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

Abstract

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 Quality: mobile 360 480 720 Download Transesophageal endoscopic ultrasound (EUS)-guided mediastinal pseudocyst drainage using a lumen-apposing metal AXIOS stent.