EUS-guided treatment of WON using lumen-apposing metal stents: protocol standardisation based on the occurrence of natural healing processes

Lumen-apposing metal stents for the treatment of pancreatic and peripancreatic fluid collections and bleeding risk: a propensity matched study

INTRODUCTION

 Endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic fluid collections (PFCs) using the Hot-Axios device has recently been associated with a significant risk of bleeding. This adverse event (AE) seems to occur less frequently with the use of a different device, the Spaxus stent. The aim of the current study was to compare the rates of bleeding between the two stents.

METHODS

 Patients admitted for treatment of PFCs by EUS plus lumen-apposing metal stent in 18 endoscopy referral centers between 10 July 2019 and 28 February 2022 were identified and their outcomes compared using a propensity-matching analysis.

RESULTS

 363 patients were evaluated. After a 1-to-1 propensity score match, 264 patients were selected (132 per group). The technical and clinical success rates were comparable between the two groups. Significantly more bleeding requiring transfusion and/or intervention occurred in the Hot-Axios group than in the Spaxus group (6.8% vs. 1.5%; P = 0.03); stent type was a significant predictor of bleeding in both univariate and multivariate regression analyses (P = 0.03 and 0.04, respectively). Bleeding necessitating arterial embolization did not however differ significantly between the two groups (3.0% vs. 0%; P = 0.12). In addition, the Hot-Axios was associated with a significantly higher rate of overall AEs compared with the Spaxus stent (9.8% vs. 3.0%; P = 0.04).

CONCLUSION

 Our study showed that, in patients with PFCs, bleeding requiring transfusion and/or intervention occurred significantly more frequently with use of the Hot-Axios stent than with the Spaxus stent, although this was not the case for bleeding requiring embolization.

The endoscopic ultrasound features of pancreatic fluid collections and their impact on therapeutic decisions: an interobserver agreement study

BACKGROUND

A validated classification of endoscopic ultrasound (EUS) morphological characteristics and consequent therapeutic intervention(s) in pancreatic and peripancreatic fluid collections (PFCs) is lacking. We performed an interobserver agreement study among expert endosonographers assessing EUS-related PFC features and the therapeutic approaches used.

METHODS

50 EUS videos of PFCs were independently reviewed by 12 experts and evaluated for PFC type, percentage solid component, presence of infection, recognition of and communication with the main pancreatic duct (MPD), stent choice for drainage, and direct endoscopic necrosectomy (DEN) performance and timing. The Gwet's AC1 coefficient was used to assess interobserver agreement.

RESULTS

A moderate agreement was found for lesion type (AC1, 0.59), presence of infection (AC1, 0.41), and need for DEN (AC1, 0.50), while fair or poor agreements were stated for percentage solid component (AC1, 0.15) and MPD recognition (AC1, 0.31). Substantial agreement was rated for ability to assess PFC-MPD communication (AC1, 0.69), decision between placing a plastic versus lumen-apposing metal stent (AC1, 0.62), and timing of DEN (AC1, 0.75).

CONCLUSIONS

Interobserver agreement between expert endosonographers regarding morphological features of PFCs appeared suboptimal, while decisions on therapeutic approaches seemed more homogeneous. Studies to achieve standardization of the diagnostic endosonographic criteria and therapeutic approaches to PFCs are warranted.

Role of endoscopic ultrasonography in the management of peripancreatic collections. Diagnostic and therapeutic approach

Pancreatic fluid collections are surrounded by a wall of granulation tissue and may contain necrotic debris. They occur following a severe acute pancreatitis and most of the cases resolve spontaneously after several weeks. However, their management may lead to a very hardto-treat condition, requiring a multidisciplinary approach. During the last decades we assisted to a change of paradigm involving Endoscopic Ultrasonography, from a pure diagnostic technique to an interventional-therapeutic one, allowing an effective, safe and less invasive approach than other existing treatment standards, historically consisting of surgical and percutaneous drainage. Treatment of pancreatic fluid collections is indicated if they become infected or symptomatic. Over the past years, exponential developments were done in interventional endoscopic approach, making it the first line suggested modality. The use of endoscopic ultrasound allows assessment of the collection, even when it is not directly bulging on gastrointestinal wall, creation of an internal fistulous tract, checking for surrounding vessels with the use of Doppler, and deployment of a stent avoiding the discomfort of external tubes. Several types of stent have been used for endoscopic drainage: plastic double pigtail stents, fully covered self-expanding metal stents and, more recently, lumen apposing metal stents, which are considered revolutionary because of their two-side flanges and wide and short internal channel, a new design that made easier direct endoscopic necrosectomy. This review aims to go through currently available literature on the diagnostic and therapeutic role of Endoscopic Ultrasonography to handle pancreatic fluid collections.