Endoscopic treatment of pancreatic pseudocysts

What We Know So Far About ECG for Pancreatic Pseudocysts

Background: Endoscopic cysto-gastrostomy (ECG) has become the treatment of choice for pancreatic pseudocysts (PPCs). Endoscopic drainage of PPCs requires the creation of an anastomosis between the lumen of the PPCs and the lumen of the gastrointestinal tract. Various types of stents are used for this purpose. The aim of the study is to compare the indications, quantity, and results of using double pigtail plastic stents (DPPSs) and lumen-apposing fully covered metal stents (LAMSs) in ECG. Methods: A retrospective analysis was conducted of 39 patients (24 men, 15 women) treated for PPCs in the Department of Digestive Tract Surgery and the Department of Gastroenterology and Hepatology between October 2018 and February 2023. The mean age of patients was 51.13 (28-77). Data about etiology, cyst diameter, type, and complications of the stents were collected. Results: DPPSs were placed in smaller cysts (108 vs. 140 millimeters, p = 0.04) and were maintained for a longer duration compared to LAMSs (106 vs. 34 days, p = 0.001). Cyst recurrence was reported less frequently in patients with a LAMS (0 (0%) vs. 4 (19.05%), p = 0.05) and the therapeutic success was non-significantly higher in the LAMS group compared to the DPPS group (100% vs. 85.71%), p = 0.095. Conclusions: Both DPPSs and LAMSs are characterized by high therapeutic success and low complication rates in patients undergoing ECG for PPCs.

Management of Pancreatic Fluid Collections: An Evidence-based Approach

Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.

Percutaneous drainage in the treatment of intrahepatic pancreatic pseudocyst with Budd-Chiari syndrome: A case report

BACKGROUND

Intrahepatic pancreatic pseudocyst (IHPP) is an extremely rare complication of acute pancreatitis, with only a few cases previously described in the literature. To the best of our knowledge, IHPP with Budd-Chiari syndrome (BCS) has not yet been described.

CASE SUMMARY

A 35-year-old male presented with abdominal pain, vomiting and anorexia, followed by severe swelling of the lower body after 4 d. The morphological assessment (using computed tomography revealed the presence of a huge cyst of 18.28 cm × 10.34 cm under the liver capsule accompanied by a large amount of ascites. Percutaneous puncture allowed us to detect a high level of amylase in the collection, confirming the diagnosis of IHPP. The cyst was treated by percutaneous drainage, producing complete resolution of the cyst.

CONCLUSION

IHPP can be treated with percutaneous drainage, endoscopic drainage, surgery or even conservative treatment, depending on the specific condition. We recommend percutaneous drainage as the first choice of treatment when IHPP with secondary BCS.

Sequential therapy with combined trans-papillary endoscopic naso-pancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts

BACKGROUND

Endoscopic retrograde pancreatic drainage (ERPD) and stent implantation has become the major treatment method for pancreatic pseudocysts. However, it is associated with a high recurrence rate and infection.

AIM

To manage pancreatic pseudocysts by sequential therapy with endoscopic naso-pancreatic drainage (ENPD) combined with ERPD and evaluate the treatment outcome.

METHODS

One hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed. There were 152 cases of intubation via the duodenal papilla, of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD (two-step procedure). The success rate of the procedure, incidence of complications (infection, bleeding, etc.), recurrence, and length and cost of hospitalization were compared between the two groups.

RESULTS

The incidence of infection was significantly higher in the ERPD group (12 cases) than in the two-step procedure group (2 cases). Twelve patients developed infection in the ERPD group, and anti-infection therapy was effective in five cases but not in the remaining seven cases. Infection presented as fever and chills in the two-step procedure group. The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group (P < 0.05). Similarly, the recurrence rate was significantly higher in the ERPD group (19 cases) than in the two-step procedure group (0 cases).

CONCLUSION

Sequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.

Endoscopic Drainage of Giant Pancreatic Pseudocysts Using Both Lumen-Apposing Metal Stent and Plastic Stent: A Report of Two Cases and Review of the Current Literature

Introduction

A pancreatic pseudocyst (PP) with major diameter equal to 10 cm or more is called a giant pseudocyst. The ideal management for giant PPs is controversial. Endoscopic drainage is an alternative nonsurgical approach for PP management. Only a few cases of giant PPs were reported to be managed by endoscopic drainage. Case Presentation. We reported two cases of giant PPs following an episode of acute pancreatitis. Both were resolved following endoscopic cystogastrostomy using metallic and double-pigtail stents with excellent outcomes. There was no history of recurrence or complications on follow-up. In addition, we extensively reviewed all available literature studies of giant pancreatic pseudocyst presentation, management, and complications. We summarized all reported cases and presented them in a comprehensive table.

Conclusion

The endoscopic cystogastrostomy approach is cost saving, can avoid surgical complications, and offers an early hospital discharge.

Diagnostic and therapeutic recommendations for chronic pancreatitis. Recommendations of the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club

This article describes the latest diagnostic and therapeutic recommendations in chronic pancreatitis, developed by the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. The recommendations refer to the diagnosis of chronic pancreatitis, autoimmune pancreatitis, conservative management, treatment of pain, and exocrine and endocrine pancreatic insufficiency, treatment of chronic pancreatitis by endoscopic and surgical methods, and oncological surveillance of chronic pancreatitis. This paper refers to the Polish recommendations published in 2011, which have been updated and supplemented. All recommendations were voted by experts of the Polish Society of Gastroenterology and the Polish Pancreas Club, who evaluated them each time on a five-degree scale, where I meant full acceptance, II – acceptance with some reservation, III – acceptance with serious reservation, IV – rejection with some reservation and V – full rejection. The results of the voting, together with a brief commentary, have been included with each recommendation put to the vote. In addition, the expert group assessed the value of clinical studies on which the statements are based, on a scale where A means high (based on meta-analyses and randomised clinical trials), B means medium (based on clinical trials and observational studies), and C means low (based mainly on expert opinion).

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

Objective

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

Method

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

Results

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

Conclusion

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

OBJECTIVE

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

METHOD

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

RESULTS

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

CONCLUSION

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Long-term results after endoscopic drainage of pancreatic pseudocysts: A single-center experience

BACKGROUND

Pancreatic pseudocysts (PPC) are collections of fluid encapsulated within a well-defined inflammatory wall that develop during pancreatic inflammation. Internal drainage represents the standard of care in lesions that persist and lead to symptoms and complications. Only limited data are available on long-term results and recurrence of PPC after drainage procedures. Thus, the aim of the present study was to analyse the long-term outcome after endoscopic drainage of PPC.

MATERIAL AND METHODS

Patient data were retrospectively collected by review of clinical records of the University Medical Center Mannheim. We assessed the clinical short-term outcome (results in the first 30 days after initial drainage procedure), medium-term outcome (results 6 months after initial drainage procedure) and long-term outcome (results after stent removal). We performed statistical analysis to identify possible risk factors for recurrence of PPC.

RESULTS

We identified 51 patients with initially successful endoscopic drainage of the PPC (n = 51/53, 96%). Among this cohort, 43 patients were available for assessment of medium-term results. In 82.9% of these 43 patients the drainage could be removed after successful treatment of the PPC. Thirty patients were available for long term follow-up with a mean observation period of 42.2 months (SD 32.8 months). Among these patients, seven (n = 7/30, 23.3%) had recurrent PPC. Approximately half of the recurrent cysts arose in different anatomical regions and most patients with recurrence had chronic pancreatitis.

CONCLUSION

Endoscopic drainage represents an effective treatment for PPC. Approximately one quarter of the patients developed recurrent PPC. Half of recurrent PPC developed in different pancreatic regions than the initial PPC.

Electrocautery vs non-electrocautery dilation catheters in endoscopic ultrasonography-guided pancreatic fluid collection drainage

AIM: To investigate the safety and utility of an electrocautery dilation catheter for endoscopic ultrasonography (EUS)-guided pancreatic fluid collection drainage.

METHODS: A single-center, exploratory, retrospective study was conducted between August 2010 and August 2014. This study was approved by the Medical Ethics Committee of our institution. Informed, written consent was obtained from each patient prior to the procedure. The subjects included 28 consecutive patients who underwent EUS-guided transmural drainage (EUS-TD) for symptomatic pancreatic and peripancreatic fluid collections (PFCs) by fine needle aspiration using a 19-gauge needle. These patients were retrospectively divided into two groups based on the use of an electrocautery dilation catheter as a fistula dilation device; 15 patients were treated with an electrocautery dilation catheter (electrocautery group), and 13 patients were treated with a non-electrocautery dilation catheter (non-electrocautery group). We evaluated the technical and clinical successes and the adverse events associated with EUS-TD for the treatment of PFCs between the two groups.

RESULTS: There were no significant differences in age, sex, type, location and diameter of PFCs between the groups. Thirteen patients (87%) in the electrocautery group and 10 patients (77%) in the non-electrocautery group presented with infected PFCs. The technical success rates of EUS-TD for the treatment of PFCs were 100% (15/15) and 100% (13/13) for the electrocautery and the non-electrocautery groups, respectively. The clinical success rates of EUS-TD for the treatment of PFCs were 67% (10/15) and 69% (9/13) for the electrocautery and the non-electrocautery groups, respectively (P = 0.794). The procedure time of EUS-TD for the treatment of PFCs in the electrocautery group was significantly shorter than that of the non-electrocautery group (mean ± SD: 30 ± 12 min vs 52 ± 20 min, P < 0.001). Adverse events associated with EUS-TD for the treatment of PFCs occurred in 0 patients and 1 patient for the electrocautery and the non-electrocautery groups, respectively (P = 0.942).

CONCLUSION: EUS-TD using an electrocautery dilation catheter as a fistula dilation device for the treatment of symptomatic PFCs appears safe and contributes to a shorter procedure time.

Pancreatic Pseudocysts: Advances in Endoscopic Management

Endoscopic drainage is the first-line therapy in the management of pancreatic pseudocysts. Before endoscopic drainage, clinicians should exclude the presence of pancreatic cystic neoplasms and avoid drainage of immature peripancreatic fluid collections or pseudoaneurysms. The indication for endoscopic drainage is not dependent on absolute cyst size alone, but on the presence of attributable signs or symptoms. Endoscopic management should be performed as part of a multidisciplinary approach in close cooperation with surgeons and interventional radiologists. Drainage may be performed either via a transpapillary approach or a transmural approach; additionally, endoscopic necrosectomy may be performed for patients with walled-off necrosis.

Endoscopic management of peripancreatic fluid collections

Peripancreatic fluid collections are a well-known complication of pancreatitis and can vary from fluid-filled collections to entirely necrotic collections. Although most of the fluid-filled pseudocysts tend to resolve spontaneously with conservative management, intervention is necessary in symptomatic patients. Open surgery has been the traditional treatment modality of choice though endoscopic, laparoscopic and transcutaneous techniques offer alternative drainage approaches. During the last decade, improvement in endoscopic ultrasound technology has enabled real-time access and drainage of fluid collections that were previously not amenable to blind transmural drainage. This has initiated a trend towards use of this modality for treatment of pseudocysts. In this review, we have summarised the existing evidence for endoscopic drainage of peripancreatic fluid collections from published studies.

Stent displacement in endoscopic pancreatic pseudocyst drainage and endoscopic management

A pancreatic pseudocyst (PPC) is a collection of pancreatic fluid enclosed by a non-epithelialized, fibrous or granulomatous wall. Endoscopic pancreatic pseudocyst drainage (PPD) has been widely used clinically to treat PPCs. The success and complications of endoscopic PPD are comparable with surgical interventions. Stent displacement is a rare complication after endoscopic PPD. Almost all the complications of endoscopic PPD have been managed surgically, and there is rare report involving the endoscopic treatment of intraperitoneal stent displacement. We report here a case of stent displacement after endoscopic ultrasound- and fluoroscopy-guided PPD in a 41-year-old female patient with a PPC in the tail of the pancreas. The endoscopic treatment was successfully performed to remove the displaced stent. The clinical course of the patient was unremarkable. The cyst had significantly reduced and disappeared by 12 wk. We found that both endoscopic ultrasound and fluoroscopy should be used during endoscopic PPD to avoid stent displacement. The displaced stent can be successfully treated by endoscopic removal.

Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm

Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues. With disease progression, patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss. Among them, a pseudoaneurysm, mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas, is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs. At present, no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation. The role of arterial embolization, the timing of surgical intervention and even surgical procedures are still controversial. In this review, we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleeders and to evaluate the associated complications such as pseudocyst formation, followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient's condition. With advances and improvements in endoscopic devices and techniques, therapeutic endoscopy for pancreatic pseudocysts is technically feasible, safe and effective. Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition, for those in whom arterial embolization of the bleeding pseudoaneurysm fails, and when endoscopic management of the pseudocyst is unsuccessful. If a bleeding pseudoaneurysm is located over the tail of the pancreas, resection is a preferential procedure, whereas if the lesion is situated over the head or body of the pancreas, relatively conservative surgical procedures are recommended.

Endoscopic ultrasound for treatment of infected pancreatic pseudocysts

AIM: To explore the clinical effect of endoscopic ultrasound (EUS) in the treatment of infected pancreatic pseudocysts (PPs).

METHODS: Between January 2008 and December 2013, 25 patients were admitted to our center for infected PPs and underwent EUS. The clinical data about therapies and recovery of the patients were analyzed.

RESULTS: All patients underwent EUS with transgastric stenting and BD drainage. One patient required laparoscopic surgery because therapeutic EUS was unsuccessful. Mean operative time was 48.3 min ± 27.6 min. Mean postoperative hospital stay was 8.4 d ± 3.7 d. The median follow-up period was 19.6 mo. No recurrence or other complications occurred.

CONCLUSION: Endoscopic ultrasound is a safe, effective and minimally invasive therapeutic method for infected PPs.

Endoscopic Ultrasound-Guided Self-Expandable Metal Stent Placement for the Treatment of Infected Pancreatic Pseudocysts

The standard endoscopic ultrasound (EUS) approach of cystogastrostomy involves the use of series of plastic pigtail stents that are placed through the wall of the cyst. The use of a single stent has also been described in the literature. Here we describe five cases of EUS-guided cystogastrostomy with irrigation of infected pancreatic pseudocysts using a single self-expandable metal stent (SEMS). To our knowledge this has not been described in the literature in the United States. This novice approach will have significant implications in the management of infected pseudocysts with a lower morbidity, mortality and overall cost compared to conventional management such as surgery or percutaneous drainage.

Endoscopic management of acute pancreatitis

Patients presenting with acute pancreatitis can be complex on different levels. Having a multifaceted approach to these patients is often necessary with radiographic, endoscopic, and surgical modalities all working to benefit the patient. Major surgical intervention can often be avoided or augmented by therapeutic and diagnostic endoscopic maneuvers. The diagnostic role of endoscopy in patients presenting with acute idiopathic pancreatitis can help define specific causative factors and ameliorate symptoms by endoscopic maneuvers. Etiologies of an acute pancreatitis episode, such as choledocholithiasis with or without concomitant cholangitis, microlithiasis or biliary sludge, and anatomic anomalies, such as pancreas divisum and pancreatobiliary ductal anomalies, often improve after endoscopic therapy.

Combined EUS-Guided Abdominal Cavity Drainage and Cystogastrostomy for the Ruptured Pancreatic Pseudocyst

Background. Endoscopic-Ultrasonography- (EUS-) guided puncture and drainage of pancreatic pseudocyst is currently one of the most widely accepted nonsurgical treatments. To date, this technique has only been used for pancreatic pseudocysts adhesive to the gastric wall. This study introduces the technique of EUS-guided pseudocyst drainage and additional EUS-guided peritoneal drainage for the ruptured pseudocyst. Methods. Transmural puncture and drainage of the cyst were performed with a 19 G needle, cystotome, and 10 Fr endoprosthesis. Intraperitoneal drainage was performed with a nasobiliary catheter when rupture of pseudocyst occurred. The entire procedure was guided by the echoendoscope. Results. A total of 21 patients, 8 men and 13 women, with a mean age of 36 years, were included in this prospective study. All of the pseudocysts were successfully drained by EUS. Peritoneal drainage was uneventfully performed in 4 patients. There were no severe complications. Complete pseudocyst resolution was established in all patients. Conclusion. The technique of EUS-guided transmural puncture and drainage, when combined with abdominal cavity drainage by a nasobiliary catheter, allows successful endoscopic management of pancreatic pseudocysts without adherence to gastric wall.

Treatment of Pancreatic Abscess with Endoscopic Ultrasound-guided Placement of a Covered Metal Stent Following Failed Balloon Dilation and Endoscopic Necrosectomy

For the management of pancreatic abscess, endoscopic ultrasound (EUS)-guided puncture and drainage has become recognized as a safer and more effective alternative to surgery. Typically, a double-pigtail plastic stent is placed for drainage. When an abscess is complicated by infected necrosis, endoscopic evacuation is essential. However, endoscopic evacuation carries a high risk of hemorrhage and needs to be performed daily to be effective. We describe EUS-guided endoscopic evacuation and placement of a fully covered metal stent following two failed evacuations. Patient recovery time was excellent, and no complications occurred.

Endoscopic management of pancreatic pseudocysts

Techniques of endoscopic pseudocyst management continue to evolve, but the principles of proper patient selection and careful consideration of the available therapeutic options remain unchanged. Endoscopic management is considered first-line therapy in the treatment of symptomatic pseudocysts. Clinicians should be vigilant in the evaluation of all peripancreatic fluid collections to exclude the presence of a pancreatic cystic neoplasm and avoid draining an immature collection. Expectant management with periodic observation should be considered for the minimally symptomatic patients, even after the traditional 6 weeks of maturation. Further, symptoms, complications, and expansion on serial imaging should prompt intervention by endoscopic, surgical, or percutaneous methods. Pseudocysts should only be punctured when the wall has had sufficient time to mature and after pseudoaneurysm has been ruled out by careful imaging. Small to moderately sized pseudocysts (< 4–6 cm) that communicate with the pancreatic duct are good candidates for endoscopic transpapillary stenting. For larger lesions requiring transmural drainage, EUS guidance is preferable, but good results can be achieved with ENL. EUS may be particularly useful in permitting drainage in patients with suspected perigastric varices or if an endoscopically visible bulge is not apparent. Necrosis is a significant factor for a worse outcome; aggressive debridement with nasocystic or percutaneous endoscopic gastrostomy-cystic catheter lavage plus manual endoscopic techniques for clearing debris should be used. Endoscopic failure, especially in cases with significant necrosis, should be managed operatively. Percutaneous drainage is a good option for immature infected pseudocysts or in patients who are not optimal candidates for other procedures. Close cooperation between endoscopists, surgeons, interventional radiologists, and other healthcare providers is paramount in successfully managing these patients.

Endoscopic management of peri-pancreatic collections

Endotherapy of peripancreatic fluid collections is an increasing utilized procedure in interventional endoscopy. The aim of this paper is to provide a general overview of the topic, highlighting the indications, technique, and important management issues relating to endoscopic management of the various forms of peri-pancreatic fluid collections.

Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients

OBJECTIVES

Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections.

METHODS

This is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7 years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively.

RESULTS

A total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6 mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356 days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, p < 0.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, p = 0.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted OR = 7.6, 95% CI [2.9, 20.1], p < 0.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection.

CONCLUSIONS

Endoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

BACKGROUND

The development of endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and stenting are relatively new alternatives to surgery for the treatment of benign lesions in the biliary duct and pancreas. The objective of this study was to assess the value of stenting in the endoscopic pancreatic duct and biliary duct in the treatment of chronic pancreatitis with distal benign biliary stricture.

METHODS

Twenty-two patients diagnosed with chronic pancreatitis with distal benign biliary stricture underwent endoscopic treatment in our center, with ERCP, EST, endoscopic retrograde biliary drainage (ERBD) and endoscopic retrograde pancreatic drainage (ERPD) with stents. A numeric rating scale was used to assess pain intensity. The clinical data on endoscopic therapies and recovery of the patients were recorded and compared.

RESULTS

ERCPs were successfully performed in 21 patients and 1 (4.5%) failed because of pancreatic ductal variation. A total of 68 ERCPs were performed with 47 pancreatic duct stents and 39 biliary duct stents. The rate of complications was 13.2% (9/68). The abdominal pain score after endoscopic treatment was significantly reduced. The levels of bilirubin and alanine transaminase in all 21 patients were improved compared to those before endoscopic treatment.

CONCLUSION

Endoscopic stent drainage of the pancreatic duct and biliary duct for chronic pancreatitis with distal biliary benign stricture can be selected as a safe, effective and minimally invasive therapeutic method.

Endoscopic ultrasound-guided transgastric drainage of pancreatic pseudocysts: An analysis of 36 cases

AIM: To assess the clinical value of endoscopic ultrasound (EUS)-guided transgastric drainage of pancreatic pseudocysts (PPs).

METHODS: The clinical data for 36 patients who underwent EUS-guided transgastric drainage of PPs at our center between February 2005 and May 2010 were retrospectively analyzed.

RESULTS: EUS-guided puncture of PPs and stent placement were successful in 34 patients, and the success rate was 94.4% (34/36). The rate of complications (infection and stent clogging or migration) was 17.6%. The mean operative time was 50 minutes (range, 40-65 min) and mean postoperative hospital stay was 4.7 d (range, 2-9 d). The mean time between stent implantation and removal was 6.9 mo (range, 4-11 mo). The mean follow-up period was 30 mo (range, 10-60 mo). Endoscopic cure rate was 97.1% (33/34). No recurrences occurred.

CONCLUSION: EUS-guided transgastric drainage is a safe, effective and minimally invasive therapeutic method for PPs.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Endoscopic transmural drainage of pseudocysts associated with pancreatic resections or pancreatitis: a comparative study

BACKGROUND

Endoscopy has been regarded as an effective modality for draining pancreatic collections, pseudocysts, and abscesses. This study analyzes our experience with endoscopic transmural drainage of pancreatic pseudocysts and compares the outcomes in patients with postsurgical and pancreatitis-associated ones.

METHODS

Patients who underwent endoscopic drainage of a pancreatic pseudocyst from January 1999 through June 2008 were included in this retrospective analysis. The specific indication for attempting the procedure was the presence of direct contact between the pseudocyst and the gastric wall. All the drainages were carried out via a transgastric approach, and one or two straight plastic stents (10 or 11.5 French) were positioned. A comparative analysis of short- and long-term results was made between patients with postoperative pseudocysts (group A) and patients with pancreatitis-associated pseudocysts (group B).

RESULTS

Fifty-five patients were included in the study, 25 in group A and 30 in group B. Overall, a single stent was inserted in 84.0% of patients, while two stents were needed in the remaining 16.0%. The technical success rate was 78.2%, whereas procedure-related complications were 16.4%. Complications included pseudocyst superinfection and major bleeding and were managed mainly by surgery. Mortality rate was 1.8% (1 patient). There were no significant differences in the technical success rate and procedure-related complications between the two groups (p=0.532 and 0.159, respectively) Recurrences were 13.9% and significantly more common in group B (p=0.021). In such cases, a second endoscopic drainage was successfully performed.

CONCLUSION

Transmural endoscopic treatment of pancreatic pseudocysts is feasible and has a technical success rate of 78.2%, without differences related to the pseudocyst etiology. Recurrences, on the other hand, are more common in patients with pancreatitis. Given the severe complications that may occur after the procedure, we recommend that endoscopic drainage be performed in a tertiary-care center with specific expertise in pancreatic surgery.

Pancreatic pseudocyst drainage guided by endoscopic ultrasound

Pancreatic pseudocysts can be managed conservatively in the majority of patients but some of them will require surgical, endoscopic or percutaneous drainage. Endoscopic drainage represents an efficient modality of drainage with a high resolution rate and lower morbidity and mortality than the surgical or percutaneous approach. In this article we review the endoscopic pseudocyst drainage procedure with special emphasis on technical details.

Endoscopic treatment of chronic pancreatitis with benign biliary stricture: an analysis of 22 cases

AIM: To explore the value of endoscopy in the treatment of chronic pancreatitis with benign biliary stricture.

METHODS: The clinical data of 22 patients with chronic pancreatitis and benign biliary stricture who underwent endoscopic treatment were retrospectively analyzed.

RESULTS: A total of 35 endoscopic treatments were performed in 22 patients. The rates of technical success and complications were 95.5% and 22.7%, respectively. Abdominal pain completely disappeared or was partially improved in 14 patients. Hepatic function recovered in all patients.

CONCLUSION: Endoscopic treatment is a safe, effective and mini-invasive method for chronic pancreatitis with benign biliary stricture.

Pancreatic pseudocysts: observation, endoscopic drainage, or resection?

BACKGROUND

Pancreatic pseudocysts are a common complication of acute and chronic pancreatitis. They are diagnosed with imaging studies and can be treated successfully with a variety of methods: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, laparoscopic surgery, or open pseudocystoenterostomy.

METHODS

Relevant publications that appeared from 1975 to 2008 were retrieved from the MEDLINE, PubMed and EMBASE databases for this review.

RESULTS

Endoscopic pseudocyst drainage has a high success rate (79.2%) and a low complication rate (12.9%). Percutaneous drainage is mainly used for the emergency treatment of infected pancreatic pseudocysts. Open internal drainage and pseudocyst resection are surgical techniques with high success rates (>92%), but also higher morbidity (16%) and mortality (2.5%) than endoscopic treatment (mortality 0.7%). Laparoscopic pseudocystoenterostomy, a recently introduced procedure, is probably similar to the endoscopic techniques with regard to morbidity and mortality.

CONCLUSIONS

An interdisciplinary approach is best suited for the safe and effective stage-specific treatment of pancreatic pseudocysts. The different interventional techniques that are currently available have yet to be compared directly in randomized trials.

Endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic collections

OBJECTIVE

To evaluate the role of endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic fluid collection.

METHODS

The clinical data of patients with symptomatic pancreatic fluid collection referred for endoscopic drainage were captured prospectively and analyzed. Pancreatic duct disruption was treated with stenting. Endosonography-guided transmural drainage and endoscopic necrosectomy were performed when indicated.

RESULTS

Fifteen consecutive patients (mean age 53.7 years; range 23-82 years) underwent endoscopic management of pancreatic fluid collections (pseudocysts: six; abscesses: six; infected walled-off necrosis: three). Pancreatic duct fistulas were present in 13 patients. The drainage techniques used were: (i) transpapillary drainage; five; (ii) transmural drainage; two (these two patients had no pancreatic duct fistulas); and (iii) combined transpapillary and transmural drainage; eight. An additional transgastric endoscopic necrosectomy was performed in five patients. The endoscopic treatment was successful in all cases. The only complication was asymptomatic pneumo-peritoneum that occurred in one patient. Combined transpapillary and transmural drainage led to the faster resolution of the fluid collection compared to transpapillary drainage (75.6 vs 147 days, P = 0.03). No recurrence occurred over a mean follow up of 486 days.

CONCLUSION

Endoscopic drainage and endoscopic necrosectomy are safe and effective techniques for the treatment of symptomatic pancreatic fluid collection.

EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis

Endoscopic ultrasound (EUS)-guided drainage has emerged as the leading treatment modality for symptomatic pancreatic fluid collections. Endoscopic ultrasound-guided endoscopic drainage is less invasive than surgery and avoids local complications related to percutaneous drainage. In addition, unlike non-EUS guided endoscopic drainage, EUS-guided drainage is able to drain non-bulging fluid collections and may reduce the risk of procedure-related bleeding. Excellent treatment success rates exceeding 90% have been reported for pancreatic pseudocysts and abscesses. In the context of infected pancreatic necrosis, adjunctive endoscopic necrosectomy is required for effective treatment. With such an aggressive approach, the treatment success rate may reach 81%-92%. The potential complications of concern for EUS-guided drainage are severe bleeding and perforation. To minimize risk, only fluid collections with a mature wall and within 1 cm of the gastrointestinal lumen should undergo endoscopic drainage. Any coagulopathy, if present, should be corrected. Patients with pseudocysts undergoing drainage should also receive prophylactic antibiotics in order to prevent secondary infection of a sterile collection.

Pancreatic pseudocyst

Pancreatic pseudocysts are complications of acute or chronic pancreatitis. Initial diagnosis is accomplished most often by cross-sectional imaging. Endoscopic ultrasound with fine needle aspiration has become the preferred test to help distinguish pseudocyst from other cystic lesions of the pancreas. Most pseudocysts resolve spontaneously with supportive care. The size of the pseudocyst and the length of time the cyst has been present are poor predictors for the potential of pseudocyst resolution or complications, but in general, larger cysts are more likely to be symptomatic or cause complications. The main two indications for some type of invasive drainage procedure are persistent patient symptoms or the presence of complications (infection, gastric outlet or biliary obstruction, bleeding). Three different strategies for pancreatic pseudocysts drainage are available: endoscopic (transpapillary or transmural) drainage, percutaneous catheter drainage, or open surgery. To date, no prospective controlled studies have compared directly these approaches. As a result, the management varies based on local expertise, but in general, endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate. A tailored therapeutic approach taking into consideration patient preferences and involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and pancreatic surgeon should be considered in all cases.

Operative and nonoperative management of pancreatic pseudocysts

The management of pancreatic pseudocysts has changed greatly over the last decade. As laparoscopic and endoscopic techniques continue to evolve, their use in the treatment of pseudocysts has gained acceptance, whereas the role of percutaneous drainage has become more limited. The literature on laparoscopic, endoscopic, and percutaneous management of pancreatic pseudocyst is reviewed here and, based on these data, a treatment algorithm is suggested.

Endoscopic drainage of pancreatic pseudocysts

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis, pancreatic trauma, or after surgery. Endoscopic treatment of pancreatic pseudocysts can be achieved using transpapillary and/or transmural (transgastric or transduodenal) approaches with acceptable success rates, complication rates, and recurrence rates. Advantages of endoscopic drainage is the avoidance of external pancreatic fistula.

Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis

BACKGROUND

In patients with chronic pancreatitis, an actively bleeding pseudoaneurysm can be life-threatening. Angioembolization is an attractive alternative to often complex operative management, and its feasibility was assessed in a retrospective analysis.

METHODS

During 1993-2005, 33 patients (27 males, median age 51 years) with bleeding pancreatic pseudoaneurysms underwent urgent angiographic evaluation followed by angioembolization if possible. Angioembolization was performed in 23 patients, whereas 10 patients required hemostatic surgery, including 6 distal pancreatectomies and 3 vessel ligations.

RESULTS

Between 1993 and 2005 33 out of 745 patients (4.4%) admitted for chronic pancreatitis had bleeding pancreatic pseudoaneurysms. The proportion of bleeders out of the total number of hospital admissions for chronic pancreatitis was 33 out of 1,892 (1.7%). The overall success rate of angioembolization was 22 out of 33 (67%) including 3 patients requiring re-embolization for recurrent bleeding. The success rate was 16 out of 20 (80%) when the pseudocyst was in the head of the pancreas, and only 50% when the splenic artery was the source of bleeding. Four of the 5 cases with free bleeding into the peritoneal cavity required operative intervention. The overall mortality and morbidity rates were 2 out of 33 (6%) and 7 out of 33 (21%) respectively, with no significant differences between embolized and operated patients. Angioembolization was associated with a significantly lower need for total blood transfusions and length of hospital stay. During the years 2000-2005, the overall success rate of angioembolization was 95%.

CONCLUSIONS

All hemodynamically stable patients with chronic pancreatitis and bleeding pseudoaneurysms should undergo prompt initial angiographic evaluation and embolization if possible. Repeated angioembolization is feasible in patients with recurrent bleeding, whether initially embolized or operated. Patients with unsuccessful embolization should undergo emergency hemostatic surgery with ligation of the bleeding vessel in the head of the pancreas and distal resection in patients bleeding from the splenic artery or its branch. The combination of angioembolization and later endoscopic drainage of the pseudocyst via endoscopic retrograde cholangiopancreatography (ERCP) is effective in the majority of the cases of pseudoaneurysms in chronic pancreatitis.

Treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.

The management of suspected pancreatic sepsis

The management of infected pancreatic necrosis is centered on image-guided fine needle aspiration followed by antibiotic therapy that is based on microbiologic culture results. The authors favor targeted antibiotic therapy rather than routine prophylactic antibiotic coverage. Prompt surgical debridement is recommended for patients who have infected necrosis who are suitable operative candidates. Newer surgical, percutaneous, and endoscopic techniques, as well as prolonged antibiotic therapy without intervention, are being evaluated as alternatives to operative debridement. Well-designed prospective trials will help to determine optimal treatment for patients who have infected pancreatic necrosis.