Preliminary experience of EUS-guided pancreatic fluid collections drainage using a new lumen-apposing metal stent mounted on a cautery device

Dear Editors, EUS-guided drainage represents the standard of care modality for treatment of pancreatic and peri-pancreatic fluid collections (PFCs). The choice of the stent to place to perform drainage remains controversial and both plastic and metal stents have been widely utilized. Specifically designed fully covered lumen-apposing metal stents (LAMSs) able to create a stable anastomosis between adjacent organs/cavities have been developed. Furthermore, the creation of an electrocautery tip (Hot-Axios™, Boston Scientific, Marlborough, Massachusetts, USA) has allowed placement of the stent in a one-step procedure, avoiding use of multiple devices and reducing overall procedural complexity. Various meta-analyses comparing LAMSs versus plastic stents for all type of PFCs have suggested LAMSs to be superior to plastic stents for both PC and WON.[12] A similar device, the Hot-Spaxus™ (Taewoong Medical Co., Gimpo, Korea), has been recently developed in which the previously created LAMS Niti-S Spaxus™ has been incorporated in a delivery system with cautery capability on its tip.[3] We, herein, report our experience with the Hot-Spaxus™ in eight patients (mean age 55.8 ± 9.7 years), with WON with ≥30% of necrotic content (six patients) and pseudocyst (two patients). The median PFCs size was 112.5 mm (range 58–200 mm). A 16-mm and a 10-mm caliber stents were, respectively, used in six and two cases, with stent deployment performed transgastrically with or without fluoroscopy in six and two cases. Technical success was obtained in all cases. Subsequent endoscopic direct necrosectomy was needed in two patients. Median stent indwelling time was 31.5 days (range 12–60 days). No AEs were observed, and PFC resolution was obtained in all cases, which persisted in the long-term follow-up in all but one patient (87.5%). Median hospital stay was 10 days (range 3–71). Our preliminary experience with the Hot-Spaxus™ for PFCs drainage showed technical and clinical success in all eight treated patients, with one case of PFC recurrence on long-term follow-up. No AEs, including bleeding or stent migration during necrosectomy were observed.[3] In patients treated with Hot-Axios™, bleeding has been reported to occur in up to 9.7% of the cases often requiring coil embolization placement by interventional radiology.4 The different design of Hot-Spaxus™ with rounded edges and flanges that fold back, allowing accommodable apposition of the two lumens should theoretically reduce intracavity bleeding risk, which occurs when the collection is shrinking. For the same stent characteristics, the so-called buried stent phenomenon should also be reduced.[5] Conversely, release of the Hot-Spaxus™ stent once inside the collection is similar to that of standard biliary metal stents and requires a tight cooperation between endoscopist and assistant. For all of us, who were accustomed to the endoscopist-driven stent release system of the Hot-Axios™, it took at least a couple of procedures to become more familiar with this system. Our experience shows that the newly designed Hot-Spaxus™ with cystotome capabilities seems safe, technically and clinically effective for the treatment of PFCs, at least from the stomach. The design of the stent may theoretically reduce risk of AEs in particular bleeding. Large prospective studies are warranted to confirm our preliminary findings. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Alberto Larghi is an editorial board member of the journal and Paolo Giorgio Arcidiacono is an associate editor. The article was subject to the journal's standard procedures, with peer review handled independently of these editors and their research groups.