, we elected to place 2 very long ureteral stents along the left paracolic gutter across the cystgastrostomy down to the percutaneous drains. Here you can see us advancing a 7F x 24-cm double-pigtail stent down the paracolic gutter. We have limited experience with this, but our hypothesis is that it maintains a tract to allow purulent fluid to wick through and around the stents and drain either through the cystgastrostomy or percutaneous drain. Otherwise, solid debris may be more likely to create pockets of purulence that are not being adequately drained.?Of note, on follow-up endoscopy one of these stents also migrated into the cavity but again was easily removed. ?The patient underwent 2 more subsequent endoscopic necrosectomies resulting in very little necrotic material remaining. Subsequent CT demonstrated very little necrosis, and the patient clinically improved. ?One last upper endoscopy was performed with removal of the lumen-apposing metal stent and placement of 2 double-pigtail plastic stents to maintain the cystgastrostomy in the setting of a disconnected pancreatic duct. ?In summary, we present the placement of a 20-mm lumen-apposing metal stent for drainage and debridement of pancreatic walled-off necrosis. ?Because of the larger diameter, the distal and proximal flanges require more care to fully deploy and plastic stents placed across the metal stent are more prone to migrating. However, the larger diameter seems to facilitate necrosectomy, but further studies will be needed to determine whether clinical outcomes are improved. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download