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

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 CO₂ 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.

• References

• 1 van Santvoort HC, Besselink MG, Bakker OJ. et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-1502
• 2 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
• 3 Garg PK, Madan K, Pande GK. 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
• 4 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
• 5 van Santvoort HC, Bakker OJ, Bollen TL. et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011; 141: 1254-1263
• 6 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
• 7 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
• 8 Bakker OJ, van Santvoort HC, van Brunschot S. et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307: 1053-1061
• 9 van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58
• 10 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
• 11 Besselink MG, Verwer TJ, Schoenmaeckers EJ. et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007; 142: 1194-1201
• 12 Wronski M, Cebulski W, Karkocha D. et al. Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg Endosc 2013; 27: 2841-2848
• 13 Mortele KJ, 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
• 14 Sugimoto M, Sonntag DP, Flint GS. 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
• 15 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
• 16 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 17 Tenner S, Baillie J, DeWitt J. et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108: 1400-1415 ; 1416
• 18 Rana SS, 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