Introduction

EUS-guided drainage using lumen-apposing metal stents (LAMS) has become standard treatment of symptomatic walled-off necrosis (WON). The development of these fully covered self-expanding metal stents with special design of the flanges and large diameter, improved the drainage of debris and facilitated further direct endoscopic necrosectomy. Delivery systems with integrated electro-cautery (EC) enable direct access and stent deployment whilst the conventional stent insertion technique requires several steps including access using a needle or cystotome, wire insertion and enlargement of the created tract before the stent placement.

Aims & Methods

In this single center study, we aimed to compare the practicality of EUS-guided procedures and their outcome between conventional LAMS (cLAMS) and those with integrated EC (LAMS-EC).
From our prospectively maintained database, we included consecutive patients undergoing EUS-guided LAMS insertion with or without integrated electro-cautery for drainage of walled-off necrosis. Infection of the walled-off pancreatic necrosis, biliary compression with cholestasis or gastric outlet obstruction were accepted indications for intervention. Data on procedure time, sedation, hospital stay, technical and clinical success as well as adverse events were analysed.

Results

We analysed 107 consecutive procedures of transmural EUS-stenting for drainage of walled-off necrosis. 39 cLAMS and 68 LAMS-EC were placed successfully. Mean size of the walled-off necrosis was 12.9 ± 4.2 cm with mean 30% ± 15% solid necrosis.
Procedure times were shorter with LAMS-EC (18 .0 ± 6.6 min vs. 39.7 ± 8.3 min; p<0.05). All EUS-guided procedures with cLAMS drainage were performed under propofol sedation administered by an anaesthetic team. In the LAMS-EC group, 36 patients tolerated the procedure under iv sedation (fentanyl/midazolam) in left lateral position and 17 interventions were performed as daycase procedures. None of the patients developed sedation related adverse events such as aspiration.
Adverse events, technical success and clinical outcome did not differ between both groups.

Conclusion

The findings of this study suggest that cLAMS and EC-LAMS achieve similar rates of technical and clinical success without difference in the rate of adverse events. Compared to cLAMS, deplayment of EC-LAMS is faster and technically less demanding. This might allow to perform the procedure under conventional intravenous sedation and as daycase procedure in carefully selected patients.

Clinical Case Summary

Patient of 71 years old with CP was admitted for painless jaundice with benign common bile duct (CBD) stricture. ERCP failed at her center due to duodenal edema that prevented seeing the papilla so the patient was transferred to our center for assisted EUS drainage.

After after a first attempt with an unsuccessful rendezvous ERCP due to guidewire loss in the exchange of devices, cholecystoduodenostomy was performed with a coaxial double pigtail after confirmation of cystic duct permeability in the cholangiogram (previously performed under EUS guidance with puncture of the CBD to perform de rendezvous). In a second attempt to treat the stricture, a rendezvous through the gallbladder was performed. After papilloplasty and dilating the stricture, a 10 x 60 mm FCMS was placed. The patient improved and the lumen apposing metal stent of the cholecystoduodenostomy was removed. In followup, proximal migration of the stent was observed, impossible to remove by ERCP at her center due to impossibility of accessing the papilla.

In our center, a new endoscopy was performed. CBD was punctured by EUS with a 22 G needle through the biliary stent to perform a rendezvous and a novagold guidewire was advanced to the duodenum. The CBD was accessed with a monorail sphincterotome over the guidewire and rigid guidewire was advanced to the biliary tract. Papilloplasty was performed againd and the migrated stent was removed with rat tooth forceps. A new FCMS was placed successfully.

To conclude, endoscopic management of patients with CP can be very complex and several advanced combined bile duct access techniques are sometimes required. So, these patients should ideally be managed in referral centers.

Clinical Case Summary

A 90-year-old woman was referred to our endoscopy unit from another hospital for urgent rescue therapy because of impacted Dormia basket during ERCP performed for symptomatic recurrent choledochal lithiasis. In attempt to perform extracanalar lithotripsy Dormia basket was broken near the handle. Another ERCP was performed, and the contrast cholangiography showed dilated common bile duct (up to 13mm) with a constriction in the middle part and impacted Dormia basket with multiple gallstones, confirmed by Spyglass single-operator per-oral cholangioscopy with direct visualization. Electrohydraulics lithotripsy with Autolith EHL system (2437 pulses, medium-high power) was performed with stones fragmentation but Dormia basket entrapped stone fragments. Dormia basket distal margin was caught with a biopsy forceps and passed in duodenoscope working channel. Then biliary clearance was completed with ballon catheter and the following cholangiography confirmed successful biliary drainage and optimal bile outflow without contrast biliary or duodenal spreading. Postprocedural course was regular, and the patient was discharged after three days of hospitalization.

Clinical Case Summary

Introduction: Superior mesenteric artery pseudoaneurysms (SMA) are rare vascular entities, but can potentially result in significant morbidity and mortality (up to 60%) if rupture occurs. Traditionally, SMA pseudoaneurysms are associated with arterial dissection, pancreatitis, infection, trauma, tumor invasion, or arise as post-operative and iatrogenic complication.^1-8
Case report: A 51-year-old man with a medical history of chronic alcohol consumption and chronic pancreatitis presented with multiple episodes of hematemesis and hematochezia, jaundice and severe abdominal pain with a supraumbilical pulsatile mass. The patient was haemodynamically unstable (BP: 79/45 mmHg, HR: 123/min) with inadequate resuscitation despite transfusions of blood products and intravenous fluids. Laboratory tests showed significant reduction in hematocrit (Hct: 23,9%, Hb: 7,7 g/dL) and abnormal liver function tests (TBL: 7,21 mg/dL, DBL: 4,88 mg/dL, SGOT: 156 U/l, SGPT: 92 U/l, γGT: 1822 U/l, ALP: 1577 U/l). An abdominal vascular lesion was suspected and an urgent CT angiography was performed. The CT scan confirmed the presence of a ruptured superior mesenteric artery pseudoaneurysm, 11.5cm in diameter, localized inside a giant pancreatic pseudocyst (Figure A). Ultimately, as the patient was a poor surgical candidate we decided to treat him using endovascular therapy. Arterial catheterization and angiographic evaluation of the superior mesenteric artery pseudoaneurysm was performed, showing active contrast agent extravasation treated by a fully covered stent placement (Figure B). The final angiogram confirmed the the success of the intervention. The postoperative course was uneventful and the patient was discharged on the 8^th postoperative day.
Conclusions: In conclusion, physicians should keep alert to this rare etiology of haemobilia. It is of utmost importance to urgently manage SMA pseudoaneurysms because of the high risk of rupture and potential life-threatening haemorrhage.

References

1. Guirgis M, Xu JH, Kaard A, Mwipatayi BP. Spontaneous Superior Mesenteric Artery Branch Pseudoaneurysm: A Rare Case Report. EJVES Short Rep. 2017 Oct 12;37:1-4.
2. Patelis N, Doukas P, Dodos I, Karampelas T, Kanellopoulos I, Kyriakopoulou K, Bisdas T. Endovascular Repair of a Complex Isolated Dissecting Aneurysm of the Superior Mesenteric Artery. EJVES Short Rep. 2019 Jun 17;44:5-8.
3. Kochar S, Sharparis Y, Banerjee B, Karasek M, Brennan S. Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm. Cureus. 2021 Sep 16;13(9):e18014.
4. Camarasa Pérez Á, Soto Sánchez A, Pérez Sánchez E, Hernández Barroso M, Hernández Hernández G, Barrera Gómez M. Obstructive jaundice secondary to a pseudoaneurysm of the superior mesenteric artery. Rev Esp Enferm Dig. 2022 Dec;114(12):756.
5. Kimbara Y, Sato Y, Hasegawa T, Morinaga H, Murata S, Imai Y, Hara K, Okuno N, Inaba Y. Covered stent placement for emergency repair of a ruptured superior mesenteric artery pseudoaneurysm in advanced pancreatic head cancer. Radiol Case Rep. 2018 Oct 29;14(1):133-135.
6. Dávila Arias C, Ruiz-Rodríguez AJ, Cabrera Peña Á. Hematochezia secondary to hemosuccus pancreaticus due to a pseudoaneurysm associated with a pancreatic pseudocyst. Rev Esp Enferm Dig. 2021 Aug;113(8):618.

Introduction

Pancreatic walled-off necrosis (WON) presents a significant challenge in acute pancreatitis management, often necessitating endoscopic intervention for drainage and necrosectomy. However, the optimal selection of stent type for endoscopic drainage remains debatable. This study aimed to evaluate the utility of the QNI classification in guiding stent selection for WON drainage.

Aims & Methods

We conducted a retrospective analysis of patients who underwent endoscopic drainage and necrosectomy for symptomatic pancreatic WON at a tertiary referral center between January 2022 and September 2023. Patients were divided into two groups based on the QNI classification: Group 1 consisted of patients who had WON affecting 1 quadrant or 2 quadrants with a necrosis of less than 30%. Group 2 consisted of patients whose WON had affected 3 quadrants, 2 quadrants with 30% necrosis, or 1 quadrant with more than 60% necrosis at the time of the index procedure. A WON-based decision was made by the endoscopist regarding the use of LAMS or plastic stents. Necrosectomy was performed in cases of infection following WON drainage. Resolution was considered in clinically asymptomatic patients with WON < 30 mm at the 3-month imaging follow-up.

Results

Forty-eight patients were included in the study, with a mean age of 55.7 (±12.28) and a male-to-female ratio of 2.4:1, 20 patients in Group 1 and 28 patients in Group 2. Except for infection, which occurred more frequently in Group 2, the indications for drainage (pain, weight loss) were similar between the two groups (28% vs 5%, p=0.03). LAMS were used more frequently in group 2 than in group 1 (64% vs 40%, p=0.001). The mean number of endoscopic procedures in Group 1 was 1.7 and in Group 2 it was 3. The interval between endoscopic procedures in Group 1 and Group 2 was 20.3 days and 12.4 days, respectively (p=0.05). Clinical resolution at 3 months showed no significant difference between groups, with rates of 90% vs 85% (p=0.87), and the complication rates was 10% vs 14.2% (p=NS). Percutaneous drainage was done in 0% vs 7.14% cases, and surgery was required in 0% vs 7.1% of cases.

Conclusion

As a result of the newly proposed QNI classification system, patients can be guided in the selection of LAMS placement as well as for multidisciplinary management. Severe QNI scores may need more aggressive interventions, yet outcomes are comparable to those with milder disease.

References

Baroud, S., Chandrasekhara, V., Storm, A. C., Law, R. J., Vargas, E. J., Levy, M. J., Mahmoud, T., Bazerbachi, F., Bofill-Garcia, A., Ghazi, R., Maselli, D. B., Martin, J. A., Vege, S. S., Takahashi, N., Petersen, B. T., Topazian, M. D., & Abu Dayyeh, B. K. (2023). Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework. Gastrointestinal endoscopy, 97(2), 300–308.

Clinical Case Summary

Pancreas divisum is the most frequent pancreatic congenital malformation and results from the failure of fusion of the dorsal and ventral pancreatic ducts during embryogenesis. In these cases, most of the pancreatic exocrine secretion is drained into the duodenum predominantly by the Santorini duct through the minor papilla. It is estimated that 5% of patients with pancreas divisum may present with symptoms, due to raised intrapancreatic dorsal ductal pressure from ductal anomalies.
The authors report a case of a 73-year-old male patient with a history of 6 admissions for acute pancreatitis in the last 12 months. These episodes were of mild severity, without cholestasis or alterations in lipid panel or serum calcium. He had no history of alcohol consumption, neither medication, nor herbal products or drug use. He denied a family history of pancreatic diseases. Between episodes of acute pancreatitis, he was asymptomatic. Magnetic Resonance Cholangiopancreatography showed a tortuous pancreatic duct with prominent caliber, with preferential drainage through the minor papilla (confirming pancreas divisum). Endoscopic ultrasound showed a diffusely dilated and tortuouspancreatic duct. Endoscopic retrograde cholangiopancreatography was performed, with successful sphincterotomy of the minor papilla and placement a pancreatic plastic stent in the Santorini duct. No complications were recorded during the procedure or the subsequent 24-hour clinical monitoring period. Two weeks after the procedure, radiographic control was performed to rule out migration of the pancreatic stent, and its endoscopic removal was accomplished. At 6 months of follow-up, the patient remained asymptomatic, without new episodes of acute pancreatitis.
This case report aims to emphasize that endotherapy for pancreas divisum, including minor papilla sphincterotomy and stenting of dorsal pancreatic duct, allows for improvement of pancreatic ductal drainage and prevention of acute pancreatitis episodes

References

Image list:

1. A tortuous pancreatic duct with prominent caliber (6mm diameter in the cephalic region), with preferential drainage through the minor papilla (Magnetic Resonance Cholangiopancreatography).
2. A diffusely dilated and tortuous Wirsung duct (Endoscopic ultrasound).
3. Successful sphincterotomy of the minor papilla and placement of a 5 Fr x 5 cm pancreatic platic stent in the Santorini duct (Endoscopic retrograde cholangiopancreatography).

Clinical Case Summary

For decompensated advanced chronic liver disease (dACLD) individuals, the onset of refractory ascites (RA) represents a dramatic event (6-month survival rate < 50%). In this setting, a relevant proportion of RA patients develop Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI) with limited therapeutic and survival chances.
An 81-year-old female dACLD RA patient was admitted to our department to receive large-volume paracentesis (LVP). Eradicated HCV infection, type II diabetes, and chronic obstructive pulmonary disease were her comorbidities.
The AKI onset imposed the intravenous (i.v.) human albumin (HA) (1 g/kg/die) administration, followed by the proper dosage of terlipressin (for HRS-AKI) within the first 72 hours (h), subsequently discontinued due to the persistence of anuria and the worsening of respiratory failure.
To simultaneously address uremic symptoms and facilitate ascites drainage, a Tenckhoff catheter was placed, and peritoneal dialysis (PD) started with a single icodextrin dwell, resulting in the removal of 14 L of ascites and an improvement in AKI within the subsequent 72h. After one week, she was discharged, receiving a specific PD schedule. After the readmission due to the difficulties in administering i.v. HA, we proposed administering HA via the intraperitoneal route, creating an HA-enriched PD (PD+HA) home-performable schedule by adding two vials of 100 ml of HA 20% to 800 ml of icodextrin solution (40 g in 1000 ml/die; lasting: 12 hours; frequency: every other day) (Figure 1).
The patient has been performing this PD schedule for 12 months (~0.5 L of ascites is discharged every other day before performing PD+HA dwell). During the follow-up, no PD-related complications (e.g., peritonitis) and liver-related events requiring hospitalization have been observed.
We report the first successful use of PD+HA, highlighting the cruciality of a multidisciplinary (hepatologists-nephrologists) approach in the management of dACLD-RA HRS-AKI patients.

References

1. Moreau, R.; Delègue, P.; Pessione, F.; Hillaire, S.; Durand, F.; Lebrec, D.; Valla, D.-C. Clinical Characteristics and Outcome of Patients with Cirrhosis and Refractory Ascites. Liver Int 2004, 24, 457–464, doi:10.1111/j.1478-3231.2004.0991.x.
2. Moore, K.P.; Wong, F.; Gines, P.; Bernardi, M.; Ochs, A.; Salerno, F.; Angeli, P.; Porayko, M.; Moreau, R.; Garcia-Tsao, G.; et al. The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club. Hepatology 2003, 38, 258–266, doi:10.1053/jhep.2003.50315.
3. Nadim, M.K.; Kellum, J.A.; Forni, L.; Francoz, C.; Asrani, S.K.; Ostermann, M.; Allegretti, A.S.; Neyra, J.A.; Olson, J.C.; Piano, S.; et al. Acute Kidney Injury in Patients with Cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) Joint Multidisciplinary Consensus Meeting. J Hepatol 2024, 81, 163–183, doi:10.1016/j.jhep.2024.03.031
4. Brown, E.A.; Blake, P.G.; Boudville, N.; Davies, S.; de Arteaga, J.; Dong, J.; Finkelstein, F.; Foo, M.; Hurst, H.; Johnson, D.W.; et al. International Society for Peritoneal Dialysis Practice Recommendations: Prescribing High-Quality Goal-Directed Peritoneal Dialysis. Perit Dial Int 2020, 40, 244–253, doi:10.1177/0896860819895364.