Introduction

Ultrasound-guided drainage is already a consolidated and advantageous option in relation to percutaneous drainage, as it promotes greater comfort and safety in addition to shorter hospital stays. The luminal apposition stent (LAMS) has further increased the effectiveness and safety of ultrasound-guided drainage, as it has a larger diameter lumen, improving drainage efficiency and enabling intraluminal access with a standard endoscope. Proximal and distal flanges promote a lower stent migration rate. Its main indications are for the drainage of intra-abdominal liquid collections, decompression of obstructed bile ducts, creation of anastomoses or creation of fistulous tracts between organs that can facilitate other specific endoscopic interventions.

Aims & Methods

We report the case of a 43-year-old male patient, victim of a motorcycle x truck collision, initially diagnosed with a clavicle fracture. Opting for conservative treatment, he was discharged from hospital. Thirty days after the accident, he sought medical attention due to pain and increased abdominal volume. Abdominal computed tomography (CT) showed grade III liver laceration, with hepatic subcapsular collections, the largest measuring 21x18x12cm, in addition to a collection next to the hepatocholedocus suggestive of biliary fistula.

Results

We opted for endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound-guided drainage of the collections. During ERCP, papillotomy was performed to correct the proximal biliary fistula. During ultrasound endoscopy, a subcapsular lesion was assessed in close contact with the gastric wall, followed by ultrasound-guided drainage using LAMS. There was drainage of 3,000mL of hematic-purulent content. Endoscopic control after 7 days revealed improvement in the capsular pattern. On the 14th day of evolution, the LAMS was removed, followed using 2 double-pigtail stents to maintain residual drainage. Two CT scans were performed 30 and 60 days after the procedure, with complete resolution of the collection observed on the last CT scan.

Conclusion

Several cases are reported in the literature of the use of LAMS for drainage of intra-abdominal collections, however, for subcapsular lesions, only one reported case was found and, like ours, there was a satisfactory result. The use of LAMS for this type of intervention is uncommon, but it suggests that it is an effective alternative. Prospective studies are needed to better evaluate the efficacy of LAMS in hepatic subcapsular lesions.

Introduction

The vacuum-assisted closure stent (VAC-stent) is a novel approach for managing esophageal defects, combining endoscopic vacuum therapy (EVT) and metal stent support to promote effective tissue healing [1].
We present a case of esophageal perforation following circumferential Endoscopic Submucosal Dissection (ESD), successfully managed with a VAC-Stent (video 1).

Aims & Methods

We report a case of a 59-year-old man with a 40mm lesion involving 75% of the esophageal circumference (Paris 0-IIa + Is), arising in Barrett’s esophagus (Prague C4M5) and consistent with adenocarcinoma, who was referred to our unit. CT scans excluded metastatic disease, and after multidisciplinary consultation, ESD was planned.

Results

Circumferential ESD was performed using a triple-tunnel approach. After the resection, muscular tears were closed with through-the-scope (TTS) clips, and pre-emptive Endoscopic Vacuum Therapy (EVT) was applied to enhance granulation and healing.
Due to rising inflammatory markers and fever onset, an esophagogastroduodenoscopy (EGD) was performed on the 3rd Post-Operative Day (POD). The EGD revealed two <5mm perforations 4cm apart, and a VAC-stent was placed to bridge the defects. At the follow-up EGD on the 9th POD, a single defect remained, and a new VAC-Stent was placed. The patient showed progressive clinical improvement and successfully resumed a liquid diet. By the 15th POD, the perforations had healed.
The patient was discharged in good clinical condition on the 18th POD.
At the EGD on the 30th POD, homogeneous healing tissue was observed, with no stricture detected at the resection site.
Histological analysis of the ESD specimen revealed moderately differentiated adenocarcinoma with submucosal invasion: pT1b (sm1) pNX G2, with R0 resection achieved and no high-risk pathological features. An oncological and endoscopic follow-up was planned.

Conclusion

Our case demonstrates that the VAC-Stent is a safe and effective method for treating perforations following esophageal ESD. In cases of circumferential ESD, VAC-stent use may also help prevent strictures.

References

[1]. Dell’Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New “Kid on the Block” Who Marries the Best of Old Techniques—A Review. Journal of Clinical Medicine 2024; 13: 3805. doi:10.3390/jcm13133805

Introduction

A 37-year-old woman was referred to our unit because of typical biliary colics with transient cholestasis. Her relevant medical history included a cholecystectomy and a sleeve gastrectomy, later on converted to a gastric bypass. After multidisciplinary discussion, we opted for an endoscopic ultrasound-directed transgastric ERCP (EDGE) using a 20/10 lumen-apposing metal stent (LAMS). Due to the previous sleeve gastrectomy, the LAMS had to be placed between the jejunum and the excluded antrum. According to international expert recommendations, the ERCP was scheduled two weeks post-LAMS placement to allow for tract maturation [1] . Nevertheless, the proximal flange of the LAMS dislocated during duodenoscope introduction and ended up in the peritoneal cavity. A decompressing needle was placed and the proximal flange was retrieved in the peritoneal cavity under fluoroscopic guidance, using a therapeutic gastroscope. After a non-successful attempt to reposition the proximal flange through the fistula tract in the jejunum, a guidewire was placed through the LAMS lumen in het excluded antrum. A bridging attempt with a 22mm x 10 cm fully covered enteral stent through the LAMS lumen failed. Subsequently, intraperitoneal endoscopic closure of the fistula towards the excluded antrum was performed with the X-tack system.
Next, we removed the LAMS and the enteral stent from the peritoneal cavity and completely sealed the fistula tract from the jejunal side with x-tack endosutures and clips. The patient was put on antibiotics and could start oral feeding the day after the procedure. Besides moderate abdominal pain the first 2 days after the procedure and a transient elevation of the CRP, the further clinical course was uneventful.

Aims & Methods

The rescue intervention was conducted with a gastroscope with 3,8 mm working channel. A 22 x 10 cm fully covered enteral SEMS was used in the attempt of bridging the excluded antrum. X-tack endosuture system was chosen to achieve the closure of the fistula.

Results

The X-tack system proved to be an effective tool in addressing not only the intraluminal perforation but also in the intraperitoneal endoscopic closure of the fistula extending towards the excluded antrum.

Conclusion

This case illustrates the potential of endoscopic suturing devices as minimally invasive alternatives to surgery for management of large iatrogenic perforations.

References

[1] S. Stefanovic et al., “International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process,” Am. J. Gastroenterol., Dec. 2023, doi: 10.14309/ajg.0000000000002571.

Disclosure

Nothing to disclosure

Introduction

Ampullary endoscopic submucosal dissection (ESD) is a technically challenging procedure requiring utmost expertise. Post ESD, access of the common bile duct (CBD) and pancreatic duct (PD) is essential for drainage to prevent pancreatitis, and delayed bleeding and perforation. When the ducts are inaccessible the traditional way, endoscopic ultrasound (EUS) guided rendezvous (RV) can salvage the situation.

Aims & Methods

We present a case where post ampullary ESD, identification of CBD and PD openings was not possible and cannulation was achieved by EUS- RV technique. An 80 year male was referred to our center for management of a duodenal tumor detected incidentally on upper endoscopy. The descending duodenal tumor was a protruding mucosal lesion of around 30mm in size with a thick stalk, and lobular head with regular surface pattern. The ampulla could not be identified separately by forward or side- viewing endoscope (SVE). EUS showed no involvement of CBD or PD. Endoscopic resection was planned using total intravenous anesthesia due to elderly age and comorbidities (hypertension and obstructive lung disease). The tumor location made it unamenable to resection by SVE. Using the forward- viewing endoscope, complete ensnarement of the tumor could not be confirmed as the distal side could not be visualised. Hence, en bloc resection was done by ESD. Clip and line traction was used to overcome the challenges of location, size, and submucosal fibrosis. Post ESD, the visualised opening in the ulcer assumed to be the ampullary opening was confirmed to be a small muscle defect. No other opening could be visualised. The muscle defect was closed with a hemoclip and it was decided to conduct EUS- RV. Analysing a post ESD ulcer in the duodenum, and a non obstructed CBD near the portal vein, a transgastric puncture of extrahepatic hilar bile duct was decided and a guidewire was negotiated antegrade into the duodenum. It revealed an inconspicuous ampullary opening at the edge of the ulcer. A 5Fr nasopancreatic and a 6Fr nasobiliary drain were placed.

Results

Total procedure time (ESD + EUS- RV) was 50 minutes. Specimen measured 28mm X 20 mm. There were no immediate or early complications. Patient was discharged on day six after endonasal tube removal and tolerating a regular diet. Check endoscopy on day six revealed a healing ulcer with healthy granulation tissue. Pathology was tubular adenoma with high grade dysplasia and all margins negative.

Conclusion

Endoscopic retrograde stenting is reported to be fairly easy after ampullary resection due to distinct visibility of the opening. This case highlights an unfamiliar challenge of an obscured post ESD ampullary opening, probably due to being undermined below the edge of the ulcer. This shows a novel indication for EUS- RV. Hence, expert technical skill and equipment in therapeutic EUS along with ESD are imperative to perform ampullary resections.