Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial

Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

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

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

Endoscopic interventions for necrotizing pancreatitis

Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.

Management of pancreatic ductal leaks and fistulae

Pancreatic duct leaks can occur as a result of both acute and chronic pancreatitis or in the setting of pancreatic trauma. Manifestations of leaks include pseudocysts, pancreatic ascites, high amylase pleural effusions, disconnected duct syndrome, and internal and external pancreatic fistulas. Patient presentations are highly variable and range from asymptomatic pancreatic cysts to patients with severe abdominal pain and sepsis from infected fluid collections. The diagnosis can often be made by high-quality cross-sectional imaging or during endoscopic retrograde cholangiopancreatography (ERCP). Because of their complexity, pancreatic leak patients are best managed by a multidisciplinary team comprised of therapeutic endoscopists, interventional radiologists, and surgeons in the field of pancreatic interventions. Minor leaks will often resolve with conservative management while severe leaks will frequently require interventions. Endoscopic treatments for pancreatic duct leaks have replaced surgical interventions in many situations. Interventional radiologists also have the ability to offer therapeutic interventions for many leak patients. The mainstay of endotherapy for pancreatic leaks is transpapillary pancreatic duct stenting with a stent that bridges the leak if possible, but varies based on the manifestation and clinical presentation. Fluid collections that result from leaks, such as pseudocysts, can often be treated by endoscopic transluminal drainage with or without endoscopic ultrasound or by percutaneous drainage. Endoscopic interventions have been shown to be effective and have an acceptable complication rate.

Endoscopic Ultrasound-guided Bilio-pancreatic Drainage

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when endoscopic retrograde cholangiopancreatography (ERCP) drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear sectorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimension on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonografic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampullary diverticula and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Diathermic dilatation of the puncturing tract is required using a 6-Fr cystostome and a plastic or metal stent is introducted. The techincal success of hepaticogastrostomy is near 98%, and complications are present in 20%: pneumoperitoneum, choleperitoneum, infection and stent disfunction. To prevent bile leakage, we have used the 2-stent techniques. The first stent introduced was a long uncovered metal stent (8 or 10 cm) and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92%, and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 14%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution. The ideal approach for pancreatic pseudocyst (PPC) puncture combines endos-copy with real time endosonography using an interventional echoendoscope. Several authors have described the use of endoscopic ultrasound (EUS) longitudinal scanners for guidance of transmural puncture and drainage procedures. The same technique could be used to access a dilated pancreatic duct in cases in which the duct cannot be drained by conventional ERCP because of complete obstruction.

Role of diagnostic and therapeutic endoscopic ultrasonography in benign pancreatic diseases

Standard imaging of pancreas is generally obtained by computed tomography and magnetic resonance imaging. However endoscopic ultrasound (EUS) has become an indispensable tool for the diagnosis of various pancreatic diseases. Because of the close proximity of the EUS probe to the pancreas, EUS provides excellent images of the pancreas. In this review, we discuss the role of EUS in the clinical management of patients with benign pancreatic diseases, i.e., various forms of pancreatitis.

A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts

BACKGROUND

Endoscopic drainage (ED) and percutaneous drainage (PD) have largely replaced surgical drainage as the initial approach for symptomatic pseudocysts. However, there are few studies comparing ED and PD.

OBJECTIVE

To compare the outcomes of ED and PD for symptomatic pseudocysts.

DESIGN

Retrospective cohort study.

SETTING

Academic center.

PATIENTS

Adult patients with symptomatic pseudocysts within ≤ 1 cm of the gastric or duodenal wall who underwent ED or PD between 1993 and 2011. Patients with walled-off pancreatic necrosis were excluded.

INTERVENTION

ED or PD.

MAIN OUTCOME MEASUREMENTS

Rates of technical success, procedural adverse events, clinical success, reinterventions, and failure. Other outcomes included the length of hospital stay and number of follow-up abdominal imaging studies.

RESULTS

There were 81 patients, 41 who underwent ED and 40 who underwent PD, with no differences in age, sex, and comorbidity between the 2 groups. There were no differences in the rates of technical success (90.2% vs 97.5%; P = .36), adverse events (14.6% vs 15%; P = .96), and clinical success (70.7% vs 72.5%; P = .86) between ED and PD, respectively. Patients who underwent PD had higher rates of reintervention (42.5% vs 9.8%; P = .001), longer length of hospital stay (14.8 ± 14.4 vs 6.5 ± 6.7 days; P = .001), and median number [quartiles] of follow-up abdominal imaging studies (6 [3.25, 10] vs 4 [2.5, 6]; P = .02) compared with patients who underwent ED.

LIMITATIONS

Single center, retrospective study.

CONCLUSION

ED and PD have similar clinical success rates for symptomatic pseudocysts. However, PD is associated with significantly higher rates of reintervention, longer length of hospital stay, and increased number of follow-up abdominal imaging studies.

Endoscopic drainage of pseudocysts

During the last decade, great progress has been made in minimally invasive endoscopic techniques. For pancreatic pseudocysts (PPCs), endoscopic drainage has become the first-line therapeutic option. Recent advances in therapeutic endoscopic ultrasound (EUS)-related techniques have focused on EUS-guided transmural drainage, which is now replacing the conventional endoscopy-guided transmural drainage. While transmural drainage is usually performed using multiple plastic stents with or without a nasocystic drain, fully covered self-expandable metal stents are now being used with increasing frequency. In this review, we discuss some of the controversies related to the endoscopic drainage of PPCs.

Interventional endoscopic ultrasonography

OPINION STATEMENT

Endoscopic ultrasound (EUS) is not only a diagnostic tool but also an interventional and therapeutic procedure. Indeed, in addition to tissue acquisition, it can also drain fluid collections adjacent to the gastrointestinal tract, provide access to biliary and pancreatic ducts, biliary, pancreatic, and gallbladder drainage, pancreatic cyst ablation, and, finally, provide anti-tumoral treatments and interventional vascular procedures. Although several improvements have been made in the last decade, the full potential of interventional EUS is yet to be completely explored. Future areas of research are the development of dedicated tools and accessories, the standardization of the interventional procedures, and the widening of the use of EUS, while increasing the expertise worldwide. In addition, more data, based on well-performed, possibly randomized clinical trials, are needed to accurately determine the risks and long-term outcomes of these interventions. We firmly believe that interventional EUS can play a pivotal role in anti-tumor treatments, by the fine-needle injection of anti-tumoral agents, tumor ablation, and assisting radiation treatment with gold fiducial placement and the implantation of intralesional seeds. The goal of the near future will be to offer targeted therapy and monitoring of tumor treatment response in a more biologically driven manner than has been available in the past. Interventional EUS will be an essential part of the multidisciplinary approach to cancer treatment.

The role of endoscopic ultrasound in the diagnosis and therapy of gastrointestinal disorders

Endoscopic ultrasound is one of those diagnostic methods in gastrointestinal endoscopy which has developed rapidly in the last decade and has became exceedingly available to visualize the walls of the internal organs in details corresponding to histological layers, or analyze the adjacent structures. Fine needles and other endoscopic accessories can be introduced into the neighbouring tissues under the guidance of endoscopic ultrasound, and diagnostic and minimally invasive therapeutic interventions can be performed. The endoscopic ultrasound became more widely available in Hungary in the recent years. This review focuses on the indications, benefits and complications of diagnostic and therapeutic endoscopic ultrasound. We dedicate this article for gastroenterologists, surgeons, internists, pulmonologists, specialists in oncology and radiology. This recommendation was based on the consensus of the Board members of the Endoscopic Ultrasound Section of the Hungarian Gastroenterological Society. Orv. Hetil., 2014, 155(14), 526–540.

Pancreatic cysts: etiology, diagnosis and management

Pancreatic cysts involve a wide spectrum of pathologies from post-inflammatory cysts to malignant neoplasms. Pancreatic pseudocysts, serous cystadenomas, mucinous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary tumors occur most frequently. Differential diagnosis involves the following imaging investigations: transabdominal ultrasonography (TUS), contrast enhanced ultrasonography (CEUS) and endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance (MR) and magnetic resonance cholangiopancretography (MRCP), endoscopic retrograde cholangiopancretography (ERCP). The cyst fluid cytology is performed in difficult differential diagnosis between pseudocysts and benign and potentially malignant or malignant tumors. Most frequently, viscosity, amylase, CEA and CA 19-9 levels are determined. Imaging findings should be correlated with cytology. The management depends on the cyst type and size. Small asymptomatic pseudocysts, serous cystadenomas and branchduct IPMNs should be carefully observed, whereas symptomatic large or uncertain serous cystadenomas and cystadenocarcinomas, mucinous cystadenomas and cystadenocarcinomas, main-duct IPMNs and large branch-duct IPMNs with malignant features, serous and mucinous cystadenocarcinomas, and solid pseudopapillary tumors require surgery. Pseudocysts are usually drained. Percutaneous / EUS-guided or surgical cyst drainage can be performed. Complicated and uncertain pseudocysts and cystic tumors need surgical resection. The type of surgery depends on cyst location and size and includes proximal, central, distal, total pancreatectomies and enucleation.

Evaluation of 19-gauge endoscopic ultrasonography aspiration needles using various echoendoscopes

BACKGROUND AND STUDY AIMS

19-gauge (19G) needles are used for EUS-guided tissue acquisition and interventions. The aim of the current study was to compare the functional characteristics of 19G EUS needles by means of using various echoendoscopes in a bench simulator.

METHODS

The angles achieved for 19G needles (EchoTip: ET-19G, EchoTip Flex: ExF-19G, Expect: Ex-19G, and ProCore: PC-19G) and for the distal tip of the echoendoscope were evaluated for maximal angulation settings of the distal tip and the elevator. Also the resistance to advancement of the 19G needles at these endoscope settings was assessed. All evaluations were done with endoscopes in a straight and in a curved position.

RESULTS

There was no large discrepancy for scope and needle angles among all echoendoscopes except for the slim Pentax scope (EG-3270UK). The ExF-19G and PC-19G needles showed better optimal angles in various conditions compared to standard 19G needles. In straight scope position, out of the 20 conditions (5 endoscopes × 2 positions of the distal tip × 2 elevator positions) the numbers of optimal angulations achieved for the Ex-19G, ExF-19G, ET-19G, and PC-19G, were 11 /20 (55 %), 20 /20 (100 %), 14 /20 (70 %) and 18 /20 (90 %), respectively. However, regarding resistance, it was impossible to advance theneedle with 14 /20 settings (70 %) for the Ex-19G, 3 /20 (15 %) for the ExF-19G, 10 /20 (50 %) for the ET-19G and 7 /20 (35 %) for the PC-19G. When the scopes were bent, with regard to the force needed to advance the needle, the numbers of optimal settings, for the Ex-19G, ExF-19G, ET-19G, and PC-19G, were 1 (5 %), 13 (65 %), 6 (30 %) and 8 (40 %), respectively. The mean maximum resistance to advancement was less for the ExF-19G than for the other needless in almost all scope and angle conditions (p < 0.05).

CONCLUSION

Although there was no difference between needles, the resistance to passage was least with the flexible 19-gauge needle (ExF-19G).

Endoscopic transmural drainage of pancreatic pseudocysts: technical challenges in the resource poor setting

Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options, the requirement for specialized equipment, technical expertise, and consumables limits the options available in low resource settings. We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers. Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware. Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

Interventional endoscopic ultrasonography: an overview of safety and complications

BACKGROUND

In recent years, endoscopic ultrasonography (EUS)-guided techniques have been developed as alternatives to surgical, radiologic, or conventional endoscopic approaches for the treatment or palliation of several digestive diseases. The use of EUS guidance allows the therapeutic area to be targeting more precisely, with a possible clinical benefit and less morbidity. Nevertheless, the risks persist and must be taken into consideration. This review gives an overview of the complications observed with the most established procedures of therapeutic EUS.

METHODS

The PubMed and Embase databases were used to search English language articles on interventional EUS. The studies considered for inclusion were those reporting on complications of EUS-guided celiac plexus block (EUS-CPB), EUS-guided celiac plexus neurolysis (EUS-CPN), drainage of fluid pancreatic and pelvic collections, and EUS-guided biliary and pancreatic drainage (EUS-BD and EUS-PD). Variations in methodology and design in most studies made a thorough statistical analysis difficult. Instead, a frequency analysis of complications and a critical discussion were performed.

RESULTS

Although EUS-guided celiac plexus injection causes mainly mild and transient complications, growing experience shows that EUS-CPN is not as benign a procedure as previously thought. Most of the major complications have been observed in patients with chronic pancreatitis. The findings show that EUS-guided drainage of fluid collections is a safe procedure. Complications occur more often after the drainage of pancreatic abscesses and necrosis. Although the heterogeneity of studies dealing with pancreatobiliary drainage makes the evaluation of risks after these procedures difficult, complications after EUS-BD and EUS-PD are relatively frequent and can be severe. The technical complexity and the lack of specifically designed devices may account for their complication rates.

CONCLUSIONS

Clinicians can consider EUS-guided celiac injection and EUS-guided drainage of fluid collections to be safe alternatives to surgical and radiologic interventions. Well-designed prospective trials are needed to assess the risks of EUS-BD and EUS-PD accurately before they are broadly advocated after a failed endoscopic retrograde cholangiopancreatography (ERCP).

Outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts by using combined endoprosthesis and a nasocystic drain

BACKGROUND

The presence of debris within a pseudocyst may impair success of endoscopic drainage.

OBJECTIVE

To compare the clinical outcomes and adverse-event rates of EUS-guided pseudocyst drainage with and without a nasocystic drain for the management of pancreatic pseudocysts with viscous solid debris-laden fluid.

DESIGN

Retrospective study.

SETTING

Single, tertiary-care referral center.

PATIENTS

Consecutive patients with pancreatic pseudocysts managed by EUS-guided drainage: those with solid debris who underwent drainage via nasocystic drains alongside stents (n = 63) and those with solid debris who underwent drainage via transmural stents only (n = 24).

INTERVENTION

Drainage via nasocystic drains alongside stents or drainage via transmural stents only.

MAIN OUTCOME MEASUREMENTS

The primary outcomes were short-term success and long-term success of the procedures. The secondary outcomes were procedure-related adverse events and reintervention.

RESULTS

The patients with viscous solid debris-laden fluid whose pseudocysts were drained by both stents and nasocystic tubes had a 3 times greater short-term success rate compared with those who had drainage by stents alone (P = .03). On 12-month follow-up, complete resolution of pseudocysts with debris drained via stents alone was less (58%) compared with those with debris who underwent drainage via nasocystic drains alongside stents (79%; P = .059). The rate of stent occlusion was higher in cysts with debris drained by stents alone (33%) compared with those drained via nasocystic drains alongside stents (13%; P = .03).

LIMITATIONS

Retrospective design; limited sample size.

CONCLUSION

In patients with pseudocysts with viscous debris-laden fluid, EUS-guided drainage by using a combination of a nasocystic drain and transmural stents improves clinical outcomes and lowers the stent occlusion rate compared with those who underwent drainage via stents alone.

Endoscopic therapy of necrotizing pancreatitis and pseudocysts

Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.

Endoscopic therapy for chronic pancreatitis

Endoscopic therapy is recommended as the first-line therapy for painful chronic pancreatitis with an obstacle on the main pancreatic duct (MPD). The clinical response should be evaluated at 6 to 8 weeks. Calcified stones that obstruct the MPD are first treated by extracorporeal shockwave lithotripsy; dominant MPD strictures are optimally treated with a single, large, plastic stent that should be exchanged within 1 year even in asymptomatic patients. Pancreatic pseudocysts for which therapy is indicated and are within endoscopic reach should be treated by endoscopy.

Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial

BACKGROUND & AIMS

Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage.

METHODS

Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs.

RESULTS

At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003).

CONCLUSIONS

In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00826501.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent

Background

Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.

Case presentation

We report a case of an immediate internal spurting arterial bleeding precipitated during EUS-guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self-expandable metal stent through mechanical hemostasis.

Conclusion

In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during pseudocyst drainage, the placement of an expandable metal stent proved to be useful.

The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease

Pancreatic and biliary disease continues to have a significant impact on the workload of the National Health Service (NHS), for which there exists a multimodality approach to investigation and diagnosis. Endoscopic ultrasound (EUS) is fast becoming a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but also because of its valuable role as a problem-solving tool and ever-improving ability in an interventional capacity. We provide a comprehensive review of the benefits of EUS in everyday clinical practice.

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic options in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections in children

BACKGROUND AND OBJECTIVE

Although endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) has evolved as the standard of care in adults, its role as a single-step drainage modality in children is unclear. The aim of the present study was to evaluate the efficacy and safety of single-step EUS-guided drainage of PFCs in children.

METHODS

This is a retrospective study of all of the children who underwent single-step EUS-guided drainage of PFCs during a 4-year period at 1 institution. An endoscopic retrograde cholangiopancreatography was attempted before EUS-guided drainage to evaluate the pancreatic duct and bridge any ductal disruption.

RESULTS

A total of 7 children (4 boys; mean age 8.4 years [standard deviation 2.1]) underwent EUS-guided drainage of PFCs. The etiology was blunt abdominal trauma in 5, hereditary pancreatitis in 1, and idiopathic pancreatitis in 1. Both technical and treatment success rates were 100% with median procedural duration of 12 minutes (interquartile range 12-20 minutes). Two patients underwent repeat EUS-guided drainage due to lack of adequate resolution of PFC on follow-up computed tomography. There were no immediate or delayed complications. At a median follow-up of 1033 days (interquartile range 193-1167 days), all of the children were doing well with no PFC recurrence.

CONCLUSIONS

Single-step EUS-guided drainage of PFC in children is technically feasible, safe, clinically effective, and when available, should be the first-line treatment modality.

Endoscopic ultrasound-guided versus conventional transmural techniques have comparable treatment outcomes in draining pancreatic pseudocysts

We carried out the first meta-analysis comparing the technical success and clinical outcomes of endoscopic ultrasound-guided drainage (EUD) and conventional transmural drainage (CTD) for pancreatic pseudocysts. We searched PubMed, Embase, Scopus, and the Cochrane library to identify relevant prospective trials. The technical success rate, short-term (4-6 weeks) success, and long-term (at 6 months) success in symptoms and the radiologic resolution of pseudocysts, complication rates, and death rates were compared. Two eligible randomized-controlled trials and two prospective studies including 229 patients were retrieved. The technical success rate was significantly higher for EUD than for CTD [risk ratio (RR)=12.38, 95% confidence interval (CI): 1.39-110.22]. When CTD failed because of the nonbulging nature of pseudocysts, a crossover was carried out to EUD (n=18), which was successfully performed in all these cases. All patients with portal hypertension and bleeding tendency were subjected to EUD to avoid severe complications. EUD was not superior to CTD in terms of short-term success (RR=1.03, 95% CI: 0.95-1.11) or long-term success (RR=0.98, 95% CI: 0.76-1.25). The overall complications were similar in both groups (RR=0.98, 95% CI: 0.52-1.86). The most common complications were bleeding and infection. There were two deaths from bleeding after CTD. The short-term and long-term treatment success of both methods is comparable only if proper drainage modality is selected in specific clinical situations. For bulging pseudocysts, either EUD or CTD can be selected whereas EUD is the treatment of choice for nonbulging pseudocysts, portal hypertension, or coagulopathy.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in “one step”, EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference

Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.

The Performance of Multiple Transgastric Procedures Using the Natural Orifice Transluminal Endoscopic Surgery Technique: Is Pure NOTES Satisfactory?

Background/Aims

Although several groups have demonstrated the usefulness of natural orifice transluminal endoscopic surgery (NOTES), there is still concern about frequent serious adverse events. We performed this study to determine the technical feasibility and safety of pure NOTES with a transgastric approach in a porcine model from the endoscopist's point of view.

Methods

Diagnostic peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation with a transgastric approach using a two-channel therapeutic endoscope were performed in 10 healthy female minipigs. These procedures were performed in two acute models and eight survival models in consecutive order.

Results

The technical success rate was 100% for peritoneoscopy (10/10), liver biopsy (5/5), salpingo-oophorectomy (10/10), and Fallopian tube ligation (10/10). Eight cases of adverse events occurred, including one case of splenic injury, one case of bleeding after liver biopsy, two cases of small bowel adhesion after salpingo-oophorectomy, two cases of hematoma at the salphingo-oophorectomy site, and two cases of partial dehiscence at the gastric closure site. The gastric puncture site was closed with seven to eight hemoclips in four cases and two hemoclips and an endoloop in four cases.

Conclusions

The use of pure NOTES for peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation may be technically feasible, but considerable adverse events can occur during or after the procedure. Further studies utilizing specialized techniques overcome several limitations of pure NOTES are therefore necessary.

Pancreatico-biliary endoscopic ultrasound: A systematic review of the levels of evidence, performance and outcomes

Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, IIb, IIa, Ib and Ia, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.

Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections (with Video)

Endoscopic ultrasound (EUS) is often used to guide drainage of pancreatic fluid collections (PFCs). EUS enhances the diagnosis of cystic pancreatic lesions and enables real-time image-guided control of PFC drainage. EUS may facilitate the endoscopic treatment of patients with pancreatic necrosis and patients with disconnected pancreatic duct syndrome.

Therapeutic endoscopic retrograde cholangiopancreatography and instrumentation

Over the last 40 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a purely diagnostic to a primarily therapeutic procedure. The 2 recent developments in ERCP-based stricture management include the increased use of cholangioscopy-guided sampling and self-expandable metal stents. The role of ERCP in pancreatic diseases continues to evolve; ERCP-based pancreatic therapy requires advanced endoscopic expertise and is associated with a high rate of postprocedure complications. Therefore, a multidisciplinary team approach at a center with expertise in pancreatic therapy should serve as a basis for very careful patient selection.

Endoscopic ultrasonography-guided hepaticogastrostomy

To date, percutaneous transhepatic biliary drainage (PTBD) has been considered as the usual biliary access after failed endoscopic retrograde cholangiopancreatography (ERCP). Since endoscopic ultrasonography (EUS)-guided bile duct puncture was first described in 1996, sporadic case reports of EUS-guided biliary drainage (EUS-BD) have suggested it as an alternative to PTBD after failed ERCP. The potential benefits of EUS-BD include internal drainage, thus avoiding long-term external drainage in cases where external PTBD drainage catheters cannot be internalized. EUS-guided hepaticogastrostomy (EUS-HG) is one form of EUS-BD. This article describes the indications, techniques, and outcomes of published data on EUS-HG.

Endoscopic ultrasonography-guided pancreatic drainage

Surgery for pancreatic pseudocysts (PPCs) may be associated with high rates of complication and mortality. Since its introduction in the late 1980s, endoscopic drainage of PPCs has become established as an alternative nonsurgical approach. The obvious limitation of this technique is its relatively blind approach. The ideal approach for PPC puncture combines endoscopy with real-time endosonography using an interventional echoendoscope. Endoscopic ultrasonographic longitudinal scanners can be used for guidance of transmural punctures and drainage procedures, as well as to access a dilated pancreatic duct if the duct cannot be drained by conventional methods because of complete obstruction. In this chapter, we will review the indications, techniques and clinical algorithm for EUS-guided pseudocyst drainage and pancreaticogastrostomy.

Endoscopic ultrasound-guided antitumor agents

The development of linear-array endoscopic ultrasonography (EUS), with its real-time guidance of needle advancement, changed EUS from a diagnostic procedure to an interventional procedure. EUS-guided fine-needle injection (EUS-FNI) is an attractive minimally invasive delivery system with potential applications in local (intratumoral) and combination therapy against esophageal and pancreatic cancers. The evidence of the feasibility of EUS-FNI of antitumor agents has been expanding with promising results.

Endoscopic management of peri-pancreatic collections

Endotherapy of peripancreatic fluid collections is an increasing utilized procedure in interventional endoscopy. The aim of this paper is to provide a general overview of the topic, highlighting the indications, technique, and important management issues relating to endoscopic management of the various forms of peri-pancreatic fluid collections.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Single-step versus two-step endo-ultrasonography-guided drainage of pancreatic pseudocyst

OBJECTIVE

The aim of this prospective study was to compare the feasibility, technical success rate and complication between single-step endo-ultrasonography (EUS)-guided and two-step EUS-guided drainage technique for symptomatic pancreatic pseudocyst (PP).

METHODS

Twenty-one PP patients with clear intra-cystic fluid that needed to be drained were divided into two groups, depending on the availability of the therapeutic echoendoscope at the time of the procedure: Group 1 (13 patients) underwent a single-step EUS-guided endoscopic drainage and Group 2 (8 patients) underwent a two-step EUS-guided drainage technique.

RESULTS

In Group 1 immediate technical success was achieved in 92.3% (12/13); two patients had recurrent PP and both were successfully treated by a second EUS-guided drainage. Clinical success was achieved in all cases. In Group 2 technical success was achieved in 75.0% of the patients (6/8). One patient (12.5%) bled 36 h after the procedure. Five out of 6 patients had long-term success. Clinical success was significantly greater in Group 1 (P < 0.05).

CONCLUSION

The technique of single-step EUS-guided drainage was superior to the technique of a two-step EUS-guided drainage technique for PP drainage.

Endoskopische Drainage von Pankreaspseudozysten

<b><i>Hintergrund: </i></b>Die Pankreaspseudozyste ist eine häufige Komplikation der akuten oder chronischen Pankreatitis. Bei symptomatischer Zyste mit Vorliegen von abdominellen Schmerzen, einer Magenausgangsstenose, Gewichtsverlust, Ikterus, Infektion oder Größenzunahme stellt die endoskopische Drainage (transpapillär und/ oder transmural) eine effektive Erstlinientherapie dar. <b><i>Methode: </i></b>Die Übersicht basiert auf einer strukturierten Analyse der aktuellen, in Pubmed gelisteten Studien. <b><i>Ergebnisse: </i></b>Die Langzeitregressionsraten liegen bei 71–90%; die Komplikationsrate beträgt 3–35% mit einer geringen Mortalität von 0–1%. Die wesentlichen Komplikationen der endoskopischen Pseudozystendrainage sind Blutungen in bis zu 9%, Infektionen in bis zu 8%, retroperitoneale Perforation in bis zu 5% und Zystenrekurrenz in bis zu 14% der Fälle. Differenziert zu betrachten sind die infizierte Nekrose und der Pankreasabszess (walled-off necrosis) nach akuter Pankreatitis. In diesen Fällen ist die endoskopische Therapie technisch komplexer und im Vergleich zur unkomplizierten Pankreaspseudozyste mit höherer Morbidität und geringerem Langzeitansprechen verbunden. Dennoch stellt die endoskopische Drainage bei technischer Machbarkeit für beide Entitäten die Methode der ersten Wahl dar. Dies basiert insbesondere auf der nach aktuellen Daten geringeren Morbidität der Methode im Vergleich zu chirurgischen Drainageverfahren. <b><i>Schlussfolgerung: </i></b>Der vorliegende Review gibt einen Überblick über Therapieindikation und Differenzialdiagnose von Pankreaspseudozysten, erläutert die Drainagetechniken und stellt die Daten zu Effektivität und Komplikationen der endoskopischen Zystendrainage umfassend dar.

EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results

BACKGROUND

EUS-guided biliary drainage (EUS-BD) has been proposed as an effective alternative for percutaneous transhepatic biliary drainage (PTBD) after failed ERCP. To date, the risk factors for adverse events and long-term outcomes of EUS-BD with transluminal stenting (EUS-BDS) have not been fully explored.

OBJECTIVE

To evaluate risk factors for adverse events and long-term outcomes of EUS-BDS.

DESIGN

Prospective follow-up study.

SETTING

Tertiary-care academic center.

PATIENTS

This study involved 57 consecutive patients with malignant or benign biliary obstruction undergoing EUS-BDS after failed ERCP.

INTERVENTION

EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy with transluminal stenting (EUS-CDS).

MAIN OUTCOME MEASUREMENTS

Risk factors for postprocedure and late adverse events and clinical outcomes of EUS-BDS.

RESULTS

The overall technical and functional success rates, respectively, in the EUS-BDS group were 96.5% (intention-to-treat, n = 55/57) and 89% (per-protocol, n = 49/55). Postprocedure adverse events developed after EUS-BDS in 11 patients (20%, n = 11/55). This included bile peritonitis (n = 2), mild bleeding (n = 2), and self-limited pneumoperitoneum (n = 7). In multivariate analysis, needle-knife use was the single risk factor for postprocedure adverse events after EUS-BDS (odds ratio 12.4; P = .01). A late adverse event in EUS-BDS was distal stent migration (7%, n = 4/55). The mean stent patencies with EUS-HGS and EUS-CDS were 132 days and 152 days, respectively.

LIMITATIONS

Single-operator performed, nonrandomized study.

CONCLUSION

EUS-HGS and EUS-CDS may be relatively safe and can be used as an alternative to PTBD after failed ERCP. Both techniques offer durable and comparable stent patency. The use of a needle-knife for fistula dilation in EUS-BDS should be avoided if possible.

Forward-viewing versus oblique-viewing echoendoscopes in transluminal drainage of pancreatic fluid collections: a multicenter, randomized, controlled trial

BACKGROUND

EUS-guided drainage of pancreatic fluid collections (PFCs) is commonly performed with oblique-viewing echoendoscopes. However, accessing the PFC under an oblique angle can make drainage difficult. These difficulties might be overcome by using a forward-viewing echoendoscope.

OBJECTIVE

To compare endoscopic PFC drainage with an oblique-viewing versus a forward-viewing echoendoscope with emphasis on ease of endoscopic drainage.

DESIGN

Multicenter, randomized, controlled trial.

SETTING

Four tertiary-care referral centers.

PATIENTS

This study involved 58 patients with PFCs.

INTERVENTION

Patients with PFCs (≥ 6 cm) in whom drainage was indicated were randomized to receive EUS-guided drainage with a forward-viewing echoendoscope or an oblique-viewing echoendoscope. In cases of failed drainage, patients were crossed over to the other study arm.

MAIN OUTCOME MEASUREMENTS

Ease of EUS-guided drainage measured by procedure time. Secondary endpoints included technical success, EUS endoscope preference, clinical success, and adverse events.

RESULTS

Fifty-eight consecutive patients underwent randomization, of whom 52 were available for primary endpoint analysis. All 26 EUS-guided procedures done with the oblique-viewing echoendoscope and 24 of the 26 procedures done with the forward-viewing echoendoscope were technically successful. Mean (± standard deviation) procedure time was 24:55 ± 9:58 minutes in the forward-viewing echoendoscope group and 27:04 ± 9:58 minutes in the oblique-viewing echoendoscope group (P = .44). Median overall procedure ease was graded as equal (easy) in both groups. Drainage-related adverse events occurred in 2 patients (8%) in the forward-viewing echoendoscope group versus none in the oblique-viewing echoendoscope group (P = .56). Overall clinical success was achieved in 82% of patients (95% confidence interval, 69%-91%).

LIMITATIONS

Derived main outcome parameter and highly specialized endoscopists in tertiary-care referral centers.

CONCLUSION

This multicenter, randomized, controlled trial comparing the performance of oblique-viewing echoendoscopes and forward-viewing echoendoscopes in draining PFCs did not show a difference in ease of EUS-guided drainage or procedure safety and efficacy between the forward-viewing echoendoscope and the oblique-viewing echoendoscope. Clinical success was achieved in 82% of patients.

[Endoscopic treatment of pancreatic pseudocyst. Practical features]

The initial treatment of most cases of pancreatic pseudocyst is endoscopic while surgery has been relegated to patients who cannot undergo this procedure for technical reasons, such as roux-en-Y roux reconstruction, or to those in whom other procedures have been unsuccessful. This change in the management of this entity is due to advances in therapeutic endoscopy (as a result of the development of guidelines, dilatation balloons, prostheses, safer techniques) as well as to better knowledge of the pathogenesis of pancreatic pseudocyst. The present study aims to describe endoscopic procedures for the drainage of pancreatic pseudocysts, particularly key technical features to ensure the maximum safety and effectiveness of this therapeutic technique.

Single-step versus multi-step transmural drainage of pancreatic pseudocysts: the use of cystostome is effective and timesaving

BACKGROUND AND AIMS

Pancreatic pseudocysts are a major complication of chronic and acute pancreatitis and often require endoscopic intervention. Endoscopic single-step and multi-step transmural drainage techniques have been reported in the literature. The aim of this study was to evaluate and compare technical results and clinical outcome rates of the single-step versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts of >4 cm size.

DESIGN

Retrospective study at an academic tertiary referral center.

PATIENTS AND METHODS

A total of 38 consecutive patients comprising 42 interventions were studied: 16 patients with pancreatic pseudocysts (18 interventions) had undergone single-step EUS-guided transmural cystostome drainage between 2007 and 2010. Results were compared with a cohort of 22 patients who had submitted to multi-step EUS-guided transmural drainage of pancreatic pseudocysts in 24 cases between 2005 and 2007.

RESULTS

The technical success rate for using the single-step procedure was 94% compared with multi-step procedure with 83% (n.s.). Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the single-step group compared with 62 ± 12 min for the multi-step access (p < 0.001).

CONCLUSIONS

The use of single-step cystostome appears useful in managing selected patients with symptomatic pancreatic pseudocysts as it is effective and timesaving.

Endoscopic access to and exploration of the lesser sac in a human cadaver model: opportunity for transgastric endoscopic pancreatic surgery (with video)

BACKGROUND

Transgastric endoscopy may represent a viable platform for diagnostic and therapeutic pancreatic interventions with reduced morbidity. In a human cadaver model, we aimed to determine the feasibility of transgastric endoscopic access to the lesser sac, creation of an adequate working space within the lesser sac, and reliable identification of lesser sac anatomic structures.

METHODS

In six human cadavers, endoscopic guidance was used to determine an appropriate access site to the lesser sac. Subsequently, endosonographic guidance was used to introduce an aspiration needle into the potential space between the stomach and the pancreas. After creating a fluid cushion and dilating the needle tract, an endoscope was advanced through the gastrotomy into the lesser sac and air insufflation was used to create a working space. Predetermined anatomic structures were systematically sought and marked when recognized. In the final two cadavers, endoscopic closure of the access site was performed.

RESULTS

All six procedures were successful in achieving access to the lesser sac and establishing an adequate working space. The access sites appeared amenable to endoscopic closure. Reliable organ identification, however, was not achieved in all cases, representing one of the immediate barriers to clinical application.

CONCLUSIONS

Transgastric endoscopic access to the lesser sac can be achieved reliably and an adequate working space can be established. Additional research addressing endoscopic orientation and organ recognition within the lesser sac is necessary. The immediate potential applications of this approach include differentiating benign from malignant pancreatic pathology.