Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Optimal timing for lumen-apposing metal stent removal following endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis

BACKGROUND

 Lumen-apposing metal stents (LAMSs) are widely used for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs). Safety is a major concern and the timing of LAMS removal is debated owing to the risk of adverse events (AEs). Previous studies showed early stent removal was associated with a reduced risk of AEs, but data are still conflicting. The aim of this systematic review with meta-analysis was to identify the optimal timing for LAMS removal.

METHODS

 Major databases were systematically searched until May 2024. The outcome assessed was the cumulative incidence of AEs related to the early (within 3-4 weeks) versus late (after 3-4 weeks) removal of the LAMS. A random-effects (DerSimonian-Laird) model was used to pool the results.

RESULTS

 Eight studies (1820 patients; mean age 54-61.6 years; 63 % men) were included in the analysis. PFCs included walled-off necrosis (WON; 58.2 %) and pseudocysts (41.8 %). Pooled LAMS-related AEs rate were similar in the late versus early removal groups (risk ratio [RR] 1.03, 95 %CI 0.47-2.28; P = 0.94). Sensitivity analysis, including only studies applying a 4-week cut-off, confirmed a comparable AEs rate (RR 0.80, 95 %CI 0.38-1.65; P = 0.59). The mean (SD) follow-up of the studies was 208 (88) days.

CONCLUSIONS

 The results of this meta-analysis showed no difference in the incidence of AEs between early and late removal of LAMSs in the presence of moderate heterogeneity across studies. Removal within 4 weeks is not warranted, and it may instead be planned on a clinical case-by-case basis according on the patient's condition.

Pancreatic Pseudocyst after Fully Covered Self-expandable Metallic Stent Placement

A 70-year-old woman presented with stage III pancreatic head cancer. After endoscopic sphincterotomy, a fully covered self-expandable metallic stent (FCSEMS) was placed in the common bile duct to manage jaundice. The patient developed a fever and abdominal pain 40 days after stent placement, with a suspected diagnosis of infected pancreatic pseudocyst. Purulent discharge from the papilla was observed during FCSEMS removal, and pancreatography revealed a pseudocyst connected to the main pancreatic duct. The pancreatic pseudocyst resolved after transpapillary drainage. Pancreatic pseudocysts should be suspected after biliary FCSEMS placement, and prompt removal and endoscopic drainage of the FCSEMS should be considered.

Drainage for fluid collections post pancreatic surgery and acute pancreatitis: similar but different?

Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.

Advances in self-expandable metal stents for endoscopic ultrasound-guided interventions

Endoscopic ultrasound (EUS)-guided interventions have evolved rapidly in recent years, with dedicated metal stents playing a crucial role in this process. Specifically, the invention of biflanged short metal-covered stents, including lumen-apposing metal stents (LAMS), and modifications in a variety of tubular self-expandable metal stents (SEMS), have led to innovations in EUS-guided interventions. LAMS or non-LAMS stents are commonly used in the EUS-guided drainage of pancreatic fluid collections, especially in cases of walled-off necrosis. Additionally, LAMS is commonly considered for drainage of the EUS-guided gallbladder or dilated common bile duct and EUS-guided gastroenterostomy. Fully or partially covered tubular SEMS with several new designs are being considered for EUS-guided biliary drainage. This review focuses on advances in SEMS for EUS-guided interventions and discusses related research results.

Neutrophil Gelatinase-Associated Lipocalin for the Differentiation of Mucinous Pancreatic Cystic Lesions

Undetermined pancreatic cystic lesion (PCL) differentiation benefits from endoscopic ultrasound (EUS) based on morphology and cyst fluid analysis, but room for new biomarkers exists. Our aim was to assess the intracystic and serum diagnostic value of neutrophil gelatinase-associated lipocalin (Ngal) and interleukin 1 beta (IL-1β) for differentiation of PCLs. This prospective study included patients from one tertiary hospital, evaluated between April 2018 and May 2020. EUS fine-needle aspiration or pancreatic pseudocysts drainage was the source of PCL intracystic liquid. The final diagnosis was based on surgery or EUS results (morphology, cytology, glucose, and CEA-carcinoembryogenic antigen). The intracystic samples were tested for Ngal, IL-1β, glucose, and CEA, and serum for Ngal and IL-1β. We evaluated 63 cysts, 33 pseudocysts, and 30 non-inflammatory cysts. The diagnostic sensitivity and specificity for mucinous PCL was 70.8% and 92.3% for intracystic Ngal (cut-off: 500-800 ng/dL), without correlation with serum Ngal, no matter the inclusion of infected pseudocysts. After exclusion of infected pseudocysts, the sensitivity and specificity for glucose were 87% and 75%, respectively, and for CEA, they were 87.1%, and 96.8%, respectively. Intracystic Ngal shows promise in differentiating mucinous PCLs, but researchers need to conduct further studies to confirm its effectiveness. Intracystic IL-1β and serum Ngal made no diagnostic contribution.

Comparative outcome of single versus two double-pigtail stents for endoscopic drainage of pancreatic fluid collections with minimal necrosis: a retrospective analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided cystogastrostomy is the treatment of choice for managing symptomatic pancreatic fluid collections (PFC). However, studies on the number of stents for optimal drainage of PFCs are limited. Hence, the present study was conducted to compare the outcome of single versus two double-pigtail stents for endoscopic drainage of PFCs.

METHODS

This is a single-center, retrospective analysis of patients undergoing endoscopic drainage of PFCs with minimal necrosis (pseudocyst or walled-off necrosis with <30% solid content) at a tertiary center in South India from October 2020 to October 2022. Post-procedure, patients were followed up for clinical improvement, and stents were removed after documentation of cyst size reduction on imaging.

RESULTS

Sixty-three patients (82.5% males, median age: 34 years) fulfilling the selection criteria were included. For single stent placement (n = 47), stents of size 8.5 Fr or 10 Fr were used, while for placement of two stents (n = 16), 7 Fr stents were used. The technical success rate was 100%. Intraprocedural and early postprocedural adverse events (all mild to moderate) were comparable between the groups (17.0% with single stent vs. 25.0% with two stents, p = NS). Clinical success was achieved in 93.6% of patients, with no difference between both groups. Three patients in the single stent group required additional procedures. All patients underwent successful stent removal after a median follow-up of 14 weeks.

CONCLUSION

A single pigtail stent of 8.5 Fr or 10 Fr size for EUSguided cystogastrostomy provides efficacy and safety similar to that of two stents.

Single balloon enteroscopy-guided endoscopic retrograde pancreatography for the treatment of a symptomatic pancreatic pseudocyst complicated by pancreaticojejunostomy stricture: A case report

RATIONALE

Endoscopic treatment of a pancreatic pseudocyst complicated by pancreaticojejunostomy (PJ) stricture is challenging.

PATIENT CONCERNS

A 76-year-old woman presented with worsening abdominal pain and dyspepsia. She had been receiving adjuvant chemotherapy (capecitabine and cisplatin) for 4 months after pylorus-preserving pancreaticoduodenectomy (PPPD) for the treatment of extrahepatic cholangiocarcinoma.

DIAGNOSES

Laboratory findings included elevated serum amylase (145 U/L) and lipase (437 U/L) levels. Abdominal computed tomography (CT) showed a pancreatic pseudocyst of approximately 3 cm in size and pancreatic duct dilatation in the remnant pancreas. According to the Response Evaluation Criteria in Solid Tumors, cholangiocarcinoma is a stable disease.

INTERVENTIONS AND OUTCOMES

Endoscopic drainage of the pancreatic pseudocyst was planned. Single-balloon enteroscopy (SBE)-guided endoscopic retrograde pancreatography (ERP) with endoscopic ultrasonography (EUS) using a mini probe demonstrated a membranous PJ stricture and a pancreatic pseudocyst. Endoscopic pseudocyst drainage using a 7-Fr plastic stent was successfully performed after needle-knife incision of the PJ stricture. Follow-up abdominal CT after 3 weeks showed complete resolution of the pseudocyst. Chemotherapy was resumed.

LESSONS

SBE-guided ERP with EUS using a mini probe may be an effective and safe treatment in a patient with a pancreatic pseudocyst complicated by membranous PJ stricture after PPPD.

A preferable modality for the differentiation of peripancreatic fluid collections: Endoscopic ultrasound

BACKGROUND AND OBJECTIVES

Peripancreatic fluid collections (PFCs), including walled-off necrosis (WON) and pancreatic pseudocysts (PPCs), are categorized by imaging modalities, including EUS, computed tomography (CT), and magnetic resonance imaging. Our study aimed to evaluate the effectiveness of EUS in differentiating PFCs compared with that of other modalities.

SUBJECTS AND METHODS

Data were collected retrospectively from 99 patients at fourteen centers who were recruited to undergo lumen-apposing metal stent placement to treat PFCs.

RESULTS

PFCs were detected by CT and EUS in 51 WON and 48 PPC patients. The accuracy in differentiating PFCs by EUS was much higher than that of CT (90.9% vs. 50.5%, P < 0.001). The accuracy in identifying WON on EUS was much higher than that on CT (82.4% vs. 13.7%, P < 0.001), while the accuracy in identifying PPC was comparable in these two modalities (89.6% vs. 100%, P > 0.05). WON patients required more times of debridement than PPC patients (P < 0.001).

CONCLUSION

EUS can categorize symptomatic PFCs with higher accuracy than CT and is a preferred imaging modality to detect solid necrotic debris.

[Disconnected pancreatic duct syndrome in acute pancreatitis]

The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.