Juan J. Vila, MD, from the Biliary and Pancreatic Diseases Unit, Endoscopy Unit, Complejo Hospitalario de Navarra in Pamplona, Spain presents this VideoGIE case, “EUS-guided transgastric drainage of a peripancreatic collection containing an arterial bypass graft.”
This video case describes drainage of an infected pancreatic collection in a patient with previous abdominal vascular surgery because of aortic dissection and superior mesenteric artery thrombosis. This patient underwent placement of an arterial bypass graft with subsequent acute pancreatitis and development of a peripancreatic infected collection after surgery. Conservative and percutaneous treatment failed to definitively solve the collection and the patient was considered to have unacceptable risk for additional surgery, so endoscopic drainage was offered.
The endoscopic technique in this patient was similar to any other collection drainage procedures, except for the presence of the arterial bypass floating inside the collection. We considered that the risk of bleeding during the procedure was under control thanks to the ultrasonographic guidance, so we oriented the puncture and stent placement away from the bypass. But we had two main concerns regarding this case. First, to erode the bypass by the stent as the collection progressively collapsed causing a fatal bleeding. In order to prevent this risk, we tried to shorten the drainage period as much as possible and the stent was retrieved after four weeks. And secondly, it is standard practice to replace surgically an infected vascular graft since it is assumed that more conservative measures will not achieve complete clearance of bacterial infection. Since in our case surgeons dismissed this option, we knew we could solve the collection, but we were not confident to solve the infection. As a consequence, we completed a lengthy collection lavage through the nasocystic catheter. Clinical evolution was good and the patient has remained asymptomatic after fifteen months follow up but for an isolated episode of bacteremia managed with antibiotics.
Therapeutic endoscopic ultrasound (TEUS) has experienced a great progress in the last years and has become the standard of care for common clinical situations such as peripancreatic collection or abscess drainage. Endoscopic ultrasound guided transmural biliary and pancreatic duct drainage is also a therapeutic alternative in those patients with failed ERCP. Vascular indications for TEUS are also increasing. We have described positive experiences with TEUS for treatment of Dieulafoy lesions, gastric varicces, and bledding tumours in previous publications. In our opinion, TEUS is a promising tool for vascular indications and will experience a great advance in the next few years.
We have shown with this case that collections with vascular involvement can be successfully managed with TEUS in selected cases, achieving better results than other therapeutic alternatives. In any form, the therapeutic approach in such complex cases must be agreed with clinicians, surgeons and radiologists, and in the last term, with patients.
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