ECHOENDOSCOPIC DRAINAGE WITH LUMENAL APPOSITION METAL STENT (LAMS) FOR INCRISATED PANCREATIC NECROSIS IN A PATIENT WITH POST COMPLICATED ACUTE ETHANOLIC PANCREATITIS

ECHOENDOSCOPIC DRAINAGE WITH LUMENAL APPOSITION METAL STENT (LAMS) FOR INCRISATED PANCREATIC NECROSIS IN A PATIENT WITH POST COMPLICATED ACUTE ETHANOLIC PANCREATITIS

Dr. Bondar Ilie Iolanda, Dr. Balaban Daniel Vasile, Dr. Coman Laura, Dr. Nedelcu Ioan Cristian, Dr. Bețianu Cezar, Dr. Nuță Ionel Petruț, Prof. Dr. Săftoiu Adrian, Prof. Dr. Jinga Mariana

We present the case of a 42-year-old male patient, who suffered in October 2021 an episode of acute necrotizing pancreatitis (AP) associated with chronic ethanol consumption, after which he developed multiple collections of closed necrosis type, with compressive effect on the gastric lumen and the main bile duct (CBP), thus requiring echoendoscopic drainage with a Lumen Apposing Metal Stent (LAMS) and endoscopic retrograde cholangio-pancreatography (ERCP) with biliary stent placement.

From the personal pathological antecedents and risk factors, we note obstructive left renal lithiasis with a Cook stent in situ, tobacco use (20PA) and chronic ethanol consumption (5 units/day).

2 months after the onset of PA, the patient presented to our clinic with sclero-integumentary jaundice, upper abdominal pain and early satiety. The biological evaluation revealed an important inflammatory syndrome (Fibrinogen 700 mg/d, CRP 68 mg/L, ESR=80 mm h), cholestasis syndrome (Total bilirubin 14.63 mg/dl, Direct bilirubin 10.39 mg/dl, Gamma-glutamyltransferase 1817 U /l, Alkaline Phosphatase 1270 U/L), cytolysis syndrome (ALT 131 U/l, AST 146 U/l), mixed dyslipidemia (Cholesterol 541 mg/dl, Triglycerides 240 mg/dl), increased pancreatic enzymes (Amylase 208 U/l, Lipase 138 U/l) and increased CA 19-9 (113 U/ml), and the endoscopic examination revealed extrinsic compression at the antral level and at the level of the duodenal bulb. Imaging (CT) showed mature peripancreatic collections – one inter-pancreato-gastric (17/19 cm), inhomogeneous content with detritus and necrosis, diffused inferiorly to the left iliac fossa subfascially at the level of the psoas muscle; one pericephalic pancreatic septate and fused inferiorly along the perirenal fascia (11/6.5 cm); Dilated CBP with progressive decalibration at the cephalic pancreatic level. (Photo 1 and 2). Cholangio-MR examination revealed voluminous fluid collections, important dilatation of CBIH and CBEH, pancreatic precephalic choledochus of 2 cm in diameter, with non-specific intracephalic effusion. (Photo 3)

In the context of Walled-off Pancreatic Necrosis (WOPN) collections secondary to an AP episode, the opportunity of EUS-guided endoscopic drainage of the corporeal-caudal pancreatic collection by mounting a lumenal apposition metal stent (LAMS) was discussed.

Echoendoscopy was performed under general anesthesia with oro-tracheal intubation, which revealed the voluminous retrogastric fluid collection (Photo 4) with inhomogeneous content and hyperechoic detritus. It was verified that the distance between the collection and the contact area with the gastric lumen was not greater than 10 mm, and the interposition of large-caliber vessels was assessed by Doppler mode. The collection was punctured and a LAMS HotAxios stent (10/15 mm) was placed (Photo 5, 6, 7) with the evacuation of 1400 ml of brown-brown liquid.

In dynamics, ERCP was also performed – CBP was selectively cannulated and the cholangiogram showed CBP dilated up to about 15mm, with filiform stenosis on the last 4 cm distal (probably due to extrinsic compression given by the peripancreatic collection). A plastic biliary stent of 10 Fr/7 cm is mounted with efficient biliary drainage (Photo 8). On successive days, 2 necrosectomy sessions were performed.

The evolution after biliary and endoscopic drainage was favorable, with the resumption of digestive tolerance and the marked improvement of cholestasis samples-Total bilirubin 2.89 mg/dl, Direct bilirubin 1.88 mg/dl, Gamma-glutamyltransferase 430 U/l, Alkaline phosphatase 306 U/L , with the normalization of liver cytolysis enzymes (ALT 18 U/l, AST 17 U/l) and pancreatic enzymes (Amylase 77 U/L, lipase 57 U/L).

3 weeks after installation, the LAMS stent was extracted using a polypectomy loop (Photos 9 and 10). Two 5 cm/10 Fr double pigtail plastic stents were mounted on the cystogastrostomy incision (Photo 11). Control imaging (CT) revealed a significant reduction in the size of the collections (PHOTO 12, 13, 14).

Later, 2.5 months after the time of endoscopic drainage, the imaging re-evaluation revealed the marked reduction to disappearance of the peripancreatic collections, and at this time the biliary stent was also extracted.

DISCUSSIONS

In the evolution of PA cysts, collections that appear in the first 4 weeks after onset are classified into acute fluid collections and acute post-necrotic collections. At a distance, usually at least 4 weeks after the PA episode, maturation of the peripancreatic collections occurs, thus:

 Acute fluid collections mature into pseudoschists – encapsulated lesions, with homogeneous content, without detritus inside.

 Acute post-necrotic collections mature into closed necrotic collections/Walled-off pancreatic necrosis (WON) – encapsulated lesions, with heterogeneous content due to the presence of necrotic detritus, which can be loculated.

Indications for drainage of peripancreatic collections vary depending on the presence of local/systemic symptoms and the presence of signs of infection:

• Early < 2 weeks from PA onset in case of: persistent organ failure, collection infection (more common in necrotic collections, associated with increased mortality), compression on adjacent organs with intra-abdominal compartment syndrome (p > 20 mmHg) .

• Late > 4 weeks from the onset of PA in case of: pain, local compression, nausea/vomiting, nutritional deficiency, presence of fistulas, persistence of the inflammatory syndrome.

In the absence of early complications, late drainage is preferable, because in this interval the maturation of the cyst and the development of the walls of the collection take place!

Depending on the location, the type of collections and the percentage of necrotic/tissue material inside them, the optimal minimally invasive drainage technique/techniques will be chosen.

For collections with a predominantly liquid content, the use of double pigtail plastic stents (preferably multiple) is recommended, and in the case of collections with a solid content > 20%, the use of LAMS stents is recommended. In addition, there is the possibility of using some combined drainage techniques (transpapillary drainage, combined endoscopic or endoscopic + transcutaneous techniques) – the so-called “multi-gateway” or “multi-modality drainage” approach.

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