1
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Chon HK, Kozarek RA. History of the Interventional Pancreaticobiliary Endoscopy. Gastrointest Endosc Clin N Am 2024; 34:383-403. [PMID: 38796288 DOI: 10.1016/j.giec.2023.12.001] [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: 05/28/2024]
Abstract
With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.
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Affiliation(s)
- Hyung Ku Chon
- Division of Biliopancreas, Department of Internal Medicine, Wonkwang University Medical School, and Hospital, Iksan, Republic of Korea; Institution of Wonkwang Medical Science, Iksan, Republic of Korea
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1100 Ninth Avenue, Seattle, WA 98101, USA; Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Avenue, Seattle, WA 98101, USA.
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2
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Wu S, Dou X, Li N, Zhu H, Wang L, Liu M, Yu C. Postponed endoscopic necrosectomy results in a lower rate of additional intervention for infected walled-off necrosis. Sci Rep 2024; 14:11610. [PMID: 38773218 PMCID: PMC11109209 DOI: 10.1038/s41598-024-61675-2] [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] [Received: 01/20/2024] [Accepted: 05/08/2024] [Indexed: 05/23/2024] Open
Abstract
Although endoscopic necrosectomy (EN) is more frequently used to manage walled-off necrosis (WON), there is still debate over how much time should pass between the initial stent placement and the first necrosectomy. This study aims to determine the effect of performing EN within different timings after placing the initial stent on clinical outcomes for WON. A retrospective study on infected WON patients compared an early necrosectomy within one week after the initial stent placement with a necrosectomy that was postponed after a week. The primary outcomes compared the rate of clinical success and the need for additional intervention after EN to achieve WON resolution. 77 patients were divided into early and postponed necrosectomy groups. The complete resolution of WON within six months of follow-up was attained in 73.7% and 74.3% of patients in both the early and postponed groups. The early group tended to a greater need for additional intervention after EN (26.8% early necrosectomy vs. 8.3% postponed necrosectomy, P = 0.036). Our study does not demonstrate that early necrosectomy is superior to postponed necrosectomy in terms of clinical success rate, total count of necrosectomy procedures, procedure-related complications, length of hospitalization and prognosis. Conversely, patients in the postponed group received fewer additional interventions.
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Affiliation(s)
- Songting Wu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaotan Dou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Na Li
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Hao Zhu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Mingdong Liu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chenggong Yu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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3
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Khizar H, Yufei H, Yanhua W, Wangyang C, Ying B, Chenyu L, Zhicheng H, Ali K, Jianfeng Y. Safety and efficacy of lumen-apposing metal stents and double-pigtail plastic stents for endoscopic ultrasound-guided drainage of walled-off necrosis; a systematic review and meta-analysis. Ann Med 2023; 55:578-591. [PMID: 36779694 PMCID: PMC9930761 DOI: 10.1080/07853890.2022.2164048] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Patients with walled-off necrosis (WON) are still challenging to treat safely and effectively. Recently, double-pigtail plastic stents (DPS), bi-flanged metallic stents (BFMS), and lumen-apposing metal stents (LAMS) have been employed with endoscopic ultrasound-guided (EUS-guided) drainage. However, there is little solid evidence to support the effectiveness and safety of using stents. This study aims to compare the outcomes of the LAMS and the PS. METHOD Till July 2022, a thorough database search was done, and studies that met the criteria were chosen. By using the RevMan software, the technical and clinical success and other secondary outcomes were calculated. Subgroup analysis was performed between the LAMS and the BFMS. RESULTS Fifteen studies (two randomized controlled trials and thirteen observational) with 687 patients receiving metal stents and 771 patients receiving plastic stents were selected for final analysis. There was no significant risk of bias or publication bias. The odds ratios (OR) for technical and clinical success were 0.36 (95% confidence interval (95% CI) 0.08, 1.52) and 2.26 (95%CI 1.62, 3.15), respectively. The OR for overall adverse events was 0.74 (95% CI 0.41, 1.34). In subgroup analysis, the LAMS and the BFMS showed the same outcomes. CONCLUSION Compared to DPS, LAMS had better clinical outcomes and fewer side effects when treating patients with WON.
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Affiliation(s)
- Hayat Khizar
- Department of Gastroenterology, International Education College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.,Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hu Yufei
- Department of Gastroenterology, The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Wu Yanhua
- Department of Gastroenterology, The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Chen Wangyang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bian Ying
- Department of Gastroenterology, The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Le Chenyu
- Department of Gastroenterology, The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Huang Zhicheng
- Department of Gastroenterology, The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Kamran Ali
- Department of Oncology, The Fourth Affiliated Hospital, International Institute of Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Jianfeng
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, China.,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, China.,Hangzhou Institute of Digestive Diseases, Hangzhou, China
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4
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Gilman AJ, Baron TH. Endoscopic Necrosectomy. Gastrointest Endosc Clin N Am 2023; 33:709-724. [PMID: 37709406 DOI: 10.1016/j.giec.2023.04.010] [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
The management of walled-off necrosis has evolved substantially over the past 23 years since its first description. In this article, we review its history and the evidence supporting modern treatment, which is still subject to heterogeneity across centers and among endoscopists. This allows for creativity and customization of what can be an endoscopic marathon. Our typical practice is discussed with image and video guides aimed at improving procedure success.
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Affiliation(s)
- Andrew J Gilman
- Division of Gastroenterology & Hepatology, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB# 7080, Chapel Hill, NC 27599-7080, USA. https://twitter.com/a_gilman
| | - Todd H Baron
- Division of Gastroenterology & Hepatology, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB# 7080, Chapel Hill, NC 27599-7080, USA.
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5
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Dayyeh BKA, Chandrasekhara V, Shah RJ, Easler JJ, Storm AC, Topazian M, Levy MJ, Martin JA, Petersen BT, Takahashi N, Edmundowicz S, Hammad H, Wagh MS, Wani S, DeWitt J, Bick B, Gromski M, Al Haddad M, Sherman S, Merchant AA, Peetermans JA, Gjata O, McMullen E, Willingham FF. Combined Drainage and Protocolized Necrosectomy Through a Coaxial Lumen-apposing Metal Stent for Pancreatic Walled-off Necrosis: A Prospective Multicenter Trial. Ann Surg 2023; 277:e1072-e1080. [PMID: 35129503 DOI: 10.1097/sla.0000000000005274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluated a protocolized endoscopic necrosectomy approach with a lumen-apposing metal stent (LAMS) in patients with large symptomatic walled-off pancreatic necrosis (WON) comprising significant necrotic content, with or without infection. SUMMARY BACKGROUND DATA Randomized trials have shown similar efficacy of endoscopic treatment compared with surgery for infected WON. DESIGN We conducted a regulatory, prospective, multicenter single-arm clinical trial examining the efficacy and safety of endoscopic ultrasound -guided LAMS with protocolized necrosectomy to treat symptomatic WON ≥6 cm in diameter with >30% solid necrosis. After LAMS placement, protocolized WON assessment was conducted and endoscopic necrosectomy was performed for insufficient WON size reduction and persistent symptoms. Patients with radiographic WON resolution to ≤ 3 cm and/or 60-day LAMS indwell had LAMS removal, then 6-month follow-up. Primary endpoints were probability of radiographic resolution by 60 days and procedure-related serious adverse events. RESULTS Forty consecutive patients were enrolled September 2018 to March 2020, of whom 27 (67.5%) were inpatients and 19 (47.5%) had clinical evidence of infection at their index procedure. Mean WON size was 15.0 ± 5.6 cm with mean 53.2% ± 16.7% solid necrosis. Radiographic WON resolution was seen in 97.5% (95% CI, 86.8%, 99.9%) by 60 days, without recurrence in 34 patients with 6-month follow-up data. Mean time to radiographic WON resolution was 34.1 ± 16.8 days. Serious adverse events occurred in 3 patients (7.5%), including sepsis, vancomycin-resistant enterococcal bacteremia and shock, and upper gastrointestinal bleeding. There were no procedure-related deaths. CONCLUSIONS Endoscopic ultrasound-guided drainage with protocolized endoscopic necrosectomy to treat large symptomatic or infected walled-off necrotic pancreatic collections was highly effective and safe. Clinicaltrials.-gov no: NCT03525808.
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Affiliation(s)
| | | | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Naoki Takahashi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - John DeWitt
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mark Gromski
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Mohammad Al Haddad
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Ambreen A Merchant
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
| | | | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
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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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Pattarapuntakul T, Charoenrit T, Wong T, Netinatsunton N, Ovartlarnporn B, Yaowmaneerat T, Tubtawee T, Boonsri P, Sripongpun P. Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis. Medicina (B Aires) 2023; 59:medicina59030569. [PMID: 36984570 PMCID: PMC10058734 DOI: 10.3390/medicina59030569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.
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Affiliation(s)
- Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
- Correspondence:
| | - Tummarong Charoenrit
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| | - Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| | - Nisa Netinatsunton
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Thanapon Yaowmaneerat
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Teeravut Tubtawee
- Division of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pattira Boonsri
- Division of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
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Lee KJ, Park SW, Park DH, Kim JH, Jung JH, Koh DH, Lee J, Kim MG. Placement of Plastic Stents after Direct Endoscopic Necrosectomy through a Novel Lumen-Apposing Metal Stent for Effective Treatment of Laterally Extended Walled-Off Necrosis: A Pilot Study. J Clin Med 2023; 12:jcm12031125. [PMID: 36769773 PMCID: PMC9917419 DOI: 10.3390/jcm12031125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/17/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Direct endoscopic necrosectomy (DEN) using a lumen-apposing metal stent (LAMS) is a standard therapy for the management of symptomatic walled-off necrosis (WON). Here, we demonstrated the efficacy of the routine placement of long plastic stents after a DEN session to treat laterally extended WON. Patients (n = 6) with symptomatic laterally extended WON who underwent DEN after long plastic stent placement were included. The primary endpoint was clinical efficacy of the procedure. The technical and clinical success rates were 100% without major adverse events. The WON extended to the pelvic cavity or pericolic area, and the WON size was between 18.6 and 35.8 cm in length. The median number of DEN sessions was 10 (range 6-16), and two or three long plastic stents were placed after every DEN session. Only one patient suffered from pneumoperitoneum during DEN, which spontaneously resolved within 20 min. Placement of a long plastic stent after DEN using LAMS is a minimally invasive and effective treatment for symptomatic laterally extended WON. Further studies are needed to define the indications and most suitable patients.
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Affiliation(s)
- Kyong Joo Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
| | - Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
- Correspondence: ; Tel.: +82-31-8086-2858; Fax: +82-31-8086-2029
| | - Da Hae Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
| | - Jung Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
| | - Jang Han Jung
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
| | - Mi Gang Kim
- Health Care Center, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Republic of Korea
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Drainage of Complex Walled-Off Pancreatic Fluid Collections in LAMS Era: A Multicenter Study. Can J Gastroenterol Hepatol 2022; 2022:9250370. [PMID: 36345379 PMCID: PMC9637039 DOI: 10.1155/2022/9250370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The lumen-apposing metal stent (LAMS) has been increasingly used for EUS-guided drainage of symptomatic walled-off pancreatic fluid collection (WOPFC) in recent years. Nevertheless, some WOPFCs may require additional drainage methods including another LAMS as a result of complexity of the lesions. This current study aimed to compare clinical parameters of patients with complex WOPFC requiring LAMS with additional methods (complex WOPFC: group A) versus single LAMS alone (noncomplex WOPFC; group B). METHOD Medical records of patients with complex (group A) versus noncomplex WOPFCs (group B) were reviewed and compared in three centers in Thailand and Malaysia, between January 2016 to December 2020. RESULT 31 patients with WOPFCs were recruited. 6 of 31 (19%) patients were in group A. Multivariate analysis showed that the maximal diameter of WOPFCs in group A was significantly larger than that of group B (18 ± 6 versus 13 ± 3 cm in diameter, respectively, p = 0.021). Solid component proportion was higher in group A versus B (35.8% versus 17.8%, respectively, p = 0.025). The prevalence of pancreatic duct leakage was significantly higher in group A (67% versus 20%, p = 0.23). The need of direct endoscopic necrosectomy (DEN) and the number of DEN sessions were higher in group A versus B (100% vs. 48%, p = 0.020 and 3.5 vs 0 p = 0.031, respectively). CONCLUSIONS Complex WOPFC had larger diameter of lesions, higher proportion of solid component, higher prevalence of pancreatic duct leakage, and higher number of DEN is required than group noncomplex lesions. Trial Registration. This trial is registered with TCTR20180223004.
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10
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Zhai YQ, Ryou M, Thompson CC. Predicting success of direct endoscopic necrosectomy with lumen-apposing metal stents for pancreatic walled-off necrosis. Gastrointest Endosc 2022; 96:522-529.e1. [PMID: 35461888 DOI: 10.1016/j.gie.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/12/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) with lumen-apposing metal stents (LAMSs) is increasingly used in the management of pancreatic walled-off necrosis (WON). However, it still remains unknown which patients will fail to respond to DEN with LAMSs and require additional surgical intervention. Therefore, the aim of our study was to explore predictors of successful DEN with LAMSs for pancreatic WON. METHODS This is a retrospective analysis of a prospectively collected database. All consecutive patients who underwent DEN with LAMSs for pancreatic WON were included. Collected data were demographics, disease severity, morphologic features, and procedure characteristics. Potential factors affecting DEN outcome were predefined and analyzed. RESULTS One hundred one consecutive patients undergoing DEN with LAMSs for WON were identified, among whom 4 patients were excluded for technical failure (n = 1) and previous debridement without LAMSs (n = 3). In the 97 included patients, clinical success was achieved in 79 patients (81.4%). In logistic multivariable regression, 3 independent factors were negatively associated with success of DEN with LAMSs: increasing Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], .70; 95% confidence interval [CI], .55-.90; P = .005), >50% pancreatic necrosis (OR, .16; 95% CI, .03-.77; P = .022), and paracolic gutter extension (OR, .08; 95% CI, .02-.42; P = .003). A receiver-operating characteristic curve of the prediction model with these 3 factors demonstrated an area under the curve of .926. CONCLUSIONS Paracolic gutter extension, increasing Acute Physiology and Chronic Health Evaluation II score, and >50% gland necrosis are negative predictors for success of DEN with LAMSs in WON. This prediction model with nomogram may be helpful in clinical decision-making and prognostication.
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Affiliation(s)
- Ya-Qi Zhai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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11
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Chen L, Li T, Wang B, Cheng Y, Zhao S, Lyu Y. Endoscopic versus percutaneous drainage for pancreatic fluid collection after pancreatic surgery: An up-to-date meta-analysis and systematic review. Asian J Surg 2022; 45:1519-1524. [PMID: 34642049 DOI: 10.1016/j.asjsur.2021.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/03/2021] [Accepted: 09/20/2021] [Indexed: 12/21/2022] Open
Abstract
Endoscopic ultrasound-guided drainage (EUSD) and percutaneous drainage (PD) have reportedly been used for postoperative pancreatic fluid collection (PFC). However, there is limited evidence regarding safety and efficacy in a comparison of EUSD and PD for postoperative PFC. We conducted a search of the databases PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov, to August 2020. Studies comparing EUSD and PD for postoperative PFC were included. The outcomes included technical success, clinical success, adverse events, and recurrence of PFC.We included a total of 6 studies involving 247 patients in the current study. There was no significant difference between EUSD and PD in terms of technical success (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.29-3.12; p = 0.94) and clinical success (OR = 1.36; 95% CI: 0.68-2.72; p = 0.39). PFC recurrence and adverse events were similar between the two groups (OR = 1.82; 95% CI: 0.75-4.37; p = 0.18 and OR = 0.78; 95% CI: 0.31-1.92; p = 0.58, respectively).This meta-analysis confirmed that EUSD has comparable safety and efficacy to PD for postoperative PFC. Additional high-quality studies are required in the future.
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Affiliation(s)
- Liang Chen
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Ting Li
- Department of the Human, Wenzhou Medical University Affiliated Dongyang Hospital; Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Yunxiao Cheng
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Sicong Zhao
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Yunxiao Lyu
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China.
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12
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McGuire SP, Maatman TK, Ceppa EP, House MG, Nakeeb A, Nguyen TK, Schmidt CM, Zyromski NJ. Contemporary Intervention in Necrotizing Pancreatitis: Improved Understanding Changing Practice. J Gastrointest Surg 2022; 26:1445-1452. [PMID: 35419679 DOI: 10.1007/s11605-022-05285-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/05/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than early open pancreatic debridement. We hypothesized that this paradigm shift would be reflected in the intervention, morbidity, and mortality profile of NP patients. STUDY DESIGN Single-institution retrospective review of 767 NP patients treated between 2005 and 2019. Two eras of NP intervention were identified relative to the introduction of a minimally invasive approach to NP. Patients treated between 2005 and 2010 were classified as the "early" group and compared with patients treated between 2011 and 2019, classified as the "late" group. RESULTS In total, 299 NP patients comprised the early group and 468 patients comprised the late group. No differences were seen in patient demographics, comorbidity profile, or NP etiology between groups. Necrosis volume, necrosis location, CT severity index (CTSI), and rates of infected necrosis were similar between groups. No difference was seen in mortality. Mechanical intervention for NP was more common in the early than the late group (86% vs. 73%, p < 0.001). Time to first intervention was similar between groups (79 ± 7d vs. 75 ± 6d). The early group had higher rates of open pancreatic debridement (72% vs. 55%, p < 0.001). Endoscopic intervention was less common in the early than the late group (7% vs. 16%, p < 0.001). NP disease duration was longer in the early than the late group (223 ± 12d vs. 179 ± 7d, p = 0.001). CONCLUSION Contemporary management of necrotizing pancreatitis is marked by less frequent operative debridement and shorter disease duration.
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Affiliation(s)
- Sean P McGuire
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Trang K Nguyen
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN, 46202, USA.
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13
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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14
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Henker R, Beyer G, Lerch MM, Mayerle J, Hoffmeister A. [Overview of relevant clinical recommendations from the new S3 guidelines on acute and chronic pancreatitis]. Chirurg 2022; 93:369-372. [PMID: 35254456 DOI: 10.1007/s00104-022-01598-8] [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] [Accepted: 01/24/2022] [Indexed: 12/07/2022]
Abstract
Acute pancreatitis is a primary sterile inflammation of the pancreas, which is characterized by an unphysiological enzyme activation. This leads to an inflammatory reaction with edema, vascular damage and cell decay. The first German interdisciplinary S3 guidelines on chronic pancreatitis were published in 2012. Under the auspices of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and with the participation of various societies and patient representatives, the guidelines were recently revised and extended, Comprehensive S3 guidelines on acute and chronic pancreatitis were compiled and agreed by consensus. This article presents the important clinical aspects on acute pancreatitis from these guidelines in a compact form and the recommendations are justified.
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Affiliation(s)
- R Henker
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - G Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, München, Deutschland
| | - M M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Greifswald, Deutschland
- LMU Klinikum, Ludwig-Maximilians-Universität München, München, Deutschland
| | - J Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, München, Deutschland
| | - A Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
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15
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Hemostasis During Endoscopic Necrosectomy: Spray Coagulation Can be a Savior! Am J Gastroenterol 2022; 117:375-376. [PMID: 35029162 DOI: 10.14309/ajg.0000000000001624] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
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16
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Fedorov AV, Ektov VN, Khodorkovsky MA. [Endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis]. Khirurgiia (Mosk) 2021:85-92. [PMID: 34480460 DOI: 10.17116/hirurgia202109185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The review is devoted to endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis. Terminology, indications and options for transluminal drainage procedures and endoscopic sequestrectomy are presented in detail. The authors analyzed the results of numerous studies devoted to effectiveness of endoscopic interventions and possible combination of treatment options. Modern international clinical guidelines indicating the feasibility of endoscopic treatment of acute necrotizing pancreatitis in multi-field specialized centers are considered.
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Affiliation(s)
- A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V N Ektov
- Burdenko Voronezh State Medical University, Voronezh, Russia
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17
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Maatman TK, McGuire SP, Flick KF, Madison MK, Al-Haddad MA, Bick BL, Ceppa EP, DeWitt JM, Easler JJ, Fogel EL, Gromski MA, House MG, Lehman GA, Nakeeb A, Schmidt CM, Sherman S, Watkins JL, Zyromski NJ. Outcomes in Endoscopic and Operative Transgastric Pancreatic Debridement. Ann Surg 2021; 274:516-523. [PMID: 34238810 PMCID: PMC9054355 DOI: 10.1097/sla.0000000000004997] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches. SUMMARY BACKGROUND DATA Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists. METHODS Patients undergoing Endo-TGD and OR-TGD at a single, high-volume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared. RESULTS Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 ± 0.5 and Endo-TGD 3.0 ± 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ± 20.8 days) compared to OR-TGD (9.4 ± 6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04). CONCLUSIONS Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.
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Affiliation(s)
- Thomas K. Maatman
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Sean P. McGuire
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Katelyn F. Flick
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Mackenzie K. Madison
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Mohammad A. Al-Haddad
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Benjamin L. Bick
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Eugene P. Ceppa
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - John M. DeWitt
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Jeffrey J. Easler
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Evan L. Fogel
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Mark A. Gromski
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Michael G. House
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Glen A. Lehman
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Attila Nakeeb
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - C. Max Schmidt
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Stuart Sherman
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - James L. Watkins
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Nicholas J. Zyromski
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
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18
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Maharshi S, Sharma SS, Ratra S, Sapra B, Sharma D. Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial. Endosc Int Open 2021; 9:E1108-E1115. [PMID: 34222637 PMCID: PMC8216781 DOI: 10.1055/a-1480-7115] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/10/2021] [Indexed: 11/04/2022] Open
Abstract
Background and study aims Walled-off necrosis (WON) is a known complication of acute necrotizing pancreatitis (ANP). There is no study comparing nasocystic irrigation with hydrogen peroxide (H 2 O 2 ) versus biflanged metal stent (BMS) in the management of WON. The aim of this study was to compare the clinical efficacy of both the treatment strategies. Patients and methods This study was conducted on patients with symptomatic WON who were randomized to nasocystic irrigation with H 2 O 2 (Group A) and BMS placement (Group B). Primary outcomes were clinical and technical success while secondary outcomes were procedure time, adverse events, need for additional procedures, duration of hospitalization, and mortality. Results Fifty patients were randomized into two groups. Group A (n = 25, age 37.8 ± 17.6 years, 16 men) and Group B (n = 25, age 41.8 ± 15.2 years, 17 men). There were no significant differences in baseline characteristics between the two groups. The most common etiology of pancreatitis was alcohol, observed in 27 (54 %) patients. Technical success (100 % vs 96 %, P = 0.98), clinical success (84 % vs 76 %, P = 0.76), requirement of additional procedures (16 % vs 24 %, P = 0.70) and adverse events (4 vs 7, P = 0.06) were comparable in both the groups. The duration to clinical success (34.4 ± 12 vs 14.8 ± 10.8 days, P = 0.001) and procedure time (36 ± 15 vs 18 ± 12 minutes, P = 0.01) were longer in Group A compared to Group B. Conclusions Nasocystic irrigation with H 2 O 2 and BMS are equally effective in the management of WON but time to clinical success and procedure time is longer with nasocystic irrigation.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Shyam Sunder Sharma
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Sandeep Ratra
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | | | - Dhruv Sharma
- Ananta Institute of Medical Sciences and Research Center, Rajsamand, India
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Binda C, Coluccio C, Sbrancia M, Fabbri C. Role of endoscopic ultrasonography in the management of peripancreatic collections. Diagnostic and therapeutic approach. Minerva Gastroenterol (Torino) 2021; 68:162-176. [PMID: 33988009 DOI: 10.23736/s2724-5985.21.02874-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pancreatic fluid collections are surrounded by a wall of granulation tissue and may contain necrotic debris. They occur following a severe acute pancreatitis and most of the cases resolve spontaneously after several weeks. However, their management may lead to a very hardto-treat condition, requiring a multidisciplinary approach. During the last decades we assisted to a change of paradigm involving Endoscopic Ultrasonography, from a pure diagnostic technique to an interventional-therapeutic one, allowing an effective, safe and less invasive approach than other existing treatment standards, historically consisting of surgical and percutaneous drainage. Treatment of pancreatic fluid collections is indicated if they become infected or symptomatic. Over the past years, exponential developments were done in interventional endoscopic approach, making it the first line suggested modality. The use of endoscopic ultrasound allows assessment of the collection, even when it is not directly bulging on gastrointestinal wall, creation of an internal fistulous tract, checking for surrounding vessels with the use of Doppler, and deployment of a stent avoiding the discomfort of external tubes. Several types of stent have been used for endoscopic drainage: plastic double pigtail stents, fully covered self-expanding metal stents and, more recently, lumen apposing metal stents, which are considered revolutionary because of their two-side flanges and wide and short internal channel, a new design that made easier direct endoscopic necrosectomy. This review aims to go through currently available literature on the diagnostic and therapeutic role of Endoscopic Ultrasonography to handle pancreatic fluid collections.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy -
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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20
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Hydrogen Peroxide as an Adjunctive Therapy for Walled-Off Pancreatic Necrosis During Direct Endoscopic Necrosectomy: A Solution to the Problem or a Problematic Solution? Am J Gastroenterol 2021; 116:666-668. [PMID: 33982932 DOI: 10.14309/ajg.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nearly 25 years after its initial description, endoscopic therapy of walled-off pancreatic necrosis has become widely accepted. Endoscopic therapy is composed of transmural placement of stents, now most commonly lumen-apposing metal stents and removal of solid debris, if needed. Removal of solid debris can be achieved with irrigation provided by percutaneously or endoscopically placed (nasocystic) tubes or by mechanically through direct necrosectomy. This editorial provides commentary on the use of hydrogen peroxide instilled at the time of direct necrosectomy for treatment of walled-off pancreatic necrosis.
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21
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Siddiqui A, Naveed M, Basha J, Lakhtakia S, Nieto J, Shah J, Binmoeller K, Murphy M, Talukdar R, Ramchandani MK, Nabi Z, Gupta R, Kowalski TE, Loren DE, Sharaiha RZ, Kahaleh M, Eyck PT, Noor A, Mumtaz T, Kalalala R, Reddy ND, Adler DG. International, multicenter retrospective trial comparing the efficacy and safety of bi-flanged versus lumen-apposing metal stents for endoscopic drainage of walled-off pancreatic necrosis. Ann Gastroenterol 2021; 34:273-281. [PMID: 33654370 PMCID: PMC7903561 DOI: 10.20524/aog.2021.0570] [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] [Received: 12/15/2019] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background To compare fully covered bi-flanged metal stents (BFMS) and lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainage/debridement of pancreatic walled-off necrosis (WON). Methods Patients with WON managed by EUS-guided therapy were divided into those who underwent: 1) drainage using BFMS; and 2) drainage using LAMS and scheduled direct endoscopic necrosectomy (DEN). Clinical success (resolution of the WON), technical success (successful stent placement), and adverse events (AEs) were evaluated. Results 387 patients underwent WON endoscopic drainage, 205 using BFMS and 182 using LAMS. The clinical success in the BFMS or LAMS groups were similar (197 [96.1%] vs. 174 [95.6%]; P=0.81). Median number of procedures required for WON resolution was significantly lower in BFMS compared to LAMS (2 vs. 3, P<0.001). Technical success for stent placement was similar in BFMS and LAMS groups (203 [99%] vs. 180 [99%], P=0.90). Procedure-related AEs were similar in the BFMS and LAMS groups (19 [9.3%] vs. 20 [10.9%], P=0.61). Stent dysfunction with occluding debris was higher in the BFMS group compared to LAMS group (21 [10.2 %] vs. 11 [5.9%], P=0.04). The migration rate was higher in the BFMS group than in the LAMS group (15 [7.3%] vs. 3 [1.6%]; P<0.001). DEN was required in 23 [11.2%] patients in the BFMS group after lack of WON resolution by conservative means. Conclusion BFMS with a “step-up approach” and LAMS with scheduled DEN are both safe and effective for EUS-guided drainage/debridement of WON.
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Affiliation(s)
- Ali Siddiqui
- Thomas Jefferson University, Philadelphia, PA, USA (Ali Siddiqui, Megan Murphy, David E. Loren, Arish Noor, Tayeban Mumtaz)
| | - Mariam Naveed
- University of Iowa, Iowa City, IA, USA (Mariam Naveed, Patrick Ten Eyck)
| | - Jahangeer Basha
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Sundeep Lakhtakia
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, FL, USA (Jose Nieto)
| | - Janak Shah
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA (Janak Shah, Kenneth Binmoeller)
| | - Kenneth Binmoeller
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA (Janak Shah, Kenneth Binmoeller)
| | - Megan Murphy
- Thomas Jefferson University, Philadelphia, PA, USA (Ali Siddiqui, Megan Murphy, David E. Loren, Arish Noor, Tayeban Mumtaz)
| | - Rupjyoti Talukdar
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Mohan K Ramchandani
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Rajesh Gupta
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Thomas E Kowalski
- New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA (Thomas E. Kowalski, Reem Z. Sharaiha, Michel Kahaleh)
| | - David E Loren
- Thomas Jefferson University, Philadelphia, PA, USA (Ali Siddiqui, Megan Murphy, David E. Loren, Arish Noor, Tayeban Mumtaz)
| | - Reem Z Sharaiha
- New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA (Thomas E. Kowalski, Reem Z. Sharaiha, Michel Kahaleh)
| | - Michel Kahaleh
- New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA (Thomas E. Kowalski, Reem Z. Sharaiha, Michel Kahaleh)
| | - Patrick Ten Eyck
- University of Iowa, Iowa City, IA, USA (Mariam Naveed, Patrick Ten Eyck)
| | - Arish Noor
- Thomas Jefferson University, Philadelphia, PA, USA (Ali Siddiqui, Megan Murphy, David E. Loren, Arish Noor, Tayeban Mumtaz)
| | - Tayebah Mumtaz
- Thomas Jefferson University, Philadelphia, PA, USA (Ali Siddiqui, Megan Murphy, David E. Loren, Arish Noor, Tayeban Mumtaz)
| | - Rakesh Kalalala
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Nageshwar D Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (Jahangeer Basha, Sundeep Lakhtakia, Rupjyoti Talukdar, Mohan K. Ramchandani, Zaheer Nabi, Rajesh Gupta, Rakesh Kalalala, Nageshwar D. Reddy)
| | - Douglas G Adler
- University of Utah, Salt Lake City, UT, USA (Douglas G. Adler)
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22
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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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Easler JJ. The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis. Korean J Intern Med 2021; 36:32-44. [PMID: 33472284 PMCID: PMC7820657 DOI: 10.3904/kjim.2020.542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatic necrosis is among the most frequently encountered local complications of acute pancreatitis and associates with severe disease. Infected pancreatic necrosis further enhances the risk for morbidity and mortality. Pancreatic fluid collections that result from pancreatic necrosis evolve from acute necrotic collections to walled off necrosis and are defined by their distinct characteristics on cross sectional imaging. A variety of interventions spanning multiple disciplines are available for the drainage and debridement of pancreatic necrosis. Prospective, randomized trials have identified management strategies that incorporate minimally invasive interventions as having the best outcomes for patients with symptomatic pancreatic necrosis. The scientific literature has confidently positioned endoscopic drainage and necrosectomy among the most effective interventions for patients with symptomatic walled off necrosis. Innovations such as the use of metallic stents, chemical debridement and multiple modalities for drainage of pancreatic necrosis show promise in improving outcomes for patients managed with endoscopic interventions.
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Affiliation(s)
- Jeffrey James Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Correspondence to Jeffrey James Easler, M.D. Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 N. University Blvd, Suite 1634, Indianapolis, IN 46202, USA Tel: +1-3179484978 Fax: +1-3179681265 E-mail:
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24
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When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis? J Clin Med 2020; 9:jcm9124072. [PMID: 33348675 PMCID: PMC7767133 DOI: 10.3390/jcm9124072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/24/2020] [Accepted: 12/15/2020] [Indexed: 12/27/2022] Open
Abstract
Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.
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25
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Wang TJ, Cortes P, Jirapinyo P, Thompson CC, Ryou M. A comparison of clinical outcomes and cost utility among laparoscopy, enteroscopy, and temporary gastric access-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Surg Endosc 2020; 35:4469-4477. [PMID: 32886240 DOI: 10.1007/s00464-020-07952-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Gastric Access Temporary for Endoscopy (GATE), also known as EUS-Directed Trangastric ERCP (EDGE), has demonstrated advantages over device-assisted enteroscopy (DAE) and laparoscopic-assisted ERCP (LA-ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy. We aimed to directly compare clinical outcomes and cost utility among the three ERCP modalities. METHODS Patients with RYGB anatomy who had DAE, LA-ERCP, or GATE from 2009 to 2019 at 2 tertiary centers were included in our review. We measured outcomes in three areas: success rate, post-procedural adverse events (AEs) and hospitalization, and cost utility per Medicare/Medicaid insurance payments. RESULTS Cohort Total 130 patients (70 underwent DAE, 42 LA-ERCP, and 18 GATE). Success rate DAE was successful in 59% of patients, compared to success rates of 98 and 100% for LA-ERCP and GATE, respectively (p < 0.001). For DAE, 62% of unsuccessful cases required rescue therapy. Adverse events and hospitalization Patients who underwent GATE had the lowest rate of hospitalization post procedure (44% vs. 77% and 100% for DAE and LA-ERCP, respectively, p < 0.01) and spent the least amount of time hospitalized (median time 0 days vs 2 and 3 days for DAE and LA-ERCP, respectively, p < 0.0001). GATE had lower AE rates than LA-ERCP (6 vs 31%, p = 0.046), and both had similar rates to DAE. Cost utility LA-ERCP carried the highest total procedural and hospitalization cost per Medicare/ Medicaid insurance payments (median payment difference of $9.7 K vs GATE and $7.9 K vs DAE, p < 0.01 for both). Procedural and hospitalization costs were similar between GATE and DAE (p = 0.76). CONCLUSIONS GATE is a safe modality for ERCP with high success rates in RYGB patients and exhibits the lowest hospitalization time and rate of adverse events when compared to DAE and LA-ERCP. GATE is similar to DAE from a cost utility approach, and both are less costly than LA-ERCP.
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Affiliation(s)
- Thomas J Wang
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pedro Cortes
- Harvard Medical School, Boston, MA, USA.,Mayo Clinic, Jacksonville, FL, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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26
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Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis. Ann Surg 2020; 271:163-168. [PMID: 30216220 DOI: 10.1097/sla.0000000000003048] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. BACKGROUND WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. METHODS A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant. RESULTS One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%). CONCLUSION Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.
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Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158:67-75.e1. [PMID: 31479658 DOI: 10.1053/j.gastro.2019.07.064] [Citation(s) in RCA: 323] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.
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Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Katherine A Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, South Carolina
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Rerknimitr R. Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods. Clin Endosc 2019; 53:49-53. [PMID: 31530792 PMCID: PMC7003012 DOI: 10.5946/ce.2019.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/22/2019] [Indexed: 12/31/2022] Open
Abstract
Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.
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Affiliation(s)
- Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand
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29
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Hyun JJ, Sahar N, Singla A, Ross AS, Irani SS, Gan SI, Larsen MC, Kozarek RA, Gluck M. Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy. Gut Liver 2019; 13:215-222. [PMID: 30602076 PMCID: PMC6430426 DOI: 10.5009/gnl18234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. Methods We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. Results Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). Conclusions This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.
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Affiliation(s)
- Jong Jin Hyun
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul, Korea
| | - Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Anand Singla
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Shayan S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael C Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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30
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Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
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Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Chen YI, Yang J, Friedland S, Holmes I, Law R, Hosmer A, Stevens T, Franco MC, Jang S, Pawa R, Mathur N, Sejpal DV, Inamdar S, Trindade AJ, Nieto J, Berzin TM, Sawhney M, DeSimone ML, DiMaio C, Kumta NA, Gupta S, Yachimski P, Anderloni A, Baron TH, James TW, Jamil LH, Ona MA, Lo SK, Gaddam S, Dollhopf M, Bukhari MA, Moran R, Gutierrez OB, Sanaei O, Fayad L, Ngamruengphong S, Kumbhari V, Singh V, Repici A, Khashab MA. Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study. Endosc Int Open 2019; 7:E347-E354. [PMID: 30834293 PMCID: PMC6395102 DOI: 10.1055/a-0828-7630] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/31/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims The use of lumen apposing metal stents (LAMS) during EUS-guided transmural drainage (EUS-TD) of pancreatic walled-off necrosis (WON) has gained popularity. Data supporting their use in WON over plastic stents (PS), however, remain scarce. The aim of this study was to compare the clinical efficacy of LAMS (Axios, Boston Scientific) with PS in WON. Patients and methods This was a multicenter, retrospective study involving 14 centers. Consecutive patients who underwent EUS-TD of WON (2012 - 2016) were included. The primary end point was clinical success defined as WON size ≤ 3 cm within a 6-month period without need for percutaneous drainage (PCD) or surgery. Results A total of 189 patients (mean age 55.2 ± 15.6 years, 34.9 % female) were included (102 LAMS and 87 PS). Technical success rates were similar: 100 % in LAMS and 98.9 % in PS ( P = 0.28). Clinical success was attained in 80.4 % of LAMS and 57.5 % of PS ( P = 0.001). Rate of PCD was similar (13.7 % LAMS vs. 16.3 % PS, P = 0.62), while PS was associated with a greater need for surgery (16.1 % PS vs. 5.6 % LAMS, P = 0.02). Adverse events (AEs) were observed in 9.8 % of LAMS and 10.3 % of PS ( P = 0.90) and were rated as severe in 2.0 % and 6.9 %, respectively ( P = 0.93). After excluding patients with < 6 months follow-up, the rate of WON recurrence following initial clinical success was greater with PS (22.9 % PS vs. 5.6 % LAMS, P = 0.04). Conclusions When compared to PS, LAMS in WON is associated with higher clinical success, shorter procedure time, lower need for surgery, and lower rate of recurrence.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Division of Gastroenterology and Hepatology, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Shai Friedland
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ian Holmes
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Amy Hosmer
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Matheus C. Franco
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Nihar Mathur
- Division of Gastroenterology and Hepatology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Divyesh V. Sejpal
- Division of Gastroenterology, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, NY, USA
| | - Sumant Inamdar
- Division of Gastroenterology, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, NY, USA
| | - Arvind J. Trindade
- Division of Gastroenterology, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, NY, USA
| | - Jose Nieto
- Division of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, FL, USA
| | - Tyler M. Berzin
- Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Mandeep Sawhney
- Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Michael L. DeSimone
- Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Christopher DiMaio
- Division of Gastroenterology and Hepatology, Mount Sinai, New York, NY, USA
| | - Nikhil A. Kumta
- Division of Gastroenterology and Hepatology, Mount Sinai, New York, NY, USA
| | - Sanchit Gupta
- Division of Gastroenterology and Hepatology, Mount Sinai, New York, NY, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University, Nashville, TN, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Theodore W. James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Laith H. Jamil
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Mel A. Ona
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Simon K. Lo
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Srinivas Gaddam
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Markus Dollhopf
- Division of Gastroenterology and Hepatology, Klinikum Neuperlach, Munich, Germany
| | - Majidah A. Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Alessandro Repici
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Corresponding author Mouen A. Khashab, MD Johns Hopkins Hospital1800 Orleans StreetSheikh Zayed TowerBaltimoreMD 21287USA+1-514-934-8547
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Shahid H. Endoscopic management of pancreatic fluid collections. Transl Gastroenterol Hepatol 2019; 4:15. [PMID: 30976718 DOI: 10.21037/tgh.2019.01.09] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/25/2019] [Indexed: 12/12/2022] Open
Abstract
Pancreatic fluid collections (PFCs) are common complications of acute pancreatitis. Asymptomatic collections do not require drainage while symptomatic or infected collections should be drained. Drainage can be performed surgically, percutaneously, or endoscopically. Recent studies have shown that endoscopic drainage of PFCs is equivalent or superior to surgical or percutaneous drainage, with less complications. Advances in tools and technology coupled with increasing expertise in management of PFCs has resulted in minimally invasive endoscopic drainage, by endosonographic guidance, being the preferred approach. New larger diameter lumen apposing metal stents (LAMS) have simplified the process of drainage. LAMS have also made performing direct endoscopic necrosectomy for walled-off necrosis (WON) easier. Technique, duration, frequency, and tools used for direct endoscopic necrosectomy are variable. Performing PFC drainage requires adequate and fundamental knowledge of diagnostic and basic therapeutic EUS.
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Affiliation(s)
- Haroon Shahid
- Department of Endoscopic Ultrasound, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients. Surg Endosc 2019; 33:2024-2033. [DOI: 10.1007/s00464-019-06715-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/19/2019] [Indexed: 12/26/2022]
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Yan L, Dargan A, Nieto J, Shariaha RZ, Binmoeller KF, Adler DG, DeSimone M, Berzin T, Swahney M, Draganov PV, Yang DJ, Diehl DL, Wang L, Ghulab A, Butt N, Siddiqui AA. Direct endoscopic necrosectomy at the time of transmural stent placement results in earlier resolution of complex walled-off pancreatic necrosis: Results from a large multicenter United States trial. Endosc Ultrasound 2019; 8:172-179. [PMID: 29882517 PMCID: PMC6590004 DOI: 10.4103/eus.eus_108_17] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives EUS-guided drainage, and direct endoscopic necrosectomy (DEN) of walled-off necrosis (WON) using a lumen-apposing metal stent (LAMS) is safe and effective. Early debridement of WON may improve overall clinical outcomes. The aim of this study is to perform a multicenter retrospective study to compare the clinical outcomes and predictors of success for endoscopic drainage of WON with LAMS followed by immediate or delayed DEN performed at standard intervals. Methods Patients with WON managed by EUS-guided drainage with LAMS were divided into 2 groups: (1) those that underwent immediate DEN at the time of stent placement and (2) those that underwent delayed DEN 1 week after stent placement. DEN was subsequently performed every 1-2 week (s). Technical success (successful placement of LAMS), adverse events (AEs), and clinical success (complete resolution of the WON) were evaluated. Results Totally, 271 patients underwent WON drainage with LAMS: 69 who underwent immediate DEN and 202 who underwent delayed DEN. The technical success for LAMS placement was 100% in both groups. There was no significant difference in the overall procedural AEs between the immediate and delayed DEN groups (P = 7.2% vs. 9.4%; P = 0.81). Stent dislodgement during index endoscopy occurred in three patients in the immediate DEN group compared to zero in the delayed DEN group (P = 0.016); all three dislodgements occurred during necrosectomy. Clinical success for WON resolution in the immediate DEN group was 91.3% compared to 86.1% in the delayed DEN group (P = 0.3). The mean number of necrosectomy sessions for WON resolution was significantly lower in the immediate DEN group compared to the delayed DEN group (3.1 vs. 3.9, P < 0.001). Performing DEN at the time of stent placement was an independent predictor for resolution of WON with lesser number of DEN sessions (odds ratio 2.3; P = 0.004). Conclusions DEN at the time of initial stent placement reduces the number of necrosectomy sessions required for successful clinical resolution of WON.
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Affiliation(s)
- Linda Yan
- Division of Gastroenterlogy, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Dargan
- Division of Gastroenterlogy, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose Nieto
- Division of Gastroenterlogy, Borland Groover Clinic, Jacksonville, FL, USA
| | - Reem Z Shariaha
- Division of Gastroenterlogy, Department of Internal Medicine, Weill Cornell Medical Center, New York City, NY, USA
| | - Kenneth F Binmoeller
- Division of Gastroenterlogy, Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Douglas G Adler
- Division of Gastroenterlogy, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael DeSimone
- Division of Gastroenterlogy, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tyler Berzin
- Division of Gastroenterlogy, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mandeep Swahney
- Division of Gastroenterlogy, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter V Draganov
- Division of Gastroenterlogy, Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Dennis J Yang
- Division of Gastroenterlogy, Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - David L Diehl
- Division of Gastroenterlogy, Department of Internal Medicine, Geisinger Health System, Danville, PA, USA
| | - Lillian Wang
- Division of Gastroenterlogy, Department of Internal Medicine, Geisinger Health System, Danville, PA, USA
| | - Asma Ghulab
- Division of Gastroenterlogy, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nausharwan Butt
- Division of Gastroenterlogy, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ali A Siddiqui
- Division of Gastroenterlogy, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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Jha AK, Goenka MK, Kumar R, Suchismita A. Endotherapy for pancreatic necrosis: An update. JGH OPEN 2018; 3:80-88. [PMID: 30834345 PMCID: PMC6386747 DOI: 10.1002/jgh3.12109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 09/28/2018] [Accepted: 10/11/2018] [Indexed: 12/16/2022]
Abstract
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step‐up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first‐line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.
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Affiliation(s)
- Ashish K Jha
- Department of Gastroenterology Indira Gandhi Institute of Medical Sciences Patna India
| | - Mahesh K Goenka
- Department of Gastrosciences, Institute of Gastrosciences, Apollo Gleneagles Hospital Kolkata India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences Patna India
| | - Arya Suchismita
- Department of Pediatrics Indira Gandhi Institute of Medical Sciences Patna India
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Aghdassi A, Simon P, Pickartz T, Budde C, Skube ME, Lerch MM. Endoscopic management of complications of acute pancreatitis: an update on the field. Expert Rev Gastroenterol Hepatol 2018; 12:1207-1218. [PMID: 30791791 DOI: 10.1080/17474124.2018.1537781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances. Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed. Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.
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Affiliation(s)
- Ali Aghdassi
- a Department of Medicine A , University Medicine Greifswald , Greifswald , Germany
| | - Peter Simon
- a Department of Medicine A , University Medicine Greifswald , Greifswald , Germany
| | - Tilman Pickartz
- a Department of Medicine A , University Medicine Greifswald , Greifswald , Germany
| | - Christoph Budde
- a Department of Medicine A , University Medicine Greifswald , Greifswald , Germany
| | - Mariya E Skube
- b Department of Surgery , University of Minnesota Medical Center , Minneapolis , MN , USA
| | - Markus M Lerch
- a Department of Medicine A , University Medicine Greifswald , Greifswald , Germany
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Elmunzer BJ. Endoscopic Drainage of Pancreatic Fluid Collections. Clin Gastroenterol Hepatol 2018; 16:1851-1863.e3. [PMID: 29601903 DOI: 10.1016/j.cgh.2018.03.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/06/2018] [Accepted: 03/14/2018] [Indexed: 02/07/2023]
Abstract
Endoscopy has emerged as a mainstay in the management of pancreatic fluid collections (PFCs), representing an important advance in clinical medicine that has significantly improved the risk-benefit ratio of treating this complex patient population. While endoscopic pseudocyst drainage has generally supplanted surgical and percutaneous approaches, the optimal strategy for walled-off necrosis remains variable and multi-disciplinary despite an emerging trend from randomized trials favoring endoscopy. Although several issues pertaining to endoscopic drainage appear to have been settled - such as the use of endoscopic ultrasound - other pressing questions - including the optimal prosthesis and debridement strategy - remain unanswered, and rigorous investigation is needed. This review aims to provide an evidence-based but practical appraisal of the endoscopic drainage of PFCs through the perspective of the author, with an emphasis on relevant clinical and endoscopic considerations and important research questions.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Orr J, Yachimski P. Timing of Endoscopic Necrosectomy Following Transmural Stent Placement for Pancreatic Necrosis. ACTA ACUST UNITED AC 2018; 16:622-625. [DOI: 10.1007/s11938-018-0211-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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Case BM, Jensen KK, Bakis G, Enestvedt BK, Shaaban AM, Foster BR. Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know. Radiographics 2018; 38:2002-2018. [PMID: 30265612 DOI: 10.1148/rg.2018180066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ©RSNA, 2018.
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Affiliation(s)
- Brendan M Case
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Kyle K Jensen
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Gene Bakis
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Brintha K Enestvedt
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Akram M Shaaban
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Bryan R Foster
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
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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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43
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Endoscopic management of pancreatic necrosis. Am J Gastroenterol 2018; 113:1269-1273. [PMID: 29686273 DOI: 10.1038/s41395-018-0060-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/24/2018] [Indexed: 12/11/2022]
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44
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Chen YI, Barkun AN, Adam V, Bai G, Singh VK, Bukhari M, Gutierrez OB, Elmunzer BJ, Moran R, Fayad L, El Zein M, Kumbhari V, Repici A, Khashab MA. Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis. Gastrointest Endosc 2018; 88:267-276.e1. [PMID: 29614262 DOI: 10.1016/j.gie.2018.03.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON. METHODS A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.$50,000 was established. RESULTS LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results. CONCLUSION LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, The McGill University Health Center, Montreal, Quebec, Canada
| | - Alan N Barkun
- Division of Gastroenterology and Hepatology, The McGill University Health Center, Montreal, Quebec, Canada
| | - Viviane Adam
- Division of Gastroenterology and Hepatology, The McGill University Health Center, Montreal, Quebec, Canada
| | - Ge Bai
- Johns Hopkins Carey Business School, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA; King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Gastroenterology, Humanitas Clinical and Research Hospital, IRCCS, Rozanno, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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45
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Park SW. Is Percutaneous Endoscopic Necrosectomy Really Safe and Effective for Symptomatic Laterally Placed Walled-off Necrosis? Clin Endosc 2018; 51:213-214. [PMID: 29739185 PMCID: PMC5997073 DOI: 10.5946/ce.2018.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/20/2018] [Indexed: 12/23/2022] Open
Affiliation(s)
- Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
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46
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Abstract
Ultrasound-guided drainage is the first-line modality for drainage of symptomatic of pancreatic fluid collections. In the context of pancreatic cancer, use of multiple double-pigtail plastic stents suffice, with high treatment efficacy. This approach provides similar success rates with low complications and better quality of life compared with surgery. Lumen apposing metallic stents (LAMSs) permit more effective drainage with larger diameter; because of their higher costs than plastic stents, their main role is probably in the context of walled-off necrosis, but the place and the use of LAMS should be studied to avoid and reduce the risks of complications.
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Affiliation(s)
- Marc Giovannini
- Medico-Surgical Digestive Oncology, Paoli-Calmettes Institute, 232 Boulevard de Sainte-Marguerite, Marseille 13009, France.
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47
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Pavic T, Hrabar D, Kralj D, Lerotic I, Ogresta D. Candidemia after endoscopic therapy with lumen-apposing metal stent for pancreatic walled-off necrosis. Clin J Gastroenterol 2018; 11:206-211. [PMID: 29383496 DOI: 10.1007/s12328-018-0823-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/25/2018] [Indexed: 01/07/2023]
Abstract
Necrotizing pancreatitis remains a challenging and unpredictable condition accompanied by various complications. Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with walled-off necrosis (WON). Endoscopic therapy via lumen-apposing metal stents (LAMS) with large diameters has shown success in the management of pancreatic fluid collections, but there are few data on specific complications of that therapy. We report a case of infected WON and concomitant fungemia following LAMS placement and necrosectomy. In addition, a systematic literature review of current related studies has been provided.
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Affiliation(s)
- Tajana Pavic
- Department of Gastroenterology and Hepatology, Clinical Hospital Center Sestre Milosrdnice, School of Medicine, University of Zagreb, 10000, Zagreb, Croatia.
| | - Davor Hrabar
- Department of Gastroenterology and Hepatology, Clinical Hospital Center Sestre Milosrdnice, School of Medicine, University of Zagreb, 10000, Zagreb, Croatia
| | - Dominik Kralj
- Department of Gastroenterology and Hepatology, Clinical Hospital Center Sestre Milosrdnice, School of Medicine, University of Zagreb, 10000, Zagreb, Croatia
| | - Ivan Lerotic
- Department of Gastroenterology and Hepatology, Clinical Hospital Center Sestre Milosrdnice, School of Medicine, University of Zagreb, 10000, Zagreb, Croatia
| | - Doris Ogresta
- Department of Gastroenterology and Hepatology, Clinical Hospital Center Sestre Milosrdnice, School of Medicine, University of Zagreb, 10000, Zagreb, Croatia
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48
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van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391:51-58. [PMID: 29108721 DOI: 10.1016/s0140-6736(17)32404-2] [Citation(s) in RCA: 410] [Impact Index Per Article: 68.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Cornelis H Dejong
- Department of Surgery and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jan-Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sijbrand H Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Johan S Laméris
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Tessa E Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | | | | | - Marin Strijker
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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49
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Metal stents versus plastic stents for the management of pancreatic walled-off necrosis: a systematic review and meta-analysis. Gastrointest Endosc 2018; 87:30-42.e15. [PMID: 28867073 DOI: 10.1016/j.gie.2017.08.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 08/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic transluminal drainage of symptomatic walled-off necrosis (WON) is a good management option, although the optimal choice of drainage site stent is unclear. We performed a systematic review and meta-analysis to compare metal stents (MSs) and plastic stents (PSs) in terms of WON resolution, likelihood of resolution after 1 procedure, and adverse events. METHODS An expert librarian queried several databases to identify studies that assessed WON management, and selection was according to a priori criteria. Publication bias, heterogeneity, and study quality were evaluated with the appropriate tools. We performed single and 2-arm meta-analyses for noncomparative and comparative studies using event rate random-effects model and odds ratio (OR)/difference in means, respectively. RESULTS We included 41 studies involving 2213 patients. In 2-arm study meta-analysis, WON resolution was more likely with MSs compared with PSs (OR, 2.8; 95% confidence interval, 1.7-4.6; P < .001). Resolution with a single endoscopic procedure was similar between stents (47% vs 44%), although for those cases requiring more than 1 intervention, the MS group had fewer interventions, favored by a mean difference of -.9 procedures (95% CI, -1.283 to -.561). In single-arm study meta-analysis, when compared with PSs, MS use was associated with lower bleeding (5.6% vs 12.6%; P = .02), a trend toward lower perforation and stent occlusion (2.8% vs 4.3%, P = .2, and 9.5% vs 17.4%, P = .07), although with higher migration (8.1% vs 5.1%; P = .1). CONCLUSION Evidence suggests that MSs are superior for WON resolution, with fewer bleeding events, trend toward less occlusion and perforation rate, but increased migration rate compared with PSs.
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50
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Abu Dayyeh BK, Mukewar S, Majumder S, Zaghlol R, Vargas Valls EJ, Bazerbachi F, Levy MJ, Baron TH, Gostout CJ, Petersen BT, Martin J, Gleeson FC, Pearson RK, Chari ST, Vege SS, Topazian MD. Large-caliber metal stents versus plastic stents for the management of pancreatic walled-off necrosis. Gastrointest Endosc 2018; 87:141-149. [PMID: 28478030 DOI: 10.1016/j.gie.2017.04.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Symptomatic pancreatic walled-off necrosis (WON) may be managed by endoscopic transmural drainage and endoscopic transmural necrosectomy, with stent placement at endoscopic drainage sites. The optimal stent choice is yet to be determined. We compared outcomes after endoscopic management of WON using either large-caliber fully covered self-expandable metal stents (LC-SEMSs) or double-pigtail plastic stents (DPPSs). METHODS We performed a retrospective comparison of outcomes among patients who received LC-SEMSs or DPPSs before endoscopic transmural necrosectomy for WON. RESULTS Among 94 patients included, WON resolution rates did not differ between the DPPS (36 patients) and LC-SEMS (58 patients) groups, whether concomitant percutaneous drainage was considered a failure (75% vs 82.8%; P = .36) or not (91.7% vs 94.8%; P = .55). Of 75 patients (80%) successfully treated without percutaneous drainage, 37 (49%) underwent endoscopic transmural drainage without subsequent endoscopic transmural necrosectomy. WON was more likely to resolve without subsequent endoscopic transmural necrosectomy in the LC-SEMS group than the DPPS group (60.4% vs 30.8%; P = .01). WON resolution without subsequent endoscopic transmural necrosectomy remained more likely with LC-SEMSs (odds ratio, 4.5 [95% confidence interval, 1.5-15.5]) after adjusting for patient age and size and location of WON. Rates of adverse events were similar except for clinically significant bleeding requiring endoscopic intervention, which was higher with DPPSs than LC-SEMSs (14% vs 2%; P = .02). CONCLUSION Management of pancreatic WON with LC-SEMSs appears to decrease both the need for repeated necrosectomy procedures and the risk of intervention-related hemorrhage.
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Affiliation(s)
- Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raja Zaghlol
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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