Drainage of pancreatic fluid collections: is EUS really necessary?

Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management

Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.

Various Endoscopic Techniques for Treatment of Consequences of Acute Necrotizing Pancreatitis: Practical Updates for the Endoscopist

Despite great progress in acute pancreatitis (AP) treatment over the last 30 years, treatment of the consequences of acute necrotizing pancreatitis (ANP) remains controversial. While numerous reports on minimally invasive treatment of the consequences of ANP have been published, several aspects of interventional treatment, particularly endoscopy, are still unclear. In this article, we attempt to discuss these aspects and summarize the current knowledge on endoscopic therapy for pancreatic necrosis. Endotherapy has been shown to be a safe and effective minimally invasive treatment modality in patients with consequences of ANP. The evolution of endoscopic techniques has made endoscopic drainage more effective and reduced the use of other minimally invasive therapies for pancreatic necrosis.

Endoscopic management of pancreatic fluid collections

Pancreatic fluid collections (PFCs) are common complications of acute pancreatitis. Asymptomatic collections do not require drainage while symptomatic or infected collections should be drained. Drainage can be performed surgically, percutaneously, or endoscopically. Recent studies have shown that endoscopic drainage of PFCs is equivalent or superior to surgical or percutaneous drainage, with less complications. Advances in tools and technology coupled with increasing expertise in management of PFCs has resulted in minimally invasive endoscopic drainage, by endosonographic guidance, being the preferred approach. New larger diameter lumen apposing metal stents (LAMS) have simplified the process of drainage. LAMS have also made performing direct endoscopic necrosectomy for walled-off necrosis (WON) easier. Technique, duration, frequency, and tools used for direct endoscopic necrosectomy are variable. Performing PFC drainage requires adequate and fundamental knowledge of diagnostic and basic therapeutic EUS.

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.

[Methods of internal drainage of pancreatic pseudocysts]

AIM

To present own experience of internal drainage and characteristics of its different variants which are applied in various countries.

MATERIAL AND METHODS

Endosonography-assisted internal drainage of pancreatic pseudocysts was performed in 25 patients. Plastic stents were implanted in one stage without change of instruments while metal stents - with change of instruments during manipulation.

RESULTS

Intervention was successful in 24 patients. In 1 case bleeding developed during cystostomy that required open surgery. Plastic and metal stents were used in 11 and 12 patients respectively. 1 patient had two pancreatic pseudocysts. Therefore 2 stents of both types were used in this case. Clinical success was achieved in 91% of cases.

CONCLUSION

Different variants of method resolve problem of surgical approach, stomy and choice of stent. However every technique is targeted to resolve separate problem while single method is not accepted. Further large comparative studies are necessary to define optimal technique of internal drainage.

The role of endoscopic ultrasonography in endoscopic debridement of walled-off pancreatic necrosis--A single center experience

BACKGROUND

In recent years the significance of endoscopic ultrasonography (EUS) has increased. In our center we have also performed EUS-guided cystostomy since 2011. Earlier we had performed this procedure without EUS. Introduction of EUS in our hospital has inspired us to perform a retrospective analysis of the influence of EUS use on the risk of complications and the effectiveness of endoscopic treatment of patients with WOPN.

METHODS

Between years 2001 and 2013 176 patients with symptomatic WOPN underwent endoscopic treatment in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk. The results and complications of treatment in relation to the use of EUS during drainage/debridement were compared retrospectively.

RESULTS

64 patients underwent EUS-guided drainage/debridement of WOPN (group 1). In the case of 112 patients endoscopic drainage/debridement was performed without EUS control (group 2). In group 1 therapeutic success was achieved in 60/64 (93.75%) patients in comparison to 104/112 (92.9%) patients in group 2 (P = 0.870). The mean duration of drainage/debridement in both groups was 25 days - 4-173 days in group 1 and 4-112 days in group 2 (P = 0.519). The complications of endotherapy occurred in 9/64 (14.06%) patients from group 1 in comparison to 29/112 (25.9%) patients from group 2 (P = 0.047).

CONCLUSIONS

In our study the use of EUS during endoscopic drainage/debridement of WOPN significantly reduced the number of procedure-related complications, mainly gastrointestinal bleeding. However, it had no influence on the duration of treatment or the effectiveness of therapy.

Non-fluoroscopic endoscopic ultrasound-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis

BACKGROUND AND AIM

Endoscopic treatment of pancreatic necrosis is less invasive than surgery but is a technically demanding procedure. The aim of the present study was to retrospectively evaluate the safety and efficacy of endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis (WOPN) without the use of fluoroscopy.

METHODS

Over the last 24 months, 20 patients (16 men) with symptomatic non-bulging WOPN were treated endoscopically at Department of Gastroenterology, PGIMER, Chandigarh, India.The WOPN was transmurally approached using a linear echoendoscope and the tract dilated over the wire and multiple stents and a nasocystic drain were placed.

RESULTS

All 20 patients had acute severe pancreatitis and the etiology of pancreatitis was alcohol in 12, gallstones in six and idiopathic in two patients. All patients were symptomatic with pain and six patients had fever and presented 5 to 16 weeks after an acute episode.The size of WOPN ranged from 5 to 16 cm.All 20 patients had marked improvement with radiological resolution noted in 19 patients and only one patient required direct endoscopic necrosectomy. One patient with multiple WOPN had a large peripherally located WOPN that did not resolve after transmural drainage and required an additional percutaneous drainage. One to seven endoscopic sessions were required and all these patients had complete resolution within 6 weeks.There were no complications of the procedure.There has been no recurrence of symptoms in these patients over a median follow up of 14 months.

CONCLUSION

EUS-guided transmural drainage of non-bulging WOPN without the use of fluoroscopy appears to be safe and effective.

Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series

BACKGROUND

Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy.

OBJECTIVE

To report the largest combined experience of DEN performed for WOPN.

DESIGN

Retrospective chart review.

SETTING

Six U.S. tertiary medical centers.

PATIENTS

A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003.

INTERVENTIONS

DEN for WOPN.

MAIN OUTCOME MEASUREMENTS

Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications.

RESULTS

Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN.

LIMITATIONS

Retrospective, highly specialized centers.

CONCLUSIONS

This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.

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 ultrasound in the evaluation of pancreaticobiliary disorders

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

Role of endosonography in drainage of fluid collections and other NOTES procedures

Endosonography (EUS) has become the accepted procedure for drainage of pancreatic fluid collections in the past decade. EUS was shown to be safe and effective and it has been the first-line therapy for uncomplicated pseudocysts. Where walled-off pancreatic necrosis was originally thought to be a contraindication for endoscopic treatment, multiple case series have now shown that these fluid collections also can be treated endoscopically with low morbidity and mortality. Analogous to the treatment of pancreatic fluid collections, others, such as abscesses in the lower and upper abdomen, have also been treated successfully, although there is limited literature in this regard, EUS appears to be a useful technique in natural orifice transluminal endoscopic surgery (NOTES) procedures as well.