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Gupta P, Siddiqui R, Singh S, Pradhan N, Shah J, Samanta J, Jearth V, Singh A, Mandavdhare H, Sharma V, Mukund A, Birda CL, Kumar I, Kumar N, Patidar Y, Agarwal A, Yadav T, Sureka B, Tiwari A, Verma A, Kumar A, Sinha SK, Dutta U. Application of deep learning models for accurate classification of fluid collections in acute necrotizing pancreatitis on computed tomography: a multicenter study. Abdom Radiol (NY) 2025; 50:2258-2267. [PMID: 39347977 DOI: 10.1007/s00261-024-04607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 09/05/2024] [Accepted: 09/17/2024] [Indexed: 10/01/2024]
Abstract
PURPOSE To apply CT-based deep learning (DL) models for accurate solid debris-based classification of pancreatic fluid collections (PFC) in acute pancreatitis (AP). MATERIAL AND METHODS This retrospective study comprised four tertiary care hospitals. Consecutive patients with AP and PFCs who had computed tomography (CT) prior to drainage were screened. Those who had magnetic resonance imaging (MRI) or endoscopic ultrasound (EUS) within 20 days of CT were considered for inclusion. Axial CT images were utilized for model training. Images were labelled as those with≤30% solid debris and >30% solid debris based on MRI or EUS. Single center data was used for model training and validation. Data from other three centers comprised the held out external test cohort. We experimented with ResNet 50, Vision transformer (ViT), and MedViT architectures. RESULTS Overall, we recruited 152 patients (129 training/validation and 23 testing). There were 1334, 334 and 512 images in the training, validation, and test cohorts, respectively. In the overall training and validation cohorts, ViT and MedVit models had high diagnostic performance (sensitivity 92.4-98.7%, specificity 89.7-98.4%, and AUC 0.908-0.980). The sensitivity (85.3-98.6%), specificity (69.4-99.4%), and AUC (0.779-0.984) of all the models was high in all the subgroups in the training and validation cohorts. In the overall external test cohort, MedViT had the best diagnostic performance (sensitivity 75.2%, specificity 75.3%, and AUC 0.753). MedVit had sensitivity, specificity, and AUC of 75.2%, 74.3%, and 0.748, in walled off necrosis and 79%, 74.2%, 75.3%, and 0.767 for collections >5 cm. CONCLUSION DL-models have moderate diagnostic performance for solid-debris based classification of WON and collections greater than 5 cm on CT.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Ruby Siddiqui
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shravya Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nikita Pradhan
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Science, New Delhi, India
| | - Chhagan Lal Birda
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Ishan Kumar
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Niraj Kumar
- Department of Interventional Radiology, Institute of Liver and Biliary Science, New Delhi, India
| | - Yashwant Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Science, New Delhi, India
| | - Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Binit Sureka
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Anurag Tiwari
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Kumar
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Basha J, Maharshi TS, Lakhtakia S. Endoscopic Step-Up Approach in Management of Necrotizing Pancreatitis. Gastroenterol Clin North Am 2025; 54:37-51. [PMID: 39880532 DOI: 10.1016/j.gtc.2024.10.002] [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: 01/31/2025]
Abstract
The endoscopic step-up approach in the management of necrotizing pancreatitis involves sequential steps of intervention at different time points in the clinical course of the disease. EUS -guided drainage of walled-off necrosis is the first step of the endoscopic step-up approach. Lumen-apposing metal stents are preferred over plastic stents for safe and effective drainage because of their wide caliber. Successive steps in the endoscopic step-up approach include direct endoscopic necrosectomy and/or irrigation using naso-cystic tube in symptomatic patients, primarily based on necrotic debris characteristics. Minimally invasive percutaneous radiological and/or surgical drainage are considered when endoscopic drainage is not feasible or successful.
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Affiliation(s)
- Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Hyderabad, India
| | | | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Hyderabad, India.
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Capurso G, Rizzo GEM, Coluccio C, Crinò SF, Cucchetti A, Facciorusso A, Hassan C, Amato A, Auriemma F, Bertani H, Binda C, Cipolletta F, Forti E, Fugazza A, Lisotti A, Maida M, Sinagra E, Sbrancia M, Spadaccini M, Tacelli M, Vanella G, Anderloni A, Fabbri C, Tarantino I, Aragona G, Arcidiacono PG, Arvanitaki M, Badas R, Barresi L, Berretti D, Bocus P, Camellini L, Cintorino D, Cugia L, Dabizzi E, De Angelis CG, Blanco GDV, Matteo FMD, Mitri RD, Ercolani G, Falconi M, Fantin A, Ligresti D, Macchiarelli R, Mangiafico S, Mangiavillano B, Manno M, Maruzzelli L, Marzioni M, Pedicini V, Piras E, Pollino V, Sethi A, Siddiqui U, Togliani T, Traina M, Tringali A, Venezia G, Zerbi A. The i-EUS consensus on the management of pancreatic fluid collections – Part 1. Dig Liver Dis 2024; 56:1663-1674. [DOI: 10.1016/j.dld.2024.06.030 pmid: 39048418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2025]
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Capurso G, Rizzo GEM, Coluccio C, Crinò SF, Cucchetti A, Facciorusso A, Hassan C, Amato A, Auriemma F, Bertani H, Binda C, Cipolletta F, Forti E, Fugazza A, Lisotti A, Maida M, Sinagra E, Sbrancia M, Spadaccini M, Tacelli M, Vanella G, Anderloni A, Fabbri C, Tarantino I. The i-EUS consensus on the management of pancreatic fluid collections - Part 1. Dig Liver Dis 2024; 56:1663-1674. [PMID: 39048418 DOI: 10.1016/j.dld.2024.06.030] [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: 05/10/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/27/2024]
Abstract
Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches; however, it has later shifted toward an endoscopy-based approach. With the development of dedicated lumen-apposing metal stents (LAMS), interventional Endoscopic Ultrasound (EUS)-guided procedures have become the standard approach for PFC drainage. However, there is still limited consensus on several aspects of the multidisciplinary management of PFCs. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript describes the first part of the results of a consensus conference organized by i-EUS with the aim of providing evidence-based guidance on aspects such as indications for treating PFCs, the timing of intervention, and different technical strategies for managing patients with PFCs.
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Affiliation(s)
- Gabriele Capurso
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center San Raffaele Scientific Institut, Milan, Italy
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy; Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy.
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Cesare Hassan
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, ASST Lecco, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy
| | - Helga Bertani
- Gastroenterologia ed Endoscopia Digestiva Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Fabio Cipolletta
- Department of Gastroenterology, Ospedale del Mare, ASL NA1 Centro, Naples, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, ASST Niguarda Hospital, Milan, Italy
| | - Alessandro Fugazza
- Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Marcello Maida
- Gastroenterology Unit, Umberto I Hospital - Department of Medicine and Surgery, University of Enna 'Kore', Enna, Italy
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Marco Spadaccini
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy
| | - Matteo Tacelli
- Pancreato-biliary Endoscopy and EUS Division, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Giuseppe Vanella
- Pancreato-biliary Endoscopy and EUS Division, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
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Paramythiotis D, Karlafti E, Tsavdaris D, Giakoustidis A, Panidis S, Ioannidis A, Prassopoulos P, Michalopoulos A. When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1592. [PMID: 39459378 PMCID: PMC11509130 DOI: 10.3390/medicina60101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Revised: 09/24/2024] [Accepted: 09/25/2024] [Indexed: 10/28/2024]
Abstract
Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.
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Affiliation(s)
- Daniel Paramythiotis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Eleni Karlafti
- Emergency Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- First Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Dimitrios Tsavdaris
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Alexandros Giakoustidis
- First Surgery Department, University General Hospital of Thessaloniki Papageorgiou, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Stavros Panidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Aristeidis Ioannidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Panos Prassopoulos
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Antonios Michalopoulos
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
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Paramythiotis D, Karlafti E, Tsavdaris D, Giakoustidis A, Panidis S, Ioannidis A, Prassopoulos P, Michalopoulos A. When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies. Medicina (B Aires) 2024; 60:1592. [DOI: https:/doi.org/10.3390/medicina60101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2025] Open
Abstract
Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.
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Affiliation(s)
- Daniel Paramythiotis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Eleni Karlafti
- Emergency Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- First Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Dimitrios Tsavdaris
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Alexandros Giakoustidis
- First Surgery Department, University General Hospital of Thessaloniki Papageorgiou, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Stavros Panidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Aristeidis Ioannidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Panos Prassopoulos
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Antonios Michalopoulos
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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Li T, Kang C, Ren G, Lv Y, Luo H, Kang X, Liang S, Wang X, Pan Y. Top 100 cited articles related to EUS: A bibliometric analysis. Endosc Ultrasound 2024; 13:259-268. [PMID: 39318756 PMCID: PMC11419419 DOI: 10.1097/eus.0000000000000081] [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: 02/20/2024] [Accepted: 05/27/2024] [Indexed: 09/26/2024] Open
Abstract
Background and Objectives Citation analysis is a fundamental method in bibliometrics for quantifying the impact and contribution of articles on a specific biomedical field. The purpose of our study was to identify and analyze the top 100 cited articles in the field of EUS. Methods All published articles in the field of EUS were searched by using "endoscopic ultrasound" and its synonyms as the search terms without time limit. The Institute for Scientific Information Web of Science Core database was searched to determine the citations. The top 100 cited articles were identified and further evaluated for characteristics including publication year, authors, journals, impact factor, countries, institutions, article type, topic term, and evidence grade, among others. Results A total of 430 articles were cited more than 100 times. The 100 most-cited articles were published between 1988 and 2018, and the medium citation was 240.5 (104.25). The top 100 cited articles mainly focused on diagnostic performance (80%) and interventional therapy (20%). The numbers of articles studying the diagnostic accuracy of FNA (n = 29) and tumor diagnosis (n = 29) were the highest among research articles on FNA and EUS of diagnostic categories, and EUS transluminal drainage (n = 14) was the most frequently used EUS technique for therapy. The focus of the majority of the articles was on diseases of pancreas (n = 55), and among the 55 articles related to pancreatic diseases, pancreatic cancer (n = 17) and solid pancreatic masses (n = 13) were the most researched topics. In addition, we found that the proportions of diagnostic and treatment-related articles at different time periods have statistical significance (P < 0.05). Conclusions Our analysis provides an insight into the top 100 articles in the field of EUS, revealing EUS-guided FNA, tumor staging, and transluminal drainage as the major advances in the past 35 years. Pancreatic diseases were the most researched, especially pancreatic cancer or solid pancreatic masses. Our research has found that the number of articles on the application of EUS treatment has significantly increased.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yanglin Pan
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
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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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Liu Q, Yang J, Zhang J. Factors affecting the time interval of endoscopic ultrasound-guided endoscopic necrosectomy of walled-off pancreatic necrosis: A retrospective single-center study in China. Pancreatology 2024; 24:357-362. [PMID: 38369393 DOI: 10.1016/j.pan.2024.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound (EUS)-guided endoscopic necrosectomy is an effective and minimally invasive treatment for walled-off pancreatic necrosis (WON). This study investigated the factors affecting the time interval of EUS-guided WON necrosectomy. METHODS Patients who received EUS-guided necrosectomy in the Endoscopy Center of the First Affiliated Hospital of Chongqing Medical University in the past 5 years were retrospectively analyzed. Data including general information, etiology, blood biochemical indexes, physical signs, CT severity grade, location, size, solid necrotic ratio, type and number of stents, and immediate necrosectomy were collected to explore the relationships between these factors and the interval of endoscopic necrosectomy. RESULTS A total of 51 WON patients were included. No significant correlation has been noted between the endoscopic debridement interval and the following indexes, including the patients' general information, the etiology of pancreatitis, blood biochemical indexes (leukocyte count, neutrophil percentage, C-reactive protein), preoperative fever, and WON's location and size, type and number of stents, and whether immediate necrosectomy. However, there were significant differences between the debridement interval and the modified CT Severity Index (MCTSI) (p < 0.001), the solid necrotic ratio of WON (p < 0.001) before the intervention, postoperative fever (p = 0.038), C-reactive protein increasing (p = 0.012) and fever before reintervention (p = 0.024). CONCLUSIONS The EUS-measured solid necrotic ratio, the MCTSI, postoperative fever, C-reactive protein increase, and fever before reintervention in patients affect the time interval of EUS-guided endoscopic necrosectomy in WON patients. These five indicators may be promisingly effective in predicting and managing endoscopic necrosectomy intervals.
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Affiliation(s)
- Qing Liu
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Junwen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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10
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Bharath PN, Rana SS. Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes. Dig Dis Sci 2024; 69:1571-1582. [PMID: 38528209 DOI: 10.1007/s10620-024-08347-3] [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: 01/02/2024] [Accepted: 02/08/2024] [Indexed: 03/27/2024]
Abstract
Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4 weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4 weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.
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Affiliation(s)
- Pardhu Neelam Bharath
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India.
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11
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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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12
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Shah J, Singh AK, Jearth V, Jena A, Dhanoa TS, Sakaray YR, Gupta P, Singh H, Sharma V, Dutta U. Endoscopic ultrasound-guided drainage of early pancreatic necrotic collection: Single-center retrospective study. Indian J Gastroenterol 2023:10.1007/s12664-023-01478-x. [PMID: 38102523 DOI: 10.1007/s12664-023-01478-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/24/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is the standard of care for drainage of pancreatic necrosis. Though initially it was mainly used for drainage of only walled-off necrosis, recently, a few studies have also shown its safety in the management of acute necrotic collections. We did a retrospective study to evaluate the safety and efficacy of EUS-guided drainage in the early phase of pancreatitis as compared to interventions in the late phase. METHODS We retrieved baseline disease-related, procedure-related and outcome-related details of patients who underwent EUS-guided drainage of pancreatic necrosis. Patients were divided into early (≤ 28 days from onset of pancreatitis) or delayed (> 28 days) drainage groups. Both groups were compared for disease-related characteristics and outcomes. RESULTS Total 101 patients were included in the study. The mean age of included patients was 35.54 ± 13.58 years and 75 were male. Thirty-five patients (34.7%) underwent early drainage. In the early group, a majority of patients underwent intervention due to infected collection (88.6% vs. 18.2%; p < 0.001). More patients in the early group had < 30% wall formation (28.6% vs. 0%; p < 0.001) and > 30% solid debris within the collection (42.9% vs. 15.2%; p = 0.005). Patients in the early group were also more likely to require endoscopic necrosectomy (57.1% vs. 27.3%; p = 0.003) and additional percutaneous drainage (31.4% vs. 12.1%; p = 0.018). Overall, three patients in the early group and one patient in the delayed group had procedure-related complications. Four patients in the early group and one patient in the delayed group succumbed to illness (p = 0.029). CONCLUSION Though delayed interventions remain standard of care in the management of acute pancreatitis, some patients may require early intervention due to infected collection with deteriorating clinical status. Early EUS-guided interventions in such carefully selected patients have in similar clinical outcomes and complication rates compared to delayed intervention. However, such patients are more likely to require additional endoscopic or percutaneous interventions.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Anupam K Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Tejdeep Singh Dhanoa
- Department of Radio-Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Yashwant Raj Sakaray
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Pankaj Gupta
- Department of Radio-Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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13
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Kakadiya R, Muktesh G, Samanta J, Mandavdhare HS, Gupta P, Shah J, Sarma P, Gupta V, Yadav TD, Jena A, Sharma V, Kochhar R. Plastic versus metal stents for transmural drainage of walled-off necrosis with significant solid debris: a randomized controlled trial. Endosc Int Open 2023; 11:E1069-E1077. [PMID: 38500708 PMCID: PMC10946060 DOI: 10.1055/a-2185-6318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/25/2023] [Indexed: 03/20/2024] Open
Abstract
Background and study aims Recently, larger-caliber metal stents have been increasingly used, resulting in higher efficacy in walled-off necrosis (WON) with more solid debris. However, none of the trials have included WON with significant solid debris. The aim of this study was to compare plastic stents and metal stents for drainage of symptomatic WON with significant solid debris (≥20%). Patients and methods We conducted a single-center, open-label, noninferiority trial including 48 patients. The primary endpoint was treatment success. Secondary outcomes were technical success, total number of procedures, adverse events (AEs), duration of procedure, and treatment failure. All the outcomes were assessed at 3 weeks after drainage. Patients were followed up for 3 months to assess recurrence. Results Treatment succeeded in 21 of 24 patients (87.5%) and 20 of 24 patients (83.3%) in the metal and plastic stent groups, respectively with P =1.05 (95% confidence interval 0.81-1.39). Assuming 10% non-inferiority margin, P <0.001 for non-inferiority, suggesting that plastic stents are non-inferior to metal stents. The technical success rate was 100%. Procedure duration was significantly shorter in the metal stent group (12.95±5.3 minutes versus 29.77±6.6 minutes, P <0.001). The number of total procedures was comparable (2.8±1 vs 2.2±1, P =0.097). There were more minor AEs in plastic stent arm but no significant difference between the two groups. A single asymptomatic recurrence was observed in the metal stent arm. Conclusions Plastic stents are not inferior to metal stents for WON drainage with significant solid debris. However, larger sample-size studies are needed to make definite conclusions.
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Affiliation(s)
- Rinkal Kakadiya
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Muktesh
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal S Mandavdhare
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jimil Shah
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Phulen Sarma
- Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuraag Jena
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Telaprolu H, Srinu D, Mangipudi UK, Yadav A, Jearth V, Shah J, Rana SS. Novel classification system for walled-off pancreatic necrosis: a step in the right direction. Gastrointest Endosc 2023; 98:873. [PMID: 37863573 DOI: 10.1016/j.gie.2023.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Harshavardhan Telaprolu
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deshidi Srinu
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Uday Kiran Mangipudi
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Yadav
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vaneet Jearth
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jimil Shah
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surinder S Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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15
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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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16
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Tiwari A, Shah A, Singh J. LAMS versus plastic stents for infected pancreatic walled off necrosis (WON): has the addition of the TENSION trial to the AXIOMA study eased the tension? Gut 2023; 72:1428-1429. [PMID: 35977814 DOI: 10.1136/gutjnl-2022-328148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/09/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Avinash Tiwari
- Gastroenterology Department, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
| | - Altaf Shah
- Gastroenterology Department, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
| | - Jaswinder Singh
- Gastroenterology Department, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
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17
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Song LJ, Xiao B. Acute pancreatitis: Structured report template of magnetic resonance imaging. World J Radiol 2023; 15:157-169. [PMID: 37424735 PMCID: PMC10324496 DOI: 10.4329/wjr.v15.i6.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/25/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Acute pancreatitis (AP) is a common acute abdomen disease of the digestive system. It has a potentially fatal risk because of its variable severity and various complications. With the widespread application of the Revised Atlanta Classification, new requirements for AP imaging reports are introduced. Experts in abdominal radiology and pancreatology in the United States published the first structured computed tomography reporting template for AP in 2020. However, there is no corresponding structured magnetic resonance imaging (MRI) reporting template globally. Therefore, this article focuses on the structured MRI report of AP images from our pancreatitis imaging center, which is intended to improve the systematic understanding of this disease and standardize the writing of MRI structured reports. In the meantime, we aim to promote the clinical diagnosis and assessment of MRI efficacy for AP and its multiple complications. It is further intended to facilitate academic exchanges and scientific research between different medical centers.
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Affiliation(s)
- Ling-Ji Song
- Department of Radiology, Sichuan Key Laboratory of Medical Imaging, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Bo Xiao
- Department of Radiology, Sichuan Key Laboratory of Medical Imaging, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
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18
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Tiwari A, Shah A, Singh J. TENSION Trial to ExTENSION Study: Has Extension Decreased Tension? Gastroenterology 2023; 164:496-497. [PMID: 35691367 DOI: 10.1053/j.gastro.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Avinash Tiwari
- Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu, and Kashmir, India
| | - Altaf Shah
- Gastroenterology Department, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu, and Kashmir, India
| | - Jaswinder Singh
- Gastroenterology Department, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu, and Kashmir, India
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Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections. Surg Endosc 2023; 37:1096-1106. [PMID: 36123547 DOI: 10.1007/s00464-022-09610-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/03/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD. METHODS This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD. RESULTS We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68-97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91-136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33-29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs. CONCLUSION Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings. CLINICAL REGISTRATION NUMBER UMIN 000030898.
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20
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Rana SS, Gupta R. Nomenclature of Pancreatic Fluid Collections following Acute Pancreatitis: Need to Further Revise the Atlanta Classification System! JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1759512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AbstractA better understanding of the disease pathophysiology, improved imaging modalities, and the development of minimally invasive interventions led to the revision of the Atlanta classification and new terminologies for the pancreatic fluid collections (PFCs) occurring in acute pancreatitis. Peripancreatic necrosis (PPN) or extra-pancreatic necrosis (EPN) has been reported as a distinct morphological entity with a better outcome than combined pancreatic and peripancreatic necrosis as well as pancreatic parenchymal necrosis alone and slightly worse than acute interstitial pancreatitis. In this news and views, we discuss a study that compared the morphological features and outcomes of endoscopic drainage of walled off necrotic collections developing after EPN alone with those developing after PN with or without EPN.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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21
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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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22
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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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23
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Zhai YQ, Ryou M, Thompson CC. Predicting success of direct endoscopic necrosectomy with lumen-apposing metal stents for pancreatic walled-off necrosis. Gastrointest Endosc 2022; 96:522-529.e1. [PMID: 35461888 DOI: 10.1016/j.gie.2022.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/12/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) with lumen-apposing metal stents (LAMSs) is increasingly used in the management of pancreatic walled-off necrosis (WON). However, it still remains unknown which patients will fail to respond to DEN with LAMSs and require additional surgical intervention. Therefore, the aim of our study was to explore predictors of successful DEN with LAMSs for pancreatic WON. METHODS This is a retrospective analysis of a prospectively collected database. All consecutive patients who underwent DEN with LAMSs for pancreatic WON were included. Collected data were demographics, disease severity, morphologic features, and procedure characteristics. Potential factors affecting DEN outcome were predefined and analyzed. RESULTS One hundred one consecutive patients undergoing DEN with LAMSs for WON were identified, among whom 4 patients were excluded for technical failure (n = 1) and previous debridement without LAMSs (n = 3). In the 97 included patients, clinical success was achieved in 79 patients (81.4%). In logistic multivariable regression, 3 independent factors were negatively associated with success of DEN with LAMSs: increasing Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], .70; 95% confidence interval [CI], .55-.90; P = .005), >50% pancreatic necrosis (OR, .16; 95% CI, .03-.77; P = .022), and paracolic gutter extension (OR, .08; 95% CI, .02-.42; P = .003). A receiver-operating characteristic curve of the prediction model with these 3 factors demonstrated an area under the curve of .926. CONCLUSIONS Paracolic gutter extension, increasing Acute Physiology and Chronic Health Evaluation II score, and >50% gland necrosis are negative predictors for success of DEN with LAMSs in WON. This prediction model with nomogram may be helpful in clinical decision-making and prognostication.
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Affiliation(s)
- Ya-Qi Zhai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Muktesh G, Samanta J, Dhar J, Agarwala R, Bellam BL, James D, Gupta P, Chauhan R, Yadav TD, Gupta V, Sinha SK, Kochhar R. Endoscopic Ultrasound-guided Drainage of Patients With Infected Walled-off Necrosis: Which Stent to Choose? Surg Laparosc Endosc Percutan Tech 2022; 32:335-341. [PMID: 35258015 DOI: 10.1097/sle.0000000000001046] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/25/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is the preferred treatment of pancreatic fluid collections (PFC). However, the choice of the stent for EUS-guided drainage in critically ill PFC cases with infected walled-off necrosis (WON) and/or organ failure (OF) remains unknown. MATERIALS AND METHODS Between January 2018 and December 2019, consecutive patients with symptomatic PFC subjected to EUS-guided drainage using biflanged metal stents (BFMS) or double-pigtail plastic stents (DPPS) were compared for technical success, clinical success, duration of the procedure, need for intensive care unit stay, duration of intensive care unit stay, ventilator need, resolution of OF, the duration for resolution of OF, complications, need for salvage percutaneous drainage or surgery and mortality. A subgroup of patients having infected WON with/without OF were analyzed separately. RESULTS Among 120 patients (84.6% males) with PFC (108 WON, 22 pseudocyst) who underwent EUS-guided drainage, there was no difference in outcome parameters in BFMS and DPPS groups. Among patients with WON, clinical success was significantly higher (96.2% vs. 81.8%, P=0.04), with significantly shorter hospital stay (6 vs. 10 d) and procedure duration (17.18±4.6 vs. 43.6±9.7 min, P<0.0001) in the BFMS group. Among patients with infected WON with/without OF, the clinical success was significantly higher (100% vs. 73.9%, P=0.02), and the duration of the procedure was significantly lower (16.28±4.4 vs. 44.39±10.7, P<0.0001) in BFMS compared with DPPS group. CONCLUSION EUS-guided drainage of WON using BFMS scores over DPPS. In patients having infected WON with/without OF, BFMS may be preferred over DPPS.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Thakur D Yadav
- Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Vikas Gupta
- Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
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25
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Cosgrove N, Shetty A, Mclean R, Vitta S, Faisal MF, Mahmood S, Early D, Mullady D, Das K, Lang G, Thai T, Syed T, Maple J, Jonnalagadda S, Andresen K, Hollander T, Kushnir V. Radiologic Predictors of Increased Number of Necrosectomies During Endoscopic Management of Walled-off Pancreatic Necrosis. J Clin Gastroenterol 2022; 56:457-463. [PMID: 33883512 DOI: 10.1097/mcg.0000000000001549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/14/2021] [Indexed: 12/10/2022]
Abstract
GOALS No established methods exist to predict who will require a higher number of endoscopic necrosectomy sessions for walled-off necrosis (WON). We aim to identify radiologic predictors for requiring a greater number of necrosectomy sessions. This may help to identify patients who benefit from aggressive endoscopic management. MATERIALS AND METHODS This is a multicenter retrospective study of patients with WON at 3 tertiary care centers. WON characteristics on preintervention computed tomography imaging were evaluated to determine if they were predictive of requiring more endoscopic necrosectomy. RESULTS A total of 104 patients were included. Seventy patients (67.3%) underwent endoscopic necrosectomy, with median of 2 necrosectomies. WON largest transverse diameters (P=0.02), largest coronal diameters (P=0.01), necrosis pattern [likelihood ratio (LR)=17.85, P<0.001], spread (LR=11.02, P=0.01), hemorrhage (LR=8.64, P=0.003), and presence of disconnected pancreatic duct (LR=6.80, P=0.01) were associated with undergoing ≥2 necrosectomies. Patients with septations/loculations were significantly less likely to undergo ≥2 necrosectomies (LR=4.86, P=0.03). CONCLUSIONS Several computed tomography radiologic features were significantly associated with undergoing ≥2 necrosectomies. These could help identify patients who will undergo a higher number of endoscopic necrosectomy sessions.
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Affiliation(s)
| | | | - Richard Mclean
- Department of Internal Medicine, Washington University in St. Louis, St. Louis
| | - Swaroop Vitta
- Department of Internal Medicine, Washington University in St. Louis, St. Louis
| | - Mir F Faisal
- Division of Gastroenterology, University of Missouri, Kansas City
| | | | | | | | | | | | | | - Taseen Syed
- Department of Internal Medicine, University of Oklahoma Health Sciences, Oklahoma City, OK
| | | | | | - Kelli Andresen
- Division of Radiology, St. Luke's Hospital of Kansas City, Kansas City, MO
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26
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Chandrasekhara V, Abu Dayyeh BK. Reply. Clin Gastroenterol Hepatol 2022; 20:e1220. [PMID: 34102341 DOI: 10.1016/j.cgh.2021.06.007] [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: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023]
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27
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Rana SS, Bush N, Gupta R. Predicting Need for Aggressive Endoscopic Therapy After Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections With Lumen Apposing Metal Stents. Clin Gastroenterol Hepatol 2022; 20:e1219-e1220. [PMID: 34000378 DOI: 10.1016/j.cgh.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nikhil Bush
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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28
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Ding L, Li XY, Tan JX, Xia L, He WH, Xiong HF, Zhu Y, Liu P, Shu X, Liu ZJ, Zhu Y, Chen YX, Lu NH. Association between morphological features of necrotizing pancreatitis on endoscopic ultrasound and outcomes of the endoscopic transmural step-up approach. J Dig Dis 2022; 23:174-182. [PMID: 35076989 DOI: 10.1111/1751-2980.13083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the association between necrotic collections on endoscopic ultrasound (EUS) and outcomes of the endoscopic transmural step-up approach in necrotizing pancreatitis (NP). METHODS Adult NP patients who had undergone endoscopic transmural step-up approach, endoscopic transmural drainage or endoscopic transmural necrosectomy, were retrospectively enrolled, and divided into groups 1, 2 and 3 based on the amount of solid necrotic debris (quantified as a percentage of the total collection size of <30%, 30%-50%, and >50%). RESULTS A total of 134 patients were included, of whom 52, 59 and 23 patients were categorized into groups 1, 2 and 3. Patients with more solid necrotic debris required more necrosectomy sessions (group 3 vs group 2 vs group 1: 2.0 vs 1.0 vs 1.0, P < 0.001), were more likely to experience stent occlusion (group 3 vs group 2 vs group 1: 34.8% vs 16.9% vs 9.6%, P = 0.011), and had a longer hospitalization (group 3 vs group 2 vs group 1: 40.0 d vs 28.0 d vs 25.5 d, P = 0.015). High procalcitonin level (adjusted odds ratio [aOR] 6.14, 95% confidence interval [CI] 1.40-26.94, P = 0.016) and any organ failure (aOR 11.51, 95% CI 2.42-54.78, P = 0.002) were independently associated with clinical failure of endoscopic transmural step-up approach. CONCLUSIONS More solid necrotic debris on EUS is related to more necrosectomy sessions, higher incidence of stent occlusion and longer hospitalization. A nomogram combining procalcitonin and any organ failure performs well in predicting clinical failure of endoscopic transmural step-up approach.
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Affiliation(s)
- Ling Ding
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xue Yang Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Ji Xue Tan
- Queen Mary School, Nanchang University, Nanchang, Jiangxi Province, China
| | - Liang Xia
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Wen Hua He
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Hui Fang Xiong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yong Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Pi Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xu Shu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Zhi Jian Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yin Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - You Xiang Chen
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Nong Hua Lu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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A Case Series of Late Gastrointestinal Fistulization in 16 Patients with Walled-Off Necrosis. Dig Dis Sci 2022; 67:661-666. [PMID: 33651255 DOI: 10.1007/s10620-021-06900-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/08/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Gastrointestinal fistulization (GIF) is a rare and potentially fatal complication of acute necrotizing pancreatitis (ANP). There is paucity of data on clinical course and outcome of GIF in walled of necrosis (WON). OBJECTIVE To evaluate frequency, clinical as well as imaging findings and outcome of spontaneous symptomatic GIF in patients with WON. METHODS Retrospective analysis of database of patients with asymptomatic WON on regular follow-up over last six years to identify patients with symptomatic GIF. RESULTS Out of 138 patients with asymptomatic WON seen during the study period, 16 (11.5%) patients (all males; mean age 41.7 ± 9.9 years) developed symptomatic GIF. The mean size of WON in patients who developed GIF was 9.5 ± 2.4 cm, and fistulization occurred after 65.1 ± 17.8 days of the onset of ANP. The site of fistulization was stomach, duodenum, jejunum, colon, and esophagus in seven (43.7%), five (31.2%), one (6.2%), two (12.5%), and one (6.2%) patients, respectively. GIF resulted in spontaneous resolution in two patients (stomach 1 and esophagus 1). The remaining patients with gastric (six patients) and duodenal (five patients) fistulization were successfully treated endoscopically by placing multiple plastic stents in the necrotic cavity after balloon dilatation of the fistulous tract. Patients with colonic fistulization required surgery. None of the patients succumbed to the illness. CONCLUSION Symptomatic GIF of WON usually occurs within the first three months of onset of ANP. It commonly occurs in either stomach or duodenum and can be successfully managed endoscopically.
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30
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Rana SS, Gupta R. Novel Resection System for Direct Endoscopic Necrosectomy of Walled-Off Pancreas Necrosis: Have We Conquered the Final Frontier? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1741066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractSurgical necrosectomy has been the traditional management for pancreatic necrosis and is done using blunt dissection. However, lack of dedicated endoscopic accessories has been a major limitation in direct endoscopic necrosectomy (DEN). Standard endoscopic accessories cannot effectively remove large necrotic material. Also, diameter of instrument channel of the endoscope limits the ability to use large-diameter graspers that can remove large chunks of necrotic material. In this news, we discuss a recent study that has evaluated a new powered endoscopic debridement system for DEN.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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31
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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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32
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Xu N, Zhai YQ, Li LS, Chai NL. Multiple hidden vessels in walled-off necrosis with high-risk bleeding: Report of two cases. World J Clin Cases 2021; 9:8214-8219. [PMID: 34621883 PMCID: PMC8462217 DOI: 10.12998/wjcc.v9.i27.8214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/17/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Walled-off necrosis (WON), as a local complication of acute necrotizing pancreatitis, is difficult to differentiate from pancreatic pseudocysts (PPC). Imaging modalities such as computed tomography show a lower accuracy than endoscopic ultrasound (EUS) in confirming the diagnosis. EUS-guided cystogastrostomy following direct endoscopic necrosectomy has achieved excellent results and has been regarded as a preferred alternative to traditional surgery. However, high-risk bleeding is one of the greatest concerns. CASE SUMMARY Two patients with symptomatic pancreatic fluid collections (PFCs) were admitted to our hospital for EUS-guided lumen-apposing metal stent therapy. The female patient suffered from intermittent abdominal pain and underwent two perioperative CT examinations. The male patient had recurrent pancreatitis and showed a growing PFC. The initial diagnosis was a PPC according to contrast-enhanced CT. However, the evidence of solid contents on EUS prompted revision of the diagnosis to WON. An endoscope was inserted into the cavity, and some necrotic debris and multiple hidden vascular structures were observed. Owing to conservative treatment by irrigation with sterile water instead of direct necrosectomy, we successfully avoided damaging hidden vessels and reduced the risk of intraoperative bleeding. CONCLUSION The application of EUS is helpful for the identification of PFCs. Careful intervention should be conducted for WON with multiple vessels to prevent bleeding.
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Affiliation(s)
- Ning Xu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Long-Song Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ning-Li Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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33
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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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34
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Rana SS, Sharma R, Kishore K, Dhalaria L, Gupta R. Safety and Efficacy of Early (<4 Weeks of Illness) Endoscopic Transmural Drainage of Post-acute Pancreatic Necrosis Predominantly Located in the Body of the Pancreas. J Gastrointest Surg 2021; 25:2328-2335. [PMID: 33547585 DOI: 10.1007/s11605-021-04945-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/21/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic transmural drainage is usually not performed for pancreatic necrotic collection (PNC) < 4 weeks after onset of acute necrotizing pancreatitis (ANP) because of lack of encapsulating wall and increased risk of complications. OBJECTIVE Study safety and efficacy of early (<4 weeks) endoscopic transluminal drainage in patients with symptomatic PNC. METHODS Retrospective analysis of data base of patients with PNC treated with endoscopic transmural drainage within 4 weeks of onset of ANP (early drainage) was done. The outcomes and complications were compared with patients with PNC who underwent delayed endoscopic drainage (≥4 weeks of onset of ANP). RESULTS Thirty-four patients (26 males; mean age: 35.9 ± 8.6 years) underwent early and 136 patients (115 males; mean age: 37.9 ± 9.4 years) underwent delayed endoscopic drainage. The PNC was significantly larger (12.3 ± 2.1 cm vs 10.5 ± 2.7 cm, p <0.001) with increased solid component (47.7 ± 8.9% vs 28.3 ± 11.7%, p <0.001) in the early group. Clinical success was achieved in 94% patients in the early group and all patients in the delayed group. Direct endoscopic necrosectomy was performed more frequently in the early group (50% vs 7.4%; p<0.001). There was increased mortality (5.7% vs 0%), need for rescue surgical necrosectomy (5.7% vs 0%), and clinically significant bleeding (20% vs 1.5%, p<0.001) in the early group as compared to the delayed group. CONCLUSION Early endoscopic drainage of PNC is feasible and seems to be safe as well as effective but is associated with increased risk of complications as compared to delayed drainage.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Ravi Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Kamal Kishore
- Department of Biostatistics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Lovneet Dhalaria
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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35
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Mukai S, Itoi T, Tsuchiya T, Tonozuka R, Yamamoto K, Sofuni A. New deployment techniques of the lumen-apposing metal stent in walled-off necrosis filled with necrotic tissue: Chick opening its mouth (with video). Dig Endosc 2021; 33:985-989. [PMID: 33991135 DOI: 10.1111/den.14016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/12/2021] [Accepted: 05/11/2021] [Indexed: 12/14/2022]
Abstract
The lumen-apposing metal stent (LAMS) on an electrocautery-enhanced delivery system for endoscopic ultrasound-guided transluminal drainage has been widely used for the treatment of walled-off necrosis (WON). However, deployment of the LAMS can be technically difficult in WON, which contains a large amount of necrotic tissue and a low liquid component, owing to insufficient space for expansion of the distal stent flange. It has been recommended that the LAMS is placed in WON containing necrotic tissue, because additional endoscopic necrosectomy can be readily performed via the lumen of the LAMS. Here we introduce two new deployment techniques of the LAMS for WON filled with necrotic tissue, namely, the two-step puncture technique and the back-and-forth technique, which enable the distal stent flange to be expanded like a chick opening its mouth. These techniques are expected to further improve the clinical outcomes of refractory WON.
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Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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36
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Zhu H, Xie P, Wang Y, Jin Z, Li Z, Du Y. The role of solid debris in endoscopic ultrasound-guided drainage of walled-off necrosis: A large cohort study. J Gastroenterol Hepatol 2020; 35:2103-2108. [PMID: 32365410 DOI: 10.1111/jgh.15086] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIM The effect of solid debris on walled-off necrosis (WON) drainage remains unknown. Our study evaluated the role of solid debris in endoscopic ultrasound (EUS)-guided drainage of WON compared lumen-apposing metal stent (LAMS) with double-pigtail plastic stent (DPPS). METHODS We retrospectively evaluated consecutive patients with WON who underwent EUS-guided drainage in our endoscopic center over a 9-year period. The amount of solid debris in WON was assessed with computed tomography or magnetic resonance imaging and EUS images. RESULTS From 2011 to 2019, 84 WON patients were included. In WON with < 20% solid debris, the short-term clinical success of LAMSs (96.8%) was significantly higher than DPPSs (66.7%) (P = 0.03), and LAMSs were safer than DPPSs with less early adverse events (P = 0.02) and late adverse events (P = 0.03). On multivariable analysis, DPPS (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.04-0.65; P = 0.01) and solid debris > 40% (OR, 0.11; 95% CI, 0.02-0.62; P = 0.01) were the predictors for failure of resolution of WON after adjusting for age and cyst size. The number of DPPSs used was significantly higher than LAMSs in managing WONs (P < 0.001). CONCLUSION For WON with < 20% solid debris, LAMSs might superior to DPPSs in terms of efficacy and safety.
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Affiliation(s)
- Huiyun Zhu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
| | - Pei Xie
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yuxin Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yiqi Du
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University/Naval Medical University, Shanghai, China
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Chandrasekhara V, Barthet M, Devière J, Bazerbachi F, Lakhtakia S, Easler JJ, Peetermans JA, McMullen E, Gjata O, Gourlay ML, Abu Dayyeh BK. Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis. Endosc Int Open 2020; 8:E1639-E1653. [PMID: 33140020 PMCID: PMC7584468 DOI: 10.1055/a-1243-0092] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P = 0.39) and perforation risk (0.5 % vs. 1.1 %, P = 0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P = 0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P = 0.72), stent migration (5.9 % vs. 6.8 %, P = 0.79), and stent occlusion (3.8 % vs. 5.2 %, P = 0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.
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Affiliation(s)
- Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Marc Barthet
- Service d'hépato-gastroentérologie, Hôpital Nord, Chemin des Bourrely, Marseille, France
| | | | - Fateh Bazerbachi
- Division of Gastroenterology, Interventional Endoscopy Program, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sundeep Lakhtakia
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jeffrey J. Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Joyce A. Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Margaret L. Gourlay
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Reply to Letter to Editor-"Catheter-Related Complications of Percutaneous Drainage in Step-up Approach for Management of Pancreatic Necrosis". J Gastrointest Surg 2020; 24:2431-2432. [PMID: 32542553 DOI: 10.1007/s11605-020-04685-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 01/31/2023]
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Lal SB, Venkatesh V, Rana SS, Anushree N, Bhatia A, Saxena A. Response to letter to editor: Natural history of pancreatic fluid collections: are children different from adults? Pancreatology 2020; 20:1253-1254. [PMID: 32814652 DOI: 10.1016/j.pan.2020.07.404] [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: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sadhna B Lal
- Division of Paediatric Gastroenterology, Hepatology & Nutrition, Institute of Medical Education & Research, Chandigarh, 160012, India.
| | - Vybhav Venkatesh
- Division of Paediatric Gastroenterology, Hepatology & Nutrition, Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Surinder S Rana
- Department of Gastroenterology, Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Neha Anushree
- Division of Paediatric Gastroenterology, Hepatology & Nutrition, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Anmol Bhatia
- Division of Paediatric Radiology, Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Akshay Saxena
- Division of Paediatric Radiology, Institute of Medical Education & Research, Chandigarh, 160012, India
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García García de Paredes A, López-Durán S, Foruny Olcina JR, Albillos A, Vázquez-Sequeiros E. Management of pancreatic collections: an update. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:483-490. [PMID: 32450706 DOI: 10.17235/reed.2020.6814/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pancreatic fluid collections frequently occur in the context of moderate and severe acute pancreatitis, and may also appear as a complication of chronic pancreatitis, pancreatic surgery or trauma. It is essential to adhere to the Atlanta classification nomenclature that subclassifies them into four categories (acute peripancreatic fluid collections, acute necrotic collections, pseudocysts, and walled-off necrosis) since it has an impact on prognosis and management. Pseudocysts and walled-off pancreatic necrosis are encapsulated pancreatic fluid collections characterized by a surrounding inflammatory wall, which typically develops three to four weeks after the onset of acute pancreatitis. Most pancreatic fluid collections resolve spontaneously and do not require intervention. However, when they become symptomatic or complicated drainage is indicated, and endoscopic ultrasound-guided drainage has become first-line treatment of encapsulated collections. Drainage of pseudocysts is relatively straightforward due to their liquid content. However, in walled-off necrosis the presence of solid necrotic debris can make treatment more challenging and therefore multidisciplinary management in experienced centers is recommended, being a step-up approach the current standard of care. In this review, we aim to address the management of pancreatic fluid collections with an especial focus on endoscopic drainage.
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Affiliation(s)
| | - Sergio López-Durán
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
| | - José Ramón Foruny Olcina
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
| | - Agustín Albillos
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
| | - Enrique Vázquez-Sequeiros
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
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Rana SS, Sharma R, Dhalaria L, Gupta R. Efficacy and safety of plastic versus lumen-apposing metal stents for transmural drainage of walled-off necrosis: a retrospective single-center study. Ann Gastroenterol 2020; 33:426-432. [PMID: 32624665 PMCID: PMC7315708 DOI: 10.20524/aog.2020.0499] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Background Lumen-apposing metal stents (LAMS) were considered a breakthrough in the endoscopic management of walled-off necrosis (WON), as their larger drainage diameter was expected to provide effective drainage of necrotic material. However, various studies and meta-analyses that have compared plastic and metal stents for the treatment of WON have shown conflicting results. We retrospectively compared the efficacy and safety of endoscopic transmural drainage between multiple plastic stents and LAMS. Methods Endoscopic data were retrospectively retrieved for patients who had undergone endoscopic ultrasound (EUS)-guided drainage/debridement of WON. Patients were divided into 2 groups according to whether multiple plastic stents or LAMS were deployed during initial drainage. The resolution and complication rates were compared between the 2 groups. Results One hundred sixty-six patients (83% male, mean age 37.5 years) with symptomatic WON were treated with EUS-guided drainage using either multiple plastic stents (n=138) or LAMS (n=28). Patients in the LAMS group had significantly larger WON and a significantly higher proportion of solid content. WON resolution rates did not differ between plastic stents and LAMS (98.5% vs. 96.4% respectively, P=0.42). However, the time taken to resolution was significantly shorter in the LAMS group than in the plastic stents group (26.7 vs. 29.8 days, P=0.03). There was no significant difference between the groups in either mortality or complication rates. Conclusions The technical success, rates of WON resolution and complications were similar in patients treated with multiple plastic stents and LAMS. However, LAMS were associated with a significantly shorter time to resolution.
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Affiliation(s)
- Surinder Singh Rana
- Departments of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Lovneet Dhalaria)
| | - Ravi Sharma
- Departments of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Lovneet Dhalaria)
| | - Lovneet Dhalaria
- Departments of Gastroenterology (Surinder Singh Rana, Ravi Sharma, Lovneet Dhalaria)
| | - Rajesh Gupta
- Departments of Division of Surgical Gastroenterology, Department of Surgery (Rajesh Gupta), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Madhusudhan KS, Srivastava DN. Ultrasonography in characterizing collections in acute pancreatitis. Abdom Radiol (NY) 2020; 45:1495-1496. [PMID: 32221670 DOI: 10.1007/s00261-020-02494-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Kumble S Madhusudhan
- Departments of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Deep N Srivastava
- Departments of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Kapoor H, Issa M, Winkler MA, Nair RT, Wesam F, Ganesh H. The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review. Abdom Radiol (NY) 2020; 45:1534-1549. [PMID: 31197462 DOI: 10.1007/s00261-019-02093-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.
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Guo J, Duan B, Sun S, Wang S, Liu X, Ge N, Liu W, Wang S, Hu J. Multivariate analysis of the factors affecting the prognosis of walled-off pancreatic necrosis after endoscopic ultrasound-guided drainage. Surg Endosc 2020; 34:1177-1185. [PMID: 31190223 DOI: 10.1007/s00464-019-06870-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 05/20/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound (EUS)-guided drainage has become the treatment of choice for walled-off pancreatic necrosis (WOPN). However, no consensus exists on the most significant patient- and procedure-related factors that affect prognosis. The aim of the study is to investigate the correlation between patient- and procedure-related factors and post-procedure complications after EUS-guided drainage. METHODS A retrospective analysis of the clinical characteristics of patients with WOPN who underwent EUS-guided drainage at our endoscopy center between November 2011 and August 2017 was performed. Chi-square analysis and binary logistic regression statistical methods were used to analyze the correlation between influencing factors and prognosis. RESULTS A total of 85 patients (male/female, 50/35) with WOPN were included in the study. The average age was 44.95 years. The cyst diameter was 10.58 ± 4.78 cm. Multivariate analysis showed that WOPN with higher solid content (> 30%) increased the probability of endoscopic necrosectomy (OR 6.798; 95% CI 1.423, 32.470; p = 0.016). The use of a metal stent increased the probability of endoscopic necrosectomy (OR 3.503; 95% CI 1.251, 9.810; p = 0.017) and the length of hospitalization (OR 3.315; 95% CI 1.192, 9.215; p = 0.022). Female patients had a higher probability of requiring endoscopic necrosectomy (OR 2.683; 95% CI 1.027, 7.007; p = 0.044) and prolonged hospitalization (OR 2.675; 95% CI 1.065, 6.721; p = 0.036). CONCLUSION The solid content of WOPN, type of stent, and sex of patients were associated with increased probability of endoscopic necrosectomy.
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Affiliation(s)
- Jintao Guo
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Bowen Duan
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China.
| | - Sheng Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Nan Ge
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Wen Liu
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Shupeng Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Jinlong Hu
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, 110004, Liaoning, China
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Zhu H, Lin H, Kong X, Jin Z, Li Z, Du Y. Lumen-apposing metal stent acted as an interim role in walled-off necrosis drainage. Gut 2019; 68:2255-2256. [PMID: 30368455 DOI: 10.1136/gutjnl-2018-317494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 12/08/2022]
Affiliation(s)
- Huiyun Zhu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Han Lin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Xiangyu Kong
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Yiqi Du
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
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Rana SS, Shah J, Kang M, Gupta R. Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management. Ann Gastroenterol 2019; 32:441-450. [PMID: 31474789 PMCID: PMC6686089 DOI: 10.20524/aog.2019.0404] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022] Open
Abstract
The development of endoscopic ultrasound (EUS)-guided drainage techniques and lumen-apposing metal stents (LAMS) has markedly reduced the complication rate of endoscopic transmural drainage of pancreatic collections and made these procedures safer and more effective. Despite its improved safety profile, various types of complications, some even life-threatening, can occur after EUS-guided drainage of pancreatic fluid collections. Stent maldeployment/migration, bleeding, gastrointestinal perforation, and air embolism are important complications of EUS-guided drainage of pancreatic collections. Delayed complications weeks after the procedure, such as bleeding and buried LAMS due to the presence of prolonged indwelling transmural stents, have also been described. Careful patient selection, with proper assessment of the size, solid necrotic content and location of the collection, as well as an in-depth understanding of various risk factors that predict complications, are important for a safer and more effective endoscopic transmural drainage. For a better clinical outcome, it is important for the endoscopist to know about various complications of EUS-guided drainage of pancreatic collections, as well as their appropriate management strategies.
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Affiliation(s)
- Surinder S Rana
- Department of Gastroenterology (Surinder S. Rana, Jimil Shah)
| | - Jimil Shah
- Department of Gastroenterology (Surinder S. Rana, Jimil Shah)
| | | | - Rajesh Gupta
- Department of Surgery (Rajesh Gupta), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Bezmarević M, van Dijk SM, Voermans RP, van Santvoort HC, Besselink MG. Management of (Peri)Pancreatic Collections in Acute Pancreatitis. Visc Med 2019; 35:91-96. [PMID: 31192242 DOI: 10.1159/000499631] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/15/2019] [Indexed: 12/12/2022] Open
Abstract
The development of (peri)pancreatic fluid collections are frequent local complications in acute pancreatitis. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection may require intervention. Interventions may include endoscopic or percutaneous catheter drainage, or in a next step endoscopic or surgical necrosectomy, minimally invasive or open. The best timing for the first intervention is still under investigation. Whereas some use antibiotics to postpone intervention until the stage of walled-off necrosis, others drain earlier. Endoscopic drainage of (peri)pancreatic fluid collections is now the preferred approach of drainage due to reduced morbidity as compared to surgical or percutaneous drainage. However, each collection must be treated according to a tailored approach. The final treatment should take into consideration anatomic characteristics, patient preference, comorbidity profile of the patient, and physician discretion. This review summarizes the current evidence on the treatment of (peri)pancreatic fluid collections.
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Affiliation(s)
- Mihailo Bezmarević
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia.,Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Rana SS, Gupta R. Endoscopic Transluminal Drainage in the Early Phase of Acute Necrotising Pancreatitis. Am J Gastroenterol 2019; 114:688-689. [PMID: 30385832 DOI: 10.1038/s41395-018-0405-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, Punjab, 160012, India
| | - Rajesh Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, Punjab, 160012, India
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Mohan BP, Jayaraj M, Asokkumar R, Shakhatreh M, Pahal P, Ponnada S, Navaneethan U, Adler DG. Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections. Endosc Ultrasound 2019; 8:82-90. [PMID: 31006706 PMCID: PMC6482598 DOI: 10.4103/eus.eus_7_19] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Lumen-apposing metal stents (LAMS) are increasingly being used in the drainage of pancreatic walled-off necrosis (WON). Best choice of stent is subject to argument, and studies are varied in the reported outcomes between LAMS and plastic stents (PS) to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception through July 2018) to identify studies that reported on the use of LAMS and PS in WON drainage. Studies published since the release of the revised Atlanta classification for pancreatic fluid collections (2014 to current) were included in the analysis. The outcomes were to estimate and compare the pooled rates of clinical success, and adverse-events. A total of 9 studies (737 patients) for LAMS and 6 studies (527 patients) for PS were included in the analysis. The pooled rate of clinical-success with LAMS was 88.5% (95% CI 82.5-92.6, I2 = 71.7) and with PS was 88.1% (95% CI 80.5-93.0, I2 = 78.1) and the difference was not statistically significant, P = 0.93. No difference was noted in the pooled rates of all adverse-events, LAMS: 11.2% (6.8-17.9, I2 = 82.0); vs PS: 15.9% (8.4-27.8, I2 = 78.8); P = 0.38. Based on our meta-analysis, LAMS and PS demonstrate equal clinical outcomes and equal adverse-events in the drainage of pancreatic WON.
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Affiliation(s)
- Babu P Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Mahendran Jayaraj
- Division of Gastroenterology/Hepatology, University of Nevada, Las Vegas, USA
| | | | - Mohammed Shakhatreh
- Department of Hospital Medicine, Rapides Regional Medical Center, Alexandria, Louisiana, USA
| | - Parul Pahal
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Suresh Ponnada
- Department of Hospital Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | | | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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