What could have caused the axio(stent) to fail, leading to sepsis, pleural effusion, and pancreatic abscess with necrotic tissue, and could it happen again?

From the Guidelines

The failure of your Axios stent likely resulted from infection of the pseudocyst despite prophylactic antibiotics, leading to complications including sepsis, pleural effusion, and pancreatic abscess with necrotic tissue, and recurrence is possible if any necrotic tissue remains or if the underlying cause of your pseudocyst persists. This complication can occur in approximately 5-15% of pancreatic drainage procedures, as pseudocysts containing solid debris or infected material can be challenging to drain completely with stents alone, and bacteria can colonize the stent despite prophylactic antibiotics 1.

Causes of Stent Failure

The initial failure likely occurred because pseudocysts containing solid debris or infected material can be challenging to drain completely with stents alone, and bacteria can colonize the stent despite prophylactic antibiotics. According to the 2019 WSES guidelines for the management of severe acute pancreatitis, interventions for necrotizing pancreatitis should preferably be done when the necrosis has become walled-off, usually after 4 weeks after the onset of the disease 1.

Prevention of Recurrence

To prevent recurrence, it is essential to:

• Complete the full course of antibiotics
• Attend all follow-up appointments for stent evaluation and possible removal
• Maintain good nutrition to support healing
• Avoid alcohol completely
• Report any symptoms like fever, chills, increased pain, or drainage immediately to your doctor The successful debridement sessions to remove necrotic tissue were crucial for treatment, as this material can harbor infection and prevent proper drainage 1.

Management of Infected Necrosis

The 2019 WSES guidelines recommend that antibiotics are always used to treat infected severe acute pancreatitis, and serum measurements of procalcitonin (PCT) may be valuable in predicting the risk of developing infected pancreatic necrosis 1. A CT-guided fine-needle aspiration (FNA) for Gram stain and culture can confirm an infected severe acute pancreatitis and drive antibiotic therapy, but is no longer in routine use 1.

Key Takeaways

• The failure of the Axios stent was likely due to infection of the pseudocyst despite prophylactic antibiotics
• Recurrence is possible if any necrotic tissue remains or if the underlying cause of the pseudocyst persists
• Prevention of recurrence requires completing the full course of antibiotics, attending follow-up appointments, maintaining good nutrition, avoiding alcohol, and reporting any symptoms immediately
• Management of infected necrosis involves the use of antibiotics, and serum measurements of PCT may be valuable in predicting the risk of developing infected pancreatic necrosis 1.

From the Research

Possible Causes of Axio(stent) Failure

• The axio(stent) failure could be attributed to various factors, including the complexity of the pancreatic ductal anatomy, which may have made stent insertion technically difficult 2.
• The failure to deploy the stent successfully may have led to an increased risk of post-ERCP pancreatitis, as seen in a study where unsuccessful pancreatic stent insertion was associated with a high risk of pancreatitis 2.
• The use of a conventional technique for stent insertion may have contributed to the failure, as a modified technique was shown to be more effective in achieving successful stent placement 2.
• The presence of necrotic tissue and infected acute necrotic collection (ANC) may have also played a role in the failure of the axio(stent), as these conditions can be challenging to manage and may require a combination of endoscopic and surgical interventions 3, 4.

Risk of Recurrence

• The risk of recurrence of axio(stent) failure and subsequent complications such as sepsis, pleural effusion, and pancreatic abscess with necrotic tissue may be influenced by various factors, including the underlying cause of the pancreatitis, the presence of infected necrosis, and the effectiveness of the treatment strategy 3, 4.
• A study on the clinical course of patients with severe pancreatitis found that the mortality rate was low, but the risk of recurrence and complications was significant, highlighting the need for close monitoring and follow-up 4.
• The use of endoscopic ultrasonography (EUS)-guided aspiration and lavage, combined with late endoscopic retrograde cholangiopancreatography (ERCP) catheter drainage, may be an effective approach for managing infected ANCs and reducing the risk of recurrence 3.

Comparison with Other Studies

• A study on the endoscopic drainage of giant pancreatic pseudocysts using both lumen-apposing metal stent and plastic stent found that the procedure was effective in resolving the pseudocysts with excellent outcomes and no history of recurrence or complications on follow-up 5.
• Another study on failed coronary stent deployment found that the incidence of failed deployment was significant, and the consequences were severe, including an overall in-hospital adverse outcome in 19% of patients 6.