Aida Rezaie, MD1, Paul Muna Aguon, MD2, Layth Al-Jashaami, MD2, Natasha Narang, DO2, Shifat Ahmed, MD2, Sarabdeep Mann, MD2, Mustafa A. Alani, MD3, Nael Haddad, MD2, Sakolwan Suchartlikitwong, MD4, Paul Kang, PhD4, Rawad Mounzer, MD5, Teodor Pitea, MD5; 1Banner Good Samaritan Medical Center, Mesa, AZ; 2University of Arizona College of Medicine, Phoenix, AZ; 3St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, Phoenix, AZ; 4Banner Good Samaritan Medical Center, Phoenix, AZ; 5Banner University Medical Center, Phoenix, AZ
Introduction: EUS guided cystenterostomy with lumen-apposing metal stents (LAMS) and endoscopic necrosectomy is now preferred for managing large pancreatic fluid collections (PFCs). Nevertheless, management of walled off necrosis (WON) demands adequate expertise. This study describes our institutional protocol on endoscopic management of WON and pancreatic pseudocyst (PP) using LAMS. Methods: A retrospective analysis was performed on patients with PFCs who underwent EUS-guided drainage with LAMS from January 2015 to December 2019. Following deployment of LAMS, delayed necrosectomy was performed to allow the stent to fully expand. Subsequent necrosectomy sessions were completed until resolution of the PFC. Double-pigtail plastic stents were placed across the cystenterostomy to prevent stent occlusion or fistula closure. Technical and clinical success was measured by adequate resolution of PFC. Results: 94 patients (mean age 53 yrs, 62% male) were included in the study. Average time from initial pancreatitis to LAMS placement was 30 days. Almost 60% of the patients had WON (38 PP, 56 WON). Technical success for LAMS placement was 100%. There were no complications related to the LAMS placement, and 1 reported stent migration due to a delay in stent removal of up to 60 days in a patient with WON lost to follow up. The number of days after initials LAMS to first necrosectomy was 3 days for all PFCs. The average interval time between necrosectomy sessions was 3.5 days for WON, and 4.23 days for PP. The mean number of follow up necrosectomy sessions was 3 (2 PP, 3 WON). LAMS was removed after an average of 21 days (21 PP, 23.5 WON). The average time for all procedures was 29 minutes. Adequate resolution of PFCs without recurrence was achieved in all patients (100%) and confirmed by follow up CT. No patients required additional surgical procedures or percutaneous drainage. Discussion: Based on our data, we recommend considering endoscopic PFC drainage on average at 30 days post pancreatitis and then repeat endoscopic necrosectomy every 3 days until clearance of WON. LAMS should be removed by day 21 or as soon as the WON is cleared of necrosis to prevent bleeding. Placing 2 double-pigtail plastic stent across the cystenterostomy prevents recurrence of PFC by maintaining long term fistula patency. ERCP is not mandatory to assess for pancreatic duct disruption.
Table 1. Pancreatic fluid collection analysis.
Disclosures: Aida Rezaie indicated no relevant financial relationships. Paul Muna Aguon indicated no relevant financial relationships. Layth Al-Jashaami indicated no relevant financial relationships. Natasha Narang indicated no relevant financial relationships. Shifat Ahmed indicated no relevant financial relationships. Sarabdeep Mann indicated no relevant financial relationships. Mustafa Alani indicated no relevant financial relationships. Nael Haddad indicated no relevant financial relationships. Sakolwan Suchartlikitwong indicated no relevant financial relationships. Paul Kang indicated no relevant financial relationships. Rawad Mounzer indicated no relevant financial relationships. Teodor Pitea indicated no relevant financial relationships.