Pediatric application of a lumen-apposing metal stent for transgastric pancreatic abscess drainage and subsequent necrosectomy.

A 14-year-old boy presented to our care with severe necrotizing pancreatitis secondary to a psychiatric medication. He had developed walled-off pancreas necrosis (WOPN) in the body of the pancreas that had become infected, as evidenced by air within a 10-cm collection on computed tomography (CT) scanning, fevers to 102°F, tachycardia, and leukocytosis. The CT scan showed the collection had a mature wall that abutted the stomach (●" Fig.1). Endoscopic ultrasound (EUS)guided (GF-UCT180; Olympus America, Center Valley, Pennsylvania, USA) transgastric drainage was therefore performed in the endoscopy suite with carbon dioxide insufflation being used. First, a cystogastrostomy tract was created and dilated under endoscopic and fluoroscopic guidance, after which a 10-mm lumen-apposing metal stent (AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) was placed. The stent drained 1000mL of frank pus that was suctioned out, which was consistent with the collection being an abscess (●" Fig.2;●" Video 1). The patient’s fever, tachycardia, and leukocytosis resolved. After 1 week the patient returned for endoscopic necrosectomy to be performed through the stent (●" Fig.3a). Necrotic debris was removed from the pancreatic cavity using a grasper, Roth net, and snare (●" Fig.3b). Only one endoscopic necrosectomy session was required to clean the pancreatic collectionofdebris. Subsequent imaging 6 weeks later showed resolution of the WOPN (●" Fig.4) and, 8 weeks after its initial placement, the stent was removed endoscopically. The patient continues to dowell. This case demonstrates that a lumenapposing metal stent can be used safely in the pediatric population for pancreatic abscess drainage and subsequent necrosectomy. Recently fully covered lumenapposing metal stents have been created for drainage of pancreatic collections [1]. There is limited literature on the use of these stents in the pediatric population with, to our knowledge, only one case having been reported in the literature [2]. This case adds to the pediatric literature Fig.2 Endoscopic view showing frank pus draining through the lumen-apposing metal stent into the stomach. Fig.1 Computed tomography (CT) scan showing the pancreatic collection (arrow) abutting the stomach prior to endoscopic drainage.