Fatal gas embolism after endoscopic transgastric necrosectomy for infected necrotizing pancreatitis

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

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches; however, it has later shifted toward an endoscopy-based approach. With the development of dedicated lumen-apposing metal stents (LAMS), interventional Endoscopic Ultrasound (EUS)-guided procedures have become the standard approach for PFC drainage. However, there is still limited consensus on several aspects of the multidisciplinary management of PFCs. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript describes the first part of the results of a consensus conference organized by i-EUS with the aim of providing evidence-based guidance on aspects such as indications for treating PFCs, the timing of intervention, and different technical strategies for managing patients with PFCs.

Complications and management of interventional endoscopic ultrasound: A critical review

In the last decades, Endoscopic ultrasound (EUS) has rapidly grown and evolved from being mainly a diagnostic procedure, to being an interventional and therapeutic tool in several pathological clinical scenarios. With the progressive growth in technical expertise and dedicated devices, interventional endoscopic ultrasound procedures (IEUSP) have shown high rates of technical and clinical success, together with a relatively safe profile. However, the description and the standardization of different and specific types of adverse events (AEs) are still scarce in literature, and, consequently, even less the management of AEs. The aim of this study is to critical review and to describe AEs related to each of the main IEUSP, and to provide an overview on the possible management strategies of endoscopic complications. Future studies and guidelines are surely required to reach a better standardization of different AEs and their best management.

Endoscopic Necrosectomy

The management of walled-off necrosis has evolved substantially over the past 23 years since its first description. In this article, we review its history and the evidence supporting modern treatment, which is still subject to heterogeneity across centers and among endoscopists. This allows for creativity and customization of what can be an endoscopic marathon. Our typical practice is discussed with image and video guides aimed at improving procedure success.

WONDER-01: immediate necrosectomy vs. drainage-oriented step-up approach after endoscopic ultrasound-guided drainage of walled-off necrosis-study protocol for a multicentre randomised controlled trial

BACKGROUND

With the increasing popularity of endoscopic ultrasound (EUS)-guided transmural interventions, walled-off necrosis (WON) of the pancreas is increasingly managed via non-surgical endoscopic interventions. However, there has been an ongoing debate over the appropriate treatment strategy following the initial EUS-guided drainage. Direct endoscopic necrosectomy (DEN) removes intracavity necrotic tissue, potentially facilitating early resolution of the WON, but may associate with a high rate of adverse events. Given the increasing safety of DEN, we hypothesised that immediate DEN following EUS-guided drainage of WON might shorten the time to WON resolution compared to the drainage-oriented step-up approach.

METHODS

The WONDER-01 trial is a multicentre, open-label, superiority, randomised controlled trial, which will enrol WON patients aged ≥ 18 years requiring EUS-guided treatment in 23 centres in Japan. This trial plans to enrol 70 patients who will be randomised at a 1:1 ratio to receive either the immediate DEN or drainage-oriented step-up approach (35 patients per arm). In the immediate DEN group, DEN will be initiated during (or within 72 h of) the EUS-guided drainage session. In the step-up approach group, drainage-based step-up treatment with on-demand DEN will be considered after 72-96 h observation. The primary endpoint is time to clinical success, which is defined as a decrease in a WON size to ≤ 3 cm and an improvement of inflammatory markers (i.e. body temperature, white blood cell count, and C-reactive protein). Secondary endpoints include technical success, adverse events including mortality, and recurrence of the WON.

DISCUSSION

The WONDER-01 trial will investigate the efficacy and safety of immediate DEN compared to the step-up approach for WON patients receiving EUS-guided treatment. The findings will help us to establish new treatment standards for patients with symptomatic WON.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05451901, registered on 11 July 2022. UMIN000048310, registered on 7 July 2022. jRCT1032220055, registered on 1 May 2022.

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.

Anesthesia for digestive tract endoscopy

PURPOSE OF REVIEW

Nonoperating room anesthesia for digestive tract endoscopy has its own specificities and requires practical training. Monitoring devices, anesthetic drugs, understanding of procedures and management of complications are critical aspects.

RECENT FINDINGS

New data are available regarding risk factors for intra- and postoperative complications (based on anesthesia registries), airway management, new anesthetic drugs, techniques of administration and management of advances in interventional endoscopy procedures.

SUMMARY

Digestive tract endoscopy is a common procedure that takes place outside the operating room most of the time and has become more and more complex due to advanced invasive procedures. Prior evaluation of the patient's comorbidities and a good understanding of the objectives and constraints of the endoscopic procedures are required. Assessing the risk of gastric content aspiration is critical for determining appropriate anesthetic protocols. The availability of adequate monitoring (capnographs adapted to spontaneous ventilation, bispectral index), devices for administration of anesthetic/sedative agents (target-controlled infusion) and oxygenation (high flow nasal oxygenation) guarantees the quality of sedation and patient' safety during endoscopic procedures. Knowledge of the specificities of each interventional endoscopic procedure (endoscopic retrograde cholangiopancreatography, submucosal dissection) allows preventing complications during anesthesia.

The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review

Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.

Air embolism secondary to endoscopy in hospitalized patients: results from the National Inpatient Sample (1998-2013)

Background:

Air embolism is a rare, but potentially catastrophic complication of endoscopic procedures. We herein evaluated the overall incidence of air embolism after endoscopy. We also measured mortality outcomes after air embolism.

Methods:

Patients who underwent endoscopy as an index procedure during hospitalization were selected from the National Inpatient Sample from 1998-2013. The primary outcome of interest was the incidence of air embolism after endoscopy. All-cause mortality after endoscopy was measured as a secondary outcome and the Charlson Comorbidity Index was calculated. Binary logistic regression was used to explore the effect of air embolism on inpatient mortality, using P<0.05 as level of significance.

Results:

A total of 2,245,291 patients met the inclusion criteria. Mean age at the time of procedure was 62.5 years. Esophagogastroduodenoscopy (EGD) was the most common endoscopic procedure, accounting for 80% of endoscopic procedures. Air embolism occurred in 13 cases, giving a rate of 0.57 per 100,000 endoscopic procedures. Air embolism was most common after endoscopic retrograde cholangiopancreatography (ERCP), occurring in 3.32 per 100,000 procedures, compared with 0.44 and 0.38 per 100,000 procedures for EGD and colonoscopy, respectively. The case fatality rate for post endoscopic air embolism was 15.4%. After adjusting for covariates, air embolism after endoscopy was independently associated with higher odds of inpatient mortality: odds ratio 10.35, 95% confidence interval 1.21-88.03 (P<0.03).

Conclusions:

Air embolism is most common after ERCP. It is frequently associated with disorders involving a breach to the gastrointestinal mucosa or vasculature. Though rare, it is an independent predictor of inpatient mortality.

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.

Complications of diagnostic and therapeutic Endoscopic Ultrasound

Endoscopic Ultrasound (EUS) provides the unique opportunity to visualize, interrogate and intervene gastrointestinal (GI) luminal, mural or peri-luminal structures and pathology with negligible adverse effects. Diagnostic, upper GI and rectal EUS is feasible, extremely safe, and efficacious. Most EUS guided interventions are safe, effective and minimally invasive, compared to peers in the percutaneous radiological or surgical procedures. As with any endoscopic procedure, EUS and its guided interventions may be accompanied by adverse events. EUS related complications are generally infrequent in expert hands, and mainly include bleeding and perforation. However, the nature and severity of adverse events associated with each EUS guided procedure are unique. Hence, it is paramount for endosonographer to have sufficient knowledge of the indications, techniques, and potential risks involved before contemplating any given procedure. Most common intervention with EUS is transmural fine needle aspiration (FNA), which is an extremely safe procedure. EUS guided drainage procedures are rapidly evolving with newer devices and methods being employed. Among them, EUS guided drainage of pancreatic fluid collection-pseudocyst or walled off necrosis (WON), has largely replaced other methods (surgical, percutaneous or non-EUS endoscopic) with acceptable complications. Currently, dedicated metal stents are more widely used compared to plastic stents for drainage of PFC, especially WON. EUS has made a definite impact in biliary access and drainage of obstructed biliary system, in patients where ERCP has failed or is technically not possible, closely competing with percutaneous biliary drainage. In spite of some complications, recent improvement in devices for bilio-enteric fistula creation and stent designs, has added to its safety and efficacy. EUS guided pancreatic duct drainage remains the most challenging of EUS guided interventions where in-roads are being made.

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

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

Cholangioscopy in liver disease

Since its introduction, cholangioscopy has been used diagnostically and therapeutically. The working channel size has increased, permitting direct visualization for tissue sampling and to guide application of lithotripsy for difficult stones. Cholangioscopy utilizes endoscope and catheter-based systems. The application of slim gastroscopes for direct cholangioscopy provides better image resolution than conventional systems. Cholangioscopy has proven effective in the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Commercially available cholangioscopes are fiberoptic; those with digital video technology remain in a prototype development phase. This review covers available cholangioscope technologies, indications, technique, efficacy, and complications.