Seguridad y eficacia del drenaje guiado por endosonografía de colecciones pancreáticas usando prótesis plásticas y metálicas tipo LAMS / Safety and efficacy of EUS-guided drainage of pancreatic fluid collections using plastic and lumen apposing metal stents (LAMS)

Background: Pancreatic fluid collections (PFC) are associated with severe acute pancreatitis. After maturation (after 4 weeks) they are classified as pancreatic pseudocyst (PP) and walled-off necrosis (WON). Endoscopic management is associated with lower morbidity and mortality compared with surgery. Aim: To describe the experience of EUS-guided drainage PFC drainage using plastic stent (PS) or metal stent (lumen apposing metal stents, or "LAMS"). Methods: Retrospective, observational study, between 2016-2019. Results: 17 patients in total. 8 cases were symptomatic PP and 9 were WON. Age 12-72 years. 12 cases in men. Indications: abdominal pain 5 cases and infection 11. The 8 cases of PFC were drained successfully using PS, without adverse effects. Regarding WON drainage, 3 cases were managed with PS and 6 with LAMS. In 5 cases, complementary endoscopic necrosectomy was required. A patient with LAMS required complementary surgical cleaning ("step-up") to treat collections far from the LAMS. Complications: one case of PS presented pigment occlusion with superinfection and another case presented migration to the stomach. Regarding LAMS, one case presented self-limited bleeding, another case presented obstruction of the stent with infection, which was managed endoscopically and with antibiotics. Conclusion: The endoscopic management of PFC is effective and safe, with plastic and metal stent (LAMS). The choice of type of stent depends on the characteristics of PFC (liquid vs solid), center experience and costs.

Introducción: Las colecciones pancreáticas (CP) se asocian a pancreatitis agudas graves. Luego de su maduración (después de las 4 semanas) se clasifican en pseudoquistes (PQ) y necrosis encapsulada (NE). El manejo endoscópico se asocia a menor morbimortalidad comparado con el quirúrgico. Objetivo: Describir la experiencia del drenaje de CP mediante el uso de prótesis plásticas (PP) o metálicas (lumen apposing metal stents, o "LAMS") mediante endosonografía. Método: Estudio retrospectivo, observacional, entre 2016-2018. Resultados: 17 pacientes en total. Ocho casos fueron PQ sintomáticos y 9 NE. Edad 12-72 años (12 casos en hombres). Indicaciones: dolor abdominal 5 casos e infección 11. Los 8 casos de PQ fueron drenados exitosamente con PP, sin efectos adversos. En relación con el drenaje de NE, 3 casos fueron manejados con PP y 6 con LAMS. En 5 casos se requirió necrosectomía endoscópica complementaria. Un paciente con LAMS requirió aseo quirúrgico complementario por colecciones alejadas al LAMS. En relación con las complicaciones, un caso de PP presentó oclusión del pigtail con sobreinfección y otro presentó migración al estómago. Respecto a LAMS, un caso presentó sangrado autolimitado y otro caso obstrucción de la prótesis con sobreinfección, que fue manejada endoscópicamente y con antibióticos. Conclusión: El manejo endoscópico de las CP es efectiva y segura, tanto con prótesis plásticas como metálicas (LAMS). La elección de la prótesis depende de las características de la lesión (líquido vs sólido), experiencia del centro y costos.

Pancreatic Fluid Collection Drainage by Endoscopic Ultrasound: An Update

Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage.