There has been a great shift in the management of peri – pancreatic fluid collections after acute pancreatitis especially after the refinements in the definition of fluid collections based on the updated Atlanta classification consensus. Recently there is more emerging and supporting evidence of endoscopic ultrasound–guided drainage of pancreatic collections vs a surgical approach. It has become apparent that an endoscopic approach is not inferior to surgical drainage with lower complications and better quality of life compared with surgery. Anatomical location of peri-pancreatic collections can dictate which approach is suitable for drainage. An endoscopic approach is deemed more favourable in centrally located collections.

The first reported case of endoscopic treatment of peri –pancreatic fluid was reported in 1975. This was carried out by using a 22-gauge needle, thereafter many cases have been done in following years.

Endoscopic drainage of peri-pancreatic fluid can be as simple as aspiration to dryness to as far as fistulotomy, naso-cystic catheter drainage, necrosectomy, insertion of plastic pigtail stents or metallic stents and multiple gateway access techniques, as well as the development of EUS specific stent systems

Hot Spaxus is a novel luminal apposing metal stent which fits nicely in the choice of endoscopic ultra-sound guided peri- pancreatic fluid drainage and gallbladder drainage collection.

Hot Spaxus can be utilised for the following indications:

Pancreato-biliary indications

1. Pseudo-cysts
2. Walled off Pancreatic Necrosis
3. Gallbladder empyema drainage
4. Obstructive gallbladder cancer

Other indications

1. Gastro-jejunostomy for benign and malignant conditions (especially for non-surgical candidates): e.g. obstructive distal gastric cancer, refractory pyloric stenosis
2. HotSpaxus can be used to facilitate EUS-guided lumen-apposing metal stent insertion to create a direct trans-enteric ERCP (EDEE), in the de novo creation of an entero-enteric anastomosis for the performance of ERCP in non–Roux-en Y gastric bypass (RYGB) patients.

The cost of HotSpaxus is very attractive when compared with similar stents in the market. The delivery system of the stent is easy and the learning curve is steep and quick.

The Hot Spaxus stent is well visualised on sonographic views and equably visible on fluoroscopy captured images which makes stent deployment safer and increase its success rates.

Variable diameter of the Hot Spaxus stent allows its use in various indications, e.g. bigger diameter stents are very helpful in draining necrotic pancreatic collections

Tips and tricks
Visual guidance on the coloured markings (blue and yellow) on the stent can be very helpful during stent deployment however this can be difficult in case of poor luminal insufflation.

Prior full deployment of the luminal flange (proximal); ideally a cone shaped appearance of the distal flange (cyst side) should be achieved on EUS views prior full deployment to avoid gastric wall deployment.

The use of JAG wire is essential in maintaining access to the collection throughout the procedure. Fluid puncture and stent deployment can be done without the use of JAG wire but this runs the risk of losing access and misses deployment of the Hot Spaxus stent

The absence of retrieval thread can make stent re positioning is difficult in case of miss deployment.

Results to date
Seven cases of peri- pancreatic collection drained using a Hot Spaxus stent, 6 of which were walled off necrosis and one case was a pseudo-cyst. These procedures were done on two sites (RBCH and Poole hospital)

The technical success was 100% for all cases and this was defined by adequate stent position on EUS and fluoroscopic views with immediate drainage achieved.  One case had gastric wall stent deployment but this was rectified by dilating the fistula tract and repositioning the stent using a stent grabber.

No intra procedural complications or delayed complications in all patients. No immediate or delayed haemorrhage noted. No mortality recorded within 30 days from the procedure date.

Radiologically all patients had significant reduction in their collection size on follow up imaging.

We envisage more use of the Hot Spaxus stent for peri –pancreatic collections (pseudo-cysts and walled off necrosis).  We are highly considering the use of Hot Spaxus for gallbladder pathology (obstructed GB).

We are very keen to trial Hot Spaxus in creating enteric anastomosis but this ideally should be done in a research project as more data is required prior to adapting this in our routine clinical practice.

Dr Ghassan El Sayed. MUDR MRCP SCE ESEGH
Consultant Physician & Gastroenterologist

Taewoong Medical are pleased to announce the opening of their online training centre (OTC). This platform has been designed to offer users across the globe the skills and expertise of using Taewoong products. The free to access platform contains a variety of content, in the form of articles, video tutorials, online events showing live cases and more, all designed to give the user confidence in the Taewoong portfolio. Taewoong offers a large range of products designed to give the specialist a choice for their procedure, and this is reflected in the content offered on the platform.

Last month saw a number of informative online events from Taewoong, such as the treatment of benign biliary and post anastomotic strictures, and the management of leaks and fistulas after bariatric surgery. For those that missed the events, the OTC platform offers the chance to watch these back.

To take a look around the OTC visit www.taewoongotc.com and register your details.

Ehsan Hussain,
Territory Manager.