Comparison of endoscopic versus percutaneous drainage of symptomatic pancreatic necrosis in the early (< 4 weeks) phase of illness

Surinder Singh Rana, Suhang Verma, Mandeep Kang, Ujjwal Gorsi, Ravi Sharma, Rajesh Gupta, Surinder Singh Rana, Suhang Verma, Mandeep Kang, Ujjwal Gorsi, Ravi Sharma, Rajesh Gupta

Abstract

Background and objective: Pancreatic fluid collections in early phase of illness <4 weeks after onset of acute pancreatitis (AP) are usually treated with percutaneous drainage (PCD). There is a paucity of data comparing early (<4 weeks) endoscopic transluminal drainage (ETD) with PCD in patients with symptomatic pancreatic necrosis (PN). The objective of this study is to compare the safety and efficacy of early ETD with PCD in patients with symptomatic PN.

Patients and methods: Retrospective analysis of database of patients with symptomatic PN treated early (<4 weeks of onset of AP) with either ETD (encapsulated wall on EUS) or PCD.

Results: Twenty-three patients (19 M; mean age: 36.1 years) were treated with ETD and 41 patients (29 M; mean age: 39.6 years) were treated with PCD, respectively. ETD and PCD were done 24.2 ± 2.3 and 24.2 ± 2.0 days after onset of AP, respectively (P = 0.84). In the ETD group, 35% of patients were treated with self-expanding metallic stents and 48% of patients required direct endoscopic necrosectomy. In the PCD group, 74% of patients were treated with multiple catheters and 91% of patients with either saline or streptokinase irrigation. As compared to the ETD group, patients in the PCD group took longer time for resolution (61.9 ± 22.9 days vs. 30.9 ± 5.6 days; P < 0.00001), increased need for surgery (30% vs. 4%; P = 0.01), and frequency of formation of external pancreatic fistula (EPF) (22% vs. nil; P = 0.02).

Conclusions: ETD of PN in early phase of illness is associated with a shorter duration for resolution and infrequent need of salvage surgery compared to PCD. EPF formation is a significant adverse event with PCD.

Keywords: acute pancreatitis; endosonography; pancreatic necrosis; stent; walled off necrosis.

Conflict of interest statement

None

Figures

Figure 1
Figure 1
(a) Computed tomography: Large necrotic collection with partially formed encapsulating wall. The area where wall seems to be incomplete has been highlighted with arrows. (b) EUS: Necrotic collection with mixed solid-liquid necrotic content. The solid content has been highlighted with arrows. (c) EUS guided drainage of necrotic collection. Transmural tract being dilated with biliary balloon (arrow). (d) Computed tomography: Residual necrotic collection with multiple plastic stents after three session of ETD and DEN. (e) Computed tomography after five session of DEN. Small residual necrotic collection with complete clinical recovery. Plastic stents are noted. ETD: Endoscopic transluminal drainage; DEN: Direct endoscopic necrosectomy
Figure 2
Figure 2
(a) Computed tomography: Large necrotic collection with encapsulating wall. (b) EUS guided drainage of pancreatic necrosis. Guide wire (arrows) seen in the predominantly solid collection. (c) BFMS placed into necrotic collection. On EUS inner opened flange of BFMS noted (arrows). (d) Computed tomography: Resolved WON with BFMS in situ. BFMS: Bi-flanged fully covered self-expanding metallic stent; WON: Walled-off necrosis

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