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Short Communications: Gastroenterology

Use of Lumen-apposing Metal Stents for Endoscopic Drainage of Intra-abdominal Fluid Collections in Pediatric Patients

Costa, Peter A.; Ho, Sammy; Manvar, Amar; Rivas, Yolanda; Novak, Inna

Author Information
Journal of Pediatric Gastroenterology and Nutrition: February 2020 - Volume 70 - Issue 2 - p 258-260
doi: 10.1097/MPG.0000000000002538
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Abstract

What Is Known/What Is New

What Is Known

  • Intraabdominal fluid collections, including perirectal abscesses and pancreatic pseudocysts, were traditionally managed surgically or by percutaneous drainage.
  • The use of lumen-apposing metal stents has been shown to be a safe and efficacious less invasive technique to manage these collections in adults.

What Is New

  • Lumen-apposing metal stents are a less invasive method to treat intraabdominal fluid collections in pediatric patients that also allows for endoscopic debridement of the collection.
  • The use of lumen-apposing metal stents can achieve excellent clinical and technical success rates for the treatment of pancreatic pseudocysts and perirectal abscesses in the pediatric population.

Technological advances in endoscopic devices have improved our ability to treat intraabdominal fluid collections that had previously required surgical intervention. Pancreatic pseudocysts and perirectal abscesses can now be drained with less invasive techniques, including the use of lumen-apposing metal stents (LAMS). LAMS have a configuration characterized by 2 flanges which help to avoid stent migration, and they also have a large inner diameter to allow endoscope passage for endoscopic debridement of the cavity (1). The stents were initially designed for the management of pancreatic fluid collections including pancreatic pseudocysts and walled-off pancreatic necrosis. Traditional treatment for this was surgical drainage and/or debridement of necrosis or percutaneous drainage with radiologic guidance. Recent reports in adults demonstrate that advanced endoscopic therapy is an acceptable and safe alternative for management of pancreatic fluid collections (2,3). Several studies show successful resolution of pancreatic fluid collections in adults, including the use of LAMS (4,5). Pediatric gastroenterologists are now beginning to use these advanced endoscopic therapies as well. Case reports are published regarding the use of LAMS for drainage of a pancreatic fluid collection in pediatric patients (6,7). Although originally Food and Drug Administration (FDA) approved for drainage of pancreatic fluid collections, LAMS have recently been used for endoscopic drainage of perirectal abscesses that previously were drained percutaneously by interventional radiologists. One study showed immediate and long-term success in perirectal and perisigmoid abscess endoscopic drainage in adults (8). We have used these stents in the endoscopic treatment of pediatric patients with pancreatic pseudocyst and perirectal abscess. This report aims to evaluate the indications, outcomes, and complications of the use of LAMS for drainage of pancreatic fluid collections and perirectal abscesses in pediatric patients at our institution (Figs. 1 and 2).

F1
FIGURE 1:
Magnetic resonance imaging of pancreatic pseudocyst before and after drainage.
F2
FIGURE 2:
Lumen-apposing metal stents containing drainage from cyst.

METHODS

A retrospective chart review was performed to study the pediatric patients who underwent endoscopic ultrasound (EUS)-guided endoscopic drainage of fluid collections using LAMS at Children's Hospital at Montefiore between 2015 and 2018. Our study was approved by the Albert Einstein College of Medicine Institutional Review Board. Patients up to 18 years of age when diagnosed and treated were included. Patients with symptomatic pancreatic pseudocysts, walled off-pancreatic necrosis, or suspected infected pelvic fluid collections were considered candidates for endoscopic drainage. Seven patients were identified and included in the study.

TECHNIQUE

Patients with pancreatic fluid collections underwent upper endoscopy followed by linear EUS evaluation (PENTAX Medical, HOYA, Tokyo, Japan). Patients with pelvic fluid collections underwent sigmoidoscopy followed by EUS evaluation. For pelvic fluid collections, fluid was aspirated under EUS guidance using 19G FNA-needle to confirm the presence of purulent fluid, which was sent for microbiological analysis. Fluid aspiration was performed for pancreatic fluid collections at the discretion of the endoscopist. Before the advent of electrocautery-enhanced (ECE) LAMS, a 0.035-inch guidewire was advanced into the cavity, and the fistula tract was dilated with a 4-mm balloon for 1 minute. The lumen-apposing metal stent was subsequently deployed under EUS and fluoroscopic guidance. Recent development of ECE LAMS (AXIOS-ECE Boston Scientific, Marlborough, MA) allowed deployment of the stent into the fluid collection without the need for a guidewire or fluoroscopic guidance. For cases in which the ECE-LAMS was used, the lumen of the stent was typically dilated with a 10 to 15 mm CRE balloon, respective to the size of the stent to facilitate drainage. The main outcome measures included technical and clinical success of LAMS placement and adverse events associated with placement or removal of these stents.

RESULTS

Between 2015 and 2018, 7 patients (2 girls) ranging from 9 to 18 years who underwent EUS-assisted drainage of intraabdominal collections using LAMS were identified (Table 1). Four patients had a perirectal abscess postperforated appendicitis, and 3 patients had pancreatic pseudocysts. All patients underwent cross-sectional imaging with either CT or MRI to evaluate collections and determine if endoscopic drainage was feasible. All 4 patients with a perirectal abscess were noted to have fever, whereas none of the patients with pancreatic pseudocyst was febrile. All patients received antibiotics periprocedure. All patients underwent endoscopic and EUS evaluation by the same interventional endoscopist before stent placement. Fluid aspiration was performed for all perirectal collections to confirm presence of purulent fluid. Stents remained in place for 2 to 100 days. The average length of indwelling time for perirectal abscess stent was 14 days and for pancreatic pseudocyst was 72 days. Repeat cross-sectional imaging was performed to ensure resolution of the collection, and stents were then removed endoscopically using a snare. Mucosal defects closed spontaneously. All patients had complete resolution of the collections. Six of the 7 patients had no complication; 1 patient with perirectal abscess had a small amount of bleeding on day 2 after stent placement, for which flexible sigmoidoscopy with endoscopic ultrasound was performed. There was no active bleeding and the collection resolved, so the stent was removed. One patient required debridement of the pseudocyst twice while the stent remained in place. One patient had pancreatic duct disruption, which required a pancreatic duct stent 1 month after placement of the LAMS. None of the patients had recurrence of the collection, and our technical success rate was 100%. Clinical success rate, defined by resolution of symptoms and resolution of the collection on imaging, was 100%.

T1
TABLE 1:
Demographics and clinical summary data for individual patients

DISCUSSION

Validation of EUS-guided drainage of intraabdominal fluid collections using LAMS in adult population has garnered interest in the application of this minimally invasive technique in the pediatric population. Our case series highlights the safety and efficacy of this technique in children. Although the number of patients in our study is limited, we demonstrated high efficacy with technical and clinical success rates of 100%. Minor postprocedure bleeding noted in our youngest patient (9 years) may have been avoided with the use of a smaller device. Development of smaller LAMS may be beneficial in a pediatric population. Larger prospective studies are needed to validate safety and efficacy of LAMS use in pediatric population, particularly off-label use as presented here.

REFERENCES

1. Wrobel PS, Kaplan J, Siddiqui AA. A new lumen-apposing metal stent for endoscopic transluminal drainage of peripancreatic fluid collections. Endosc Ultrasound 2014; 3:203–204.
2. Bakker OJ, van Santvoort HC, van Brunschot S, et al. Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307:1053–1061.
3. Varadarajulu S, Bang JY, Sutton BS, et al. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145:583.e1–590.e1.
4. Shah RJ, Shah JN, Waxman I, et al. Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents. Clin Gastroenterol Hepatol 2015; 13:747–752.
5. Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73:718–726.
6. Giefer MJ, Balmadrid BL. Pediatric application of the lumen-apposing metal stent for pancreatic fluid collections. Gastrointest Endosc 2016; 84:188–189.
7. Trindade AJ, Inamdar S, Bitton S. Pediatric application of a lumen-apposing metal stent for transgastric pancreatic abscess drainage and subsequent necrosectomy. Endoscopy 2016; 48: (Suppl 1): E204–E205.
8. Poincloux L, Caillol F, Allimant C, et al. Long-term outcome of endoscopic ultrasound-guided pelvic abscess drainage: a two-center series. Endoscopy 2017; 49:484–490.
Keywords:

endoscopy; endoscopic drainage; lumen-apposing metal stent (LAMS); pancreatic pseudocyst; pediatric; perirectal abscess

Copyright © 2020 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition