Endoscopic ultrasound-guided endoscopic necrosectomy of the pancreas: is irrigation necessary?

The 1st i-EUS consensus on the management of pancreatic fluid collections - Part 2

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches. The treatment of patients with PFCs has already focused toward an endoscopy-based approach, and with the development of dedicated lumen-apposing metal stents (LAMS), it has almost totally shifted towards interventional Endoscopic Ultrasound (EUS)-guided procedures. However, there is still limited consensus on several aspects of PFCs treatment within the multidisciplinary management. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript focuses on the second part of the results of a consensus conference organized by i-EUS, with the aim of providing evidence-based guidance on several intra- and post-procedural aspects of PFCs drainage, such as clinical management and follow-up.

Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group, Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Controversies in EUS-guided treatment of walled-off necrosis

This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.

RWON Study: The Real-World Walled-off Necrosis Study

Background/Aims

The management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce.

Methods

Prospectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities.

Results

A total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group.

Conclusions

ED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.

Endotherapy for pancreatic necrosis: An update

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step-up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first-line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.

Endoscopic management of complications of acute pancreatitis: an update on the field

INTRODUCTION

Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances. Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed. Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.

Update: Role of surgery in acute necrotizing pancreatitis

Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably decreased the need for laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.

Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment

Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.

Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management

Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

Endoscopic necrosectomy of walled-off pancreatic necrosis using a lumen-apposing metal stent and irrigation technique

BACKGROUND

Endoscopic management of walled-off pancreatic necrosis (WOPN) is an area of great interest with many still unanswered questions, including the role of mechanical necrosectomy versus irrigation. The aim of this study was to evaluate a new method of endoscopic transmural necrosectomy.

METHODS

Patients with WOPN after necrotizing pancreatitis, who underwent endoscopic transmural necrosectomy using a lumen-apposing metal stent with vigorous irrigation sessions, were prospectively recruited between September 2011 and August 2014. Initial endoscopic session was performed by EUS-guided drainage and lavage sessions by flushing saline through the stent. Technical and clinical success rates, number of repeat interventions, and adverse events were analyzed.

RESULTS

Twelve patients with 13 WOPN collections (median size 12.4 ± 2.94 cm) underwent endoscopic treatment. Clinical success was achieved in 100 % of cases after a median of three sessions per patient (range 2-8). The median length of hospitalization was 15.9 days. Median procedure time of the access session was 31 ± 10.16 min. No adverse events (AE) were described during the procedures or 24 h after. There were four AE (two infections and two bleedings) between sessions, but only two were severe (16.6 %). There was no need for surgery, and no mortalities occurred. Mean time to stent retrieval was 9 ± 3.4 weeks. Mean follow-up was 13 months with only one recurrence at 12 months after stent removal.

CONCLUSIONS

This new variant of irrigation endoscopic transmural necrosectomy without mechanical debridement helps to simplify the technique, is feasible, and has excellent outcomes in WOPN treatment.

Endoscopic necrosectomy under fluoroscopic guidance - a single center experience

INTRODUCTION

Our report presents a technique of necrotic tissue removal during transmural drainage of walled-off pancreatic necrosis (WOPN) that is an alternative to the one that has already been described in the literature.

AIM

To assess the effectiveness and safety of endoscopic necrosectomy performed during transmural drainage of symptomatic WOPN.

MATERIAL AND METHODS

Within the years 2012-2013, 64 patients underwent endoscopic treatment of symptomatic WOPN in our center. Eight patients underwent endoscopic necrosectomy during transmural drainage. Fragments of necrotic tissues were removed from the collection's cavity under fluoroscopic guidance using a Dormia basket. The results and complications of treatment were compared retrospectively.

RESULTS

Sixty-four patients with WOPN underwent transmural drainage under endoscopic ultrasonography (EUS) guidance. Eight patients (12.5%, 5 women and 3 men, mean age 57.25 years) were qualified for endoscopic necrosectomy. Transmural transgastric access was made in 7 patients and transduodenal access in 1 patient. Additional percutaneous drainage was used in 2 patients. Active drainage was continued for 24 days (11-44 days). The mean number of endoscopic procedures was 4.75 (3-9). The average number of necrosectomy procedures during drainage was 1.75 (1-4). Complications of endotherapy occurred in 2/8 (25%) patients, and they were not directly connected with necrosectomy. Therapeutic success after the end of active drainage was achieved in all patients. During a 6-month follow-up no recurrence of the collection was observed.

CONCLUSIONS

Endoscopic necrosectomy under fluoroscopic guidance is an effective and safe method of minimally invasive treatment in a selected group of patients with symptomatic WOPN.

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.

Minimally invasive treatment of infected pancreatic necrosis

Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.

The role of therapeutic endoscopic ultrasound now and for the future

Therapeutic endoscopic ultrasound (EUS) became possible after the advent of the linear echoendoscope and the EUS guided fine needle aspiration. Over the past two decades, the indications for therapeutic EUS have expanded and evidence regarding its utility has been steadily accumulating. Randomized studies have shown EUS to be effective for cancer pain relief (celiac plexus neurolysis), pancreatic fluid collection drainage, and biliary drainage. Prospective studies have shown EUS-guided biliary drainage to be safe and effective in patients with failed ERCP. There is evidence to suggest that EUS is effective for pancreatic duct drainage, gallbladder drainage, and drainage of pelvic collections. EUS may also be useful for targeted cancer treatment via brachytherapy, radiofrequency ablation, or injection therapy. Therapeutic EUS is likely to play an increasingly important role in endoscopic therapy of gastrointestinal diseases in the near future.

Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

Endotherapy for organized pancreatic necrosis: perspectives after 20 years

It has been nearly 20 years since the first peroral endoscopic necrosectomy was performed for patients with pancreatitis. We have since increased our understanding of pancreatitis, and the nomenclature has changed to define disease in which necrosis becomes organized (called "walled-off"). Endoscopic approaches to evaluate and treat pancreatitis have progressed from making small transmural tracts for irrigation to making large tracts, which allow the endoscope to move directly into necrotic cavities and perform endoscopic necrosectomy. The purpose of endoscopic debridement is to irrigate and/or remove areas of necrosis. Collaboration between therapeutic endoscopists and interventional radiologists has led to a combined approach to organized pancreatic necrosis. We discuss the history of peroral endoscopic treatment of organized (walled-off) pancreatic necrosis and current endoscopic approaches to therapy.