Comparison of early and delayed EUS-guided drainage of pancreatic fluid collection

Tanyaporn Chantarojanasiri, Natsuyo Yamamoto, Yousuke Nakai, Tomotaka Saito, Kei Saito, Ryunosuke Hakuta, Kazunaga Ishigaki, Tsuyoshi Takeda, Rie Uchino, Naminatsu Takahara, Suguru Mizuno, Hirofumi Kogure, Saburo Matsubara, Minoru Tada, Hiroyuki Isayama, Kazuhiko Koike, Tanyaporn Chantarojanasiri, Natsuyo Yamamoto, Yousuke Nakai, Tomotaka Saito, Kei Saito, Ryunosuke Hakuta, Kazunaga Ishigaki, Tsuyoshi Takeda, Rie Uchino, Naminatsu Takahara, Suguru Mizuno, Hirofumi Kogure, Saburo Matsubara, Minoru Tada, Hiroyuki Isayama, Kazuhiko Koike

Abstract

Background and study aims While endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collection (PFC) is recommended to be performed ≥ 4 weeks after onset of acute pancreatitis (AP), early (< 4 weeks) interventions are needed in some symptomatic cases. Despite feasibility of early percutaneous drainage, there have been few studies about early EUS-guided drainage of PFC. Patients and methods Consecutive patients who received EUS-guided drainage (EUS-PCD) of infected or symptomatic PFC at the University of Tokyo were retrospectively studied. Contraindications for EUS-PCD are lack of encapsulation or adhesion to the gastrointestinal tract. Safety and effectiveness of early vs delayed (≥ 4 weeks) EUS-PCD were compared. Results A total of 35 patients underwent EUS-PCD (12 early and 23 delayed) using 19 large-bore fully-covered metallic stent and 16 plastic stents. The median diameter of PFC was 110 mm (40 - 180) and 122 mm (17 - 250) in the early and delayed drainage groups, respectively. Median time from onset of AP to drainage was 23 and 85 days for early and delayed drainage, respectively. The technical success rate of EUS-guided drainage was 100 %. Endoscopic necrosectomy was performed in six early and 16 cases of delayed drainage. The adverse event rate was 25 % (3 bleeding) and 13 % (2 perforations and 1 CO 2 retention) in the early and delayed drainage groups, respectively. Two patients died (1 early and 1 delayed) due to multiorgan failure. Conclusion Endoscopic drainage and subsequent necrosectomy of symptomatic PFC within 4 weeks after onset of acute pancreatitis was feasible, given that the collection was encapsulated and attached to the gastrointestinal tract.

Conflict of interest statement

Competing interests None

Figures

Fig. 1
Fig. 1
A 44-year old male with history of alcoholic pancreatitis developed acute necrotic collection 15 days after onset of acute pancreatitis. He had high fever with clinical suspicion of infected ANC. Computed tomography demonstrated the well-form cavity with presence of intracavity air.
Fig. 2
Fig. 2
CT scan of the same patient after endoscopic drainage using Nagi stent and the pigtail nasocystic tube. The image shows the collection with presence of the stent and drainage tube. No free air or newly developed ascites was seen.
Fig. 3a
Fig. 3a
Under EUS guidance, the collection was punctured using the 19 G EUS fine-needle aspiration (EUS-FNA) needle.bThe guidewire was inserted through the EUS-FNA needle and the tract was initially dilated using a 6 Fr coaxial dilator.cAdditional balloon dilation was performed.dSubsequently, the fully-cover self-expandable metal stent (Nagi stent, Taewoong Medical Co, Ltd, Gyeonggi-do, Korea) was inserted,efollowed by the pigtail nasocystic tube.
Fig. 4
Fig. 4
Flowchart demonstrating EUS-guided treatment of patients with PFC in our study.

References

    1. van Santvoort H C, Besselink M G, Bakker O J et al.A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–1502.
    1. Banks P A, Bollen T L, Dervenis C et al.Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–111.
    1. Garg P K, Madan K, Pande G K et al.Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis. Clin Gastroenterol Hepatol. 2005;3:159–166.
    1. Isayama H, Nakai Y, Rerknimitr R et al.The Asian consensus statements on endoscopic management of walled-off necrosis Part1: Epidemiology, diagnosis and treatment. J Gastroenterol Hepatol. 2016;31:1546–1554.
    1. van Santvoort H C, Bakker O J, Bollen T L et al.A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011;141:1254–1263.
    1. Isayama H, Yamamoto K, Mizuno S et al.NOTES and endoscopic pancreatic necrosectomy for the GI endoscopist. J Hepatobiliary Pancreat Surg. 2009;16:270–273.
    1. Isayama H, Nakai Y, Rerknimitr R et al.Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol. 2016;31:1546–1554.
    1. Bakker O J, van Santvoort H C, van Brunschot S et al.Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307:1053–1061.
    1. van Brunschot S, van Grinsven J, van Santvoort H C et al.Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018;391:51–58.
    1. Yamamoto N, Isayama H, Kawakami H et al.Preliminary report on a new, fully covered, metal stent designed for the treatment of pancreatic fluid collections. Gastrointest Endosc. 2013;77:809–814.
    1. Besselink M G, Verwer T J, Schoenmaeckers E J et al.Timing of surgical intervention in necrotizing pancreatitis. Arch Surg. 2007;142:1194–1201.
    1. Wronski M, Cebulski W, Karkocha D et al.Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg Endosc. 2013;27:2841–2848.
    1. Mortele K J, Girshman J, Szejnfeld D et al.CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol. 2009;192:110–116.
    1. Sugimoto M, Sonntag D P, Flint G S et al.Better outcomes if percutaneous drainage is used early and proactively in the course of necrotizing pancreatitis. J Vasc Interv Radiol. 2016;27:418–425.
    1. Isayama H, Nakai Y, Rerknimitr R et al.Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management. J Gastroenterol Hepatol. 2016;31:1555–1565.
    1. Cotton P B, Eisen G M, Aabakken L et al.A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71:446–454.
    1. Tenner S, Baillie J, DeWitt Jet al.American College of Gastroenterology guideline: management of acute pancreatitis Am J Gastroenterol 20131081400–1415.; 1416
    1. Rana S S, Gupta R, Kang M et al.Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness. Endosc Ultrasound. 2018;7:41–47.

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