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Chandrasekhara V, Barthet M, Devière J, Bazerbachi F, Lakhtakia S, Easler JJ, Peetermans JA, McMullen E, Gjata O, Gourlay ML, Abu Dayyeh BK. Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis. Endosc Int Open 2020; 8:E1639-E1653. [PMID: 33140020 PMCID: PMC7584468 DOI: 10.1055/a-1243-0092] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P = 0.39) and perforation risk (0.5 % vs. 1.1 %, P = 0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P = 0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P = 0.72), stent migration (5.9 % vs. 6.8 %, P = 0.79), and stent occlusion (3.8 % vs. 5.2 %, P = 0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.
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Affiliation(s)
- Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Marc Barthet
- Service d'hépato-gastroentérologie, Hôpital Nord, Chemin des Bourrely, Marseille, France
| | | | - Fateh Bazerbachi
- Division of Gastroenterology, Interventional Endoscopy Program, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sundeep Lakhtakia
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jeffrey J. Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Joyce A. Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Margaret L. Gourlay
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Jagielski M, Smoczyński M, Szeliga J, Adrych K, Jackowski M. Various Endoscopic Techniques for Treatment of Consequences of Acute Necrotizing Pancreatitis: Practical Updates for the Endoscopist. J Clin Med 2020; 9:jcm9010117. [PMID: 31906294 PMCID: PMC7019492 DOI: 10.3390/jcm9010117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/20/2019] [Accepted: 12/30/2019] [Indexed: 12/12/2022] Open
Abstract
Despite great progress in acute pancreatitis (AP) treatment over the last 30 years, treatment of the consequences of acute necrotizing pancreatitis (ANP) remains controversial. While numerous reports on minimally invasive treatment of the consequences of ANP have been published, several aspects of interventional treatment, particularly endoscopy, are still unclear. In this article, we attempt to discuss these aspects and summarize the current knowledge on endoscopic therapy for pancreatic necrosis. Endotherapy has been shown to be a safe and effective minimally invasive treatment modality in patients with consequences of ANP. The evolution of endoscopic techniques has made endoscopic drainage more effective and reduced the use of other minimally invasive therapies for pancreatic necrosis.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 87-100 Toruń, Poland; (J.S.); (M.J.)
- Correspondence:
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (M.S.); (K.A.)
| | - Jacek Szeliga
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 87-100 Toruń, Poland; (J.S.); (M.J.)
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (M.S.); (K.A.)
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 87-100 Toruń, Poland; (J.S.); (M.J.)
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Jagielski M, Smoczyński M, Studniarek M, Adrych K. Spontaneous regression of asymptomatic walled-off pancreatic necrosis. Arch Med Sci 2019; 15:1278-1287. [PMID: 31572474 PMCID: PMC6764315 DOI: 10.5114/aoms.2018.75606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 04/15/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Asymptomatic walled-off pancreatic necrosis (WOPN) should be treated conservatively, irrespective of the extent and size of the necrosis. The aim of this study was to evaluate the efficacy and safety of a strategy involving the observation of patients with asymptomatic WOPN over a long period of time. MATERIAL AND METHODS This study involved the retrospective analysis of 368 patients hospitalized in our department between 2010 and 2016, due to acute pancreatitis and its consequences in the form of pancreatic and peripancreatic fluid collection. RESULTS Walled-off pancreatic necrosis was identified in 168/368 (46%) patients. 124/168 (74%) patients with WOPN required interventional treatment due to clinical symptoms arising from the presence of the WOPN. Asymptomatic WOPN was identified in 44/168 (26%) patients. The mean observation time of patients with asymptomatic WOPN was 417.02 days (range: 47-1149 days). Only 1 out of the 44 patients (2%) failed to complete the follow-up. Complete regression of WOPN occurred in 30/44 (68%) patients. The presence of symptoms related to WOPN were identified in 13/44 (30%) patients during the observation. The most frequent indication for interventional treatment of WOPN was infection of the pancreatic necrosis, which was identified in 6/13 patients (46%). Altogether, 137/168 (82%) patients with WOPN required interventional treatment. CONCLUSIONS The majority of patients with WOPN required interventional treatment. This study provided evidence to support the view that careful observation of patients with asymptomatic WOPN is an efficient and safe treatment strategy. Long-term observation of such patients showed that most will experience spontaneous regression of asymptomatic WOPN without any other form of interventional treatment.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Michał Studniarek
- Department of Radiology, Medical University of Gdansk, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
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Jagielski M, Smoczyński M, Adrych K. Single transluminal gateway transcystic multiple drainage for extensive walled-off pancreatic necrosis - a single-centre experience. PRZEGLAD GASTROENTEROLOGICZNY 2018; 13:242-248. [PMID: 30302171 PMCID: PMC6173077 DOI: 10.5114/pg.2018.78290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/07/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In last three decades we have observed development in minimally invasive techniques in the treatment of walled-off pancreatic necrosis (WOPN). Endoscopic treatment of the consequences of acute necrotising pancreatitis is a accepted and common minimally invasive method. AIM Evaluation of the efficiency and safety of the innovative endoscopic treatment method (single transluminal gateway transcystic multiple drainage - SGTMD) in patients with extensive walled-off pancreatic necrosis. MATERIAL AND METHODS The retrospective analysis of 114 consecutive patients with symptomatic WOPN, who were treated endoscopically in our medical centre between 2011 and 2016. RESULTS Single transluminal gateway transcystic multiple drainage was performed in 21/114 (18.42%) patients. Endoscopic necrosectomy under fluoroscopic guidance was performed in 12/21 (57.14%) patients. Complications of treatment appeared in 7/21 (33.33%) patients. The most common of complication was upper gastrointestinal bleeding treated conservatively with packed red blood cells transfusions. There were no deaths. Therapeutic success was reached in 20/21 (95.24%) patients. No patient required surgery. The medium time of follow-up was 22 months (16-47). During the observation the recurrence of pancreatic fluid collection was noticed in 1/21 (4.76%) patients. Long-term success of endoscopic treatment was achieved in 19/21 (90.47%) patients. CONCLUSIONS Single transluminal gateway transcystic multiple drainage is an effective method of endoscopic treatment for extensive walled-off pancreatic necrosis with an acceptable amount of complications. However, the method of interventional treatment of pancreatic necrosis should depend not only on the location of necrosis, but also on the experience of the medical centre.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
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Cost-effectiveness of benign Wirsung duct strictures treatment in chronic pancreatitis. Wideochir Inne Tech Maloinwazyjne 2018; 13:17-26. [PMID: 29643954 PMCID: PMC5890842 DOI: 10.5114/wiitm.2018.72578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/29/2017] [Indexed: 01/22/2023] Open
Abstract
Introduction Chronic pancreatitis (CP) is an important problem for modern medicine, the healthcare system (Poland – NFZ) and the national insurance system (Poland – ZUS). The chronic nature of the disease, the lack of targeted treatment and the low mortality rate lead to an accumulation of patients who demand expensive treatment, both conservative and invasive. Rising costs in health care are forcing the need for a more cost-effective method of treatment. Aim The primary aim of this study was to perform a retrospective calculation of costs in both surgical and endoscopic treatment, hospital stay, healthcare, and public insurance of patients suffering from chronic pancreatitis. Parallel quality of life analysis was performed. It was possible to develop a cost-effective therapeutic algorithm for patients with an uncomplicated stricture of Wirsung’s duct within the Polish health care system. Results In Poland, the hospital costs of endoscopic treatment of patients with chronic pancreatitis were higher than those of the surgical treatment group despite both resulting in a similar life quality. Conclusions From a cost-effectiveness perspective, it was shown that surgical intervention is a more cost-effective therapy than endotherapy. Furthermore, patients with benign stricture of the main pancreatic duct in chronic pancreatitis should not be treated with endotherapy for longer than 12 months.
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Jagielski M, Smoczyński M, Jabłońska A, Adrych K. The Development of Endoscopic Techniques for Treatment of Walled-Off Pancreatic Necrosis: A Single-Center Experience. Gastroenterol Res Pract 2018; 2018:8149410. [PMID: 29805446 PMCID: PMC5902068 DOI: 10.1155/2018/8149410] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/11/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endotherapy is a common method of treatment in patients with symptomatic walled-off pancreatic necrosis (WOPN). The aim of this study is to indicate the potential therapeutic possibilities created by the combination of several new endoscopic techniques and the evaluation of their efficacy in the treatment of WOPN. METHODS The retrospective analysis of results and complications in the group of 101 patients, who underwent endoscopic treatment of symptomatic WOPN between years 2011 and 2015. RESULTS Endoscopic treatment was started in 101 patients (71 men, 30 women; mean age 50.97 years) with symptomatic WOPN. Single transluminal gateway technique (SGT) was used in 93/101 (92.08%) patients. SGT in combination with multiple transluminal gateway technique (MTGT) was exploited in 4/93 (4.30%) patients, while in combination with single transluminal gateway transcystic multiple drainage (SGTMD) in 22/93 (23.66%) patients. Transpapillary access was used in 11/101 (10.89%) patients. 20/101 (19.80%) patients underwent percutaneous drainage. Fluoroscopy-guided endoscopic necrosectomy was performed in 19/101 (18.81%) patients. The combinations of endoscopic techniques depended on the extent of necrosis. Procedure-related complications occurred in 16/101 (15.84%) patients. The mortality rate was 0.99% (1/101 patient). Therapeutic success was achieved in 99/101 (98.02%) patients. The long-term success of endoscopic treatment was achieved in 97/101 (96.04%) patients with symptomatic WOPN. CONCLUSIONS Application of new endoscopic techniques in the treatment of the patients with symptomatic WOPN significantly improves the efficiency of endotherapy with an acceptable amount of complications.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, Gdańsk, Poland
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Jabłońska
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, Gdańsk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, Gdańsk, Poland
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Jagielski M, Smoczyński M, Adrych K. Endoscopic treatment of walled-off pancreatic necrosis complicated with pancreaticocolonic fistula. Surg Endosc 2018; 32:1572-1580. [PMID: 29344783 PMCID: PMC5807501 DOI: 10.1007/s00464-018-6032-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022]
Abstract
Background Pancreaticocolonic fistulas (PCFs) are serious complication of acute pancreatitis related with high mortality. The aim of this study was to evaluate the efficiency and safety of endoscopic treatment in patients with walled-off pancreatic necrosis (WOPN) complicated with PCF. Methods This is a retrospective analysis of results and complications in the group of 226 patients, who underwent endoscopic treatment of symptomatic WOPN between years 2001 and 2016 in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk. Results PCF was recognized in 21/226 (9.29%) patients. Transmural drainage was performed in 20/21 (95.24%) patients. Transpapillary drainage was used in 2/21 (9.52) patients. The mean time since the start of endotherapy to the diagnosis of a fistulas was 9 (3–21) days. Fluoroscopic nasocystic tube-check imaging of an existing drain was the initial imaging diagnosis of a PCF in 19/21 (90.48%) patients. The mean duration of endoscopic drainage of WOPN was 39.29 (15–87) days. Procedure-related adverse events occurred in 10/21 (47.62%) patients and most of them were treated conservatively. Three patients required surgical treatment. One patient died during endotherapy. The closure of PCF was confirmed via imaging in 17/21 (80.95%) patients. The average time since the recognition till the closure of PCF was 21 (14–48) days. Complete therapeutic success of WOPN complicated with PCF was reached in 16/21 (76.19%) patients. Long-term success of endoscopic treatment was achieved in 15/21 (71.43%) patients. Conclusions Endoscopic treatment of patients with WOPN complicated with PCF is an effective method with an acceptable number of complications. The complete regression of the WOPN may lead to spontaneous closure of pancreaticocolonic fistulas. Electronic supplementary material The online version of this article (10.1007/s00464-018-6032-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland.
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
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Is minimally invasive surgical treatment justified for severe acute necrotizing pancreatitis patients with dysfunction of two or more organ systems? Wideochir Inne Tech Maloinwazyjne 2017; 12:225-230. [PMID: 29062441 PMCID: PMC5649498 DOI: 10.5114/wiitm.2017.68792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 05/31/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction When minimally invasive therapy was introduced, it became possible to cure some patients without open surgery, or at least delay the operation for longer than a month. Aim To determine the optimal timing to operate on patients with severe acute necrotizing pancreatitis based on the severity of organ insufficiency. Material and methods A retrospective analysis was performed in all severe acute necrotizing pancreatitis patients treated in Vilnius University Hospital Santaros Klinikos (VUL SK) from 2007 to 2016. The patients were divided into groups based on the number of dysfunctional organ systems (one or more) and whether the minimally invasive step-up approach to treatment was used. Results The patients with one organ dysfunction had a delay of 35 (without the step-up approach) and 36 (with the step-up approach) days before the open surgery, while the patients with two or more organ systems’ dysfunction had almost an identical delay of 28 days, using both surgical treatment methods. The mortality of the patients who had one organ dysfunction and in whom the step-up approach was used was 0%, while in patients without the step-up approach it was 41.7%. In the two or more organ systems’ dysfunction group, the mortality for those treated with a step-up approach was 64.3%, and without it 70.7%. Conclusions The surgical treatment should be initiated with a minimally invasive procedure. Additionally, the surgery on patients with two or more organ systems’ dysfunction should not be delayed for more than one month.
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Jagielski M, Smoczyński M, Adrych K. Endoscopic treatment of multilocular walled-off pancreatic necrosis with the multiple transluminal gateway technique. Wideochir Inne Tech Maloinwazyjne 2017; 12:199-205. [PMID: 28694909 PMCID: PMC5502345 DOI: 10.5114/wiitm.2017.68298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/21/2017] [Indexed: 01/03/2023] Open
Abstract
The development of minimally invasive techniques allowed access to the necrotic cavity through transperitoneal, retroperitoneal, transmural and transpapillary routes. The choice of access to walled-off pancreatic necrosis (WOPN) should depend not only on the spread of necrosis, but also on the experience of the clinical center. Herein we describe treatment of a patient with multilocular symptomatic walled-off pancreatic necrosis using minimally invasive techniques. The single transmural access (single transluminal gateway technique - SGT) to the necrotic collection of the patient was ineffective. The second gastrocystostomy was performed using the same minimally invasive technique as an extra way of access to the necrosis (multiple transluminal gateway technique - MTGT). In the described case the performance of the new technique consisting in endoscopic multiplexing transmural access (MTGT) was effective enough and led to complete recovery of the patient.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
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