The endoscopic ultrasound features of pancreatic fluid collections and their impact on therapeutic decisions: an interobserver agreement study

Carlo Fabbri; Todd H. Baron; Giulia Gibiino; Paolo Giorgio Arcidiacono; Cecilia Binda; Andrea Anderloni; Gianenrico Rizzatti; Manuel Pérez-Miranda; Andrea Lisotti; Loredana Correale; Joan B. Gornals; Ilaria Tarantino; Maria Chiara Petrone; Paolo Cecinato; Pietro Fusaroli; Alberto Larghi

doi:10.1055/a-1640-4365

Endoscopy, Table of Contents

Endoscopy 2022; 54(06): 555-562
DOI: 10.1055/a-1640-4365

Original article

The endoscopic ultrasound features of pancreatic fluid collections and their impact on therapeutic decisions: an interobserver agreement study

Carlo Fabbri

¹Unit of Gastroenterology and Digestive Endoscopy, Morgagni-Pierantoni Hospital of Forlì and Bufalini Hospital of Cesena, AUSL Romagna, Italy

,

Todd H. Baron

²Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA

,

Giulia Gibiino

¹Unit of Gastroenterology and Digestive Endoscopy, Morgagni-Pierantoni Hospital of Forlì and Bufalini Hospital of Cesena, AUSL Romagna, Italy

,

Paolo Giorgio Arcidiacono

³Pancreato-biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy

,

Cecilia Binda

¹Unit of Gastroenterology and Digestive Endoscopy, Morgagni-Pierantoni Hospital of Forlì and Bufalini Hospital of Cesena, AUSL Romagna, Italy

,

Andrea Anderloni

⁴Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milano, Italy

,

Gianenrico Rizzatti

⁵Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

⁶CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy

,

Manuel Pérez-Miranda

⁷Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain

,

Andrea Lisotti

⁸Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

,

Loredana Correale

⁵Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

,

Joan B. Gornals

⁹Endoscopy Unit, Digestive Diseases Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain

,

Ilaria Tarantino

¹⁰Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy

,

Maria Chiara Petrone

³Pancreato-biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy

,

Paolo Cecinato

¹¹Gastroenterology and Digestive Endoscopy Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy

,

Pietro Fusaroli

⁸Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

,

Alberto Larghi

⁵Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

⁶CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy

› Author Affiliations

Abstract

Background A validated classification of endoscopic ultrasound (EUS) morphological characteristics and consequent therapeutic intervention(s) in pancreatic and peripancreatic fluid collections (PFCs) is lacking. We performed an interobserver agreement study among expert endosonographers assessing EUS-related PFC features and the therapeutic approaches used.

Methods 50 EUS videos of PFCs were independently reviewed by 12 experts and evaluated for PFC type, percentage solid component, presence of infection, recognition of and communication with the main pancreatic duct (MPD), stent choice for drainage, and direct endoscopic necrosectomy (DEN) performance and timing. The Gwet’s AC1 coefficient was used to assess interobserver agreement.

Results A moderate agreement was found for lesion type (AC1, 0.59), presence of infection (AC1, 0.41), and need for DEN (AC1, 0.50), while fair or poor agreements were stated for percentage solid component (AC1, 0.15) and MPD recognition (AC1, 0.31). Substantial agreement was rated for ability to assess PFC–MPD communication (AC1, 0.69), decision between placing a plastic versus lumen-apposing metal stent (AC1, 0.62), and timing of DEN (AC1, 0.75).

Conclusions Interobserver agreement between expert endosonographers regarding morphological features of PFCs appeared suboptimal, while decisions on therapeutic approaches seemed more homogeneous. Studies to achieve standardization of the diagnostic endosonographic criteria and therapeutic approaches to PFCs are warranted.

Full Text

References

References
1 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13: e1-e15
2 Crockett SD, Wani S, Gardner TB. et al. American Gastroenterological Association Institute Guideline on initial management of acute pancreatitis. Gastroenterology 2018; 154: 1096-1101
3 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
4 Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet 2015; 386: 85-96
5 Baron TH, Thaggard WG, Morgan DE. et al. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996; 111: 755-764
6 Kamal A, Singh VK, Akshintala VS. et al. CT and MRI assessment of symptomatic organized pancreatic fluid collections and pancreatic duct disruption: an interreader variability study using the revised Atlanta classification 2012. Abdom Imaging 2015; 40: 1608-1616
7 Sternby H, Verdonk RC, Aguilar G. et al. Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis - An international multicenter evaluation of the revised Atlanta classification. Pancreatology 2016; 16: 791-797
8 Giovannini M. Endoscopic ultrasound-guided drainage of pancreatic fluid collections. Gastrointest Endosc Clin N Am 2018; 28: 157-169
9 Rimbaş M, Pizzicanella M, Larghi A. EUS-guided treatment of WON using lumen-apposing metal stents: protocol standardisation based on the occurrence of natural healing processes. Gut 2019; 68: 1334-1335
10 Baron TH, Harewood GC, Morgan DE. et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56: 7-17
11 Tyberg A, Karia K, Gabr M. et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol 2016; 22: 2256-2270
12 Rerknimitr R. Endoscopic transmural necrosectomy: timing, indications, and methods. Clin Endosc 2020; 53: 49-53
13 Gwet KL. Computing inter-rater reliability and its variance in the presence of high agreement. Br J Math Stat Psychol 2008; 61: 29-48
14 Feinstein AR, Cicchetti DV. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990; 43: 543-549
15 Byrt T, Bishop J, Carlin JB. Bias, prevalence and kappa. J Clin Epidemiol 1993; 46: 423-429
16 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
17 Yip HC, Teoh AYB. Endoscopic management of peri-pancreatic fluid collections. Gut Liver 2017; 11: 604-611
18 Bouwense SA, van Brunschot S, van Santvoort HC. et al. Describing peripancreatic collections according to the revised Atlanta classification of acute pancreatitis: an international interobserver agreement study. Pancreas 2017; 46: 850-857
19 Sternby H, Verdonk RC, Aguilar G. et al. Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis - An international multicenter evaluation of the revised Atlanta classification. Pancreatology 2016; 16: 791-797
20 Badat N, Millet I, Corno L. et al. Revised Atlanta classification for CT pancreatic and peripancreatic collections in the first month of acute pancreatitis: interobserver agreement. Eur Radiol 2019; 29: 2302-2310
21 Morgan DE, Baron TH, Smith JK. et al. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology 1997; 203: 773-778
22 Varadarajulu S, Bang JY, Sutton BS. et al. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145: 583-590
23 Akshintala VS, Saxena P, Zaheer A. et al. A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts. Gastrointest Endosc 2014; 79: 921-928
24 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
25 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
26 Rizzatti G, Rimbaș M, Larghi A. Which stent to use for the management of pancreatic pseudocysts? Time for randomized controlled studies. Endoscopy 2020; 52: 321
27 Bang JY, Varadarajulu S. Lumen-apposing metal stents for endoscopic ultrasonography-guided interventions. Dig Endosc 2019; 31: 619-626
28 Giovannini M. Endoscopic ultrasound-guided drainage of pancreatic fluid collections. Gastrointest Endosc Clin N Am 2018; 28: 157-169
29 Bang JY, Navaneethan U, Hasan MK. et al. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68: 1200-1209
30 Bang JY, Navaneethan U, Hasan MK. et al. EUS correlates of disconnected pancreatic duct syndrome in walled-off necrosis. Endosc Int Open 2016; 4: E883-E889
31 Bazerbachi F, Sawas T, Vargas EJ. et al. Metal stents versus plastic stents for the management of pancreatic walled-off necrosis: a systematic review and meta-analysis. Gastrointest Endosc 2018; 87: 30-42
32 Hammad T, Khan MA, Alastal Y. et al. Efficacy and safety of lumen-apposing metal stents in management of pancreatic fluid collections: are they better than plastic stents? A systematic review and meta-analysis. Dig Dis Sci 2018; 63: 289-301
33 Saunders R, Ramesh J, Cicconi S. et al. A systematic review and meta-analysis of metal versus plastic stents for drainage of pancreatic fluid collections: metal stents are advantageous. Surg Endosc 2019; 33: 1412-1425
34 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50: 524-546
35 Baron TH, DiMaio CJ, Wang AY. et al. American Gastroenterological Association Clinical Practice Update: Management of pancreatic necrosis. Gastroenterology 2020; 158: 67-75
36 Yan L, Dargan A, Nieto J. et al. 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. Endosc Ultrasound 2019; 8: 172-179

Supplementary Material

Supplementary material