Systematic review comparing endoscopic, percutaneous and surgical pancreatic pseudocyst drainage

A rare presentation of pleural pseudocyst in chronic calcific pancreatitis: A case report

Chronic calcific pancreatitis (CP) is a progressive inflammatory disorder that can lead to complications in multiple organ systems. Pleural pseudocysts, a rare thoracic manifestation of chronic pancreatitis, pose significant diagnostic and therapeutic challenges. This case report highlights the presentation, diagnostic approach, and management of a patient with pleural pseudocyst associated with chronic calcific pancreatitis. A 41-year-old male presented with a one-month history of abdominal pain and a persistent cough. Clinical evaluation and imaging revealed chronic calcific pancreatitis with multiple pseudocysts, left-sided hydropneumothorax, a right pleural pseudocyst, and massive ascites. Diagnostic imaging, including high-resolution computed tomography (HRCT) of the thorax and contrast-enhanced computed tomography (CECT) of the abdomen, confirmed the diagnosis. Biochemical analysis showed elevated amylase levels in pleural and ascitic fluids, consistent with pseudocyst rupture. The patient was managed conservatively with intercostal drain (ICD) insertion, pigtail catheterization, nasojejunal feeding, and broad-spectrum antibiotics. Despite stabilization, the patient declined further surgical interventions, including decortication and endoscopic retrograde cholangiopancreatography (ERCP). This case underscores the importance of a multidisciplinary approach in managing rare complications of chronic pancreatitis. Advanced imaging and biochemical analysis are pivotal for diagnosis, while nutritional optimization and minimally invasive interventions form the cornerstone of management. Definitive surgical or endoscopic procedures are often required but may be limited by patient preferences or resource constraints. Pleural pseudocyst is a rare but significant complication of chronic pancreatitis requiring prompt diagnosis and tailored management. This report emphasizes the role of a patient-centric approach in addressing complex clinical scenarios.

Practical management of severe acute pancreatitis

Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.

Pancreatic pseudocyst: The past, the present, and the future

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.

Endoscopic ultrasound-guided drainage of pancreatic collections with dedicated metal stents: A nationwide, multicenter, propensity score-matched comparison

BACKGROUND

The new dedicated stents for endoscopic ultrasound (EUS)-guided transluminal drainage of peri‑pancreatic fluid collections (PFCs) demonstrated optimal efficacy and safety profiles.

AIMS

This study aimed to evaluate the safety, technical and clinical success, and recurrence rate of PFCs drained with Lumen Apposing Metal Stent (LAMS) or Bi-Flanged Metal Stent (BFMS).

METHODS

Data from a multicenter series of PFCs treated with LAMS or BFMS at 30 Italian centers during a 5-year period were retrieved. The rate of adverse events (AEs), technical success, clinical success, PFC recurrence were evaluated. To overcome biases, a 1-to-1 match was created using propensity score analysis.

RESULTS

Out of 476 patients, 386 were treated with LAMS and 90 with BFMS, with a median follow-up of 290 days (95% CI 244 to 361). Using propensity score matching, 84 patients were assigned to each group. The incidence of AEs did not differ between the two stents (13.1% versus 15.5%, p = 0.29), mainly bleeding or recurrence rate (4.7% versus 3.5%, p = 1). Technical and clinical success in the BFMS and LAMS groups were 92% versus 95% (p = 0.36) and 91% versus 94% (p = 0.64), respectively.

CONCLUSION

Our study demonstrates that LAMS and BFMS have comparable safety profiles with similar technical and clinical success rates for EUS-guided PFC drainage.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

INTRODUCTION

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

AIM

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

MATERIAL AND METHODS

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

RESULTS AND CONCLUSIONS

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

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.

Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

Analysis of pancreatic pseudocyst drainage procedural outcomes: a population based study

BACKGROUND

A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts.

METHODS

The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann-Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates.

RESULTS

Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07-1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23-0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27-0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15-5.82, p = 0.02).

CONCLUSIONS

Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database.

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.

Giant Hemorrhagic Pancreatic Pseudocyst: A Case Report and Guidelines for Care

Pancreatic pseudocysts are potential sequelae of acute or chronic pancreatitis. In some cases, enzymatic degradation of the lining between a pseudocyst and the splenic artery, or surrounding vessels, can occur, resulting in a hemorrhagic pancreatic pseudocyst. Very few of these hemorrhagic pseudocysts meet the criteria for giant pseudocysts. We discuss the case of a 30-year-old male patient with a history of alcohol abuse who presented to the hospital with a giant hemorrhagic pancreatic pseudocyst; he was admitted for expectant management and was subsequently discharged. This case report seeks to shed light on the dearth of similar cases.

Endoscopic Retroperitoneal Necrosectomy for Infected Pancreatic Necrosis Using a Self-Expandable Metal Stent

Infected walled-off pancreatic necrosis (WOPN) is a severe complication of acute pancreatitis. Surgery in these critically ill patients can be associated with increased morbidity and mortality. Hence, minimally invasive therapies have emerged as an alternative to surgery. Herein, we report a case of severe acute pancreatitis with WOPN which was treated percutaneously with a flexible endoscope through an esophageal self-expanding metal stent using a total retroperitoneal approach. Percutaneous direct endoscopic necrosectomy (p-DEN) using the retroperitoneal route improved the patient's parameters dramatically with resolution of sepsis without the need for surgery. p-DEN using a flexible endoscope passed through a large bore metal stent shows promise in selected patients with WOPN and can be used in patients who are not ideal candidates for transmural or surgical drainage.

Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis

PURPOSE

The main goal of this systematic review was to assess the technical and clinical success, adverse events (AEs), surgery, and overall mortality proportion after percutaneous catheter drainage (PCD) of two pancreatic lesions.

METHODS

An extant search in online databases including Scopus, PubMed (Medline), Embase (Elsevier), Web of Science, Cochrane library, and Google Scholar, was conducted to recognize all studies that used PCD intervention in the management of pancreatic necrosis (PN) and pancreatic pseudocysts (PP). Random effects meta-analysis was performed, and Cochrane's Q test and I²statistic were utilized to determine heterogeneity. In addition, meta-regression was used to explore the influence of categorical variables on heterogeneity.

RESULTS

Thirty-two studies (1398 patients) including PN in 26 (1256 cases, 89.8%) studies and PP in 6 (142 cases, 10.2%) studies were identified. Technical success proportion was 100% (95% confidence interval [CI] 100%-100%, I²: 0.0%), clinical success 63% (95% CI 55%-71%, I²: 92.9%), AEs 26% (95% CI 21%-31%, I²: 78%), surgery after PCD intervention 33% (95% CI 25%-40%, I²: 92.4%), and overall mortality was 13% (95% CI 9%-17%, I²: 82.8%). The most common ADs after PCD intervention were development of fistula (106, 42.6%), hemorrhage (44, 17.7%), sepsis (40, 16.1%).

CONCLUSION

A significant clinical success proportion with low AEs, surgery, and overall mortality proportion after PCD intervention was found, although the results should be interpreted with caution due to the high heterogeneity.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

EUS-guided drainage of pancreatic fluid collection, using a modified technique of cystotome alone without a FNA needle

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage for pancreatic fluid collection (PFC) involves puncture with a fine-needle aspiration (FNA) needle, followed by tract dilation involving exchange of multiple accessories, and finally deployment of stent. The procedure is time consuming and carries a risk of loss of wire access and hence technical failure. We used a modified technique with a 10-F cystotome alone instead of a FNA needle and dilators.

METHODS

We retrospectively analysed records of consecutive patients who had undergone EUS-guided drainage of PFC using a modified technique, with puncture of PFC using a 10-Fcystotome, followed by passage of a guidewire through it into the PFC cavity and deployment of a biflanged, 2-cm-long, fully covered self-expanding metal stent over it. Technical and clinical success rates and procedure time were assessed.

RESULTS

Forty-five patients underwent PFC drainage, median age was 35 (12-76), and 35 (77.8%) were males. The median (range) duration of symptoms was 125 (38-1080) days, while the median PFC size was 11.8 × 11 × 11 cm, and the follow-up period after stent removal was 111 ± 72 (18-251) weeks. The procedure took 10 (8-12) min and had technical and clinical success rates of 100 and 97.8%, respectively. Minor complications occurred in six (13.3%) patients, while recurrence occurred in one.

CONCLUSION

EUS-guided drainage of PFC using a cystotome is a quick, effective and safe procedure. It may also be less expensive since it obviates the use of FNA needles and dilators, and is likely to be a useful alternative to the conventional technique.

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

Endoscopic cystogastrostomy: Still a viable option in children with symptomatic pancreatic fluid collection

BACKGROUND/OBJECTIVES

Endoscopic transmural drainage is the preferred method of drainage of pancreatic fluid collections (PFCs) in adults; however, there is scant literature in children. We analyzed our experience of 33 endoscopic cystogastrostomies done in 29 children to find its efficacy and safety.

METHODS

We retrospectively analyzed the prospectively collected database of 31 consecutive children (<18 years) who underwent endoscopic cystogastrostomy from June 2013 to December 2017. The procedure was done using the standard technique with an adult duodenoscope. Data related to clinical details, technical success, complications and follow-up were collected.

RESULTS

The median age was 14 (3-17) years (22 males). Indications were early satiety in 28 (90%), vomiting in 15 (48%), and duodenal obstruction and infected pseudocyst in 2 children each. Etiology includes acute pancreatitis 22, post-traumatic 4 and chronic pancreatitis 5. The procedure was successful in 29 of 31 (93.5%) children with no mortality. Adverse events happened in four cases (12.9%); two infections, another with bleeding and another with pneumoperitonium, both of which resolved spontaneously. Incidents (minor bleeding) were noted in 6 (19%). Stents were removed in 26 (90%) after 12 (7-20) weeks and got spontaneously migrated out in 3 (10%) cases. Over a median follow-up of 26 (5-48) months, 26 (90%) had no recurrence of pseudocyst and 3 (10%) had recurrence of a small, asymptomatic pseudocyst.

CONCLUSIONS

Endoscopic cystogastrostomy is a safe and effective method of draining bulging PFCs in children. The procedure carries acceptable morbidity with minimal recurrence. In younger children it may be the preferred method of drainage of PFCs.

Pancreatic pseudocyst, pancreatitis, and incomplete pancreas divisum in a child treated with endotherapy: a case report

Pancreatic divisum (PD) is caused by the lack of fusion of the pancreatic duct during the embryonic period. Considering the incidence rate of PD, clinicians lack an understanding of the disease, which is usually asymptomatic. Some patients with PD may experience recurrent pancreatitis and progress to chronic pancreatitis. Recently, a 13-year-old boy presented with pancreatic pseudocyst, recurrent pancreatitis, and incomplete PD, and we report this patient's clinical data regarding the diagnosis, medical imagining, and treatment. The patient had a history of recurrent pancreatitis and abdominal pain. Magnetic resonance cholangiopancreatography was chosen for diagnosis of PD, pancreatitis, and pancreatic pseudocyst, followed by endoscopic retrograde cholangiopancreatography, minor papillotomy, pancreatic pseudocyst drainage, and stent implantation. In the follow-up, the pseudocyst lesions were completely resolved, and no recurrent pancreatitis has been observed.

Clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis and pancreatic pseudocyst, and the effects on IL-6 and CRP

The study aimed to investigate the clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis (SAP) and pancreatic pseudocyst (PP), and its effects on serum inflammatory factors. Altogether 94 patients complicated with SAP and PP who were admitted to Weifang People's Hospital (Weifang, China) from September 2015 to December 2018 were included. Based on the different operation methods, 49 patients who underwent traditional laparotomy under laparoscopic surgery were included in group A, and 45 patients who underwent duodenoscopy and laparoscopy under duodenoscope to treat the drainage of nipple and pancreatic pseudocysts were included in group B. The expression levels of related serum indexes and serum stress indexes before and at 48 h after surgery, the postoperative nausea, vomiting and abdominal pain scores, as well as the clinical efficacy, perioperative related indexes, recovery and complications were compared between the two groups. The prognostic factors in both groups were assessed via Logistic univariate and multivariate analyses. C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-β (IL-β), endotoxin and nuclear factor κB (NF-κB) were significantly lower in group B than those in group A (P<0.001). Upregulating cortisol and norepinephrine in group B was lower than that in group A (P<0.001). The total effective rate in group B was higher than that in group A (P<0.05). The perioperative related indexes, recovery, and postoperative complications in group B were better than those in group A (P<0.05). Scores of abdominal pain, nausea and vomiting in group B were markedly lower than those in group A (P<0.001). Multivariate Logistic regression analysis showed that CRP, TNF-α, IL-6, IL-β and surgical methods were independent risk factors for the prognosis of patients with SAP and PP. In conclusion, the combined treatment with duodenoscopy and laparoscopic surgery has little inflammatory and stress reaction, and it is highly safe, worthy to be popularized.

Pancreatic pseudocyst: Dilemma of its recent management (Review)

Advances in radiological techniques have led to an increase in the number of diagnoses of pancreatic pseudocyst, which is the most common pancreatic cyst lesion disease, accounting for two-thirds of all pancreatic cyst lesions. Historically, the management of pancreatic pseudocyst has been achieved through the use of conservative treatments and surgery; however, due to the complications and recurrence rate associated with these techniques, the management of pancreatic pseudocyst is challenging. Surgeons and gastroenterologists have attempted to determine the optimal management technique to treat pancreatic pseudocyst to reduce complications and the recurrence rate. From these investigations, percutaneous catheter, surgical and endoscopic drainage with ultrasonography guidance have become promising management techniques. The present review aimed to summarize the diagnostic and therapeutic methods used for the management of pancreatic pseudocyst and to compare percutaneous catheter, surgical and endoscopic drainage.

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

BACKGROUND

Endoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention.

AIM

To assess the feasibility, efficacy and safety of EGF for WON.

METHODS

Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.

RESULTS

EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.

CONCLUSION

EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management

Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.

Endoscopic ultrasound-guided anastomosis: Is it ready for prime time?

Significant advancements in endoscopic ultrasound (EUS)-guided drainage procedures and EUS-guided anastomosis have recently been described. The described procedures include EUS-guided drainage of pancreatic fluid collections, biliary drainage, pancreatic duct drainage, gallbladder drainage, and gastroenterostomy. These procedures have been made possible with novel devices that can reduce the difficulties of the procedures and potentially reducing the risk of adverse events. The procedures are also becoming standardized, which is essential for dissemination of the techniques. Furthermore, results from randomized studies are becoming available showing definite benefits associated with these procedures. In this paper, we will provide a review on EUS-guided anastomotic procedures.

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.

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.

Comparative outcomes of endoscopic ultrasound-guided cystogastrostomy for peripancreatic fluid collections: a systematic review and meta-analysis

Background:

Endoscopic ultrasound–guided cystogastrostomy has become the first-line treatment for symptomatic peripancreatic fluid collections. The aim of this study is to analyze the efficacy and safety of cystogastrostomy via a meta-analysis of the literature.

Methods:

We performed a systematic search of PubMed and Medline databases for studies published from January 2005 to May 2018. We included randomized controlled trials along with retrospective and prospective observational studies reporting endoscopic ultrasound–guided cystogastrostomy stent placement for peripancreatic fluid collections. The primary outcome for our meta-analysis was complete peripancreatic fluid collection resolution on imaging. Our secondary outcomes included comparative efficacy and safety of the procedure for pseudocysts and walled-off pancreatic necrosis using metal and plastic stents.

Results:

Seventeen articles involving 1708 patients met our inclusion criteria for meta-analysis. Based upon the random effects model, the pooled technical success rate of cystogastrostomy was 88% (95% confidence interval = 83–92 with I² = 85%). There was no difference in the technical success rate between pancreatic pseudocysts and walled-off pancreatic necrosis (91% and 86%, respectively p = nonsignificant). The adverse event rates for metal and plastic stents were equivalent (14% and 18%, respectively, p = nonsignificant).

Conclusion:

Endoscopic ultrasound–guided cystogastrostomy stents are effective in the treatment of pancreatic pseudocysts and walled-off pancreatic necrosis. We found no difference in technical success or adverse event rates of drainage based on peripancreatic fluid collection type or stent used.

Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP).

METHODS

The researchers did a search in Medline, EMBASE, Scielo/Lilacs, and Cochrane electronic databases for studies comparing surgical and endoscopic drainage of PP s in adult patients. Then, the extracted data were used to perform a meta-analysis. The outcomes were therapeutic success, drainage-related adverse events, general adverse events, recurrence rate, cost, and time of hospitalization.

RESULTS

There was no significant difference between treatment success rate (risk difference [RD] -0.09; 95% confidence interval [CI] [0.20,0.01]; P = .07), drainage-related adverse events (RD -0.02; 95% CI [-0.04,0.08]; P = .48), general adverse events (RD -0.05; 95% CI [-0.12, 0.02]; P = .13) and recurrence (RD: 0.02; 95% CI [-0.04,0.07]; P = .58) between surgical and endoscopic treatment.Regarding time of hospitalization, the endoscopic group had better results (RD: -4.23; 95% CI [-5.18, -3.29]; P < .00001). When it comes to treatment cost, the endoscopic arm also had better outcomes (RD: -4.68; 95% CI [-5.43,-3.94]; P < .00001).

CONCLUSION

There is no significant difference between surgical and endoscopic treatment success rates, adverse events and recurrence for PP. However, time of hospitalization and treatment costs were lower in the endoscopic group.

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

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.

Pancreatic pseudocyst drainage in children by image-guided cystogastrostomy and stent insertion

BACKGROUND

Endoscopic ultrasound is seldom available at paediatric centres; therefore drainage of pancreatic pseudocysts in children has traditionally been achieved by surgery.

OBJECTIVE

This study assessed the feasibility and safety of performing image-guided internal drainage of pancreatic pseudocysts with a flanged self-expanding covered nitinol pancreatic pseudocyst drainage stent.

MATERIALS AND METHODS

We conducted a retrospective case note review of children undergoing image-guided cystogastrostomy at two paediatric hospitals. Percutaneous access to the stomach was achieved via an existing gastrostomy tract or image-guided formation of a new tract. Under combined ultrasound, fluoroscopic or cone-beam CT guidance the pancreatic pseudocysts were punctured through the posterior wall of the stomach. A self-expanding covered nitinol stent was deployed to create a cystogastrostomy opening.

RESULTS

Image-guided cystogastrostomy was performed in 6 children (4 male; median age 6 years, range 46 months to 15 years; median weight 18 kg, range 13.8-47 kg). Two children had prior failed attempts at surgical or endoscopic drainage. Median maximum cyst diameter was 11.5 cm (range 4.7-15.5 cm) pre-procedure. Technical success was 100%. There were no complications. There was complete pseudocyst resolution in five children and a small (2.1-cm) residual pseudocyst in one. Pseudocyst-related symptoms resolved in all children.

CONCLUSION

Pancreatic pseudocyst drainage can be successfully performed in children by image-guided placement of a cystogastrostomy stent. In this cohort of six children there were no complications.

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.

Lumen Apposing Metal Stents (LAMSs) for Drainage of Pancreatic and Gallbladder Collections: A Meta-analysis

BACKGROUND AND AIMS

Endoscopic ultrasound-guided transmural drainage using lumen apposing metal stents (LAMSs) is becoming a popular and promising therapeutic approach for drainage of intra-abdominal fluid collections. There has been an increasing number of studies evaluating LAMS for drainage of pancreatic pseudocysts (PP), walled-off pancreatic necrosis (WOPN), and gallbladder (GB) drainage. The aim of this meta-analysis is to analyze the literature to date regarding the clinical success, technical success, and adverse events of LAMS in treatment of pancreatic fluid collections and GB drainage.

METHODS

A comprehensive search of multiple literature databases through November 2016 was performed. Human studies with at least 10 subjects that examined the clinical success, technical success, and adverse events of LAMS in treating PP, WOPN, and GB drainage were included.

RESULTS

A total of 993 patients (608-WOPN; 204-PP; 181-GB drainage) underwent drainage from 20 trials. For drainage of WOPN, the pooled technical success was 98.9% [95% confidence interval (CI): 98.2% to 99.7%] and clinical success was 90% (95% CI: 87% to 93%) (τ=0.001). For drainage of PP, the pooled technical success was 97% (95% CI: 95% to 99%) and clinical success was 98% (95% CI: 96% to 100%), (τ=0.001). For GB drainage, the pooled technical success was 95% (95% CI: 91% to 99%) and clinical success was 93% (95% CI: 90% to 97%), (τ=0.001). Total adverse events occurred in 11% of patients with higher complication rates observed in GB drainage. There was no evidence of publication bias in this meta-analysis.

CONCLUSIONS

Endoscopic ultrasound-guided transmural drainage using LAMS is becoming a widely accepted therapeutic approach for the treatment of PP, WOPN, and GB drainage with high clinical and technical success rates and acceptable adverse events. Further prospective randomized trials reporting long-term clinical efficacy and cost-effectiveness are needed to validate LAMS as a therapeutic modality for pancreatic and GB collections.

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.

Endoscopic Management of Peri-Pancreatic Fluid Collections

In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic "step up" approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.

Modern Management of Pancreatic Fluid Collections

The last decade has seen dramatic shift in paradigm in the management of pancreatic fluid collections with the rise of endoscopic therapy over radiologic or surgical management. Endosonographic drainage is now considered the gold standard therapy for pancreatic pseudocyst. Infected pancreatic necroses are being offered endoscopic necrosectomy that has been facilitated by the arrival on the market of large diameter lumen-apposing metal stent. Severe pancreatitis or failure to thrive should receive enteral nutrition while pancreatic ductal disruption or strictures are best treated by pancreatic stenting.

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

Objective

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

Method

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

Results

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

Conclusion

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

OBJECTIVE

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

METHOD

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

RESULTS

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

CONCLUSION

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Endoscopic ultrasound-guided transduodenal drainage of idiopathic retroperitoneal abscess in an immunocompromised patient: A case report

RATIONALE

Idiopathic retroperitoneal abscesses are insidious, occult illnesses with high mortality if inadequately drained. Endoscopic ultrasound-guided drainage is an alternative to percutaneous or surgical drainage, it is not widely performed for retroperitoneal abscesses other than peripancreatic fluid collection.

PATIENT CONCERNS

We present a 76-year-old Japanese woman with abdominal pain, high fever, and a history of rheumatism on treatment with immunosuppressants.

DIAGNOSES

The patient was diagnosed with idiopathic retroperitoneal abscess based on results obtained from her clinical course and findings on computed tomography.

INTERVENTIONS

We performed Endoscopic ultrasound-guided drainage. After we performed needle puncture via the descending portion of the duodenum, the fistula was expanded using a dilator, and a double-pigtail stent and endoscopic nasobiliary drainage tube were inserted.

OUTCOMES

The patient was kept nil by mouth, together with intravenous antibiotic therapy, and repeated washing of the abscess cavity with saline was performed. After that, we confirmed disappearance of the cavity, and, after removing the tubes, commenced oral feeding. We were able to avoid surgery in this immunosuppressed patient.

LESSONS

Endoscopic ultrasound (EUS)-guided abscess drainage can be overall considered a safe and useful procedure. We also propose the double-stent method, with both internal and external stents, for the treatment of idiopathic retroperitoneal abscesses.

Large pancreatic pseudocyst penetrating into posterior mediastinum

We report a rare case of a large mediastinal pancreatic pseudocyst compressing the left atrium and the esophagus and causing dyspnea, palpitations, and emesis. Chest radiograph was non-diagnostic, esophagogastroduodenoscopy showed diffuse extrinsic compression of the distal esophagus and gastric corpus, but a definitive diagnosis was confirmed by computed tomography. We decided to perform surgery due to the recurrence of the pancreatic pseudocyst, a history of unsuccessful radiologically guided external drainage a few years earlier, and a very large diameter of the pseudocyst causing acute cardio-pulmonary distress syndrome.

Endoscopic ultrasonography-guided drainage of pancreatic fluid collections

Endoscopic ultrasound (EUS)-guided drainage is now firmly established as the best option for drainage of walled-off pancreatic fluid collections (PFC). It has high clinical efficacy, similar to surgical and percutaneous approaches, but with lower morbidity and costs. It is superior to non-EUS-guided approaches because even collections without endoluminal bulging can be successfully drained. Transmural drainage alone is sufficient for pseudocysts, but in the context of walled-off pancreatic necrosis (WON), adjunctive direct endoscopic necrosectomy (DEN) may be required. Traditionally, double pigtail plastic stents (PS) were used for transmural drainage, but, recently, fully covered self-expandable metallic stents (FCSEMS) customized for PFC drainage have become available and are increasingly used, especially in the management of WON, because the larger-diameter stent facilitates drainage and insertion of an endoscope into the WON cavity for DEN. The present review will discuss the evidence for EUS-guided drainage and DEN, the technical problems involved, and the roles of PS and FCSEMS in PFC drainage.

Endoscopic management of pancreatic fluid collections-revisited

The development of pancreatic fluid collections (PFC) is one of the most common complications of acute severe pancreatitis. Most of the acute pancreatic fluid collections resolve and do not require endoscopic drainage. However, a substantial proportion of acute necrotic collections get walled off and may require drainage. Endoscopic drainage of PFC is now the preferred mode of drainage due to reduced morbidity and mortality as compared to surgical or percutaneous drainage. With the introduction of new metal stents, the efficiency of endoscopic drainage has improved and the task of direct endoscopic necrosectomy has become easier. The requirement of re-intervention is less with new metal stents as compared to plastic stents. However, endoscopic drainage is not free of adverse events. Severe complications including bleeding, perforation, sepsis and embolism have been described with endoscopic approach to PFC. Therefore, the endoscopic management of PFC is a multidisciplinary affair and involves interventional radiologists as well as GI surgeons to deal with unplanned adverse events and failures. In this review we discuss the recent advances and controversies in the endoscopic management of PFC.

The role of endoscopic intervention in the management of inflammatory pancreatic fluid collections

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis, or less commonly, pancreatic trauma or surgery. The revised Atlanta Classification categorizes PFCs as acute or chronic, with further subclassification of acute collections into acute peripancreatic collections and acute necrotic collections and of chronic fluid collections into pseudocysts and walled-off pancreatic necrosis. Acute PFCs are generally only subjected to an intervention when they are infected and not responding to antibiotics and are not managed endoscopically. Chronic PFCs, both pseudocysts and walled-off pancreatic necrosis, require intervention only when symptomatic or enlarging over time. Endoscopic ultrasound-guided drainage has become the mainstay of management for chronic PFCs that require intervention. Developments in medical devices over the past few years have significantly simplified and shortened the duration of the procedure itself, but the optimum choice of stent in different clinical scenarios remains to be defined, as does the place of endoscopic necrosectomy. To optimize outcomes, these patients should undergo a careful preprocedure workup and discussion in a multidisciplinary environment and procedures should be carried out in high-volume pancreatic units.