PICTURES IN DIGESTIVE PATHOLOGY

 

Double endosonography-guided transgastric and transduodenal drainage of infected pancreatic-fluid collections using metallic stents

Doble drenaje transgástrico y transduodenal de una colección líquida infectada pancreática guiado endosonográficamente mediante prótesis metálicas

 

 

Joan B. Gornals¹, Catalina Parra¹, Nuria Peláez², Lluis Secanella² and Isabel Ornaque³

¹Endoscopy Unit. Department of Digestive Diseases. Departments of ²Surgery and ³Anesthesiology. Hospital Universitari de Bellvitge-IDIBELL. Barcelona, Spain

 

 

Introduction

The use of self-expanding metallic stents (SEMSs) in draining PFC has been reported in small case series (1,2). The practice of more than one transluminal drainage is rarely described (3,4).

 

Case report

A 34-year-old male was referred to our hospital for drainage of symptomatic pancreatic fluid collections (PFCs) secondary to an acute pancreatitis. He was affected by gastro-duodenal and biliary obstruction. CT scan images revealed 1 perigastric pseudocyst (well-defined wall, without necrosis content, 70 x 120 mm) and 1 periduodenal walled-off pancreatic necrosis (WOPN) (thickened wall, partially liquefied collection containing solid content, 80 x 90 mm).

Both PFC were accessed under endoscopic ultrasound (EUS)-guidance with a 6 Fr-cystotom and dilation tract using a 10 mm balloon (Fig. 1). First, the pseudocyst was drained transgastrically with a fully covered SEMS with bilateral anchor flanges (AXIOS^™, 10 x 15 mm; Xlumena, MountainView, CA) and 800 ml of turbid fluid was aspirated (Fig. 2). Five days later, a WOPN was drained under EUS-guidance via transduodenal and a 10 x 40 mm fully covered SEMS (WallFlex biliary Rx, Boston Scientific, Natick, MA) plus a coaxial 10 Fr x 5 cm, double-pigtail stent to prevent migration were delivered and a purulent fluid was drained. At day 6, abdominal pain and duodenal obstruction were persistent and a CT scan showed total resolution of the perigastric PFC and a decrease in size of the WOPN by < 30 % with presence of necrotic contents (Fig. 3). An necrosectomy was performed delivering a new specific SEMS (Yo-Yo stent, 10 x 10 mm, Niti-S; TaewoongMedical, Seoul, Korea) to keep open the duodenostomy (Fig. 4). Patient symptoms improved, with a significant resolution of the WOPN in a CT scan 15 days later. At 3 weeks follow-up, complete lesion resolution was revealed in CT scan images and all stents were removed.

 

Discussion

The practice of more than one transmural drainage with SEMSs is effective for the treatment of infected PFC. The use of diabolo-shaped SEMSs improved the overall management.

 

References

1. Talreja JP, Shami VM, Ku J, Morris TD, Ellen K, Kahaleh M. Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video). Gastrointest Endosc 2008;68:1199-203.         [ Links ]

2. Itoi T, Binmoeller KF, Shah J, Sofuni A, Itokawa F, Kurihara T, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc. 2012;75:870-6.         [ Links ]

3. Mathew A, Gaffney RR, Moyer MT. EUS-guided double cystgastrostomy of two infected pseudocysts in series: A novel case of endoscopic cystocystgastrostomy. Gastrointest Endosc 2012;75:227.         [ Links ]

4. Varadarajulu S, Phadnis MA, Christein, Wilcox CM. Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis. Gastrointest Endosc 2011;74:74-80.         [ Links ]