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Zeng Y, Zhang JW, Yang J. Efficacy and Safety of Anhydrous Ethanol-Assisted Endoscopic Ultrasound-Guided Transluminal Necrosectomy in Infected Necrotizing Pancreatitis. Dig Dis Sci 2024; 69:1889-1896. [PMID: 38517560 DOI: 10.1007/s10620-024-08389-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024]
Abstract
AIM Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP. METHODS A single-center observational cohort study of INP patients was conducted in a tertiary endoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively. RESULTS A total of 55 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups. CONCLUSION Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainly in reducing the number of endoscopic necrosectomies without increasing perioperative AEs.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Binda C, Fabbri S, Perini B, Boschetti M, Coluccio C, Giuffrida P, Gibiino G, Petraroli C, Fabbri C. Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:333. [PMID: 38399620 PMCID: PMC10890047 DOI: 10.3390/medicina60020333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
Pancreatic fluid collections (PFCs) are well-known complications of acute pancreatitis. The overinfection of these collections leads to a worsening of the prognosis with an increase in the morbidity and mortality rate. The primary strategy for managing infected pancreatic necrosis (IPN) or symptomatic PFCs is a minimally invasive step-up approach, with endosonography-guided (EUS-guided) transmural drainage and debridement as the preferred and less invasive method. Different stents are available to drain PFCs: self-expandable metal stents (SEMSs), double pigtail stents (DPPSs), or lumen-apposing metal stents (LAMSs). In particular, LAMSs are useful when direct endoscopic necrosectomy is needed, as they allow easy access to the necrotic cavity; however, the rate of adverse events is not negligible, and to date, the superiority over DPPSs is still debated. Moreover, the timing for necrosectomy, the drainage technique, and the concurrent medical management are still debated. In this review, we focus attention on indications, timing, techniques, complications, and particularly on aspects that remain under debate concerning the EUS-guided drainage of PFCs.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Barbara Perini
- Gastroenterology and Digestive Endoscopy Unit, Azienda ULSS 5, 45100 Rovigo, Italy
| | - Martina Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Paolo Giuffrida
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Chiara Petraroli
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, AUSL Romagna, Forlì-Cesena Hospitals, 47121 Forlì, Italy
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Nakai Y, Hamada T, Saito T, Shiomi H, Maruta A, Iwashita T, Iwata K, Takenaka M, Masuda A, Matsubara S, Sato T, Mukai T, Yasuda I, Isayama H. Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum. Dig Endosc 2023; 35:700-710. [PMID: 37209365 DOI: 10.1111/den.14598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/16/2023] [Indexed: 05/22/2023]
Abstract
Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e. the step-up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Rana SS. Endoscopic treatment of pancreatic necrosis: Still searching for perfection! J Gastroenterol Hepatol 2023; 38:1252-1258. [PMID: 37309053 DOI: 10.1111/jgh.16262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
Over last few years, there has been a paradigm shift in the management of infected pancreatic necrosis with endoscopic and minimally invasive "step-up" management approach replacing open surgical necrosectomy. Because of being associated with reduced occurrence of new onset multi-organ failure, external pancreatic fistulae, shorter hospital stay, lower costs, and better quality of life compared with minimally invasive surgical approach, endoscopic "step-up" management approach is the preferred intervention for endoscopically accessible pancreatic necrotic collections at expert centers with endoscopic expertise. Development of lumen apposing metal stents and improvised accessories for interventional endoscopic ultrasound has revolutionized the endoscopic management of pancreatic necrosis making it more effective and safer. Despite these promising developments, endoscopic transluminal necrosectomy (ETN) remains the Achilles heel. Lack of dedicated endoscopic accessories, poor endoscopic visualization within the necrotic cavity, limited diameter of the instrument channel of the endoscope that is a significant impediment to remove large amount of necrotic material, and uncertain ability to avoid vessels and vital structures in the necrotic cavity are important limitations during endoscopic necrosectomy. Recent devices and solutions including use of cap assisted necrosectomy, over the scope grasper and powered endoscopic debridement device are welcome steps in our pursuit for an ideal, safer, and efficacious ETN device. This review will discuss recent advances as well as challenges in the endoscopic management of pancreatic necrosis.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Zeng Y, Yang J, Zhang JW. Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges. World J Clin Cases 2023; 11:1888-1902. [PMID: 36998953 PMCID: PMC10044952 DOI: 10.12998/wjcc.v11.i9.1888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Zeng Y, Yang J, Zhang JW. Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges. World J Clin Cases 2023; 11:1888-1902. [PMID: 36998953 DOI: 10.12998/wjcc.v11.i9.1888' and 2*3*8=6*8 and 'usf6'='usf6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 01/29/2024] Open
Abstract
Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Zeng Y, Yang J, Zhang JW. Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges. World J Clin Cases 2023; 11:1888-1902. [PMID: 36998953 DOI: 10.12998/wjcc.v11.i9.1888ki89seqx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 01/29/2024] Open
Abstract
Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives. J Gastroenterol 2023; 58:98-111. [PMID: 36342540 DOI: 10.1007/s00535-022-01935-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
Pancreatic fluid collections (PFCs) commonly develop as complications of acute pancreatitis and ductal disruption due to chronic pancreatitis. In the revised Atlanta classification, PFCs were classified based on the presence of necrosis and duration following the onset of acute pancreatitis. Interventions are required in cases of symptomatic pancreatic pseudocysts or walled-off necrosis (WON). In the management of these PFCs, endoscopic ultrasound-guided transluminal drainage and subsequent direct endoscopic necrosectomy for WON are increasingly utilized as less invasive treatment modalities compared to surgical debridement. To date, researchers have focused predominantly on the technical aspects of endoscopic therapy for symptomatic PFCs. Given the poor physical condition of patients receiving endoscopic treatment for PFCs, systemic support may have a substantial impact on the short- and long-term outcomes of these patients. A multidisciplinary approach is required to improve the clinical outcomes of patients with infected PFCs and their associated comorbidities. However, non-interventional support during the periprocedural period of endoscopic treatment of PFCs has not been fully discussed, and there have been considerable variations in the selection of treatment options between endoscopists and centers. To address these unmet needs in the clinical management of PFCs and promote future research to improve the clinical outcomes, we conducted a review of the literature within a multicenter consortium of expert endoscopists with specific expertise in the endoscopic treatment of PFCs. In this review, we summarize the current evidence on non-interventional supportive care (e.g., continuous lavage, medications, nutritional support, and antimicrobials) and propose potential topics for future research.
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Hydrogen peroxide-assisted endoscopic necrosectomy of pancreatic walled-off necrosis: a systematic review and meta-analysis. Gastrointest Endosc 2022; 95:1060-1066.e7. [PMID: 35124071 DOI: 10.1016/j.gie.2022.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/21/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIMS Use of hydrogen peroxide (H2O2) has been reported in direct endoscopic necrosectomy (DEN) of pancreatic walled-off necrosis (WON). The aim of this meta-analysis was to study the pooled clinical outcomes of H2O2-assisted DEN of pancreatic WON. METHODS We conducted a comprehensive search of several databases (inception to July 2021) to identify studies reporting on the use of H2O2 in DEN of WON. A random-effects model was used to calculate pooled rates and I2 values, and 95% prediction intervals were used to assess heterogeneity. The outcomes studied were technical success, clinical success, and adverse events in H2O2-assisted DEN of pancreatic WON. RESULTS In 7 analyzed studies, 186 patients underwent H2O2-assisted DEN of WON. The pooled rate of technical success was 95.8% (95% confidence interval [CI], 88.5-98.5), clinical success was 91.6% (95% CI, 86.1-95), and cumulative rate of overall adverse events was 19.3% (95% CI, 7.6-41). The pooled rate of bleeding was 7.9% (95% CI, 2.4-22.7), stent migration was 11.3% (95% CI, 4.9-23.9), perforation 5.4% (95% CI, 1.7-15.7), infection 5.7% (95% CI, 2-15.1), and pulmonary adverse event 2.9% (95% CI, 1.3-6.1). Mean treatment sessions ranged from 2 to 5. CONCLUSIONS H2O2-assisted DEN of WON demonstrated excellent clinical outcomes, with minimal heterogeneity. No adverse events attributable to H2O2 were reported. Future controlled studies are warranted comparing the clinical outcomes with and without H2O2 before H2O2 use can be established in DEN of pancreatic WON.
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