On-and-off deployment technique of a lumen-apposing metal stent during endoscopic pancreatic necrosectomy
On-and-off deployment technique of a lumen-apposing metal stent during endoscopic pancreatic necrosectomy
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内镜胰腺坏死切除术中管腔对置金属支架的断断续续展开技术
DOI：
10.1055/a-1046-1513
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发表时间：
2019
期刊：
影响因子：
9.3
通讯作者：
Kataoka Hiromi
中科院分区：
文献类型：
--
作者：
Yoshida Michihiro;Naitoh Itaru;Yamada Ruriko;Hayashi Kazuki;Natsume Makoto;Hori Yasuki;Kataoka Hiromi
内镜超声引导下透壁引流（EUS-TMD）与管腔贴壁金属支架（LAMS）和内镜下坏死切除术被广泛认为是壁离性胰腺坏死（WON）的有效治疗方法[1][2][3]。然而，在特定情况下，LAMS成为内镜下坏死切除术的意外分支。此外，坏死切除装置有时会偶然捕获LAMS，这可能导致LAMS迁移。一名35岁男性因坏死性胰腺炎引起的外侧广泛和形状不规则的WON接受了使用15× 10 mm LAMS（AXIOS; Boston Scientific，马尔伯勒，马萨诸塞州，美国）的EUS-TMD（[图1]）。在初始坏死切除术中，LAMS远端被对侧壁堵塞，WON入路被紧紧阻塞，导致内镜下经LAMS推进至腔体失败（[图2]）。为了打开路径，首先用圈套器取出LAMS，并使用5爪钳进行坏死切除术以抓取较大的坏死组织。治疗结束后，使用一种新技术重新部署LAMS，以防止瘘管闭合。使用15 mm圈套器，通过双通道胃镜的通道抓住LAMS的远端凸缘。然后挤压LAMS，将其向后装载到内窥镜的另一个通道中。通过圈套器和推送导管的协同推进，将圈套器抓住的远端凸缘插入WON。近端凸缘在胃腔中完全展开后，抓取圈套器释放远端凸缘以完成LAMS重新展开（[图3]，[视频1]）。这种“开-关”手术总共进行了6次，直到完成内镜下坏死切除术，没有任何并发症。
Endoscopic ultrasound-guided transmural drainage (EUS-TMD) with lumen-apposing metal stent (LAMS) and endoscopic necrosectomy are widely recognized as effective treatments for walled-off pancreatic necrosis (WON)[1][2][3]. However, in particular situations, the LAMS becomes an unexpected encumbrance to endoscopic necrosectomy. Moreover, necrosectomy devices sometimes catch the LAMS incidentally, which might result in LAMS migration.A 35-year-old man underwent EUS-TMD with a 15× 10 mm LAMS (AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) for lateral widespread and irregular-shaped WON caused by necrotizing pancreatitis ([Fig. 1]). On initial necrosectomy, the distal end of the LAMS was clogged by the opposite wall, and WON access was tightly obstructed, resulting in failure of endoscopic trans-LAMS advancement to the cavity ([Fig. 2]). To open the route, the LAMS was first removed with a snare, and necrosectomy was performed using 5-prong forceps to grab the larger necrotic tissues. After the session, the LAMS was redeployed with a novel technique to prevent the fistula from closing. Using a 15-mm snare, the distal flange of the LAMS was grasped through the channel of a two-channel gastroscope. The LAMS was then squeezed to load backward into the other channel of the endoscope. The distal flange grasped by the snare was inserted into the WON by cooperative advancement of the snare and a pusher catheter. After full deployment of the proximal flange in the gastric lumen, the grasping snare released the distal flange to complete LAMS redeployment ([Fig. 3],[Video 1]). This “on-and-off” procedure was performed six times in total until endoscopic necrosectomy was accomplished, without any complications.