EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study

Efficacy of endoscopic ultrasound-guided pelvic abscess drainage for pelvic abscesses: A case series study

BACKGROUND AND STUDY AIM

This is a retrospective study to evaluate the safety and efficacy of endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD) in a single hospital setting.

PATIENTS AND METHODS

The referral criteria for EUS-PAD included patients with a pelvic abscess (PA) that was amenable for the procedure. A total of 14 patients with PA treated with EUS-PAD were included in this study. The mean patient age was 57.4 years, and male-to-female ratio was 7:7. Overall, there were six cases of appendiceal perforation, five of rectal cancer and one case each of the diverticular perforation, perianal abscess, and walled-off necrosis.

RESULTS

Overall, 100% of procedures were successful. Clinical success was achieved in 11 patients and they were discharged after EUS-PAD within 21.4 days on an average and the average duration of stent placement before removal was 27.0 days. Of all, six patients achieved complete improvement status where the cause was appendiceal perforation while two and one of the patients were recovered where the causes were post-curative operation for carcinoma and walled-off necrosis, respectively. Eight out of eleven patients who exhibited appendiceal perforation or underwent radical rectal cancer surgery were discharged after an average of 9.4 days post EUS-PAD. Although two patients showed temporary improvement, with perianal abscess and controlled rectal carcinoma, the PA worsened as the primary disease intensified. The PA drainage was ineffective in three patients where two of them had uncontrolled rectal cancer and one had diverticular perforation.

CONCLUSION

Conclusively, the EUS-PAD is not only a reliable, safe, and efficient alternative to surgical and percutaneous drainage but also a valuable procedure with a high success rate for patients with acute infections, such as those who have had an appendiceal perforation or curative surgery. Poor indications and contraindications for EUS-PAD include uncontrolled gastrointestinal perforation and direct tumor invasion.

Endoscopic removal of lumen-apposing metal stents - risk factors for stent embedment, complex removals, and adverse events: analysis from a multicenter prospective case series

BACKGROUND

Removing lumen-apposing metal stents (LAMSs) may be difficult and even harmful, but these features have seldom been analyzed. We aimed to generate a comprehensive assessment of the feasibility and safety of LAMS retrieval procedures.

METHODS

A prospective multicenter case series including all technically successfully deployed LAMSs between January 2019 and January 2020 that underwent endoscopic stent removal. All retrieval-related data were prospectively recorded using standardized telephone questionnaires as part of centralized follow-up that ended after stent removal had been performed. Multivariable logistic regression models assessed the potential risk factors for complex removal.

RESULTS

For the 407 LAMSs included, removal was attempted in 158 (38.8 %) after an indwell time of 46.5 days (interquartile range [IQR] 31-70). The median (IQR) removal time was 2 (1-4) minutes. Removal was labelled as complex in 13 procedures (8.2 %), although advanced endoscopic maneuvers were required in only two (1.3 %). Complex removal risk factors were stent embedment (relative risk [RR] 5.84, 95 %CI 2.14-15.89; P = 0.001), over-the-wire deployment (RR 4.66, 95 %CI 1.60-13.56; P = 0.01), and longer indwell times (RR 1.14, 95 %CI 1.03-1.27; P = 0.01). Partial and complete embedment were observed in 14 (8.9 %) and five cases (3.2 %), respectively. The embedment rate during the first 6 weeks was 3.1 % (2/65), reaching 15.9 % (10/63) during the following 6 weeks (P = 0.02). The adverse event rate was 5.1 %, including seven gastrointestinal bleeds (5 mild, 2 moderate).

CONCLUSIONS

LAMS removal is a safe procedure, mostly requiring basic endoscopic techniques attainable in conventional endoscopy rooms. Referral to advanced endoscopy units should be considered for stents with known embedment or long indwell times, which may require more technically demanding procedures.

Endoscopic Ultrasound-Guided Drainage of a Postoperative Fluid Collection in the Setting of Roux-en-Y Anatomy

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The use of endoscopic ultrasound in the management of post-surgical and pancreatic fluid collections

Fluid collections after abdominal surgeries, particularly pancreatic surgeries, are associated with high morbidity and mortality. Up until recently, percutaneous drainage was the first line therapy, but not without disadvantages, including high maintenance, risk of infection and chronic fistulas, electrolyte losses, and impact on quality of life. Endoscopic ultrasound (EUS)-guided drainage of post-surgical fluid collections (PSFCs) is safe and effective, carrying similar success, adverse event (AE), and recurrence rates as percutaneous drainage. Despite limited data on EUS-guided drainage of PSFCs, especially with regards to direct comparisons to percutaneous drainage, EUS management of these collections is becoming the first-line approach in many expert institutions.

Endoscopic ultrasound-guided drainage of pelvic abscess: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

As an emerging minimally invasive technology, endoscopic ultrasound (EUS) has been reported to treat pelvic abscess instead of surgical or image-guided percutaneous drainage (PCD) under certain conditions. The aim of this study was to assess the efficacy and safety of EUS-guided drainage for patients with pelvic abscesses.

METHODS

We conducted a comprehensive literature search on PubMed, Embase, Cochrane Library, and Web of Science databases (inception-March 2022). The main outcomes were technical success, clinical success, and complications. Comprehensive meta-analysis software was used to calculate the pooled event rate.

RESULTS

Twelve studies containing 272 patients were included. These pelvic abscesses most frequently developed after abdominal and pelvic surgery (n = 180, 66.2%), inflammatory bowel disease (n = 32, 11.8%), and other inflammatory conditions. Respectively, the pooled technical and clinical success rate was 100% and 88.7% [95% confidence interval (CI): 83.8-92.2%, I² = 1.0%, p < 0.001]. After excluding an individual study, the pooled rate of complications changed from 11.5% (95% CI: 7.4-17.4%, I² = 38.8%, p < 0.001) to 8.2% (95% CI: 5.0-13.3%, I² = 0, p < 0.001).

CONCLUSIONS

EUS-guided drainage of the pelvic abscess was feasible, effective, and safe. Further randomized-controlled studies with large-sample sizes were required in the future.

Role of endoscopic ultrasound in vascular interventions: Where are we now?

From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Clinical outcomes of EUS-guided transluminal drainage with a novel lumen-apposing metal stent for postoperative pancreatic fluid collection after pancreatic surgery

BACKGROUND AND AIMS

EUS-guided transluminal drainage (EUS-TD) is increasingly used for the treatment of postoperative pancreatic fluid collections (POPFCs). A novel lumen-apposing metal stent (LAMS) was recently developed and used for the drainage of POPFCs. This study aimed to evaluate the efficacy and safety of a novel LAMS in patients with POPFCs.

METHODS

Forty-seven patients with symptomatic POPFCs who underwent EUS-TD with a novel LAMS (Niti-S SPAXUS; Taewoong Medical Co, Ltd, Ilsan, South Korea) between April 2019 and July 2020 were included in this study. Clinical outcomes, including technical success, clinical success, and adverse events, were retrospectively evaluated.

RESULTS

EUS-TD was technically successful in 41 of 47 patients (87.2%). Clinical success was achieved in 37 of 41 patients (90.2%). The mean procedure time was 13.7 ± 3.5 minutes. The mean POPFC size was 59 ± 18.9 mm. The mean time interval from surgery to EUS-TD was 24.2 ± 37.6 days. Five patients experienced 6 procedural adverse events (12.8%): 4 (8.5%) POPFC infections and 2 (4.3%) distal stent migrations. The 4 patients with POPFC infection underwent additional endoscopic interventions. Of the 2 patients with stent migration, 1 underwent laparoscopic exploration and surgical extraction of the stent and 1 (2.1%) experienced POPFC recurrence, which was managed with percutaneous drainage.

CONCLUSIONS

EUS-TD for symptomatic POPFCs with a novel LAMS is technically feasible and effective, with an acceptable adverse event rate. Further larger-scale prospective studies are required to confirm the findings of this study.

Futuristic Developments and Applications in Endoluminal Stenting

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.

Endoscopic ultra-sound (EUS) guided management of symptomatic pelvic collections: puncture-aspiration or drainage? Results from mono-centric retrospective experience with therapeutic algorithm

BACKGROUND

Pelvic collections may occur after surgery or in medical diseases. EUS transmural (TM) treatment has been shown as highly effective and safe, becoming an alternative to surgery or radiology. We aimed to assess the results of EUS management of pelvic collections.

METHODS

Retrospective, single-center observational study conducted between 2004 and 2018. Patients with symptomatic collections treated by EUS-TM approach were enrolled. The procedures were performed with a therapeutic EUS-scope, following two possible options: puncture-aspiration-injection of antibiotics PAIA (group 1) or EUS-drainage by plastic double pigtail stents (DPS) with an ano-cavitary drain (ACD) or lumen-apposing metal Stent (LAMS) (group 2). The main objective was to assess the clinical effectiveness based on symptoms and collection resolution.

RESULTS

Seventy-three patients were included. Mean age was 42.5 years [12-87]. 30 patients in group 1 (41%) underwent PAIA and 43 in group 2 (59%) underwent DPS ± ACD in 41 patients (95%) and LAMS in 2. The collection was postoperative in 58%. The mean size was 48.9 mm [8-120], 33 +/- 17 mm in group 1, compared to 67 ± 21 mm in group 2 (p < .0001). All the procedures were technically successful. Overall clinical success was 96% (93% in group 1 (28/30), 98% (42/43) in group 2). Failures occurred in 2 post sigmoiditis abscesses and 1 ileo-colic Crohn's disease. No adverse event was reported. During the median follow-up of 7.5 years [4.4-8.9], no patient had recurrence.

CONCLUSIONS

EUS-TM with either PAIA or drainage depending on the collection size is confirmed to be highly effective and safe.

Systematic review and meta-analysis of endoscopic ultrasound drainage for the management of fluid collections after pancreas surgery

BACKGROUND

The outcomes of endoscopic ultrasonography-guided drainage (EUSD) in treatment of pancreas fluid collection (PFC) after pancreas surgeries have not been evaluated systematically. The current systematic review and meta-analysis aim to evaluate the outcomes of EUSD in patients with PFC after pancreas surgery and compare it with percutaneous drainage (PCD).

METHODS

PubMed and Web of Science databases were searched for studies reporting outcomes EUSD in treatment of PFC after pancreas surgeries, from their inception until January 2022. Two meta-analyses were performed: (A) a systematic review and single-arm meta-analysis of EUSD (meta-analysis A) and (B) two-arm meta-analysis comparing the outcomes of EUSD and PCD (meta-analysis B). Pooled proportion of the outcomes in meta-analysis A as well as odds ratio (OR) and mean difference (MD) in meta-analysis B was calculated to determine the technical and clinical success rates, complications rate, hospital stay, and recurrence rate. ROBINS-I tool was used to assess the risk of bias.

RESULTS

The literature search retrieved 610 articles, 25 of which were eligible for inclusion. Included clinical studies comprised reports on 695 patients. Twenty-five studies (477 patients) were included in meta-analysis A and eight studies (356 patients) were included in meta-analysis B. In meta-analysis A, the technical and clinical success rates of EUSD were 94% and 87%, respectively, with post-procedural complications of 14% and recurrence rates of 9%. Meta-analysis B showed comparable technical and clinical success rates as well as complications rates between EUSD and PCD. EUSD showed significantly shorter duration of hospital stay compared to that of patients treated with PCD.

CONCLUSION

EUSD seems to be associated with high technical and clinical success rates, with low rates of procedure-related complications. Although EUSD leads to shorter hospital stay compared to PCD, the certainty of evidence was low in this regard.

Double pigtail stent placement as an adjunct to lumen-apposing metal stents for drainage of pancreatic fluid collections may not affect outcomes: A multicenter experience

Background and Objectives:

EUS-guided drainage of pancreatic fluid collections (PFCs) has been increasingly performed using lumen-apposing metal stents (LAMS). However, recent data have suggested higher adverse event rates with LAMS compared to double pigtail plastic stents (DPS) alone. To decrease risks, there has been anecdotal use of placing DPS through the LAMS. We aimed to determine whether the placement of DPS through cautery-enhanced LAMS at time of initial placement decreases adverse events or need for reintervention.

Methods:

We performed a multicenter retrospective study between January 2015 and October 2017 examining patients who underwent EUS-guided drainage of pseudocysts (PP), walled-off necrosis (WON), and postsurgical fluid collection using a cautery enhanced LAMS with and without DPS.

Results:

There were 68 patients identified at 3 US tertiary referral centers: 44 PP (65%), 17 WON (25%), and 7 PFSC (10%). There were 35 patients with DPS placed through LAMS (Group 1) and 33 with LAMS alone (Group 2). Overall technical success was 100%, clinical success was 94%, and adverse events (bleeding, perforation, stent occlusion, and stent migration) occurred in 28% of patients. Subgroup analysis compared specific types of PFCs and occurrence of adverse events between each group with no significant difference detected in adverse event or reintervention rates.

Conclusion:

This multicenter study of various types of PFCs requiring EUS-guided drainage demonstrates that deployment of DPS across cautery-enhanced LAMS at the time of initial drainage does not have a significant effect on clinical outcomes, adverse events, or need for reinterventions.

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

Backgrounds/Aims

Post-operative pancreatic fistulas (POPF) and fluid 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™ lumen apposing metal stent (LAMS).

Methods

We conducted a retrospective study, encompassing all consecutive patients with POPFC managed using Hot AXIOS™ 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™ LAMS during the study period. Mean age of patients was 67.8 &plusmn; 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™ LAMS is a safe and effective treatment modality with technical and clinical success rates of 100% in our experience.

The Role of EUS-Guided Drainage in the Management of Postoperative Fluid Collections after Pancreatobiliary Surgery

Postoperative fluid collection (POFC) is a challenging complication following pancreatobiliary surgery. Traditional treatment with surgical drainage is associated with significant morbidity, while percutaneous drainage is associated with a higher rate of recurrence and the need for repeated interventions. Studies have shown that endoscopic ultrasound (EUS)-guided drainage may offer a promising solution to this problem. There are limited data on the ideal therapeutic protocol for EUS-guided drainage of POFC including the timing for drainage; type, size, and number of stents to use; and the need for endoscopic debridement and irrigation. Current practices extrapolated from the treatment of pancreatic pseudocysts and walled-off necrosis may not be applicable to POFC. There are increasing data to suggest that drainage procedures may be performed within two weeks after surgery. While most authors advocate the use of double pigtail plastic stents (DPPSs), there have been a number of reports on the use of novel lumen-apposing metal stents (LAMSs), although no direct comparisons have been made between the two.

Endoscopic ultrasound-guided pelvic abscess drainage: a report of 2 cases and literature review

BACKGROUND

Drainage is essential for source control of the infection in a pelvic abscess. The purpose of this study was to report 2 cases of endoscopic ultrasound (EUS)-guided drainage of the pelvic abscess and review the literature of different modalities of EUS-guided drainage of pelvic abscess.

CASE PRESENTATION

A 60-year-old male developed a pelvic abscess 1 month after laparoscopic complete tumor resection. An abdominal CT showed a mass shadow (about 7.1 cm × 5.1 cm) in the right pelvic region. Another case was an 85-year-old male who developed a pelvic abscess 3 days after recurrent tumor resection of multiple organs. The CT showed pelvic effusion and gas accumulation (approximately 6.5 cm × 4.2 cm), and the intestinal tube above the small intestinal anastomosis was dilated with effusion. A 19G-A puncture needle was used to puncture the abscess. An 8-mm cylindrical balloon was inserted, followed by a 10 Fr-3 cm double pigtail stent and an 8.5 Fr drainage tube. After EUS-guided drainage of pelvic abscess, the symptoms disappeared without recurrence.

CONCLUSIONS

EUS-guided drainage is an effective and safe method for treating pelvic abscesses as long as the drainage modality is appropriately selected based on the etiology, size, and mucus viscosity of the abscess.

Novel Uses of Lumen-apposing Metal Stents: A Review of the Literature

The field of therapeutic endoscopy has seen many recent advancements. One such emerging field is the use of lumen-apposing metal stents (LAMS). Although a few LAMS have been developed, the most commonly reviewed and the only Food and Drug Administration (FDA)-approved LAMS is the Axios stent by Boston Scientific. In 2013, LAMS were initially approved by the FDA for the management of pancreatic fluid collection drainage in the presence walled-off necrosis. Pancreatic fluid collections are traditionally drained with either a plastic stent or a covered biliary self-expanding metal stent. Plastic stents have a double pigtail feature which prevents stent migration. However, their narrow lumen poses limitations as it can lead to early stent occlusion. Fully covered metal stents have larger diameters, allowing improved drainage and decreased stent occlusion but their tubular shape is prone to migration. Consequently, this results in leakage, and frequent retrievals. Over the years, due to their versatility, LAMS now have many off label uses. This includes management of gastric outlet obstruction, superior mesenteric artery syndrome, strictures, gallbladder drainage, and postsurgical collection drainage. In this review, we will be discussing the FDA approved and the nonapproved uses of LAMS.

Endoscopic ultrasound-guided drainage of a fungal liver abscess using a lumen-apposing metal stent: case report and literature review

Liver abscesses are rare entities for which percutaneous drainage is traditionally employed. The technique is simple, but associated with a significant rate of side effects and patient discomfort. We herein report a case of fungal left liver lobe abscess that was successfully treated by using EUS-guided drainage, with insertion of a large caliber lumen-apposing metal stent. The literature review we performed on the topic seems to favor, at least for abscess in the left and/or caudate liver lobes, EUS as compared to percutaneous drainage.

Effectiveness of early endoscopic ultrasound-guided drainage for postoperative fluid collection

BACKGROUND

Postoperative abdominal fluid collections (PAFCs) are a potentially fatal complication of pancreatobiliary surgery. Endoscopic ultrasound (EUS)-guided drainage has recently been shown to be effective in treating PAFCs of more than 4 weeks old. Little is currently known, however, regarding the EUS-guided drainage of PAFCs of less than 4 weeks. This study assessed the efficacy and safety of the early drainage (< 4 weeks) of PAFCs via EUS guidance.

METHODS

The data of patients who had undergone EUS-guided PAFC drainage between July 2008 and January 2018 were retrospectively analyzed. Data of EUS-guided PAFC drainage were obtained from prospectively collected EUS database of our institute and reviewed of patients' clinical parameters based on electrical medical record.

RESULTS

A total of 48 patients who had undergone EUS-guided PAFC drainage within 4 weeks of pancreatobiliary surgery were enrolled. The indications of procedure included abdominal pain (n = 27), fever (n = 18), leukocytosis (n = 2), and increased size of PAFC during external tube drainage (n = 1). Technical success was achieved in all cases, and the clinical success rate was 95.8% (46/48). Four patients underwent secondary procedures. The median period from surgery to EUS-guide drainage was 14 days (Interquartile range [IQR] 10-16), and median time to resolution was 23.5 days (IQR 8.5-33.8). Adverse events occurred in two cases that were developed intracystic bleeding and were successfully resolved by arterial coil embolization.

CONCLUSIONS

Early EUS-guided drainage is a technically feasible, effective, and safe method in patients who have developing PAFCs within 4 weeks of pancreatobiliary surgery.

Efficacy of Early Endoscopic Ultrasound-Guided Transluminal Drainage for Postoperative Pancreatic Fistula

BACKGROUND

Endoscopic ultrasound-guided transluminal drainage (EUS-TD) is generally performed 4 weeks after disease onset for evacuating pancreatic fluid collections. However, the optimal timing for conducting the procedure in those diagnosed with postoperative pancreatic fistula (POPF) has not been established. We aimed to elucidate the efficacy and safety of early EUS-TD procedures for treating POPF.

METHODS

We retrospectively reviewed patients diagnosed with POPF who underwent EUS-TD in the Kyushu University Hospital between 2008 and 2019. Clinical features were comparatively analyzed between the two patient groups who underwent either early (≤15 days postoperatively) or late (>15 days postoperatively) EUS-TD. Factors prolonging hospital stay were also analyzed using Cox proportional hazard models.

RESULTS

Thirty patients (median age, 64.5 years) were enrolled. The most common initial operation was distal pancreatectomy with splenectomy (60.0%). Median size of POPF was 69.5 (range, 38-145) mm, and median time interval between surgery and EUS-TD was 17.5 (range, 3-232) days. Totally, 47% patients underwent early EUS-TD. Rates of technical success, clinical success, and complications were 100%, 97%, and 6.9%, respectively. No recurrence of POPF occurred during a median follow-up period of 14 months. Clinical characteristics and outcomes were comparable between the early and late drainage patient groups, except for the rates of infection and nonencapsulation of POPF, which were significantly higher in the early drainage group. Performing simultaneous internal and external drainage (hazard ratio (HR): 0.31; 95% confidence interval (CI): 0.11-0.93, p=0.04) and conducting ≥2 treatment sessions (HR: 0.26; 95% CI: 0.08-0.84, p=0.02) were significantly associated with prolonged hospitalization after EUS-TD.

CONCLUSIONS

EUS-TD is a safe and effective method for managing POPF, regardless of when it is performed in the postoperative period. Once infected POPF occurs, clinicians should not hesitate to perform EUS-TD even within 15 days of the initial operation.

EUS-guided pelvic drainage: A systematic review and meta-analysis

Background and Objectives:

EUS-guided pelvic abscess drainage (EUS-PAD) is a procedure that utilizes an echoendoscope to visualize an area of interest for needle insertion and placement of a stent, catheter, or both for drainage of the target abscess. The aim of this study was to perform a systematic review and meta-analysis for the safety and efficacy of EUS-PAD.

Materials and Methods:

We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to February 2020). The primary outcomes for this study were the technical and clinical success of EUS-PAD. The secondary outcomes assessed for this study were adverse events of the procedure and subgroup analysis of individual adverse events.

Results:

Eight studies with a total of 135 patients combined were included in our analysis. The rate of technical success was 100% and the calculated pooled rate of clinical success was 92% (95% confidence interval [CI]: 87%, 98%; P = 0.31; I² = 15%). The calculated pooled rate of adverse events was 9.4% (±17.9%), with stent migration (5.5 ± 18.06%) being the most common adverse event.

Conclusion:

EUS-PAD offers a viable alternative that can minimize the need for surgical intervention in the drainage of pelvic abscesses. EUS-PAD has also demonstrated long-term clinical success with an acceptable rate of complications.

Transrectal Endoscopic Ultrasound-Guided Drainage of a Tubo-Ovarian Abscess Via a Lumen-Apposing Metal Stent

Tubo-ovarian abscess (TOA) is a potentially lethal condition, often requiring a combination of medical and surgical interventions. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic fluid collections, but its role for the treatment of TOA is not well documented. We report the first known case of successful treatment of a large TOA with EUS-guided transrectal drainage using a lumen-apposing metal stent.

Lumen-apposing metal stents for approved and off-label indications: a single-centre experience

BACKGROUND AND STUDY AIMS

Lumen-apposing stents (LAMS) are approved to treat peripancreatic collections and for gallbladder and bile duct drainage. Over the last years, LAMS have also been used for off-label indications including gastrojejunostomy, gastro-gastrostomy and drainage of postsurgical collections. We aimed to analyze indications, technical/clinical success rates and complications of all LAMS placed over the last 2 years.

PATIENTS AND METHODS

Data from 61 consecutive LAMS (Hot Axios, Boston Scientific) in 57 patients were analyzed. Technical success was defined as successful deployment of the LAMS in the desired position. Clinical success was defined as follows: for pancreatic collections: resolution without the need for non-endoscopic interventions; for choledochoduodenostomy: ≥ 50% drop in baseline serum bilirubin within 2 weeks AND patient can receive chemotherapy if indicated; for gastrojejunostomy: resolution of gastric outlet obstruction and successful re-initiation of oral intake; for gastro-gastrostomy: successful endoscopic access to the excluded stomach; for gallbladder or postsurgical collection drainage: resolution of sepsis.

RESULTS

Indications were drainage of peripancreatic collections in 24 cases (39.3%), choledochoduodenostomy in 13 (21.3%), gastrojejunostomy in 6 (9.8%), gastro-gastrostomy in 13 (21.3%), gallbladder drainage in 1 (1.6%) and postsurgical collection drainage in 4 (6.6%). Overall technical and clinical success rates were high (57/61; 93.4% and 54/61; 88.5%, respectively). Clinical success rate for non-approved indications was 95.6% (22/23 cases). Complications occurred in 13 patients (21.3%, 4 serious).

CONCLUSIONS

LAMS are increasingly used in interventional endoscopy. In our cohort, more than one third of LAMS are placed for off-label indications, with a high success rate and acceptable complication rate.

Alternative uses of lumen apposing metal stents

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series

Background and Aims

Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs.

Methods

A retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included.

Results

Five patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 × 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed.

Conclusion

EUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- × 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy.

Acute and early EUS-guided transmural drainage of symptomatic postoperative fluid collections

BACKGROUND AND AIMS

EUS-guided postoperative drainage (EUS-POD) of postoperative fluid collections (POFCs) is typically delayed until a thick wall has formed to optimize safety. Thus, percutaneous drainage is the mainstay of early POFC management. The primary aim of this study was to compare technical and clinical success and adverse event (AE) rate between early (0-30 days postoperative) compared with delayed (>30 days) EUS-POD. The secondary aim was to determine predictors for clinical success and AE rate associated with early compared with delayed EUS-POD.

METHODS

This was a retrospective analysis of consecutive patients undergoing EUS-POD between November 2013 and November 2018 at a single tertiary academic center. Demographic, procedural, and outcomes data were recorded. Clinical success was defined as resolution of symptoms and the fluid collection on cross-sectional imaging without recurrence after transluminal stent removal.

RESULTS

Seventy-five patients underwent EUS-POD; 42 (56%) were early, of whom 20 were acute. Sixty-three patients (84%) had undergone distal pancreatectomy. Technical success was 100%, and clinical success was achieved in 70 patients (93%) after a mean 2.2 procedures (range, 1-5). Prior percutaneous drainage had been performed in 13 patients (17.3%). Both acute and early drainage versus delayed EUS-POD demonstrated similar rates of clinical success (95% and 93% vs 94%, P = .99) and AEs (21.4% and 15% vs 30.3%, P = .43). Necrosectomy was required less often in the early versus the delayed group. No predictors of clinical success were identified. Early EUS-POD was not a predictor of AEs (P = .65). Infection and collection size >10 cm correlated with increased AE risk (P = .048 and .007, respectively).

CONCLUSIONS

Early and even acute EUS-POD of POFCs appears to be technically feasible, clinically effective, and safe. EUS-POD should be considered for definitive management of early symptomatic POFCs.

EUS-directed transenteric ERCP in non-Roux-en-Y gastric bypass surgical anatomy patients (with video)

BACKGROUND AND AIMS

Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper GI anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in the de novo creation of an enteroenteric anastomosis for the performance of ERCP in non-Roux-en Y gastric bypass (RYGB) patients.

METHODS

This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions), and secondary outcomes were technical success and rate/severity of adverse events.

RESULTS

Eighteen patients (mean age, 63 years; 13 women) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100% and of ERCP was 94.44% (17/18). Fourteen patients underwent separate-session EDEE with a median of 21 days (interquartile range [IQR], 11.5-36) between the 2 procedures. Median total procedure time was 111 minutes (IQR, 81-192). Clinical success and adverse events occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 days (IQR, 54-142).

CONCLUSIONS

This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

Endoscopic Ultrasound Guided Drainage of a Post-Surgical Fluid Collection Using a Lumen-Apposing Metal Stent in a Patient With Crohn's Disease

Patients with Crohn's disease (CD) are susceptible to postsurgical fluid collections and abscesses. Traditionally, these have been drained either percutaneously or surgically. Endoscopic ultrasound-guided drainage using a lumen apposing metal stent has not been used commonly for drainage of abdominal abscesses in patients with CD, given the concern of fistula formation because of transmural inflammation in patients with CD. We report a case of a large perigastric abscess that was drained through the stomach, using a lumen apposing metal stent with complete resolution of the abscess.

Lumen-apposing metal stents in interventional endoscopy: a state-of-the-art review with focus on technical and clinical successes and complications

Endoscopic transmural drainage is considered the initial treatment option for pancreatic fluid collections. Recently, lumen-apposing metal stents have been introduced for pancreatic fluid collections drainage under endoscopic ultrasound guidance, in addition to evolving data in bile duct and gallbladder drainage. We aimed to perform systematic review with reporting pooled data analysis on technical success, clinical success and complications rate of endoscopic ultrasound-guided lumen-apposing metal stents uses. A MEDLINE/PubMed and EMBASE search for all studies on lumen-apposing metal stents uses in pancreatic, biliary and other indications was conducted. Data regarding safety, complications and yield were extracted and included in the final pooled analysis. Overall, 19 articles dealing with pancreatic fluid collections drainage, 18 articles reporting on bile duct drainage and 19 articles relevant to gallbladder drainage were identified. Technical and clinical successes in all disease conditions were high and reached more than 95%. Complications rate in pancreatic fluid collections, bile duct and gallbladder drainages were 12%, 11.2% and 9.8%, respectively. Endoscopic ultrasound-guided lumen-apposing metal stents is technically feasible with very high success rate and acceptable complications rate.

Endoscopic Ultrasonography-Guided Versus Percutaneous Drainage for the Recurrent Pancreatic Fluid Collections

BACKGROUND Ultrasonography-guided percutaneous drainage for pancreatic fluid collections is associated with a high recurrence rate and endoscopic ultrasonography (EUS)-guided drainage is a valuable approach. Our aim was to compare the efficacy and safety of percutaneous and EUS-guided drainage for the recurrent pancreatic fluid collections. MATERIAL AND METHODS A retrospective analysis of percutaneous-guided and EUS-guided procedures for pancreatic fluid collections drainages at a single tertiary care center between February 2017 and May 2018 was performed. Treatment success, adverse events, recurrence, need for surgery, length of hospital stays, and number of follow-up computed tomography (CT) scan were assessed. RESULTS A total of 119 pancreatic fluid collections treated with initial percutaneous drainage were included in this study and 35 patients had recurrent pancreatic fluid collections. Recurrent patients were classified based on drainage method: EUS-guided drainage (18 patients) and the second percutaneous drainage (17 patients). EUS-guided drainage revealed a shorter length of hospital stays (P<0.001), less re-intervention (P=0.047), fewer number of follow-up CT scans (P=0.006) compared with the initial percutaneous drainage. Furthermore, we also compared the clinical outcomes between the EUS-guided drainage and the second percutaneous drainage for the recurrent PFC after initially failed percutaneous drainage. EUS-guided drainage showed higher clinical success (P=0.027), shorter length of hospital stays (P<0.001), less re-intervention (P=0.012), fewer number of follow-up CT scan (P<0.001) and less recurrence P=0.027) compared to the second percutaneous drainage procedure. CONCLUSIONS EUS-guided drainage is an effective and appropriate method to treat the recurrent pancreatic fluid collections after initially failed percutaneous drainage procedure, with the advantage of higher clinical success, shorter length of hospital stays, less re-intervention, fewer number of follow-up CT scan and less recurrence compared to the percutaneous drainage.

Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.

Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses

BACKGROUND AND AIM

Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) has become the standard treatment for peripancreatic fluid collections. Its use in other intra-abdominal abscesses has been reported, although there is limited evidence.

METHODS

We carried out a single-center retrospective cohort study comparing percutaneous drainage (PCD) and EUS-D of upper abdominal abscesses between January 2012 and June 2017. Pancreatic fluid collections and liver transplant recipients were excluded. Primary endpoints were technical and clinical success rates.

RESULTS

We included 18 EUS-D (nine hepatic and nine intraperitoneal abscesses) and 62 PCD. There were no differences regarding age, gender and etiology. Size was larger in the PCD group (80 vs 65.5 mm, P = 0.04) and perivesicular location was more frequent in the PCD group (24.2% vs 11.1%, P = 0.003). In the EUS-D group, metal stents were deployed in 16 (88.9%) subjects (eight lumen-apposing metal stents and eight self-expandable metal stents), coaxial double-pigtail plastic stents in six (33.3%) and lavage/debridement was carried out in five (27.8%). There were no significant differences in technical success (EUS-D: 88.9%, PCD: 96.8%, P = 0.22) or clinical success (EUS-D: 88.9%, PCD: 82.3%, P = 0.50), with no relapses in the EUS-D group and 10 (16.1%) in the PCD group (P = 0.11). There were four (22.2%) adverse events in the EUS-D group, none of them severe, and 13 (21%) in the PCD group (P = 0.91).

CONCLUSIONS

EUS-D is an alternative to PCD in the treatment of upper abdominal abscesses, reaching similar success, relapse and adverse events rates.

EUS-guided drainage of postsurgical pelvic abscesses using lumen-apposing metal stents

Endoscopic ultrasound (EUS) guided drainage of pelvic collections is an alternative to percutaneous or surgical drainage. We present our experience using lumen-apposing metal stents (LAMS) for the drainage of postoperative pelvic abscesses.

Large lymphoepithelial cyst of pancreas: a rare entity managed using lumen-apposing metal stent-case report and review of the literature

Lymphoepithelial cysts (LECs) are extremely rare nonmalignant cysts of the pancreas. Asymptomatic LECs are managed conservatively, but symptomatic LECS have traditionally been managed with surgical resection. We report the first case of symptomatic infected LEC of the pancreas successfully managed with EUS guided endoscopic drainage with lumen-apposing metal stent. We also review the relevant literature and discuss the diagnosis and management of this rare cyst of the pancreas.

Use of Lumen-Apposing Stents for the Treatment of Postsurgical Fluid Collections: A Case Series and a Review of Literature

Lumen-apposing metal stents (LAMS) use in gastrointestinal endoscopy has been on the rise for various indications for the last few years. Currently, LAMS is a well-established treatment for post-pancreatitis peri-pancreatic fluid collections and walled-off necrosis (WON), but it is still not a standard of care in the treatment of post-surgical fluid collections (PSFC). Most of the earlier studies for treatment of PSFC utilized double pigtail plastic stents (DPS). We present a series of 3 cases where LAMS was successfully used for PSFC drainage. The cases include a patient with perigastric abscess after Whipple's procedure, a case of peri-pancreatic collection after distal pancreatectomy, and a patient with peri-pancreatic fluid collection after right partial hepatectomy and splenectomy due to lacerations from a motor vehicle accident.

EUS versus percutaneous management of postoperative pancreatic fluid collection: A systematic review and meta-analysis

Postoperative pancreatic fluid collection (POPFC) is an important complication following abdominal surgery. POPFC causes significant morbidity and mortality. Management options are time-consuming and severely affect patient's quality of life. Surgical and/or percutaneous drainage (PCD) is the traditional mainstay of treatment. Studies have shown that EUS could have a role to play in the management of POPFC. Data are limited in the comparison of clinical outcomes with EUS as compared to PCD to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, LILACS, and Web of Science databases (earliest inception through September 2018) to identify studies that reported on the clinical outcomes of EUS and PCD in the management of POPFC. The goals were to estimate and compare the pooled rates of technical success, clinical success, adverse events, and POPFC recurrence with EUS and PCD. A total of 13 studies were included in the analysis. Ten studies (239 patients) used EUS and 6 studies (267 patients) used PCD in the management of POPFC. The pooled rate of clinical success with EUS was 93.2% (95% confidence interval [CI] 88.2–96.2, I² = 0) and with PCD was 79.8% (95% CI 70–87, I² = 74). The difference was statistically significant, P = 0.002. Recurrence rate was significantly lower with EUS as compared to PCD (9.4%: 95% CI 5.2–16.5 vs. 25.7%: 95% CI 24.3–41.7; P = 0.02). Pooled rates of technical success and adverse events were similar with EUS and PCD. Our meta-analysis shows that EUS has significantly better clinical outcomes, in terms of clinical success and disease recurrence, in the management of POPFC as compared to PCD.

Current uses and outcomes of lumen-apposing metal stents

The lumen-apposing metal stent (LAMS) is one of the revolutionary devices recently developed for gastrointestinal endoscopy. This device has a saddle-shaped design and large lumen. It was originally designed for drainage of transmural pancreatic fluid collection and in the last few years it has been used extensively for that indication. More recently, other in- and off-label indications have been proposed. Several types of LAMS are available, with or without an electrocautery-enhanced delivery system. In the current review we discuss the state of the art with regard to LAMS and their indications, usage, and outcomes.