Pancreatic Necrosectomy Through a Novel Double-flange Lumen-apposing Covered Metal Stent (Video)

Pancreatic fluid collections (PFCs) represent a complication of acute pancreatitis. Endoscopic management of PFCs is an alternative to surgery [1]. Classic strategies include access to the collection under endoscopic ultrasound (EUS)-guidance and placement of several double-pigtail stents. PFCs containing organized necrosis are classified as walled-off necrosis (WON). In those cases necrosis is hardly evacuated and will require necrosectomy in most cases. Every necrosectomy session needs prior removal of the stents, dilatation of the tract, debridement and placement of new stents adding up a considerable overall cost to the intervention. A novel double-flanged lumen-apposing fully-covered self-expandable metal stent (FC-SEMS) with a 15 mm diameter accelerates exit of the necrosis and facilitates multiple necrosectomy sessions.We present a 60 year old patient admitted to the intensive care unit for severe acute pancreatitis that developed WON with superinfection. The intensivists and surgeons indicated endoscopic cystgastrostomy to evacuate the collection. Using the echoendoscope we found a large collection adherent to the gastric wall. The collection was accessed under EUS-guidance using the Hot AXIOS™ catheter that features a cautery tip, then a 15 mm AXIOS™ stent was deployed through the cystgastrostomy orifice to keep it patent. The patient required two necrosectomy sessions to clean the cavity. The WON resolved in 6 weeks and the stent was removed unevently. The patient was discharged.A double flange lumen apposing FC-SEMS used as a port for necrosectomy significantly improves management of walled-off pancreatic necrosis. Placement of this stents should be considered when multiple necrosectomy sessions are anticipated. Procedure time can be significantly decreased using a catheter that combines a cautery tip and stent delivery system.