Endoscopic ultrasound-guided transesophageal drainage of a mediastinal pancreatic pseudocyst using a novel lumen-apposing metal stent

There have been a few previous reports of transesophageal endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFC). In these reports the drainage modality has been a single aspiration or deployment of a plastic stent [1] [2] [3] [4]. We report a patient who underwent transesophageal EUS-guided drainage of a mediastinal PFC using a novel lumen-apposing metal stent.

A 37-year-old man with a history of right-sided pneumothorax and four episodes of acute pancreatitis was referred for drainage of a PFC. He was experiencing abdominal pain and cysts of increasing size had been seen on his imaging procedures. Computed tomography (CT) scanning revealed an 80 × 50-mm PFC, which had herniated into the mediastinum adjacent to the lower esophagus.

The PFC was accessed from the lower esophagus using a linear echoendoscope and a novel access device (NAVIX; Xlumena Inc., Mountain View, California, USA) that enables dilation of a tract up to 10 mm and placement of a guide wire. Once the cystoesophagostomy had been created, a fully covered metal stent with bilateral anchor flanges that can appose nonadherent lumens (AXIOS, 10 × 10 mm; Xlumena) was placed across the tract ([Fig. 1], [Fig. 2] and [Video 1]) and 900 mL of fluid was aspirated. An immediate chest radiograph revealed a tension pneumothorax on the right side, which required intercostal drainage. The thoracic surgeon who performed the drainage procedure felt that this was a complication of the orotracheal positive pressure.

Fig. 1 View during endoscopic ultrasound (EUS)-guided placement of a lumen-apposing metal AXIOS stent across the cystoesophagostomy.

Fig. 2 Endoscopic view of the intraluminal end of the stent within the lower esophagus.

By day 7, the patient reported resolution of his abdominal pain and a repeat CT scan revealed a marked reduction in the size of the PFC ([Fig. 3]). The AXIOS stent was removed ([Fig. 4]) and the patient was discharged with marked improvement in the pneumothorax. Follow-up imaging after 6 weeks showed complete resolution of the lesion by both EUS and CT scanning ([Fig. 5]). The patient remains asymptomatic 4 months later.

Fig. 3 Follow-up computed tomography (CT) scan after 7 days showing the AXIOS stent (arrowhead) still in place with significant resolution of the lesion (arrow).

Fig. 4 Endoscopic view of the cystoesophagostomy after the stent had been removed.

Fig. 5 Follow-up endoscopic ultrasound (EUS) image 6 weeks later showing complete resolution of the lesion.

EUS-guided transesophageal drainage of PFCs has become an alternative to surgery or percutaneous drainage [1] [2] [3] [4]. We describe the first case of transesophageal EUS-guided drainage of a PFC using a novel lumen-apposing metal stent. The procedure was technically successful and led to complete resolution of the lesion, although a pneumothorax occurred as an immediate complication.

Endoscopy_UCTN_Code_TTT_1AS_2AC

Transesophageal endoscopic ultrasound (EUS)-guided mediastinal pseudocyst drainage using a lumen-apposing metal AXIOS stent.

• References

• 1 Trevino J, Christein J, Varadarajulu S. EUS-guided transesophageal drainage of peripancreatic fluid collections. Gastrointest Endosc 2009; 70: 793-797
• 2 Saftouia A, Cuirea T, Dumitrescu D et al. Endoscopic ultrasound-guided transesophageal drainage of a mediastinal pancreatic pseudocyst. Endoscopy 2006; 38: 538-539
• 3 Baron TH, Wiersema MJ. EUS-guided transesophageal pancreatic pseudocyst drainage. Gastrointest Endosc 2000; 52: 545-549
• 4 Gupta R, Munoz JC, Garg P et al. Mediastinal pancreatic pseudocyst: a case report and review of the literature. Med Gen Med 2007; 9: 8-13