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Endoscopic drainage of pancreatic fluid collections has conventionally been a tedious procedure. Endoscopic drainage may be performed with or without the use of EUS. Conventionally, EUS-guided cystogastrostomy involved EUS-guided needle puncture, repurposed devices, and multiple exchanges over a guidewire. A simple single-device technique can facilitate the procedure.
A coaxial lumen-apposing metal stent (LAMS) incorporates a wide stent lumen (15-20 mm: Hot LAMS; Boston Scientific, Marlborough, Mass, USA) and anchoring flanges that maintain the opposition of the collection and gastric wall, holding the stent in position and facilitating subsequent procedures such as necrosectomy. The LAMS with integrated electrocautery (Hot LAMS) enables the transluminal puncture without preceding tract dilation to deliver a wide lumen-apposing stent. In this video (Video 1, available online at www.VideoGIE.org), we demonstrate 4 techniques outlining the evolution of EUS-guided cystogastrostomy creation (Fig. 1):
1.
Conventional multistep procedure with double pigtail plastic stents; this approach involves needle puncture and advancement of a guidewire, over which a balloon or catheter dilation is performed, followed by deployment of 1 or more plastic stents with or without a second guidewire. This technique may also be used for deployment of an esophageal or biliary fully covered self-expandable metal stent.
2.
Cold coaxial LAMS over a guidewire; this approach involves needle puncture and advancement of a guidewire, over which a balloon or catheter dilation is performed, followed by deployment of a LAMS.
3.
LAMS with integrated electrocautery over a guidewire; this approach involves needle puncture and advancement of a guidewire without the need for dilation, followed by LAMS deployment.
4.
LAMS with integrated electrocautery without a guidewire; in this approach, the cystogastrostomy is performed by the use of freehand cautery-assisted puncture and direct advancement of the device into the collection, followed by deployment of the LAMS.
Figure 1A, Balloon dilation of cystogastrostomy tract. B, 2 guidewires in cystogastrostomy tract. C, 2 pigtail plastic stents deployed across the cystogastrostomy tract. D, Hot lumen-apposing metal stent (LAMS) before gastric wall is punctured without use of a guidewire. E, View of operator’s hands during deployment of LAMS. F, Deployment of distal flange of the LAMS under EUS guidance. G, Endoscopic view of proximal flange of the LAMS draining a pancreatic fluid collection. H, Fluoroscopic image of LAMS in position after deployment. I, Sagittal CT image of LAMS in place at follow-up, showing decrease in size of pancreatic fluid collection.
The LAMS with integrated cautery and no guidewire provides a direct method for creation of a cystogastrostomy, using a single device with no needle puncture, no device exchanges, and minimal fluoroscopy exposure. This approach minimizes the duration and complexity of the procedure.
Disclosure
Dr Willingham is a consultant for Oncolys Biopharma and the recipient of research funding to the university from RedPath, Cook Medical, Xlumena, and Boston Scientific. Dr Cai is a consultant for Boston Scientific.
Demonstrative video outlining the evolution of EUS-guided cystogastrostomy, from the conventional multistep procedure with several device exchanges, to a simpler procedure using a coaxial lumen-apposing metal stent with a cautery-enhanced delivery system.
Article info
Publication history
Published online: January 09, 2019
Footnotes
This study was supported in part by a development grant from the Department of Medicine at Emory University School of Medicine.
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