Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

BACKGROUND

Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated.

METHODS

This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates.

RESULTS

Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0).

CONCLUSIONS

Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease—Novel Interventional Procedures

There is growing evidence supporting the substantial, essential and indispensable role of endoscopic ultrasound (EUS) as a key diagnostic armamentarium for upper GI oncologic surgery. Well described in countless publications, EUS holds that position in gastroenterological expert centers all over Europe. Despite its undisputable contributions to oncologic upper GI surgery, the availability of this technique at the expert level shows up in an irregular spread pattern. Endoscopic ultrasound’s primary use during the first few years after its creation was the detection of pancreatic cancer. From then on, EUS developed in different directions, becoming a diagnostic tool that increasingly better defines its status as a method of minimally invasive therapeutic applications and a useful addition to surgical options. As a result, several surgical interventions could even be replaced by ultrasound-targeted interventions. This process took place in just a few years and was made possible by technical development that sensibly combined high-resolution ultrasound with therapeutic endoscopy. The present article will serve to cover the most prevalent uses with supporting data considering the growing list of suggested indications for EUS while also examining cutting-edge initiatives that might soon become the standard of clinical practice. Endoscopic centers with high expertise are needed to train future experts in the growing field of EUS interventions.

Endoscopic ultrasound-guided drainage of peripancreatic fluid collections: What impacts treatment duration?

BACKGROUND

Peripancreatic fluid collections (PFCs) are complications resulting from acute or chronic pancreatitis and require treatment in certain clinical conditions. The present study aimed to identify the factors influencing the duration of endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic pseudocysts (PPCs), walled-off necrosis (WON), and acute necrotic collections (ANCs).

METHODS

This was a retrospective cohort study of 68 patients with PFCs who underwent EUS-guided drainage. The timing and duration of EUS-guided drainage of various PFCs (ANC, WON, and PPCs) were compared, and the factors influencing the duration of endoscopic treatment were identified.

RESULTS

The mean time to first EUS-guided PFC drainage since the acute pancreatitis episode was 372.0, 505.0, and 18.7 days for WON, PPC, and ANC, respectively, and the mean duration of treatment was 90, 60, and 63 days, respectively. A disconnected pancreatic duct, a history of percutaneous drainage, and an infected PFC were identified as factors influencing the treatment duration. A positive correlation was observed between the treatment duration and patients' age. Patients with a disconnected pancreatic duct had to undergo more procedures. In patients with PPC, clinically successful drainage was more frequently achieved after a single procedure without the need for repeated procedures than in those with WON (90% vs. 59%, P = 0.01).

CONCLUSIONS

Patients with a history of percutaneous drainage, disconnected pancreatic duct, or PFC infection may require longer endoscopic treatment.

Clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis and pancreatic pseudocyst, and the effects on IL-6 and CRP

The study aimed to investigate the clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis (SAP) and pancreatic pseudocyst (PP), and its effects on serum inflammatory factors. Altogether 94 patients complicated with SAP and PP who were admitted to Weifang People's Hospital (Weifang, China) from September 2015 to December 2018 were included. Based on the different operation methods, 49 patients who underwent traditional laparotomy under laparoscopic surgery were included in group A, and 45 patients who underwent duodenoscopy and laparoscopy under duodenoscope to treat the drainage of nipple and pancreatic pseudocysts were included in group B. The expression levels of related serum indexes and serum stress indexes before and at 48 h after surgery, the postoperative nausea, vomiting and abdominal pain scores, as well as the clinical efficacy, perioperative related indexes, recovery and complications were compared between the two groups. The prognostic factors in both groups were assessed via Logistic univariate and multivariate analyses. C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-β (IL-β), endotoxin and nuclear factor κB (NF-κB) were significantly lower in group B than those in group A (P<0.001). Upregulating cortisol and norepinephrine in group B was lower than that in group A (P<0.001). The total effective rate in group B was higher than that in group A (P<0.05). The perioperative related indexes, recovery, and postoperative complications in group B were better than those in group A (P<0.05). Scores of abdominal pain, nausea and vomiting in group B were markedly lower than those in group A (P<0.001). Multivariate Logistic regression analysis showed that CRP, TNF-α, IL-6, IL-β and surgical methods were independent risk factors for the prognosis of patients with SAP and PP. In conclusion, the combined treatment with duodenoscopy and laparoscopic surgery has little inflammatory and stress reaction, and it is highly safe, worthy to be popularized.

Is endoscopic drainage better than percutaneous drainage for patients with pancreatic fluid collections? A comparative meta-analysis

INTRODUCTION

though endoscopic and percutaneous drainage have emerged as the most common minimally invasive treatments for pancreatic fluid collections (PFCs), estimates of therapeutic superiority for either treatment have yielded inconsistent results.

METHODS

we retrieved studies comparing the efficacy and safety of these two approaches in PubMed, Embase, and the Cochrane Library. Primary outcomes were differences in technical success, clinical success, and adverse events, and secondary outcomes included differences in reintervention, need for surgical intervention, mortality, recurrence rate, and length of hospital stay.

RESULTS

there were nonsignificant differences in technical success rate (OR 0.54; CI: 0.15-1.86), clinical success rate (OR 1.39; CI: 0.82-2.37), adverse events rate (OR 1.21; CI: 0.70-2.11), mortality rate (OR 0.81; CI: 0.30-2.16), and recurrence rate (OR 1.94; CI 0.74-5.07) between the two groups. Reintervention rate (OR 0.19; CI: 0.08-0.45) and percentage of need for surgical intervention (OR 0.08; CI: 0.02-0.39) in the endoscopic drainage group were much lower than in the percutaneous drainage group. Total length of hospital stay (standard mean difference [SMD] -0.60; CI: -0.84 to -0.36) in the endoscopic drainage group was shorter; however, there was a nonsignificant difference in the length of post-procedure hospital stay (SMD: -0.30; CI: -1.05-0.44) between the two groups.

CONCLUSION

endoscopic drainage is effective for PFCs, and superior in terms of lower reintervention and need for surgery rates over traditional percutaneous drainage, despite a similar clinical efficacy and safety compared with traditional percutaneous drainage.

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.

Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis

Background and study aims  Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods  In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results  Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P =  0.39) and perforation risk (0.5 % vs. 1.1 %, P =  0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P =  0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P =  0.72), stent migration (5.9 % vs. 6.8 %, P =  0.79), and stent occlusion (3.8 % vs. 5.2 %, P =  0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions  LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.

Comparative outcomes of endoscopic ultrasound-guided cystogastrostomy for peripancreatic fluid collections: a systematic review and meta-analysis

Background:

Endoscopic ultrasound–guided cystogastrostomy has become the first-line treatment for symptomatic peripancreatic fluid collections. The aim of this study is to analyze the efficacy and safety of cystogastrostomy via a meta-analysis of the literature.

Methods:

We performed a systematic search of PubMed and Medline databases for studies published from January 2005 to May 2018. We included randomized controlled trials along with retrospective and prospective observational studies reporting endoscopic ultrasound–guided cystogastrostomy stent placement for peripancreatic fluid collections. The primary outcome for our meta-analysis was complete peripancreatic fluid collection resolution on imaging. Our secondary outcomes included comparative efficacy and safety of the procedure for pseudocysts and walled-off pancreatic necrosis using metal and plastic stents.

Results:

Seventeen articles involving 1708 patients met our inclusion criteria for meta-analysis. Based upon the random effects model, the pooled technical success rate of cystogastrostomy was 88% (95% confidence interval = 83–92 with I² = 85%). There was no difference in the technical success rate between pancreatic pseudocysts and walled-off pancreatic necrosis (91% and 86%, respectively p = nonsignificant). The adverse event rates for metal and plastic stents were equivalent (14% and 18%, respectively, p = nonsignificant).

Conclusion:

Endoscopic ultrasound–guided cystogastrostomy stents are effective in the treatment of pancreatic pseudocysts and walled-off pancreatic necrosis. We found no difference in technical success or adverse event rates of drainage based on peripancreatic fluid collection type or stent used.

Intrasplenic Pancreatic Pseudocyst after Chemoradiation of a Pancreatic Adenocarcinoma Mimicking Progressive Disease: A Case Report and Review of the Literature

Chemoradiation is one of the therapeutic options in palliative treatment of locally advanced pancreatic adenocarcinoma, with a well-known safety profile. In this case report, we describe the treatment-related occurrence of an intrasplenic pancreatic pseudocyst which was successfully removed by gastrocystic drainage. This rare complication should be considered in the follow-up and clinical management of patients, particularly if left-sided complaints occur.

Therapeutic EUS: New tools, new devices, new applications

Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.

Lumen-apposing metal stents (LAMS) versus plastic stents for EUS-guided drainage of walled-off necrosis (WON) (LVPWON): study protocol for a multicenter randomized controlled trial

Background

Endoscopic ultrasonography (EUS)-guided drainage has become the first-line therapy for late peri-pancreatic fluid collection (PFC). Double pigtail plastic stents (DPPS) and lumen-apposing metal stents (LAMS) are commonly used for PFC drainage. Recently, a multi-institutional consensus on PFC drainage has recommended that LAMS should be the standard care for patients with walled-off necrosis (WON). However, given the poor quality of evidence, we aim to perform a large-scale randomized controlled trial to determine whether LAMS is superior to DPPS for WON drainage.

Methods/design

The study is an open-label, prospective, parallel-group, superiority, multicenter randomized controlled trial. Two hundred and fifty-six patients with WON who will attend 18 tertiary hospitals in China will be randomly allocated to the LAMS or DPPS group before the procedure. The primary endpoint is the clinical success at one month after drainage (reduction in the size of WON to < 2 cm). Secondary endpoints include technical success, operation time, recurrence, adverse events, and secondary interventions.

Discussion

The LVPWON trial is designed to determine whether LAMS is effective, safe, and superior to DPPS for WON drainage.

Trial registration

ClinicalTrials.gov, NCT03027895. Registered on 14 January 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2901-3) contains supplementary material, which is available to authorized users.