Endoscopic ultrasound-guided transmural drainage of infected pancreatic fluid collections with placement of covered self-expanding metal stents: a case series

Self-Expandable Metal Stent (SEMS) Versus Lumen-Apposing Metal Stent (LAMS) for Drainage of Pancreatic Fluid Collections: A Randomized Clinical Trial

Background and aim Endoscopic ultrasound (EUS)-guided drainage is the gold standard approach for the treatment of encapsulated pancreatic collections (EPCs) including pseudocyst and walled-off pancreatic necrosis (WON), and is associated with an equivalent clinical efficacy to surgical drainage with fewer complications and less morbidity. Drainage may be achieved via several types of stents including a fully covered self-expandable metallic stent (SEMS) and lumen-apposing metal stent (LAMS). However, to date there have been no randomized trials to compare these devices. This study aimed to compare the efficacy and safety of the SEMS versus LAMS for EUS-guided drainage of EPCs. Methods A phase IIB randomized trial was designed to compare the SEMS versus LAMS for the treatment of EPCs. Technical success, clinical success, adverse events (AEs), and procedure time were evaluated. A sample size of 42 patients was determined. Results There was no difference between the two groups in technical (LAMS 80.95% vs 100% SEMS, p=0.107), clinical (LAMS 85.71% vs 95.24% SEMS, p=0.606) or radiological success (LAMS 92.86% vs 83.33% SEMS, p=0.613). There was no difference in AEs including stent migration rate and mortality. The procedure time was longer in the LAMS group (mean time 43.81 min versus 24.43 min, p=0.001). There was also a difference in the number of intra-procedure complications (5 LAMS vs 0 SEMS, p=0.048). Conclusion SEMS and LAMS have similar technical, clinical, and radiological success as well as AEs. However, SEMS has a shorter procedure time and fewer intra-procedure complications compared to non-electrocautery-enhanced LAMS in this phase IIB randomized controlled trial (RCT). The choice of the type of stent used for EUS drainage of EPCs should consider device availability, costs, and personal and local experience.

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.

Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopic necrosectomy (EN) is the preferred approach for management of symptomatic or infected walled-off pancreatic necrosis (WOPN). Hydrogen peroxide (H₂O₂) has been reported to be a good adjunctive therapy for EN. We performed a systematic review and meta-analysis to evaluate effectiveness and safety of H₂O₂ assisted EN for WOPN.

METHODS

A comprehensive search of multiple databases (through December 2020) was performed to identify studies that reported outcomes of H₂O₂ assisted EN for WOPN. Outcomes assessed included clinical success, technical success, and adverse events.

RESULTS

A total of 454 patients with mean age (47.3 ± 7.9 years) and WOPN size (12.4 ± 3.1 cm) were included from 15 studies. The median H₂O₂ concentration was 3% (range 0.1-3%), with dilution and volume ranging from 1:1 to 10:1 and 20 ml to 1 L, respectively. The rates of technical success, clinical success and adverse events was 97.3% (95% confidence interval [CI]: 94.8-98.6, I² = 0), 89.8% (95% CI: 86.3-92.5, I² = 0) and 17.9% (95% CI: 12.6-24.7, I² = 38), respectively. The most common adverse event was bleeding (7.1%) followed by stent migration (5.3%). On meta-regression, WOPN size, patient age, use of metal stent, number of necrosectomies and transgastric access were not significant predictor for technical success, clinical success or adverse events.

CONCLUSION

H₂O₂ assisted EN is effective and safe for management of WOPN. Its use may be encouraged, and future randomized controlled studies are needed to study the optimal technique, concentration and best predictors of success.

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.

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.

A novel lumen-apposing metal stent with an anti-reflux valve for endoscopic ultrasound-guided drainage of pseudocysts and walled-off necrosis: A pilot study

BACKGROUND

Pancreatic pseudocysts (PC) and walled-off necrosis (WON) are common complications of severe pancreatitis. Endoscopic ultrasound (EUS)-guided drainage has replaced surgery as the standard treatment for PC/WON. We developed a novel lumen-apposing metal stent (LAMS) with an anti-reflux valve to prevent infectious complications caused by food reflux into the cyst cavity. This retrospective study investigated the efficacy and safety of EUS-guided drainage using this LAMS.

METHODS

We investigated and compared the treatment outcomes and complications rates between EUS-guided drainage using a novel LAMS (n = 10) versus plastic stents (n = 18) from December 2013 to October 2016. Technical success was defined as successful stent placement without immediate complications. Clinical success was defined as resolution of the PC/WON and disappearance of symptoms.

RESULTS

Among 10 patients in LAMS group, 4 patients had complicated PC and 6 patients had WON. In the plastic stent group, 15 and 3 patients had PC and WON, respectively. The median fluid collection size before treatment was 82.5 (interquartile range [IQR], 60.75-118.25) mm and 92.0 (IQR, 75.75-130.25) mm in the LAMS and plastic stent groups, respectively. There were no statistically significant differences in technical success rates (90% vs. 94.4%; p = 0.999), clinical success rates (80% vs. 77.8%; p = 0.999), and complication rates (20% vs. 27.8%; p = 0.999) between the two groups.

CONCLUSIONS

Treatment outcomes of EUS-guided drainage using a novel LAMS were feasible despite the significantly high proportion of WON. The LAMS allowed acceptable treatment outcomes for EUS-guided drainage.

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.

Advanced Endoscopic Procedures: An Update for Radiologists

OBJECTIVE. The purposes of this article are to familiarize radiologists with endoscopic techniques currently in use and to improve identification of clinically relevant imaging findings and procedural complications related to common endoscopic interventions. CONCLUSION. The frequency of performance of therapeutic endoscopic ultrasound-guided procedures has risen precipitously in the last decade. These procedures are replacing surgical and percutaneous approaches to a variety of disease entities. Recent advances include endoscopic bariatric procedures, endoscopic myotomies, and endoscopic ultrasound-guided drainage procedures.

Radical treatment for walled-off necrosis: Transmural nasocyst continuous irrigation

BACKGROUND AND AIM

Treatment efficiency of walled-off necrosis (WON) using endoscopic ultrasound-guided drainage (EUS-D) with a double pigtail stent (DPS) is limited. Endoscopic necrosectomy is often carried out if EUS-D fails. However, endoscopic necrosectomy is associated with significant morbidity and mortality. Thus, we developed transmural nasocyst continuous irrigation (TNCCI) as an alternative therapeutic option for WON. This study aimed to evaluate the usefulness of TNCCI therapy for WON.

METHODS

Between April 2009 and March 2018, 19 of 39 patients admitted with WON underwent EUS-D. Ten consecutive patients also received TNCCI therapy (TNCCI group) between May 2015 and March 2018. TNCCI was carried out by inserting an external tube from the gastroduodenal lumen into the WON under endoscopic ultrasonography guidance and then continuously irrigating the WON with saline at a rate of 40 ml/h. Nine consecutive patients who underwent EUS-D without TNCCI therapy between April 2009 and April 2015 were used for comparison (control group). Various parameters were compared between the TNCCI and control groups.

RESULTS

Time taken to reduce WON (6 vs 32 days, P = 0.001), implementation rate of endoscopic necrosectomy (0% vs 55.6%, P = 0.01), and number of endoscopic necrosectomy sessions per patient (0 vs 0.8 ± 1.0, P = 0.008) were significantly lower in the TNCCI group than in the control group.

CONCLUSIONS

Walled-off necrosis can be effectively and safely treated by endoscopic drainage with a DPS and TNCCI. This technique can be an alternative therapeutic option before carrying out endoscopic necrosectomy.

A novel self-expanding biflanged metal stent vs tubular metal stent for EUS-guided transmural drainage of pancreatic pseudocyst: A retrospective, cohort study

Although endoscopic ultrasound (EUS)-guided transmural drainage of pancreatic fluid collections with metal stents is generally preferred over plastic stents, its superiority among different types of metal stents has not yet been well studied. We conducted this study to compare clinical outcomes and complications of a novel self-expanding biflanged metal stent (BFMS) and a traditional-shaped tubular metal stent (TMS) in treating pancreatic pseudocyst (PPC).This was a retrospective analysis on consecutive patients with PPC underwent EUS-guided transmural drainage with either TMS or BFMS in a single tertiary center with expertise in management of complex biliary and pancreatic problems. The technical and functional success rate, reintervention, complications, and recurrence rate were evaluated.From September 2013 to January 2018, 125 patients (66.4% male, median age 47 years) underwent EUS-guided transmural drainage for PPC. Among them, 49 used TMS and 76 used BFMS. All patients met the inclusion criteria that cyst diameter was >6 cm or the distance between cyst and stomach wall was shorter than 1 cm. There was no difference in technical success (98% vs 97.4%, P = 1.0) or functional success rate (87.8% vs 92.1%, P = .54) using 2 types of metal stents. However, more procedure related complications occurred in TMS than in BFMS group. TMS group had a much higher migration rate than BFMS group (14.6% vs 0, P = .001), even though there was no significant difference in bleeding, infection, or death rate between 2 groups. With similar clinical outcomes, TMS group required more additional plastic stent placement than BFMS group for better drainage.TMS and BFMS placement can both be considered as methods of endoscopic transmural PPC drainage with equal efficacy, whereas BFMS could be preferred for fewer complications or less need of additional plastic stent placement.

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.

[Treatment of Pancreatic Fluid Collections]

Pancreatic Fluid Collection (PFC) develops as a result of acute pancreatitis, chronic pancreatitis, trauma, and postoperation. Although percutaneous drainage, surgery and Endoscopic Retrograde Panceatogram are used as conventional treatments in complicated PFC, the clinical course of PFC is unsatisfactory due to its clinical success rate and the risk of procedure-related complications. Endoscopic ultrasonography-guided transmural drainage of PFC is a safe and effective modality for the management of PFC, particularly in patients with pancreas necrosis. A range of techniques and stents have been introduced and a newly designed metal stent is now available.

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.

Endoscopic Ultrasound-Guided Choledochoduodenostomy Using a Lumen-Apposing Metal Stent in Pancreatic Head Neoplasm-Associated Biliary Obstruction

Endoscopic ultrasound (EUS)-guided transluminal drainage of obstructed bile duct with conventional metal and plastic stents has been in practice for several years, but this modality carries its own potential complications and obstacles. Nevertheless, the novel Hot AXIOS stent (Boston Scientific Corp., Marlborough, MA) has been shown to overcome some of those factors, which justifies its application in a variety of clinical indications, such as EUS-guided choledochoduodenostomy (EUS-CDS) for biliary drainage after failed endoscopic retrograde cholangiopancreatography. We present a case of EUS-CDS with an electrocautery enhanced lumen-apposing stent for biliary drainage.

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.

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 Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

Objective

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

Method

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

Results

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

Conclusion

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

Objective

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

Method

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

Results

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

Conclusion

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Clinical impact of EUS treatment of walled-off pancreatic necrosis with dedicated devices

BACKGROUND AND STUDY AIMS

 Walled-off pancreatic necrosis (WOPN) represents the major risk factor for sepsis-related multiple organ failure. Surgical debridement is an invasive approach associated with high rates of adverse events (AEs) and death. As an alternative, endoscopic ultrasound-guided cysto-gastro-anastomosis has emerged as an effective treatment for WOPNs. Recently a new dedicated-lumen apposing metal stent (LAMS) has been used with satisfactory results in treating peri-pancreatic fluid collections, including WOPNs. The primary outcomes of this study were to evaluate survival and clinical success. Secondary outcomes included: technical success, adverse events and recurrence rate.

PATIENTS AND METHODS

 All consecutive patients with infected WOPN between February 2014 and June 2016 were retrospectively reviewed. Patients underwent placement of a new LAMS incorporated in an electrocautery-enhanced delivery system and direct endoscopic necrosectomy (DEN). DEN was performed immediately after stent deployment and repeated every 3 to 7 days until complete resolution.

RESULTS

 In the study period we treated 20 consecutive patients with infected WOPN using the new LAMS. Technical success was achieved in 95 % of patients. Clinical success was achieved in 73 % and 84.2 % of patients at 1 and 3 months, respectively. Survival rate was 84.2 % and 79 %. Mean length of hospital stay was 19 days (range 3 - 43). No AEs occurred. Patients were followed up after stent retrieval for a mean time of 554,7 days (range 70 - 986) and no recurrence was observed.

CONCLUSIONS

 DEN following "1-step, exchange-free" LAMS positioning recorded excellent results. We believe that simplicity of procedure plays a key role in terms of safety.

Endoscopic "step-up approach" using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos)

BACKGROUND AND AIMS

EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic "step-up approach" for drainage of symptomatic WON.

METHODS

We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN.

RESULTS

Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2).

CONCLUSIONS

The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN.

Necrotizing Pancreatitis: Current Management and Therapies

Acute necrotizing pancreatitis accounts for 10% of acute pancreatitis (AP) cases and is associated with a higher mortality and morbidity. Necrosis within the first 4 weeks of disease onset is defined as an acute necrotic collection (ANC), while walled off pancreatic necrosis (WOPN) develops after 4 weeks of disease onset. An infected or symptomatic WOPN requires drainage. The management of pancreatic necrosis has shifted away from open necrosectomy, as it is associated with a high morbidity, to less invasive techniques. In this review, we summarize the current management and therapies for acute necrotizing pancreatitis.

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.

Endoscopic ultrasonography-guided drainage combined with trans-duodenoscope cyclic irrigation technique for walled-off pancreatic necrosis

BACKGROUND

Endoscopic ultrasonography-guided drainage has been established as a good treatment modality in the management of walled-off pancreatic necrosis, but the unmanageable infection of postoperation is still a thorny problem due to the poor drainage ability for solid necrotic debris only through transmural stent and nasocystic catheter.

AIMS

Introduce a novel therapeutic method, namely endoscopic ultrasonography-guided drainage combined with cyclic irrigation technique in managing patients with walled-off pancreatic necrosis.

METHODS

18 patients with severe acute pancreatitis complicated with walled-off pancreatic necrosis received treatment with endoscopic ultrasonography-guided drainage combined with cyclic irrigation were involved in this retrospective study.

RESULTS

17 of 18 patients with walled-off pancreatic necrosis were treated by this new therapeutic method. Subsequent surgery was performed in 1 case due to uncontrolled infection, complications such as perforation, bleeding or multiple organ failure were not observed. Treatment success rate was high (16 in 17, 94.12%).

CONCLUSION

Endoscopic ultrasonography-guided drainage combined with cyclic irrigation is an effective treatment option for symptomatic walled-off pancreatic necrosis to facilitate drainage and obviate the need for subsequent surgery or endoscopic necrosectomy.

Endoscopic Therapy With Lumen-apposing Metal Stents Is Safe and Effective for Patients With Pancreatic Walled-off Necrosis

BACKGROUND & AIMS

Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON.

METHODS

We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n = 78), pancreatic duct stent placement for leak (n = 19), hydrogen peroxide-assisted necrosectomy (n = 38), and nasocystic irrigation (n = 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events.

RESULTS

The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions).

CONCLUSIONS

On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.

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.

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

BACKGROUND AND AIMS

Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior.

METHODS

This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery.

RESULTS

The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome.

CONCLUSIONS

An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.

[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.

Management of pancreatic fluid collections: A comprehensive review of the literature

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.

EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video)

BACKGROUND AND AIMS

A lumen-apposing, self-expanding metal stent incorporated in an electrocautery-enhanced delivery system for EUS-guided drainage of pancreatic fluid collections (PFCs) recently has become available. The aim of this study was to analyze the safety and clinical effectiveness of this newly developed device in this clinical setting.

METHODS

This was a retrospective analysis of all consecutive patients with PFCs who underwent EUS-guided drainage using the study device in 13 European centers.

RESULTS

Ninety-three patients with PFCs (80% with complex collections) underwent drainage using the study device. Penetration of the PFC was accomplished directly with the study device in 74.2% of patients, and successful stent placement was accomplished in all but 1 patient, mostly without fluoroscopic assistance. Direct endoscopic necrosectomy (DEN) was carried out in 31 of 52 cases (59.6%) of walled-off necrosis and in 2 of 4 cases (50%) of acute peripancreatic fluid collection. Complete resolution of the PFC was obtained in 86 cases (92.5%), with no recurrence during follow-up. Treatment failure occurred in 6 patients because of persistent infection requiring surgery (n = 3), perforation and massive bleeding caused by the nasocystic drainage catheter (NCDC) (n = 2), and the need for a larger opening to extract large necrotic tissue pieces (n = 1). Major adverse events occurred in 5 patients (perforation and massive bleeding caused by the NCDC in 2 patients, 1 pneumoperitoneum and 1 stent dislodgement during DEN, and 1 postdrainage infection) and were mostly not related to the drainage procedure.

CONCLUSIONS

EUS-guided drainage with the electrocautery-enhanced delivery system is a safe, easy to perform, and a highly effective minimally invasive treatment modality for PFCs.

Endosonography guided management of pancreatic fluid collections

The revised Atlanta classification of acute pancreatitis was adopted by international consensus, and is based on actual local and systemic determinants of disease severity. The local determinant is pancreatic necrosis (sterile or infected), and the systemic determinant is organ failure. Local complications of pancreatitis can include acute peri-pancreatic fluid collection, acute necrotic collection, pseudocyst formation, and walled-off necrosis. Interventional endoscopic ultrasound (EUS) has been increasing utilized in managing these local complications. After performing a PubMed search, the authors manually applied pre-defined inclusion criteria or a filter to identify publications relevant to EUS and pancreatic collections (PFCs). The authors then reviewed the utility, efficacy, and risks associated with using therapeutic EUS and involved EUS devices in treating PFCs. Due to the development and regulatory approval of improved and novel endoscopic devices specifically designed for transmural drainage of fluid and necrotic debris (access and patency devices), the authors predict continuing evolution in the management of PFCs. We believe that EUS will become an indispensable part of procedures used to diagnose PFCs and perform image-guided interventions. After draining a PFC, the amount of tissue necrosis is the most important predictor of a successful outcome. Hence, it seems logical to classify these collections based on their percentage of necrotic component or debris present when viewed by imaging methods or EUS. Finally, the authors propose an algorithm for managing fluid collections based on their size, location, associated symptoms, internal echogenic patterns, and content.

Metal versus plastic for pancreatic pseudocyst drainage: clinical outcomes and success

BACKGROUND

Endoscopic transmural drainage of pancreatic pseudocysts (PPs) by using double-pigtail (DP) plastic stents requires placement of multiple stents and can be restricted by inadequate drainage and leakage risk. Recently, the use of fully covered self-expanding metal stents (FCSEMSs) has been reported as an alternative to DP plastic stents.

OBJECTIVE

To evaluate the clinical outcomes, success rate, and adverse events of EUS-guided drainage of PPs with DP plastic stents and FCSEMSs.

DESIGN

Retrospective cohort study.

SETTING

Two tertiary-care academic medical centers.

PATIENTS

This study involved 230 patients (mean age, 52.6 years) with PPs who underwent EUS-guided transmural drainage including 118 that were drained by using DP plastic stents and 112 by using FCSEMSs. A transgastric approach was used in 210 patients (91%), and transduodenal drainage was performed in 20 patients (9%).

INTERVENTIONS

Stent deployment under EUS guidance.

MAIN OUTCOME MEASUREMENTS

Technical success, early adverse events, stent occlusion requiring reintervention, and long-term success.

RESULTS

At 12-month follow-up after the initial procedure, complete resolution of PPs by using DP plastic stents was lower compared with those that underwent drainage with FCSEMSs (89% vs 98%; P = .01). Procedural adverse events were noted in 31% in the DP plastic stent group and 16% in the FCSEMS group (P = .006). On multivariable analysis, patients with plastic stents were 2.9 times more likely to experience adverse events (odds ratio 2.9; 95% confidence interval, 1.4-6.3).

LIMITATIONS

Retrospective study.

CONCLUSION

In patients with PPs, EUS-guided drainage by using FCSEMSs improves clinical outcomes and lowers adverse event rates compared with those drained with DP plastic stents.

EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self-expandable metal stents with pancreatic ductal stenting in selected patients

BACKGROUND

EUS-guided pseudocyst drainage with fully covered self-expandable metal stents (FCSEMSs) was recently described. The appropriate period for stent removal is not known.

OBJECTIVE

To assess the safety and efficacy of EUS-guided FCSEMS placement for 3 weeks, along with pancreatic ductal stenting in selected patients.

STUDY DESIGN

Prospective, single-center evaluation.

SETTING

Tertiary referral center.

PATIENTS

Symptomatic pseudocysts in the body and tail region of the pancreas.

INTERVENTIONS

EUS-guided transgastric placement of FCSEMS. MRCP was performed after 3 weeks. Patients with a suspected pancreatic duct leak underwent ERCP and plastic stent placement. The FCSEMSs were removed at 3 weeks.

MAIN OUTCOME MEASUREMENTS

Success of FCSEMS placement, adverse events, and recurrence rate.

RESULTS

Forty-seven patients met the eligibility criteria. Technical and functional success was achieved in 43 patients (intention to treat, 91.48% and 95.34% patients [per protocol, 41/43, respectively]). Adverse events occurred in 2 patients (cyst infections, 4.6%). Follow-up of 42 patients at 3 weeks was performed. MRCP detected a ductal leak in 3 patients (7.1%) and a disconnected duct in 2 patients (4.7%). ERCP and stenting were successful in all 3 patients with a ductal leak. During a median follow-up of 306 days in 42 patients, 2 recurrences (4.7%) were detected, both in patients with disconnected duct. Multivariate analysis showed that pancreatic ductal leak or disconnection was an independent factor affecting pseudocyst resolution at 3 weeks (P = .0001).

LIMITATIONS

Single-center study.

CONCLUSION

Short-term placement of FCSEMSs with pancreatic ductal stenting in selected patients appears safe and effective for the treatment of pseudocysts.

Endoscopic ultrasound-guided drainage of pancreatic pseudocysts

Pancreatic pseudocysts are fluid collections in the peripancreatic tissues associated with acute or chronic pancreatitis. Endoscopic ultrasound (EUS)-guided drainage has become an established indication, having better results as compared to percutaneous drainage, nonguided endoscopic drainage, or surgical drainage. The aim of this review is to assess critically the current literature concerning EUS-guided pseudocyst drainage and to review the place of the procedure in the clinical decision management algorithms of these patients.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

Endoscopic ultrasound guided interventional procedures

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

New fully covered large-bore wide-flare removable metal stent for drainage of pancreatic fluid collections: results of a multicenter study

BACKGROUND AND AIM

Endoscopic transmural drainage (ETMD) of peripancreatic fluid collections (PFC) is an effective alternative to surgical drainage. Conventional drainage using plastic stents has its limitations. A wide-bore short-length wide flange fully covered self-expandable metallic stent (FCSEMS) has recently been developed. The present study evaluates the efficacy of this new FCSEMS for ETMD of PFC.

METHODS

This was a retrospective, multicenter study. Patients with PFC undergoing endoscopic ultrasound (EUS)-guided drainage of PFC using specially designed FCSEMS were included. Parameters evaluated were technical success of stent placement, clinical success as defined by resolution of PFC without any further surgical intervention, ability to carry out endoscopic necrosectomy, complications and feasibility of endoscopic stent removal.

RESULTS

Twenty-one PFC in 19 patients were drained using FCSEMS. Technical and clinical success for drainage was seen in all patients (100%). Endoscopic necrosectomy was carried out in seven (33%) PFC. Complications occurred in two patients (10.5%). Stents could be endoscopically removed in all patients (100%).

CONCLUSIONS

The new specially designed FCSEMS is safe and effective for drainage of PFC. Necrosectomy can be carried out through the stent. Stent can be removed endoscopically at the end of the treatment period.

Efficacy of metal and plastic stents for transmural drainage of pancreatic fluid collections: a systematic review

BACKGROUND AND AIM

Metal stents are being used more frequently for transmural endoscopic drainage of pancreatic fluid collections (PFC) despite lack of data. The present systematic review was conducted to compare the rates of treatment success, adverse events and recurrence between patients undergoing metal versus plastic stent placement for endoscopic transmural drainage of PFC.

METHODS

MEDLINE and EMBASE were searched to identify all published manuscripts that evaluated metal stents for endoscopic transmural drainage of PFC. All published studies from the same period involving plastic stent placement for PFC drainage that included >50 patients were also identified. Main outcome measures were to compare the rates of treatment success, adverse events and recurrence between the metal and plastic stent cohorts.

RESULTS

Seventeen studies (881 patients) met inclusion criteria. There was no difference in overall treatment success between patients treated with plastic and metal stents (81% [95% CI, 77-84%] vs 82% [95% CI, 74-88%]) for both pseudocysts (85% [95% CI, 81-89%] vs 83% [95% CI, 74-89%]) and walled-off necrosis (70% [95% CI, 62-76%] vs 78% [95% CI, 50-93%]). Also, there was no difference in the rates of adverse events (16% [95% CI, 14-39%] vs 23% [95% CI, 16-33%]) or recurrence (10% [95% CI, 8-13%] vs 9% [95% CI, 4-19%]) between plastic and metal stents.

CONCLUSIONS

Current evidence does not support routine placement of metal stents for transmural drainage of PFC. Randomized trials are needed to justify the use of metal stents for PFC drainage.

Endoscopic ultrasound guided drainage of pancreatic fluid collections: Assessment of the procedure, technical details and review of the literature

Endoscopic ultrasound (EUS) guided drainage of pancreatic fluid collections (PFC) has become increasingly popular and become first line management option in many centers. Use of therapeutic echoendoscopes has greatly increased the applicability of EUS guided transmural drainage. Drainage is indicated in symptomatic PFCs, PFC related infection, bleed, luminal obstruction, fistulization and biliary obstruction. EUS guided transmural drainage of PFCs is preferred in patients with non bulging lesions, portal hypertension, bleeding tendency and in those whom conventional drainage has failed. In the present decade significant progress has been made in minimally invasive endoscopic techniques. There are newer stent designs, access devices and techniques for more efficient drainage of PFCs. In this review, we discuss the EUS guided drainage of PFCs in acute pancreatitis.

Endoscopic extra-cavitary drainage of pancreatic necrosis with fully covered self-expanding metal stents (fcSEMS) and staged lavage with a high-flow water jet system

AIM

To present a novel, less-invasive method of endoscopic drainage (ED) for walled-off pancreatic necrosis (WON).We describe the feasibility, success rate, and complications of combined ED extra-cavitary lavage and debridement of WON using a biliary catheter and high-flow water jet system (water pump).

PATIENTS AND METHODS

Endoscopic ultrasound (EUS)-guided drainage was performed with insertion of two 7-Fr, 4-cm double pigtail stents. Subsequently a fully covered self-expanding metal stent (fcSEMS) was placed. The key aspect of the debridement was the insertion of a 5-Fr biliary catheter through or along the fcSEMS into the cavity, with ensuing saline lavage using a high-flow water jet system. The patients were then brought back for repeated, planned endoscopic lavages of the WON. No endoscopic intra-cavitary exploration was performed.

RESULTS

A total of 17 patients (15 men, 2 women; mean age 52.6, range 24 - 69; mean American Society of Anesthesiologists [ASA] score of 3) underwent ED of WON with this new method. The mean initial WON diameter was 9.5 cm, range 8 to 26 cm. The total number of ED was 84, range 2 to 13. The mean stenting period was 42.5 days. The mean follow-up was 51 days, range 3 to 370. A resolution of the WON was achieved in 14 patients (82.3 %). There were no major complications associated with this method.

CONCLUSION

ED of complex WON with fcSEMS followed by repeated endoscopic extra-cavitary lavage and debridement using a biliary catheter and high-flow water jet system is a minimally invasive, feasible method with high technical and clinical success and minimal complications.

Stent displacement in endoscopic pancreatic pseudocyst drainage and endoscopic management

A pancreatic pseudocyst (PPC) is a collection of pancreatic fluid enclosed by a non-epithelialized, fibrous or granulomatous wall. Endoscopic pancreatic pseudocyst drainage (PPD) has been widely used clinically to treat PPCs. The success and complications of endoscopic PPD are comparable with surgical interventions. Stent displacement is a rare complication after endoscopic PPD. Almost all the complications of endoscopic PPD have been managed surgically, and there is rare report involving the endoscopic treatment of intraperitoneal stent displacement. We report here a case of stent displacement after endoscopic ultrasound- and fluoroscopy-guided PPD in a 41-year-old female patient with a PPC in the tail of the pancreas. The endoscopic treatment was successfully performed to remove the displaced stent. The clinical course of the patient was unremarkable. The cyst had significantly reduced and disappeared by 12 wk. We found that both endoscopic ultrasound and fluoroscopy should be used during endoscopic PPD to avoid stent displacement. The displaced stent can be successfully treated by endoscopic removal.

Endoscopic management of pancreatic pseudocysts and necrosis

Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.

Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos)

BACKGROUND

Recent medical literature on novel lumen-apposing stents for the treatment of pancreatic fluid collections (PFCs) is limited by small numbers, solo operators, and single-center experience.

OBJECTIVE

To evaluate a recently developed lumen-apposing, fully covered self-expandable metal stent (FCSEMS) in the management of PFCs.

DESIGN

Retrospective case series.

SETTING

Thirteen tertiary and private health care centers across Australia.

PATIENTS

Forty-seven patients (median age 51 years) who underwent endoscopic management of PFCs.

INTERVENTION

Insertion of FCSEMS after PFC puncture under EUS guidance. A subgroup of 9 patients underwent direct endoscopic necrosectomy.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success rate, adverse event rate.

RESULTS

The technical success rate was 53 of 54 patients (98.1%), and the initial clinical success rate was 36 of 47 (76.6%), which was sustained for more than 6 months in 34 of 36 (94.4%). Early adverse events included 4 cases (7.4%) of stent migration during direct endoscopic necrosectomy, 4 cases (7.4%) of sepsis, 1 case (1.9%) of bleeding, and 1 case (1.9%) of stent migration into the fistula tract. Late adverse events were 6 (11.1%) spontaneous stent migrations, 3 (5.6%) recurrent stent occlusions, 3 (5.6%) tissue ingrowth/overgrowth, and 2 (3.7%) bleeding into PFC. The majority of stents inserted (48 of 54, 88.9%) and removed (31 of 35, 88.6%) in our study were described by the operator as superior to pigtail stents with regard to ease of use.

LIMITATIONS

Retrospective study.

CONCLUSION

Although FCSEMSs are technically easier to insert and remove compared with traditional pigtail stents, there are significant limitations to the widespread use of FCSEMSs in the management of PFCs. These include cost, adverse events, and lower-than-expected resolution rates.