EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis

The global research status and trends of the application of endoscopic ultrasonography in pancreatic tumors over the last decades: A bibliometric study

Background

To describe the development process and structural relationships of scientific achievements in endoscopic ultrasonography (EUS) in pancreatic tumors over the past decades and to reveal the key research topics using bibliometric analysis.

Methods

All relevant publications covering the research of EUS in pancreatic tumors from 1984 to 2021 were involved through the Web of Science Core Collection. R-bibliometrix was used to conduct the bibliometric analysis, and VOSviewer software was used to explore the hot spots and networks related to this field.

Results

Between 1984 and 2021, 4071 publications were involved. The number of annual publications increased from 1 to 310. The United States contributed the most publications to this field (n=1433, 35.20%), followed by Japan (n=827, 20.31%) and Germany (n=319, 7.84%). There was active cooperation between countries/regions. Gastrointestinal Endoscopy (GIE) was the most productive journal and the most influential journal. Professor Giovannini M, who produced the most publications, had a great influence on this research. The focus in this field was clarified by analyzing the top 10 citations and co-citations publications. Moreover, the analysis of the keywords showed Important topics: “Classification of pancreatic tumor disease” “Development of EUS in the diagnosis of pancreatic tumor diseases,” and “Development of EUS in the treatment of pancreatic tumor diseases.”

Conclusion

For the first time, bibliometric analysis was used to gain a deep understanding of the global trends of studies investigating EUS in pancreatic tumor diseases. The EUS field is rapidly evolving, and our study may be a critical reference for clinical researchers related to this field.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

A novel value-based scoring system for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a single-centre comparative study of plastic and lumen-apposing metal stents (NOVA study)

OBJECTIVE

Healthcare resources are finite. Value in healthcare can be defined as patient health outcomes achieved per monetary unit spent. Attempts have been made to quantify the value of luminal endoscopy, but there is little in the medical literature describing the value of the complex therapeutic endoscopic activity. This study aimed to characterise the value of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) with either plastic or lumen-apposing metal stents (LAMSs).

METHODS

This is a single-centre, retrospective-prospective comparative study of 39 patients, who underwent EUS-guided PFC drainage between 2009 and 2018. Procedure value was calculated using the formula Q/(T/C), where Q is the quality of procedure adjusted for complications, T procedure duration and C is the complexity adjustment. Quality and complexity were estimated on a 1-4 Likert scale based on the American Society for Gastrointestinal Endoscopy criteria. Time (in minutes) was recorded from the patient entering and leaving the procedure room. Endoscopy time calculated from procedure time was considered a surrogate marker of cost as individual components of procedure cost were not itemized.

RESULTS

Of 39 identified patients who underwent EUS-guided PFC drainage, 11 received double pigtail plastic stents (DPPSs) and 28 received LAMSs. The two groups were comparable in age, gender and aetiology. Nearly 40% of the LAMS interventions were considered high value but only 11% of the plastic stent interventions achieved the same. The difference predominantly was due to a higher rate of complications and longer procedure time.

CONCLUSION

In this single-centre study, EUS-guided PFC drainage using LAMS was found to be a higher value procedure compared to the use of DPPS.

Fluid collection after partial pancreatectomy: EUS drainage and long-term follow-up

Background and Objectives:

Postoperative fluid collection due to pancreatic leak is the most frequent complication after pancreatic surgery. EUS-guided drainage of post-pancreatic surgery fluid collection is the gold standard procedure; however, data on outcomes of this procedure are limited. The primary endpoint of our study was relapse over longterm followup, and the secondary endpoint was the efficiency and safety of EUS-guided drainage of post-pancreatic surgery fluid collection.

Patients and Methods:

This retrospective study was conducted at a single center from December 2008 to April 2016. Global morbidity was defined as the occurrence of an event involving additional endoscopic procedures, hospitalization, or interventional radiologic or surgical procedures. EUS-guided drainage was considered a clinical failure if surgery was required to treat a relapse after stent removal.

Results:

Fortyone patients were included. The technical success rate was 100%. Drainage was considered a clinical success in 93% (39/41) of cases. Additionally, 19 (46%) complications were identified as global morbidity. The duration between surgery and EUS-guided drainage was not a significantly related factor for morbidity rate (P = 0.8); however, bleeding due to arterial injuries (splenic artery and gastroduodenal artery) from salvage drainage procedures occurred within 25 days following the initial surgery. There was no difference in survival between patients with and without complications. No relapse was reported during the followup (median: 44.75 months; range: 29.24 to 65.74 months).

Conclusion:

EUSguided drainage for post-pancreatic surgery fluid collection was efficient with no relapse during longterm followup. Morbidity rate was independent of the duration between the initial surgery and EUS-guided drainage; however, bleeding risk was likely more important in cases of early drainage.

EUS-Guided Transluminal Interventions

The role of endoscopic ultrasound (EUS) has transitioned from a diagnostic to a therapeutic one over the past 40 years. With the advent of curvilinear array echoendoscopes in the 1990s with an accessory channel, multiple tools and devices have been developed and used for a variety of transluminal interventions. EUS provides a viable option and is becoming the procedure of choice for many interventions, including bile and pancreatic duct drainage, guiding angiotherapy, pancreatic fluid collection management, gallbladder drainage, and creating a gastrojejunostomy. Although reports demonstrate the technical success of these interventions, there is tremendous study heterogeneity and a relative lack of controlled randomized trials, which may limit our understanding of their role and utility. Furthermore, adverse events are relatively common and occasionally severe. Despite the limitations, available data strongly indicate the efficacy of EUS interventions when performed by well-trained endosonographers in carefully selected patients and managed in a multidisciplinary setting.

Decision Making in Necrotizing Pancreatitis

The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.

Past, Present, and Future of Gastrointestinal Stents: New Endoscopic Ultrasonography-Guided Metal Stents and Future Developments

Innovations in stent technology and technological advances in endoscopic ultrasonography have led to rapid expansion of their use in the field of gastrointestinal diseases. In particular, endoscopic ultrasonography-guided metal stent insertion has been used for the management of pancreatic fluid collection, bile duct drainage, gallbladder decompression, and gastric bypass. Endoscopic ultrasonography-guided drainage of intra-abdominal fluid collections using a plastic or metal stent is well established. Because of the various limitations—such as stent migration, injury and bleeding in the lumen—recently developed, fully covered self-expanding metal stents or lumen-apposing metal stents have been introduced for those fluids management. This article reviews the recent literature on newly developed endoscopic ultrasonography-guided metal stents and the efficacy thereof.

Endoscopic versus percutaneous drainage of symptomatic pancreatic fluid collections: a 14-year experience from a tertiary hepatobiliary centre

INTRODUCTION

Endoscopic transmural drainage (ED) or percutaneous drainage (PD) has mostly replaced surgery for the initial management of patients with symptomatic pancreatic fluid collections (PFCs). This study aimed to compare outcomes for patients undergoing ED or PD of symptomatic PFCs.

METHODS

Between January 2000 and December 2013, all patients who required PD or ED of a PFC were included. Rates of treatment success, length of hospital stay, adverse events, re-interventions and length of follow-up were recorded retrospectively in all cases.

RESULTS

In total, 164 patients were included in the study; 109 patients underwent ED; and 55 had PD alone. During the 14-year study period, the incidence of ED increased and PD fell. In the 109 patients who were managed by ED, treatment success was considerably higher than in those managed by PD (70 vs. 31 %). Rates of procedural adverse events were higher in the ED cohort compared to the PD group (10 vs. 1 %), but patients managed by ED required fewer interventions (median of 1.8 vs. 3.3) had lower rates of residual collections (21 vs. 67 %) and need for surgical intervention (4 vs. 11 %). In the ED group, treatment success was similar for walled-off pancreatic necrosis (WOPN) and pseudocysts (67 vs. 72 %, P = 0.77). There were no procedure-related deaths.

CONCLUSION

Compared with PD, ED of symptomatic PFCs was associated with higher rates of treatment success, lower rates of re-intervention, including surgery and shorter lengths of hospital stay. Outcomes in WOPN were comparable to those in patients with pseudocysts.

Therapeutic role of endoscopic ultrasound in pancreaticobiliary disease: A comprehensive review

With the development of technology and accessories, the role of endoscopic ultrasound (EUS) has evolved from diagnostics to therapeutics. In order to characterise the therapeutic role of EUS, we searched Web of Knowledge database and reviewed articles associated with therapeutic EUS. There are two modalities for the therapeutic purpose: drainage and fine-needle injection. EUS-guided drainage is a promising procedure for the treatment of peripancreatic fluid collection and biliary obstruction; EUS-guided fine-needle injections such as celiac plexus neurolysis, for the purpose of pain relief for pancreatic cancer and chronic pancreatitis, has emerged as a promising procedure. The aim of the study was to perform a comprehensive and conscientious review on the techniques, complications and clinical outcomes of those EUS-based procedures.

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.

Endoscopic ultrasound-guided transluminal drainage for peripancreatic fluid collections: where are we now?

Endoscopic drainage for pancreatic and peripancreatic fluid collections (PFCs) has been increasingly used as a minimally invasive alternative to surgical or percutaneous drainage. Recently, endoscopic ultrasound-guided transluminal drainage (EUS-TD) has become the standard of care and a safe procedure for nonsurgical PFC treatment. EUS-TD ensures a safe puncture, avoiding intervening blood vessels. Single or multiple plastic stents (combined with a nasocystic catheter) were used for the treatment of PFCs for EUS-TD. More recently, the use of covered self-expandable metallic stents (CSEMSs) has provided a safer and more efficient approach route for internal drainage. We focused our review on the best approach and stent to use in endoscopic drainage for PFCs. We reviewed studies of EUS-TD for PFCs based on the original Atlanta Classification, including case reports, case series, and previous review articles. Data on clinical outcomes and adverse events were collected retrospectively. A total of 93 patients underwent EUS-TD of pancreatic pseudocysts using CSEMSs. The treatment success and adverse event rates were 94.6% and 21.1%, respectively. The majority of complications were of mild severity and resolved with conservative therapy. A total of 56 patients underwent EUS-TD using CSEMSs for pancreatic abscesses or infected walled-off necroses. The treatment success and adverse event rates were 87.8% and 9.5%, respectively. EUS-TD can be performed safely and efficiently for PFC treatment. Larger diameter CSEMSs without additional fistula tract dilation for the passage of a standard scope are needed to access and drain for PFCs with solid debris.

Endoscopic ultrasound-guided endoluminal drainage of the gallbladder

For patients with acute cholecystitis who are not suitable for surgery, endoscopic ultrasound-guided endoluminal drainage of the gallbladder (EUS-GBD) has been developed to overcome the limitations of percutaneous transhepatic gallbladder drainage when endoscopic transpapillary gallbladder drainage is not feasible. In the present review we have summarized the studies describing EUS-GBD. Indications, techniques, accessories, endoprostheses, limitations and complications reported in the different studies are discussed. There were 90 documented cases in the literature. The overall reported technical success rate was 87/90 (96.7%). All patients with technical success were clinically successful. A total of 11/90 (12.2%) patients had complications including pneumoperitoneum, bile peritonitis and stent migration. The advantage of EUS-GBD is its ability to provide gallbladder drainage especially in situations where percutaneous or transpapillary drainage is not feasible or is technically challenging. It also provides the option of internal drainage and the ability to carry out therapeutic maneuvers via cholecystoscopy.

Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications

Pancreatic cystic lesions are being detected with an increasing frequency. Endoscopic ultrasound (EUS) provides both diagnostic and therapeutic means for pancreatic cystic lesions. Detailed imaging and EUS-guided fine-needle aspiration provide additional information on pancreatic cystic lesions. EUS-guided pseudocyst drainage has advantages over conventional drainage modalities. EUS-guided cyst ablation is a promising therapeutic modality.

Stent selection for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a multicenter study in china. Gastroenterol Res Pract. 2014;2014:193562. [PMID: 25018767 PMCID: PMC4074944 DOI: 10.1155/2014/193562]

Aims. We attempted to establish some guidelines for the selection of transmural stents during endoscopic drainage of PFCs by retrospective review of the clinical data obtained from three tertiary hospitals. Patients and Methods. Clinical data of 93 patients with attempted endoscopic drainage of symptomatic PFCs were obtained through chart review and prospective follow-up. Results. Treatment success for acute pseudocyst (n = 67), chronic pseudocyst (n = 9), and WOPN (n = 17) was 95.3%, 100%, and 88.2%, respectively (P = 0.309). Clinical success for single-stent drainage was 93.9% (46/49) versus 97.4% (37/38) for multiple-stent drainage (P = 0.799). Secondary infection for single-stent drainage was 18.4% (9/49) versus 5.3% (2/38) for multiple-stent drainage (P = 0.134). Secondary infection for stent diameter less than or equal to 8.5 F was 3.4% (1/29) versus 17.2% (10/58) for stent diameter larger than or equal to 10 F (P = 0.138). Conclusion. EUS-guided transmural drainage is an effective therapy for PFCs. Single-stent transmural drainage of PFCs is enough and does not seem to influence clinical success. The number or diameter of stents does not seem to be associated with secondary infection.

Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

INTRODUCTION

Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris.

METHODS

This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates.

RESULTS

Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered.

CONCLUSION

DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.

Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections

BACKGROUND

Pancreatic leak is a major cause of morbidity after pancreatectomy. Traditionally, peripancreatic fluid collections have been managed by percutaneous or operative drainage. Data for endoscopic ultrasound (EUS)-guided drainage of postoperative fluid collections are limited. Here we report on the safety, efficacy, and timing of EUS-guided drainage of postoperative peripancreatic collections.

STUDY DESIGN

This is a retrospective review of 31 patients who underwent EUS-guided drainage of fluid collections after pancreatic resection. Technical success was defined as successful transgastric deployment of at least one double pigtail plastic stent. Clinical success was defined as resolution of the fluid collection on follow-up CT scan and resolution of symptoms. Early drainage was defined as initial transmural stent placement within 30 days after surgery.

RESULTS

Endoscopic ultrasound-guided drainage was performed effectively with a technical success rate of 100%. Clinical success was achieved in 29 of 31 patients (93%). Nineteen of the 29 patients (65%) had complete resolution of their symptoms and collection with the first endoscopic procedure. Repeat drainage procedures, including some with necrosectomy, were required in the remaining 10 patients, with eventual resolution of collection and symptoms. Two patients who did not achieve durable clinical success required percutaneous drainage by interventional radiology. Seventeen (55%) of 31 patients had successful early drainage completed within 30 days of their operation.

CONCLUSIONS

Endoscopic ultrasound-guided drainage of fluid collections after pancreatic resection is safe and effective. Early drainage (<30 days) of postoperative pancreatic fluid collections was not associated with increased complications in this series.

The role of imaging-guided percutaneous procedures in the multidisciplinary approach to treatment of pancreatic fluid collections

Pancreatic fluid collections include a wide range of entities such as cystic neoplasms, both benign and malignant; vascular pathology such as pseudoaneurysms and hematomas; and a host of other entities such as pseudocysts, seromas, abscesses, and bilomas. The distinction between these entities requires correlating an often complex and overlapping clinical presentation with findings on imaging studies, typically computed tomography, magnetic resonance imaging, and ultrasound. As complex as the diagnostic work-up may be, the treatment of pancreatic collections poses its own set of challenges and often requires a multidisciplinary collaboration among interventional radiologists, surgeons, and gastroenterologists. The best treatment algorithm is determined by careful review of radiologic imaging studies combined with endoscopic retrograde cholangiopancreatography to apply therapies such as surgical resection; drainage or debridement; endoscopic ultrasound-guided drainage; aspiration or biopsy; and imaging-guided percutaneous drainage, aspiration, or biopsy. This article focuses on the diagnosis and multidisciplinary management of pancreatic fluid collections such as abscesses, pseudocysts, and necrosis.

Treatment of necrotizing pancreatitis

Acute pancreatitis is a common and potentially lethal disease. It is associated with significant morbidity and consumes enormous health care resources. Over the last 2 decades, the treatment of acute pancreatitis has undergone fundamental changes based on new conceptual insights and evidence from clinical studies. The majority of patients with necrotizing pancreatitis have sterile necrosis, which can be successfully treated conservatively. Emphasis of conservative treatment is on supportive measures and prevention of infection of necrosis and other complications. Patients with infected necrosis generally need to undergo an intervention, which has shifted from primary open necrosectomy in an early disease stage to a step-up approach, starting with catheter drainage if needed, followed by minimally invasive surgical or endoscopic necrosectomy once peripancreatic collections have sufficiently demarcated. This review provides an overview of current standards for conservative and invasive treatment of necrotizing pancreatitis.

Current Status of Direct Endoscopic Necrosectomy

The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy.

The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment

An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.

Long-term results after endoscopic drainage and necrosectomy of symptomatic pancreatic fluid collections

AIMS

To determine the immediate and long-term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections.

METHODS

The data of 80 patients with symptomatic pancreatic fluid collections (mean diameter: 11.7 cm, range 3-20; pseudocysts: 24/80, abscess: 20/80, infected walled-off necrosis: 36/80) referred for endoscopic management from October 1997 to March 2008 were analyzed retrospectively.

RESULTS

Endoscopic drainage techniques included endoscopic ultrasound (EUS)-guided aspiration (2/80), EUS-guided transenteric drainage (70/80) and non-EUS-guided drainage across a spontaneous transenteric fistula (8/80). Endoscopic necrosectomy was carried out in 49/80 (abscesses: 14/20; infected necrosis: 35/36). Procedural complications were bleeding (12/80), perforation (7/80), portal air embolism (1/80) and Ogilvie Syndrome (1/80). Initial technical success was achieved in 78/80 (97.5%) and clinical resolution of the collections was achieved endoscopically in 67/80 (83.8%), with surgery required in 13/80 (perforation: four; endoscopically inaccessible areas: two; inadequate drainage: seven). Within 6 months five patients required surgery due to recurrent fluid collections; over a mean follow up of 31 months, surgery was required in four more patients due to recurrent collections as a consequence of underlying pancreatic duct abnormalities that could not be treated endoscopically. The long-term success of endoscopic treatment was 58/80 (72.5%).

CONCLUSIONS

Endoscopic drainage of symptomatic pancreatic fluid collections is safe and effective, with excellent immediate and long-term results. Endoscopic necrosectomy has a risk of serious complications. The underlying pancreatic duct abnormalities must be addressed to prevent recurrence of fluid collections.

Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients

OBJECTIVES

Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections.

METHODS

This is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7 years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively.

RESULTS

A total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6 mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356 days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, p < 0.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, p = 0.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted OR = 7.6, 95% CI [2.9, 20.1], p < 0.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection.

CONCLUSIONS

Endoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

Percutaneous management of pancreatic abscesses: long term results in a single center

BACKGROUND

Several authors consider that surgical intervention is the gold standard for treatment of pancreatic abscesses. Recently, considerable interest has been generated in the minimally invasive management of pancreatic abscess with mixed results reported in the literature.

AIM

To evaluate the efficacy of percutaneous aspiration and/or drainage for patients with pancreatic abscesses.

METHODS

We performed a retrospective analysis of 62 patients with 87 pancreatic abscesses treated by percutaneous management from 1989 to 2009. All patients received appropriate antibiotic therapy. Patients with pancreatic abscess <50mm in diameter were initially treated by ultrasound-guided percutaneous needle aspiration (PNA) and those with abscess ≥50mm were initially treated by ultrasound-guided percutaneous catheter drainage (PCD). Surgery was planned only when there was no clinical improvement after the initial percutaneous treatment. Primary outcome was conversion rate to surgery.

RESULTS

Two patients (3.2%) received supportive treatment only and one of them died. PNA was performed in 16 patients (25.8%), and 8 of them required PCD because of recurrence of abscess. In 44 patients (70.1%), PCD was performed initially. PCD was performed twice in 6 patients and 3 times in 2 patients. There were 5 patients converted to surgery (8.1%) and one of them died. Medians (interquartile ranges) of hospital stay and catheter dwell-time were 17 (12-26) and 12 (9-21) days, respectively. There were no complications related to the procedure.

CONCLUSIONS

Percutaneous aspiration and/or drainage are effective and safe for the treatment of pancreatic abscesses.

Bedside Endoscopic Ultrasound in Critically Ill patients

Background. The aim of this study was to evaluate the role and impact of EUS in the management of critically ill patients. Methods. We retrospectively identified all patients at our institution over a 68-month period in whom bedside inpatient EUS was performed. EUS was considered to have a significant impact if a new diagnosis was established and/or the findings altered subsequent clinical management. Results. Fifteen patients (9 male; mean age 58 ± 15 years) underwent bedside EUS without complications. EUS-FNA (median 4 passes; range 2-7) performed in 12 (80%) demonstrated a malignant mediastinal mass/lymph node (5), pancreatic abscess (1), excluded a pelvic abscess (1), established enlarged gastric folds as benign (1) and excluded malignancy in enlarged mediastinal (1) and porta hepatis adenopathy (1). In two patients, EUS-FNA failed to diagnose mediastinal histoplasmosis (1) and a hemorrhagic pancreatic pseudocyst (1). In three diagnostic exams without FNA, EUS correctly excluded choledocholithaisis (n = 1) and cholangiocarcinoma (1), and found gastric varices successfully thrombosed after previous cyanoacrylate injection (1). EUS was considered to have an impact in 13/15 (87%) patients. Conclusions. In this series, bedside EUS in critically ill patients was technically feasible, safe and had a major impact on the majority of patients.

EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses

AIM: To compare the results for endoscopic ultrasound (EUS)-guided drainage of clear fluid pancreatic pseudocysts with the results for abscess drainage.

METHODS: All patients referred for endoscopic drainage of a fluid collection were prospectively included. The outcome was recorded.

RESULTS: Altogether 26 pseudocysts or abscesses were treated in 25 (6 female) patients. One endoscopist performed the procedures. Non-infected pseudocysts were present in 15 patients and 10 patients had infected fluid collections. The cyst size ranged between 28 cm × 13 cm and 5 cm × 5 cm. The EUS drainage was successful in 94% of the pseudocysts and in 80% of the abscesses (P = 0.04). The complication rate in pseudocysts was 6% and in abscesses was 30% (P = 0.02). Recurrence of a pseudocyst occurred in one patient (4%) after 6 mo; the patient was successfully retreated.

CONCLUSION: EUS-guided drainage of pseudocysts is associated with a higher success rate and a lower complication rate compared with abscess drainage.