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.
