Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial

Validation of the Orlando Protocol for endoscopic management of pancreatic fluid collections in the era of lumen-apposing metal stents

OBJECTIVES

Although lumen-apposing metal stents (LAMS) are being increasingly used in lieu of plastic stents, the clinical approach to endoscopic management of pancreatic fluid collections (PFCs) is poorly standardized. We compared outcomes of approaches over two time intervals, initially using plastic stents and later integrating LAMS.

METHODS

This was a retrospective, observational, before-after study of prospectively collected data on consecutive patients with symptomatic PFCs managed over two time periods. In the initial period (January 2010-January 2015) endoscopic treatment was undertaken with plastic stents and in the later period (February 2015-August 2020) by integration of LAMS with selective use of plastic stents. The treatment strategy in both periods were tailored to size, extent, type of PFC and stepwise response to intervention. The main outcome was treatment success, defined as resolution of PFC and presenting symptoms at 6-month follow-up.

RESULTS

A total of 160 patients were treated with plastic stents and 227 patients were treated using an integrated LAMS approach. Treatment success was significantly higher for the integrated approach compared to using only plastic stents (95.6 vs. 89.4%; P = 0.018), which was confirmed to be predictive of treatment success on multivariable logistic regression analysis (odds ratio 2.7, 95% confidence interval 1.1-6.4; P = 0.028).

CONCLUSIONS

A structured approach integrating LAMS with selective use of plastic stents improved treatment success in patients with PFCs compared to an approach using only plastic stents.

Nanomaterials: A Promising Therapeutic Approach for Cardiovascular Diseases

Cardiovascular diseases (CVDs) are a primary cause of death globally. A few classic and hybrid treatments exist to treat CVDs. However, they lack in both safety and effectiveness. Thus, innovative nanomaterials for disease diagnosis and treatment are urgently required. The tiny size of nanomaterials allows them to reach more areas of the heart and arteries, making them ideal for CVDs. Atherosclerosis causes arterial stenosis and reduced blood flow. The most common treatment is medication and surgery to stabilize the disease. Nanotechnologies are crucial in treating vascular disease. Nanomaterials may be able to deliver medications to lesion sites after being infused into the circulation. Newer point-of-care devices have also been considered together with nanomaterials. For example, this study will look at the use of nanomaterials in imaging, diagnosing, and treating CVDs.

Endotherapy in Pancreatic Diseases

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

A Novel Strategy for Transmural Stent Removal in Necrotizing Pancreatitis Undergoing Endoscopic Transmural Necrosectomy

BACKGROUND

Although metal stents have been widely used in the endoscopic step-up approach for necrotizing pancreatitis, the exact timing of transmural stent removal has not been well studied. Here, we report a novel strategy for stent removal and compare it with the conventional strategy.

MATERIALS AND METHODS

This retrospective, nested, case-control study analyzed all adult necrotizing pancreatitis patients who underwent endoscopic transmural necrosectomy (ETN). Clinical outcomes were compared between case group (a novel strategy in which the stents were removed during the last necrosectomy when the ETN endpoint was achieved) and 1:1 necrosis extent matched control group (the conventional strategy).

RESULTS

Baseline characteristics was comparable between case group (n=37) and control group (n=37). Three (8.1%) patients in case group and 1 (2.7%) patient in control group needed additional ETN after stent removal (P>0.05). Nearly all patients (case: 97.3%; control: 94.6%) achieved clinical success. There was no difference in disease-related (case: 40.5%; control: 37.8%) or stent-related (case: 27.0%; control: 16.2%) complications. Case group had a trend of shorter length of stent placement (median: 20.0 vs. 29.5 d, P>0.05).

CONCLUSIONS

The novel strategy of transmural stent removal during last necrosectomy might be feasible which needed further validation. Compared with the convention strategy, the novel strategy avoids one endoscopy procedure and should be considered in clinical practice.

Experimental study of a physician-controlled electrocautery-enhanced delivery system incorporating a newly developed lumen-apposing metal stent for interventional endoscopic ultrasound (with videos)

BACKGROUND/PURPOSE

Although the lumen-apposing metal stent (LAMS) is useful for interventional endoscopic ultrasound (EUS) procedures, there has been some concern about the potential for stent-induced adverse events because of the high lumen-apposing force. A newly designed LAMS with less lumen-apposing force has been developed for use with a physician-controlled electrocautery-enhanced delivery system. The aim of this animal study was to evaluate the feasibility of performing interventional EUS using this newly designed LAMS system.

METHODS

EUS-guided cystogastrostomy was performed using the novel LAMS 3 times in a wet simulation model. EUS-guided gastroenterostomy and EUS-guided gallbladder drainage were then performed using the system in 4 pigs.

RESULTS

The LAMS was successfully placed in all 3 EUS-guided cystogastrostomy procedures using the wet simulation model and in all 4 EUS-guided gastroenterostomy and gallbladder drainage procedures in the animal model. In the 3 weeks following the procedure, eating behavior was normal in all animals and there were no adverse events. The stents remained patent during this time and were removed without difficulty. The fistula was mature in all cases and a standard upper gastrointestinal endoscope was easily advanced via the fistula to observe the afferent and efferent loops or the lumen of the gallbladder. Necropsy confirmed complete adhesion between the stomach and the wall of the jejunum or gallbladder.

CONCLUSIONS

Our study findings demonstrate the feasibility of this new LAMS system and its potential clinical value for interventional EUS.

Diagnosis of Gastric Cancer in the Excluded Stomach After RYGB by Jejunogastrostomy Using a LAMS

For patients after bariatric surgery, diagnosis of gastric cancer is a challenge. We present a patient after Roux-en-Y gastric bypass with upper abdominal pain and abnormal computed tomography scan with diffuse wall thickening of the gastric antrum. Various biopsy techniques have been described, with surgical (laparoscopic) exploration being the most common. We were able to successfully diagnose gastric cancer in the excluded stomach by biopsy using a jejunogastrostomy, which proved to be safe and effective.

Efficacy and safety of endoscopic drainage of peripancreatic fluid collections: a retrospective multicenter European study

BACKGROUND

Endoscopic ultrasound (EUS)-guided transmural drainage allows treatment of symptomatic peripancreatic fluid collections (PFCs), with lumen-apposing metal stents (LAMS) and double pigtail plastic stents (DPPS) being the 2 most frequently used modalities.

METHODS

Consecutive patients undergoing PFC drainage in 10 European centers were retrospectively retrieved. Technical success (successful deployment), clinical success (satisfactory drainage), rate and type of early adverse events, drainage duration and complications on stent removal were evaluated.

RESULTS

A total of 128 patients-92 men (71.9%), age 57.2±11.9 years-underwent drainage, with pancreatic pseudocyst (PC) and walled-off necrosis (WON) in 92 (71.9%) and 36 (28.1%) patients, respectively. LAMS were used in 80 (62.5%) patients and DPPS in 48 (37.5%). Technical success was achieved in 124 (96.9%) of the cases, with no difference regarding either the type of stent (P>0.99) or PFC type (P=0.07). Clinical success was achieved in 119 (93%); PC had a better response than WON (91/92 vs. 28/36, P<0.001), but the type of stent did not affect the clinical success rate (P=0.29). Twenty patients (15.6%) had at least one early complication, with bleeding being the most common (n=7/20, 35%). No difference was detected in complication rate per type of stent (P=0.61) or per PFC type (P=0.1). Drainage duration was significantly longer with DPPS compared to LAMS: 88 (70-112) vs. 35 (29-55.3) days, P<0.001.

CONCLUSIONS

EUS-guided drainage of PFCs achieves high percentages of technical and clinical success. Drainage using LAMS is of shorter duration, but the complication rate is similar between the 2 modalities.

Progress in research of minimally invasive therapy of local complications of acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas that can be life-threatening. Patients with severe acute pancreatitis require further rescue treatment in the intensive care unit. In recent years, treatment of local complications of acute pancreatitis has undergone considerable changes, including multidisciplinary team mode and individualized treatment scheme, and traditional open surgery has been gradually replaced by minimally invasive treatment. This article summarizes the progress in research on minimally invasive therapy of the local complications of acute pancreatitis in recent years.

Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopic necrosectomy (EN) is the preferred approach for management of symptomatic or infected walled-off pancreatic necrosis (WOPN). Hydrogen peroxide (H₂O₂) has been reported to be a good adjunctive therapy for EN. We performed a systematic review and meta-analysis to evaluate effectiveness and safety of H₂O₂ assisted EN for WOPN.

METHODS

A comprehensive search of multiple databases (through December 2020) was performed to identify studies that reported outcomes of H₂O₂ assisted EN for WOPN. Outcomes assessed included clinical success, technical success, and adverse events.

RESULTS

A total of 454 patients with mean age (47.3 ± 7.9 years) and WOPN size (12.4 ± 3.1 cm) were included from 15 studies. The median H₂O₂ concentration was 3% (range 0.1-3%), with dilution and volume ranging from 1:1 to 10:1 and 20 ml to 1 L, respectively. The rates of technical success, clinical success and adverse events was 97.3% (95% confidence interval [CI]: 94.8-98.6, I² = 0), 89.8% (95% CI: 86.3-92.5, I² = 0) and 17.9% (95% CI: 12.6-24.7, I² = 38), respectively. The most common adverse event was bleeding (7.1%) followed by stent migration (5.3%). On meta-regression, WOPN size, patient age, use of metal stent, number of necrosectomies and transgastric access were not significant predictor for technical success, clinical success or adverse events.

CONCLUSION

H₂O₂ assisted EN is effective and safe for management of WOPN. Its use may be encouraged, and future randomized controlled studies are needed to study the optimal technique, concentration and best predictors of success.

Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system

BACKGROUND AND AIM

Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice.

METHODS

A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers.

RESULTS

Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion.

CONCLUSIONS

This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.

The Role of EUS-Guided Drainage in the Management of Postoperative Fluid Collections after Pancreatobiliary Surgery

Postoperative fluid collection (POFC) is a challenging complication following pancreatobiliary surgery. Traditional treatment with surgical drainage is associated with significant morbidity, while percutaneous drainage is associated with a higher rate of recurrence and the need for repeated interventions. Studies have shown that endoscopic ultrasound (EUS)-guided drainage may offer a promising solution to this problem. There are limited data on the ideal therapeutic protocol for EUS-guided drainage of POFC including the timing for drainage; type, size, and number of stents to use; and the need for endoscopic debridement and irrigation. Current practices extrapolated from the treatment of pancreatic pseudocysts and walled-off necrosis may not be applicable to POFC. There are increasing data to suggest that drainage procedures may be performed within two weeks after surgery. While most authors advocate the use of double pigtail plastic stents (DPPSs), there have been a number of reports on the use of novel lumen-apposing metal stents (LAMSs), although no direct comparisons have been made between the two.

Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy

BACKGROUND

Long-term transmural double-pigtail stent (DPS) placement is recommended for patients with disconnected pancreatic duct syndrome (DPDS) and peripancreatic fluid collections (peri-PFCs). The long-term safety and efficacy of indwelling DPSs were evaluated.

METHODS

Medical files of patients treated with DPS for DPDS-associated peri-PFC and with a follow-up ≥ 48 months were reviewed. Early ( < 30 days) and late complications of DPS placement were evaluated and the primary endpoint, i. e., incidence of late complications per 100 patient-years of follow-up, was calculated. Short- and long-term success rates of endoscopic treatment and rate of peri-PFC recurrence were among secondary endpoints.

RESULTS

From 2002 to 2014 we identified 116 patients, with mean (SD) follow-up of 80.6 (34.4) months. Among early complications (n = 20), 6 occurred peri-interventionally. Late complications (n = 17) were mainly pain due to DPS-induced ulcer or erosion (n = 10) and 14 of these were treated conservatively or by stent removal; 2 gastro-pancreatico-colo-cutaneous fistulas and 1 persisting bleed required surgical intervention. No DPS-related deaths were recorded. The incidence rate (95 %CI) of late complications was 2.18 (1.27-3.49) per 100 patient-years of follow-up. Short- and long-term success rates (with 95 %CI) of endoscopic treatment were 97.4 % (94.5 %-100 %) and 94 % (89.6 %-98.3 %), respectively. The peri-PFC recurrence rate was 28 % (20.1 %-35.9 %), and 92.3 % of these occurred within the first 2 years. Stent migration, chronic pancreatitis, and length of stent (> 6 cm) were independently associated with higher rates of peri-PFC recurrence.

CONCLUSIONS

Long-term transmural drainage with DPS is a safe and effective treatment for DPDS-associated peri-PFCs. However, about one quarter of peri-PFCs will recur.

Lumen-apposing metal stents: How far are we from standardization? An Italian survey

Background and Objectives:

EUS-guided transluminal drainage has increasingly developed, especially after the era of lumen-apposing metal stent (LAMS): a fully covered, barbell-shaped, metal stent with anti-migratory properties allowing direct therapeutic interventions through a wide and short channel. The aim of this survey is to investigate the current management of patients undergoing LAMS placement nationwide.

Materials and Methods:

Forty-eight questions were submitted to Italian centers about expertise, peri- and intra-procedural aspects, budget/refund, and future perspectives. Statistical analyzer was SPSS®.

Results:

Thirty-six centers completed the survey. Indications for LAMS positioning are pancreatic fluid collection drainage (PFCD, 97.2%), biliary drainage (BD, 80.5%), gallbladder drainage (GBD, 75%), and gastroentero-anastomosis (GEA, 19.4%). A total of 77.7% of the endoscopists perform only on-label procedures and 22.2% both on-label and off-label. 38.8% attended a training preliminary course, 27.7% were just supported by an expert, 22.2% had both the opportunities, and 8.3% none of them. Management of antiplatelets and sedation protocol is very heterogeneous. Only 50% involves a multidisciplinary meeting and 30.5% has a specialized clinic for follow-up. Acid suppression is usually continued after PFCD. The type and timing of postprocedural imaging varies widely. 8.3% of the endoscopists work without fluoroscopy. Refund for LAMS is mostly not guaranteed. Main future growing indications appear to be BD, GBD, and GEA (69.4%, 55.5%, and 55.5%, respectively).

Conclusions:

This is the first survey assessing the state of the art on LAMS almost 10 years after their advent. There are currently wide variations in practice nationwide, which demonstrates a pressing need to define technical, qualitative, and peri-procedural requirements to carry out this procedure, toward a standardization.

Endoscopic transmural drainage tailored to quantity of necrotic debris versus laparoscopic transmural internal drainage for walled-off necrosis in acute pancreatitis: A randomized controlled trial

BACKGROUND AND AIMS

Both endoscopic and laparoscopic transmural internal drainage are practiced for drainage of walled-off necrosis (WON) following acute pancreatitis (AP) but the superiority of either is not established. Our aim was to compare transperitoneal laparoscopic drainage with endoscopic drainage using either lumen apposing metal stents (LAMS) or plastic stents tailored to the amount of necrotic debris in WON.

METHODS

In a randomized controlled trial, adequately powered to exclude the null hypothesis, patients with symptomatic WON were randomized to either endoscopic or laparoscopic drainage. In the endoscopy group, two plastic stents were placed if the WON contained <1/3rd necrotic debris and a LAMS was placed if it was >1/3rd. Primary outcome was resolution of WON within 4 weeks without re-intervention for secondary infection. Secondary outcome was overall success (resolution of WON at 6 months) and adverse events.

RESULTS

Forty patients were randomized: 20 to each group. Baseline characteristics were comparable between the groups. Primary outcome was similar between the groups [16 (80%) in laparoscopy and 15 (75%) in endoscopy group; p = 0.89]. The overall success was similar [18 (90%) in laparoscopy vs. 17 (85%) in endoscopy; p = 0.9]. Median duration of hospital stay was shorter in endoscopy group [4 (4-8) vs. 6 days (5-9); p = 0.03]. Adverse events were comparable between the groups.

CONCLUSION

Laparoscopic drainage was not superior to endoscopic transmural drainage with placement of multiple plastic stent or LAMS depending on the amount of necrotic debris for symptomatic WON in AP. The hospital stay was shorter with the endoscopic approach.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series

AIM

Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).

METHODS

All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.

RESULTS

Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).

CONCLUSIONS

Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

[Interventional endoscopic treatment in acute pancreatitis]

BACKGROUND

Acute pancreatitis (AP) represents a frequent gastrointestinal diseases. Approximately 80% of patients have a mild course of the disease and conservative treatment is sufficient; however, 20% of patients develop a severe AP with local and systemic complications. This article focuses on the currently recommended endoscopic management of severe AP.

OBJECTIVE

Classification of AP by the revised Atlanta classification and the occurrence of local or systemic complications. Summary of current evidence with respect to endoscopic management.

MATERIAL AND METHODS

Inspection of the current literature from specialist journals and current guidelines.

RESULTS

The AP is classified as mild, moderate or severe based on systemic (hypotension, renal failure, lung failure) and/or local complications, such as acute peripancreatic fluid collections (APFC), peripancreatic pseudocysts (PPC), acute necrotic collections (ANC) and walled-off necrosis (WON). In recent years the staged endoscopic treatment of infected ANC, WON and PPC has become established. The initial step is the endoscopic ultrasound-guided puncture and drainage with plastic or lumen-apposing metal stents. For solid components or insufficient drainage, a transgastric endoscopic necrosectomy is recommended. The treatment of severe AP requires an interdisciplinary management in specialized centers and regular re-evaluation of the therapeutic efficacy.

CONCLUSION

Interventional endoscopy has become established as the standard for treatment of severe AP.

[Endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis]

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.

Interventional endoscopic ultrasound

PURPOSE OF REVIEW

To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques.

RECENT FINDINGS

The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment.

SUMMARY

Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.

Lumen-apposing metal stents (with videos)

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) are a novel class of devices that have expanded the spectrum of endoscopic GI interventions. LAMSs with their dumbbell configuration, short saddle length, and large inner luminal diameter provide favorable stent characteristics to facilitate anastomosis formation between the gut lumen and adjacent structures.

METHODS

The MEDLINE database was searched through April 2021 for articles related to LAMSs by using additional relevant keywords such as "walled-off pancreatic necrosis," "pseudocysts," "pancreatic fluid collection," "cholecystitis," "gastroenterostomy," in addition to "endoscopic treatment" and "endoscopic management," among others.

RESULTS

This technology review describes the full spectrum of LAMS designs and delivery systems, techniques for deployment, procedural outcomes, safety, training issues, and financial considerations.

CONCLUSIONS

Although LAMSs were initially introduced for drainage of pancreatic pseudocysts and walled-off necrosis, the versatility of these devices has led to a variety of off-label uses including gallbladder drainage, enteric bypass with the creation of gastroenterostomies, and treatment of luminal GI strictures.

Metal Versus Plastic Stents for Pancreatic Fluid Collection Drainage: A Systematic Review and Meta-analysis

OBJECTIVES

The therapeutic efficacy of metal stents (MSs) for pancreatic fluid collections (PFCs) is invariably controversial. Here, we conducted a meta-analysis to summarize the results of efficacy of MSs and plastic stents (PSs) in PFC drainage.

SUBJECTS AND METHODS

We performed a literature search of PubMed/MEDLINE, EMBASE, and COCHRANE for all of the published studies regarding the use of MSs and PSs for endoscopic transmural drainage of PFCs from January, 1 2015 to June 1, 2020. We extracted data from 9 studies (1359 patients) that met the inclusion criteria. The main outcome measures were the rates of treatment success, including technique success and clinical success (CS), adverse events, recurrence, procedure time, and length of hospital stay (LOS).

RESULTS

There was no difference in overall technique success between patients treated with MSs and PSs for PFCs. However, MSs showed a higher CS rate 92% versus 82% (P<0.01) and a lower overall adverse event rate 20% versus 31% (P<0.01) than PSs. The recurrence rate of PFCs using MSs also had significant advantages over PSs 3% versus 10% (P<0.01) and MSs needed a shorter procedure time than PSs (26.73 vs. 45.40 min, P<0.01). In comparing direct endoscopic necrosectomy use and LOS, there was no difference between MSs and PSs.

CONCLUSIONS

Bringing together the results of the current study, endoscopic ultrasound-guided drainage of PFCs using MSs may be superior to PSs in terms of CS, adverse events rates and recurrence rate, with similar LOS and direct endoscopic necrosectomy use.

Novel Uses of Lumen-apposing Metal Stents: A Review of the Literature

The field of therapeutic endoscopy has seen many recent advancements. One such emerging field is the use of lumen-apposing metal stents (LAMS). Although a few LAMS have been developed, the most commonly reviewed and the only Food and Drug Administration (FDA)-approved LAMS is the Axios stent by Boston Scientific. In 2013, LAMS were initially approved by the FDA for the management of pancreatic fluid collection drainage in the presence walled-off necrosis. Pancreatic fluid collections are traditionally drained with either a plastic stent or a covered biliary self-expanding metal stent. Plastic stents have a double pigtail feature which prevents stent migration. However, their narrow lumen poses limitations as it can lead to early stent occlusion. Fully covered metal stents have larger diameters, allowing improved drainage and decreased stent occlusion but their tubular shape is prone to migration. Consequently, this results in leakage, and frequent retrievals. Over the years, due to their versatility, LAMS now have many off label uses. This includes management of gastric outlet obstruction, superior mesenteric artery syndrome, strictures, gallbladder drainage, and postsurgical collection drainage. In this review, we will be discussing the FDA approved and the nonapproved uses of LAMS.

Effect of pancreatic endotherapy on quality of life in chronic pancreatitis patients: A systematic review

BACKGROUND

Pancreatic endotherapy provides treatment options for the management of chronic pancreatitis-related structural complications such as pancreatic duct stones, strictures, and pancreatic fluid collections. Most studies detailing endotherapy, however, have focused on technical success outcomes such as stone clearance or stricture resolution.

AIM

To review the effect of pancreatic endotherapy on patient-centered outcomes.

METHODS

Systematic review of studies examining pancreatic endotherapy.

RESULTS

A total of 13 studies including 3 randomized clinical trials were included. The majority of studies found an improvement in quality of life with pancreatic endotherapy.

CONCLUSION

While pancreatic endotherapy does appear to improve quality of life, there are clear gaps in knowledge regarding many pancreatic endotherapy modalities. Furthermore, qualitative analysis is lacking in these studies and further work is needed to elucidate the patient experience with pancreatic endotherapy.

Comparative Effectiveness of Lumen-Apposing Metal Stents and Plastic Stents for the Treatment of Pancreatic Walled-Off Necrosis: A Meta-analysis

Background

Plastic stents (PS), lumen-apposing metal stents (LAMS) and biflanged metal stents (BFMS) are used for initial drainage of pancreatic walled-off necrosis (WON). There are no strong evidence to support the use of LAMS/BFMS over PS, and prior systematic reviews lack comparative analyses and also lack both trial data and observational studies for WON efficacy outcomes. The aim of this study is to compare the efficacy and adverse events (AEs) in LAMS/BFMS versus PS in patients with pancreatic WON.

Methods

A comprehensive search up to December 1, 2020, was performed. The primary outcome was clinical improvement after drainage. Secondary outcomes included AEs and technical failure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were reported using random effects models. Heterogeneity was evaluated with the Cochrane I  2 statistic. Subgroup and sensitivity analyses were performed. The quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results

Nine studies (one randomized controlled trial and eight observational) were included for the primary outcome including 493 patients treated with LAMS/BFMS and 514 with PS. LAMS/BFMS were associated with higher odds of clinical improvement compared with PS (OR 2.58; 95% CI 1.81, 3.68; I  2 = 1%). This association remained robust in sensitivity analyses. The use of LAMS/BFMS was not associated with higher AEs (OR 1.22; 0.61, 2.46; I2 = 71%). There was no difference in technical failure (OR 1.06; 0.19, 6.00; I2 = 12%).

Conclusions

LAMS/BFMS seem to result in better clinical outcomes compared with PS in patients with pancreatic WON, with comparable AEs and technical failure. Larger randomized controlled trials for this comparison are warranted.

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

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

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

Therapeutic interventional endoscopic ultrasound in pancreato-biliary disorders: Does it really replace the surgical/percutaneous approach?

Pancreato-biliary disorders are still incredibly challenging in the field of gastroenterology, as they would sometimes require multi-approach interventional procedures. Recently, therapeutic interventional endoscopic ultrasound (EUS) has emerged as a potential alternative to surgical or percutaneous approaches. Unfortunately, considering the high cost of EUS, lack of facility and expertise, most gastroenterologists still often refer cases to undergo surgical interventions without contemplating the possibility of utilizing EUS first. EUS-guided biliary drainage has become one of the best choices for establishing access to biliary system, given the clear visualization of pancreas, gallbladder, and common bile duct. Although there are still only a few studies which directly compare EUS-guided and surgical approaches for biliary drainage, current evidence demonstrated the superiority of EUS-guided approach in terms of adverse events and re-intervention rates, with similarly high technical and clinical success rates compared to percutaneous and surgical approaches, especially in patients with history of failed endoscopic retrograde cholangiopancreatography attempt. Comparable success rates with shorter length of hospital stay between endoscopic and surgical approaches have also been exhibited for pancreatic pseudocysts and walled-off necrosis. Recent findings about the progress of EUS approach in gastroenterostomy/jejunostomy also indicated a promising potential of EUS, as a less invasive approach, for managing gastric outlet obstruction.

Head-to-head comparison between endoscopic ultrasound guided lumen apposing metal stent and plastic stents for the treatment of pancreatic fluid collections: A systematic review and meta-analysis

BACKGROUND/AIMS

Peripancreatic fluid collections (PFCs) result from acute or chronic pancreatic inflammation that suffers a rupture of its ducts. Currently, there exists three options for drainage or debridement of pancreatic pseudocysts and walled-off necrosis (WON). The traditional procedure is drainage by placing double pigtail plastic stents (DPPS); lumen-apposing metal stent (LAMS) has a biflanged design with a wide lumen that avoids occlusion with necrotic tissue, which is more common with DPPS and reduces the possibility of migration. We performed a systematic review and meta-analyses head-to-head, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS.

METHODS

We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. This meta-analysis considers studies published from 2014 to 2020, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS.

RESULTS

Thirteen studies were included in the meta-analyses. Only one of all studies was a randomized controlled trial. These studies comprise 1584 patients; 68.2% were male, and 31.8% were female. Six hundred sixty-three patients (41.9%) were treated with LAMS, and 921 (58.1%) were treated with DPPS. Six studies included only WON in their analysis, two included only pancreatic pseudocysts, and five studies included both pancreatic pseudocysts and WON. The technical success was similar in patients treated with LAMS and DPPS (97.6% vs 97.5%, respectively, P = .986, RR = 1.00 [95% CI 0.93-1.08]). The clinical success was similar in both groups (LAMS: 90.1% vs DPPS: 84.2%, P = .139, RR = 1.063 [95% CI 0.98-1.15]). Patients treated with LAMS had a lower complication rate than the DPPS groups, with a significant statistical difference (LAMS: 16.0% vs DPPS: 20.2%, P = .009, RR = 0.746 [95% CI 0.60-0.93]). Bleeding was the most common complication in the LAMS group (33 patients, [5.0%]), whereas infection was the most common complication in the DPPS group (56 patients, [6.1%]). The LAMS migration rate was lower than in the DPPS (0.9% vs 2.2%, respectively, P = .05). The mortality rate was similar in both groups, 0.6% in the LAMS group (four patients) and 0.4% in the DPPS group (four patients; P = .640).

CONCLUSION

The PFCs drainage is an indication when persistent symptoms or PFCs-related complications exist. EUS guided drainage with LAMS has similar technical and clinical success to DPPS drainage for the management of PFCs. The technical and clinical success rates are high in both groups. However, LAMS drainage has a lower adverse events rate than DPPS drainage. More randomized controlled trials are needed to confirm the real advantage of LAMS drainage over DPPS drainage.

Management of Severe Acute Pancreatitis: An Update

BACKGROUND

Severe acute pancreatitis (AP) continues to be a serious gastrointestinal disease with relevant morbidity and mortality.

SUMMARY

Successful clinical management requires close interdisciplinary cooperation and coordination from experienced gastroenterologists, intensive care physicians, surgeons, and radiologists. While the early phase of the disease is characterized by intensive care aspects that focus primarily on treatment of organ failure, later complications are characterized especially by (infected) necrotic collections. Here, we discuss current clinical standards and developments for conservative and interventional management of patients with severe AP. Key messages: Early targeted fluid therapy within the first 48 h is critical to improve the outcome of severe AP. Thoracic epidural analgesia may have prognostically beneficial effects due to suspected anti-inflammatory effects and increased perfusion of splanchnic vessels. Enteral feeding should be started early during severe AP. Persistent organ failure (>48 h) is the strongest predictor of poor prognosis, and local complications such as infected walled-off necrosis should be primarily treated by minimally invasive endoscopic step-up approaches that are usually superior to surgical therapy options.

Importance of Disconnected Pancreatic Duct Syndrome in Recurrence of Pancreatic Fluid Collections Initially Drained Using Lumen-Apposing Metal Stents

BACKGROUND & AIMS

Indwelling plastic endoprosthesis in patients with disconnected pancreatic duct syndrome (DPDS) reduces the risk of pancreatic fluid collection (PFC) recurrence. Although lumen-apposing metal stents (LAMS) are used with increasing frequency for PFC drainage, they require timely removal and little is known about their effects in patients with DPDS and recurrence of PFC.

METHODS

We performed a prospective study of patients who underwent endoscopic ultrasound-guided drainage of PFC using LAMS and were found to have DPDS. After resolution of PFC, LAMS were replaced with double-pigtail plastic stents. The primary outcome was to compare PFC recurrence between patients with DPDS who did vs did not receive replacements with plastic stents after removal of the LAMS.

RESULTS

Of 188 PFC patients treated with LAMS, 94 had DPDS, 71 had intact pancreatic ducts, and duct patency was unknown in 23. In patients with DPDS, replacement of LAMS with plastic stents was successful in 70 patients (74.5%) and technically unsuccessful in 24 patients (25.5%). At a median follow up of 183 days (interquartile range, 179-188 days), although none of the patients with an intact duct had a recurrence of PFC, 7 of the 94 patients with DPDS had recurrence of PFC (7.4%) (P = .020). PFC recurred in 1 of 70 patients with DPDS in whom replacement of LAMS with plastic stent was successful (1.4%) and in 6 of 24 patients with unsuccessful stent replacement (25.0%) (P = .001).

CONCLUSIONS

In treatment of PFCs with LAMS in patients with DPDS, it is important to replace the LAMS with indwelling plastic stents to minimize PFC recurrence and reduce morbidity. Clinicaltrials.gov no: NCT02422095.

Role of endoscopic ultrasonography in the management of peripancreatic collections. Diagnostic and therapeutic approach

Pancreatic fluid collections are surrounded by a wall of granulation tissue and may contain necrotic debris. They occur following a severe acute pancreatitis and most of the cases resolve spontaneously after several weeks. However, their management may lead to a very hardto-treat condition, requiring a multidisciplinary approach. During the last decades we assisted to a change of paradigm involving Endoscopic Ultrasonography, from a pure diagnostic technique to an interventional-therapeutic one, allowing an effective, safe and less invasive approach than other existing treatment standards, historically consisting of surgical and percutaneous drainage. Treatment of pancreatic fluid collections is indicated if they become infected or symptomatic. Over the past years, exponential developments were done in interventional endoscopic approach, making it the first line suggested modality. The use of endoscopic ultrasound allows assessment of the collection, even when it is not directly bulging on gastrointestinal wall, creation of an internal fistulous tract, checking for surrounding vessels with the use of Doppler, and deployment of a stent avoiding the discomfort of external tubes. Several types of stent have been used for endoscopic drainage: plastic double pigtail stents, fully covered self-expanding metal stents and, more recently, lumen apposing metal stents, which are considered revolutionary because of their two-side flanges and wide and short internal channel, a new design that made easier direct endoscopic necrosectomy. This review aims to go through currently available literature on the diagnostic and therapeutic role of Endoscopic Ultrasonography to handle pancreatic fluid collections.

Comparison Between Lumen-Apposing Metal Stents and Plastic Stents in Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collection: A Meta-analysis and Systematic Review

OBJECTIVES

This study aimed to explore efficacy and safety between LAMSs (lumen-apposing metal stents) and DPPSs (double-pigtail plastic stents) in endoscopic ultrasound-guided drainage for pancreatic fluid collections.

METHODS

Electronic databases were searched to identify relevant studies published until July 20, 2020.

RESULTS

Fifteen studies were identified in this study. Endoscopic ultrasound-guided drainage with LAMS has higher clinical success (90.01% vs 82.56%) (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.79-3.33; P < 0.00001), less recurrence (OR, 0.44; 95% CI, 0.29-0.68; P = 0.0002), and fewer additional interventions (OR, 0.34; 95% CI, 0.211-0.55; P < 0.001). There was no significant difference between LAMS and DPPS in technical success (97.45% vs 97.38%) (OR, 0.92; 95% CI, 0.50-1.70; P = 0.80), adverse events (OR, 0.92; 95% CI, 0.41-2.09; P = 0.84), stent-related adverse events (OR, 0.78; 95% CI, 0.39-1.54; P = 0.47), and bleeding (OR, 1.47; 95% CI, 0.57-3.28; P = 0.42). Lumen-apposing metal stents have slightly more perforations (OR, 7.10; 95% CI, 1.22-41.30; P = 0.03) in studies of walled-off necrosis.

CONCLUSIONS

Lumen-apposing metal stents have the advantage of higher clinical success, less recurrence, and fewer additional interventions. However, LAMS may increase perforation for walled-off necrosis.

Long-term Outcomes of Direct Endoscopic Necrosectomy for Complicated or Symptomatic Walled-Off Necrosis: A Korean Multicenter Study

Background/Aims

The endoscopic step-up approach is accepted as the preferred treatment for complicated or symptomatic walled-off necrosis (WON). Direct endoscopic necrosectomy (DEN) is an effective therapeutic option, but few reports describe long-term follow-up in this patient population. Thus, we aim to assess the long-term outcomes of DEN following severe necrotizing pancreatitis.

Methods

The data of all acute pancreatitis patients who underwent DEN following endoscopic transmural drainage from six referral centers between 2007 and 2017 were retrospectively collected.

Results

Sixty patients (76.7% male, mean age 48.3 years) underwent a median of 4 sessions of DEN starting at a median of 45.5 days after the onset of acute pancreatitis. Clinical success was achieved in 51 patients (85%), with a 35% complication rate and a 5% mortality rate. Using multivariate analysis, the risk factor associated with DEN failure or major DEN complications requiring intervention or surgery was an identified bacterial/fungal WON infection (odds ratio, 19.3; 95% confidence interval, 1.5 to 261.7). During the median follow-up period of 27 months, complicated WON recurrence was observed in 5.3% of patients, and long-term complications occurred in 24.6% of patients (four exocrine insufficiency, nine newly developed diabetes mellitus, one recurrent small bowel obstruction, one chylous ascites).

Conclusions

Considering that long-term complications are similar to those observed after pancreatectomy, DEN should be performed meticulously while minimizing damage to the viable pancreatic parenchyma with adequate antibiotic escalation.

Endoscopic management of walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life-threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step-up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step-up approach might be more advantageous than a minimally invasive surgical step-up approach. A lumen apposing metal stent (LAMS) with a cautery-enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent-related complications than conventional plastic stents, especially in patients with long-term placement. Therefore, early removal of LAMS at 3 weeks post-intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.

Antireflux metal stent for biliary obstruction: Any benefits?

Endoscopic retrograde cholangiopancreatography with stent placement has been utilized as standard palliative management of distal malignant biliary obstruction (MBO). Compared to plastic stents, metal stents can provide longer-term relief of symptoms. When a large-bore metal stent is placed across the ampulla, patients are predisposed to the risk of cholangitis or stent dysfunction due to reflux of duodenal contents. To mitigate the risk of adverse events associated with the duodenobiliary reflux, efforts have been directed to development of antireflux metal stents (ARMSs). The antireflux property has been introduced through adding of an antireflux valve to the duodenal stent end. Evidence from clinical studies indicates that ARMSs may not only reduce the risk of ascending cholangitis during follow-up but also prolong stent patency time. However, the results of clinical studies testing ARMSs are inconsistent owing to heterogeneous designs of antireflux valves and stent bodies. Metal stents are increasingly indicated for benign biliary strictures and MBO in the setting of neoadjuvant chemotherapy, and therefore, research is warranted to evaluate ARMSs for those indications. Given that endoscopic ultrasound (EUS)-guided transmural biliary drainage has gained popularity, the optimal timing of placing an ARMS in relation to EUS-guided and percutaneous drainage should be investigated. Development and evaluation of ARMSs require an integrative approach utilizing phantom and animal models, measurements of stent mechanical properties, and in vivo functional study after stent placement. In this review article, we summarize updated evidence on ARMSs for MBO and discuss issues that should be addressed in future studies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lumen-apposing covered self-expanding metallic stent for symptomatic pancreatic fluid collections: assessment of outcomes and complications with CT and MRI

PURPOSE

To assess technical and clinical outcomes following lumen-apposing covered self-expanding metallic stent (LAMS) placement for symptomatic pancreatic fluid collections (PFC) with CT and MRI.

METHODS

In this retrospective study, patients with PFC who underwent LAMS placement between March 2015 and June 2018 were included. Primary outcomes included technical success, defined as successful stent placement with resolution of PFC, and clinical success, defined as lack of fluid recurrence after stent removal. Secondary outcomes included time duration from stent placement to removal, complications, and re-intervention need.

RESULTS

28 consecutive patients (20 men, mean age: 53 years ± 17; range 21-75) who underwent endoscopic drainage of symptomatic walled-off necrosis (WON, 21/28, 75%), pseudocyst (PC, 5/28, 18%) or acute necrotic collection (ANC, 2/28, 7%) were included. LAMS were placed successfully in 27/28 (96%) patients. On follow-up imaging after at least one month (n = 24), the volume of the PFC decreased by 99.9% from 425 cm³ [IQR 214 - 636] to 0.6 cm³ [IQR 0-43.9]. After stent removal, 26/27 (96%) patients remained collection free. The median time duration from stent placement to removal was 42 days [IQR 34-71]. Complications (10/28; 36%) included stent occlusion (n = 1), stent migration (n = 3), intraprocedural bleeding (n = 2), postprocedural bleeding (n = 2), and pseudoaneurysm formation (n = 2). Re-intervention was required in 7/27 (26%).

CONCLUSION

Following LAMS placement in patients with symptomatic PFC, high technical and clinical success rates of 96% and 96%, respectively, are achieved. Awareness of common complications seen on cross-sectional imaging might help radiologists and gastroenterologist in the patients' management.

Efficacy of Early Endoscopic Ultrasound-Guided Transluminal Drainage for Postoperative Pancreatic Fistula

BACKGROUND

Endoscopic ultrasound-guided transluminal drainage (EUS-TD) is generally performed 4 weeks after disease onset for evacuating pancreatic fluid collections. However, the optimal timing for conducting the procedure in those diagnosed with postoperative pancreatic fistula (POPF) has not been established. We aimed to elucidate the efficacy and safety of early EUS-TD procedures for treating POPF.

METHODS

We retrospectively reviewed patients diagnosed with POPF who underwent EUS-TD in the Kyushu University Hospital between 2008 and 2019. Clinical features were comparatively analyzed between the two patient groups who underwent either early (≤15 days postoperatively) or late (>15 days postoperatively) EUS-TD. Factors prolonging hospital stay were also analyzed using Cox proportional hazard models.

RESULTS

Thirty patients (median age, 64.5 years) were enrolled. The most common initial operation was distal pancreatectomy with splenectomy (60.0%). Median size of POPF was 69.5 (range, 38-145) mm, and median time interval between surgery and EUS-TD was 17.5 (range, 3-232) days. Totally, 47% patients underwent early EUS-TD. Rates of technical success, clinical success, and complications were 100%, 97%, and 6.9%, respectively. No recurrence of POPF occurred during a median follow-up period of 14 months. Clinical characteristics and outcomes were comparable between the early and late drainage patient groups, except for the rates of infection and nonencapsulation of POPF, which were significantly higher in the early drainage group. Performing simultaneous internal and external drainage (hazard ratio (HR): 0.31; 95% confidence interval (CI): 0.11-0.93, p=0.04) and conducting ≥2 treatment sessions (HR: 0.26; 95% CI: 0.08-0.84, p=0.02) were significantly associated with prolonged hospitalization after EUS-TD.

CONCLUSIONS

EUS-TD is a safe and effective method for managing POPF, regardless of when it is performed in the postoperative period. Once infected POPF occurs, clinicians should not hesitate to perform EUS-TD even within 15 days of the initial operation.

Endoscopic Management of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) are a common sequela of pancreatitis. Most PFCs can be managed conservatively, but symptomatic PFCs require either surgical, percutaneous, or endoscopic intervention. Recent advances in the therapeutics of PFCs, including the step-up approach, endoscopic ultrasound-guided transmural drainage with lumen apposing metal stents, and direct endoscopic necrosectomy, have ushered endoscopy to the forefront of PFCs management and have allowed for improved patient outcomes and decreased morbidity. In this review, we explore the progress and future of endoscopic management of PFCs.

The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis

Pancreatic necrosis is among the most frequently encountered local complications of acute pancreatitis and associates with severe disease. Infected pancreatic necrosis further enhances the risk for morbidity and mortality. Pancreatic fluid collections that result from pancreatic necrosis evolve from acute necrotic collections to walled off necrosis and are defined by their distinct characteristics on cross sectional imaging. A variety of interventions spanning multiple disciplines are available for the drainage and debridement of pancreatic necrosis. Prospective, randomized trials have identified management strategies that incorporate minimally invasive interventions as having the best outcomes for patients with symptomatic pancreatic necrosis. The scientific literature has confidently positioned endoscopic drainage and necrosectomy among the most effective interventions for patients with symptomatic walled off necrosis. Innovations such as the use of metallic stents, chemical debridement and multiple modalities for drainage of pancreatic necrosis show promise in improving outcomes for patients managed with endoscopic interventions.

Interventional Endoscopic Ultrasound: Current Status and Future Directions

The evolution of endoscopic ultrasound (EUS) from a diagnostic to a therapeutic procedure has resulted in a paradigm shift toward endoscopic management of disease states that previously required percutaneous or surgical approaches. The past few years have seen additional techniques and devices that have enabled endoscopists to expand its diagnostic and therapeutic capabilities. Some of these techniques initially were reported more than a decade ago; however, with further device development and refinement in techniques there is potential for expanding the application of these techniques and new technologies to a broader group of interventional gastroenterologists. Lack of formalized training, devices, and prospective data regarding their use in addition to a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors impeding the growth of the field of interventional EUS. In April 2019, the American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology conducted its annual Tech Summit and a key session focused on interventional EUS. This article is a White Paper generated from the conference, discusses the published literature pertaining to the topic of interventional EUS, and outlines a proposed framework for the implementation of interventional EUS techniques into clinical practice. Three primary areas of interventional EUS are addressed: (1) EUS-guided access; (2) EUS-guided tumor ablation; and (3) endohepatology. There was general agreement among participants on several key components. The introduction of these novel interventions requires better tools, more data on safety/outcomes, and improved training for endoscopists. Participants also agreed that widespread implementation and use of these techniques will require support from Gastrointestinal Societies and other key stakeholders including payers. Continued work by the Gastrointestinal Societies and manufacturers to provide training programs, appropriate equipment/work environments, and policies that motivate endoscopists to adopt new techniques is essential for growing the field of interventional EUS.

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections

Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.

Which Are the Most Suitable Stents for Interventional Endoscopic Ultrasound?

Endoscopic ultrasound (EUS)-guided interventions provide easy access to structures adjacent to the gastrointestinal tract, effectively targeting them for therapeutic purposes. They play an important role in the management of pancreatic fluid collections (PFC) and bile duct (BD) and pancreatic duct (PD) drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) or gallbladder (GB) drainage. Specially designed stents and delivery systems for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. In fact, EUS-guided drainage has emerged as the treatment of choice for the management of PFC, and recent innovations such as fully covered metal stents (including lumen-apposing metal stents) have improved outcomes in patients with walled-off necrosis. Similarly, EUS-guided BD and PD drainage with specially designed stents can be beneficial for patients with failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy. EUS-guided GB drainage is also performed using dedicated stents in patients with acute cholecystitis who are not fit for surgery. Although the field of dedicated stents for interventional EUS is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent improves clinical outcomes and safety in EUS-guided drainage. Herein, the current status and problems of the available stents are reviewed, including the applicable indications, long-term clinical outcomes, comparison between each stent, and their future prospects.

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

BACKGROUND

Endoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention.

AIM

To assess the feasibility, efficacy and safety of EGF for WON.

METHODS

Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.

RESULTS

EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.

CONCLUSION

EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis

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.