Role of endosonography in drainage of fluid collections and other NOTES procedures

Therapeutic Upper Gastrointestinal Endoscopy in Pediatric Gastroenterology

This paper seeks to give a broad overview of pediatric upper gastrointestinal (GI) pathologies that we are now able to treat endoscopically, acquired or congenital, and we hope this delivers the reader an impression of what is increasingly available to pediatric endoscopists and their patients.

Endoscopic ultrasonography-guided drainage combined with trans-duodenoscope cyclic irrigation technique for walled-off pancreatic necrosis

BACKGROUND

Endoscopic ultrasonography-guided drainage has been established as a good treatment modality in the management of walled-off pancreatic necrosis, but the unmanageable infection of postoperation is still a thorny problem due to the poor drainage ability for solid necrotic debris only through transmural stent and nasocystic catheter.

AIMS

Introduce a novel therapeutic method, namely endoscopic ultrasonography-guided drainage combined with cyclic irrigation technique in managing patients with walled-off pancreatic necrosis.

METHODS

18 patients with severe acute pancreatitis complicated with walled-off pancreatic necrosis received treatment with endoscopic ultrasonography-guided drainage combined with cyclic irrigation were involved in this retrospective study.

RESULTS

17 of 18 patients with walled-off pancreatic necrosis were treated by this new therapeutic method. Subsequent surgery was performed in 1 case due to uncontrolled infection, complications such as perforation, bleeding or multiple organ failure were not observed. Treatment success rate was high (16 in 17, 94.12%).

CONCLUSION

Endoscopic ultrasonography-guided drainage combined with cyclic irrigation is an effective treatment option for symptomatic walled-off pancreatic necrosis to facilitate drainage and obviate the need for subsequent surgery or endoscopic necrosectomy.

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.

Endoscopic ultrasonography-guided drainage is an effective and relatively safe treatment for peripancreatic fluid collections in a cohort of 108 symptomatic patients

BACKGROUND AND STUDY AIMS

Endoscopic drainage [i.e. conventional, endoscopic ultrasonography (EUS)-assisted, or EUS-guided] is an accepted treatment modality for symptomatic peripancreatic fluid collections (PFC), but data on the efficacy and safety of EUS-guided drainage performed in a large patient cohort are not widely available. Our aim was to evaluate the clinical success and complication rate of EUS-guided drainage of PFCs and to identify prognostic factors for complications and recurrence of PFCs.

PATIENTS AND METHODS

A retrospective analysis was carried out of consecutive patients undergoing EUS-guided drainage of a symptomatic PFC in the period 2004-2011. Technical success was defined as the ability to enter and drain a PFC by the placement of one or more double-pigtail stents, whereas clinical success was defined as complete resolution of a PFC on follow-up computed tomography.

RESULTS

In total, 108 patients [56% men, mean age 55 (SD 14) years], underwent EUS-guided drainage of a symptomatic PFC. The procedure was technically successful in 105/108 (97%) patients and a median of 2 (range 1-3) pigtail stents were placed. Clinical success was observed in 87/104 (84%) patients after a median follow-up of 53 (interquartile range 21-130) weeks, whereas PFC recurrence was noted in 15/83 (18%) patients. Complications occurred in 21/105 (20%) patients and procedure-related mortality was not observed. Prognostic factors for complications and recurrence of PFCs could not be identified.

CONCLUSION

EUS-guided drainage of PFCs is effective in the majority of patients. Although the complication rate of the procedure is not negligible (20%), they could be managed in almost all patients by conservative and/or endoscopic means and did not result in mortality.

Critical analysis of hot topics in NOTES

Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.