EUS-Guided Transmural Drainage of Pancreatic Pseudocysts: Does the Presence of Solid Debris Impact Clinical Outcomes? A Large, Multicenter Study

Abstract

Introduction: EUS-guided transmural drainage (TM) of pancreatic pseudocysts is well established. It remains unclear if TM alone is sufficient treatment in pseudocysts containing solid debris. Aim: To compare clinical outcomes in patients who undergo TM of pancreatic pseudocysts that are debris-free (PDF) vs those that contain solid debris (PSD). Methods: Multi-center retrospective cohort study across 15 centers of patients who underwent TM of pancreatic pseudocysts during a 6-year period (2008-2014). Outcome measures included technical success, symptom resolution, radiologic resolution, endoscopic re-intervention and adverse events (AE). PSD was defined as a pseudocyst containing solid material at time of index EUS TM drainage. Patients with obvious walled-off necrosis on index imaging were excluded. Technical success was defined as drainage with successful placement of ≥ of 1 transmural stent. Short-term (ST) followup was designated as ≥ 2 weeks following TM, but before stent removal. Long-term (LT) follow-up was defined as ≥ 2 weeks following stent removal. Symptom resolution was defined as the complete absence of symptoms at follow-up. Radiologic resolution was defined as the absence of the pseudocyst on repeat imaging. Re-intervention was defined as the need to repeat endoscopic drainage within a 4-week period. Results: A total of 142 patients underwent TM: 90 PDF and 52 PSD. There were no differences in patient characteristics, indication for drainage, size and location of pseudocyst between the two groups (Table 1). Technical success: PDF 87/90 (97%) vs PSD 51/52 (98%, p=1.00). Endoscopic re-intervention rate was similar between the two groups: PDF 5/90 (6%) vs PSD 6/52 (12%, p=0.21). One patient with PSD underwent endoscopic necrosectomy following initial TM. Median ST and LT follow-up were similar between the two cohorts (Table 2). There was no statistically significant difference in ST symptom resolution rate and LT outcomes in the two groups. ST radiologic resolution was higher in PDF 45/68(66%) compared to PSD 21/41(51%; p=0.009). Overall, procedure-related AE occurred in 13 (14%) in the PDF and 9 (17%) in the PSD group (P=0.64).Table 1: Baseline CharacteristicsTable 2: Short-term (ST) and long-term (LT) outcome measuresConclusion: There is no difference in technical success, ST or LT clinical outcomes in performing TM of PSD, when compared to patients with PDF. Thus, TM alone can be considered a suitable initial intervention in patients with PSD, without increased risk of infectious complications or need for endoscopic debridement.