Percutaneous transgastric snaring for repositioning of a dislocated internal drain from a pancreatic pseudocyst

Outcomes of a single-step endoscopic ultrasound-guided drainage of pancreatic-fluid collections using an electrocautery-enhanced coaxial lumen-apposing, self-expanding metal stent with and without fluoroscopy

Background

Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections (PFCs). An electrocautery-enhanced coaxial lumen-apposing, self-expanding metal stent (ELAMS) facilitates a single-step procedure and may avoid the need for fluoroscopy. This study compares the treatment outcomes using ELAMS with and without fluoroscopy.

Methods

Patients with PFCs who had cystogastrostomy from January 2014 to February 2017 were enrolled. Two groups were studied based on fluoroscopy use. Technical success was defined as uneventful insertion of ELAMS at time of procedure. Clinical success was defined as (i) clinical resolution of symptoms after the procedure and (ii) >75% reduction in cyst size on computed tomography 8 weeks after stent placement. Adverse events including bleeding, stent migration, and infection were recorded.

Results

A total of 21 patients (13 males) had PFCs drainage with ELAMS in the study period. The mean age was 51.6 ± 14.2 years. Thirteen patients had walled-off necrosis while eight had a pancreatic pseudocyst. The mean size of the PFCs was 11.3 ± 3.3 cm. Fluoroscopy was used in seven cases (33%) and was associated with a longer procedure time compared to non-fluoroscopy (43.1 ± 10.4 vs 33.3 ± 10.5 min, P = 0.025). This association was independent of the size, location, or type of PFCs. Fluoroscopy had no effect on the technical success rates. In fluoroless procedures, the clinical resolution was 91% as compared to 71% in fluoroscopy procedures (P = 0.52) and the radiologic resolution was 57% as compared to 71% in fluoroscopy procedures (P = 0. 65). Three cases of stent migration/displacement occurred in the fluoroless procedures.

Conclusions

ELAMS may avoid the need for fluoroscopy during cystogastrostomy. Procedures without fluoroscopy were significantly shorter and fluoroscopy use had no impact on the technical or clinical success rates.

Delayed, diffuse acute peritonitis secondary to misplacement of a cystogastrostomic "pigtail" drain in an outpatient after discharge

Background and aim of the work: Pancreatic pseudocyst endoscopic drainage by pancreatogastrostomy “pigtail” drain placement is spreading worldwide, with high success-rate and low morbidity, and is increasingly performed as outpatient procedure. The paper reports an unusual very early complication of this procedure and discusses the peculiar aspects of this event in an outpatient setting. Methods: The first case of a 56-year-old outpatient developing a postoperative diffused acute peritonitis by gastric juice spilling caused by the misplacement of the distal end of two transgastric drains not reaching the pseudocyst is reported. As the case was programmed as outpatient and acute peritonitis symptoms occurred eight hours postoperatively, the patient was discharged and rehospitalized. A review of the literature of rare perforative complications of pancreatogastrostomy is performed. Results: CT scan allowed the prompt diagnosis, as it showed massive pneumoperitoneum, free fluid collection, and pigtail drain misplacement. Emergency laparoscopy allowed the removal of the two misplaced drains and gastric reparation. The procedure lasted 65 minutes, mostly needed for lavage. The patient was discharged 5 days later and outcomes are unremarkable 7 months after the procedure. Conclusion: The indication to endoscopic pancreatogastrostomy and its outpatient management should be carefully pondered. Pancreogastrostomy drain misplacement may cause a life-threatening acute peritonitis associated with early aspecific symptoms, resulting in a challenging situation, especially in an outpatient setting. CT-scan may allow prompt diagnosis and effective management by minimally invasive surgery. (www.actabiomedica.it)

Removing a metal foreign object successfully from a patient's retroperitoneal space using laparoscopy and a novel navigation system

Trauma with foreign objects retained within the human body has become a common surgical emergency condition. Traditional surgical methods often involve creating large incisions in soft tissue and may lead to additional complications during wound healing. We have developed a new method of removing foreign bodies from patients' abdomens by using laparoscopy with the help of a novel navigation system that provides accurate positioning. This approach is minimally invasive and simple. This is the first combination of both technologies in this field.

Removal of a retroperitoneal foreign body through single port laparoscopy using nephroscope

Foreign bodies are rare and challenging issues leading to symptoms according to the location. Laparoscopy is a popular and minimally invasive method used for removal of foreign bodies in the abdominal cavity or retroperitoneum. We herein report a case with retroperitoneal foreign body that was removed through retroperitoneal single- port laparoscopy using nephroscope. To our knowledge this is the first case of removal of a retroperitoneal foreign body through single- port laparoscopy using nephroscope.

Percutaneous Approach for Removal of a Migrated Cystogastric Stent from a Pancreatic Pseudocyst: A Case Report and Review of the Literature

Stent migration into pancreatic pseudocysts during endosonographic (EUS) cystogastrostomy is a relatively rare complication. The migrated stent may induce, if it remains within the body, infection and perforation. Therefore, retrieval and/or re-stenting is necessary. Endoscopic retrieval is commonly attempted first. However, it is technically challenging and largely dependent on the skill of the endoscopists; if retrieval is unsuccessful, surgery is usually carried out. We report a case of stent migration into a pancreatic pseudocyst that was retrieved with a percutaneous approach under imaging guidance using a simple technique with available devices. A technique that enhances the role of interventional radiology in the management of this rare complication.

Endoscopic removal of a migrated cystogastrostomy double pigtail stent through a pancreatico-duodenal fistula tract

A common complication of pancreatitis is pseudocyst formation. Endoscopic drainage is a widely used treatment for pancreatic pseudocysts, and offers a definitive solution in approximately 75% of cases. Drainage-related complications may be related directly to the procedure or may occur later as stents and drains migrate or erode into adjacent structures. Procedure-related complications included bleeding, pancreatitis, and infection while stent-related complications may involve dislocation or clogging with subsequent infection. This report is the first description of the successful endoscopic removal of a migrated cystogastrostomy double pigtail stent through a pancreatico-duodenal fistula tract that developed more than six years after the stent was originally misplaced into a pseudocyst.

Percutaneous fluoroscopically guided removal of a deep retroperitoneal foreign body with a laparoscopic trocar and grasping device

Traditionally, soft tissue foreign body removal is performed surgically. Superficial foreign body removal under ultrasonographic and fluoroscopic guidance has been reported. Herein, the authors report a case of percutaneous removal of a retroperitoneal foreign body under fluoroscopic guidance by using a modified laparoscopic trocar device and a laparoscopic grasping device. Iodinated contrast medium administered via the trocar device allowed visualization of the foreign body and distended the retroperitoneal space to allow for manipulation of the foreign body. The procedure was completed in a relatively short time and the patient made an excellent rapid postoperative recovery.