Endoscopic ultrasonography-guided drainage of pancreatic fluid collections

Tardive Peritonitis After Endoscopic Ultrasound-Guided Pancreatic Pseudocyst Drainage: A Case Report

Here, we report a case of tardive peritonitis after endoscopic ultrasound (EUS)-guided transmural pancreatic pseudocyst drainage. A 50-year-old man was diagnosed with acute pancreatitis and a pancreatic pseudocyst measuring 5 cm. Ten months later, his pancreatic pseudocyst was 10 cm. We performed EUS-guided transmural drainage using a lumen-apposing metal stent. After two months, the stent was replaced with a double-pigtail plastic stent. Two months later, the patient developed fever and abdominal pain, and computed tomography revealed abdominal free air. He was diagnosed with peritonitis due to free air caused by a fistula rupture. The double-pigtail plastic stent was removed, and clipping was performed at the fistula site to achieve closure. The patient's symptoms subsequently improved. Long-term placement of a plastic stent for pancreatic pseudocysts makes recurrence less likely, but late adverse events due to stent placement can occur. Notably, fistula rupture can occur even when the fistula is well-formed several months after the initial drainage.

Impact of endoscopic ultrasound-guided transmural drainage for postoperative pancreatic fistula after pancreatic surgery

Objectives

Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound-guided transmural drainage (EUS-TD) has been widely used to manage pancreatic pseudocysts after acute pancreatitis. Several studies have reported the effectiveness of EUS-TD for POPF, although there is insufficient evidence regarding the performance of EUS-TD for POPF. We herein report on the safety, efficacy, and appropriate timing of EUS-TD for POPF compared with conventional percutaneous intervention.

Methods

Eight patients who underwent EUS-TD of POPF and 36 patients who underwent percutaneous intervention were retrospectively enrolled. Clinical outcomes, including technical success, clinical success, and complications, were analyzed among the two groups.

Results

In terms of clinical outcomes between the EUS-TD and percutaneous intervention groups, significant differences were observed in the number of interventions (1 vs. 4, p = 0.011), period of clinical success (6 days vs. 11 days, p = 0.001), incidence of complications (0 vs. 3, p = 0.021), postoperative hospital stays (27 days vs. 34 days, p = 0.027), and recurrence of POPF (0 vs. 5, p = 0.001).

Conclusions

EUS-TD for POPF appears to be safe and technically feasible. This approach should be considered a therapeutic option in patients with POPF after pancreatic surgery.

Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives

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.

Evaluating the role of endoscopic ultrasound in pancreatitis

INTRODUCTION

Endoscopic ultrasound (EUS) provides high-resolution images of both pancreatic parenchyma and duct and therefore is an integral component of evaluating and treating patients with pancreatitis and its complications. The development of enhanced EUS imaging techniques and newer EUS-specific accessories has expanded the diagnostic and therapeutic role of EUS in patients with acute and chronic pancreatitis (CP).

AREAS COVERED

This review discusses the current diagnostic and therapeutic role of EUS in acute pancreatitis (AP), CP, and autoimmune pancreatitis (AIP).

EXPERT OPINION

EUS plays a vital role in patients with AP by confirming the presence of common bile duct (CBD) stones in patients with acute biliary pancreatitis and intermediate probability of CBD stones. It plays an important role in the etiological evaluation of patients with idiopathic acute and recurrent pancreatitis. EUS is also an essential modality for diagnosing and managing pancreatico-biliary as well as gastroduodenal complications associated with CP. EUS-guided FNB using newer generation core biopsy needles has made possible accurate diagnosis of AIP by providing tissue samples with preserved architecture.

Usefulness of the double-guidewire technique for endoscopic procedures in the field of biliary and pancreatic diseases

The double-guidewire method has been increasingly used in endoscopic procedures for biliary and pancreatic diseases in recent years, including endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography-related procedures. In addition, double-lumen catheters with uneven distal and proximal lumen openings have been introduced, making it possible to easily create a double-guidewire situation, and the usefulness of the double-guidewire technique using uneven double-lumen cannulas has been widely reported. Although the advantages of using two guidewires depend on the particular situation and the appropriate use of the two guidewires, deepening the knowledge of the double-guidewire method will contribute greatly to troubleshooting in daily practice. In this review, the usefulness of the double-guidewire technique is discussed with respect to two main areas: selective insertion of guidewires and devices and biliary cannulation.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

Metal Versus Plastic Stents for Pancreatic Fluid Collection Drainage: A Systematic Review and Meta-analysis

OBJECTIVES

The therapeutic efficacy of metal stents (MSs) for pancreatic fluid collections (PFCs) is invariably controversial. Here, we conducted a meta-analysis to summarize the results of efficacy of MSs and plastic stents (PSs) in PFC drainage.

SUBJECTS AND METHODS

We performed a literature search of PubMed/MEDLINE, EMBASE, and COCHRANE for all of the published studies regarding the use of MSs and PSs for endoscopic transmural drainage of PFCs from January, 1 2015 to June 1, 2020. We extracted data from 9 studies (1359 patients) that met the inclusion criteria. The main outcome measures were the rates of treatment success, including technique success and clinical success (CS), adverse events, recurrence, procedure time, and length of hospital stay (LOS).

RESULTS

There was no difference in overall technique success between patients treated with MSs and PSs for PFCs. However, MSs showed a higher CS rate 92% versus 82% (P<0.01) and a lower overall adverse event rate 20% versus 31% (P<0.01) than PSs. The recurrence rate of PFCs using MSs also had significant advantages over PSs 3% versus 10% (P<0.01) and MSs needed a shorter procedure time than PSs (26.73 vs. 45.40 min, P<0.01). In comparing direct endoscopic necrosectomy use and LOS, there was no difference between MSs and PSs.

CONCLUSIONS

Bringing together the results of the current study, endoscopic ultrasound-guided drainage of PFCs using MSs may be superior to PSs in terms of CS, adverse events rates and recurrence rate, with similar LOS and direct endoscopic necrosectomy use.

Utility of endoscopic transpapillary pancreatic cyst drainage for intraductal papillary mucinous neoplasm infection

A 61-year-old woman with intraductal papillary mucinous neoplasm (IPMN) infection, who was treated with antibiotics, developed IPMN reinfection with febrile epigastric pain and was febrile. CT showed that the diameter of the IPMN had grown and hardened, with thickening of the cyst wall. Endoscopic retrograde pancreatography was then performed and a nasopancreatic cyst drainage tube was placed into the cyst. Symptoms and inflammatory findings improved considerably 17 days after endoscopic drainage. Few reports and evidence have been found regarding IPMN infections, and the frequency of onset, route of infection and optimal drainage method remain unknown. This study indicated that endoscopic transpapillary pancreatic cyst drainage was effective and is highly recommended for IPMN infection.

Acute necrotizing pancreatitis: Has conservative management replaced surgery? Perspective from a tertiary care centre in Pakistan: A cross-sectional study

Background

The main purpose of this study was to review the trends in management of patients presenting with acute necrotizing pancreatitis (ANP) over the last seven years and its effect on morbidity and mortality.

Methods

A cross-sectional study was conducted on all patients presenting with the diagnosis of acute necrotizing pancreatitis to the Aga Khan University Hospital in between the year 2008-2015. The study population was broadly categorized in to two groups based on the way these were managed. The first group consisted of patient who underwent surgery for acute necrotizing pancreatitis while the second group was composed of those patients with necrotizing pancreatitis who were conservatively managed. Patient outcomes were assessed in terms of hospital stay, complication rates and in-hospital mortality. Data was analyzed using SPSS version 20. Comparison of outcomes between two groups was done using chi-square test, Fischer exact test or t-test wherever applicable. A p-value of less than 0.05 was considered statistically significant.

Results

A total of n = 110 patients were included in the study with 68% (n = 75) males and 32% (n = 35) females. Nasojejunal route was found to be the most commonly utilized route of feeding in these patients consisting of around 49% (n = 54) patients with forty percent (n = 44) tolerating direct oral diet. The outcomes in both these groups in terms of hospital stay, complication rate, and in hospital mortality were not found to be statistically significant. The conservative group however was significant in terms of cost-effectiveness which was shown by a p value of (0.035). The management of this clinically important disease over the years showed an increased trend towards conservative approach in our institute.

Conclusion

Our study further substantiates the recent global trend of conservative approach towards managing patients with acute necrotizing pancreatitis as reflected in the recent available literature. Therefore surgeons of the developing world need to evolve and adapt to these new measures for better outcomes in patient management.

Efficacy of Early Endoscopic Ultrasound-Guided Transluminal Drainage for Postoperative Pancreatic Fistula

BACKGROUND

Endoscopic ultrasound-guided transluminal drainage (EUS-TD) is generally performed 4 weeks after disease onset for evacuating pancreatic fluid collections. However, the optimal timing for conducting the procedure in those diagnosed with postoperative pancreatic fistula (POPF) has not been established. We aimed to elucidate the efficacy and safety of early EUS-TD procedures for treating POPF.

METHODS

We retrospectively reviewed patients diagnosed with POPF who underwent EUS-TD in the Kyushu University Hospital between 2008 and 2019. Clinical features were comparatively analyzed between the two patient groups who underwent either early (≤15 days postoperatively) or late (>15 days postoperatively) EUS-TD. Factors prolonging hospital stay were also analyzed using Cox proportional hazard models.

RESULTS

Thirty patients (median age, 64.5 years) were enrolled. The most common initial operation was distal pancreatectomy with splenectomy (60.0%). Median size of POPF was 69.5 (range, 38-145) mm, and median time interval between surgery and EUS-TD was 17.5 (range, 3-232) days. Totally, 47% patients underwent early EUS-TD. Rates of technical success, clinical success, and complications were 100%, 97%, and 6.9%, respectively. No recurrence of POPF occurred during a median follow-up period of 14 months. Clinical characteristics and outcomes were comparable between the early and late drainage patient groups, except for the rates of infection and nonencapsulation of POPF, which were significantly higher in the early drainage group. Performing simultaneous internal and external drainage (hazard ratio (HR): 0.31; 95% confidence interval (CI): 0.11-0.93, p=0.04) and conducting ≥2 treatment sessions (HR: 0.26; 95% CI: 0.08-0.84, p=0.02) were significantly associated with prolonged hospitalization after EUS-TD.

CONCLUSIONS

EUS-TD is a safe and effective method for managing POPF, regardless of when it is performed in the postoperative period. Once infected POPF occurs, clinicians should not hesitate to perform EUS-TD even within 15 days of the initial operation.

The role of solid debris in endoscopic ultrasound-guided drainage of walled-off necrosis: A large cohort study

BACKGROUND AND AIM

The effect of solid debris on walled-off necrosis (WON) drainage remains unknown. Our study evaluated the role of solid debris in endoscopic ultrasound (EUS)-guided drainage of WON compared lumen-apposing metal stent (LAMS) with double-pigtail plastic stent (DPPS).

METHODS

We retrospectively evaluated consecutive patients with WON who underwent EUS-guided drainage in our endoscopic center over a 9-year period. The amount of solid debris in WON was assessed with computed tomography or magnetic resonance imaging and EUS images.

RESULTS

From 2011 to 2019, 84 WON patients were included. In WON with < 20% solid debris, the short-term clinical success of LAMSs (96.8%) was significantly higher than DPPSs (66.7%) (P = 0.03), and LAMSs were safer than DPPSs with less early adverse events (P = 0.02) and late adverse events (P = 0.03). On multivariable analysis, DPPS (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.04-0.65; P = 0.01) and solid debris > 40% (OR, 0.11; 95% CI, 0.02-0.62; P = 0.01) were the predictors for failure of resolution of WON after adjusting for age and cyst size. The number of DPPSs used was significantly higher than LAMSs in managing WONs (P < 0.001).

CONCLUSION

For WON with < 20% solid debris, LAMSs might superior to DPPSs in terms of efficacy and safety.

Which Are the Most Suitable Stents for Interventional Endoscopic Ultrasound?

Endoscopic ultrasound (EUS)-guided interventions provide easy access to structures adjacent to the gastrointestinal tract, effectively targeting them for therapeutic purposes. They play an important role in the management of pancreatic fluid collections (PFC) and bile duct (BD) and pancreatic duct (PD) drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) or gallbladder (GB) drainage. Specially designed stents and delivery systems for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. In fact, EUS-guided drainage has emerged as the treatment of choice for the management of PFC, and recent innovations such as fully covered metal stents (including lumen-apposing metal stents) have improved outcomes in patients with walled-off necrosis. Similarly, EUS-guided BD and PD drainage with specially designed stents can be beneficial for patients with failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy. EUS-guided GB drainage is also performed using dedicated stents in patients with acute cholecystitis who are not fit for surgery. Although the field of dedicated stents for interventional EUS is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent improves clinical outcomes and safety in EUS-guided drainage. Herein, the current status and problems of the available stents are reviewed, including the applicable indications, long-term clinical outcomes, comparison between each stent, and their future prospects.

Endoscopic ultrasound in chronic liver disease

Endoscopic ultrasound (EUS) is a minimally invasive diagnostic and therapeutic modality with a number of established as well as evolving uses in patients with chronic liver disease. Compared to other diagnostic tools such as cross-sectional imaging or conventional endoscopy, EUS has been shown to increase diagnostic sensitivity and therapeutic success for many clinical scenarios and applications with a low rate of adverse events. In this review, we discuss and focus on the current and growing role of EUS in the evaluation and/or treatment of hepatobiliary masses, hepatic parenchymal disease, portal hypertension, esophageal and other varices, and indeterminate biliary strictures.

Endoscopic Ultrasound Guided Pancreatic Pseudocyst drainage experience at a tertiary care unit

Objective:

To evaluate the clinical success, technical success and complications related to Endoscopic ultrasound (EUS) guided Pancreatic pseudocyst (PPC) drainage.

Methods:

This retrospective study was conducted on the patients with symptomatic PPC who presented over a period of three years, between January 2015 and September 2018, at Endoscopic Suite of Surgical Unit 4, Civil Hospital, Karachi. Record was analyzed for demographic data, indications for the procedure, complications and success related to EUS guided drainage. Statistical analyses were performed using the SPSS Version 22.

Results:

Total number of patients was 71. Mean age was 37.20 ± 17.27 years with a range of 6 to 68 years. Complications occurred in 12 (8.52%) patients, including stent migration (5/12), bleeding (4/12), infection (1/12), intra-abdominal abscess (1/12) and perforation (1/12). Technical success was achieved in 100% and clinical success in 97.1%. There was no procedure-related mortality.

Conclusion:

Pancreatic pseudocyst (PPC) is a known complication of acute as well as chronic pancreatitis which can have dreaded and appalling effects. In this part of the world with limited and scarce resources, EUS guided drainage of PPC is most feasible and rational with minimal complications, thus making it a front runner procedure.

Advancements in the endoscopic treatment of pancreatic fluid collections

Endoscopic drainage of pancreatic fluid collections (PFCs) with fewer complications and less trauma has gradually replaced surgery or percutaneous drainage to become the first-line treatment for PFCs. In recent years, the differential efficacy of various stent techniques to drain different types of PFCs has been controversial. This review summarizes the clinical applications of endoscopic ultrasound-guided stent placement for PFCs drainage.

Prospective multicenter international study on the outcomes of a newly developed self-approximating lumen-apposing metallic stent for drainage of pancreatic fluid collections and endoscopic necrosectomy

BACKGROUND

A novel self-approximating lumen-apposing metallic stent (LAMS; Niti-S Spaxus, Taewoong Medical, Gyeonggi-do, Korea) has recently become available. The aim of the present study was to evaluate the outcomes for drainage of pancreatic fluid collections (PFC).

METHODS

This was a prospective international multicentered study conducted in six high-volume institutions across Asia. Consecutive patients suffering from pancreatic pseudocyst or walled-off pancreatic necrosis (WOPN) requiring endoscopic ultrasonography-guided drainage were recruited. Outcomes included technical and clinical success, adverse events, procedural events, interventions through the stent and recurrence rates.

RESULTS

Between August 2016 and November 2017, 59 patients were recruited to this study. Thirty-nine patients (66.1%) had WOPN and mean (SD) size of PFC was 11.5 (5.1) cm. Technical and clinical success rates were 100%. Mean (SD) procedural time was 35.0 (17.2) minutes. Sixteen-millimeter stents were used in 66.1% of the patients. Fifty-four sessions of necrosectomy were carried out with the stent in situ in 17 patients. Stent-related adverse event (AE) rate was 6.8%. Three patients (5.1%) suffered from bleeding after stenting and one required angiographic embolization. Two patients (3.4%) suffered from recurrence during a mean (SD) follow-up time of 325.6 (355.5) days. There were no differences in outcomes between those with pseudocysts or WOPN except for the duration of hospital stay (P = 0.012).

CONCLUSION

Use of a self-approximating LAMS for drainage of PFC was safe and effective. Endoscopic necrosectomy could be carried out through the stent with ease. The device was associated with a low rate of stent-related AE.

Endoscopic ultrasonography-guided drainage for spontaneous rupture of a pancreatic pseudocyst into the peritoneal cavity in a patient with autoimmune pancreatitis

A 75-year-old man was referred to our hospital due to a huge pancreatic cyst. Computed tomography revealed a monocular cyst 15 cm in size without a solid mass lesion nearby. He was diagnosed with pancreatic pseudocyst. Endoscopic ultrasound (EUS)-guided drainage was planned for the next day due to abdominal distension; however, the pseudocyst ruptured into the peritoneal cavity before treatment could be applied. To prevent the progression of peritonitis, EUS-guided drainage of the pseudocyst was performed. A nasocystic tube and plastic stent were placed into the ruptured cyst via the gastric wall through the same puncture tract. After the treatment, the cyst rapidly decreased in size, and the peritonitis improved without surgery. The patient's serum IgG4 level was found to be elevated to 820 mg/dL. Endoscopic retrograde cholangiopancreatography revealed main pancreatic duct stricture without obstruction. No communication between the main pancreatic duct and the pseudocyst was found. An EUS-guided fine-needle aspiration biopsy of the hypoechoic site was performed, revealing IgG4-positive plasma cell infiltration. He was finally diagnosed with AIP associated with the rupture of a pseudocyst. Oral corticosteroid (30 mg/day) treatment was started and gradually tapered. There has been no recurrence in the 28 months since the initiation of treatment.

Lumen-apposing metal stents versus biliary fully-covered metal stents for EUS-guided drainage of pancreatic fluid collections: a case control study: Meeting presentations: European Society of Gastrointestinal Endoscopy ESGE Days 2018

Background and study aims  Endoscopic ultrasound (EUS)-guided drainage has become first-line treatment for pancreatic fluid collections (PFC). The aim of this study was to compare the effectiveness and safety of biliary fully-covered self-expandable metal stents (BFCSEMS) and lumen-apposing metal stents with electrocautery (EC-LAMS). Patients and methods  From April 2008 to March 2017, consecutive patients with symptomatic PFC drained under EUS-guidance with metal stents were included. Patients drained with EC-LAMS were considered the study group and those drained with BFCSEMS the control group. Two primary endpoints were evaluated: effectiveness (defined as reduction of ≥ 50 % of PFC size in cross-sectional imaging and improvement of symptoms 6 months after the transmural drainage) and safety. Results  Thirty patients were drained with EC-LAMS and 60 patients with BFCSEMS. Patients and PFC baseline characteristics in both groups were similar. Use of a coaxial double pigtail plastic stent and a nasocystic lavage catheter was significantly less frequent in patients drained with EC-LAMS (33 % vs. 100 %, and 13 % vs. 58 %, respectively; P  < 0.0001). Technical success was 100 % in both groups. Procedure time was < 30 minutes in all patients drained with EC-LAMS and over 30 minutes in all patients drained with BFCSEMS ( P  = 0.0001). Clinical success was higher with a tendency to significance in patients drained with EC-LAMS (96 % vs. 82 %, P  = 0.055) and the adverse event rate was lower (4 % vs. 18 %, P  = 0.04). No case of procedure-related mortality was recorded. Conclusions  EC-LAMS and BFCSEMS are both effective for EUS-guided drainage of PFC. However, EC-LAMS requires less time to be performed and appears to be safer.

Lumen-apposing metal stents for endoscopic ultrasonography-guided interventions

Lumen-apposing metal stents (LAMS) are integrated in a single-step delivery platform and can be deployed under endoscopic ultrasound-guidance for the drainage of intra-abdominal fluid collections, decompression of obstructed ductal systems, establishment of anastomosis or creation of fistulous tracts between organs that can facilitate further endoscopic interventions if required. A unique feature of LAMS is their ability to approximate the adjoining structures, thereby minimizing the potential for leak and perforation. Consequently, the innovation has advanced our ability to carry out complex therapeutic interventions and obviate the need for high-risk surgical procedures, particularly in morbid patients. However, a keen awareness of the technical design of LAMS and its implication on treatment effect is important to minimize adverse events and to improve clinical outcomes. This review outlines the technical approach to placement of LAMS, procedural challenges, adverse events, current clinical indications and emerging applications.

A novel lumen-apposing metal stent with an anti-reflux valve for endoscopic ultrasound-guided drainage of pseudocysts and walled-off necrosis: A pilot study

BACKGROUND

Pancreatic pseudocysts (PC) and walled-off necrosis (WON) are common complications of severe pancreatitis. Endoscopic ultrasound (EUS)-guided drainage has replaced surgery as the standard treatment for PC/WON. We developed a novel lumen-apposing metal stent (LAMS) with an anti-reflux valve to prevent infectious complications caused by food reflux into the cyst cavity. This retrospective study investigated the efficacy and safety of EUS-guided drainage using this LAMS.

METHODS

We investigated and compared the treatment outcomes and complications rates between EUS-guided drainage using a novel LAMS (n = 10) versus plastic stents (n = 18) from December 2013 to October 2016. Technical success was defined as successful stent placement without immediate complications. Clinical success was defined as resolution of the PC/WON and disappearance of symptoms.

RESULTS

Among 10 patients in LAMS group, 4 patients had complicated PC and 6 patients had WON. In the plastic stent group, 15 and 3 patients had PC and WON, respectively. The median fluid collection size before treatment was 82.5 (interquartile range [IQR], 60.75-118.25) mm and 92.0 (IQR, 75.75-130.25) mm in the LAMS and plastic stent groups, respectively. There were no statistically significant differences in technical success rates (90% vs. 94.4%; p = 0.999), clinical success rates (80% vs. 77.8%; p = 0.999), and complication rates (20% vs. 27.8%; p = 0.999) between the two groups.

CONCLUSIONS

Treatment outcomes of EUS-guided drainage using a novel LAMS were feasible despite the significantly high proportion of WON. The LAMS allowed acceptable treatment outcomes for EUS-guided drainage.

CT-guided percutaneous catheter drainage of pancreatic postoperative collections

Objective: To examine the clinical characteristics of fluid collections after pancreatic surgery and evaluate the safety and effectiveness of CT-guided percutaneous catheter drainage (CT-PCD).Material and methods: A retrospective, cross-sectional study was carried out. 51 patients enrolled in this study underwent CT-PCD for collections after pancreatic surgery. The clinical and imaging data were collected and analysed.Results: In all 51 cases, CT scans showed that the samples were collected from the upper abdomen in 94.1% (48/51) of the patients. Apparent clinical symptoms before puncture manifested in 88.2% (45/51) of the patients. The average interval between surgery and puncture was 14.3 ± 7.9 days. In 76.4% (39/51) of the patients, the abdominal drainage catheter inserted during surgery was still not removed during CT-PCD. Amylase levels in drainage fluid were more than three times that of serum amylase in 66.7% (24/36) of the patients. The drainage fluid of 37 patients was sent for bacterial cultures; of these, 64.9% (24/37) tested positive. Full recovery after single puncture procedure occurred in 84.3% (43/51) of the patients. The incidence of puncture-related complications was 3.9%.Conclusions: Pancreatic postoperative collections requiring clinical puncture were mostly located in the upper abdomen. CT-PCD is a safe technique with good therapeutic effects in patients with collections.

Complications of Long-Term Indwelling Transmural Double Pigtail Stent Placement for Symptomatic Peripancreatic Fluid Collections

BACKGROUND

Endoscopic transmural drainage is performed for symptomatic peripancreatic fluid collections (PPFCs). Long-term transmural double-pigtail stent (DPS) placement is useful in preventing recurrences. There are few reports on the long-term safety of DPS placement. Thus, this study aimed to examine the complications of long-term indwelling DPS for PPFCs.

METHODS

Among 53 patients who underwent endoscopic ultrasound-guided transmural drainage for symptomatic PPFCs between April 2006 and March 2017, those followed up for over one year were included. Complications of long-term indwelling DPS were examined retrospectively.

RESULTS

This study enrolled 36 patients [30 men, median age 54 years (range 22-82)]. Walled-off necrosis was present in 22 cases (including 9 disconnected pancreatic duct syndrome cases) and pancreatic pseudocysts, in 14 cases. The median stenting period was 20.9 (range 0.8-142.3) months, and median observation period was 56.2 (range 12.4-147.1) months. Colon perforation due to DPS occurred in 3 cases (8.3%), at 5.8, 17.1, and 33.7 months after indwelling DPS placement; 2 cases developed perforation from the serosal side. In 1 case, the patient was treated surgically, and in 2 cases, the patients underwent endoscopic removal of the stent and showed improvement with conservative treatment.

CONCLUSION

Long-term indwelling transmural DPS for symptomatic PPFCs poses a risk of intestinal perforation. Thus, if possible, it may be better to avoid long-term placement.

Endoscopic treatment of refractory external pancreatic fistulae with disconnected pancreatic duct syndrome

BACKGROUND

External pancreatic fistulae (EPF) developing in setting of disconnected pancreatic duct syndrome (DPDS) are associated with significant morbidity and surgery is the only effective treatment.

AIM

To describe safety and efficacy of various endoscopic including endoscopic ultrasound (EUS) guided drainage techniques for resolving EPF in DPDS.

METHODS

Retrospective analysis of data base of 18 patients (15 males; mean age: 37.6 ± 7.1years) with EPF and DPDS who were treated with various endoscopic techniques including EUS guided transmural drainage.

RESULTS

EPF developed post percutaneous drainage (PCD) (n = 15) or post-surgical necrosectomy (n = 3) of acute necrotic collections. All patients had refractory EPF with daily output of >50 ml/day with mean duration being 19.2 ± 6.1 weeks. One patient had failed surgical fistulo-jejunostomy. Various endoscopic techniques used were: transmural placement of pigtail stent through gastric opening of trans-gastric PCD (n = 5), EUS guided transmural puncture of fluid collection created by clamping PCD (n = 5) or by instillation of water though PCD (n = 3), direct EUS-guided puncture of fistula tract (n = 1) and EUS guided pancreaticogastrostomy (n = 4). EPF healed in 17/18 (94%) patients within 5-21 days and there has been no recurrence over follow up of 16.7 ± 12.8 weeks. Asymptomatic spontaneous external migration of stents was observed in 5/18 (29.4%) patients.

CONCLUSION

Management of refractory EPFs in setting of DPDS is challenging. In our experience, combination of various endoscopic techniques including EUS guided transmural drainage appears to be safe and effective treatment modality for treating these complex EPF's. However, further studies to identify patient selection and best treatment approaches are needed.

Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel

OBJECTIVES

Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures.

METHODS

Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question.

RESULTS

A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required.

CONCLUSIONS

The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.

Novel lumen-apposing metal stent for the drainage of pancreatic fluid collections: An Italian multicentre experience

Background

Endoscopic ultrasound (EUS)-guided drainage is the procedure of choice for pancreatic fluid collection (PFC) management. Recently developed lumen-apposing fully covered self-expandable metal stents (LAMSs) may facilitate drainage, especially of necrotic and complex PFCs.

Objective

To evaluate the feasibility and efficacy of a newly developed LAMS (Nagi, Taiwong Medical Co. Ltd, South Korea) in the drainage of PFCs.

Methods

Retrospective analysis of LAMS drainage of PFCs from seven centres. Patient demographic, EUS and radiological findings, PFCs aetiology, procedural technical and clinical success, and adverse events were evaluated.

Results

Sixty-seven patients with mean age 58.8 ± 14 years (68.7% males) were included in the analysis. Of these, 44 patients had pseudocyst (PP) and 23 patients had walled-off pancreatic necrosis (WOPN). Technical success was achieved in 98.5% of cases and clinical success in 94%. The adverse event rate was 24.2%, higher and mostly due to stent migration and occlusion in the WOPN group as compared to the PP group, despite the time to stent removal being significantly lower in the WOPN group.

Conclusions

PFC drainage using the Nagi stent is highly feasible and effective, with a relatively safe profile. Future studies enrolling more patients with complex PFCs are needed to clearly establish the role of this stent in PFC management.