Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience

Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved

Pancreatic fluid collections (PFCs) are well-known complications of acute pancreatitis. The overinfection of these collections leads to a worsening of the prognosis with an increase in the morbidity and mortality rate. The primary strategy for managing infected pancreatic necrosis (IPN) or symptomatic PFCs is a minimally invasive step-up approach, with endosonography-guided (EUS-guided) transmural drainage and debridement as the preferred and less invasive method. Different stents are available to drain PFCs: self-expandable metal stents (SEMSs), double pigtail stents (DPPSs), or lumen-apposing metal stents (LAMSs). In particular, LAMSs are useful when direct endoscopic necrosectomy is needed, as they allow easy access to the necrotic cavity; however, the rate of adverse events is not negligible, and to date, the superiority over DPPSs is still debated. Moreover, the timing for necrosectomy, the drainage technique, and the concurrent medical management are still debated. In this review, we focus attention on indications, timing, techniques, complications, and particularly on aspects that remain under debate concerning the EUS-guided drainage of PFCs.

Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Endoscopic treatment of pancreatic necrosis: Still searching for perfection!

Over last few years, there has been a paradigm shift in the management of infected pancreatic necrosis with endoscopic and minimally invasive "step-up" management approach replacing open surgical necrosectomy. Because of being associated with reduced occurrence of new onset multi-organ failure, external pancreatic fistulae, shorter hospital stay, lower costs, and better quality of life compared with minimally invasive surgical approach, endoscopic "step-up" management approach is the preferred intervention for endoscopically accessible pancreatic necrotic collections at expert centers with endoscopic expertise. Development of lumen apposing metal stents and improvised accessories for interventional endoscopic ultrasound has revolutionized the endoscopic management of pancreatic necrosis making it more effective and safer. Despite these promising developments, endoscopic transluminal necrosectomy (ETN) remains the Achilles heel. Lack of dedicated endoscopic accessories, poor endoscopic visualization within the necrotic cavity, limited diameter of the instrument channel of the endoscope that is a significant impediment to remove large amount of necrotic material, and uncertain ability to avoid vessels and vital structures in the necrotic cavity are important limitations during endoscopic necrosectomy. Recent devices and solutions including use of cap assisted necrosectomy, over the scope grasper and powered endoscopic debridement device are welcome steps in our pursuit for an ideal, safer, and efficacious ETN device. This review will discuss recent advances as well as challenges in the endoscopic management of pancreatic necrosis.

Combined Drainage and Protocolized Necrosectomy Through a Coaxial Lumen-apposing Metal Stent for Pancreatic Walled-off Necrosis: A Prospective Multicenter Trial

OBJECTIVE

We evaluated a protocolized endoscopic necrosectomy approach with a lumen-apposing metal stent (LAMS) in patients with large symptomatic walled-off pancreatic necrosis (WON) comprising significant necrotic content, with or without infection.

SUMMARY BACKGROUND DATA

Randomized trials have shown similar efficacy of endoscopic treatment compared with surgery for infected WON.

DESIGN

We conducted a regulatory, prospective, multicenter single-arm clinical trial examining the efficacy and safety of endoscopic ultrasound -guided LAMS with protocolized necrosectomy to treat symptomatic WON ≥6 cm in diameter with >30% solid necrosis. After LAMS placement, protocolized WON assessment was conducted and endoscopic necrosectomy was performed for insufficient WON size reduction and persistent symptoms. Patients with radiographic WON resolution to ≤ 3 cm and/or 60-day LAMS indwell had LAMS removal, then 6-month follow-up. Primary endpoints were probability of radiographic resolution by 60 days and procedure-related serious adverse events.

RESULTS

Forty consecutive patients were enrolled September 2018 to March 2020, of whom 27 (67.5%) were inpatients and 19 (47.5%) had clinical evidence of infection at their index procedure. Mean WON size was 15.0 ± 5.6 cm with mean 53.2% ± 16.7% solid necrosis. Radiographic WON resolution was seen in 97.5% (95% CI, 86.8%, 99.9%) by 60 days, without recurrence in 34 patients with 6-month follow-up data. Mean time to radiographic WON resolution was 34.1 ± 16.8 days. Serious adverse events occurred in 3 patients (7.5%), including sepsis, vancomycin-resistant enterococcal bacteremia and shock, and upper gastrointestinal bleeding. There were no procedure-related deaths.

CONCLUSIONS

Endoscopic ultrasound-guided drainage with protocolized endoscopic necrosectomy to treat large symptomatic or infected walled-off necrotic pancreatic collections was highly effective and safe. Clinicaltrials.-gov no: NCT03525808.

Controversies in EUS-guided treatment of walled-off necrosis

This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Endotherapy in Pancreatic Diseases

Interventional endoscopy is now considered an effective minimally invasive treatment modality for the management of pancreatic diseases. It is important for the clinician to know the indications and contraindications as well as the timing of various endoscopic interventions. This will help in its safe and effective use and consequently decrease morbidity and mortality from various pancreatic diseases. This review will provide a broad overview of the indications, techniques, and outcomes of pancreatic endotherapy.

Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis

Objectives

Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency.

Methods

This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected.

Results

Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications.

Conclusions

CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

Endoscopic ultrasound-guided transmural drainage of post-traumatic pancreatic fluid collections

Background

Pancreatic injury is an uncommon consequence of abdominal trauma, and surgery has been the conventional treatment. The role and timing of endoscopic ultrasound (EUS)-guided treatment of the consequences of traumatic pancreatic injury is unclear. Our study evaluated the safety and efficacy of EUS-guided transmural drainage of post-traumatic pancreatic fluid collections (PFC).

Methods

A retrospective analysis of 13 patients (mean age 20.2±4.4 years; 12 males) with post-traumatic PFC treated with EUS-guided transmural drainage over the last 10 years was performed. Patient demographics, imaging findings, size of PFC, details of endoscopic transmural drainage procedure, outcome details, as well complications were retrieved from our database.

Results

The patients underwent drainage at 26.8±7.4 days after abdominal trauma, and the mean size of PFC was 11.8±3.2 cm with 2 patients having multiple fluid collections. Ten patients had PFC with a well-formed wall and 3 patients had an incompletely formed wall. Endoscopic drainage was technically successful in all 13 patients and 11 patients underwent transmural drainage with multiple plastic stents whereas 2 patients were treated with lumen apposing metal stents. The PFC resolved in all patients over a mean period of 2.7±0.4 weeks. One patient developed gastrointestinal bleeding 6 days after the procedure, successfully treated with angio-embolization.

Conclusion

EUS-guided transmural drainage of post-traumatic PFC is safe and effective and can be safely performed at an early phase (<4 weeks) after pancreatic trauma.

Safety and Efficacy of Early (<4 Weeks of Illness) Endoscopic Transmural Drainage of Post-acute Pancreatic Necrosis Predominantly Located in the Body of the Pancreas

BACKGROUND

Endoscopic transmural drainage is usually not performed for pancreatic necrotic collection (PNC) < 4 weeks after onset of acute necrotizing pancreatitis (ANP) because of lack of encapsulating wall and increased risk of complications.

OBJECTIVE

Study safety and efficacy of early (<4 weeks) endoscopic transluminal drainage in patients with symptomatic PNC.

METHODS

Retrospective analysis of data base of patients with PNC treated with endoscopic transmural drainage within 4 weeks of onset of ANP (early drainage) was done. The outcomes and complications were compared with patients with PNC who underwent delayed endoscopic drainage (≥4 weeks of onset of ANP).

RESULTS

Thirty-four patients (26 males; mean age: 35.9 ± 8.6 years) underwent early and 136 patients (115 males; mean age: 37.9 ± 9.4 years) underwent delayed endoscopic drainage. The PNC was significantly larger (12.3 ± 2.1 cm vs 10.5 ± 2.7 cm, p <0.001) with increased solid component (47.7 ± 8.9% vs 28.3 ± 11.7%, p <0.001) in the early group. Clinical success was achieved in 94% patients in the early group and all patients in the delayed group. Direct endoscopic necrosectomy was performed more frequently in the early group (50% vs 7.4%; p<0.001). There was increased mortality (5.7% vs 0%), need for rescue surgical necrosectomy (5.7% vs 0%), and clinically significant bleeding (20% vs 1.5%, p<0.001) in the early group as compared to the delayed group.

CONCLUSION

Early endoscopic drainage of PNC is feasible and seems to be safe as well as effective but is associated with increased risk of complications as compared to delayed drainage.

Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial

Background and study aims  Walled-off necrosis (WON) is a known complication of acute necrotizing pancreatitis (ANP). There is no study comparing nasocystic irrigation with hydrogen peroxide (H ₂ O ₂ ) versus biflanged metal stent (BMS) in the management of WON. The aim of this study was to compare the clinical efficacy of both the treatment strategies. Patients and methods  This study was conducted on patients with symptomatic WON who were randomized to nasocystic irrigation with H ₂ O ₂ (Group A) and BMS placement (Group B). Primary outcomes were clinical and technical success while secondary outcomes were procedure time, adverse events, need for additional procedures, duration of hospitalization, and mortality. Results  Fifty patients were randomized into two groups. Group A (n = 25, age 37.8 ± 17.6 years, 16 men) and Group B (n = 25, age 41.8 ± 15.2 years, 17 men). There were no significant differences in baseline characteristics between the two groups. The most common etiology of pancreatitis was alcohol, observed in 27 (54 %) patients. Technical success (100 % vs 96 %, P  = 0.98), clinical success (84 % vs 76 %, P  = 0.76), requirement of additional procedures (16 % vs 24 %, P  = 0.70) and adverse events (4 vs 7, P  = 0.06) were comparable in both the groups. The duration to clinical success (34.4 ± 12 vs 14.8 ± 10.8 days, P  = 0.001) and procedure time (36 ± 15 vs 18 ± 12 minutes, P  = 0.01) were longer in Group A compared to Group B. Conclusions  Nasocystic irrigation with H ₂ O ₂ and BMS are equally effective in the management of WON but time to clinical success and procedure time is longer with nasocystic irrigation.

Large-duct pattern invasive adenocarcinoma of the pancreas–a variant mimicking pancreatic cystic neoplasms: A minireview

Pancreatic cancer currently has no subtypes that inform clinical decisions; hence, there exists an opportunity to rearrange the morphological and molecular taxonomy that guides a better understanding of tumor characteristics. Nonetheless, accumulating studies to date have revealed the large-duct type variant, a unique subtype of pancreatic ductal adenocarcinoma (PDA) with cystic features. This subtype often radiographically mimics intraductal papillary mucinous neoplasms (IPMNs) and involves multiple small cysts occasionally associated with solid masses. The “bunch-of-grapes” sign, an imaging characteristic of IPMNs, is absent in large-duct PDA. Large-duct PDA defines the mucin profile, and genetic alterations are useful in distinguishing large-duct PDA from IPMNs. Histologically, neoplastic ducts measure over 0.5 mm, forming large ductal elements. Similar to classic PDAs, this subtype is frequently accompanied by perineural invasion and abundant desmoplastic reactions, and KRAS mutations in codon 12 are nearly ubiquitous. Despite such morphological similarities with IPMNs, the prognosis of large-duct PDA is equivalent to that of classic PDA. Differential diagnosis is therefore essential.

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.

Effectiveness of early endoscopic ultrasound-guided drainage for postoperative fluid collection

BACKGROUND

Postoperative abdominal fluid collections (PAFCs) are a potentially fatal complication of pancreatobiliary surgery. Endoscopic ultrasound (EUS)-guided drainage has recently been shown to be effective in treating PAFCs of more than 4 weeks old. Little is currently known, however, regarding the EUS-guided drainage of PAFCs of less than 4 weeks. This study assessed the efficacy and safety of the early drainage (< 4 weeks) of PAFCs via EUS guidance.

METHODS

The data of patients who had undergone EUS-guided PAFC drainage between July 2008 and January 2018 were retrospectively analyzed. Data of EUS-guided PAFC drainage were obtained from prospectively collected EUS database of our institute and reviewed of patients' clinical parameters based on electrical medical record.

RESULTS

A total of 48 patients who had undergone EUS-guided PAFC drainage within 4 weeks of pancreatobiliary surgery were enrolled. The indications of procedure included abdominal pain (n = 27), fever (n = 18), leukocytosis (n = 2), and increased size of PAFC during external tube drainage (n = 1). Technical success was achieved in all cases, and the clinical success rate was 95.8% (46/48). Four patients underwent secondary procedures. The median period from surgery to EUS-guide drainage was 14 days (Interquartile range [IQR] 10-16), and median time to resolution was 23.5 days (IQR 8.5-33.8). Adverse events occurred in two cases that were developed intracystic bleeding and were successfully resolved by arterial coil embolization.

CONCLUSIONS

Early EUS-guided drainage is a technically feasible, effective, and safe method in patients who have developing PAFCs within 4 weeks of pancreatobiliary surgery.

Efficacy and safety of plastic versus lumen-apposing metal stents for transmural drainage of walled-off necrosis: a retrospective single-center study

Background

Lumen-apposing metal stents (LAMS) were considered a breakthrough in the endoscopic management of walled-off necrosis (WON), as their larger drainage diameter was expected to provide effective drainage of necrotic material. However, various studies and meta-analyses that have compared plastic and metal stents for the treatment of WON have shown conflicting results. We retrospectively compared the efficacy and safety of endoscopic transmural drainage between multiple plastic stents and LAMS.

Methods

Endoscopic data were retrospectively retrieved for patients who had undergone endoscopic ultrasound (EUS)-guided drainage/debridement of WON. Patients were divided into 2 groups according to whether multiple plastic stents or LAMS were deployed during initial drainage. The resolution and complication rates were compared between the 2 groups.

Results

One hundred sixty-six patients (83% male, mean age 37.5 years) with symptomatic WON were treated with EUS-guided drainage using either multiple plastic stents (n=138) or LAMS (n=28). Patients in the LAMS group had significantly larger WON and a significantly higher proportion of solid content. WON resolution rates did not differ between plastic stents and LAMS (98.5% vs. 96.4% respectively, P=0.42). However, the time taken to resolution was significantly shorter in the LAMS group than in the plastic stents group (26.7 vs. 29.8 days, P=0.03). There was no significant difference between the groups in either mortality or complication rates.

Conclusions

The technical success, rates of WON resolution and complications were similar in patients treated with multiple plastic stents and LAMS. However, LAMS were associated with a significantly shorter time to resolution.

Clinical and morphological consequences of permanent indwelling transmural plastic stents in disconnected pancreatic duct syndrome

Background:

Long-term indwelling transmural stents in patients with walled-off necrosis (WON) and disconnected pancreatic duct syndrome (DPDS) is an effective strategy to decrease risk of recurrence of pancreatic fluid collection (PFC). However, long-term studies on the safety and efficacy of this strategy are lacking.

Methods:

Retrospective analysis of database of patients with WON treated with endoscopic transmural drainage over the past 8 years was done to identify patients with DPDS and indwelling transmural stents for >3 years.

Results:

During the past 8 years, 56 patients with indwelling transmural stent for >3 years were identified and 67.85% of these patients had 10 Fr stents and 32.15% of patients had 7 Fr stents. On follow-up, 5 (8.9%) patients had pancreatic pain with one patient (1.78%) developing recurrence of PFC despite stent being in situ. Two (3.5%) patients had asymptomatic spontaneous external migration of the transmural stent. Fourteen (25%) patients developed diabetes. Two (3.5%) patients developed local complications due to indwelling stent (stent eroded into descending colon in one patient and stent-induced parenchymal calcification in the other). Forty-eight (85.7%) patients underwent EUS on follow-up and disconnected pancreas revealed ≥5 criteria for the diagnosis of chronic pancreatitis in 15 (31.25%) patients.

Conclusions:

Long-term indwelling transmural plastic stents in patients with WON and DPDS are safe and effective with minimal complications. Despite the presence of stents, disconnected pancreas develops morphological changes resembling chronic pancreatitis in one-third patients and clinical consequences of these changes need to be further evaluated.

Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods

Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.

Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management

The development of endoscopic ultrasound (EUS)-guided drainage techniques and lumen-apposing metal stents (LAMS) has markedly reduced the complication rate of endoscopic transmural drainage of pancreatic collections and made these procedures safer and more effective. Despite its improved safety profile, various types of complications, some even life-threatening, can occur after EUS-guided drainage of pancreatic fluid collections. Stent maldeployment/migration, bleeding, gastrointestinal perforation, and air embolism are important complications of EUS-guided drainage of pancreatic collections. Delayed complications weeks after the procedure, such as bleeding and buried LAMS due to the presence of prolonged indwelling transmural stents, have also been described. Careful patient selection, with proper assessment of the size, solid necrotic content and location of the collection, as well as an in-depth understanding of various risk factors that predict complications, are important for a safer and more effective endoscopic transmural drainage. For a better clinical outcome, it is important for the endoscopist to know about various complications of EUS-guided drainage of pancreatic collections, as well as their appropriate management strategies.

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.

Endoscopic treatment of refractory external pancreatic fistulae with disconnected pancreatic duct syndrome

BACKGROUND

External pancreatic fistulae (EPF) developing in setting of disconnected pancreatic duct syndrome (DPDS) are associated with significant morbidity and surgery is the only effective treatment.

AIM

To describe safety and efficacy of various endoscopic including endoscopic ultrasound (EUS) guided drainage techniques for resolving EPF in DPDS.

METHODS

Retrospective analysis of data base of 18 patients (15 males; mean age: 37.6 ± 7.1years) with EPF and DPDS who were treated with various endoscopic techniques including EUS guided transmural drainage.

RESULTS

EPF developed post percutaneous drainage (PCD) (n = 15) or post-surgical necrosectomy (n = 3) of acute necrotic collections. All patients had refractory EPF with daily output of >50 ml/day with mean duration being 19.2 ± 6.1 weeks. One patient had failed surgical fistulo-jejunostomy. Various endoscopic techniques used were: transmural placement of pigtail stent through gastric opening of trans-gastric PCD (n = 5), EUS guided transmural puncture of fluid collection created by clamping PCD (n = 5) or by instillation of water though PCD (n = 3), direct EUS-guided puncture of fistula tract (n = 1) and EUS guided pancreaticogastrostomy (n = 4). EPF healed in 17/18 (94%) patients within 5-21 days and there has been no recurrence over follow up of 16.7 ± 12.8 weeks. Asymptomatic spontaneous external migration of stents was observed in 5/18 (29.4%) patients.

CONCLUSION

Management of refractory EPFs in setting of DPDS is challenging. In our experience, combination of various endoscopic techniques including EUS guided transmural drainage appears to be safe and effective treatment modality for treating these complex EPF's. However, further studies to identify patient selection and best treatment approaches are needed.

An overview of walled-off pancreatic necrosis for clinicians

Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.

Endoscopic Drainage of Pancreatic Fluid Collections

Endoscopy has emerged as a mainstay in the management of pancreatic fluid collections (PFCs), representing an important advance in clinical medicine that has significantly improved the risk-benefit ratio of treating this complex patient population. While endoscopic pseudocyst drainage has generally supplanted surgical and percutaneous approaches, the optimal strategy for walled-off necrosis remains variable and multi-disciplinary despite an emerging trend from randomized trials favoring endoscopy. Although several issues pertaining to endoscopic drainage appear to have been settled - such as the use of endoscopic ultrasound - other pressing questions - including the optimal prosthesis and debridement strategy - remain unanswered, and rigorous investigation is needed. This review aims to provide an evidence-based but practical appraisal of the endoscopic drainage of PFCs through the perspective of the author, with an emphasis on relevant clinical and endoscopic considerations and important research questions.

Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study

Background and study aims  Endoscopic drainage with dedicated lumen-apposing metal stents (LAMS) is routinely performed for symptomatic pancreatic fluid collections (PFCs), walled-off necrosis (WON) and pseudocyst (PP). There has been increasing concern regarding delayed adverse events associated with the indwelling LAMS.  Patients and methods  Multicenter retrospective analysis of consecutive patients who underwent endoscopic ultrasound (EUS)-guided LAMS placement for PFC from January 2010 to May 2017. Main outcomes included: (1) resolution of the PFC, (2) rate of delayed adverse events at follow-up, and (3) predictors of treatment failure and delayed adverse events on logistic regression. Results  A total of 122 patients (mean age 50.9 years, 68 % male) underwent LAMS insertion for 64 WON (98.4 %) and 58 PP (98.3 %). PFC mean size was 10.6 cm. PFC resolution was significantly lower for WON (62.3 %) vs. PP (96.5 %) ( P  < 0.001) on imaging at a median of 4 weeks. Stent occlusion was identified in 18 (29.5 %) and 10 (17.5 %) patients with WON and PP, respectively ( P  = 0.13). There were no cases of delayed bleeding or buried stent on follow-up endoscopy. Use of electrocautery-enhanced LAMS was the only factor associated with treatment failure of WON (OR = 13.2; 95 % ci: 3.33 - 51.82, P  = 0.02) on logistic regression. There were no patient, operator, or procedure-related factors predictive of stent occlusion. Conclusions  EUS-guided LAMS for PFC is associated with a low incidence of delayed adverse events. While nearly all PPs resolve at 4 weeks permitting LAMS removal shortly thereafter, many WON persist, with use of electrocautery-enhanced LAMS being the sole predictor of treatment failure.

Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness

Background and Objectives:

Infected pancreatic necrosis (IPN) in the early phase is treated with “step up approach” involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is a paucity of data on a combined approach of initial PCD followed by endoscopic drainage and necrosectomy. A retrospectively study on safety and efficacy of initial PCD followed by endoscopic transluminal drainage and necrosectomy in IPN.

Methods:

Retrospective analysis of data of 23 patients with IPN who were treated with a combined approach. Patients were divided into two groups as follows: patients with central necrosis in whom PCD and endoscopic drainage were done in the same collection (n = 11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis, and endoscopic drainage was done for central necrosis (n = 12).

Results:

Endoscopic drainage could be done successfully in all 23 patients with mean time for the resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while direct endoscopic necrosectomy (DEN) was needed in 8 (34.8%) patients and fully covered self-expanding metal stent was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%), and 7 in 3 (13%) patients, respectively. Patients of central walled-off pancreatic necrosis (WOPN) with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter.

Conclusion:

The combined approach of initial PCD followed by endoscopic drainage and necrosectomy is safe and effective treatment alternative for patients with IPN.

Management of Inflammatory Fluid Collections and Walled-Off Pancreatic Necrosis

OPINION STATEMENT

Pancreatic fluid collections are a frequent complication of acute pancreatitis. The revised Atlanta criterion classifies chronic fluid collections into pseudocysts and walled-off pancreatic necrosis (WON). Symptomatic PFCs require drainage options that include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, minimally invasive endoscopic drainage has now become the preferred approach. An endoscopic ultrasonography (EUS)-guided approach for pancreatic fluid collection drainage is now 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 WON. Direct endoscopic necrosectomy is often required in WON. Lumen apposing metal stents allow for direct endoscopic necrosectomy and debridement through the stent lumen and are now preferred in these patients. Endoscopic retrograde cholangiopancreatography with pancreatic duct exploration should be performed concurrent to PFC drainage in patients with suspected PD disruption. 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. Ideally, pancreatic ductal disruption should be bridged with endoscopic stenting.

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals

BACKGROUND

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals.

METHODS

Retrospective analysis of collected database of patients (n=18; age 40.94±8.43 years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals.

RESULTS

Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5 cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3 ± 0.79 and time to resolution was 4.4 ± 1.3 weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2 weeks.

CONCLUSION

EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

Safety and efficacy of angioembolisation followed by endoscopic ultrasound guided transmural drainage for pancreatic fluid collections associated with arterial pseudoaneurysm

BACKGROUND AND AIMS

Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC's) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients.

AIM

To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC's associated with pseudoaneurysms.

METHODS

Retrospective analysis of data base of eight patients (all males; mean age: 36.9 + 9.2 years; age range: 26-51 years) who underwent angioembolisation of pseudoaneurysm followed by EUS guided transmural drainage of the PFC's.

RESULTS

The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gall stones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastro-duodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolisation. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC's resolved in 3.9 + 2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient.

CONCLUSIONS

Arterial pseudoaneurysms associated with PFC's can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage.