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Li Z, Siddiqui A, Singh G, Redstone E, Weinstein J, Mitchell DG. Pancreatic Walled-Off Necrosis: Cross-Sectional Imaging Depiction of Debris Predicts the Success of Endoscopic Drainage Using Lumen-Apposing Metal Stents. Dig Dis 2024; 42:380-388. [PMID: 38663364 DOI: 10.1159/000538472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/12/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION The use of endoscopic ultrasound (EUS)-guided transmural stent placement for pancreatic walled-off necrosis (WON) drainage is widespread. This study retrospectively analyzed imaging parameters predicting the outcomes of WON endoscopic drainage using lumen-apposing metal stents (LAMS). METHODS This study analyzed the data of 115 patients who underwent EUS-guided debridement using LAMS from 2011 to 2015. Pre-intervention CT or MRI was used to analyze the total volume of WON, percentage of debris, multilocularity, and density. Success measures included technical success, the number of endoscopic sessions, the requirement of percutaneous drainage, long-term success, and recurrence. RESULTS The primary cause of pancreatitis was gallstones (50.4%), followed by alcohol (27.8%), hypertriglyceridemia (11.3%), idiopathic (8.7%), and autoimmune (1.7%). The mean WON size was 674 mL. All patients underwent endoscopic necrosectomy, averaging 3.1 sessions. Stent placement was successful in 96.5% of cases. Procedural complications were observed in 13 patients (11.3%) and 6 patients (5.2%) who needed additional percutaneous drainage. No patients reported recurrent WON posttreatment. Univariate analysis indicated a significant correlation between debris percentage and the need for additional drainage and long-term success (p < 0.001). The number of endoscopic sessions correlated significantly with debris percentage (p < 0.001). CONCLUSION Pre-procedural imaging, particularly debris percentage within WON, significantly predicts the number of endoscopic sessions, the need for further percutaneous drainage, and overall long-term success.
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Affiliation(s)
- Zhenteng Li
- Department of Radiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ali Siddiqui
- Division of Gastroenterology, Inova Health System, Fairfax, Virginia, USA
| | - Gurshawn Singh
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Ellen Redstone
- Department of Radiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jonathan Weinstein
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Plainview, New York, USA
| | - Donald G Mitchell
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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2
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Binda C, Fabbri S, Perini B, Boschetti M, Coluccio C, Giuffrida P, Gibiino G, Petraroli C, Fabbri C. Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:333. [PMID: 38399620 PMCID: PMC10890047 DOI: 10.3390/medicina60020333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
Pancreatic fluid collections (PFCs) are well-known complications of acute pancreatitis. The overinfection of these collections leads to a worsening of the prognosis with an increase in the morbidity and mortality rate. The primary strategy for managing infected pancreatic necrosis (IPN) or symptomatic PFCs is a minimally invasive step-up approach, with endosonography-guided (EUS-guided) transmural drainage and debridement as the preferred and less invasive method. Different stents are available to drain PFCs: self-expandable metal stents (SEMSs), double pigtail stents (DPPSs), or lumen-apposing metal stents (LAMSs). In particular, LAMSs are useful when direct endoscopic necrosectomy is needed, as they allow easy access to the necrotic cavity; however, the rate of adverse events is not negligible, and to date, the superiority over DPPSs is still debated. Moreover, the timing for necrosectomy, the drainage technique, and the concurrent medical management are still debated. In this review, we focus attention on indications, timing, techniques, complications, and particularly on aspects that remain under debate concerning the EUS-guided drainage of PFCs.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Barbara Perini
- Gastroenterology and Digestive Endoscopy Unit, Azienda ULSS 5, 45100 Rovigo, Italy
| | - Martina Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Paolo Giuffrida
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Chiara Petraroli
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
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3
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Cui Y, Kozarek RA. Evolution of Pancreatic Endotherapy. Gastrointest Endosc Clin N Am 2023; 33:679-700. [PMID: 37709404 DOI: 10.1016/j.giec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.
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Affiliation(s)
- YongYan Cui
- Department of Gastroenterology, Virginia Mason Medical Center
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4
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Radlinski MJ, Strand DS, Shami VM. Evolution of interventional endoscopic ultrasound. Gastroenterol Rep (Oxf) 2023; 11:goad038. [PMID: 37398926 PMCID: PMC10313421 DOI: 10.1093/gastro/goad038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.
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Affiliation(s)
- Mark J Radlinski
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Corresponding author. Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA 22908, USA. Tel: +1-434-989-4381;
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5
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Lera Dos Santos ME, Proença IM, de Moura DTH, Ribeiro IB, Matuguma SE, Cheng S, de Freitas Júnior JR, Luz GDO, McCarty TR, Jukemura J, de Moura EGH. Self-Expandable Metal Stent (SEMS) Versus Lumen-Apposing Metal Stent (LAMS) for Drainage of Pancreatic Fluid Collections: A Randomized Clinical Trial. Cureus 2023; 15:e37731. [PMID: 37214030 PMCID: PMC10191807 DOI: 10.7759/cureus.37731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 05/23/2023] Open
Abstract
Background and aim Endoscopic ultrasound (EUS)-guided drainage is the gold standard approach for the treatment of encapsulated pancreatic collections (EPCs) including pseudocyst and walled-off pancreatic necrosis (WON), and is associated with an equivalent clinical efficacy to surgical drainage with fewer complications and less morbidity. Drainage may be achieved via several types of stents including a fully covered self-expandable metallic stent (SEMS) and lumen-apposing metal stent (LAMS). However, to date there have been no randomized trials to compare these devices. This study aimed to compare the efficacy and safety of the SEMS versus LAMS for EUS-guided drainage of EPCs. Methods A phase IIB randomized trial was designed to compare the SEMS versus LAMS for the treatment of EPCs. Technical success, clinical success, adverse events (AEs), and procedure time were evaluated. A sample size of 42 patients was determined. Results There was no difference between the two groups in technical (LAMS 80.95% vs 100% SEMS, p=0.107), clinical (LAMS 85.71% vs 95.24% SEMS, p=0.606) or radiological success (LAMS 92.86% vs 83.33% SEMS, p=0.613). There was no difference in AEs including stent migration rate and mortality. The procedure time was longer in the LAMS group (mean time 43.81 min versus 24.43 min, p=0.001). There was also a difference in the number of intra-procedure complications (5 LAMS vs 0 SEMS, p=0.048). Conclusion SEMS and LAMS have similar technical, clinical, and radiological success as well as AEs. However, SEMS has a shorter procedure time and fewer intra-procedure complications compared to non-electrocautery-enhanced LAMS in this phase IIB randomized controlled trial (RCT). The choice of the type of stent used for EUS drainage of EPCs should consider device availability, costs, and personal and local experience.
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Affiliation(s)
- Marcos Eduardo Lera Dos Santos
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, BRA
| | - Igor Mendonça Proença
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, BRA
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - Igor Braga Ribeiro
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - Sergio Eiji Matuguma
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - Spencer Cheng
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - João Remi de Freitas Júnior
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - Gustavo de Oliveira Luz
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - José Jukemura
- Division of Gastrointestinal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, BRA
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, BRA
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6
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Sameera S, Mohammad T, Liao K, Shahid H, Sarkar A, Tyberg A, Kahaleh M. Management of Pancreatic Fluid Collections: An Evidence-based Approach. J Clin Gastroenterol 2023; 57:346-361. [PMID: 36040932 DOI: 10.1097/mcg.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.
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Affiliation(s)
- Sohini Sameera
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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7
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Jo SJ, Moon JH, Lee YN, Park JK, Lee TH, Park SH, Park SI, Jeong S, Lee DH. A novel bipolar electrocautery-enhanced delivery system with a lumen-apposing metal stent for EUS-guided drainage: A porcine study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:263-268. [PMID: 35583204 DOI: 10.1002/jhbp.1180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/02/2022] [Accepted: 03/27/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND An electrocautery-enhanced delivery system with a lumen-apposing metal stent (LAMS) is available for one-step endoscopic ultrasound-guided transmural drainage (EUS-TD). Bipolar electrosurgery has several potential clinical advantages, including reduced collateral thermal damage, enhanced hemostasis, and no requirement for a return electrode plate. In this study, we compared the technical feasibility and safety of a newly developed bipolar electrocautery-enhanced delivery system with a conventional delivery system for EUS-TD using a LAMS in a porcine model. METHOD Ten days before the study, 12 mini pigs underwent common bile duct ligation for EUS-guided gallbladder drainage. Transenteric puncture was performed, followed by placement of a guidewire. In six pigs, a bipolar electrocautery-enhanced delivery system with LAMS (Hot SPAXUS) was inserted over the guidewire and advanced into the gallbladder, without prior dilation of the tract, by applying a bipolar cut current. In the remaining six pigs, a conventional delivery system with LAMS (Cold SPAXUS) was inserted after tract dilatation using a cystotome. The stent was removed after 4 weeks. RESULTS In all pigs, the stent was successfully inserted and deployed in the gallbladder without adverse events. The mean procedure time of EUS-TD was significantly lower in the Hot SPAXUS group than that of the Cold SPAXUS group (mean ± standard deviation: 188.7 ± 5.2 vs 449.5 ± 97.5 s, P = .0019). Stent migration was not observed, and all stents were removed successfully. CONCLUSIONS Endoscopic ultrasound-guided transmural drainage using a bipolar electrocautery-enhanced LAMS is feasible for reducing the procedure time while maintaining the high success rate and safety of conventional LAMS.
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Affiliation(s)
- Seok Jung Jo
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Jae Keun Park
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Tae Hoon Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Cheonan, Korea
| | | | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
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8
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Jearth V, Rana SS. Endoscopic step up: When and how. Surg Open Sci 2022; 10:135-144. [PMID: 36193259 PMCID: PMC9526220 DOI: 10.1016/j.sopen.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/16/2022] [Accepted: 09/12/2022] [Indexed: 11/01/2022] Open
Abstract
The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.
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9
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Purschke B, Bolm L, Meyer MN, Sato H. Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes. World J Gastroenterol 2022; 28:3383-3397. [PMID: 36158258 PMCID: PMC9346450 DOI: 10.3748/wjg.v28.i27.3383] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/07/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.
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Affiliation(s)
- Birte Purschke
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Louisa Bolm
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Max Nikolaus Meyer
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Hiroki Sato
- Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Department of Gastroenterology, Asahikawa Kosei Hospital, Asahikawa 0788211, Hokkaido, Japan
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10
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Khan S, Chandran S, Chin J, Karim S, Mangira D, Nasr M, Ermerak G, Trinh A, Kia CYH, Mules T, Zad M, Ang TL, Johns E, Tee D, Kaul A, Ratanachu-Ek T, Jirathan-Opas J, Fisher L, Cameron R, Welch C, Lim G, Metz AJ, Moss A, Bassan M, Saxena P, Kaffes A, St John A, Hourigan LF, Tagkalidis P, Weilert F, Vaughan R, Devereaux B. Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. J Gastroenterol Hepatol 2021; 36:3395-3401. [PMID: 34370869 DOI: 10.1111/jgh.15658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 06/05/2021] [Accepted: 07/25/2021] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Saad Khan
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Jerry Chin
- Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Shwan Karim
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Dileep Mangira
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Mohamad Nasr
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Goktug Ermerak
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Andrew Trinh
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher Y H Kia
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Thomas Mules
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Mohammadali Zad
- Department of Gastroenterology, Townsville Hospital, Townsville, Queensland, Australia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Estella Johns
- Department of Gastroenterology, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Derrick Tee
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Abha Kaul
- Department of Gastroenterology, Peninsula Health, Melbourne, Victoria, Australia
| | | | - Jirat Jirathan-Opas
- Department of Gastroenterology, Hatyai Hospital, Hat Yai, Songkhla Province, Thailand
| | - Leon Fisher
- Department of Gastroenterology, Peninsula Health, Melbourne, Victoria, Australia
| | - Rees Cameron
- Department of Gastroenterology, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Christine Welch
- Department of Gastroenterology, Townsville Hospital, Townsville, Queensland, Australia
| | - Gary Lim
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew J Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Milan Bassan
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Arthur Kaffes
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew St John
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Medicine, Toowoomba Hospital, Toowoomba, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Gallipoli Medical Research Institute, School of Medicine, University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Frank Weilert
- Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Rhys Vaughan
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Rai P, Harish KC, Majeed A, Goel A. EUS-guided drainage of pancreatic fluid collection, using a modified technique of cystotome alone without a FNA needle. Saudi J Gastroenterol 2021; 27:283-288. [PMID: 34677161 PMCID: PMC8555769 DOI: 10.4103/sjg.sjg_132_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage for pancreatic fluid collection (PFC) involves puncture with a fine-needle aspiration (FNA) needle, followed by tract dilation involving exchange of multiple accessories, and finally deployment of stent. The procedure is time consuming and carries a risk of loss of wire access and hence technical failure. We used a modified technique with a 10-F cystotome alone instead of a FNA needle and dilators. METHODS We retrospectively analysed records of consecutive patients who had undergone EUS-guided drainage of PFC using a modified technique, with puncture of PFC using a 10-Fcystotome, followed by passage of a guidewire through it into the PFC cavity and deployment of a biflanged, 2-cm-long, fully covered self-expanding metal stent over it. Technical and clinical success rates and procedure time were assessed. RESULTS Forty-five patients underwent PFC drainage, median age was 35 (12-76), and 35 (77.8%) were males. The median (range) duration of symptoms was 125 (38-1080) days, while the median PFC size was 11.8 × 11 × 11 cm, and the follow-up period after stent removal was 111 ± 72 (18-251) weeks. The procedure took 10 (8-12) min and had technical and clinical success rates of 100 and 97.8%, respectively. Minor complications occurred in six (13.3%) patients, while recurrence occurred in one. CONCLUSION EUS-guided drainage of PFC using a cystotome is a quick, effective and safe procedure. It may also be less expensive since it obviates the use of FNA needles and dilators, and is likely to be a useful alternative to the conventional technique.
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Affiliation(s)
- Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India,Address for correspondence: Dr. Praveer Rai, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226014, Uttar Pradesh, India. E-mail:
| | - KC Harish
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Abdul Majeed
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Goel
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Predictors of the need for necrosectomy in patients with walled-off pancreatic necrosis treated with lumen apposition metal stents. Surg Endosc 2021; 36:1339-1346. [PMID: 33660124 DOI: 10.1007/s00464-021-08411-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Endoscopic necrosectomy through lumen apposition metal stents (LAMS) is increasingly being used for complicated walled-off pancreatic necrosis (WOPN), but the need for necrosectomy after stent placement is not well understood. The aim of this study was to evaluate clinical, endoscopic, and radiologic predictors of the need for necrosectomy in patients treated with LAMS. METHODS We retrospectively reviewed patients with WOPN treated with LAMS from 2014 to 2017. Necrosectomy was performed only in patients who had recurrent fever or hemodynamic instability during follow-up. Univariate and multivariate analyses were performed. RESULTS We included 15 patients, 67% men and median age was 75 (54-76) years. Two (13%) presented adverse events, one immediate and one delayed. In the first case, the stent migrated to the gastric cavity during deployment but was relocated in the same procedure. In the second case, the patient presented bleeding on day 36 due to a pseudoaneurysm that was successfully treated with embolization. Clinical success was 100%, but five patients (33%) required endoscopic necrosectomy (4 mechanical and 1 irrigation) and one (7%) required surgical necrosectomy of distant collections. The percentage of necrosis in the collection detected in a previous CT scan (45 [35-66]% vs 10 [5-17]%) was the only factor to predict the need for necrosectomy in the multivariate analysis (OR 1.18 [1.01-1.39]). CONCLUSION LAMS is efficient to treat WOPN but more than a third will need necrosectomy. The percentage of necrosis in the collection detected in the CT scan seems to predict the need for necrosectomy.
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Dorrell R, Pawa S, Pawa R. Endoscopic Management of Pancreatic Fluid Collections. J Clin Med 2021; 10:jcm10020284. [PMID: 33466752 PMCID: PMC7835868 DOI: 10.3390/jcm10020284] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Robert Dorrell
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Swati Pawa
- Department of Medicine, Section of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Rishi Pawa
- Department of Medicine, Section of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
- Correspondence:
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Sato Y, Hara K, Okuno N, Murata S, Hasegawa T, Morinaga H, Kimbara Y, Imai Y, Yamaura H, Inaba Y. Endoscopic necrosectomy through a self-expandable metallic stent placed percutaneously for walled-off pancreatic necrosis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yozo Sato
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shinichi Murata
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takaaki Hasegawa
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroyuki Morinaga
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yuki Kimbara
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yugo Imai
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hidekazu Yamaura
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshitaka Inaba
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
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15
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Li J, Yu Y, Li P, Zhang ST. Advancements in the endoscopic treatment of pancreatic fluid collections. Chronic Dis Transl Med 2020; 6:158-164. [PMID: 32885152 PMCID: PMC7451715 DOI: 10.1016/j.cdtm.2020.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Indexed: 12/12/2022] Open
Abstract
Endoscopic drainage of pancreatic fluid collections (PFCs) with fewer complications and less trauma has gradually replaced surgery or percutaneous drainage to become the first-line treatment for PFCs. In recent years, the differential efficacy of various stent techniques to drain different types of PFCs has been controversial. This review summarizes the clinical applications of endoscopic ultrasound-guided stent placement for PFCs drainage.
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Affiliation(s)
- Jing Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Yang Yu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
| | - Shu-Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing 100050, China
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16
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Comparative Study Evaluating Lumen Apposing Metal Stents Versus Double Pigtail Plastic Stents for Treatment of Walled-Off Necrosis. Pancreas 2020; 49:236-241. [PMID: 31972728 PMCID: PMC7018618 DOI: 10.1097/mpa.0000000000001476] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Lumen-apposing metal stents (LAMSs) are increasingly used for direct endoscopic necrosectomy (DEN) in the management of walled-off necrosis (WON). We compared LAMS and traditional cystoenterostomy in the management of WON. METHODS Retrospective analysis of patients who underwent DEN for management of WON was performed. Primary outcome was rate of WON resolution. Secondary outcomes included technical and clinical success, time and number of procedures until resolution, requirement for alternative therapy, recurrence, and adverse events. RESULTS One hundred twelve patients underwent DEN with LAMS (n = 34) or traditional cystoenterostomy (n = 78). Mean WON size was 90.2 × 60.1 mm, and 61.8% had infected necrosis. Overall WON resolution was similar between LAMS and traditional cystoenterostomy (94.1% vs 92.1%, P = 0.510), with similar number of procedures until resolution (1.5 vs 1.5, P = 0.871). The LAMSs were associated with faster resolution (86.9 vs 133.6 days, P = 0.038), lower recurrence (6.3% vs 23.1%, P = 0.032), and decreased requirement for surgery (0% vs 12.8%, P = 0.031) compared with traditional cystoenterostomy, but higher adverse event rates (41.2% vs 7.7%, P < 0.001). CONCLUSIONS Despite higher adverse event rates, initial LAMS cystoenterostomy for management of WON results in faster resolution, lower recurrence, and decreased requirement for surgery.
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17
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Jagielski M, Smoczyński M, Szeliga J, Adrych K, Jackowski M. Various Endoscopic Techniques for Treatment of Consequences of Acute Necrotizing Pancreatitis: Practical Updates for the Endoscopist. J Clin Med 2020; 9:jcm9010117. [PMID: 31906294 PMCID: PMC7019492 DOI: 10.3390/jcm9010117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/20/2019] [Accepted: 12/30/2019] [Indexed: 12/12/2022] Open
Abstract
Despite great progress in acute pancreatitis (AP) treatment over the last 30 years, treatment of the consequences of acute necrotizing pancreatitis (ANP) remains controversial. While numerous reports on minimally invasive treatment of the consequences of ANP have been published, several aspects of interventional treatment, particularly endoscopy, are still unclear. In this article, we attempt to discuss these aspects and summarize the current knowledge on endoscopic therapy for pancreatic necrosis. Endotherapy has been shown to be a safe and effective minimally invasive treatment modality in patients with consequences of ANP. The evolution of endoscopic techniques has made endoscopic drainage more effective and reduced the use of other minimally invasive therapies for pancreatic necrosis.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 87-100 Toruń, Poland; (J.S.); (M.J.)
- Correspondence:
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (M.S.); (K.A.)
| | - Jacek Szeliga
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 87-100 Toruń, Poland; (J.S.); (M.J.)
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (M.S.); (K.A.)
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 87-100 Toruń, Poland; (J.S.); (M.J.)
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18
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EUS-guided drainage of pancreatic fluid collections using lumen apposing metal stents: An international, multicenter experience. Dig Liver Dis 2019; 51:1557-1561. [PMID: 31272934 DOI: 10.1016/j.dld.2019.05.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 04/28/2019] [Accepted: 05/28/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Lumen apposing metal stents (LAMS) have been used increasingly for drainage of pancreatic fluid collections (PFC). We present an international, multicenter study evaluating the safety and efficacy of LAMS in PFCs. METHODS Consecutive patients undergoing LAMS placement for PFC at 12 international centers were included (ClinicalTrials.gov NCT01522573). Demographics, clinical history, and procedural details were recorded. Technical success was defined as successful LAMS deployment. Clinical success was defined as PFC resolution at three-month follow-up. RESULTS 192 patients were included (140 males (72.9%), mean-age 53.8 years), with mean follow-up of 4.2 months ± 3.8. Mean PFC size was 11.9 cm (range 2-25). The median number of endoscopic interventions was 2 (range 1-14). Etiologies for PFC were gallstone (n = 82, 42.7%), alcohol (n = 50, 26%), idiopathic (n = 26, 13.5%), and other (n = 34, 17.7%). Technical success was achieved in 189 patients (98.4%). Clinical success was observed in 125 of 135 patients (92.6%). Adverse events included bleeding (n = 11, 5.7), infection (n = 2, 1%), and perforation (n = 2, 1%). Three or more endoscopy sessions were a positive predictor for PFC resolution and the only significant predictor for AEs. CONCLUSION LAMS has a high technical and clinical success rate with a low rate of AEs. PFC drainage via LAMS provides a minimally invasive, safe, and efficacious procedure for PFC resolution.
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19
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Ali SE, Benrajab K, Mardini H, Su L, Gabr M, Frandah WM. Anchoring lumen-apposing metal stent with coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: any benefit? Ann Gastroenterol 2019; 32:620-625. [PMID: 31700240 PMCID: PMC6826067 DOI: 10.20524/aog.2019.0414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 07/21/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Anchoring double-pigtail plastic stents (DPSs) within lumen-apposing metal stents (LAMSs) has been proposed to prevent adverse events during endoscopic drainage of pancreatic fluid collections (PFCs). We sought to compare the outcomes of patients who received LAMSs alone and those who received both LAMSs and anchoring DPSs for drainage of PFCs. Methods: A retrospective study was conducted at the University of Kentucky. Patients with PFCs who underwent endoscopic ultrasound-guided drainage using LAMSs, with or without DPSs, between January 2016 and March 2018 were included. Categorical data were analyzed using chi-square tests, and continuous variables using 2-sample t-tests. Adverse events were defined according to the American Society for Gastrointestinal Endoscopy’s Lexicon. The primary outcome was to evaluate the efficacy (PFC resolution), and safety (adverse events) of LAMSs with or without DPSs used to drain PFCs. Results: Fifty-seven patients with PFCs were treated by 2 experienced endoscopists over 26 months. Twenty-one (37%) patients received LAMSs alone, and 36 (63%) received LAMSs plus DPSs. Forty-three patients had walled-off pancreatic necrosis, and 14 patients had pancreatic pseudocyst. Clinical success (resolution of PFCs) was achieved in 15 patients (71.4%) in the LAMSs alone group, and 21 patients (58.3%) with LAMSs plus DPSs (P=0.32). In patients with LAMSs alone, 6 patients (28.6%) had adverse events, while in those with LAMSs plus DPSs, 14 (38.9%) patients had adverse events (P=0.43). Conclusion: No significant difference was identified in fluid resolution or adverse events between patients with LAMSs alone and those with LAMSs plus DPSs.
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Affiliation(s)
- Saad Emhmed Ali
- Department of aInternal Medicine, Division of Hospital Medicine (Saad Emhmed Ali)
| | - Karim Benrajab
- Internal Medicine, Gastroenterology and Hepatology (Karim Benrajab, Houssam Mardini, Moamen Gabr, Wesam M. Frandah)
| | - Houssam Mardini
- Internal Medicine, Gastroenterology and Hepatology (Karim Benrajab, Houssam Mardini, Moamen Gabr, Wesam M. Frandah)
| | - Leon Su
- Statistics, College of Arts and Sciences, College of Public Health (Leon Su), University of Kentucky, USA
| | - Moamen Gabr
- Internal Medicine, Gastroenterology and Hepatology (Karim Benrajab, Houssam Mardini, Moamen Gabr, Wesam M. Frandah)
| | - Wesam M Frandah
- Internal Medicine, Gastroenterology and Hepatology (Karim Benrajab, Houssam Mardini, Moamen Gabr, Wesam M. Frandah)
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20
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Rosenfeld EH, Vogel AM, Jafri M, Burd R, Russell R, Beaudin M, Sandler A, Thakkar R, Falcone RA, Wills H, Upperman J, Burke RV, Escobar MA, Klinkner DB, Gaines BA, Gosain A, Campbell BT, Mooney D, Stallion A, Fenton SJ, Prince JM, Juang D, Kreykes N, Naik-Mathuria BJ. Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children. Pediatr Surg Int 2019; 35:861-867. [PMID: 31161252 DOI: 10.1007/s00383-019-04492-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE III STUDY TYPE: Case series.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Surgery, Baylor College of Medicine, 6701 Fannin Street # 1210, Houston, TX, 77030, USA
| | - Adam M Vogel
- Department of Surgery, Saint Louis University Children's Hospital, St. Louis, MO, USA
| | - Mubeen Jafri
- Department of Surgery, Randall Children's Hospital at Legacy Emmanuel, Portland, OR, USA.,Doernbecher Children's Hospital Oregon Health and Science University, Portland, OR, USA
| | - Randall Burd
- Department of Surgery, Children's National Medical Center, Washington, DC, USA
| | - Robert Russell
- Department of Surgery, Children's of Alabama, Birmingham, AL, UK
| | - Marianne Beaudin
- Department of Surgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Alexis Sandler
- Department of Surgery, Children's National Medical Center, Washington, DC, USA
| | - Rajan Thakkar
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard A Falcone
- Department of Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Hale Wills
- Department of Surgery, Hasbro Children's Hospital, Providence, RI, USA
| | - Jeffrey Upperman
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Rita V Burke
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Mauricio A Escobar
- Department of Surgery, MultiCare Mary Bridge Children's Hospital and Health Center, Tacoma, WA, USA
| | | | | | - Ankush Gosain
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Brendan T Campbell
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT, USA
| | - David Mooney
- Department of Surgery, Boston Children's, Boston, MA, USA
| | - Anthony Stallion
- Department of Surgery, Carolinas HealthCare System, Charlotte, NC, USA
| | - Stephon J Fenton
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jose M Prince
- Department of Surgery, Cohen's Children's Hospital, Aurora, CO, USA
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | | | - Bindi J Naik-Mathuria
- Department of Surgery, Baylor College of Medicine, 6701 Fannin Street # 1210, Houston, TX, 77030, USA.
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Tamura T, Itonaga M, Tanioka K, Kawaji Y, Nuta J, Hatamaru K, Yamashita Y, Yoshida T, Ida Y, Maekita T, Iguchi M, Kitano M. Radical treatment for walled-off necrosis: Transmural nasocyst continuous irrigation. Dig Endosc 2019; 31:307-315. [PMID: 30565758 DOI: 10.1111/den.13319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Treatment efficiency of walled-off necrosis (WON) using endoscopic ultrasound-guided drainage (EUS-D) with a double pigtail stent (DPS) is limited. Endoscopic necrosectomy is often carried out if EUS-D fails. However, endoscopic necrosectomy is associated with significant morbidity and mortality. Thus, we developed transmural nasocyst continuous irrigation (TNCCI) as an alternative therapeutic option for WON. This study aimed to evaluate the usefulness of TNCCI therapy for WON. METHODS Between April 2009 and March 2018, 19 of 39 patients admitted with WON underwent EUS-D. Ten consecutive patients also received TNCCI therapy (TNCCI group) between May 2015 and March 2018. TNCCI was carried out by inserting an external tube from the gastroduodenal lumen into the WON under endoscopic ultrasonography guidance and then continuously irrigating the WON with saline at a rate of 40 ml/h. Nine consecutive patients who underwent EUS-D without TNCCI therapy between April 2009 and April 2015 were used for comparison (control group). Various parameters were compared between the TNCCI and control groups. RESULTS Time taken to reduce WON (6 vs 32 days, P = 0.001), implementation rate of endoscopic necrosectomy (0% vs 55.6%, P = 0.01), and number of endoscopic necrosectomy sessions per patient (0 vs 0.8 ± 1.0, P = 0.008) were significantly lower in the TNCCI group than in the control group. CONCLUSIONS Walled-off necrosis can be effectively and safely treated by endoscopic drainage with a DPS and TNCCI. This technique can be an alternative therapeutic option before carrying out endoscopic necrosectomy.
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Affiliation(s)
- Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Itonaga
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kensuke Tanioka
- Clinical Study Support Center, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yuki Kawaji
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Junya Nuta
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Keiichi Hatamaru
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takeichi Yoshida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshiyuki Ida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takao Maekita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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22
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Wang Z, Zhao S, Meng Q, Wang S, Chen Y, Wang F, Li Q, Yao J, Du Y, Jin Z, Bai Y, Li Z, Wang D. Comparison of three different stents for endoscopic ultrasound-guided drainage of pancreatic fluid collection: A large retrospective study. J Gastroenterol Hepatol 2019; 34:791-798. [PMID: 30475420 DOI: 10.1111/jgh.14557] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic transmural drainage has been recognized as the first-line treatment for pancreatic fluid collection (PFC). Currently, three different types of stents have been extensively applied, including double pigtail plastic stent (PS), fully covered self-expanding metal stent (FCSEMS), and novel lumen-apposing metal stent (LAMS). Nonetheless, limited data are available about the comparison among them in terms of their clinical outcomes and safety for endoscopic ultrasound-guided drainage of PFC. METHODS The current retrospective study was carried on 160 PFC patients undergoing endoscopic ultrasound-guided drainage from 2010 to 2018 at a single tertiary care center. Patients were divided into three groups based on different drainage ways: drainage using PS, FCSEMS, or LAMS. RESULTS A total of 160 PFC patients (104 male and 56 female) were analyzed in this retrospective study, including 62 patients drained with PS, 28 with FCSEMS, and 70 with LAMS. Typically, the technical success (93.5% vs 96.4% vs 94.3%, P = 1.000) and treatment success rates (84.6% vs 85.2% vs 89.2%, P = 0.763) were similar between PS, FCSEMS, and LAMS. With regard to major adverse events, four patients (FCSEMS: n = 2 and LAMS: n = 2) with pseudoaneurysms developed severe bleeding; among them, 75% (3/4) of patients were observed within 2 weeks after intervention, and two patients in LAMS group died. CONCLUSIONS There are no significant differences in the clinical outcomes of PFC patients treated with PS, FCSEMS, or LAMS. Nonetheless, severe (or even fatal) bleeding may occur at the early stage after metal stent placement, which should be paid particular attention to.
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Affiliation(s)
- Zhijie Wang
- Department of Gastroenterology, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Gongli Hospital, Second Military Medical University, Shanghai, China
| | - Shengbing Zhao
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Qianqian Meng
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Shuling Wang
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Yan Chen
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Fuming Wang
- Intervention Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Li
- Department of Gastroenterology, Zaozhuang Hospital of Zaozhuang Mining Group, Zaozhuang, Shandong, China
| | - Jun Yao
- Department of Gastroenterology, Jinan University of Second Clinical Medical Sciences, Shenzhen Municipal People's Hospital, Shenzhen City, Guangdong, China
| | - Yiqi Du
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Yu Bai
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Zhaoshen Li
- Department of Gastroenterology, Second Military Medical University, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Gongli Hospital, Second Military Medical University, Shanghai, China
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23
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Yao Y, Zhang D, Guo J, Qi K, Li F, Zhu J, Wang D, Chen J, Xu C, Wang L, Wang K, Jin Z, Li Z. A novel self-expanding biflanged metal stent vs tubular metal stent for EUS-guided transmural drainage of pancreatic pseudocyst: A retrospective, cohort study. Medicine (Baltimore) 2019; 98:e14179. [PMID: 30653165 PMCID: PMC6370115 DOI: 10.1097/md.0000000000014179] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Although endoscopic ultrasound (EUS)-guided transmural drainage of pancreatic fluid collections with metal stents is generally preferred over plastic stents, its superiority among different types of metal stents has not yet been well studied. We conducted this study to compare clinical outcomes and complications of a novel self-expanding biflanged metal stent (BFMS) and a traditional-shaped tubular metal stent (TMS) in treating pancreatic pseudocyst (PPC).This was a retrospective analysis on consecutive patients with PPC underwent EUS-guided transmural drainage with either TMS or BFMS in a single tertiary center with expertise in management of complex biliary and pancreatic problems. The technical and functional success rate, reintervention, complications, and recurrence rate were evaluated.From September 2013 to January 2018, 125 patients (66.4% male, median age 47 years) underwent EUS-guided transmural drainage for PPC. Among them, 49 used TMS and 76 used BFMS. All patients met the inclusion criteria that cyst diameter was >6 cm or the distance between cyst and stomach wall was shorter than 1 cm. There was no difference in technical success (98% vs 97.4%, P = 1.0) or functional success rate (87.8% vs 92.1%, P = .54) using 2 types of metal stents. However, more procedure related complications occurred in TMS than in BFMS group. TMS group had a much higher migration rate than BFMS group (14.6% vs 0, P = .001), even though there was no significant difference in bleeding, infection, or death rate between 2 groups. With similar clinical outcomes, TMS group required more additional plastic stent placement than BFMS group for better drainage.TMS and BFMS placement can both be considered as methods of endoscopic transmural PPC drainage with equal efficacy, whereas BFMS could be preferred for fewer complications or less need of additional plastic stent placement.
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Affiliation(s)
- Yao Yao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Dingguo Zhang
- Department of Gastroenterology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Jiefang Guo
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Ke Qi
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Feng Li
- Department of Gastroenterology and Hepatology, CHRISTUS Mother Frances Hospital, Tyler, TX
| | - Jianwei Zhu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Dong Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Jie Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Can Xu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Luowei Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Kaixuan Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University
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24
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Abstract
Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents.
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Affiliation(s)
- Steven Shamah
- University of Chicago Medical Center, CERT Division, 5700 South Maryland Avenue, MC 8043, Chicago, IL 60637, USA
| | - Patrick I Okolo
- Division of Gastroenterology, Lenox Hill Hospital, 100 East 77th Street, 2nd Floor, New York, NY 10075, USA.
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25
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Jiang TA, Xie LT. Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections. World J Clin Cases 2018; 6:308-321. [PMID: 30283794 PMCID: PMC6163138 DOI: 10.12998/wjcc.v6.i10.308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/05/2018] [Accepted: 07/16/2018] [Indexed: 02/05/2023] Open
Abstract
Pancreatic fluid collections (PFCs), common sequelae of acute or chronic pancreatitis, are broadly classified as pancreatic pseudocysts or walled-off necrosis according to the revised Atlanta classification. Endoscopic ultrasound (EUS)-guided drainage is often considered a standard first-line therapy preferable to surgical or interventional radiology approaches for patients with symptomatic PFC. EUS-guided drainage is effective and successful; it has a technical success rate of 90%-100% and a clinical success rate of 85%-98%. Recent studies have shown a 5%-30% adverse events (AEs) rate for the procedure. The most common AEs include infection, hemorrhage, perforation and stent migration. Hemorrhage, a severe and sometimes deadly outcome, requires a well-organized and appropriate treatment strategy. However, few studies have reported the integrated management of hemorrhage during EUS-guided drainage of PFC. Establishing a practical therapeutic strategy is an essential and significant step in standardized management. The aim of this review is to describe the current situation of EUS-guided drainage of PFCs, including the etiology and treatment of procedure-related bleeding as well as current problems and future perspectives. We propose a novel and meaningful algorithm for systematically managing hemorrhage events. To our limited knowledge, a multidisciplinary algorithm for managing EUS-guided drainage for PFC-related bleeding has not been previously reported.
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Affiliation(s)
- Tian-An Jiang
- Department of Ultrasound, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Li-Ting Xie
- Department of Ultrasound, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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26
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Yoon SB, Chang JH, Lee IS. [Treatment of Pancreatic Fluid Collections]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:97-103. [PMID: 30270591 DOI: 10.4166/kjg.2018.72.3.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pancreatic Fluid Collection (PFC) develops as a result of acute pancreatitis, chronic pancreatitis, trauma, and postoperation. Although percutaneous drainage, surgery and Endoscopic Retrograde Panceatogram are used as conventional treatments in complicated PFC, the clinical course of PFC is unsatisfactory due to its clinical success rate and the risk of procedure-related complications. Endoscopic ultrasonography-guided transmural drainage of PFC is a safe and effective modality for the management of PFC, particularly in patients with pancreas necrosis. A range of techniques and stents have been introduced and a newly designed metal stent is now available.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyuck Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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27
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Falk V, Kenshil S, Sandha S, Teshima C, D'Souza P, Sandha G. The Evolution of EUS-Guided Transluminal Drainage for the Treatment of Pancreatic Fluid Collections: A Comparison of Clinical and Cost Outcomes with Double-Pigtail Plastic Stents, Conventional Metal Stents and Lumen-Apposing Metal Stents. J Can Assoc Gastroenterol 2018; 3:26-35. [PMID: 34169224 PMCID: PMC8218535 DOI: 10.1093/jcag/gwy049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background While most pancreatic fluid collections (PFCs) resolve spontaneously, endoscopic ultrasound-guided transluminal drainage (EUS-TD) may be necessary. EUS-TD has evolved from multiple double-pigtail plastic stents (DPPS) to fully covered self-expanding metal stents (FCSEMS) and lumen-apposing metal stents (LAMS). This study compares clinical attributes of DPPS, FCSEMS and LAMS. Methods This is a single-centre retrospective review of EUS-TD for PFCs. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, hospital length of stay (HLOS), number of endoscopies, need for necrosectomy, adverse events (AEs) and overall cost. Results Fifty-eight patients (37 male, average age 49 years) underwent a total of 60 EUS-TD procedures for PFCs (average size 11.2 cm with 29 pseudocysts and 29 walled-off necrosis). Ten patients (17%) underwent EUS-TD with DPPS and 48 patients (83%) with metal stents (32 FCSEMS, 16 LAMS). Overall technical and clinical success was 100% and 84%, respectively. Lumen-apposing metal stents had shorter procedure times (14.9 versus 63.6 DPPS, 39.1 min FCSEMS, P < 0.001), and no difference in AEs (3 of 16 versus 4 of 10 DPPS, 12 of 34 FCSEMS, ns). Double-pigtail plastic stents required more endoscopies (3.7 versus 2.3 LAMS, 2.3 FCSEMS, P = 0.013) and necrosectomies (4 of 10 [40%]) compared with 5 of 34 [15%] in the FCSEMS group and 3 of 16 [19%] in the LAMS group, respectively, P = 0.001) to achieve clinical resolution. The overall cost and HLOS was not significantly different between groups. Conclusion The use of LAMS for PFCs is not associated with any significant increase in cost despite technical (shorter procedure time) and clinical advantages (shorter indwell time, reduced need for necrosectomy and no increase in AEs).
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Affiliation(s)
- Vanessa Falk
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada.,Department of General Surgery, Medical University of Newfoundland, St. John's, Newfoundland, Canada
| | - Sana Kenshil
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Simrat Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Christopher Teshima
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Pernilla D'Souza
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Gurpal Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
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28
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Brimhall B, Han S, Tatman PD, Clark TJ, Wani S, Brauer B, Edmundowicz S, Wagh MS, Attwell A, Hammad H, Shah RJ. Increased Incidence of Pseudoaneurysm Bleeding With Lumen-Apposing Metal Stents Compared to Double-Pigtail Plastic Stents in Patients With Peripancreatic Fluid Collections. Clin Gastroenterol Hepatol 2018; 16:1521-1528. [PMID: 29474970 PMCID: PMC6429551 DOI: 10.1016/j.cgh.2018.02.021] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/26/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been few studies that compared the effects of lumen-apposing metal stents (LAMS) and double-pigtail plastic stents (DPS) in patients with peripancreatic fluid collections from pancreatitis. We aimed to compare technical and clinical success and adverse events in patients who received LAMS vs DPS for pancreatic pseudocysts and walled-off necrosis. METHODS We performed a retrospective study of endoscopic ultrasound-mediated drainage in 149 patients (65% male; mean age, 47 y) with pancreatic pseudocysts or walled-off necrosis (97 received LAMS and 152 received DPS), from January 2011 through September 2016 at a single center. We collected data on patient characteristics, outcomes, hospitalizations, and imaging findings. Technical success was defined as LAMS insertion or a minimum of 2 DPS. Clinical success was defined as resolution of pancreatic pseudocysts or walled-off necrosis based on imaging results. The primary outcome was resolution of peripancreatic fluid collection with reduced abdominal pain or obstructive signs or symptoms. Secondary outcomes included the identification and management of adverse events, number of additional procedures required to resolve fluid collection, and the recurrence of fluid collection. RESULTS Patients who received LAMS had larger peripancreatic fluid collections than patients who received DPS prior to intervention (P = .001), and underwent an average 1.7 interventions vs 1.9 interventions for patients who received DPS (P = .93). Technical success was achieved for 90 patients with LAMS (92.8%) vs 137 patients with DPS (90.1%) (odds ratio [OR] for success with DPS, 0.82; 95% CI, 0.33-2.0; P = .67). Despite larger fluid collections in the LAMS group, there was no significant difference in proportions of patients with clinical success following placement of LAMS (82 of 84 patients, 97.6%) vs DPS (118 of 122 patients, 96.7%) (OR for clinical success with DPS, 0.73; 95% CI, 0.13-4.0; P = .71). Adverse events developed in 24 patients who received LAMS (24.7%) vs 27 patients who received DPS (17.8%) (OR for an adverse event in a patient receiving a DPS, 0.82; 95% CI, 0.33-2.0; P = .67). However, patients with LAMS had a higher risk of pseudoaneurysm bleeding than patients with DPS (OR, 10.0; 95% CI, 1.19-84.6; P = .009). CONCLUSIONS In a retrospective study of patients undergoing drainage of pancreatic pseudocysts or walled-off necrosis, we found LAMS and DPS to have comparable rates of technical and clinical success and adverse events. Drainage of walled-off necrosis or pancreatic pseudocysts using DPS was associated with fewer bleeding events overall, including pseudoaneurysm bleeding, but bleeding risk with LAMS should be weighed against the trend of higher actionable perforation and infection rates with DPS.
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Affiliation(s)
- Bryan Brimhall
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samuel Han
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Philip D Tatman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Toshimasa J Clark
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian Brauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Augustin Attwell
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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29
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Teoh AYB, Dhir V, Kida M, Yasuda I, Jin ZD, Seo DW, Almadi M, Ang TL, Hara K, Hilmi I, Itoi T, Lakhtakia S, Matsuda K, Pausawasdi N, Puri R, Tang RS, Wang HP, Yang AM, Hawes R, Varadarajulu S, Yasuda K, Ho LKY. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67:1209-1228. [PMID: 29463614 DOI: 10.1136/gutjnl-2017-314341] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 12/22/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures. METHODS Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question. RESULTS A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required. CONCLUSIONS The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.
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Affiliation(s)
- Anthony Y B Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Mumbai, Maharashtra, India
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara City, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Zhen Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, Seoul, Republic of Korea
| | - Majid Almadi
- Department of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Ida Hilmi
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Koji Matsuda
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Kawasaki, Japan
| | - Nonthalee Pausawasdi
- Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rajesh Puri
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences Medanta, The Medicity, Gurgaon, India
| | - Raymond S Tang
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ai Ming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Dongcheng-qu, Beijing, China
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Kenjiro Yasuda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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30
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Endoscopic Ultrasound-Guided Choledochoduodenostomy Using a Lumen-Apposing Metal Stent in Pancreatic Head Neoplasm-Associated Biliary Obstruction. ACG Case Rep J 2018; 5:e41. [PMID: 29915789 PMCID: PMC5992338 DOI: 10.14309/crj.2018.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 03/23/2018] [Indexed: 01/09/2023] Open
Abstract
Endoscopic ultrasound (EUS)-guided transluminal drainage of obstructed bile duct with conventional metal and plastic stents has been in practice for several years, but this modality carries its own potential complications and obstacles. Nevertheless, the novel Hot AXIOS stent (Boston Scientific Corp., Marlborough, MA) has been shown to overcome some of those factors, which justifies its application in a variety of clinical indications, such as EUS-guided choledochoduodenostomy (EUS-CDS) for biliary drainage after failed endoscopic retrograde cholangiopancreatography. We present a case of EUS-CDS with an electrocautery enhanced lumen-apposing stent for biliary drainage.
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31
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Abstract
The lumen-apposing metal stent is the first stent specifically designed for endoscopic ultrasound-guided transluminal drainage of extraintestinal fluid collections. With the "hot" electrocautery-enhanced delivery system, this platform marks the most recent evolutionary stage of endoscopic therapy of pancreatic fluid collections. The lumen-apposing metal stent platform has made endoscopic drainage of pancreatic fluid collections easier and safer, while serving as a port for safe entry into the cyst cavity to extend the reach of endoscopic diagnosis and therapy. Tools conceived for endoscopic ultrasound-guided transluminal intervention have emerged and are opening the door to new frontiers of endoscopic transluminal therapy.
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Affiliation(s)
- Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, Suite 600, San Francisco, CA 94115, USA.
| | - Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, Suite 600, San Francisco, CA 94115, USA
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32
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Abstract
Numerous lumen-apposing metal stents (LAMS) have been designed for transluminal applications, including complex pancreatic fluid collections (PFCs) and difficult biliary access. Limited high-quality data exist directly comparing the various LAMS models, and their use remains largely dependent on availability and operator expertise. LAMS placement has been streamlined by the addition of electrocautery, allowing for single-step or modified "hot" approach, if desired. Therapeutic endoscopists continue to explore the application of this technology in a variety of clinical scenarios, and future innovations will be needed to meet these evolving clinical demands.
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Affiliation(s)
- Matthew W Stier
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, 5841 South Maryland Avenue, MC4076, Room M421, Chicago, IL 60637, USA
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, 5700 South Maryland Avenue, MC 8043, Chicago, IL 60637, USA.
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33
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Abstract
The last decade has seen dramatic shift in paradigm in the management of pancreatic fluid collections with the rise of endoscopic therapy over radiologic or surgical management. Endosonographic drainage is now considered the gold standard therapy for pancreatic pseudocyst. Infected pancreatic necroses are being offered endoscopic necrosectomy that has been facilitated by the arrival on the market of large diameter lumen-apposing metal stent. Severe pancreatitis or failure to thrive should receive enteral nutrition while pancreatic ductal disruption or strictures are best treated by pancreatic stenting.
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Affiliation(s)
- Iman Andalib
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
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34
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EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates. Gastrointest Endosc 2018; 87:150-157. [PMID: 28713067 DOI: 10.1016/j.gie.2017.06.029] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/20/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Transmural drainage with double-pigtail plastic stents (DPPSs) was the mainstay of endoscopic therapy for symptomatic peripancreatic fluid collections (PPFCs) until the introduction of lumen-apposing covered self-expanding metal stents (LAMSs). Currently, there are limited data regarding the efficacy and adverse event rate of LAMSs compared with DPPSs. METHODS A retrospective analysis of EUS-guided PPFC drainage at a single tertiary care center between 2008 and 2015 was performed. Patients were classified based on drainage method: DPPSs and LAMSs. Adverse event rates, unplanned endoscopic procedures/necrosectomies, and PPFC resolution within 6 months were recorded. Significant bleeding was defined as necessitating transfusion or requiring endoscopic treatment/radiographic embolization. Subsequent endoscopic procedures were defined as unplanned procedures; stent removals were excluded. RESULTS A total of 103 patients met inclusion criteria (84 DPPSs, 19 LAMSs). PPFCs were classified as walled-off necrosis (WON) in 23 (14 DPPSs, 9 LAMSs). There were significantly more bleeding episodes in the LAMS group (4 [19%]: 2 splenic artery pseudo-aneurysms, 1 collateral vessel bleed, 1 intracavitary variceal bleed; P = .0003) than in the DPPS group (1 (1%]: stent erosion into the gastric wall). One perforation occurred in the DPPS group. Unplanned repeat endoscopy was more frequent in the LAMS group (10% vs 26%, P = .07). Among retreated LAMS patients in with WON, 5 (56%) had obstruction by necrotic debris. In patients for whom follow-up was available, 67 of 70 (96%) with DPPSs and 16 of 17 (94%) with LAMSs had resolution of PPFCs within 6 months (P = .78). CONCLUSIONS DPPSs and LAMSs are effective methods for treatment of PPFCs. In our cohort, use of LAMSs was associated with significantly higher rates of procedure-related bleeding and greater need for repeat endoscopic intervention.
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Chen Y, Zhu H, Jin Z, Li Z, Du Y. An unusual complication of cardia occlusion with lumen-apposing metal stent therapy for pancreatic pseudocyst. Endosc Ultrasound 2018; 7:61-63. [PMID: 29451171 PMCID: PMC5838730 DOI: 10.4103/eus.eus_99_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Yan Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Huiyun Zhu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yiqi Du
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
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Bekkali NLH, Nayar MK, Leeds JS, Charnley RM, Huggett MT, Oppong KW. A comparison of outcomes between a lumen-apposing metal stent with electrocautery-enhanced delivery system and a bi-flanged metal stent for drainage of walled-off pancreatic necrosis. Endosc Int Open 2017; 5:E1189-E1196. [PMID: 29202002 PMCID: PMC5698007 DOI: 10.1055/s-0043-120831] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Bi-flanged metal stents (BFMS) have shown promise in the drainage of walled-off pancreatic necrosis (WON), but their placement requires multiple steps and the use of other devices. More recently, a novel device consisting of a combined lumen-apposing metal stent (LAMS) and electrocautery-enhanced delivery system has been introduced. The aim of this study was to compare the placement and outcomes of the two devices. PATIENTS AND METHODS This was a retrospective review of consecutive patients undergoing endoscopic ultrasound-guided placement of BFMS or LAMS for drainage of symptomatic WON. Data from procedures between October 2012 and December 2016 were taken from a prospectively maintained database. We compared technical and clinical success, procedure time, costs, and composite end point of significant events (adverse events, stent migration, additional percutaneous drainage) between BFMS and LAMS. RESULTS 72 consecutive patients underwent placement of BFMS (40 patients, 44 stents) or LAMS (32 patients, 33 stents). Technical success was 91 % for BFMS and 97 % for LAMS. Clinical success was 65 % vs. 78 %, respectively. Median in-room procedure time was significantly shorter in the LAMS group (45 minutes [range 30 - 80]) than in the BFMS group (62.5 minutes [range 35 - 135]; P < 0.001) and fewer direct endoscopic necrosectomies (DEN) were performed (median 1 [0 - 2.0] vs. 2 [0 - 3.7], respectively; P = 0.005). If only inpatients were considered (35 BFMS and 19 LAMS), there was no significant difference in DEN 2 (range 0 - 11) and 2 (range 0 - 8), respectively. The composite end point of 32 % vs. 24 % was not significantly different. Median procedural costs for all patients with successful stent placement for WON treatment was €4427 (range 1630 - 12 926) for BFMS vs. €3500 (range 2509 - 13 393) for LAMS ( P = 0.10). CONCLUSION LAMS was superior to BFMS in terms of procedure time, with comparable adverse events, success, and costs.
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Affiliation(s)
- Noor L. H. Bekkali
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Manu K. Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John S. Leeds
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Richard M. Charnley
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Matthew T. Huggett
- Department of Gastroenterology, St. James’s University Hospital, Leeds, United Kingdom
| | - Kofi W. Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Corresponding author Kofi W. Oppong, MD HPB UnitFreeman HospitalNewcastle upon Tyne NE7 7DNUnited Kingdom+44-191-2231249
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Law ST, De La SernaHiguera C, Simón PG, Pérez-MirandaCastillo M. Comparison of clinical efficacies and safeties of lumen-apposing metal stent and conventional-type metal stent-assisted EUS-guided pancreatic wall-off necrosis drainage: a real-life experience in a tertiary hospital. Surg Endosc 2017; 32:2448-2453. [PMID: 29101565 DOI: 10.1007/s00464-017-5946-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 10/17/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage of pancreatic wall-off necrosis (WON) with transmural stent is regarded as firstline therapy. We aimed at comparing its efficacy and safety with using fully covered self-expandable metal stent (FCSEMS) and lumen-apposing metal stent (LAMS). METHODS A retrospective review was performed on all consecutive patients with pancreatic WONs who underwent EUS-guided drainage by either FCSEMS or LAMS. RESULTS From 2011 to 2016, 68 patients (66.2% male, median age, 66.5 years) underwent WON drainage (22/68 (32.4%) using FCSEMSs of size 10 × 60 mm (14/22, Hanarostent; 8/22 Wallflex); 46/68 (67.6%) using LAMSs (38/46 and 8/46 with AXIOS of size 15 × 10 mm and 10 × 10 mm, respectively). These two groups were matched for age (66 vs. 70 years, p 0.514), APACHE II (11.5 vs. 10, p 0.693), causes [72.7 vs. 80.4% by gallstone pancreatitis (p 0.472); 9.1 vs. 10.9% by alcoholism (p 0.818)], WON size (8.5 vs. 9 cm, p 0.322), location (36.4 vs. 26.1% at pancreatic head, p 0.384; 54.5 vs. 65.2% at body/tail, p 0.395), and enterostomy site [63.6 vs. 76.1% via transgastric (p 0.285); 31.8 vs. 19.6% via transduodenal (p 0.267)] and their number of necrosectomy (p 0.978). The technical (100 vs. 93.5%, p 0.219) and clinical (95.5 vs. 93.5%, p 0.749) success and adverse event (22.7 vs. 39.1%, p 0.180; 9.1 vs. 19.6% with bleeding, p 0.271; 4.5 vs. 13% with spontaneous stent migration, p 0.28; 9.1 vs. 6.5% with dislodgement during necrosectomy, p 0.704) of the two groups were comparable without significant different. However, the LAMS group associated with early stent revision compared with FCSEMS group (log rank p 0.048). CONCLUSIONS EUS-guided drainage of WON using FCSEMSs and LAMSs are comparable in efficacy and safety; however, the latter is associated with early stent revision.
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Affiliation(s)
- Siu Tong Law
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong.
| | - Carlos De La SernaHiguera
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Paula Gil Simón
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
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DeSimone ML, Asombang AW, Berzin TM. Lumen apposing metal stents for pancreatic fluid collections: Recognition and management of complications. World J Gastrointest Endosc 2017; 9:456-463. [PMID: 28979710 PMCID: PMC5605345 DOI: 10.4253/wjge.v9.i9.456] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/02/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023] Open
Abstract
For patients recovering from acute pancreatitis, the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery, and introduces difficult management decisions with regard to when, whether, and how the collection should be drained. Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction. Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement), and the placement of percutaneous drains. Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients, when local expertise is available. Lumen-apposing metal stents (LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections, and less commonly, for other indications, such as gallbladder drainage. Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding, migration, buried stent, stent occlusion, and perforation. Because of the patient complexity associated with severe pancreatitis, management of pancreatic fluid collections can be a complex and multidisciplinary endeavor. Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques, including how to recognize and manage expected complications.
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Affiliation(s)
- Michael L DeSimone
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Akwi W Asombang
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Tarantino I, Ligresti D, Tuzzolino F, Barresi L, Curcio G, Granata A, Traina M. Clinical impact of EUS treatment of walled-off pancreatic necrosis with dedicated devices. Endosc Int Open 2017; 5:E784-E791. [PMID: 28791329 PMCID: PMC5546896 DOI: 10.1055/s-0043-112494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/29/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Walled-off pancreatic necrosis (WOPN) represents the major risk factor for sepsis-related multiple organ failure. Surgical debridement is an invasive approach associated with high rates of adverse events (AEs) and death. As an alternative, endoscopic ultrasound-guided cysto-gastro-anastomosis has emerged as an effective treatment for WOPNs. Recently a new dedicated-lumen apposing metal stent (LAMS) has been used with satisfactory results in treating peri-pancreatic fluid collections, including WOPNs. The primary outcomes of this study were to evaluate survival and clinical success. Secondary outcomes included: technical success, adverse events and recurrence rate. PATIENTS AND METHODS All consecutive patients with infected WOPN between February 2014 and June 2016 were retrospectively reviewed. Patients underwent placement of a new LAMS incorporated in an electrocautery-enhanced delivery system and direct endoscopic necrosectomy (DEN). DEN was performed immediately after stent deployment and repeated every 3 to 7 days until complete resolution. RESULTS In the study period we treated 20 consecutive patients with infected WOPN using the new LAMS. Technical success was achieved in 95 % of patients. Clinical success was achieved in 73 % and 84.2 % of patients at 1 and 3 months, respectively. Survival rate was 84.2 % and 79 %. Mean length of hospital stay was 19 days (range 3 - 43). No AEs occurred. Patients were followed up after stent retrieval for a mean time of 554,7 days (range 70 - 986) and no recurrence was observed. CONCLUSIONS DEN following "1-step, exchange-free" LAMS positioning recorded excellent results. We believe that simplicity of procedure plays a key role in terms of safety.
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Affiliation(s)
- Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy,Corresponding author Ilaria Tarantino, MD Endoscopy ServiceDepartment of Diagnostic and Therapeutic ServicesIRCCS-ISMETTVia Tricomi 590127 PalermoItaly+39 091 21 92 400
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Fabio Tuzzolino
- Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Gabriele Curcio
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
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Madácsy L, Kaltsidis H. Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- László Madácsy
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Teaching Hospital, University of Szeged, Kecskemét, Hungary
| | - Harry Kaltsidis
- Department of Gastroenterology, University Hospitals of South Manchester, Manchester, UK
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Nabi Z, Basha J, Reddy DN. Endoscopic management of pancreatic fluid collections-revisited. World J Gastroenterol 2017; 23:2660-2672. [PMID: 28487603 PMCID: PMC5403745 DOI: 10.3748/wjg.v23.i15.2660] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 02/27/2017] [Accepted: 03/21/2017] [Indexed: 02/06/2023] Open
Abstract
The development of pancreatic fluid collections (PFC) is one of the most common complications of acute severe pancreatitis. Most of the acute pancreatic fluid collections resolve and do not require endoscopic drainage. However, a substantial proportion of acute necrotic collections get walled off and may require drainage. Endoscopic drainage of PFC is now the preferred mode of drainage due to reduced morbidity and mortality as compared to surgical or percutaneous drainage. With the introduction of new metal stents, the efficiency of endoscopic drainage has improved and the task of direct endoscopic necrosectomy has become easier. The requirement of re-intervention is less with new metal stents as compared to plastic stents. However, endoscopic drainage is not free of adverse events. Severe complications including bleeding, perforation, sepsis and embolism have been described with endoscopic approach to PFC. Therefore, the endoscopic management of PFC is a multidisciplinary affair and involves interventional radiologists as well as GI surgeons to deal with unplanned adverse events and failures. In this review we discuss the recent advances and controversies in the endoscopic management of PFC.
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The role of endoscopic intervention in the management of inflammatory pancreatic fluid collections. Eur J Gastroenterol Hepatol 2017; 29:371-379. [PMID: 28009718 DOI: 10.1097/meg.0000000000000818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis, or less commonly, pancreatic trauma or surgery. The revised Atlanta Classification categorizes PFCs as acute or chronic, with further subclassification of acute collections into acute peripancreatic collections and acute necrotic collections and of chronic fluid collections into pseudocysts and walled-off pancreatic necrosis. Acute PFCs are generally only subjected to an intervention when they are infected and not responding to antibiotics and are not managed endoscopically. Chronic PFCs, both pseudocysts and walled-off pancreatic necrosis, require intervention only when symptomatic or enlarging over time. Endoscopic ultrasound-guided drainage has become the mainstay of management for chronic PFCs that require intervention. Developments in medical devices over the past few years have significantly simplified and shortened the duration of the procedure itself, but the optimum choice of stent in different clinical scenarios remains to be defined, as does the place of endoscopic necrosectomy. To optimize outcomes, these patients should undergo a careful preprocedure workup and discussion in a multidisciplinary environment and procedures should be carried out in high-volume pancreatic units.
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Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc 2017; 85:758-765. [PMID: 27566053 DOI: 10.1016/j.gie.2016.08.014] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 08/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic transmural drainage/debridement of pancreatic walled-off necrosis (WON) has been performed using double-pigtail plastic (DP), fully covered self-expanding metal stents (FCSEMSs), or the novel lumen-apposing fully covered self-expanding metal stent (LAMS). Our aim was to perform a retrospective cohort study to compare the clinical outcomes and adverse events of EUS-guided drainage/debridement of WON with DP stents, FCSEMSs, and LAMSs. METHODS Consecutive patients in 2 centers with WON managed by EUS-guided debridement were divided into 3 groups: (1) those who underwent debridement using DP stents, (2) debridement using FCSEMSs, (3) debridement using LAMSs. Technical success (ability to access and drain a WON by placement of transmural stents), early adverse events, number of procedures performed per patient to achieve WON resolution, and long-term success (complete resolution of the WON without need for further reintervention at 6 months after treatment) were evaluated. RESULTS From 2010 to 2015, 313 patients (23.3% female; mean age, 53 years) underwent WON debridement, including 106 who were drained using DP stents, 121 using FCSEMSs, and 86 using LAMSs. The 3 groups were matched for age, cause of the pancreatitis, WON size, and location. The cause of the patients' pancreatitis was gallstones (40.6%), alcohol (30.7%), idiopathic (13.1%), and other causes (15.6%). The mean cyst size was 102 mm (range, 20-510 mm). The mean number of endoscopy sessions was 2.5 (range, 1-13). The technical success rate of stent placement was 99%. Early adverse events were noted in 27 of 313 (8.6%) patients (perforation in 6, bleeding in 8, suprainfection in 9, other in 7). Successful endoscopic therapy was noted in 277 of 313 (89.6%) patients. When comparing the 3 groups, there was no difference in the technical success (P = .37). Early adverse events were significantly lower in the FCSEMS group compared with the DP and LAMS groups (1.6%, 7.5%, and 9.3%; P < .01). At 6-month follow-up, the rate of complete resolution of WON was lower with DP stents compared with FCSEMSs and LAMSs (81% vs 95% vs 90%; P = .001). The mean number of procedures required for WON resolution was significantly lower in the LAMS group compared with the FCSEMS and DP groups (2.2 vs 3 vs 3.6, respectively; P = .04). On multivariable analysis, DP stents remain the sole negative predictor for successful resolution of WON (odds ratio [OR], 0.18; 95% confidence interval, 0.06-0.53; P = .002) after adjusting for age, sex, and WON size. Although there was no significant difference between FCSEMSs and LAMSs for WON resolution, the LAMS was more likely to have early adverse events (OR, 6.6; P = .02). CONCLUSIONS EUS-guided drainage/debridement of WON using FCSEMSs and LAMSs is superior to DP stents in terms of overall treatment efficacy. The number of procedures required for WON resolution was significantly lower with LAMSs compared with FCSEMSs and DP stents.
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Alali A, Mosko J, May G, Teshima C. Endoscopic Ultrasound-Guided Management of Pancreatic Fluid Collections: Update and Review of the Literature. Clin Endosc 2017; 50:117-125. [PMID: 28391671 PMCID: PMC5398360 DOI: 10.5946/ce.2017.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 03/22/2017] [Indexed: 12/19/2022] Open
Abstract
Severe acute pancreatitis is often complicated by the development of pancreatic fluid collections (PFCs), which may be associated with significant morbidity and mortality. It is crucial to accurately classify these collections as a pseudocyst or walled-off necrosis (WON) given significant differences in outcomes and management. Interventions for PFCs have increasingly shifted to less invasive strategies, with endoscopic ultrasound (EUS)-guided methods being shown to be safer and equally effective as more invasive surgical techniques. In recent years, many new developments have improved the safety and efficacy of EUS-guided interventions, such as the introduction of lumen-apposing metal stents (LAMS), direct endoscopic necrosectomy (DEN) and multiple other adjunctive techniques. Despite these developments, treatment of PFCs, and infected WON in particular, continues to be associated with significant morbidity and mortality. In this article, we discuss the EUS-guided management of PFCs while reviewing the latest developments and controversies in the field. We end by summarizing our own approach to managing PFCs.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Gary May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Christopher Teshima
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, ON, Canada
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Bapaye A, Dubale NA, Sheth KA, Bapaye J, Ramesh J, Gadhikar H, Mahajani S, Date S, Pujari R, Gaadhe R. Endoscopic ultrasonography-guided transmural drainage of walled-off pancreatic necrosis: Comparison between a specially designed fully covered bi-flanged metal stent and multiple plastic stents. Dig Endosc 2017; 29:104-110. [PMID: 27463528 DOI: 10.1111/den.12704] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/25/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Endoscopic ultrasonography (EUS)-guided drainage of walled-off necrosis (WON) may be carried out by placement of multiple plastic stents (MPS) or specially designed fully covered bi-flanged metal stents (BFMS). Comparative data on efficacy of these two stent types for WON drainage are limited. This retrospective study compares outcomes of WON drainage using BFMS and MPS. METHODS During a 10-year period, 133 patients underwent EUS-guided WON drainage. MPS or BFMS were placed in a WON cavity through a single puncture, and direct endoscopic necrosectomy (DEN) was carried out whenever clinically necessary. Data in the two cohorts were retrospectively compared for primary outcomes - clinical success, adverse events and mortality; and secondary outcomes - DEN requirement, mean DEN sessions, need for salvage surgery and hospital stay. RESULTS MPS were placed in 61 and BFMS in 72 patients. Patients undergoing BFMS drainage required fewer DEN sessions (mean 1.46 vs 2.74, P < 0.05), had fewer adverse events (5.6% vs 36.1%, P < 0.05), needed salvage surgery less often (2.7% vs 26.2%, P < 0.05), and had significantly shorter hospital stay (4.1 vs 8 days, P < 0.05) compared to those undergoing MPS drainage. There was no difference in DEN requirement (P = 0.217) and mortality (P = 0.5) in both groups. Overall clinical success with BFMS was superior to MPS (94% vs 73.7%, P < 0.05). CONCLUSION BFMS appear to be superior to MPS for EUS-guided WON drainage in terms of clinical success, number of DEN sessions, adverse events, need for salvage surgery and hospital stay.
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Affiliation(s)
- Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Nachiket A Dubale
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Keyur A Sheth
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jay Bapaye
- Smt. Kashibai Navale Medical College, Pune, India
| | - Jayapal Ramesh
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Harshal Gadhikar
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Sheetal Mahajani
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Suhas Date
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Rajendra Pujari
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Ravindra Gaadhe
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Guo J, Saftoiu A, Vilmann P, Fusaroli P, Giovannini M, Mishra G, Rana SS, Ho S, Poley JW, Ang TL, Kalaitzakis E, Siddiqui AA, De La Mora-Levy JG, Lakhtakia S, Bhutani MS, Sharma M, Mukai S, Garg PK, Lee LS, Vila JJ, Artifon E, Adler DG, Sun S. A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy. Endosc Ultrasound 2017; 6:285-291. [PMID: 29063871 PMCID: PMC5664848 DOI: 10.4103/eus.eus_85_17] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.
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Affiliation(s)
- Jintao Guo
- Endoscopy Center, Sheng Jing Hospital of Medical University, Shenyang, China
| | - Adrian Saftoiu
- Department of Endoscopy, University of Medicine and Pharmacy, Craiova, Romania
| | - Peter Vilmann
- Endoscopy Department, GastroUnit, Copenhagen University Hospital, Copenhagen, Denmark
| | - Pietro Fusaroli
- Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Marc Giovannini
- Pathology Unit (Flora Poizat), Institute Paoli-Calmettes, Marseille, France
| | | | - Surinder S Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sammy Ho
- Montefiore Medical Center, New York, USA
| | - Jan-Werner Poley
- Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tiing Leong Ang
- Gastroenterology Department, Changi General Hospital, Singapore
| | - Evangelos Kalaitzakis
- Endoscopy Unit, Digestive Disease Center, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ali A Siddiqui
- Division of Digestive and Liver Diseases, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, USA
| | - Manoop S Bhutani
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Malay Sharma
- Department of Gastroenterology, Jaswant Rai Specialty Hospital, Meerut, Uttar Pradesh, USA
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Pramod Kumar Garg
- Department of Gastroenterology, All Institute of Medical Sciences, New Delhi, India
| | - Linda S Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Juan J Vila
- Endoscopy Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Everson Artifon
- Department of Surgery, Ana Costa Hospital, Sao Paulo, Brazil
| | - Douglas G Adler
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Siyu Sun
- Endoscopy Center, Sheng Jing Hospital of Medical University, Shenyang, China
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Abstract
Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.
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Adler JM, Gardner TB. Lumen-Apposing Metal Stents for Walled-Off Necrosis: How Effective Are They? Clin Gastroenterol Hepatol 2016; 14:1804-1805. [PMID: 27521508 DOI: 10.1016/j.cgh.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 08/07/2016] [Accepted: 08/07/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Jeffrey M Adler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Vazquez-Sequeiros E, Baron TH, Pérez-Miranda M, Sánchez-Yagüe A, Gornals J, Gonzalez-Huix F, de la Serna C, Gonzalez Martin JA, Gimeno-Garcia AZ, Marra-Lopez C, Castellot A, Alberca F, Fernandez-Urien I, Aparicio JR, Legaz ML, Sendino O, Loras C, Subtil JC, Nerin J, Perez-Carreras M, Diaz-Tasende J, Perez G, Repiso A, Vilella A, Dolz C, Alvarez A, Rodriguez S, Esteban JM, Juzgado D, Albillos A. Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry. Gastrointest Endosc 2016; 84:450-457.e2. [PMID: 26970012 DOI: 10.1016/j.gie.2016.02.044] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. METHODS This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery. RESULTS The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome. CONCLUSIONS An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.
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Affiliation(s)
- Enrique Vazquez-Sequeiros
- Endoscopy Unit, Gastroenterology Division, University Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; Gastroenterology Division, University Hospital Quirón, Madrid, Spain
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Manuel Pérez-Miranda
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Andres Sánchez-Yagüe
- Gastroenterology Department, Hospital Costa del Sol, Marbella, Spain; Gastroenterology Department, Vithas Xanit Internacional Hospital, Benalmadena, Spain
| | - Joan Gornals
- Endoscopy Unit, Digestive Disease Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | | | - Carlos de la Serna
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Juan Angel Gonzalez Martin
- Endoscopy Unit, Gastroenterology Division, University Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Antonio Z Gimeno-Garcia
- Gastroenterology Department, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Spain
| | - Carlos Marra-Lopez
- Gastroenterology Department, Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Ana Castellot
- Complejo Hospitalario Universitario Insular Materno Infantil, Gran Canaria, Spain
| | - Fernando Alberca
- Gastroenterology Department, Unidad de Gestión Clínica Digestivo, Hospital Clinico Universitario de la Arrixava, Murcia, Spain
| | | | | | - Maria Luisa Legaz
- Gastroenterology Department, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - Oriol Sendino
- Endoscopy Unit, Gastroenterology Department, Institute of Digestive and Metabolic Diseases, Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Carmen Loras
- Gastroenterology Department, Servei Aparell Digestiu-Unitat d'Endoscòpia, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Jose Carlos Subtil
- Gastroenterology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan Nerin
- Gastroenterology Department, Hospital Clínico Universitario "Lozano Blesa," Zaragoza, Spain
| | - Mercedes Perez-Carreras
- Endoscopy Unit, Gastroenterology Department, Servicio de Medicina de Aparato Digestivo, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jose Diaz-Tasende
- Endoscopy Unit, Gastroenterology Department, Servicio de Medicina de Aparato Digestivo, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Gustavo Perez
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Alejandro Repiso
- Endoscopy Unit, Gastroenterology Department, Hospital Virgen de la Salud, Toledo, Spain
| | - Angels Vilella
- Endoscopy Unit, Gastroenterology Department. Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Carlos Dolz
- Endoscopy Unit, Gastroenterology Department. Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Alberto Alvarez
- Gastroenterology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Santiago Rodriguez
- Gastroenterology Department, Complejo Asistencial Universitario de Zamora, Zamora, Spain
| | | | - Diego Juzgado
- Gastroenterology Division, University Hospital Quirón, Madrid, Spain
| | - Agustin Albillos
- Endoscopy Unit, Gastroenterology Division, University Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
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50
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Tyberg A, Kahaleh M. Endoscopic drainage of pancreatic fluid collections: the inevitable shift to metal. Gastrointest Endosc 2016; 84:458-9. [PMID: 27530479 DOI: 10.1016/j.gie.2016.04.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/27/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Amy Tyberg
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
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