Ann Hepatobiliary Pancreat Surg.  2021 Nov;25(4):500-508. 10.14701/ahbps.2021.25.4.500.

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

• Chhabra P
• Maher B
• Trivedi D
• Karavias D
• Arshad A
• Wright M
• Tehami N

• KMID: 2523054
• DOI: http://doi.org/10.14701/ahbps.2021.25.4.500

Abstract

Backgrounds/Aims
Post-operative pancreatic fistulas (POPF) and f luid 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^TM lumen apposing metal stent (LAMS).
Methods
We conducted a retrospective study, encompassing all consecutive patients with POPFC managed using Hot AXIOS ^TM 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^TM 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^TM LAMS is a safe and effective treatment modality with technical and clinical success rates of 100% in our experience.

Keyword

Pancreatic fistula; Endosonography

Figure

• 

  Fig. 1 Pancreatic fluid collection at the resection site extending up to the under surface of the greater curvature of the stomach. Contrast enhanced computed tomography of abdomen (pre-endoscopic ultrasound drainage).

• 

  Fig. 2 Organised pancreatic fluid collection at the surgical bed with multiple locules of air (post percutaneous drainage). An incidental simple cyst of liver and a left tissue breast implant can also be seen. Contrast enhanced computed tomography of abdomen (pre-endoscopic ultrasound drainage).

• 

  Fig. 3 Pancreatic fluid collection between the tail of the pancreas and the remnant spleen. Contrast enhanced computed tomography of abdomen (pre-endoscopic ultrasound drainage).

• 

  Fig. 4 Large pancreatic fluid collection of 6 cm in size in the visualized plane with echogenic component. Endoscopic ultrasound images.

• 

  Fig. 5 A well-defined thick-walled collection with echogenic fluid consistent with pus. Endoscopic ultrasound images.

• 

  Fig. 6 Hot AXIOS™ stent with a delivery catheter and a deployed distal flange within the collection. Endoscopic ultrasound images.

• 

  Fig. 7 Hot AXIOS™ stent with a delivery catheter and a deployed distal flange within the collection. Endoscopic ultrasound images.

• 

  Fig. 8 Contrast enhanced computed tomography abdomen demonstrating marked reduction in the size of collection post drainage with lumen apposing metal stent in situ. Contrast enhanced computed tomography of abdomen (post-endoscopic ultrasound drainage and pre-removal of AXIOS).

• 

  Fig. 9 Contrast enhanced computed tomography abdomen demonstrating complete resolution of the collection with lumen apposing metal stent in situ. Contrast enhanced computed tomography of abdomen (post-endoscopic ultrasound drainage and pre-removal of AXIOS).

• 

  Fig. 10 Hot AXIOS™ lumen apposing metal stent after removal.

Reference

1. Jayaraman S, Gonen M, Brennan MF, D'Angelica MI, DeMatteo RP, Fong Y, Jarnagin WR, et al. 2010; Laparoscopic distal pancreatectomy: evolution of a technique at a single institution. J Am Coll Surg. 211:503–509. DOI: 10.1016/j.jamcollsurg.2010.06.010. PMID: 20868976.

2. Ferrone CR, Warshaw AL, Rattner DW, Berger D, Zheng H, Rawal B, et al. 2008; Pancreatic fistula rates after 462 distal pancreatectomies: staplers do not decrease fistula rates. J Gastrointest Surg. 12:1691–1697. discussion 1697–1698. DOI: 10.1007/s11605-008-0636-2. PMID: 18704597. PMCID: PMC3806097.

3. Kleeff J, Diener MK, Z'graggen K, Hinz U, Wagner M, Bachmann J, et al. 2007; Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg. 245:573–582. DOI: 10.1097/01.sla.0000251438.43135.fb. PMID: 17414606. PMCID: PMC1877036.

4. Iacono C, Verlato G, Ruzzenente A, Campagnaro T, Bacchelli C, Valdegamberi A, et al. 2013; Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg. 100:873–885. DOI: 10.1002/bjs.9136. PMID: 23640664.

5. Benoist S, Dugué L, Sauvanet A, Valverde A, Mauvais F, Paye F, et al. 1999; Is there a role of preservation of the spleen in distal pancreatectomy? J Am Coll Surg. 188:255–260. DOI: 10.1016/S1072-7515(98)00299-3. PMID: 10065814.

6. Shankar S, Theis B, Russell RC. 1990; Management of the stump of the pancreas after distal pancreatic resection. Br J Surg. 77:541–544. DOI: 10.1002/bjs.1800770525. PMID: 2354339.

7. Sheehan MK, Beck K, Creech S, Pickleman J, Aranha GV. 2002; Distal pancreatectomy: does the method of closure influence fistula formation? Am Surg. 68:264–267. discussion 267–268. PMID: 11893105.

8. Suzuki Y, Fujino Y, Tanioka Y, Hori Y, Ueda T, Takeyama Y, et al. 1999; Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas. Br J Surg. 86:608–611. DOI: 10.1046/j.1365-2168.1999.01120.x. PMID: 10361178.

9. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. 2017; The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 161:584–591. DOI: 10.1016/j.surg.2016.11.014. PMID: 28040257.

10. Pedrazzoli S. 2017; Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): a systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore). 96:e6858. DOI: 10.1097/MD.0000000000006858. PMID: 28489778. PMCID: PMC5428612.

11. Men S, Akhan O, Köroğlu M. 2002; Percutaneous drainage of abdominal abcess. Eur J Radiol. 43:204–218. DOI: 10.1016/S0720-048X(02)00156-0. PMID: 12204403.

12. Freeny PC, Hauptmann E, Althaus SJ, Traverso LW, Sinanan M. 1998; Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol. 170:969–975. DOI: 10.2214/ajr.170.4.9530046. PMID: 9530046.

13. Matthews JB. 2011; Prevention, evaluation, and treatment of leaks after pancreatic surgery. J Gastrointest Surg. 15:1327–1328. DOI: 10.1007/s11605-011-1516-8. PMID: 21499953.

14. Vin Y, Sima CS, Getrajdman GI, Brown KT, Covey A, Brennan MF, et al. 2008; Management and outcomes of postpancreatectomy fistula, leak, and abscess: results of 908 patients resected at a single institution between 2000 and 2005. J Am Coll Surg. 207:490–498. DOI: 10.1016/j.jamcollsurg.2008.05.003. PMID: 18926450.

15. Goasguen N, Bourrier A, Ponsot P, Bastien L, Lesurtel M, Prat F, et al. 2009; Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation. Am J Surg. 197:715–720. DOI: 10.1016/j.amjsurg.2008.03.005. PMID: 18789426.

16. Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M. 2013; Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center. Case Rep Gastroenterol. 7:332–339. DOI: 10.1159/000354136. PMID: 24019766. PMCID: PMC3764947.

17. Puri R, Thandassery RB, Alfadda AA, Kaabi SA. 2015; Endoscopic ultrasound guided drainage of pancreatic fluid collections: assessment of the procedure, technical details and review of the literature. World J Gastrointest Endosc. 7:354–363. DOI: 10.4253/wjge.v7.i4.354. PMID: 25901214. PMCID: PMC4400624.

18. Arvanitakis M, Dumonceau JM, Albert J, Badaoui A, Bali MA, Barthet M, et al. 2018; Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 50:524–546. DOI: 10.1055/a-0588-5365. PMID: 29631305.

19. Bang JY, Varadarajulu S. 2013; Metal versus plastic stent for transmural drainage of pancreatic fluid collections. Clin Endosc. 46:500–502. DOI: 10.5946/ce.2013.46.5.500. PMID: 24143311. PMCID: PMC3797934.

20. Sharaiha RZ, DeFilippis EM, Kedia P, Gaidhane M, Boumitri C, Lim HW, et al. 2015; Metal versus plastic for pancreatic pseudocyst drainage: clinical outcomes and success. Gastrointest Endosc. 82:822–827. DOI: 10.1016/j.gie.2015.02.035. PMID: 25936453.

21. Penn DE, Draganov PV, Wagh MS, Forsmark CE, Gupte AR, Chauhan SS. 2012; Prospective evaluation of the use of fully covered self-expanding metal stents for EUS-guided transmural drainage of pancreatic pseudocysts. Gastrointest Endosc. 76:679–684. DOI: 10.1016/j.gie.2012.04.457. PMID: 22732874.

22. Siddiqui AA, Adler DG, Nieto J, Shah JN, Binmoeller KF, Kane S, et al. 2016; EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos). Gastrointest Endosc. 83:699–707. DOI: 10.1016/j.gie.2015.10.020. PMID: 26515956.

23. Siddiqui AA, Kowalski TE, Loren DE, Khalid A, Soomro A, Mazhar SM, et al. 2017; Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc. 85:758–765. DOI: 10.1016/j.gie.2016.08.014. PMID: 27566053.

24. Rinninella E, Kunda R, Dollhopf M, Sanchez-Yague A, Will U, Tarantino I, et al. 2015; EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video). Gastrointest Endosc. 82:1039–1046. DOI: 10.1016/j.gie.2015.04.006. PMID: 26014960.

25. Li L, Cristofaro S, Qu C, Liang S, Li X, Cai Q. 2018; EUS-guided drainage of pancreatic fluid collection with a Hot AXIOS stent in a patient with pancreatitis following distal pancreatectomy (with video). Endosc Ultrasound. 7:347–348. DOI: 10.4103/eus.eus_55_17. PMID: 29848832. PMCID: PMC6199910.

26. Mudireddy PR, Sethi A, Siddiqui AA, Adler DG, Nieto J, Khara H, et al. 2018; EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study. Gastrointest Endosc. 87:1256–1262. DOI: 10.1016/j.gie.2017.08.011. PMID: 28843581.

27. Priyanka P, Hsueh W, Nasr J. 2019; Use of Lumen-apposing stents for the treatment of postsurgical fluid collections: a case series and a review of literature. Case Rep Gastrointest Med. 2019:7656950. DOI: 10.1155/2019/7656950. PMID: 30809400. PMCID: PMC6364124.

28. Denzer UW, Sioulas AD, Abdulkarim M, Groth S, Rösch T, Busch P, et al. 2016; Endoscopic ultrasound-guided drainage of abdominal fluid collections after pancreatic surgery: efficacy and long-term follow-up. Z Gastroenterol. 54:1047–1053. DOI: 10.1055/s-0042-112032. PMID: 27612217.

29. Varadarajulu S, Trevino JM, Christein JD. 2009; EUS for the management of peripancreatic fluid collections after distal pancreatectomy. Gastrointest Endosc. 70:1260–1265. DOI: 10.1016/j.gie.2009.06.007. PMID: 19660749.

30. Kwon YM, Gerdes H, Schattner MA, Brown KT, Covey AM, Getrajdman GI, et al. 2013; Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage. Surg Endosc. 27:2422–2427. DOI: 10.1007/s00464-012-2752-z. PMID: 23361258.

31. Futagawa Y, Imazu H, Mori N, Kanazawa K, Chiba M, Furukawa K, et al. 2017; The effectiveness and feasibility of endoscopic ultrasound-guided transgastric drainage of postoperative fluid collections early after pancreatic surgery. Surg Laparosc Endosc Percutan Tech. 27:267–272. DOI: 10.1097/SLE.0000000000000413. PMID: 28520649.

32. Mohan BP, Shakhatreh M, Dugyala S, Geedigunta V, Gadalay A, Pahal P, et al. 2019; EUS versus percutaneous management of postoperative pancreatic fluid collection: a systematic review and meta-analysis. Endosc Ultrasound. 8:298–309. DOI: 10.4103/eus.eus_18_19. PMID: 31249160. PMCID: PMC6791105.