• Users Online:470
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
COMMENTARY
Year : 2017  |  Volume : 6  |  Issue : 9  |  Page : 132-137

Pancreatic fluid collections and necrosectomy with plastic stents versus lumen-apposing stents


1 Division of Gastroenterology, Weill Cornell Medical College, New York, USA
2 Department of Gastroenterology, Erasme Hospital, University of Brussels, Brussels, Belgium

Date of Submission12-Jul-2017
Date of Acceptance31-Aug-2017
Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. Michel Kahaleh
Department of Medicine, Medical Director Pancreas Program, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY 10021
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_80_17

Rights and Permissions

How to cite this article:
Saumoy M, Arvanitakis M, Kahaleh M. Pancreatic fluid collections and necrosectomy with plastic stents versus lumen-apposing stents. Endosc Ultrasound 2017;6, Suppl S3:132-7

How to cite this URL:
Saumoy M, Arvanitakis M, Kahaleh M. Pancreatic fluid collections and necrosectomy with plastic stents versus lumen-apposing stents. Endosc Ultrasound [serial online] 2017 [cited 2020 Jan 28];6, Suppl S3:132-7. Available from: http://www.eusjournal.com/text.asp?2017/6/9/132/221949




  Introduction Top


The incidence of hospitalizations for acute pancreatitis is rising, with 5%–15% of patients with pancreatitis developing pancreatic fluid collections (PFCs).[1],[2] In addition to acute pancreatitis, other causes of PFCs include chronic injury, trauma, surgical resection, and/or injury to the pancreas during abdominal surgery.[3],[4] Management paradigms for these collections, particularly if they are complicated by infected necrosis, have changed over the past decade. Advances in endoscopic tools have driven a new era of minimally invasive techniques to manage both pancreatic pseudocysts (PPs) and walled-off necrosis (WON). This step-up approach with initial interventions using less invasive procedures rather than surgical necrosectomy was described by van Santvoort et al. and has been associated with an overall decreased mortality, fewer number of complications, and lower healthcare costs.[2],[5] The primarily liquid content of PP can be drained in a single endoscopic session with a transmural drain to allow for collapse and resolution. However, the solid, necrotic tissue contained within WON often does not drain as easily and has the potential of developing infection, requiring larger caliber transmural drains. Therefore, successful management of PFCs must be tailored based on the characteristics of the collection.


  Conventional Transmural Drainage With Plastic Stents Top


Transenteric drainage of PFC has been described in several series, initially as conventional transmural drainage (CTD) with plastic stents. This requires the PFC to create a visible bulge into the luminal wall to direct the endoscopist to identify where to create the cystgastrostomy or cystduodenostmy fistulous tract. Success rates of CTD with plastic stents have been reported between 70% and 100%, with recurrence rates up to 20%.[6],[7] There is also a wide range of reported complication rates for CTD, reported between 2% and 40%, from bleeding, perforation, and infection from stent occlusion or migration.[2],[8]


  Endoscopic Drainage of Pancreatic Fluid Collections Through Plastic Stents Top


Outcomes of pancreatic fluid collection drainage with plastic stents

Introducing endoscopic ultrasound for PFC drainage (EUD) has improved the technique because endoscopists can now identify the cyst cavity when there is no obvious bulge. EUD with plastic stents has been shown to be successful in management of PFCs. Multiple retrospective studies have demonstrated EUD success rates ranging from 80% to 100% and complication rates averaging around 10%. Given the low complication rate and the ease of identification of the PFCs, Kahaleh et al. performed a prospective case–control study comparing CTD and EUD in patients with PFC if there was an identifiable bulge. There was no significant difference between CTD and EUD in technical/clinical success or complication rate.[9] However, in 42%–48% of cases, the characteristic bulge is not identifiable, which limits the overall use of the CTD technique.[10] Moreover, subsequent prospective trials have found higher technical success with EUS drainage.[11],[12] Therefore, EUD has become standard of care for drainage with PFCs.

Endoscopic ultrasound-guided drainage technique

PFC drainage procedures are typically performed from the stomach or proximal duodenum using endoscopic ultrasound. Color Doppler ultrasound is routinely used to identify regional vasculature. A fistula between the PFC and the stomach or duodenum is created by introducing a 19-gauge needle or a cystotome into the PFC. A guidewire is then introduced through the needle and coiled within the PFC using EUS and fluoroscopic guidance. The cystoenterostomy fistula was dilated with either a wire-guided balloon or the large portion of the cystotome. The balloon or cystotome is then exchanged off the guidewire and one or two 10-Fr double-pigtail endoprostheses are placed across the cystoenterostomy fistula at the discretion of the endoscopist.[9]


  Biflanged Metal Stents Top


There is a growing body of evidence demonstrating that the use of large caliber metal stents is both technically feasible and allow for a significant rate of resolution of PFC and particularly of WON.[13],[14],[15],[16] Initially, endoscopists demonstrated success with the use of fully covered self-expanding metal stents (FCSEMS).[17] Biliary and esophageal FCSEMS provided a large diameter for drainage as compared with plastic stents, and esophageal FCSEMS allowed for endoscopically directed mechanical debridement of WON.[18],[19],[20],[21] However, both stents were limited by the risk of migration.

Advances in endoscopic tools have led to the development of multiple novel stents that are designed for deployment under endoscopic ultrasound guidance, and ideal for the management of PFCs. These stents have a large diameter which prevents obstruction from necrotic material as well as fully covered to allow for ease of debris removal.[22] Finally, these stents have two large flanges to allow for apposition of the collection to the stomach or duodenum and prevent migration. There are an increasing number of the commercially available covered biflanged metal stents: Axios (Boston Scientific, Marlborough, Massachusetts), Nagi and Spaxus (Taewoong Medical, Gyeonggi-do, South Korea), Hanaro stent (M. I. Tech Seoul, South Korea), and Aix stent PPS (Leufen Medical, Aachen, Germany) [Table 1]. However, at this time, only the Axios stent is available in the United States.
Table 1: Commercially available biflanged and lumen apposing metal stents

Click here to view


One key difference between the stents is the angled biflanged design versus the flat anchoring flanges, which have been coined lumen-apposing metal stents (LAMS). The perpendicular flanges allow for strong tissue wall apposition. Teoh et al. demonstrated that the Axios and Spaxus stent generated a larger lumen-apposing force when attempting to pull apart a simulated anastomosis as compared with the Nagi stent.[23] When shortening the stent by dilating the internal diameter to its maximal size, there is a mechanical force applied to the anastomosis by the opposing ends of the stent. This applies an even pressure on the luminal walls.[24] The covering of the metal stent and the fusion of the two lumens generate an intact fistulous tract to prevent leakage as well as prevent tissue ingrowth. Further, the “dog bone” shape of the stent also potentially decreases the risk of migration. Finally, these stents are easily removable after resolution of the PFC. Therefore, these stents should be preferentially used when creating anastomosis between a nonadherent collection and a luminal organ, with a goal to generate enough force to hold the cyst cavity against the stomach or duodenum despite in vivo peristalsis. Most of the currently published literature with LAMS for PFC is using the Axios stent, likely because of its wider commercial availability.


  Endoscopic Drainage of Pancreatic Collections Through Lumen-Apposing Metal Stents Top


Technique

After the implementation of the Atlanta classification in 1992 and the revised classification in 2012, endoscopists have been able to classify types of PFCs and determine when a collection requires intervention.[4],[25] On determination, the endoscopist can use an echoendoscope to identify an appropriate access point for transmural drainage. The collection is punctured with a 19-guage needle, and a guidewire is coiled within the collection. The fistulous tract is then dilated with a dilating balloon and/or electrocautery device and the LAMS is deployed across the fistula tract. In particular, the Axios delivery system has been modified with a cautery device integrated into the nosecone at the catheter tip. This enables transmural advancement of the stent without preliminary tract dilation and without over-the-wire exchanges of separate cautery devices. Alternatively, the cautery-assisted Axios delivery system can be used “freestyle” without initial needle puncture. After the LAMS is deployed, the large diameter of the stent allows for direct visualization within the cavity for endoscopic necrosectomy [Figure 1].
Figure 1: (a) Endosonographic visualization to identify a pancreatic fluid collection, (b) endosonographic visualization of the distal flange of the lumen-apposing metal stents deployed within the pancreatic fluid collection, (c) endoscopic visualization of the proximal flange deployed within the stomach

Click here to view


Outcomes of pseudocyst drainage with lumen-apposing metal stents

PP drainage with LAMS has been shown to be both clinically and technically successful in published retrospective case series. Itoi et al. described the first case series of LAMS for drainage of PP. Fifteen patients underwent LAMS for drainage and demonstrated a 100% clinical success rate, but a 26.7% complication rate.[26] Other published case series have described a combination of WON and PP. For example, Rinninella et al. described a 93 patient case series, with 18 patients who had PP. There was an overall 92.5% clinical success and only 1 of the 18 PP patients (5.56%) had an adverse event.[27] Walter et al. conducted a multicenter prospective trial of 61 patients, with 14 patients who had PP. They described a 93% clinical success rate in the PP group, and none of the PP patients required additional endoscopic intervention to achieve clinical success. There was one patient (7.14%) who had a perforation after stent deployment, which was the only major complication.[28] Siddiqui et al. also performed a multicenter retrospective trial of 14 patients with PP and 68 patients with WON, all drained with LAMS. Two of the 14 patients (14.3%) with PP had stent misdeployment, (85.7% technical success), 1 of the 14 patients (7.1%) had self-limited bleeding, and 1 of the 14 patients (7.1%) developed infection of the PP cavity. The patients with successful PP stent placement with 100% clinical success, with 83.3% of patients requiring only one endoscopic session for PP resolution.[13]

Comparison of plastic and lumen-apposing metal stents for pancreatic pseudocysts drainage

Bang et al. conducted a retrospective case–control study, comparing patients who underwent PFC drainage with LAMS with plastic stents according to PFC type. Using a 1:2 comparison, 7 patients had LAMS drainage of PP and 14 patients had plastic stent drainage of PP. LAMS patients had a 100% clinical success rate with no adverse events. There was no statistically significant difference between LAMS and plastic stents for PP, and they also suggested a lower overall cost with plastic stents compared to LAMS.[29]

Overall, PP drainage with LAMS has been demonstrated in retrospective trials to be safe and effective. However, the case–control study from Bang et al. suggests that there may not be a difference in PFC resolution from plastic stents. Given the cost differential, at this time, PP drainage with plastic stents is likely the most cost-effective option. However, randomized control trials with an associated cost analysis are necessary to definitely compare types of stents in the management of PP to determine the appropriate role of LAMS.

Outcomes of walled-off necrosis with lumen-apposing metal stents

Symptomatic WON (especially infected WON) has significant morbidity and mortality.[30] Direct endoscopic necrosectomy with debridement of WON using an endoscope that is inserted directly into the collection through the LAMS. Before LAMS, direct endoscopy necrosectomy for WON was associated with 80% clinical success, but a 26% complication rate and a 7.5% mortality rate at 30 days.[31] However, in recent case series, necrosectomy through a LAMS has been associated with similar, if not higher, clinical success rate, and a lower complication rate.

The previously described series by Rinninella et al. demonstrated an adverse event rate of 3 of 52 patients (5.77%) with WON.[27] Similarly in the prospective trial by Walter et al., clinical success was achieved in 81% of the patients (35 of 43) with WON. Four patients (7.02%) had complications with new-onset infection of the collections requiring endoscopic necrosectomy, antibiotics, and nasocystic drainage. In total, 43% of patients required either an additional necrosectomy and/or irrigation to achieve clinical success.[28] The multicenter case series by Siddiqui et al. reviewed 68 patients with WON drained with LAMS. Five of 68 (7.3%) had self-limited bleeding and 4 of 68 (5.9%) patients had infection of the necrotic cavity. They had an 88.2% clinical success rate, and patients with WON required a higher number of endoscopic sessions (mean 2.8 sessions) for resolution as compared to PP though this was not statistically significantly different.[13]

Bang et al. compared 13 patients with LAMS to 26 patients with plastic stent drainage for WON. In their case–control study, they demonstrated a clinical success rate of 92.3% in both groups, with an adverse event rate of 15.4% in the LAMS group. There was no statistically significant difference between the LAMS and plastic stent group in either adverse event, number of reinterventions performed, or length of stay.[29] Sharaiha et al. published the largest case series to date of 124 patients with only WON drained by LAMS. These patients had a high clinical success rate (86.3%) with a low rate of adverse events (18.5%).[15] And finally, a randomized control trial (NCT02685865) is currently recruiting patients to compare plastic stents versus LAMS for WON. Interim analysis of the 21 recruited patients reported a 50% adverse event rate (bleeding, biliary obstruction, or buried stent syndrome) in the LAMS group requiring the investigators to change their clinical practice protocol to include a CT scan 3 weeks post-LAMS drainage.[32]

The data are varied among clinicians reporting overall complication rates for management of WON with LAMS. Complications reported are typically bleeding, perforation, infection of the cavity after obstruction of the LAMS, stent misdeployment, or migration/dislodgement. Similar to PP, additional randomized control trials are needed to evaluate the role of LAMS, and whether specific protocols for follow-up imaging, or even additional double pigtail plastic stents through the LAMS, are necessary to further decrease complication rates.


  Conclusions Top


In this new era of advances in endoscopic devices, management of PFCs is rapidly expanding the domain of therapeutic endoscopists. Primary drainage is a key in the management of PFCs. Minimally invasive techniques are gaining favor because of significant morbidity and mortality associated with surgical drainage and the poor success rate of percutaneous catheter drainage.[5],[33] In addition, complication rates can vary by the type of PFC, with a lower documented complication rate of PP compared to WON.[34] To decrease the risk of complications, the use of these specifically designed, saddle-like LAMS is now becoming the mainstay for management, particularly of WON. Future randomized control trials will determine when the use of LAMS is the most effective. Moreover, in the coming years, novel endoscopic devices, similar to the transformative LAMS, will only further improve procedural safety and efficacy when managing patients with PFCs.



 
  References Top

1.
Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology 2013;144:1252-61.  Back to cited text no. 1
[PUBMED]    
2.
Tyberg A, Karia K, Gabr M, et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol 2016;22:2256-70.  Back to cited text no. 2
[PUBMED]    
3.
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis-2012: Revision of the atlanta classification and definitions by international consensus. Gut 2013;62:102-11.  Back to cited text no. 3
[PUBMED]    
4.
Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128:586-90.  Back to cited text no. 4
    
5.
van Santvoort HC, Besselink MG, Bakker OJ, et al. Astep-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502.  Back to cited text no. 5
[PUBMED]    
6.
Binmoeller KF, Seifert H, Walter A, et al. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42:219-24.  Back to cited text no. 6
[PUBMED]    
7.
Cremer M, Deviere J, Engelholm L. Endoscopic management of cysts and pseudocysts in chronic pancreatitis: Long-term follow-up after 7 years of experience. Gastrointest Endosc 1989;35:1-9.  Back to cited text no. 7
[PUBMED]    
8.
Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56:7-17.  Back to cited text no. 8
[PUBMED]    
9.
Kahaleh M, Shami VM, Conaway MR, et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: A prospective comparison with conventional endoscopic drainage. Endoscopy 2006;38:355-9.  Back to cited text no. 9
[PUBMED]    
10.
Antillon MR, Shah RJ, Stiegmann G, et al. Single-step EUS-guided transmural drainage of simple and complicated pancreatic pseudocysts. Gastrointest Endosc 2006;63:797-803.  Back to cited text no. 10
[PUBMED]    
11.
Varadarajulu S, Christein JD, Tamhane A, et al. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2008;68:1102-11.  Back to cited text no. 11
[PUBMED]    
12.
Park DH, Lee SS, Moon SH, et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: A prospective randomized trial. Endoscopy 2009;41:842-8.  Back to cited text no. 12
[PUBMED]    
13.
Siddiqui AA, Adler DG, Nieto J, et al. 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 2016;83:699-707.  Back to cited text no. 13
    
14.
Siddiqui AA, Kowalski TE, Loren DE, et al. 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 2017;85:758-65.  Back to cited text no. 14
[PUBMED]    
15.
Sharaiha RZ, Tyberg A, Khashab MA, et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016;14:1797-803.  Back to cited text no. 15
[PUBMED]    
16.
Lakhtakia S, Basha J, Talukdar R, et al. Endoscopic “step-up approach” using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos). Gastrointest Endosc 2017;85:1243-252.  Back to cited text no. 16
[PUBMED]    
17.
Sharaiha RZ, DeFilippis EM, Kedia P, et al. Metal versus plastic for pancreatic pseudocyst drainage: Clinical outcomes and success. Gastrointest Endosc 2015;82:822-7.  Back to cited text no. 17
[PUBMED]    
18.
Penn DE, Draganov PV, Wagh MS, et al. Prospective evaluation of the use of fully covered self-expanding metal stents for EUS-guided transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 2012;76:679-84.  Back to cited text no. 18
[PUBMED]    
19.
Sarkaria S, Sethi A, Rondon C, et al. Pancreatic necrosectomy using covered esophageal stents: A novel approach. J Clin Gastroenterol 2014;48:145-52.  Back to cited text no. 19
[PUBMED]    
20.
Fabbri C, Luigiano C, Cennamo V, et al. Endoscopic ultrasound-guided transmural drainage of infected pancreatic fluid collections with placement of covered self-expanding metal stents: A case series. Endoscopy 2012;44:429-33.  Back to cited text no. 20
[PUBMED]    
21.
Attam R, Trikudanathan G, Arain M, et al. Endoscopic transluminal drainage and necrosectomy by using a novel, through-the-scope, fully covered, large-bore esophageal metal stent: Preliminary experience in 10 patients. Gastrointest Endosc 2014;80:312-8.  Back to cited text no. 21
[PUBMED]    
22.
Weilert F, Binmoeller KF. Specially designed stents for translumenal drainage. Gastrointest Interv 2015;4:40-5.  Back to cited text no. 22
    
23.
Teoh AY, Ng EK, Chan SM, et al. Ex vivo comparison of the lumen-apposing properties of EUS-specific stents (with video). Gastrointest Endosc 2016;84:62-8.  Back to cited text no. 23
[PUBMED]    
24.
Rodrigues-Pinto E, Baron TH. Evaluation of the AXIOS stent for the treatment of pancreatic fluid collections. Expert Rev Med Devices 2016;13:793-805.  Back to cited text no. 24
[PUBMED]    
25.
Bollen TL, van Santvoort HC, Besselink MG, et al. The atlanta classification of acute pancreatitis revisited. Br J Surg 2008;95:6-21.  Back to cited text no. 25
[PUBMED]    
26.
Itoi T, Binmoeller KF, Shah J, 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.  Back to cited text no. 26
[PUBMED]    
27.
Rinninella E, Kunda R, Dollhopf M, et al. 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 2015;82:1039-46.  Back to cited text no. 27
[PUBMED]    
28.
Walter D, Will U, Sanchez-Yague A, et al. Anovel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: A prospective cohort study. Endoscopy 2015;47:63-7.  Back to cited text no. 28
[PUBMED]    
29.
Bang JY, Hasan MK, Navaneethan U, et al. Lumen-apposing metal stents for drainage of pancreatic fluid collections: When and for whom? Dig Endosc 2017;29:83-90.  Back to cited text no. 29
[PUBMED]    
30.
van Brunschot S, Bakker OJ, Besselink MG, et al. Treatment of necrotizing pancreatitis. Clin Gastroenterol Hepatol 2012;10:1190-201.  Back to cited text no. 30
[PUBMED]    
31.
Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: A multicentre study with long-term follow-up (the GEPARD study). Gut 2009;58:1260-6.  Back to cited text no. 31
[PUBMED]    
32.
Bang JY, Hasan M, Navaneethan U, et al. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: May not be business as usual. Gut 2016; Aug 31 [epub]  Back to cited text no. 32
    
33.
Kumar N, Conwell DL, Thompson CC. Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: Comparison of clinical outcome and health care utilization. Pancreas 2014;43:1334-9.  Back to cited text no. 33
[PUBMED]    
34.
Varadarajulu S, Bang JY, Phadnis MA, et al. Endoscopic transmural drainage of peripancreatic fluid collections: Outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest Surg 2011;15:2080-8.  Back to cited text no. 34
[PUBMED]    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Endoscopic Ultrasound-guided Gastroenterostomy: A Promising Alternative to Surgery
Guoxin Wang,Xiang Liu,Sheng Wang,Nan Ge,Jintao Guo,Siyu Sun
Journal of Translational Internal Medicine. 2019; 7(3): 93
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
  Introduction
   Conventional Tra...
   Endoscopic Drain...
   Biflanged Metal ...
   Endoscopic Drain...
  Conclusions
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed942    
    Printed9    
    Emailed0    
    PDF Downloaded187    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]