AXIOS STENTS: TRANSFORMING THE MANAGEMENT OF PANCREATIC FLUID COLLECTIONS

Pancreatic fluid collections (PFCs) are frequent complications of acute pancreatitis. These are divided into 4 subtypes as per the revised Atlanta classification: acute peri-pancreatic fluid collections (APFC) and acute necrotic collections (ANC) when occurring less than 4 weeks following an episode of acute pancreatitis; pseudocysts and walled-off pancreatic necrosis (WOPN) if greater than 4 weeks interval.

Classically the management of PFCs involved open cyst-gastrostomy and/or necrosectomy. However, following the landmark PANTER trial¹ the focus has shifted to less invasive interventions. This Dutch study reported that a minimally-invasive ‘step-up’ approach was superior to open surgery in patients with acute necrotising pancreatitis. More recently, the TENSION multi-centre randomized control trial² has shown endoscopic transluminal stenting to be a viable alternative to percutaneous drainage, with lower rates of pancreatic fistula, shorter length of hospital stay and at a lower overall cost.

The evidence from these trials has been incorporated into the management of complicated pancreatitis at the regional Hepatobiliary unit in Belfast with the recent introduction of lumen-apposing self-expandable AXIOS stents. These stents are inserted under endoscopic ultrasound guidance and enable PFCs to be drained into the stomach; they incorporate a dual flange that prevents migration, and once placed can function as a port to facilitate debridement and irrigation.

In a recent study of 45 consecutive patients who underwent AXIOS stent placement in the Belfast Trust, the procedure was noted to be technically successful in 43 cases (95.6%) and clinically successful in 33 cases (73.3%). Only 5 patients (11.1%) required further surgical management within 40 days of stent removal. Overall the results have shown that AXIOS stents are an effective first line management of PFCs, avoiding the need for more invasive surgical procedures.