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Tsujimae M, Saito T, Sakai A, Takenaka M, Omoto S, Hamada T, Ota S, Shiomi H, Takahashi S, Fujisawa T, Suda K, Matsubara S, Uemura S, Iwashita T, Yoshida K, Maruta A, Okuno M, Iwata K, Hayashi N, Mukai T, Yasuda I, Isayama H, Nakai Y, Masuda A. Necrosectomy and its timing in relation to clinical outcomes of EUS-guided treatment of walled-off pancreatic necrosis: a multicenter study. Gastrointest Endosc 2025; 101:1174.e1-1174.e20. [PMID: 39603541 DOI: 10.1016/j.gie.2024.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/29/2024] [Accepted: 11/18/2024] [Indexed: 11/29/2024]
Abstract
BACKGROUND AND AIMS EUS-guided transmural drainage with on-demand endoscopic necrosectomy (EN) is increasingly used to manage walled-off necrosis (WON). It has not been fully elucidated how EN and its timing are correlated with treatment outcomes compared with the drainage-based approach. METHODS Within a multi-institutional cohort of 423 patients with pancreatic fluid collections, including 227 patients with WON, 153 patients were identified who received the step-up treatment after the initial EUS-guided drainage of symptomatic WON; this included 102 EN patients and 51 non-EN (drainage) patients. Using the competing-risks multivariable proportional hazards regression model with adjustment for potential confounders, we calculated subdistribution hazard ratios (SHRs) for clinical treatment success (WON resolution) according to use of EN and its timing. RESULTS Compared with drainage alone, the EN-based treatment was associated with a shorter time to clinical success with a multivariable SHR of 1.66 (95% confidence interval, 1.12-2.46). Despite a higher risk of procedure-related bleeding in the EN group, there were no differences in the rates of severe adverse events (7.8% vs 5.9% in the EN and non-EN groups, respectively) or mortality (6.9% vs 9.8%). In the EN-treated patients, the timing of EN was not statistically significantly associated with the time to clinical success (Ptrend = .34). CONCLUSIONS Among patients receiving EUS-guided treatment of symptomatic WON, the use of EN in addition to drainage procedures was associated with earlier disease resolution. Further research is desired to determine the optimal timing of initiating EN considering a risk-benefit balance and cost-effectiveness.
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Affiliation(s)
- Masahiro Tsujimae
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shogo Ota
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan; Division of Hepatobiliary and Pancreatic Diseases, Department of Gastroenterology, Hyogo Medical University, Hyogo, Japan
| | - Hideyuki Shiomi
- Division of Hepatobiliary and Pancreatic Diseases, Department of Gastroenterology, Hyogo Medical University, Hyogo, Japan
| | - Sho Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kentaro Suda
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Kensaku Yoshida
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Nobuhiko Hayashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan.
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Hamesch K, Hollenbach M, Guilabert L, Lahmer T, Koch A. Practical management of severe acute pancreatitis. Eur J Intern Med 2025; 133:1-13. [PMID: 39613703 DOI: 10.1016/j.ejim.2024.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/29/2024] [Accepted: 10/30/2024] [Indexed: 12/01/2024]
Abstract
Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.
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Affiliation(s)
- Karim Hamesch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcus Hollenbach
- Department of Gastroenterology, Endocrinology, Infectious Diseases, University of Marburg UKGM, Marburg, Germany
| | - Lucía Guilabert
- Department of Gastroenterology, Dr. Balmis General University Hospital- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Tobias Lahmer
- Clinic for Internal Medicine II, Klinikum rechts der Isar der Technischen, University of Munich, Munich, Germany
| | - Alexander Koch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany.
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Rainho A, Sridharan M, Strand DS. Pancreatic necrosis: a scoping review. Minerva Gastroenterol (Torino) 2025; 71:48-64. [PMID: 39480250 DOI: 10.23736/s2724-5985.24.03658-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2024]
Abstract
Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.
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Affiliation(s)
- Anthony Rainho
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Mira Sridharan
- Department of Medicine, Boston University Medical Center, Boston, MA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA -
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Matsuyama M, Matsuzawa H, Kimura K, Izumiya Y, Sugawara K, Tsuda S, Tuji T, Nakane K, Komatsu M, Iijima K. Successful Treatment of Bilocular Walled-off Necrosis with Transmural Naso-cyst Continuous Irrigation. Intern Med 2025; 64:195-200. [PMID: 38839331 PMCID: PMC11802231 DOI: 10.2169/internalmedicine.3770-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/17/2024] [Indexed: 06/07/2024] Open
Abstract
Recently, transmural naso-cyst continuous irrigation (TNCCI) has been reported as an effective and safe treatment for walled-off necrosis (WON). We herein report a case of bilocular WON that was successfully treated with TNCCI. The patient was a 60-year-old man. The patient underwent endoscopic ultrasound-guided cyst drainage of the main cavity and subcavity using a single transluminal gateway transcystic multiple drainage technique, which was ineffective. Subsequently, a lumen-apposing metal stent (LAMS) was placed in the main cavity and TNCCI was successfully performed in the subcavity. TNCCI with LAMS was effective in treating bilocular WON.
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Affiliation(s)
- Mari Matsuyama
- Department of Gastroenterology, Akita City Hospital, Japan
- Department of Gastroenterology, Graduate School of Medicine, Akita University, Japan
| | | | - Kazuya Kimura
- Department of Gastroenterology, Akita City Hospital, Japan
| | - Yuki Izumiya
- Department of Gastroenterology, Akita City Hospital, Japan
| | - Kae Sugawara
- Department of Gastroenterology, Akita City Hospital, Japan
| | - Satoko Tsuda
- Department of Gastroenterology, Akita City Hospital, Japan
| | | | - Kunio Nakane
- Department of Gastroenterology, Akita City Hospital, Japan
| | | | - Katsunori Iijima
- Department of Gastroenterology, Graduate School of Medicine, Akita University, Japan
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Wahba G, Lee JH. Updates on therapeutic endoscopic ultrasound. Curr Opin Gastroenterol 2025; 41:16-28. [PMID: 39560626 DOI: 10.1097/mog.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2024]
Abstract
PURPOSE OF REVIEW Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms. RECENT FINDINGS Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted. SUMMARY Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.
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Affiliation(s)
- George Wahba
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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6
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Takenaka M, Gonoi W, Sato T, Saito T, Hanaoka S, Hamada T, Omoto S, Masuda A, Tsujimae M, Iwashita T, Uemura S, Ota S, Shiomi H, Fujisawa T, Takahashi S, Matsubara S, Suda K, Maruta A, Yoshida K, Iwata K, Okuno M, Hayashi N, Mukai T, Isayama H, Yasuda I, Nakai Y, Sakai A, Nakano R, Iwasa Y. Artificial intelligence–based skeletal muscle estimates and outcomes of EUS-guided treatment of pancreatic fluid collections. IGIE 2024; 3:382-392.e8. [DOI: 10.1016/j.igie.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2025]
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AbiMansour J, Jaruvongvanich V, Velaga S, Law R, Storm AC, Topazian M, Levy MJ, Alexander R, Vargas EJ, Bofill-Garica A, Martin JA, Petersen BT, Abu Dayyeh BK, Chandrasekhara V. Coaxial plastic stent placement within lumen-apposing metal stents for the management of pancreatic fluid collections: a systemic review and meta-analysis. Clin Endosc 2024; 57:595-603. [PMID: 39044669 PMCID: PMC11474481 DOI: 10.5946/ce.2023.297] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/06/2024] [Accepted: 01/19/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND/AIMS Coaxial placement of double pigtail plastic stents (DPPS) through lumen-apposing metal stents (LAMSs) is commonly performed to reduce the risk of LAMS obstruction, bleeding, and stent migration when used for the drainage of pancreatic fluid collections (PFCs). A systematic review and meta-analysis were performed to compare the outcomes of LAMS alone and LAMS with coaxial DPPS placement in the management of PFCs. METHODS A systematic review was conducted to identify studies comparing LAMS and LAMS/DPPS for PFC drainage. Primary outcomes included the rate of clinical success, overall adverse events (AEs), bleeding, infection, occlusion, and stent migration. The pooled effect size was summarized using a random-effects model and compared between LAMS and LAMS/DPPS by calculating odds ratios (ORs). RESULTS Nine studies involving 709 patients were identified (338 on LAMS and 371 on LAMS/DPPS). LAMS/DPPS was associated with a reduced risk of stent obstruction (OR, 0.59; p=0.004) and infection (OR, 0.55; p=0.001). No significant differences were observed in clinical success (OR, 0.96; p=0.440), overall AEs (OR, 0.57; p=0.060), bleeding (OR, 0.61; p=0.120), or stent migration (OR, 1.03; p=0.480). CONCLUSIONS Coaxial DPPS for LAMS drainage of PFCs is associated with a reduced risk of stent occlusion and infection; however, no difference was observed in the overall AE rates or bleeding.
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Affiliation(s)
| | | | | | - Ryan Law
- Mayo Clinic Rochester, Rochester, MN, USA
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González-Haba Ruiz M, Betés Ibáñez MT, Martínez Moreno B, Repiso Ortega A, de la Serna Higuera C, Iglesias García J, Sendino García O, Moris Felgueroso M, Agudo Castillo B, Esteban López-Jamar JM, Lindo Ricce MD, Soria San Teodoro MT, Moya Valverde E, Muñoz López D, Uribarri González L, Sevilla Ribota S, Lariño Noia J, Pérez Miranda M, Aparicio Tormo JR, Vila Costas JJ, Vázquez Sequeiros E, Subtil Íñigo JC, Pérez-Cuadrado-Robles E, Sánchez Yagüe A, Núñez Otero JA, Foruny Olcina JR. Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group, Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:423-437. [PMID: 38305682 DOI: 10.17235/reed.2024.10276/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
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 few 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, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended 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.
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Brown NG, Sethi A. Endoscopic Drainage of Pancreatic Fluid Collections. Gastrointest Endosc Clin N Am 2024; 34:553-575. [PMID: 38796299 DOI: 10.1016/j.giec.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pancreatic fluid collections (PFCs) are commonly encountered complications of acute and chronic pancreatitis. With the advancement of endoscopic ultrasound (EUS) techniques and devices, EUS-directed transmural drainage of symptomatic or infected PFCs has become the standard of care. Traditionally, plastic stents have been used for drainage, although lumen-apposing metal stents (LAMSs) are now favored by most endoscopists due to ease of use and reduced procedure time. While safety has been repeatedly demonstrated, follow-up care for these patients is critical as delayed adverse events of indwelling drains are known to occur.
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Affiliation(s)
- Nicholas G Brown
- Department of Medicine, Columbia University Irving Medical Center, Weill Cornell Medicine, NewYork-Presbyterian/Brooklyn Methodist Hospital, 515 6th Street, Concourse, Brooklyn, NY 11215, USA; Weill Cornell, 1283 York Avenue, New York, NY 10065, USA; Division of Digestive and Liver Disease, Columbia University Irving Medical Center, 630 West 168th Street, P&S 3-401, New York, NY 10032, USA.
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, 630 West 168th Street, P&S 3-401, New York, NY 10032, USA
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10
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Choudhary S, Gupta P, Shah J, Singh A, Jearth V, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Dutta U. Role of imaging in evaluating the complications of endoscopic management of pancreatic fluid collections in acute pancreatitis. Abdom Radiol (NY) 2024; 49:2449-2458. [PMID: 38763937 DOI: 10.1007/s00261-024-04348-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/21/2024]
Abstract
Acute pancreatitis is associated with local and systemic complications. Pancreatic fluid collection (PFC) is the most common local complication. Infected or symptomatic PFCs need drainage. Endoscopic drainage (ED) is the first-line procedure for accessible PFCs adjacent to the stomach and duodenum. ED is performed under endoscopic ultrasound (EUS) guidance. The technical and clinical success rates of EUS-guided ED in well-encapsulated PFCs are high. ED of poorly encapsulated PFCs is associated with complications. Bleeding and perforation are the most common complications. Contrast-enhanced computed tomography is critical in planning ED and early detection and management of complications. With the increasing utilization of ED for PFC, the radiologist must be familiar with the ED techniques, types of stents, and the complications related to ED. In this review, we discuss the technical aspects of the ED as well as the imaging findings of ED-related complications.
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Affiliation(s)
- Sonam Choudhary
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anupam Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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11
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Shah J, Fernandez Y Viesca M, Jagodzinski R, Arvanitakis M. Infected pancreatic necrosis-Current trends in management. Indian J Gastroenterol 2024; 43:578-591. [PMID: 38625518 DOI: 10.1007/s12664-023-01506-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 04/17/2024]
Abstract
Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium.
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12
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Saito T, Omoto S, Takenaka M, Tsujimae M, Masuda A, Sato T, Hamada T, Ota S, Shiomi H, Takahashi S, Fujisawa T, Nakagawa K, Matsubara S, Uemura S, Iwashita T, Yoshida K, Maruta A, Okuno M, Iwata K, Hayashi N, Mukai T, Isayama H, Yasuda I, Nakai Y. Risk factors for adverse outcomes at various phases of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Data from a multi-institutional consortium. Dig Endosc 2024; 36:600-614. [PMID: 37702186 DOI: 10.1111/den.14683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/10/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVES No comprehensive study has examined short- and long-term adverse outcomes of endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs) including walled-off necrosis (WON) and pseudocysts. METHODS In a multi-institutional cohort of 357 patients receiving EUS-guided treatment of PFCs (228 with WON and 129 with pseudocysts), we examined PFC type-specific risk factors for procedure-related adverse events (AEs), clinical failure, and recurrence. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the logistic and Cox regression models, respectively, adjusting for potential confounders. RESULTS Adverse events were observed predominantly in WON, and risk factors were WON extension to the pelvis (OR 2.49; 95% CI 1.00-6.19) and endoscopic necrosectomy (OR 5.15; 95% CI 1.61-16.5). Risk factors for clinical failure in WON treatment included higher Charlson Comorbidity Index (OR for ≥3 vs. ≤2, 2.58; 95% CI 1.05-6.35), extension to the pelvis (OR 3.63; 95% CI 1.57-8.43), nonuse of a lumen-apposing metal stent (OR 2.88; 95% CI 1.10-7.54), and percutaneous drainage (OR 3.73; 95% CI 1.27-10.9). Patients with pseudocysts extending to the paracolic gutter and the need for more than two endoscopic/percutaneous procedures had ORs for clinical failure of 5.28 (95% CI 1.10-25.3) and 5.52 (95% CI 1.61-18.9), respectively. Pseudocysts requiring the multigateway approach were associated with a high risk of recurrence (HR 4.00; 95% CI 1.11-11.6). CONCLUSION The adverse outcomes at various phases of EUS-guided PFC treatment may be predictable based on clinical parameters. Further research is warranted to optimize treatment strategies for high-risk patients.
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Affiliation(s)
- Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Masahiro Tsujimae
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shogo Ota
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Sho Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Keito Nakagawa
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Kensaku Yoshida
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Nobuhiko Hayashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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13
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Tiwari A, Mehrotra M, Hasan A, Agarwal J, Singh GK. The DESTIN trial: to step up or not? Lancet Gastroenterol Hepatol 2024; 9:289-290. [PMID: 38460532 DOI: 10.1016/s2468-1253(24)00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/03/2024] [Accepted: 01/03/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Avinash Tiwari
- Department of Gastroenterology, Regency Hospital, Kanpur 208005, India.
| | - Mayank Mehrotra
- Department of Gastroenterology, Regency Hospital, Kanpur 208005, India
| | - Ajmal Hasan
- Department of Gastroenterology, Regency Hospital, Kanpur 208005, India
| | - Jaya Agarwal
- Department of Gastroenterology, Regency Hospital, Kanpur 208005, India
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14
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Binda C, Perini B, Coluccio C, Giuffrida P, Fabbri S, Gibiino G, Vizzuso A, Giampalma E, Fabbri C. Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis. Minerva Surg 2024; 79:183-196. [PMID: 38127434 DOI: 10.23736/s2724-5691.23.10132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.
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Affiliation(s)
- Cecilia Binda
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Barbara Perini
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy -
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, Padua, Italy
| | - Chiara Coluccio
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Paolo Giuffrida
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
- Section of Gastroenterology and Hepatology, Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Stefano Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Giulia Gibiino
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Antonio Vizzuso
- Unit of Radiology, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Emanuela Giampalma
- Unit of Radiology, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Carlo Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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15
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Valente R, Zarantonello L, Del Chiaro M, Vujasinovic M, Baldaque-Silva F, Scandavini CM, Rangelova E, Vespasiano F, Anzillotti G, Löhr JM, Arnelo U. Lumen apposing metal stents vs. double pigtail plastic stents for the drainage of pancreatic walled-off necrosis. Minerva Gastroenterol (Torino) 2024; 70:1-9. [PMID: 35112820 DOI: 10.23736/s2724-5985.22.03055-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Few studies compared lumen-apposing metal stents (LAMS) and standard double pigtail plastic stents (PS) for the endoscopic drainage of pancreatic walled-off necrosis (WON). Albeit sometimes large, previously described cohorts display considerable heterogeneity and often pooled together data from several centers, involving multiple operators and techniques. Moreover, they often lack a control group for the comparison of outcomes. The aim of this study was to compare clinical efficacy and safety of PS versus LAMS for the endoscopic drainage of infected WON. METHODS Thirty patients were enrolled between 2011 and 2017. The present study is a single-center, 1:1 case-control study. We compared patients undergoing endoscopic drainages of infected WON through LAMS (cases) or PS (controls). The primary endpoint was the clinical efficacy (resolution of the WON/sepsis), the secondary endpoint was safety (procedure-related complications). RESULTS Cases and controls were homogeneous in terms of etiology and clinical characteristics: 93% of cases and 86.7% of controls were clinically successfully treated, with no significant differences in rates of postoperative infections, bleedings, and stent migrations (respectively 13.3% vs. 21.4%; P=0.65; 13.3% vs. 0%; P=0.48; 13.3% vs. 7.1%; P=1.00). No difference was shown regarding the need for additional percutaneous or surgical treatments (33.3% vs. 13.3%; P=0.39). Cases, however, displayed a significantly prolonged mean hospital stay (90.2 days vs. 18.5 days; P<0.01) and a higher mean number of endoscopic procedures per patient (4.8 vs. 1.5; P<0.01). CONCLUSIONS PS might be not inferior to LAMS for the treatment WONs. Further prospective RCT is needed to compare clinical efficacy and safety in the two groups.
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Affiliation(s)
- Roberto Valente
- Department of Surgery, Karolinska Institute, Stockholm, Sweden -
- Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, CO, USA -
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden -
| | | | - Marco Del Chiaro
- Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Miroslav Vujasinovic
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Chiara M Scandavini
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden
| | - Elena Rangelova
- Department of Surgery, Sahlgrenska Hospital, Gothenburg, Sweden
| | - Francesca Vespasiano
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Anzillotti
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes M Löhr
- Department of Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Department of Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden
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16
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Binda C, Fabbri S, Perini B, Boschetti M, Coluccio C, Giuffrida P, Gibiino G, Petraroli C, Fabbri C. Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:333. [PMID: 38399620 PMCID: PMC10890047 DOI: 10.3390/medicina60020333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Barbara Perini
- Gastroenterology and Digestive Endoscopy Unit, Azienda ULSS 5, 45100 Rovigo, Italy
| | - Martina Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Paolo Giuffrida
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Chiara Petraroli
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
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17
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Troncone E, Amendola R, Gadaleta F, De Cristofaro E, Neri B, De Vico P, Paoluzi OA, Monteleone G, Anderloni A, Del Vecchio Blanco G. Indications, Techniques and Future Perspectives of Walled-off Necrosis Management. Diagnostics (Basel) 2024; 14:381. [PMID: 38396420 PMCID: PMC10888331 DOI: 10.3390/diagnostics14040381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Necrotizing pancreatitis is a complex clinical condition burdened with significant morbidity and mortality. In recent years, the huge progress of interventional endoscopic ultrasound (EUS) has allowed a shift in the management of pancreatic necrotic collections from surgical/percutaneous approaches to mini-invasive endoscopic internal drainage and debridement procedures. The development of lumen-apposing metal stents (LAMSs), devices specifically dedicated to transmural EUS interventions, further prompted the diffusion of such techniques. Several studies have reported excellent outcomes of endoscopic interventions, in terms of technical success, clinical efficacy and safety compared to surgical interventions, and thus endoscopic drainage of walled-off necrosis (WON) has become a fundamental tool for the management of such conditions. Despite these advancements, some critical unresolved issues remain. Endoscopic therapeutic approaches to WON are still heterogeneous among different centers and experts. A standardized protocol on indication, timing and technique of endoscopic necrosectomy is still lacking, and experts often adopt a strategy based on personal experience more than robust data from well-conducted studies. In this review, we will summarize the available evidence on endoscopic management of WON and will discuss some unanswered questions in this rapidly evolving field.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (E.T.)
| | - Rosa Amendola
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (E.T.)
| | - Fabio Gadaleta
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (E.T.)
| | - Elena De Cristofaro
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (E.T.)
| | - Benedetto Neri
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (E.T.)
| | - Pasquale De Vico
- Department of Anaesthesia, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (E.T.)
| | - Andrea Anderloni
- Endoscopy Unit, First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 27029 Pavia, Italy
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18
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Willems P, Varadarajulu S. Endoscopic Ultrasound Guided Walled-off Necrosis Drainage. Gastrointest Endosc Clin N Am 2023; 33:725-735. [PMID: 37709407 DOI: 10.1016/j.giec.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Walled-off necrosis is a well-recognized complication of necrotizing pancreatitis that can cause sepsis, luminal or ductal obstruction, or persistent unwellness requiring multidisciplinary care. Recent data suggest that minimally invasive endoscopic treatment strategies are preferred over more invasive surgical approaches. Although endoscopic transmural drainage with or without necrosectomy is the primary approach for patients requiring an intervention, for collections not amenable to endoscopic approach, percutaneous drain placement followed by video-assisted retroperitoneal debridement or laparoscopic cystogastrostomy with internal debridement are other alternatives. More studies are required to optimize post-procedure care to shorten the length of stay and minimize resource utilization.
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Affiliation(s)
- Philippe Willems
- Center for Advanced Endoscopy, Research & Education; Orlando Health Digestive Health Institute, 52 West Underwood Street, Orlando, FL 32806, USA
| | - Shyam Varadarajulu
- Center for Advanced Endoscopy, Research & Education; Orlando Health Digestive Health Institute, 52 West Underwood Street, Orlando, FL 32806, USA.
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19
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Hamada T, Michihata N, Saito T, Iwashita T, Shiomi H, Takenaka M, Matsui H, Fushimi K, Isayama H, Yasuda I, Yasunaga H, Nakai Y. Inverse association of hospital volume with in-hospital mortality rate of patients receiving EUS-guided interventions for pancreatic fluid collections. Gastrointest Endosc 2023; 98:597-606.e2. [PMID: 37150410 DOI: 10.1016/j.gie.2023.04.2091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/31/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND AND AIMS EUS-guided interventions currently serve as first-line treatment for symptomatic pancreatic fluid collections (PFCs) but require high-level expertise and multidisciplinary care. Hospital caseload has not been fully examined in relation to clinical outcomes of patients with endoscopically managed PFCs. METHODS Using the Diagnosis Procedure Combination database (a Japanese nationwide inpatient database), we identified 4053 patients receiving EUS-guided treatment of PFCs at 486 hospitals between 2010 and 2020 and examined an association of hospital volume (average annual number of cases at a hospital) with in-hospital mortality. Associations with bleeding, length of stay, and total costs were examined as secondary analyses. Multivariable logistic regression analysis was conducted with adjustment for potential confounders. RESULTS The hospital volume was inversely associated with the risk of in-hospital mortality (Ptrend < .001). The adjusted odds ratio for in-hospital mortality comparing the extreme quintiles of hospital volume was .17 (95% confidence interval, .09-.33). A restricted cubic spline analysis yielded no statistically significant evidence on the nonlinear relationship (Pnonlinearity = .19). The types of stents (plastic vs lumen-apposing metal stent) seemed to have no effect modification on the volume-mortality relationship (Pinteraction = .58). Higher hospital volume was also associated with lower risk of bleeding, shorter length of stay, and lower medical costs of inpatient care. CONCLUSIONS Higher hospital volume was associated with a lower risk of in-hospital mortality of patients receiving EUS-guided treatment of PFCs. A further investigation is warranted to justify the volume-based selective referral of the patients.
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine; Department of Hepato-Biliary-Pancreatic Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | | | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine; Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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20
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Saito T, Hamada T, Nakai Y. Balloon ride to WONderland: Balloon overtube-assisted transduodenal necrosectomy for walled-off pancreatic necrosis. Dig Endosc 2023; 35:791. [PMID: 37306583 DOI: 10.1111/den.14614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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21
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Rana SS. Endoscopic treatment of pancreatic necrosis: Still searching for perfection! J Gastroenterol Hepatol 2023; 38:1252-1258. [PMID: 37309053 DOI: 10.1111/jgh.16262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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22
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Seicean A, Pojoga C, Rednic V, Hagiu C, Seicean R. Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach? Therap Adv Gastroenterol 2023; 16:17562848231180047. [PMID: 37485492 PMCID: PMC10357067 DOI: 10.1177/17562848231180047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/18/2023] [Indexed: 07/25/2023] Open
Abstract
Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4 weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation.
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Affiliation(s)
- Andrada Seicean
- ‘Iuliu Hațieganu’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology ‘Prof. Dr. Octavian Fodor’, Cluj-Napoca, Romania
| | - Cristina Pojoga
- UBBMed, Babeș Bolyai University, Cluj-Napoca, Romania
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology ‘Prof. Dr. Octavian Fodor’, Cluj-Napoca, Romania
| | - Voicu Rednic
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology ‘Prof. Dr. Octavian Fodor’, Cluj-Napoca, Romania
| | - Claudia Hagiu
- ‘Iuliu Hațieganu’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology ‘Prof. Dr. Octavian Fodor’, Cluj-Napoca, Romania
| | - Radu Seicean
- First Department of Surgery, ‘Iuliu Hațieganu’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
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23
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Karstensen JG, Novovic S, Hansen EF, Jensen AB, Jorgensen HL, Lauritsen ML, Werge MP, Schmidt PN. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: a single-centre randomised controlled trial. Gut 2023; 72:1167-1173. [PMID: 36446550 DOI: 10.1136/gutjnl-2022-328225] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE In treating pancreatic walled-off necrosis (WON), lumen-apposing metal stents (LAMS) have not proven superior to the traditional double pigtail technique (DPT). Among patients with large WON (>15 cm) and their associated substantial risk of treatment failure, the increased drainage capacity of a novel 20-mm LAMS might improve clinical outcomes. Hence, we conducted a study comparing the DPT and 20-mm LAMS in patients with large WON. DESIGN A single-centre, open-label, randomised, controlled superiority trial using an endoscopic step-up approach in patients with WON exceeding 15 cm in size. The primary endpoint was the number of necrosectomies needed to achieve clinical success (clinical and CT resolution), while the secondary endpoints included technical success, adverse events, length of stay and mortality. RESULTS Twenty-two patients were included in the DPT group and 20 in the LAMS group, with no significant differences in patient characteristics. The median size of WON was 24.1 cm (P25-P75: 19.6-31.1). The technical success rates were 100% for DPT and 95% for LAMS (p=0.48), while clinical success rates were 95.5% and 94.7%, respectively (p=1.0). The mean number of necrosectomies was 2.2 for DPT and 3.2 for LAMS (p=0.42). Five patients (12%) developed procedure-related serious adverse events (DPT=4, LAMS=1, p=0.35). The median length of stay was 43 (P25-P75: 40-67) and 58 days (P25-P75: 40-86) in the DPT and LAMS groups (p=0.71), respectively, with an overall mortality of 4.8%. CONCLUSIONS For treating large WON, LAMS are not superior to DPT. The techniques are associated with comparable needs for necrosectomy and hospital stay, and no gross difference in adverse events. TRIAL REGISTRATION NUMBER NCT04057846.
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Affiliation(s)
- John Gásdal Karstensen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Srdan Novovic
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Erik Feldager Hansen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Annette Bojer Jensen
- Department of Radiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Henrik Lovendahl Jorgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Morten Laksafoss Lauritsen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Parsberg Werge
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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24
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Dayyeh BKA, Chandrasekhara V, Shah RJ, Easler JJ, Storm AC, Topazian M, Levy MJ, Martin JA, Petersen BT, Takahashi N, Edmundowicz S, Hammad H, Wagh MS, Wani S, DeWitt J, Bick B, Gromski M, Al Haddad M, Sherman S, Merchant AA, Peetermans JA, Gjata O, McMullen E, Willingham FF. Combined Drainage and Protocolized Necrosectomy Through a Coaxial Lumen-apposing Metal Stent for Pancreatic Walled-off Necrosis: A Prospective Multicenter Trial. Ann Surg 2023; 277:e1072-e1080. [PMID: 35129503 DOI: 10.1097/sla.0000000000005274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | | | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Naoki Takahashi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - John DeWitt
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mark Gromski
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Mohammad Al Haddad
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Ambreen A Merchant
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
| | | | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
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25
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Sameera S, Mohammad T, Liao K, Shahid H, Sarkar A, Tyberg A, Kahaleh M. Management of Pancreatic Fluid Collections: An Evidence-based Approach. J Clin Gastroenterol 2023; 57:346-361. [PMID: 36040932 DOI: 10.1097/mcg.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.
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Affiliation(s)
- Sohini Sameera
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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26
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Zeng Y, Yang J, Zhang JW. Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges. World J Clin Cases 2023; 11:1888-1902. [PMID: 36998953 PMCID: PMC10044952 DOI: 10.12998/wjcc.v11.i9.1888] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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27
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Chon HK, Kim SH. Endoscopic ultrasound-guided drainage for local complications related to pancreatitis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2023; 12:7-15. [DOI: 10.18528/ijgii220037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/01/2022] [Accepted: 08/01/2022] [Indexed: 09/01/2023] Open
Affiliation(s)
- Hyung Ku Chon
- Department of Internal Medicine, Institute of Wonkwang Medical Science, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
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28
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Hocke M, Burmeister S, Braden B, Jenssen C, Arcidiacono PG, Iglesias-Garcia J, Ignee A, Larghi A, Möller K, Rimbas M, Siyu S, Vanella G, Dietrich CF. Controversies in EUS-guided treatment of walled-off necrosis. Endosc Ultrasound 2022; 11:442-457. [PMID: 35313415 PMCID: PMC9921978 DOI: 10.4103/eus-d-21-00189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/22/2021] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Michael Hocke
- Medical Department II, Helios Klinikum Meiningen, Meiningen, Germany
| | - Sean Burmeister
- Hepato-Pancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Christian Jenssen
- Medical Department, Krankenhaus Maerkisch-Oderland, Strausberg, Germany
- Brandenburg Institute of Clinical Medicine at Medical University Brandenburg, Neuruppin, Germany
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela (IDIS), University Hospital of Santiago de Compostela, Spain
| | - André Ignee
- Medical Department, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Kathleen Möller
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, Berlin, Germany
| | - Mihai Rimbas
- Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Sun Siyu
- Department of Endoscopy Center, Shengjing Hospital of China Medical University, Liaoning Province, China
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Christoph F. Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland
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29
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Drainage of Complex Walled-Off Pancreatic Fluid Collections in LAMS Era: A Multicenter Study. Can J Gastroenterol Hepatol 2022; 2022:9250370. [PMID: 36345379 PMCID: PMC9637039 DOI: 10.1155/2022/9250370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The lumen-apposing metal stent (LAMS) has been increasingly used for EUS-guided drainage of symptomatic walled-off pancreatic fluid collection (WOPFC) in recent years. Nevertheless, some WOPFCs may require additional drainage methods including another LAMS as a result of complexity of the lesions. This current study aimed to compare clinical parameters of patients with complex WOPFC requiring LAMS with additional methods (complex WOPFC: group A) versus single LAMS alone (noncomplex WOPFC; group B). METHOD Medical records of patients with complex (group A) versus noncomplex WOPFCs (group B) were reviewed and compared in three centers in Thailand and Malaysia, between January 2016 to December 2020. RESULT 31 patients with WOPFCs were recruited. 6 of 31 (19%) patients were in group A. Multivariate analysis showed that the maximal diameter of WOPFCs in group A was significantly larger than that of group B (18 ± 6 versus 13 ± 3 cm in diameter, respectively, p = 0.021). Solid component proportion was higher in group A versus B (35.8% versus 17.8%, respectively, p = 0.025). The prevalence of pancreatic duct leakage was significantly higher in group A (67% versus 20%, p = 0.23). The need of direct endoscopic necrosectomy (DEN) and the number of DEN sessions were higher in group A versus B (100% vs. 48%, p = 0.020 and 3.5 vs 0 p = 0.031, respectively). CONCLUSIONS Complex WOPFC had larger diameter of lesions, higher proportion of solid component, higher prevalence of pancreatic duct leakage, and higher number of DEN is required than group noncomplex lesions. Trial Registration. This trial is registered with TCTR20180223004.
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30
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Jearth V, Rana SS. Endoscopic step up: When and how. Surg Open Sci 2022; 10:135-144. [PMID: 36193259 PMCID: PMC9526220 DOI: 10.1016/j.sopen.2022.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/16/2022] [Accepted: 09/12/2022] [Indexed: 11/01/2022] Open
Abstract
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.
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31
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Takenaka M, Kudo M. Usefulness of the double-guidewire technique for endoscopic procedures in the field of biliary and pancreatic diseases. Clin Endosc 2022; 55:605-614. [PMID: 35996347 PMCID: PMC9539287 DOI: 10.5946/ce.2022.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/16/2022] [Indexed: 11/14/2022] Open
Abstract
The double-guidewire method has been increasingly used in endoscopic procedures for biliary and pancreatic diseases in recent years, including endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography-related procedures. In addition, double-lumen catheters with uneven distal and proximal lumen openings have been introduced, making it possible to easily create a double-guidewire situation, and the usefulness of the double-guidewire technique using uneven double-lumen cannulas has been widely reported. Although the advantages of using two guidewires depend on the particular situation and the appropriate use of the two guidewires, deepening the knowledge of the double-guidewire method will contribute greatly to troubleshooting in daily practice. In this review, the usefulness of the double-guidewire technique is discussed with respect to two main areas: selective insertion of guidewires and devices and biliary cannulation.
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Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
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32
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Zhang LY, Kunda R, Aerts M, Messaoudi N, Pawa R, Pawa S, Robles-Medranda C, Oleas R, Al-Haddad MA, Obaitan I, Muniraj T, Fabbri C, Binda C, Anderloni A, Tarantino I, Bejjani M, Ghandour B, Singh V, Khashab MA. Novel 15-mm-long lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections located ≥10 mm from the luminal wall. Endoscopy 2022; 54:706-711. [PMID: 34905796 DOI: 10.1055/a-1682-7095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located < 10 mm from the luminal wall. We present outcomes of the use of a novel 15-mm-long cautery-enhanced LAMS for drainage of PFCs located ≥ 10 mm away. METHODS This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence. RESULTS 35 patients (median age 57 years; interquartile range [IQR] 47-64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64-117) maximal diameter and located 11.8 mm (IQR 10-12.3; range 10-14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58-236). Three complications occurred (9 %; one mild, two moderate). CONCLUSIONS The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10-14 mm from the luminal wall.
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Affiliation(s)
- Linda Y Zhang
- Department of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology-Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Maridi Aerts
- Department of Gastroenterology and Hepatology, Universitair Ziekenhuis Brussel (UZB)/Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Nouredin Messaoudi
- Department of Surgery, Universitair Ziekenhuis Brussel (UZB)/Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Rishi Pawa
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Carlos Robles-Medranda
- Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Roberto Oleas
- Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Itegbemie Obaitan
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Thiruvengadam Muniraj
- Department of Gastroenterology and Hepatology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forli-Cesena, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forli-Cesena, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
| | - Michael Bejjani
- Department of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Bachir Ghandour
- Department of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Vikesh Singh
- Department of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, United States
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Bhakta D, de Latour R, Khanna L. Management of pancreatic fluid collections. Transl Gastroenterol Hepatol 2022; 7:17. [PMID: 35548474 PMCID: PMC9081921 DOI: 10.21037/tgh-2020-06] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/10/2021] [Indexed: 12/28/2023] Open
Abstract
Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).
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Affiliation(s)
- Dimpal Bhakta
- New York University School of Medicine, New York, USA
| | | | - Lauren Khanna
- New York University School of Medicine, New York, USA
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Morita M, Yokota T, Yano R, Amano M, Ochi H, Azemoto N, Mashiba T, Joko K. A case of walled-off necrosis extending into the pelvic cavity successfully treated by endoscopic necrosectomy using a lumen-apposing metal stent. DEN OPEN 2022; 2:e120. [PMID: 35873503 PMCID: PMC9302297 DOI: 10.1002/deo2.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/04/2023]
Abstract
A 31‐year‐old man developed massive walled‐off necrosis extending into the pelvic cavity following severe acute alcoholic pancreatitis. Endoscopic ultrasound‐guided fistula drainage was performed using a lumen‐apposing metal stent, but this was insufficiently effective, and endoscopic necrosectomy was also performed, after which the patient improved. Percutaneous drainage and surgery are other options for the treatment of walled‐off necrosis extending into the pelvic cavity, but a valuable case in which the patient improved with endoscopic treatment alone is presented.
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Affiliation(s)
- Makoto Morita
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Tomoyuki Yokota
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Ryo Yano
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Michiko Amano
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Hironori Ochi
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Nobuaki Azemoto
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Toshie Mashiba
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Kouji Joko
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
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Bang JY, Wilcox CM, Arnoletti JP, Peter S, Christein J, Navaneethan U, Hawes R, Varadarajulu S. Validation of the Orlando Protocol for endoscopic management of pancreatic fluid collections in the era of lumen-apposing metal stents. Dig Endosc 2022; 34:612-621. [PMID: 34331485 PMCID: PMC9290475 DOI: 10.1111/den.14099] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 07/21/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Although lumen-apposing metal stents (LAMS) are being increasingly used in lieu of plastic stents, the clinical approach to endoscopic management of pancreatic fluid collections (PFCs) is poorly standardized. We compared outcomes of approaches over two time intervals, initially using plastic stents and later integrating LAMS. METHODS This was a retrospective, observational, before-after study of prospectively collected data on consecutive patients with symptomatic PFCs managed over two time periods. In the initial period (January 2010-January 2015) endoscopic treatment was undertaken with plastic stents and in the later period (February 2015-August 2020) by integration of LAMS with selective use of plastic stents. The treatment strategy in both periods were tailored to size, extent, type of PFC and stepwise response to intervention. The main outcome was treatment success, defined as resolution of PFC and presenting symptoms at 6-month follow-up. RESULTS A total of 160 patients were treated with plastic stents and 227 patients were treated using an integrated LAMS approach. Treatment success was significantly higher for the integrated approach compared to using only plastic stents (95.6 vs. 89.4%; P = 0.018), which was confirmed to be predictive of treatment success on multivariable logistic regression analysis (odds ratio 2.7, 95% confidence interval 1.1-6.4; P = 0.028). CONCLUSIONS A structured approach integrating LAMS with selective use of plastic stents improved treatment success in patients with PFCs compared to an approach using only plastic stents.
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Affiliation(s)
- Ji Young Bang
- Digestive Health InstituteOrlando HealthOrlandoFLUSA
| | - C. Mel Wilcox
- Department of Specialized SurgeryAdventHealth OrlandoOrlandoFLUSA
| | - Juan Pablo Arnoletti
- Division of Gastroenterology and HepatologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Shajan Peter
- Department of Specialized SurgeryAdventHealth OrlandoOrlandoFLUSA
| | - John Christein
- Department of Hepatobiliary and Pancreatic SurgeryGrandview Cancer CenterBirminghamUSA
| | | | - Robert Hawes
- Digestive Health InstituteOrlando HealthOrlandoFLUSA
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Jagielski M, Piątkowski J, Jackowski M. Early endoscopic treatment of symptomatic pancreatic necrotic collections. Sci Rep 2022; 12:308. [PMID: 35013375 PMCID: PMC8748752 DOI: 10.1038/s41598-021-03924-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 12/10/2021] [Indexed: 12/20/2022] Open
Abstract
EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22-79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland.
| | - Jacek Piątkowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
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Flor de Lima M, Nunes N, Chálim Rebelo C, Moura DB, Rego AC, Duarte MA. Infected Walled-Off Pancreatic Necrosis Treated with Multiple-Gateway EUS-Guided Drainage. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 28:436-439. [PMID: 34901454 DOI: 10.1159/000514009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/09/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Margarida Flor de Lima
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Nuno Nunes
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Carolina Chálim Rebelo
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Diogo Bernardo Moura
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Ana Catarina Rego
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Maria Antónia Duarte
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
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Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis. Pancreatology 2021; 21:1540-1547. [PMID: 34565668 DOI: 10.1016/j.pan.2021.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/04/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic necrosectomy (EN) is the preferred approach for management of symptomatic or infected walled-off pancreatic necrosis (WOPN). Hydrogen peroxide (H2O2) has been reported to be a good adjunctive therapy for EN. We performed a systematic review and meta-analysis to evaluate effectiveness and safety of H2O2 assisted EN for WOPN. METHODS A comprehensive search of multiple databases (through December 2020) was performed to identify studies that reported outcomes of H2O2 assisted EN for WOPN. Outcomes assessed included clinical success, technical success, and adverse events. RESULTS A total of 454 patients with mean age (47.3 ± 7.9 years) and WOPN size (12.4 ± 3.1 cm) were included from 15 studies. The median H2O2 concentration was 3% (range 0.1-3%), with dilution and volume ranging from 1:1 to 10:1 and 20 ml to 1 L, respectively. The rates of technical success, clinical success and adverse events was 97.3% (95% confidence interval [CI]: 94.8-98.6, I2 = 0), 89.8% (95% CI: 86.3-92.5, I2 = 0) and 17.9% (95% CI: 12.6-24.7, I2 = 38), respectively. The most common adverse event was bleeding (7.1%) followed by stent migration (5.3%). On meta-regression, WOPN size, patient age, use of metal stent, number of necrosectomies and transgastric access were not significant predictor for technical success, clinical success or adverse events. CONCLUSION H2O2 assisted EN is effective and safe for management of WOPN. Its use may be encouraged, and future randomized controlled studies are needed to study the optimal technique, concentration and best predictors of success.
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Pinto S, Bellizzi S, Badas R, Canfora ML, Loddo E, Spada S, Khalaf K, Fugazza A, Bergamini S. Direct Endoscopic Necrosectomy: Timing and Technique. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121305. [PMID: 34946249 PMCID: PMC8707414 DOI: 10.3390/medicina57121305] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022]
Abstract
Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.
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Affiliation(s)
- Sergio Pinto
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
- Correspondence: ; Tel.: +39-07051096423
| | - Saverio Bellizzi
- Medical Epidemiologist, Independent Consultant, 1202 Geneva, Switzerland;
| | - Roberta Badas
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Maria Laura Canfora
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Erica Loddo
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Simone Spada
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milano, Italy;
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital-IRCCS, 20089 Rozzano, Italy;
| | - Silvio Bergamini
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
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40
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Jagielski M, Jackowski M. The Role of Lumen-Apposing Metal Stents in Transmural Endoscopic Drainage of Postinflammatory Pancreatic and Peripancreatic Fluid Collections. Gastroenterol Res Pract 2021; 2021:4351151. [PMID: 34691174 PMCID: PMC8528637 DOI: 10.1155/2021/4351151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/23/2021] [Indexed: 12/14/2022] Open
Abstract
Rapid development of advanced gastrointestinal endoscopic techniques contributed to the appearance of new biomedical materials including polymers, which are used for the production of different types of endoprostheses. Endotherapy (ET) of postinflammatory pancreatic and peripancreatic fluid collections (PPFCs) with the use of lumen-apposing metal stent (LAMS) is an effective method of treatment. This paper describes the high efficacy of ET and its potential complications, which are mostly related to the design of the LAMS used. The high efficacy of LAMS in the transmural drainage of PPFCs is associated with lower safety of treatment. Complications of ET presented in the manuscript are mainly related to endoprosthesis' construction. This paper presents possible directions of development in the field of transmural LAMSs, which in the future may contribute to the invention of an innovative type of LAMS based on new biomedical technologies. Possibly, subsequent novel endoprosthesis projects, based on the above results, will be able to meet the current needs and requirements associated with endoscopic transmural drainage procedures in cases of postinflammatory PPFCs. The ultimate goal is to improve safety of minimally invasive techniques for treatment of the local consequences of pancreatitis.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University, Torun, Poland
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University, Torun, Poland
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Oh CH, Lee JK, Song TJ, Park JS, Lee JM, Son JH, Jang DK, Choi M, Byeon JS, Lee IS, Lee ST, Choi HS, Kim HG, Chun HJ, Park CG, Cho JY. Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections. Gut Liver 2021; 15:677-693. [PMID: 34305047 PMCID: PMC8357592 DOI: 10.5946/ce.2021.185] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Jun Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - Jin-Seok Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jun Hyuk Son
- Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dong Kee Jang
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - In Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea Seoul ST. Mary’s Hospital, Seoul, Korea
| | - Soo Teik Lee
- Division of Gastroenterology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | - Ho Soon Choi
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Ho Gak Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Chan Guk Park
- Division of Gastroenterology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha University Bundang Medical Center, Seongnam, Korea
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Oh CH, Song TJ, Lee JK, Park JS, Lee JM, Son JH, Jang DK, Choi M, Byeon JS, Lee IS, Lee ST, Choi HS, Kim HG, Chun HJ, Park CG, Cho JY. Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections. Gut Liver 2021; 15:677-693. [PMID: 34305047 PMCID: PMC8444102 DOI: 10.5009/gnl210001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 11/21/2022] Open
Abstract
Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - Jun Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jin-Seok Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jun Hyuk Son
- Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dong Kee Jang
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Miyoung Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - In Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea Seoul St. Mary’s Hospital, Seoul, Korea
| | - Soo Teik Lee
- Division of Gastroenterology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | - Ho Soon Choi
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Ho Gak Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Chan Guk Park
- Division of Gastroenterology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, CHA University Bundang Medical Center, Seongnam, Korea
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Li J, Zhang Q, Zhou A, Zhao G, Li P. Comparative outcomes of endoscopic ultrasound-guided lumen-apposing mental stents drainage for pancreatic pseudocysts and walled-off necrosis: Case series and meta-analysis. Chronic Dis Transl Med 2021; 7:157-168. [PMID: 34505016 PMCID: PMC8413123 DOI: 10.1016/j.cdtm.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Indexed: 12/29/2022] Open
Abstract
Background Endoscopic ultrasound (EUS)-guided transmural drainage for pancreatic fluid collections (PFCs) has become the first-line treatment with quicker recovery and more minor injury compared with surgery and percutaneous drainage. The efficacy of stents implantation and drainage for different PFCs remains controversial, especially lumen-apposing metal stents (LAMS). This study aimed to compare the efficacy and safety of LAMS drainage for pancreatic pseudocysts (PPC) and walled-off necrosis (WON). Methods A meta-analysis was performed for LAMS drainage for WON and PPC by systematically searching PubMed, Cochrane, and Embase databases from January 2010 to January 2020. From 2017 to 2019, 12 patients who were treated with LAMS drainage for PFCs in our medical center were also reviewed and included in this study. Results Combining 11 copies of documents with the data from our medical center, a total of 585 patients with PFCs were enrolled in this meta-analysis, including 343 patients with WON and 242 with PPC. The technical success rate in WON is not significantly different from that of PPC (P = 0.08 > 0.05). The clinical success of LAMS placement was achieved in 99% vs 89% in PPC and WON, respectively (RR = 0.92, 95% CI: 0.86-0.98, P = 0.01 < 0.05). The further intervention of direct endoscopic necrosectomy was required by 60% of patients in WON group. There was no significant difference in the incidence of adverse events, including infection, bleeding, stent migration and stent occlusion, after LAMS placement between WON and PPC. Conclusions Endoscopic ultrasound-guided LAMS for PFCs are feasible, effective with preferable technical and clinical success rates. The clinical effect of LAMS on PPC is slightly better than that of WON, but its adverse reactions still need to be verified in a large-sample prospective study.
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Affiliation(s)
- Jing Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing 100050, China
| | - Qian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing 100050, China
| | - Anni Zhou
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing 100050, China
| | - Guiping Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing 100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing 100050, China
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44
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Fedorov AV, Ektov VN, Khodorkovsky MA. [Endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis]. Khirurgiia (Mosk) 2021:85-92. [PMID: 34480460 DOI: 10.17116/hirurgia202109185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The review is devoted to endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis. Terminology, indications and options for transluminal drainage procedures and endoscopic sequestrectomy are presented in detail. The authors analyzed the results of numerous studies devoted to effectiveness of endoscopic interventions and possible combination of treatment options. Modern international clinical guidelines indicating the feasibility of endoscopic treatment of acute necrotizing pancreatitis in multi-field specialized centers are considered.
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Affiliation(s)
- A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V N Ektov
- Burdenko Voronezh State Medical University, Voronezh, Russia
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45
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Feng L, Guo J, Wang S, Liu X, Ge N, Wang G, Sun S. Endoscopic Transmural Drainage and Necrosectomy in Acute Necrotizing Pancreatitis: A Review. J Transl Int Med 2021; 9:168-176. [PMID: 34900627 PMCID: PMC8629413 DOI: 10.2478/jtim-2021-0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Acute necrotizing pancreatitis occurs in 10%-20% of patients with acute pancreatitis (AP) which is one of the most important acute abdominal diseases that require hospital admission. Pancreatic necrosis is also associated with high mortality and morbidity. In the past 20 years, the treatment of pancreatic necrosis has shifted from open necrosectomy to minimally invasive techniques, such as endoscopic interventions. With the development of endoscopic techniques, the safety and effectiveness of endoscopic interventions have improved, but there exist several unresolved problems. Currently, there is no unified standard approach for endoscopic treatment of pancreatic necrosis that takes into account local expertise, anatomical features of necrosis, patients' preferences, and comorbidity profile. We reviewed the current status of endoscopic therapy for acute necrotizing pancreatitis, focusing on the new endoscopic drainage technique and necrosectomy protocol.
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Affiliation(s)
- Linlin Feng
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jintao Guo
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Sheng Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiang Liu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Nan Ge
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Guoxin Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Iwashita T, Iwasa Y, Shimizu M. Multiple transluminal gateway technique with transplantation of lumen-apposing metal stent for direct endoscopic necrosectomy in a patient with infected walled-off pancreatic necrosis. Dig Endosc 2021; 33:e123-e124. [PMID: 34128274 DOI: 10.1111/den.14014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Yuhei Iwasa
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Maharshi S, Sharma SS, Ratra S, Sapra B, Sharma D. Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial. Endosc Int Open 2021; 9:E1108-E1115. [PMID: 34222637 PMCID: PMC8216781 DOI: 10.1055/a-1480-7115] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/10/2021] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Shyam Sunder Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Sandeep Ratra
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | | | - Dhruv Sharma
- Ananta Institute of Medical Sciences and Research Center, Rajsamand, India
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [PMID: 35227422 DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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50
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Binda C, Coluccio C, Sbrancia M, Fabbri C. Role of endoscopic ultrasonography in the management of peripancreatic collections. Diagnostic and therapeutic approach. Minerva Gastroenterol (Torino) 2021; 68:162-176. [PMID: 33988009 DOI: 10.23736/s2724-5985.21.02874-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy -
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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