Outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts by using combined endoprosthesis and a nasocystic drain

Endoscopic interventions for managing pancreatic fluid collections associated with acute pancreatitis: A state-of-the-art review (with videos)

Acute pancreatitis is an acute inflammatory disease, which may be associated with pancreatic and peri-pancreatic necrosis and development of (peri)pancreatic fluid collections (PFCs). Interventions in acute pancreatitis have evolved over the years with a paradigm shift from open surgical drainage and necrosectomy to minimally invasive approaches. Depending on the presence of necrosis, the PFCs may be acute necrotic collections or acute pancreatic fluid collections, which evolve over a period of three to four weeks to walled-off necrosis and pseudocysts, respectively. Patients with symptomatic and infected PFCs require drainage. In general, drainage should be delayed beyond three to four weeks when the collection wall has matured and the necrotic debris is liquefied. However, some patients may merit early drainage (within the first three to four weeks), if they have suspected infected pancreatic necrosis and worsening organ dysfunction despite antibiotics and supporting therapy. Endoscopic transmural drainage and necrosectomy have now emerged as the most favored treatment modality in suitable pancreatic collections located predominantly in the lesser sac. Being minimally invasive, per-oral endoscopic direct necrosectomy is as effective as surgical necrosectomy in patients with infected necrotic collections but with fewer adverse events. Percutaneous endoscopic necrosectomy is an important addition to our armamentarium for laterally placed collections as an effective alternative to surgical video-assisted retroperitoneal debridement. The current review provides an overview of the evolution, indications, approaches, techniques and outcomes of endoscopic interventions in the management of pancreatic fluid collections associated with acute pancreatitis. Future direction for better outcomes has been highlighted.

Approach to the Diagnosis and Management of Infected Pancreatic Necrosis: A Narrative Review

Infected pancreatic necrosis (IPN) is a dreaded complication of acute necrotizing pancreatitis and is linked to persistent organ failure, sepsis, and increased morbidity and mortality. Clinical indicators of IPN include fever, clinical deterioration, and worsening inflammatory markers. The diagnosis of IPN is based on clinical signs, microbiological confirmation, and radiological evidence, with contrast-enhanced CT being the preferred imaging modality. In the absence of tests with high sensitivity, a high clinical suspicion is required for early recognition and treatment. Although there is no way to prevent IPN, a systematic management approach with parenteral antibiotics, nutritional management, and minimally invasive procedures has become the cornerstone of the treatment. The step-up approach includes minimally invasive procedures that minimize procedure-related complications and are associated with improved outcomes. The percutaneous route remains the most common route for drainage, while endoscopic interventions are preferred for perigastric or periduodenal encapsulated collections. The use of lumen-apposing metal stents is associated with excellent outcomes in cases of infected walled-off necrosis. Patients with significant quantities of infected necrosis may benefit from direct or percutaneous endoscopic necrosectomy. Minimally invasive surgical techniques followed by open surgeries are reserved for patients who do not improve with percutaneous or endoscopic necrosectomies. The outcome can be maximized through a multidisciplinary approach by a team of interventional radiologists, advanced therapeutic endoscopists, and surgeons.

Guidewire-assisted successful closure of mis-punctured transverse colon during endoscopic ultrasound-guided cyst drainage

Endoscopic ultrasound-guided cyst drainage (EUS-CD) was performed for walled-off pancreatic necrosis. Computed tomography performed the next day showed that the tip of the external drainage tube was located in the transverse colon, confirming an accidental EUS-CD-associated complication of mis-puncture. A colonoscopy was performed to confirm the puncture site, which was identified as a defect measuring 2 mm in diameter. The external drainage tube was removed immediately via a guidewire. We intentionally retained the guidewire as a landmark for the puncture site in the colon. The defect was approximated using an endoclip under full vision, with the guidewire covered with surrounding mucosa. After removing the guidewire smoothly, complete closure was achieved with additional endoclips. Four days later, EUS-CD was successfully repeated, resulting in the resolution of the walled-off pancreatic necrosis. This is the first known case in which an accidental puncture of the transverse colon occurred during EUS-CD for walled-off pancreatic necrosis, and guidewire-guided clip closure of the colon contributed to troubleshooting.

Endoscopic Step-Up Approach in Management of Necrotizing Pancreatitis

The endoscopic step-up approach in the management of necrotizing pancreatitis involves sequential steps of intervention at different time points in the clinical course of the disease. EUS -guided drainage of walled-off necrosis is the first step of the endoscopic step-up approach. Lumen-apposing metal stents are preferred over plastic stents for safe and effective drainage because of their wide caliber. Successive steps in the endoscopic step-up approach include direct endoscopic necrosectomy and/or irrigation using naso-cystic tube in symptomatic patients, primarily based on necrotic debris characteristics. Minimally invasive percutaneous radiological and/or surgical drainage are considered when endoscopic drainage is not feasible or successful.

Endoscopic Drainage of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) are commonly encountered complications of acute and chronic pancreatitis. With the advancement of endoscopic ultrasound (EUS) techniques and devices, EUS-directed transmural drainage of symptomatic or infected PFCs has become the standard of care. Traditionally, plastic stents have been used for drainage, although lumen-apposing metal stents (LAMSs) are now favored by most endoscopists due to ease of use and reduced procedure time. While safety has been repeatedly demonstrated, follow-up care for these patients is critical as delayed adverse events of indwelling drains are known to occur.

Infected pancreatic necrosis-Current trends in management

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Indications, Techniques and Future Perspectives of Walled-off Necrosis Management

Necrotizing pancreatitis is a complex clinical condition burdened with significant morbidity and mortality. In recent years, the huge progress of interventional endoscopic ultrasound (EUS) has allowed a shift in the management of pancreatic necrotic collections from surgical/percutaneous approaches to mini-invasive endoscopic internal drainage and debridement procedures. The development of lumen-apposing metal stents (LAMSs), devices specifically dedicated to transmural EUS interventions, further prompted the diffusion of such techniques. Several studies have reported excellent outcomes of endoscopic interventions, in terms of technical success, clinical efficacy and safety compared to surgical interventions, and thus endoscopic drainage of walled-off necrosis (WON) has become a fundamental tool for the management of such conditions. Despite these advancements, some critical unresolved issues remain. Endoscopic therapeutic approaches to WON are still heterogeneous among different centers and experts. A standardized protocol on indication, timing and technique of endoscopic necrosectomy is still lacking, and experts often adopt a strategy based on personal experience more than robust data from well-conducted studies. In this review, we will summarize the available evidence on endoscopic management of WON and will discuss some unanswered questions in this rapidly evolving field.

From Scalpel to Scope: How Surgical Techniques Made Way for State-of-The-Art Endoscopic Procedures

The continuous evolution of endoscopic tools over the years has paved the way for minimally invasive alternatives to surgical procedures for multiple gastrointestinal conditions. While few endoscopic techniques have supplanted their surgical counterparts like percutaneous gastrostomy tubes, many have emerged as noninferior, less morbid alternatives for such diverse conditions as achalasia (peroral endoscopic myotomy), obesity (endoscopic sleeve gastroplasty), drainage of pancreatic walled off necrosis (EUS-guided cystogastrostomy), and gastric outlet obstruction (EUS-guided gastrojejunostomy). These techniques were based on surgical concepts and would not have been feasible without collaboration between surgeons and endoscopists. Such collaboration is exemplified by the antireflux fundoplication, which features combined hiatal hernia repair with transoral and incisionless fundoplication. The burgeoning armamentarium of endoscopic alternatives to traditional surgical procedures requires a multidisciplinary discussion and individually tailored treatment plans that consider patient preferences as well as the relative risks and benefits of surgical and endoscopic approaches. As technological advances give rise to ever more innovative endoscopic techniques, studies to evaluate clinical outcomes and define their role in treatment algorithms will be required.

Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum

Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e. the step-up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.

Endoscopic treatment of pancreatic necrosis: Still searching for perfection!

Over last few years, there has been a paradigm shift in the management of infected pancreatic necrosis with endoscopic and minimally invasive "step-up" management approach replacing open surgical necrosectomy. Because of being associated with reduced occurrence of new onset multi-organ failure, external pancreatic fistulae, shorter hospital stay, lower costs, and better quality of life compared with minimally invasive surgical approach, endoscopic "step-up" management approach is the preferred intervention for endoscopically accessible pancreatic necrotic collections at expert centers with endoscopic expertise. Development of lumen apposing metal stents and improvised accessories for interventional endoscopic ultrasound has revolutionized the endoscopic management of pancreatic necrosis making it more effective and safer. Despite these promising developments, endoscopic transluminal necrosectomy (ETN) remains the Achilles heel. Lack of dedicated endoscopic accessories, poor endoscopic visualization within the necrotic cavity, limited diameter of the instrument channel of the endoscope that is a significant impediment to remove large amount of necrotic material, and uncertain ability to avoid vessels and vital structures in the necrotic cavity are important limitations during endoscopic necrosectomy. Recent devices and solutions including use of cap assisted necrosectomy, over the scope grasper and powered endoscopic debridement device are welcome steps in our pursuit for an ideal, safer, and efficacious ETN device. This review will discuss recent advances as well as challenges in the endoscopic management of pancreatic necrosis.

Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach?

Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4 weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation.

Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives

Pancreatic fluid collections (PFCs) commonly develop as complications of acute pancreatitis and ductal disruption due to chronic pancreatitis. In the revised Atlanta classification, PFCs were classified based on the presence of necrosis and duration following the onset of acute pancreatitis. Interventions are required in cases of symptomatic pancreatic pseudocysts or walled-off necrosis (WON). In the management of these PFCs, endoscopic ultrasound-guided transluminal drainage and subsequent direct endoscopic necrosectomy for WON are increasingly utilized as less invasive treatment modalities compared to surgical debridement. To date, researchers have focused predominantly on the technical aspects of endoscopic therapy for symptomatic PFCs. Given the poor physical condition of patients receiving endoscopic treatment for PFCs, systemic support may have a substantial impact on the short- and long-term outcomes of these patients. A multidisciplinary approach is required to improve the clinical outcomes of patients with infected PFCs and their associated comorbidities. However, non-interventional support during the periprocedural period of endoscopic treatment of PFCs has not been fully discussed, and there have been considerable variations in the selection of treatment options between endoscopists and centers. To address these unmet needs in the clinical management of PFCs and promote future research to improve the clinical outcomes, we conducted a review of the literature within a multicenter consortium of expert endoscopists with specific expertise in the endoscopic treatment of PFCs. In this review, we summarize the current evidence on non-interventional supportive care (e.g., continuous lavage, medications, nutritional support, and antimicrobials) and propose potential topics for future research.

"Orphaned" Stomach-An Infrequent Complication of Gastric Bypass Revision

While generally safe, bariatric operations have a variety of possible complications. We present an uncommon complication after gastric bypass revision, namely the creation of an "orphaned" segment of remnant stomach that was left inadvertently in discontinuity, leading to recurrent intra-abdominal abscesses. Sinogram ultimately proved the diagnosis, and the issue was successfully treated using a combination of surgical and endoscopic methods to control the abscess and to allow internal drainage.

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Management of pancreatic fluid collections

Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).

Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know

Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.

[Interventional endoscopic treatment in acute pancreatitis]

BACKGROUND

Acute pancreatitis (AP) represents a frequent gastrointestinal diseases. Approximately 80% of patients have a mild course of the disease and conservative treatment is sufficient; however, 20% of patients develop a severe AP with local and systemic complications. This article focuses on the currently recommended endoscopic management of severe AP.

OBJECTIVE

Classification of AP by the revised Atlanta classification and the occurrence of local or systemic complications. Summary of current evidence with respect to endoscopic management.

MATERIAL AND METHODS

Inspection of the current literature from specialist journals and current guidelines.

RESULTS

The AP is classified as mild, moderate or severe based on systemic (hypotension, renal failure, lung failure) and/or local complications, such as acute peripancreatic fluid collections (APFC), peripancreatic pseudocysts (PPC), acute necrotic collections (ANC) and walled-off necrosis (WON). In recent years the staged endoscopic treatment of infected ANC, WON and PPC has become established. The initial step is the endoscopic ultrasound-guided puncture and drainage with plastic or lumen-apposing metal stents. For solid components or insufficient drainage, a transgastric endoscopic necrosectomy is recommended. The treatment of severe AP requires an interdisciplinary management in specialized centers and regular re-evaluation of the therapeutic efficacy.

CONCLUSION

Interventional endoscopy has become established as the standard for treatment of severe AP.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Endoscopic Transmural Drainage and Necrosectomy in Acute Necrotizing Pancreatitis: A Review

Acute necrotizing pancreatitis occurs in 10%-20% of patients with acute pancreatitis (AP) which is one of the most important acute abdominal diseases that require hospital admission. Pancreatic necrosis is also associated with high mortality and morbidity. In the past 20 years, the treatment of pancreatic necrosis has shifted from open necrosectomy to minimally invasive techniques, such as endoscopic interventions. With the development of endoscopic techniques, the safety and effectiveness of endoscopic interventions have improved, but there exist several unresolved problems. Currently, there is no unified standard approach for endoscopic treatment of pancreatic necrosis that takes into account local expertise, anatomical features of necrosis, patients' preferences, and comorbidity profile. We reviewed the current status of endoscopic therapy for acute necrotizing pancreatitis, focusing on the new endoscopic drainage technique and necrosectomy protocol.

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 cystogastrostomy: Still a viable option in children with symptomatic pancreatic fluid collection

BACKGROUND/OBJECTIVES

Endoscopic transmural drainage is the preferred method of drainage of pancreatic fluid collections (PFCs) in adults; however, there is scant literature in children. We analyzed our experience of 33 endoscopic cystogastrostomies done in 29 children to find its efficacy and safety.

METHODS

We retrospectively analyzed the prospectively collected database of 31 consecutive children (<18 years) who underwent endoscopic cystogastrostomy from June 2013 to December 2017. The procedure was done using the standard technique with an adult duodenoscope. Data related to clinical details, technical success, complications and follow-up were collected.

RESULTS

The median age was 14 (3-17) years (22 males). Indications were early satiety in 28 (90%), vomiting in 15 (48%), and duodenal obstruction and infected pseudocyst in 2 children each. Etiology includes acute pancreatitis 22, post-traumatic 4 and chronic pancreatitis 5. The procedure was successful in 29 of 31 (93.5%) children with no mortality. Adverse events happened in four cases (12.9%); two infections, another with bleeding and another with pneumoperitonium, both of which resolved spontaneously. Incidents (minor bleeding) were noted in 6 (19%). Stents were removed in 26 (90%) after 12 (7-20) weeks and got spontaneously migrated out in 3 (10%) cases. Over a median follow-up of 26 (5-48) months, 26 (90%) had no recurrence of pseudocyst and 3 (10%) had recurrence of a small, asymptomatic pseudocyst.

CONCLUSIONS

Endoscopic cystogastrostomy is a safe and effective method of draining bulging PFCs in children. The procedure carries acceptable morbidity with minimal recurrence. In younger children it may be the preferred method of drainage of PFCs.

International, multicenter retrospective trial comparing the efficacy and safety of bi-flanged versus lumen-apposing metal stents for endoscopic drainage of walled-off pancreatic necrosis

Background

To compare fully covered bi-flanged metal stents (BFMS) and lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainage/debridement of pancreatic walled-off necrosis (WON).

Methods

Patients with WON managed by EUS-guided therapy were divided into those who underwent: 1) drainage using BFMS; and 2) drainage using LAMS and scheduled direct endoscopic necrosectomy (DEN). Clinical success (resolution of the WON), technical success (successful stent placement), and adverse events (AEs) were evaluated.

Results

387 patients underwent WON endoscopic drainage, 205 using BFMS and 182 using LAMS. The clinical success in the BFMS or LAMS groups were similar (197 [96.1%] vs. 174 [95.6%]; P=0.81). Median number of procedures required for WON resolution was significantly lower in BFMS compared to LAMS (2 vs. 3, P<0.001). Technical success for stent placement was similar in BFMS and LAMS groups (203 [99%] vs. 180 [99%], P=0.90). Procedure-related AEs were similar in the BFMS and LAMS groups (19 [9.3%] vs. 20 [10.9%], P=0.61). Stent dysfunction with occluding debris was higher in the BFMS group compared to LAMS group (21 [10.2 %] vs. 11 [5.9%], P=0.04). The migration rate was higher in the BFMS group than in the LAMS group (15 [7.3%] vs. 3 [1.6%]; P<0.001). DEN was required in 23 [11.2%] patients in the BFMS group after lack of WON resolution by conservative means.

Conclusion

BFMS with a “step-up approach” and LAMS with scheduled DEN are both safe and effective for EUS-guided drainage/debridement of WON.

Pancreatic pseudocyst: Dilemma of its recent management (Review)

Advances in radiological techniques have led to an increase in the number of diagnoses of pancreatic pseudocyst, which is the most common pancreatic cyst lesion disease, accounting for two-thirds of all pancreatic cyst lesions. Historically, the management of pancreatic pseudocyst has been achieved through the use of conservative treatments and surgery; however, due to the complications and recurrence rate associated with these techniques, the management of pancreatic pseudocyst is challenging. Surgeons and gastroenterologists have attempted to determine the optimal management technique to treat pancreatic pseudocyst to reduce complications and the recurrence rate. From these investigations, percutaneous catheter, surgical and endoscopic drainage with ultrasonography guidance have become promising management techniques. The present review aimed to summarize the diagnostic and therapeutic methods used for the management of pancreatic pseudocyst and to compare percutaneous catheter, surgical and endoscopic drainage.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections

Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.

Giant pseudocyst of the pancreas: A report of three cases

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Giant pseudocysts of pancreas may not be as rare as they were thought to be.

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They can be effectively managed by cysto-gastrostomy.

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Gastroscopy is a useful tool for follow up.

Background

A Pancreatic pseudocyst is usually a complication of pancreatitis but may follow abdominal trauma in children. Giant pseudocysts are rare and usually complicate chronic pancreatitis.

Aim

To report 3 cases of giant pseudocysts of the pancreas managed in our Centre within a three-month-period.

Case reports

Two female patients aged 22 years and 65 years respectively, and an 11-year-old boy presented with giant pancreatic pseudocysts (>10 cm in diameter each) to our unit and were successfully managed.

They all underwent exploratory laparotomy and cysto-gastrostomy with good outcome.

Conclusion

Giant pseudocysts of pancreas may not be as rare as they were thought to be. They can be effectively managed by cysto-gastrostomy

Endoscopic drainage with local infusion of antibiotics to avoid necrosectomy of infected walled-off necrosis

BACKGROUND

Current treatment of infected pancreatic necrosis (IPN) follows a step-up approach. Our group designed a step-up protocol that associates endoscopic drainage with local infusion of antibiotics through transmural nasocystic catheter. Aim of our study was to evaluate our step-up protocol for IPN in terms of proportion of patients avoiding necrosectomy.

METHODS

Retrospective analysis of patients admitted with acute pancreatitis (AP) between January 2015 and December 2018. The number of patients who responded to each therapeutic step were analysed: step 1, systemic antibiotics; step 2, endoscopic transmural drainage and local infusion of antibiotics; step 3, endoscopic necrosectomy.

RESULTS

1158 patients with AP were included. 110 patients (8.4%) suffered from necrotising pancreatitis; 48 of them had IPN (42.6% of necrotising pancreatitis) and were treated with systemic antibiotics. Nineteen patients (39.6% of IPN) responded and did not required any invasive therapy. Six patients with IPN on systemic antibiotics died within the first 4 weeks of disease before step 2 could be applied. Urgent surgical necrosectomy in the first 4 weeks was performed in three additional patients. Endoscopic drainage and local antibiotic therapy was performed in the remaining 20 patients; 9 (45% of them) did well and 9 patients underwent necrosectomy (18.7% of IPN). Two patients died on drainage. Overall mortality of the total cohort of AP was 2.53% CONCLUSIONS: Addition of local infusion of antibiotics to endoscopic drainage avoids the need of necrosectomy in half of patients with IPN not responding to systemic antibiotics.

Lumen-apposing metal stents versus biliary fully-covered metal stents for EUS-guided drainage of pancreatic fluid collections: a case control study: Meeting presentations: European Society of Gastrointestinal Endoscopy ESGE Days 2018

Background and study aims  Endoscopic ultrasound (EUS)-guided drainage has become first-line treatment for pancreatic fluid collections (PFC). The aim of this study was to compare the effectiveness and safety of biliary fully-covered self-expandable metal stents (BFCSEMS) and lumen-apposing metal stents with electrocautery (EC-LAMS). Patients and methods  From April 2008 to March 2017, consecutive patients with symptomatic PFC drained under EUS-guidance with metal stents were included. Patients drained with EC-LAMS were considered the study group and those drained with BFCSEMS the control group. Two primary endpoints were evaluated: effectiveness (defined as reduction of ≥ 50 % of PFC size in cross-sectional imaging and improvement of symptoms 6 months after the transmural drainage) and safety. Results  Thirty patients were drained with EC-LAMS and 60 patients with BFCSEMS. Patients and PFC baseline characteristics in both groups were similar. Use of a coaxial double pigtail plastic stent and a nasocystic lavage catheter was significantly less frequent in patients drained with EC-LAMS (33 % vs. 100 %, and 13 % vs. 58 %, respectively; P  < 0.0001). Technical success was 100 % in both groups. Procedure time was < 30 minutes in all patients drained with EC-LAMS and over 30 minutes in all patients drained with BFCSEMS ( P  = 0.0001). Clinical success was higher with a tendency to significance in patients drained with EC-LAMS (96 % vs. 82 %, P  = 0.055) and the adverse event rate was lower (4 % vs. 18 %, P  = 0.04). No case of procedure-related mortality was recorded. Conclusions  EC-LAMS and BFCSEMS are both effective for EUS-guided drainage of PFC. However, EC-LAMS requires less time to be performed and appears to be safer.

Efficacy and Safety of Lumen-Apposing Stents for Management of Pancreatic Fluid Collections in a Community Hospital Setting

Background/Aims

Endoscopic ultrasound-guided transmural drainage and necrosectomy employing lumen-apposing metal stent (LAMS) are used for treating pancreatic fluid collections (PFCs) with excellent results from academic centers. Herein, we report the efficacy and safety of LAMS in the treatment of PFCs at a community hospital.

Methods

We retrospectively reviewed the etiology of pancreatitis, type and size of PFCs, length of procedure, technical success, clinical success, adverse events, and stent removal. The primary outcome was the rate of clinical success, and secondary outcomes were technical success and adverse events.

Results

Twenty-seven patients with a mean age of 54.1±6.5 years were included, 44% of which were men. The mean size of the PFCs was 9.7±5.0 cm (range, 3–21). The most common etiology of pancreatitis was alcohol (44%) followed by idiopathic causes (30%) and presence of gallstones (22%). The diagnosis was pseudocyst in 44.4% (12/27) and walled off necrosis in 55.6% (15/27) of patients. There was 100% technical success without any complications. Clinical success was achieved in 22 of 27 patients (81.5%) who underwent stent removal.

Conclusions

Our study is the first to report that endoscopic therapy of PFCs using LAMS is safe and effective even in a community hospital setting with limited resources and support compared to large academic centers.

Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach

The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.

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.

Endoscopic Drainage of Pancreatic Fluid Collections

Endoscopy has emerged as a mainstay in the management of pancreatic fluid collections (PFCs), representing an important advance in clinical medicine that has significantly improved the risk-benefit ratio of treating this complex patient population. While endoscopic pseudocyst drainage has generally supplanted surgical and percutaneous approaches, the optimal strategy for walled-off necrosis remains variable and multi-disciplinary despite an emerging trend from randomized trials favoring endoscopy. Although several issues pertaining to endoscopic drainage appear to have been settled - such as the use of endoscopic ultrasound - other pressing questions - including the optimal prosthesis and debridement strategy - remain unanswered, and rigorous investigation is needed. This review aims to provide an evidence-based but practical appraisal of the endoscopic drainage of PFCs through the perspective of the author, with an emphasis on relevant clinical and endoscopic considerations and important research questions.

Systematic Review of Endoscopic Cyst Gastrostomy

Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents.

Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections

Pancreatic fluid collections (PFCs), common sequelae of acute or chronic pancreatitis, are broadly classified as pancreatic pseudocysts or walled-off necrosis according to the revised Atlanta classification. Endoscopic ultrasound (EUS)-guided drainage is often considered a standard first-line therapy preferable to surgical or interventional radiology approaches for patients with symptomatic PFC. EUS-guided drainage is effective and successful; it has a technical success rate of 90%-100% and a clinical success rate of 85%-98%. Recent studies have shown a 5%-30% adverse events (AEs) rate for the procedure. The most common AEs include infection, hemorrhage, perforation and stent migration. Hemorrhage, a severe and sometimes deadly outcome, requires a well-organized and appropriate treatment strategy. However, few studies have reported the integrated management of hemorrhage during EUS-guided drainage of PFC. Establishing a practical therapeutic strategy is an essential and significant step in standardized management. The aim of this review is to describe the current situation of EUS-guided drainage of PFCs, including the etiology and treatment of procedure-related bleeding as well as current problems and future perspectives. We propose a novel and meaningful algorithm for systematically managing hemorrhage events. To our limited knowledge, a multidisciplinary algorithm for managing EUS-guided drainage for PFC-related bleeding has not been previously reported.

Endoscopic Management of Infected Necrotizing Pancreatitis: an Evidence-Based Approach

PURPOSE OF REVIEW

Endoscopic management of infected necrotizing pancreatitis has evolved rapidly over the past years and there have been interesting innovations in this field. This review provides an update on the most recently published literature regarding endoscopic management of infected necrotizing pancreatitis.

RECENT FINDINGS

A recent randomized trial demonstrated no difference in mortality and major morbidity between endoscopic and surgical step-up treatment of infected necrotizing pancreatitis. However, endoscopic therapy resulted in shorter hospital stay and less pancreatic fistulas. Various innovations have been investigated with the aim to further optimize endoscopic therapy, in particular lumen-apposing metal stents. While major stent-related complications were also reported, findings from recent studies indicated that their use was associated with higher resolution rates of walled-off necrosis compared to double-pigtail stents. Other innovations, such as the multiple gateway technique and dual-modality mode, can be considered for treatment of particular cases. Furthermore, research suggests that irrigation of walled-off necrosis can be performed by using a nasocystic tube and discontinuation of proton-pump inhibitors may be considered. Endoscopic treatment should be the preferred treatment modality in patients with infected necrotizing pancreatitis who are eligible for endoscopic drainage. Although data suggests that lumen-apposing metal stents are superior to double-pigtail stents, prospective multicenter studies focusing on safety as well as long-term follow-up are first needed.

Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel

OBJECTIVES

Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures.

METHODS

Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question.

RESULTS

A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required.

CONCLUSIONS

The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.

The Role of Endoscopic Ultrasound-guided Drainage for Autoimmune Pancreatitis-associated Pancreatic Cysts: A Report of Five Cases and a Literature Review

Objective Autoimmune pancreatitis (AIP) has been recognized as a benign disease, which that shows a prompt response to corticosteroid treatment (CST). It was previously believed to not be associated with cyst formation; however, a few cases of AIP-associated pancreatic cyst (PC) have been reported. Some cases were reported to have been effectively treated by CST, while others were refractory to CST. Many of the patients received interventional treatment. Until now, there has been no consensus on the therapeutic strategies for AIP-associated PC. The aim of the present study is to describe a therapeutic strategy for this condition. Methods We conducted a retrospective study of 5 cases of AIP-associated PC that were treated by endoscopic ultrasonography-guided pancreatic fluid collection drainage (ESPD) or CST at Tokyo Medical University Hospital between March 2012 and October 2016, analyzed the therapeutic outcomes, and performed a literature review. Results The initial treatments included CST (n=2) and ESPD (n=3). All of the PCs disappeared after treatment In 1 of the patients who received CST case and 3 of the patients who received ESPD; however, the PC did not disappear in one of the patients who received CST (corticosteroid maintenance therapy), even after the dose of corticosteroids was increased; ESPD was eventually performed and the PC disappeared. There were no procedure-related complaints. Conclusion We propose that CST be administered as the first-line treatment for AIP-associated PC, particularly in cases of PC without a history of CST. However, ESPD can be applied to treat cases of corticosteroid refractory PC.

Endoscopic drainage of pancreatic fluid collections: Long-term outcomes in children

BACKGROUND AND AIM

Endoscopic drainage of pancreatic fluid collections (PFC) is the standard of care in adult patients. The literature is limited in children. In the present study, we aim to evaluate the safety and long-term efficacy of endoscopic ultrasound (EUS)-guided drainage of PFC in children.

METHODS

Data of all children (<18 years) with PFC who underwent EUS-guided drainage with plastic stents were analyzed retrospectively for technical feasibility, clinical efficacy and adverse events (AE).

RESULTS

Thirty children (boys 22, girls 8) with PFC underwent EUS drainage (January 2013 to June 2016). Mean age of children was 13.07 ± 3.41 years (5-17 years). Majority of children had idiopathic pancreatitis (23), followed by trauma-related (6) and gallstone-related pancreatitis (1). Of 30 PFC, 13 (43.3%) and 17 (56.7%) were classified as pseudocyst and walled-off necrosis, respectively. Median size of PFC was 95 mm (61-175). EUS drainage was successfully completed in 29 children (technical success 96.7%). Clinical success was achieved in 28/30 (93.3%) children. AE included perforation (2), major bleed (1), minor bleed (2), stent migration (4) and readmission as a result of hematemesis (1). Imaging revealed disconnected pancreatic duct in nine, ductal leak in two and stricture in one child. Cystogastric stents were left in situ in children with disconnected duct. At median follow up of 829 days (150-1230), two recurrences of PFC were noticed.

CONCLUSIONS

EUS-guided drainage using plastic stents is safe and effective in children with PFC. Cystogastric plastic stents can be left safely long term. However, more studies with larger sample sizes are required.

A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy

There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.

Efficacy and safety of metallic stents in comparison to plastic stents for endoscopic drainage of peripancreatic fluid collections: a meta-analysis and trial sequential analysis

Metallic stents are being increasingly used for endoscopic drainage of peripancreatic fluid collections (PFCs) but their superiority over plastic stents has not been proven. We carried out a meta-analysis to consolidate the results from available studies and to suggest evidence-based recommendations. Studies that compared plastic and metallic stents for endoscopic drainage of PFCs and published before October 2016 were searched. Comparisons were performed for clinical success, adverse events, salvage interventions, mortality, technical success and recurrence. We included six studies with 856 patients (479 in the metallic stent group and 377 in the plastic stent group). The clinical success rate was significantly higher with metallic stents than with plastic stents (Mantel-Haenszel odds ratio [MH-OR] 3.22; 95% CI 1.87-5.54; P < 0.001). The rate of adverse events (MH-OR 0.40; 95% CI 0.24-0.65; P < 0.001) and the need for salvage procedures (MH-OR 0.31; 95% CI 0.13-0.70; P = 0.01) were also significantly lower with the use of metallic stents. Subgroup analysis for the type of PFC also found better results with the metallic stents. The results of Egger's regression test (X-axis intercept at -0.63, P = 0.47) and funnel plot did not suggest any significant publication bias. We conclude that compared to plastic stents, the use of metallic stents for endoscopic drainage of PFCs is associated with significantly better clinical success and significantly lower rates of adverse events and the need for salvage procedures. However, further high-quality randomized trials are required to confirm these findings.

Endoscopic management of pancreatic fluid collections-revisited

The development of pancreatic fluid collections (PFC) is one of the most common complications of acute severe pancreatitis. Most of the acute pancreatic fluid collections resolve and do not require endoscopic drainage. However, a substantial proportion of acute necrotic collections get walled off and may require drainage. Endoscopic drainage of PFC is now the preferred mode of drainage due to reduced morbidity and mortality as compared to surgical or percutaneous drainage. With the introduction of new metal stents, the efficiency of endoscopic drainage has improved and the task of direct endoscopic necrosectomy has become easier. The requirement of re-intervention is less with new metal stents as compared to plastic stents. However, endoscopic drainage is not free of adverse events. Severe complications including bleeding, perforation, sepsis and embolism have been described with endoscopic approach to PFC. Therefore, the endoscopic management of PFC is a multidisciplinary affair and involves interventional radiologists as well as GI surgeons to deal with unplanned adverse events and failures. In this review we discuss the recent advances and controversies in the endoscopic management of PFC.

Endoscopic Ultrasound-Guided Management of Pancreatic Fluid Collections: Update and Review of the Literature

Severe acute pancreatitis is often complicated by the development of pancreatic fluid collections (PFCs), which may be associated with significant morbidity and mortality. It is crucial to accurately classify these collections as a pseudocyst or walled-off necrosis (WON) given significant differences in outcomes and management. Interventions for PFCs have increasingly shifted to less invasive strategies, with endoscopic ultrasound (EUS)-guided methods being shown to be safer and equally effective as more invasive surgical techniques. In recent years, many new developments have improved the safety and efficacy of EUS-guided interventions, such as the introduction of lumen-apposing metal stents (LAMS), direct endoscopic necrosectomy (DEN) and multiple other adjunctive techniques. Despite these developments, treatment of PFCs, and infected WON in particular, continues to be associated with significant morbidity and mortality. In this article, we discuss the EUS-guided management of PFCs while reviewing the latest developments and controversies in the field. We end by summarizing our own approach to managing PFCs.

Clinical outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts: a large multicenter study

Background and study aims Data on clinical outcomes of endoscopic drainage of debris-free pseudocysts (PDF) versus pseudocysts containing solid debris (PSD) are very limited. The aims of this study were to compare treatment outcomes between patients with PDF vs. PSD undergoing endoscopic ultrasound (EUS)-guided drainage via transmural stents. Patients and methods Retrospective review of 142 consecutive patients with pseudocysts who underwent EUS-guided transmural drainage (TM) from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM technical success, treatment outcomes (symptomatic and radiologic resolution), need for endoscopic re-intervention at follow-up, and adverse events (AEs). Results TM was performed in 90 patients with PDF and 52 with PSD. Technical success: PDF 87 (96.7 %) vs. PSD 51 (98.1 %). There was no difference in the rates for endoscopic re-intervention (5.5 % in PDF vs. 11.5 % in PSD; P = 0.33) or AEs (12.2 % in PDF vs. 19.2 % in PSD; P = 0.33). Median long-term follow-up after stent removal was 297 days (interquartile range [IQR]: 59 - 424 days) for PDF and 326 days (IQR: 180 - 448 days) for PSD (P = 0.88). There was a higher rate of short-term radiologic resolution of PDF (45; 66.2 %) vs. PSD (21; 51.2 %) (OR = 0.30; 95 % CI: 0.13 - 0.72; P = 0.009). There was no difference in long-term symptomatic resolution (PDF: 70.4 % vs. PSD: 66.7 %; P = 0.72) or radiologic resolution (PDF: 68.9 % vs. PSD: 78.6 %; P = 0.72) Conclusions There was no difference in need for endoscopic re-intervention, AEs or long-term treatment outcomes in patients with PDF vs. PSD undergoing EUS-guided drainage with transmural stents. Based on these results, the presence of solid debris in pancreatic fluid collections does not appear to be associated with a poorer outcome.

Endoscopic Management of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.

Risk factors for infection after endoscopic ultrasonography-guided drainage of specific types of pancreatic and peripancreatic fluid collections (with video)

BACKGROUND

Endoscopic ultrasonography (EUS)-guided drainage is widely used for the treatment of specific types of peripancreatic fluid collections (PFCs). Infectious complications have been reported. It is recommended that the infection rate should be assessed by measuring risk factors. The objectives of this study were to measure whether the risk of infection after EUS-guided drainage was associated with patient- and procedure-related factors.

METHODS

Eighty-three patients were eligible for inclusion from September 2008 to November 2012. EUS-guided drainage was performed in all patients. Infectious complications were observed, and data on patient- and procedure-related factors were collected. Patient-related factors mainly included age, sex, etiology of PFC, and cyst location and diameter. Procedure-related factors mainly included approach of EUS-guided drainage and stent diameter. Separate multivariate logistic regression models for all EUS-guided drainage were carried out.

RESULTS

Complete EUS-guided drainage was achieved in all patients. A definitive diagnosis of infection after EUS-guided drainage was made in seven patients. All seven patients had a history of acute pancreatitis, and the cyst diameters were all >15 cm. Three patients had diabetes mellitus.

CONCLUSIONS

The cyst diameter was an independent risk factor for infection. Larger cysts with a diameter >15 cm should perhaps be drained initially with multiple pigtail or a larger diameter self-expandable metal stents to try to avoid infection.

[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.