Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope

Present and future of endoscopic ultrasonography

Endoscopic ultrasonography and endoscopic ultrasonography-guided fine needle aspiration are well-established techniques, encompassing a variety of diagnostic and therapeutic applications. Along with traditional indications that constitute everyday clinical practice in all endoscopic ultrasonography centres, new indications are emerging that resemble the continuing research carried on in this field. Some of these are innovative applications, developed by highly experienced endosonographers and with a putative role for clinical practice in the near future. Others are merely experimental applications, carried out on in animal models or in highly selected groups of patients, opening up new fascinating areas of research but not for imminent introduction in clinical practice. The purpose of this review, after summarising the present indications of endoscopic ultrasonography, is to focus on the future applications and try to establish their possible advent, either in the near or in the far future.

Future therapeutic indications for endoscopic ultrasound

Attempts to perform therapy guided by endoscopic ultrasound (EUS) are rare. Some new indications for interventional and therapeutic endoscopic procedures performed under EUS control have been developed in areas that have been purely surgical for many years. Indications, procedures, and related tools for EUS-guided endosurgery are described, all of which are experimental but may open a new corridor for endoscopists to enter a variety of transluminal procedures in real time without soiling the peritoneal or mediastinal cavity.

Endoscopic ultrasound-guided pancreatic pseudocyst drainage

In this article, we detail the different techniques of endoscopic ultrasound-guided cystogastrostomy or duodenostomy and the complications and results of this new technical approach.

Traitement endoscopique de la dystrophie kystique de la paroi duodénale

Optimal management of cystic dystrophy of a heterotopic duodenal pancreas or cystic dystrophy of the duodenal wall has not yet been established. Surgical treatment by pancreaticoduodenectomy or by-pass procedure is indicated in patients with the most serious symptoms. Endoscopic cystic drainage is an alternative to surgery. We report three cases of cystic dystrophy of the duodenal wall successfully treated by endoscopic drainage. Symptoms disappeared immediately in all cases. No complications were observed. In one case, a second drainage was necessary 15 months after the first one. The 3 patients were free of symptoms after 6, 36, and 44 months of follow-up, respectively. No recurrence was found with CT-scan. The long-term efficiency of the endoscopic procedure must to be evaluated.

Endoscopic management of pancreatic fistula after pancreatic and other abdominal surgery

Post-operative pancreatic fistulae represent a challenge for all the actors in gastroenterology: for surgeons, because they want to prevent and treat conservatively this complication since re-operation is associated with high morbidity and mortality rates; for radiologists, because they have to provide the best staging and informations without any additional risk; and for endoscopists, because endoluminal treatment is emerging as a safe and effective procedure provided it is performed in highly experienced tertiary centres in the setting of a multidisciplinary approach. Herein, we review the definitions, the causes, the staging and the possible options to prevent or treat post-operative pancreatic fistulae. Special attention is paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Practical problems and issues are clearly outlined as well as the need for future improvements in staging and management of the patients having such complications.

Approaches to the drainage of pancreatic pseudocysts

PURPOSE OF REVIEW

Review the current methods for the drainage of pancreatic pseudocysts, focusing on the recent developments in the new methods of endoscopic drainage.

RECENT FINDINGS

Pancreatic pseudocysts are collections of inflammatory fluid associated with acute and chronic pancreatitis. A leak in the pancreatic ductal system is most commonly the source of the fluid accumulation in these inflammatory cavities adjacent to the pancreas. Although most pseudocysts are not symptomatic and many resolve spontaneously over time, drainage of pseudocysts is occasionally required. There are several different approaches to the drainage: surgical, radiologic, and endoscopic. Surgical drainage is accomplished using the creation of a large anastomosis between the gastrointestinal tract and the pseudocyst cavity. Radiologically, pseudocysts are drained externally using a percutaneous, transabdominal drainage catheter. Endoscopy has offered the most recent advance, using the placement of transgastric or transduodenal stents. Most recently, therapeutic endoscopic ultrasound scopes have been used to introduce large stents that provide drainage into the upper gastrointestinal tract.

SUMMARY

Of the three methods for the drainage of a pancreatic pseudocyst, only the endoscopic approach can provide minimally invasive internal drainage.

Ultrasound-guided endoscopic surgery

Ten years' development of sectorial linear endoscopic ultrasound (EUS) has allowed us to perform guided biopsies of lymph nodes, mediastinal masses and pancreatic tumours. Furthermore, biopsy guided by EUS has been the first step in the development of interventional EUS. This development, in turn, has been made possible by the appearance of the interventional echoendoscope with a large working channel. EUS-guided biopsy obtains the best results for lymph nodes, anastomotic relapses and extrinsicz compression as well as for pancreatic tumours. Results in the literature show a global sensitivity of the technique that varies between 76 and 91%, a specificity of 84-100% and an accuracy of 78-94%. Using alcohol injection of the plexus nerves, the coeliac block guided by EUS is a simple technique. It will replace percutaneous access under US or CT scan guidance. Data from the literature show a significant reduction in pain of the order of 85-90% of cases-results that would have been good for percutaneous techniques. The technique of cystoenterostomy guided by EUS allows more accurate drainage of the cysts with a lower risk of perforation and haemorrhage. With regard to haemorrhage it should be emphasized that colour Doppler and power Doppler assessment of the punctures rules out the risk of vascular perforation during puncture but the risk of haemorrhage due to decompression of a vascular lesion in the vicinity of the cyst remains. The new ultrasound echoendoscope EG 38X, with a large working channel (3.8 mm), is now available. This system allows more effective drainage and also enables the placement of cystodigestive stents.

Endoscopic technique for the management of pancreatitis and its complications

Therapeutic endoscopy is now increasingly used to treat gallstone pancreatitis, acute pancreatitis of other aetiologies, chronic pancreatitis and complications associated with acute or chronic pancreatitis. This chapter is a brief review of the endoscopic interventions currently performed in patients with acute or chronic pancreatitis. These interventions include biliary and pancreatic endoscopic sphincterotomy at the major or minor papilla, stricture dilatation on the common bile duct or main pancreatic duct, stent placement in the biliary or pancreatic ducts, stone extraction with or without extracorporeal shock wave lithotripsy, and transmural or transpapillary drainage of pancreatic fluid collections. As most of the studies reported were uncontrolled and retrospective, uncertainties persist with regard to the best approaches for treating the patients concerned. Appropriate patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential prerequisites of a high success rate in improving the clinical condition of these patients.

Laparoscopic pancreatic surgery: current indications and surgical results

BACKGROUND

Although minimally invasive surgery has achieved worldwide acceptance in various fields, laparoscopic surgery for pancreatic diseases has been reported only rarely. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery.

METHODS

Fifteen patients, comprising eight men and seven women with an average age of 54 years, underwent laparoscopic pancreatic surgery. Distal pancreatectomy was indicated for solid tumors ( n = 4), cystic lesions ( n = 3), and chronic pancreatitis ( n = 2). Cystogastrostomy was performed for pseudocysts ( n = 4) and enucleation for insulinomas ( n = 2). The lesions varied in size from 1 to 9 cm (2.9 +/- 2.4 cm) and were located in the pancreatic head ( n = 2), body ( n = 3), or tail ( n = 10). For distal pancreatectomy, the splenic artery was divided and the parenchyma was transected with a linear stapler. Laparoscopic ultrasonography was used to determine the distance between the tumor and the main pancreatic duct for enucleation as well as to localize the lesion for distal pancreatectomy. Cystogastrostomy, 4.5 cm in length, was also performed with the linear stapler through the window of the lesser omentum.

RESULTS

Mean operation time was 249 +/- 70 min (293 +/- 58 min in distal pancreatectomy, 185 +/- 14 min in enucleation, 204 +/- 50 min in cystogastrostomy), and mean blood loss was 138 +/- 184 g (213 +/- 227 g, 75 +/- 35 g, 38 +/- 48 g, respectively). Two distal pancreatectomies (13%) were converted to open surgery due to severe peripancreatic inflammation. There was no related mortality, but there were two cases (15%) of pancreatic fistula, one in a distal pancreatectomy case and the other in an enucleation case, and both were treated conservatively.

CONCLUSIONS

Laparoscopic pancreatic surgery is safe and feasible for patients with benign tumors and cystic lesions.

Endoscopic therapy of chronic pancreatitis

We present an overview of endoscopic therapies for chronic pancreatitis (CP) and its associated conditions. It is evident that endoscopy can be a definite therapy for pancreatic pseudocysts, pancreatic ascites and pancreatic duct (PD) disruption. Endoscopic therapy has also been useful in the short-term and medium therapy of common bile duct strictures due to CP, the best results being obtained if there are no calcifications in the head of the pancreas. Although most experts agree that obstruction to the outflow of pancreatic juice and the resulting increased pressure within the main PD is one of the major factors contributing to pain and that endoscopic therapy has been proven effective to remove stones as well as to dilate PD strictures and place stents across the PD, there is no convincing evidence from randomized trials that the patient's dominant symptom of CP, i.e. pain, is resolved in an appropriate and long-term fashion. We believe that there are other factors which are important in the etiology of chronic pain such as pancreatic inflammation and peripancreatic fibrosis with resulting nerve entrapment around the gland. The reader is reminded that endoscopic therapy is associated with significant and important complications, therefore appropriate patient selection and patient information are of paramount importance. Nevertheless, it is important to consider that one advantage of endoscopic management of CP is that it is less invasive as compared with surgery, often effective for years, does not hinder further surgery, and can be repeated. Finally we want to emphasize that there are many valid surgical, radiological and endoscopic techniques to treat the complications of CP. Therefore, the approach to CP and its complications should be by a multidisciplinary team of gastroenterologists, surgeons, radiologists, endoscopists and pain specialists.

Endoscopic management of chronic pancreatitis

Endoscopic management of CP is generally safe, minimally invasive, and often effective for years, does not hinder further surgery, and can be repeated. It should be applied as a first-line approach to improving the clinical condition of patients with this chronic disease. The best results are obtained when endoscopic treatment is performed early in the course of CP. Proper patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential. New technologies will continue to be developed and to extend the scope of therapeutic pancreatic endoscopy.

Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis

PFCs are heterogeneous, with different underlying pathology and pathophysiology. Each type of PFC is amenable to drainage, although not in every patient. Collections with only a fluid component that have either apposition to the gastric or duodenal wall demonstrated by CT or communication with the main pancreatic duct demonstrated by pancreatography can be drained endoscopically using transmural or transpapillary approaches, respectively. Collections containing significant amounts of solid debris that are treated endoscopically require placement of an irrigation system to evacuate solid debris. Endoscopists considering endoscopic therapy of a pancreatic collection must identify the type of collection being drained and exclude masqueraders of PFCs such as cystic neoplasms. EUS-guided drainage, if available, may decrease the complications of bleeding and perforation during transmural entry of PFCs. Refinement in endoscopic techniques to improve the safety and studies comparing the efficacy of endoscopic therapy with that of other drainage methods are needed.

Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature

Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross-references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.

Interventional endoscopic ultrasound

Endoscopic ultrasound (EUS) has been used in clinical practice for the past two decades, mainly for staging upper gastrointestinal tract tumours. More recently the technique has been used to guide interventional procedures, particularly EUS-guided biopsy. In this review we describe the equipment and technique required for interventional EUS. We also discuss with illustrations the current clinical applications, potential complications and developments for the future.

Future developments in endoscopic imaging

Flexible gastrointestinal endoscopy was introduced more than 30 years ago; this chapter will try to look into its future. Developments are expected in five different categories. We will see better with the use of high-resolution magnification endoscopy as well as by using other light-tissue interactions (such as spectroscopy). We will also be able to look just below the surface with laser-scanning microscopy and optical coherence tomography with a resolution of 1 microm (in vivo histology). Computers will assist with the interpretation of what we see, and the availability of broadband networks all around the world will allow real-time consultation globally. Invisible areas of the gastrointestinal tract will be seen with the help of improved endoscopy capsules and virtual endoscopy. Finally, we will treat endoscopically, with the help of new instruments and accessories, more of the lesions that we see.

Laparoscopic endogastric pseudocyst gastrostomy: a report of three cases

The transgastric pseudocyst-gastrostomy is the standard approach for internal drainage of persistent and large retrogastric pancreatic pseudocysts that complicate acute necrotizing pancreatitis. We report on the application of a laparoscopic endogastric approach for drainage of pancreatic pseudocysts and discuss the merits of this technique as well as of the other previously described minimally invasive approaches for the management of pancreatic pseudocysts. Between January 2001 and August 2001, three female patients presented with large symptomatic pseudocysts 3-10 months after an episode of acute necrotizing pancreatitis. Internal drainage was effected by a laparoscopic endogastric pseudocyst gastrostomy, and the necrotic pancreas was debrided. There were no conversions and no postoperative complications. The median postoperative hospital stay was 4 days (range, 3-5). All patients remain asymptomatic, and resolution of the pseudocyst was radiologically evident at a median follow-up of 6 months (range, 4-11). The laparoscopic endogastric pseudocyst gastrostomy appears to be a safe and effective minimally invasive approach for internal drainage of large retrogastric pancreatic pseudocysts and facilitates debridement of the necrotic pancreas.

Endoscopic ultrasound of the pancreas: tissue acquisition and intervention

Endoscopic ultrasound is an established modality for staging gastrointestinal and pancreatic malignancies. Since the development of the linear array echoendoscope, the field of interventional endoscopy has continued to evolve as an adjunctive method to standard endosonography. The ability to sample extraluminal lesions or lymph nodes has overcome the initial limitations of endoscopic ultrasound and provided a list of attractive endoscopic ultrasound-guided therapeutic applications.This review focuses on recent advancements in the field of interventional endosonography related to the diagnosis and therapy of pancreatic diseases. In particular, the article reviews the role of endoscopic ultrasound-guided fine-needle aspiration in diagnosing various pancreatic diseases; the role of endoscopic ultrasound-guided fine-needle injection in delivering neurolytic, chemotherapeutic, or biologic agents; and emerging procedures like endoscopic ultrasound-assisted biliary bypass in the setting of malignant biliary obstruction.

Interventional treatment of chronic pancreatitis

Endoscopic treatment of chronic pancreatitis is becoming a reality: more and more endoscopy centres are developing the technique, and it is no longer a matter of extreme specialization. Among treatments which have been shown to be feasible, it is possible to distinguish between those approaches that are now considered as efficient with good results and very low risk (e.g. MPD drainage), or are efficient but with risks that seem to be lower than those of surgery (e.g. drainage of cysts), and drainage of the main bile duct, which is easy to perform, but, so far, has not been demonstrated enough as useful.

Endoscopic cystenterostomy of nonbulging pancreatic fluid collections

BACKGROUND

A prerequisite for endoscopic drainage of pancreatic fluid collections without EUS is the presence of a visible bulge in the GI wall. Our experience with endoscopic cystostomy of nonbulging pancreatic fluid collections is described.

METHODS

Thirty-three patients underwent 34 endoscopic attempts at transmural drainage of nonbulging pancreatic fluid collections over a 2-year period. The etiology of the nonbulging pancreatic fluid collections was chronic pancreatitis in 26 cases and acute pancreatitis in 7. Indications for drainage included one or more of the following: abdominal pain, infection, biliary obstruction, and external fistula. The diameter of the collections ranged from 20 to 160 mm (median 52 mm).

RESULTS

Thirty-two of 34 drainage attempts were successful (94%). Eighteen cystostomies were performed under fluoroscopy alone and 14 by EUS together with fluoroscopy. Procedure-related complications occurred with 3 of 34 attempts (8%). Surgery was not required for treatment of the complications and there were no deaths from the procedure. Follow-up was available for 31 patients (median 21 months, range 9 to 40 months). One nonbulging pancreatic fluid collections recurred 7 months after drainage.

CONCLUSIONS

Endoscopic cystenterostomy of nonbulging pancreatic collections is feasible, and the results of the procedure are similar to those of cystenterostomy for bulging collections.