Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry

Efficacy of Metal Stents Versus Plastic Stents for Treatment of Walled-Off Pancreatic Necrosis: A Systematic Review and Meta-Analysis

Background

Walled-off necrosis (WON) is a potentially fatal condition best treated endoscopically with metal or plastic stents. This study compares the clinical outcomes of these stents.

Methods

PubMed and Cochrane were searched for trials comparing metal and plastic stents for WON. Primary outcomes were clinical and technical success.

Results

Seven studies with 230 metal stent patients and 226 plastic stent patients were included. Metal stents showed significantly shorter procedure times (SMD -0.80, 95% CI: -1.25 to -0.34), better 4-week clinical success (OR 1.94, 95% CI: 1.00 to 3.77), and higher procedure costs (SMD 1.38, 95% CI: 0.56 to 2.20). No significant differences were observed in hospital stay (SMD -0.05, 95% CI: -0.35 to 0.25), technical success (OR 1.45, 95% CI: 0.22 to 9.43), clinical success (OR 1.13, 95% CI: 0.54 to 2.39), interventions (SMD -0.02, 95% CI: -0.34 to 0.29), need for necrosectomy (RR 1.10, 95% CI: 0.59 to 2.04), necrosectomy sessions (SMD 0.35, 95% CI: -0.42 to 1.11), need for percutaneous drainage (RR 0.82, 95% CI: 0.36 to 1.85), stent migration (RR 0.88, 95% CI: 0.29 to 2.66), bleeding (RR 0.97, 95% CI: 0.53 to 1.75), WON recurrence (RR 1.66, 95% CI: 0.70 to 3.92), treatment failure (death) (RR 0.75, 95% CI: 0.37 to 1.53), disconnected pancreatic duct (RR 0.93, 95% CI: 0.79 to 1.11), and total cost (SMD -0.02, 95% CI: -0.29 to 0.26).

Conclusion

Metal stents offer shorter procedure time and better 4-week clinical success, although at a higher cost, with most clinical outcomes showing no significant differences between stent types.

Timing of lumen-apposing metal stents removal in pancreatic fluid collections: Could we go beyond?

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMS) are the mainstay treatment for pancreatic fluid collections (PFC). A 4-weeks interval for LAMS removal has been suggested to avoid adverse events (AEs). Primary aim is to evaluate the AEs rate in patients with LAMS removal <4 and >4 weeks from placement and possible associated factors.

METHODS

Retrospective study on patients underwent EUS-guided drainage of PFC with LAMS at two Italian centers between January 2017 and November 2023. PFC and LAMS features were collected. AEs were defined as bleeding, obstruction and buried LAMS.

RESULTS

108 patients were enrolled (62.9 % males; mean age 61 ± 14 years old). In 38 % PFC was in pancreatic head. In 64.8 % of patients LAMS ≥15 mm was used. Mean time of LAMS indwelling was 71 ± 87 days and in 73.1 % of patients the LAMS was removed after 4 weeks. AE occurred in 8.3 % of patients and the most common (77.8 %) was bleeding. There was no association between LAMS indwelling >4 weeks (8/9 vs 65/93 p = 0.44) and the rate of AE. A comparable mean time of LAMS persistence (108 ± 96 vs 67 ± 86 p = 0.18) between patients with and without AE was observed. PFC in the head (7/9 vs 33/93 p = 0.02) and LAMS ≥15 mm (9/9 vs 58/93 p = 0.03) were associated with a higher rate of AE.

CONCLUSION

When needed, LAMS removal >4 weeks appears to be as safe as LAMS removal within 4 weeks. LAMS ≥15 mm and Head location were associated with higher rate of AE and thus should arouse more caution.

Role of imaging in evaluating the complications of endoscopic management of pancreatic fluid collections in acute pancreatitis

Acute pancreatitis is associated with local and systemic complications. Pancreatic fluid collection (PFC) is the most common local complication. Infected or symptomatic PFCs need drainage. Endoscopic drainage (ED) is the first-line procedure for accessible PFCs adjacent to the stomach and duodenum. ED is performed under endoscopic ultrasound (EUS) guidance. The technical and clinical success rates of EUS-guided ED in well-encapsulated PFCs are high. ED of poorly encapsulated PFCs is associated with complications. Bleeding and perforation are the most common complications. Contrast-enhanced computed tomography is critical in planning ED and early detection and management of complications. With the increasing utilization of ED for PFC, the radiologist must be familiar with the ED techniques, types of stents, and the complications related to ED. In this review, we discuss the technical aspects of the ED as well as the imaging findings of ED-related complications.

Management of Pancreatic Fluid Collections: An Evidence-based Approach

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

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.

The Role of Lumen-Apposing Metal Stents in Transmural Endoscopic Drainage of Postinflammatory Pancreatic and Peripancreatic Fluid Collections

Rapid development of advanced gastrointestinal endoscopic techniques contributed to the appearance of new biomedical materials including polymers, which are used for the production of different types of endoprostheses. Endotherapy (ET) of postinflammatory pancreatic and peripancreatic fluid collections (PPFCs) with the use of lumen-apposing metal stent (LAMS) is an effective method of treatment. This paper describes the high efficacy of ET and its potential complications, which are mostly related to the design of the LAMS used. The high efficacy of LAMS in the transmural drainage of PPFCs is associated with lower safety of treatment. Complications of ET presented in the manuscript are mainly related to endoprosthesis' construction. This paper presents possible directions of development in the field of transmural LAMSs, which in the future may contribute to the invention of an innovative type of LAMS based on new biomedical technologies. Possibly, subsequent novel endoprosthesis projects, based on the above results, will be able to meet the current needs and requirements associated with endoscopic transmural drainage procedures in cases of postinflammatory PPFCs. The ultimate goal is to improve safety of minimally invasive techniques for treatment of the local consequences of pancreatitis.

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.

Comparative outcomes of endoscopic ultrasound-guided lumen-apposing mental stents drainage for pancreatic pseudocysts and walled-off necrosis: Case series and meta-analysis

Background

Endoscopic ultrasound (EUS)-guided transmural drainage for pancreatic fluid collections (PFCs) has become the first-line treatment with quicker recovery and more minor injury compared with surgery and percutaneous drainage. The efficacy of stents implantation and drainage for different PFCs remains controversial, especially lumen-apposing metal stents (LAMS). This study aimed to compare the efficacy and safety of LAMS drainage for pancreatic pseudocysts (PPC) and walled-off necrosis (WON).

Methods

A meta-analysis was performed for LAMS drainage for WON and PPC by systematically searching PubMed, Cochrane, and Embase databases from January 2010 to January 2020. From 2017 to 2019, 12 patients who were treated with LAMS drainage for PFCs in our medical center were also reviewed and included in this study.

Results

Combining 11 copies of documents with the data from our medical center, a total of 585 patients with PFCs were enrolled in this meta-analysis, including 343 patients with WON and 242 with PPC. The technical success rate in WON is not significantly different from that of PPC (P = 0.08 > 0.05). The clinical success of LAMS placement was achieved in 99% vs 89% in PPC and WON, respectively (RR = 0.92, 95% CI: 0.86-0.98, P = 0.01 < 0.05). The further intervention of direct endoscopic necrosectomy was required by 60% of patients in WON group. There was no significant difference in the incidence of adverse events, including infection, bleeding, stent migration and stent occlusion, after LAMS placement between WON and PPC.

Conclusions

Endoscopic ultrasound-guided LAMS for PFCs are feasible, effective with preferable technical and clinical success rates. The clinical effect of LAMS on PPC is slightly better than that of WON, but its adverse reactions still need to be verified in a large-sample prospective study.

A drainage strategy for postoperative pancreatic fistula after left-sided pancreatectomy based on the wall status of collected fluid

PURPOSE

Postoperative pancreatic fistula (POPF) after pancreatectomy is one of the severe postoperative adverse events. We aimed to clarify the outcomes of a strategy for POPF after left-sided pancreatectomy with one-step endoscopic ultrasonography-guided drainage (EUSD) and percutaneous drainage (PCD) based on the wall status of collected fluid.

METHODS

From January 2012 to September 2017, 90 of 336 patients developed grade B/C POPF and were retrospectively analyzed. Primary outcome measures were the technical and clinical success and resolution rates. Secondary outcome measures were time from surgery to intervention, and time from intervention to discharge/resolution or stent/tube removal and adverse events.

RESULTS

Seventeen patients underwent EUSD and 73 patients underwent PCD for POPF. The technical success rates were 100% in both the EUSD and PCD groups. The clinical success and resolution rates in the EUSD group were 100%, while those in the PCD group were 98.6%. The time from surgery to intervention was significantly longer in the EUSD group than in the PCD group (20 vs. 11 days, p < 0.001). The time from intervention to discharge/resolution was significantly shorter in the EUSD group than in the PCD group (11 vs. 22 days, p < 0.001/10 vs. 20 days, p < 0.001). The time from intervention to stent/tube removal was significantly shorter in the PCD group than in the EUSD group (20.5 vs. 873 days, p < 0.001). Adverse event rates were similar in the two groups (11.8% vs. 5.5%).

CONCLUSION

A drainage strategy for POPF based on the wall status of collected fluid is appropriate.

A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients

Objective

To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis.

Summary Background Data

Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods.

Methods

A meta-analysis of 5500 patients.

Results

Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods.

Conclusions

In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.

Single-center experience demonstrating low adverse events and high efficacy with self-expandable metal esophageal and biliary stents for pseudocyst and walled off necrosis drainage

Background and study aims  Lumen-apposing metal stents (LAMS) have been designed as proprietary stents for the management of pseudocysts (PC)/walled off necrosis (WON). There has been concern about adverse events (AEs) with LAMS including bleeding, buried stent syndrome and migration. Prior to LAMS becoming available, fully-covered self-expandable metal esophageal and biliary stents (FCSEMSs) were used off-label for management of PC/WON with many centers demonstrating low rates of AEs. The primary aim of this study was to study the safety and efficacy of FCSEMS for the management of pseudocysts/WON. Patients and methods  This was a retrospective review of all endoscopic ultrasound (EUS)-guided placement of FCSEMSs for drainage of PC/WON cases performed at our institution over 4-year period. The primary outcomes studied were technical success, AEs, PC/WON resolution, and salvage surgical/radiologic intervention. Results  Technical success achieved in 65 of 65 (100 %) study patients. An AE occurred 0 of 25 patients (0 %) with PC, and in 10 of 40 patients (25 %) with WON: bleeding (3 %), migration (5 %) and stent dysfunction/infection (18 %). There was resolution in 25 of 25 patients (100 %) with a PC and 31 of 40 patients (78 %) with a WON. Salvage therapy by interventional radiology or surgery was performed in nine of 40 patients (22 %). Conclusions  This single-center 4-year experience in the pre-LAMS era showed that FCSEMS was safe and effective in all patients with PC and over 75 % of patients with WON. Given the large cost differential between LAMS and FCSEMS and the efficacy and safety shown with FCSEMS, we believe that FCSEMS should still be considered a first-line option for patients with pancreatic fluid collections, particularly in patients with PCs.

Management of pancreatic collections: an update

Pancreatic fluid collections frequently occur in the context of moderate and severe acute pancreatitis, and may also appear as a complication of chronic pancreatitis, pancreatic surgery or trauma. It is essential to adhere to the Atlanta classification nomenclature that subclassifies them into four categories (acute peripancreatic fluid collections, acute necrotic collections, pseudocysts, and walled-off necrosis) since it has an impact on prognosis and management. Pseudocysts and walled-off pancreatic necrosis are encapsulated pancreatic fluid collections characterized by a surrounding inflammatory wall, which typically develops three to four weeks after the onset of acute pancreatitis. Most pancreatic fluid collections resolve spontaneously and do not require intervention. However, when they become symptomatic or complicated drainage is indicated, and endoscopic ultrasound-guided drainage has become first-line treatment of encapsulated collections. Drainage of pseudocysts is relatively straightforward due to their liquid content. However, in walled-off necrosis the presence of solid necrotic debris can make treatment more challenging and therefore multidisciplinary management in experienced centers is recommended, being a step-up approach the current standard of care. In this review, we aim to address the management of pancreatic fluid collections with an especial focus on endoscopic drainage.

Advancements in the endoscopic treatment of pancreatic fluid collections

Endoscopic drainage of pancreatic fluid collections (PFCs) with fewer complications and less trauma has gradually replaced surgery or percutaneous drainage to become the first-line treatment for PFCs. In recent years, the differential efficacy of various stent techniques to drain different types of PFCs has been controversial. This review summarizes the clinical applications of endoscopic ultrasound-guided stent placement for PFCs drainage.

Recent advances in treatment of pancreatic pseudocyst with endoscopic ultrasonography guided lumen-apposing metal stents

Endoscopic pancreatic pseudocyst (PPC) drainage has become one of the most important methods for the treatment of PPC. With the continuous application of the new lumen-apposing metal stent (LAMS), it has shown better efficacy and clinical practical value. This paper focuses on the current situation of endoscopic PPC drainage, especially the therapeutic effect, complications, and countermeasures with endoscopic ultrasound-guided LAMS.

Multivariate analysis of the factors affecting the prognosis of walled-off pancreatic necrosis after endoscopic ultrasound-guided drainage

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS)-guided drainage has become the treatment of choice for walled-off pancreatic necrosis (WOPN). However, no consensus exists on the most significant patient- and procedure-related factors that affect prognosis. The aim of the study is to investigate the correlation between patient- and procedure-related factors and post-procedure complications after EUS-guided drainage.

METHODS

A retrospective analysis of the clinical characteristics of patients with WOPN who underwent EUS-guided drainage at our endoscopy center between November 2011 and August 2017 was performed. Chi-square analysis and binary logistic regression statistical methods were used to analyze the correlation between influencing factors and prognosis.

RESULTS

A total of 85 patients (male/female, 50/35) with WOPN were included in the study. The average age was 44.95 years. The cyst diameter was 10.58 ± 4.78 cm. Multivariate analysis showed that WOPN with higher solid content (> 30%) increased the probability of endoscopic necrosectomy (OR 6.798; 95% CI 1.423, 32.470; p = 0.016). The use of a metal stent increased the probability of endoscopic necrosectomy (OR 3.503; 95% CI 1.251, 9.810; p = 0.017) and the length of hospitalization (OR 3.315; 95% CI 1.192, 9.215; p = 0.022). Female patients had a higher probability of requiring endoscopic necrosectomy (OR 2.683; 95% CI 1.027, 7.007; p = 0.044) and prolonged hospitalization (OR 2.675; 95% CI 1.065, 6.721; p = 0.036).

CONCLUSION

The solid content of WOPN, type of stent, and sex of patients were associated with increased probability of endoscopic necrosectomy.

Protocol of early lumen apposing metal stent removal for pseudocysts and walled off necrosis avoids bleeding complications

Background: EUS-guided drainage of pancreatic fluid collections (PFCs; pancreatic pseudocyst (PPC) or walled-off necrosis (WON)) using lumen apposing metal stents (LAMSs) is now standard of care. We adopted a protocol of early LAMS removal and prospectively followed patients to determine if this protocol avoids bleeding complications.Methods: Prospective, consecutive case series of all patients with PPC and WON who underwent drainage with LAMS at a tertiary care referral center from July 2016 to November 2018. LAMS was removed within 4 weeks for PPC and within 6 weeks for WON. Patients with residual necrosis after 6 weeks underwent removal of initial LAMS and replacement with new LAMS every 6 weeks until resolution. Patients were followed within protocol while monitoring for bleeding complications and clinical success. We also performed a literature review to determine rates of LAMS related bleeding at various timepoints.Results: Forty patients (PPC n = 19, WON n = 21) underwent drainage with LAMS. Median time for LAMS removal was 21.0 days for PPC and 33.5 days for WON. Technical success and clinical success were achieved in 40/40 patients with zero cases of delayed bleeding. A literature review of 21 studies and 1378 patients showed 52/1378 (3.8%) bleeding events with 24/52 (46.2%) events occurring within 1 week of LAMS placement.Conclusions: An early removal LAMS protocol for PFC is highly efficacious and prevents delayed bleeding. Based on analysis of published cases, half of LAMS related bleeding occurs within the first week suggesting procedural factors rather than stent dwell time impact risk of bleeding.

Comparative Study Evaluating Lumen Apposing Metal Stents Versus Double Pigtail Plastic Stents for Treatment of Walled-Off Necrosis

OBJECTIVES

Lumen-apposing metal stents (LAMSs) are increasingly used for direct endoscopic necrosectomy (DEN) in the management of walled-off necrosis (WON). We compared LAMS and traditional cystoenterostomy in the management of WON.

METHODS

Retrospective analysis of patients who underwent DEN for management of WON was performed. Primary outcome was rate of WON resolution. Secondary outcomes included technical and clinical success, time and number of procedures until resolution, requirement for alternative therapy, recurrence, and adverse events.

RESULTS

One hundred twelve patients underwent DEN with LAMS (n = 34) or traditional cystoenterostomy (n = 78). Mean WON size was 90.2 × 60.1 mm, and 61.8% had infected necrosis. Overall WON resolution was similar between LAMS and traditional cystoenterostomy (94.1% vs 92.1%, P = 0.510), with similar number of procedures until resolution (1.5 vs 1.5, P = 0.871). The LAMSs were associated with faster resolution (86.9 vs 133.6 days, P = 0.038), lower recurrence (6.3% vs 23.1%, P = 0.032), and decreased requirement for surgery (0% vs 12.8%, P = 0.031) compared with traditional cystoenterostomy, but higher adverse event rates (41.2% vs 7.7%, P < 0.001).

CONCLUSIONS

Despite higher adverse event rates, initial LAMS cystoenterostomy for management of WON results in faster resolution, lower recurrence, and decreased requirement for surgery.

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.

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.

Lumen-apposing metal stents in interventional endoscopy: a state-of-the-art review with focus on technical and clinical successes and complications

Endoscopic transmural drainage is considered the initial treatment option for pancreatic fluid collections. Recently, lumen-apposing metal stents have been introduced for pancreatic fluid collections drainage under endoscopic ultrasound guidance, in addition to evolving data in bile duct and gallbladder drainage. We aimed to perform systematic review with reporting pooled data analysis on technical success, clinical success and complications rate of endoscopic ultrasound-guided lumen-apposing metal stents uses. A MEDLINE/PubMed and EMBASE search for all studies on lumen-apposing metal stents uses in pancreatic, biliary and other indications was conducted. Data regarding safety, complications and yield were extracted and included in the final pooled analysis. Overall, 19 articles dealing with pancreatic fluid collections drainage, 18 articles reporting on bile duct drainage and 19 articles relevant to gallbladder drainage were identified. Technical and clinical successes in all disease conditions were high and reached more than 95%. Complications rate in pancreatic fluid collections, bile duct and gallbladder drainages were 12%, 11.2% and 9.8%, respectively. Endoscopic ultrasound-guided lumen-apposing metal stents is technically feasible with very high success rate and acceptable complications rate.

Multicenter study of plastic vs. self-expanding metal stents in endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis - PROMETHEUS: a randomized controlled trial protocol

BACKGROUND

It seems that lumen-apposing metal stents (LAMS) are displacing plastic stents in the therapy of pancreatic-fluid collection in walled-off necrosis (WON). To date, there is no quality of evidence to recommend LAMS as the standard treatment in the management of WON. The theoretical benefit of LAMS over plastic stents needs to be proven.

METHODS/DESIGN

This is a randomized controlled, multicenter, prospective clinical trial with two parallel groups, without masking. One-hundred and fourteen patients with WON will undergo endoscopic ultrasound (EUS)-guided transmural draining in nine tertiary hospitals in Spain and will be randomized to the LAMS or plastic-stent group. The primary endpoint is the short-term (4 weeks) clinical success determined by the reduction of the collection (to < 50% or < 5 cm in size), along with clinical improvement. Secondary endpoints: long-term (4 months) clinical success (total resolution or 5 cm), procedure duration, level of difficulty, safety, and recurrences.

DISCUSSION

The PROMETHEUS trial has been designed to determine whether LAMS are superior to plastic stents in EUS-guided transmural drainage of WON.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03100578. Registered on 4 April 2017. https://clinicaltrials.gov/ct2/home.

Endoscopic ultrasonography and small-bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.

Anchoring lumen-apposing metal stent with coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: any benefit?

Background:

Anchoring double-pigtail plastic stents (DPSs) within lumen-apposing metal stents (LAMSs) has been proposed to prevent adverse events during endoscopic drainage of pancreatic fluid collections (PFCs). We sought to compare the outcomes of patients who received LAMSs alone and those who received both LAMSs and anchoring DPSs for drainage of PFCs.

Methods:

A retrospective study was conducted at the University of Kentucky. Patients with PFCs who underwent endoscopic ultrasound-guided drainage using LAMSs, with or without DPSs, between January 2016 and March 2018 were included. Categorical data were analyzed using chi-square tests, and continuous variables using 2-sample t-tests. Adverse events were defined according to the American Society for Gastrointestinal Endoscopy’s Lexicon. The primary outcome was to evaluate the efficacy (PFC resolution), and safety (adverse events) of LAMSs with or without DPSs used to drain PFCs.

Results:

Fifty-seven patients with PFCs were treated by 2 experienced endoscopists over 26 months. Twenty-one (37%) patients received LAMSs alone, and 36 (63%) received LAMSs plus DPSs. Forty-three patients had walled-off pancreatic necrosis, and 14 patients had pancreatic pseudocyst. Clinical success (resolution of PFCs) was achieved in 15 patients (71.4%) in the LAMSs alone group, and 21 patients (58.3%) with LAMSs plus DPSs (P=0.32). In patients with LAMSs alone, 6 patients (28.6%) had adverse events, while in those with LAMSs plus DPSs, 14 (38.9%) patients had adverse events (P=0.43).

Conclusion:

No significant difference was identified in fluid resolution or adverse events between patients with LAMSs alone and those with LAMSs plus DPSs.

Endoscopic Ultrasonography-Guided Versus Percutaneous Drainage for the Recurrent Pancreatic Fluid Collections

BACKGROUND Ultrasonography-guided percutaneous drainage for pancreatic fluid collections is associated with a high recurrence rate and endoscopic ultrasonography (EUS)-guided drainage is a valuable approach. Our aim was to compare the efficacy and safety of percutaneous and EUS-guided drainage for the recurrent pancreatic fluid collections. MATERIAL AND METHODS A retrospective analysis of percutaneous-guided and EUS-guided procedures for pancreatic fluid collections drainages at a single tertiary care center between February 2017 and May 2018 was performed. Treatment success, adverse events, recurrence, need for surgery, length of hospital stays, and number of follow-up computed tomography (CT) scan were assessed. RESULTS A total of 119 pancreatic fluid collections treated with initial percutaneous drainage were included in this study and 35 patients had recurrent pancreatic fluid collections. Recurrent patients were classified based on drainage method: EUS-guided drainage (18 patients) and the second percutaneous drainage (17 patients). EUS-guided drainage revealed a shorter length of hospital stays (P<0.001), less re-intervention (P=0.047), fewer number of follow-up CT scans (P=0.006) compared with the initial percutaneous drainage. Furthermore, we also compared the clinical outcomes between the EUS-guided drainage and the second percutaneous drainage for the recurrent PFC after initially failed percutaneous drainage. EUS-guided drainage showed higher clinical success (P=0.027), shorter length of hospital stays (P<0.001), less re-intervention (P=0.012), fewer number of follow-up CT scan (P<0.001) and less recurrence P=0.027) compared to the second percutaneous drainage procedure. CONCLUSIONS EUS-guided drainage is an effective and appropriate method to treat the recurrent pancreatic fluid collections after initially failed percutaneous drainage procedure, with the advantage of higher clinical success, shorter length of hospital stays, less re-intervention, fewer number of follow-up CT scan and less recurrence compared to the percutaneous drainage.

Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management

The development of endoscopic ultrasound (EUS)-guided drainage techniques and lumen-apposing metal stents (LAMS) has markedly reduced the complication rate of endoscopic transmural drainage of pancreatic collections and made these procedures safer and more effective. Despite its improved safety profile, various types of complications, some even life-threatening, can occur after EUS-guided drainage of pancreatic fluid collections. Stent maldeployment/migration, bleeding, gastrointestinal perforation, and air embolism are important complications of EUS-guided drainage of pancreatic collections. Delayed complications weeks after the procedure, such as bleeding and buried LAMS due to the presence of prolonged indwelling transmural stents, have also been described. Careful patient selection, with proper assessment of the size, solid necrotic content and location of the collection, as well as an in-depth understanding of various risk factors that predict complications, are important for a safer and more effective endoscopic transmural drainage. For a better clinical outcome, it is important for the endoscopist to know about various complications of EUS-guided drainage of pancreatic collections, as well as their appropriate management strategies.

A retrospective, multicenter analysis of incidents associated with Axios™ lumen-apposing stents

INTRODUCTION

there is controversy with regard to the risks associated with lumen-apposing metal stents (LAMSs), with significant variations between available reports.

OBJECTIVES

to describe the types and proportions of complications that arise during the permanence time and removal of Axios™ LAMS. Furthermore, the relationship between patency time, therapeutic target and the presence of complications was also described.

METHODS

a retrospective, multicenter case series study was performed of all patients with an implanted LAMS to access extra-luminal structures during 2017. Only technically successful cases were recorded.

RESULTS

a total of 179 patients from seven sites (range, 4-68 cases/site) were included in the study, with a mean age of 64.3 years (SD: 15.8; range: 24.6-98.8 years) and 122 (68.2%) were male. Most common indications included encapsulated necrosis (58, 32.4%), pseudocysts (31, 17.3%) and gallbladder drains (26, 14.5%). Complications during LAMS stay were reported in 19 patients (10.9%); stent lumen or gastroduodenal obstruction (8, 4.5%) and bleeding (7, 3.9%) were the most common. LAMS were not removed in 86 (48%) patients due to the following reasons: a permanent stent was used (46, 53.5%), loss to follow-up (18, 20.9%), patient demise (16, 18.6%) and stent migration (6, 7%). Five (5.4%) complications were reported during stent removal, which were three bleeds and two perforations. No association was found between stent duration and complications (p = 0.67).

CONCLUSION

complications secondary to LAMS insertion are uncommon but may be serious. This study found no association between complications and stent duration.

Comparison of three different stents for endoscopic ultrasound-guided drainage of pancreatic fluid collection: A large retrospective study

BACKGROUND AND AIM

Endoscopic transmural drainage has been recognized as the first-line treatment for pancreatic fluid collection (PFC). Currently, three different types of stents have been extensively applied, including double pigtail plastic stent (PS), fully covered self-expanding metal stent (FCSEMS), and novel lumen-apposing metal stent (LAMS). Nonetheless, limited data are available about the comparison among them in terms of their clinical outcomes and safety for endoscopic ultrasound-guided drainage of PFC.

METHODS

The current retrospective study was carried on 160 PFC patients undergoing endoscopic ultrasound-guided drainage from 2010 to 2018 at a single tertiary care center. Patients were divided into three groups based on different drainage ways: drainage using PS, FCSEMS, or LAMS.

RESULTS

A total of 160 PFC patients (104 male and 56 female) were analyzed in this retrospective study, including 62 patients drained with PS, 28 with FCSEMS, and 70 with LAMS. Typically, the technical success (93.5% vs 96.4% vs 94.3%, P = 1.000) and treatment success rates (84.6% vs 85.2% vs 89.2%, P = 0.763) were similar between PS, FCSEMS, and LAMS. With regard to major adverse events, four patients (FCSEMS: n = 2 and LAMS: n = 2) with pseudoaneurysms developed severe bleeding; among them, 75% (3/4) of patients were observed within 2 weeks after intervention, and two patients in LAMS group died.

CONCLUSIONS

There are no significant differences in the clinical outcomes of PFC patients treated with PS, FCSEMS, or LAMS. Nonetheless, severe (or even fatal) bleeding may occur at the early stage after metal stent placement, which should be paid particular attention to.

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.

Novel lumen-apposing metal stent for the drainage of pancreatic fluid collections: An Italian multicentre experience

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage is the procedure of choice for pancreatic fluid collection (PFC) management. Recently developed lumen-apposing fully covered self-expandable metal stents (LAMSs) may facilitate drainage, especially of necrotic and complex PFCs.

OBJECTIVE

To evaluate the feasibility and efficacy of a newly developed LAMS (Nagi, Taiwong Medical Co. Ltd, South Korea) in the drainage of PFCs.

METHODS

Retrospective analysis of LAMS drainage of PFCs from seven centres. Patient demographic, EUS and radiological findings, PFCs aetiology, procedural technical and clinical success, and adverse events were evaluated.

RESULTS

Sixty-seven patients with mean age 58.8 ± 14 years (68.7% males) were included in the analysis. Of these, 44 patients had pseudocyst (PP) and 23 patients had walled-off pancreatic necrosis (WOPN). Technical success was achieved in 98.5% of cases and clinical success in 94%. The adverse event rate was 24.2%, higher and mostly due to stent migration and occlusion in the WOPN group as compared to the PP group, despite the time to stent removal being significantly lower in the WOPN group.

CONCLUSIONS

PFC drainage using the Nagi stent is highly feasible and effective, with a relatively safe profile. Future studies enrolling more patients with complex PFCs are needed to clearly establish the role of this stent in PFC management.

Balloon dilator controls massive bleeding during endoscopic ultrasound-guided drainage for pancreatic pseudocyst: A case report and review of literature

Pancreatic pseudocyst (PPC), a common sequela of acute or chronic pancreatitis, was defined by the revised Atlanta classification as “a collection.” Endoscopic ultrasound (EUS)-guided drainage is often considered a standard first-line therapy for patients with symptomatic PPC. This effective approach exhibits 90%-100% technical success and 85%-98% clinical success. Bleeding is a deadly adverse event associated with EUS-guided drainage procedures, and the bleeding rate ranges from 3% to 14%. Hemostasis involves conservative treatment, endoscopy, interventional radiology-guided embolization and surgery. However, few studies have reported on EUS-guided drainage with massive, multiple hemorrhages related to severe pancreatogenic portal hypertension (PPH). Thus, the aim of this case report was to present a case using a balloon dilator to achieve successful hemostasis for PPH-related massive bleeding in EUS-guided drainage of PPC. To our knowledge, this method has not been previously reported.

Lumen Apposing Metal Stents (LAMSs) for Drainage of Pancreatic and Gallbladder Collections: A Meta-analysis

BACKGROUND AND AIMS

Endoscopic ultrasound-guided transmural drainage using lumen apposing metal stents (LAMSs) is becoming a popular and promising therapeutic approach for drainage of intra-abdominal fluid collections. There has been an increasing number of studies evaluating LAMS for drainage of pancreatic pseudocysts (PP), walled-off pancreatic necrosis (WOPN), and gallbladder (GB) drainage. The aim of this meta-analysis is to analyze the literature to date regarding the clinical success, technical success, and adverse events of LAMS in treatment of pancreatic fluid collections and GB drainage.

METHODS

A comprehensive search of multiple literature databases through November 2016 was performed. Human studies with at least 10 subjects that examined the clinical success, technical success, and adverse events of LAMS in treating PP, WOPN, and GB drainage were included.

RESULTS

A total of 993 patients (608-WOPN; 204-PP; 181-GB drainage) underwent drainage from 20 trials. For drainage of WOPN, the pooled technical success was 98.9% [95% confidence interval (CI): 98.2% to 99.7%] and clinical success was 90% (95% CI: 87% to 93%) (τ=0.001). For drainage of PP, the pooled technical success was 97% (95% CI: 95% to 99%) and clinical success was 98% (95% CI: 96% to 100%), (τ=0.001). For GB drainage, the pooled technical success was 95% (95% CI: 91% to 99%) and clinical success was 93% (95% CI: 90% to 97%), (τ=0.001). Total adverse events occurred in 11% of patients with higher complication rates observed in GB drainage. There was no evidence of publication bias in this meta-analysis.

CONCLUSIONS

Endoscopic ultrasound-guided transmural drainage using LAMS is becoming a widely accepted therapeutic approach for the treatment of PP, WOPN, and GB drainage with high clinical and technical success rates and acceptable adverse events. Further prospective randomized trials reporting long-term clinical efficacy and cost-effectiveness are needed to validate LAMS as a therapeutic modality for pancreatic and GB collections.

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.

Endoscopic ultrasound-guided transmural drainage by cautery-tipped lumen-apposing metal stent: exploring the possible indications

Background

The recently introduced Hot AXIOS™ system for endoscopic ultrasound (EUS)-guided transenteric drainage has the potential to change interventional endoscopy significantly. The aim of our study was to assess the effectiveness and safety of this new type of lumen-apposing metal stent (LAMS) with cautery system for pancreatic collection, and gallbladder and biliary tree drainage.

Methods

We retrospectively reviewed consecutive patients undergoing EUS-guided drainage by LAMS with cautery system in a tertiary-care academic medical center between March 2014 and March 2017. All patients were included in our prospectively maintained institutional EUS database. The main outcome measures were technical success, clinical effectiveness, and adverse events.

Results

A total of 45 patients (20 men, mean age 69.6 years) underwent LAMS placement. Indications were pancreatic fluid collections (19 patients, 42.2%), acute cholecystitis (10 patients, 22.2%), and biliary drainage (16 patients, 35.5%). Technical success was achieved in all patients except one (97.7%). Clinical success was achieved in 86.4% (38/44) of cases and adverse events occurred in 5 (11.4%) of patients.

Conclusions

In our experience, EUS-guided LAMS placement performed by expert endoscopists was feasible and effective in the endoscopic management of pancreatic fluid collection, and biliary and gallbladder drainage. Optimization of transmural drainage by new dedicated devices could improve efficacy and safety in appropriately selected patients.

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.

Clinical Impact of the Intra-scope Channel Stent Release Technique in Preventing Stent Migration During EUS-Guided Hepaticogastrostomy

BACKGROUNDS

Stent migration following endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) may sometimes be fatal because there are no adhesions between the biliary tract and stomach. To prevent stent migration and minimize the stent length in the abdominal cavity, we recently performed EUS-HGS using the technique of releasing the stent within the scope channel.

AIMS

To examine the technical feasibility of the intra-scope channel stent release technique.

METHODS

Forty-one consecutive patients who underwent EUS-HGS were enrolled. Between October 2015 and December 2015, EUS-HGS was performed using the extra-scope channel release technique, while the intra-scope channel release technique was performed between January 2016 and March 2016.

RESULTS

The distance between the hepatic parenchyma and the stomach wall after EUS-HGS in the intra-scope channel stent release group was significantly shorter than that in the extra-scope channel release group (0.66 ± 1.25 vs 2.52 ± 0.97, P < 0.05). Adverse events, such as biloma or stent migration, were seen in only the extra-scope channel release group.

CONCLUSION

In conclusion, although additional cases and randomized controlled studies using metal stents of various lengths are needed, our technique is likely to be clinically useful for the prevention of early and late stent migration.

Metal versus plastic stents for drainage of pancreatic fluid collection: A meta-analysis

BACKGROUND

Although metal stents are increasingly being used for endoscopic transmural drainage of pancreatic fluid collection (PFC), the advantages of metal stents in comparison with plastic stents are not clear.

OBJECTIVE

The aim of this study is to compare the clinical outcomes and adverse events between patients receiving endoscopic transmural drainage of PFCs through metal or plastic stents.

METHODS

We performed a systematic literature search to identify all published manuscripts comparing metal and plastic stents for PFC drainage. The primary outcome was clinical success, and the secondary outcomes were technical success, procedure time, overall cost, adverse events, and recurrence.

RESULTS

Seven studies were considered to be appropriate for this meta-analysis. Metal stents showed a higher clinical success rate (odds ratio (OR) 3.39, 95% confidence interval (CI) 2.05-5.60) and a lower overall adverse event rate (OR 0.37, 95% CI 0.21-0.66) than plastic stents. In subgroup analyses, metal stents showed higher clinical success rates than plastic stents both for pseudocyst (OR 5.35, 95% CI 1.35-21.19) and walled-off necrosis (OR 3.37, 95% CI 1.89-5.99).

CONCLUSIONS

Metal stents are superior to plastic stents for endoscopic transmural drainage of PFC because they have a higher clinical success rate and lower rate of adverse events.

Candidemia after endoscopic therapy with lumen-apposing metal stent for pancreatic walled-off necrosis

Necrotizing pancreatitis remains a challenging and unpredictable condition accompanied by various complications. Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with walled-off necrosis (WON). Endoscopic therapy via lumen-apposing metal stents (LAMS) with large diameters has shown success in the management of pancreatic fluid collections, but there are few data on specific complications of that therapy. We report a case of infected WON and concomitant fungemia following LAMS placement and necrosectomy. In addition, a systematic literature review of current related studies has been provided.

Endoscopic Management of Peri-Pancreatic Fluid Collections

In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic "step up" approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.

Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using self-expanding metal stents without fluoroscopy

AIM

To investigate whether endoscopic ultrasound (EUS)-guided insertion of fully covered self-expandable metal stents in walled-off pancreatic necrosis (WOPN) is feasible without fluoroscopy.

METHODS

Patients with symptomatic pancreatic WOPN undergoing EUS-guided transmural drainage using self-expandable and fully covered self expanding metal stents (FCSEMS) were included. The EUS visibility of each step involved in the transmural stent insertion was assessed by the operators as “visible” or “not visible”: (1) Access to the cyst by needle or cystotome; (2) insertion of a guide wire; (3) introducing of the diathermy and delivery system; (4) opening of the distal flange; and (5) slow withdrawal of the delivery system until contact of distal flange to cavity wall. Technical success was defined as correct positioning of the FCSEMS without the need of fluoroscopy.

RESULTS

In total, 27 consecutive patients with symptomatic WOPN referred for EUS-guided drainage were included. In 2 patients large traversing arteries within the cavity were detected by color Doppler, therefore the insertion of FCSEMS was not attempted. In all other patients (92.6%) EUS-guided transgastric stent insertion was technically successful without fluoroscopy. All steps of the procedure could be clearly visualized by EUS. Nine patients required endoscopic necrosectomy through the FCSEMS. Adverse events were two readmissions with fever and one self-limiting bleeding; there was no procedure-related mortality.

CONCLUSION

The good endosonographic visibility of the FCSEMS delivery system throughout the procedure allows safe EUS-guided insertion without fluoroscopy making it available as bedside intervention for critically ill patients.

Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocyst

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) are used to perform necrosectomy in walled-off necrosis (WON). Although necrosectomy is not required for pancreatic pseudocyst (PP), an increasing number of PPs are also being drained with LAMSs in view of their ease of deployment. The aim of the present study was to evaluate the safety and efficacy of using LAMSs to drain PPs.

METHODS

At 1 tertiary center from January 2014 to May 2016, all consecutive patients with PPs were drained by LAMSs, and the data were retrospectively reviewed. After observing cyst-cavity infection in patients enrolled initially (group I), 10F double-pigtail stents (DPSs) were placed across LAMSs in the subsequent patients (group II). Data on technical success, PP resolution, adverse events, and reintervention rates were collected.

RESULTS

Forty-seven patients with PPs (mean size, 9.5 ± 4.0 cm) were enrolled (group I, 24; group II, 23). There was 1 perforation at deployment (technical success, 98%). In the remaining 46 patients, resolution of the PP was observed in 44 patients (96%). Four patients (17%) in group I presented with PP infection requiring reinterventions. Food material was observed in the cyst cavity. None of the patients in group II had PP infection (relative risk, .84; 95% confidence interval, .71-1.0; P = .054).

CONCLUSIONS

Similar to WON, LAMSs are also effective in endoscopic drainage of PPs. However, there was a trend toward higher PP infection with LAMSs, and placing a DPS across the LAMS minimized this risk.

Lumen-Apposing Metal Stents: Which One and Why?

Numerous lumen-apposing metal stents (LAMS) have been designed for transluminal applications, including complex pancreatic fluid collections (PFCs) and difficult biliary access. Limited high-quality data exist directly comparing the various LAMS models, and their use remains largely dependent on availability and operator expertise. LAMS placement has been streamlined by the addition of electrocautery, allowing for single-step or modified "hot" approach, if desired. Therapeutic endoscopists continue to explore the application of this technology in a variety of clinical scenarios, and future innovations will be needed to meet these evolving clinical demands.

Multicenter experience from the UK and Ireland of use of lumen-apposing metal stent for transluminal drainage of pancreatic fluid collections

BACKGROUND AND STUDY AIMS

 Pancreatic fluid collection (PFC) is a common complication of pancreatitis for which endoscopic ultrasound-guided drainage is first-line treatment. A new single-device, lumen-apposing, covered self-expanding metal stent (LAMS) has been licensed for PFC drainage. We therefore present our multicenter experience with the LAMS for PFC drainage in a multicenter prospective case series to assess success and complication rates.

PATIENTS AND METHODS

 All adult patients from 11 tertiary centers who had LAMS placement for PFC from July 2015 to July 2016 were included. Data including indications, technical success, clinical success, collection resolution, stent removal, early and late adverse events (AEs), mortality and recurrence at 6 months were collected.

RESULTS

 116 patients, median age 52.5 years (range 16 - 80) and 67 % male, were treated with a single LAMS in each case. The indication was walled off necrosis (WON) in 70 and pseudocyst in 46. Median size of the PFC was 11 cm (5 - 21 cm) and the estimated median necrotic volume in WON was 30 % (5 % - 90 %). Stent insertion was technically successful in 115 (99.1 %) and clinically successful in 109 (94 %). Early serious AEs (SAEs): n = 7 sepsis, n = 1 stent blockage with food, n = 1 stent migration requiring laparotomy, n = 1 stent dislodgement and n = 1 bleeding requiring emboliZation. Late AEs: n = 1 buried stent and n = 1 esophageal fistula. Non-procedure-related deaths: n = 3 (2.5 %).

CONCLUSION

 This multicenter case series demonstrates that use of the new LAMS is feasible, effective and relatively safe in draining PFC with a technical success rate of 99 % and cumulative SAE rate of 11.2 %.

Fluoroscopy-assisted vs fluoroless endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections: A comparative study

INTRODUCTION

The need for fluoroscopy guidance in patients undergoing endoscopic ultrasound-guided transmural drainage (EUS-TMD) of peripancreatic fluid collections (PFCs) remains unclear.

AIMS

The aim of this study was to compare general outcomes of EUS-TMD of PFCs under fluoroscopy (F) vs fluoroless (FL).

METHODS

This is a comparative study with a retrospective analysis of a prospective and consecutive inclusion database at a tertiary centre, from 2009 to 2015. All patients were symptomatic pseudocyst (PSC) and walled-off pancreatic necrosis (WON). Two groups were assigned depending on availability of fluoroscopy. The groups were heterogeneous in terms of their demographic characteristics, PFCs and procedure. The main outcome measures included technical and clinical success, incidences, adverse events (AEs), and follow-up.

RESULTS

Fifty EUS-TMD of PFCs from 86 EUS-guided drainages were included during the study period. Group F included 26 procedures, PSC 69.2%, WON 30.8%, metal stents 61.5% (46.1% lumen-apposing stent) and plastic stents 38.5%. Group FL included 24 procedures, PSC 37.5%, WON 62.5%, and metal stents 95.8% (lumen-apposing stents). Technical success was 100% in both groups, and clinical success was similar (F 88.5%, FL 87.5%). Technical incidences and intra-procedure AEs were only described in group F (7.6% and 11.5%, respectively) and none in group FL. Procedure time was less in group FL (8min, p=0.0341).

CONCLUSIONS

Fluoroless in the EUS-TMD of PFCs does not involve more technical incidences or intra-procedure AEs. Technical and clinical success was similar in the two groups.

EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates

BACKGROUND AND AIMS

Transmural drainage with double-pigtail plastic stents (DPPSs) was the mainstay of endoscopic therapy for symptomatic peripancreatic fluid collections (PPFCs) until the introduction of lumen-apposing covered self-expanding metal stents (LAMSs). Currently, there are limited data regarding the efficacy and adverse event rate of LAMSs compared with DPPSs.

METHODS

A retrospective analysis of EUS-guided PPFC drainage at a single tertiary care center between 2008 and 2015 was performed. Patients were classified based on drainage method: DPPSs and LAMSs. Adverse event rates, unplanned endoscopic procedures/necrosectomies, and PPFC resolution within 6 months were recorded. Significant bleeding was defined as necessitating transfusion or requiring endoscopic treatment/radiographic embolization. Subsequent endoscopic procedures were defined as unplanned procedures; stent removals were excluded.

RESULTS

A total of 103 patients met inclusion criteria (84 DPPSs, 19 LAMSs). PPFCs were classified as walled-off necrosis (WON) in 23 (14 DPPSs, 9 LAMSs). There were significantly more bleeding episodes in the LAMS group (4 [19%]: 2 splenic artery pseudo-aneurysms, 1 collateral vessel bleed, 1 intracavitary variceal bleed; P = .0003) than in the DPPS group (1 (1%]: stent erosion into the gastric wall). One perforation occurred in the DPPS group. Unplanned repeat endoscopy was more frequent in the LAMS group (10% vs 26%, P = .07). Among retreated LAMS patients in with WON, 5 (56%) had obstruction by necrotic debris. In patients for whom follow-up was available, 67 of 70 (96%) with DPPSs and 16 of 17 (94%) with LAMSs had resolution of PPFCs within 6 months (P = .78).

CONCLUSIONS

DPPSs and LAMSs are effective methods for treatment of PPFCs. In our cohort, use of LAMSs was associated with significantly higher rates of procedure-related bleeding and greater need for repeat endoscopic intervention.