Endoscopic Transluminal Drainage Research Articles

Infected pancreatic necrosis-Current trends in management.

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, amajority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

A New Step-Up Dual Endoscopic Approach for Large-Size Infected Pancreatic Necrosis: Percutaneous Endoscopic Necrosectomy Followed by Transluminal Endoscopic Drainage/Necrosectomy.

Acute pancreatitis in 10% to 20% of cases can be associated with necrosis of the pancreatic gland, peripancreatic tissue, or both. We report a case series of a new endoscopic approach to treat infected pancreatic necrosis (IPN). Consecutive patients with IPN, extending from the perigastric area up to the paracolic gutters or into the pelvis, were prospectively studied from January 2017 to June 2022. The treatment protocol was radiologic percutaneous drainage as the first step, followed by fully covered metal stent placement (FC-SEMS) in the track of the catheter. Percutaneous endoscopic necrosectomy (PEN) was performed 2 to 4 days later using a flexible endoscope through the percutaneous tract. About 2 to 4 weeks later, when a matured sac was visible, EUS-guided endoscopic transluminal drainage (ETD) with lumen-apposing metal stents (LAMS) was performed. Control of sepsis with resolution of collection(s) was the primary outcome measure. We included 18 patients, males in 50% of cases with age 60±12 years old. Most frequent cause of pancreatitis was biliary (7 cases) followed by alcoholic in 6 cases; in 3 cases pancreatitis was caused by hyperlipemia and in 2 cases was idiopathic. Mean size of WON was 18±2cm. For PEN, SEMSs used were esophageal FC-SEMS. LAMS used for ETD were Hot Axios, Hot Spaxus and Nagistent. Mean time of endoscopic intervention for PEN and ETD was 18±3 and 37±4 days, respectively. In 5 cases adverse events occurred: 3 cases of overinflations resolved with introduction of Verres needles in abdomen. In 2 cases postprocedural GI bleeding required endoscopic intervention. In all cases control of sepsis was reached together with resolution of collections. No cases of deaths were observed. Step-up percutaneous and transluminal endoscopic necrosectomy therapy is an effective strategy for large-size IPN with combined central and peripheral necrosis.

Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes.

Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.

DPDS Demystified: Imaging Insights and Minimally Invasive Management

Abstract Aim This article retrospectively evaluates the radiological imaging features in establishing the diagnosis of pancreatic duct disconnection along with outlining the effective management protocols. Materials and Methods Sixty-three patients with radiological or clinical suspicion of pancreatic duct disconnection were identified. Their computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) images, clinical data, and laboratory parameters from medical records were retrieved and analyzed. Endoscopic retrograde cholangiopancreatography (ERCP) findings or raised amylase values in the necrotic collection higher than three times the reference range were considered as proven cases of disconnected pancreatic duct syndrome (DPDS) for the study. Multiple parameters were assessed on imaging to establish the diagnosis of DPDS. SPSS software was used for statistical analysis and radiological imaging features of pancreatic duct disconnection were evaluated. Laboratory parameters of serum amylase/lipase and amylase/lipase values from the collection were also studied along with the mode of clinical management and outcome on follow-up. Results The radiological imaging features of pancreatic duct disconnection were assessed in 63 patients in which it was seen that magnetic resonance imaging had a significantly higher accuracy rate in diagnosing DPDS as opposed to CT. Minimally invasive procedures such as endoscopic cystogastrostomy was the preferred management in most cases with ERCP stenting being the next favored management of choice. Resolution or reduction of symptoms was mostly seen on follow-up with 12.69% of patients developing complications. Conclusion This study highlighted the imaging features of DPDS apart from ascertaining the parameters that could be assessed to aid in early diagnosis of DPDS. MRCP has a higher accuracy rate compared with CT in diagnosing DPDS. A combination of two or more parameters on MRCP was more accurate in the identification of DPDS rather than a single parameter. Minimally invasive treatment options such as endoscopic transluminal drainage with or without stenting are currently preferred in the treatment of DPDS over surgical management. Early diagnosis and prompt management of DPDS is essential to reduce the onset of serious complications apart from improving the quality of life of these patients posttreatment.

A Rare Observation of Endoscopic Transluminal Drainage of Pancreatogenic Destruction Areas in Infected Necrotizing Pancreatitis

Necrotizing forms of acute pancreatitis, as the most severe in terms of prognosis, occur in 25–30% of cases with a mortality rate of 27–32%, while in most cases these are adults of working age, which emphasizes the social significance of this problem. This article presents a rare observation of endoscopic intraluminal drainage of zones of pancreatogenic destruction in severe necrotizing pancreatitis. The multidisciplinary individual approach we have chosen makes it possible to treat this group of patients most effectively, which confirms the presented clinical observation.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges.

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

Gastrovesical fistula as a rare complication following endoscopic transluminal drainage of walled-off necrosis—a case report

Gastrovesical fistula as a rare complication following endoscopic transluminal drainage of walled-off necrosis—a case report

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Current Controversies and Challenges in Endoscopic Management of Necrotizing Pancreatitis

The current paradigm for intervention in necrotizing pancreatitis involves a staged multidisciplinary step-up approach with endoscopic transluminal drainage (ETD) or percutaneous drainage as the initial step based on the location of the collection and the availability of localized expertise (Figure 1). 1 Trikudanathan G. Wolbrink D.R.J. Santvoort HC van et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019; 156: 1994-2007 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Endoscopic step-up approach is associated with reduced occurrence of new-onset multiorgan failure and physiological stress, reduced risk of external fistulae, shorter hospital stay, lower costs, and better quality of life with no significant difference in mortality when compared with surgical approach as shown in 3 randomized trials. 1 Trikudanathan G. Wolbrink D.R.J. Santvoort HC van et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019; 156: 1994-2007 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar The endoscopic approach involves ETD (cystenterostomy) followed by endoscopic transluminal necrosectomy (ETN) as needed, and has significantly evolved with new innovations. However, there are controversies in the timing and choice of stents for ETD, with challenges and need for further refinement and standardization of technique of ETN, which is addressed in this focused review.

Usefulness of endoscopic ultrasound-guided transluminal drainage for postoperative peripancreatic fluid collection

Usefulness of endoscopic ultrasound-guided transluminal drainage for postoperative peripancreatic fluid collection

Potential of Minimally Invasive Drainage Interventions for Acute Pancreatitis

The article reviews literature data on the potential use of minimally invasive drainage interventions in the treatment of acute necrotizing pancreatitis. Detailed information is provided on the terminology, indications and technical features of the main types of drainage interventions - percutaneous and endoscopic transluminal drainage. The results of numerous studies evaluating drainage effectiveness and possible combined applications are presented. The article also focuses on the current international clinical guidelines evidencing advisability of minimally invasive drainage interventions as part of a phased intervention strategy for the treatment of infected necrotizing pancreatitis.

Comparison of lumen-apposing metal stents versus double-pigtail plastic stents for infected necrotising pancreatitis

ObjectiveLumen-apposing metal stents (LAMS) are believed to clinically improve endoscopic transluminal drainage of infected necrosis when compared with double-pigtail plastic stents. However, comparative data from prospective studies are very limited.DesignPatients...

Clinical outcomes following endoscopic or video-assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled-off pancreatic necrosis: Retrospective, single tertiary center cohort study.

Acute pancreatitis with walled-off necrosis (WON) is associated with considerable morbidity and mortality. Previous studies have evaluated outcomes in WON collections of limited size, while data about large WON with long-term follow-up are lacking. We aimed to report our experience in managing large WON. Between 2010 and 2020, consecutive patients with large (>15 cm) WON were identified from a prospectively maintained database. Patients with chronic pancreatitis or an index intervention 90 days or more from the debut of symptoms were excluded. We registered clinical and technical outcomes following minimally invasive treatment in WON >15 cm. Follow-up was a minimum of 1 year. Overall, 144 patients with WON >15 cm, with a median age of 60 (interquartile range [IQR] 49-69) years, were included. The median WON size was 19.2 cm (IQR 16.8-22.1). Most patients were treated with endoscopic transluminal drainage (93%). The median length of stay was 53 days (IQR 39-76) and 61 (42%) patients needed intensive care support during their hospital stay. As 143 patients (99%) were managed using endoscopic or video-assisted retroperitoneal techniques, only one (0.7%) patient needed an open necrosectomy. Procedure-related adverse events occurred in 10 (7%) patients. Overall, 24 patients (17%) died during admission, all due to multiorgan failure. The median follow-up was 35 months (IQR 15-63.5). Complete resolution was achieved in all remaining patients. Minimally invasive treatment of large WON is feasible, with a minimal need for surgery and acceptable rates of morbidity and mortality.

The Combination of Double Pigtail Plastic Stent, Nasocystic Tube and Percutaneous Catheter in Endoscopic Ultrasound-Guided Transluminal Drainage for Peripancreatic Fluid Collection

Background: Endoscopic ultrasound-guided drainage is first-line treatment of Pancreatic fluid collection. The invention of metallic stents has provided a safer and more efficient approach route for internal drainage. But because of the high cost of metal stents, a large number of patients still choose plastic stents, which can help them from the disease with much lower cost. Patients and Methods: Between March to December in 2017, 20 patients with Peripancreatic fluid collections were prospectively enrolled to receive the double pigtail plastic stent with nasocystic tube and/or percutaneous catheter. Results: There were 20 cases of pseudocyst including 4 cases of infected pseudocyst. The causes of the PFC were mainly gallstones (60%), followed with alcohol (30%) and hyperlipoidemia (10%). Technical success was achieved in 100% of the cases. All patients were completely resolved with the evidence of CT scan and clinical evaluation. The mean time for resolution was 15±20 days. The mean follow-up was 3 months. Conclusion: The combination drainage of double pigtail plastic stent with nasocystic tube and/or percutaneous catheter of pancreatic pseudocyst is feasible and efficacious to most patients. Using a titanium clip could prevent migration occurrence. With the economic benefits of plastic stents, they are still wildly used in developing countries.

Endoscopic transluminal drainage for infected pancreatic necrosis

To evaluate the effectiveness of intraluminal drainage of acute fluid accumulations for infected pancreatic necrosis. There were 848 patients with acute pancreatitis between January 2018 and December 2020 at the Sklifosovsky Research Institute for Emergency Care. Necrotizing pancreatitis was detected in 232 (27.4%) patients. Among necrotic forms, pancreatic parenchymal necrosis was detected in 56 (24.1%) patients, its combination with peripancreatic necrosis - in 176 (75.9%) patients. All patients underwent transabdominal ultrasound, CT of the abdomen and retroperitoneal space, esophagogastroduodenoscopy, endo-ultrasonography of pancreatobiliary zone. Dimensions and localization of acute necrotic accumulations were established using ultrasound and CT data. Endoscopic transluminal drainage was performed in 22 patients with necrotizing pancreatitis and fluid accumulations attached to the stomach or duodenum. There were 12 men (55%) and 10 women (45%) aged 48.5 [39; 56] (35; 88) years. Effectiveness of endoscopic treatment was assessed considering clinical, endoscopic data and reduction of fluid accumulations confirmed by ultrasound and CT data. Among 22 patients, connection with pancreatic ductal system was detected in 3 patients (13.6%) that required pancreaticoduodenal stenting. Early postoperative period was complicated by bleeding from the area of pancreatogenic destruction in 4 patients (18.1%). Therefore, angiography and endovascular embolization of a. gastroduodenalis were required in 2 (9.1%) cases. In 1 (4.5%) case, we performed endoscopic hemostasis using Hemoblock hemostatic solution (4 ml). Combination of both methods was used in 1 (4.5%) patient. In 11 (50%) patients, endoscopic drainage was the final method of surgical treatment of necrotizing pancreatitis. Four patients (18.1%) died. Multiple organ failure caused mortality in 3 patients (13.6%). One (4.5%) patient died from severe nosocomial pneumonia developed in 32 days after drainage. Spurs not drained into the stomach with US-confirmed suspension and sequestration were observed in 11 (50%) out of 22 patients. These accumulations required additional ultrasound-assisted percutaneous drainage. Endoscopic transluminal drainage is a perspective minimally invasive method for necrotizing pancreatitis.

Safety and Efficacy of Early (

BackgroundEndoscopic transmural drainage is usually not performed for pancreatic necrotic collection (PNC) < 4 weeks after onset of acute necrotizing pancreatitis (ANP) because of lack of encapsulating wall and increased risk of complications. ObjectiveStudy safety and efficacy of early (<4 weeks) endoscopic transluminal drainage in patients with symptomatic PNC. MethodsRetrospective analysis of data base of patients with PNC treated with endoscopic transmural drainage within 4 weeks of onset of ANP (early drainage) was done. The outcomes and complications were compared with patients with PNC who underwent delayed endoscopic drainage (≥4 weeks of onset of ANP). ResultsThirty-four patients (26 males; mean age: 35.9±8.6 years) underwent early and 136 patients (115 males; mean age: 37.9±9.4 years) underwent delayed endoscopic drainage. The PNC was significantly larger (12.3±2.1 cm vs 10.5±2.7 cm, p <0.001) with increased solid component (47.7 ± 8.9% vs 28.3 ± 11.7%, p <0.001) in the early group. Clinical success was achieved in 94% patients in the early group and all patients in the delayed group. Direct endoscopic necrosectomy was performed more frequently in the early group (50% vs 7.4%; p<0.001). There was increased mortality (5.7% vs 0%), need for rescue surgical necrosectomy (5.7% vs 0%), and clinically significant bleeding (20% vs 1.5%, p<0.001) in the early group as compared to the delayed group. ConclusionEarly endoscopic drainage of PNC is feasible and seems to be safe as well as effective but is associated with increased risk of complications as compared to delayed drainage.

Diagnosis and treatment of pancreatic duct disruption or disconnection: an international expert survey and case vignette study

BackgroundPancreatic duct disruption or disconnection is a potentially severe complication of necrotizing pancreatitis. With no existing treatment guidelines, it is unclear whether there is any consensus among experts in clinical practice. We evaluated current expert opinion regarding the diagnosis and treatment of pancreatic duct disruption and disconnection in an international case vignette study. MethodsAn online case vignette survey was sent to 110 international expert pancreatologists. Expert selection was based on publications in the last 5 years and/or participation in development of IAP/APA and ESGE guidelines on acute pancreatitis. Consensus was defined as agreement by at least 75% of the experts. ResultsThe response rate was 51% (n = 56). Forty-four experts (79%) obtained a MRI/MRCP and 52 experts (93%) measured amylase levels in percutaneous drain fluid to evaluate pancreatic duct integrity. The majority of experts favored endoscopic transluminal drainage for infected (peri)pancreatic necrosis and pancreatic duct disruption (84%, n = 45) or disconnection (88%, n = 43). Consensus was lacking regarding the treatment of patients with persistent percutaneous drain production, and with persistent sterile necrosis. ConclusionThis international survey of experts demonstrates that there are many areas for which no consensus existed, providing clear focus for future investigation.

Endoscopic transluminal drainage of infected pancreatic necrosis

To report initial experience of endoscopic transluminal drainage of infected pancreatic necrosis. There were 8 patients with acute severe pancreatitis and large-focal pancreatic necrosis who underwent transluminal drainage of destruction zones for the period from December 2018 to October 2019. Transluminal drainage of pancreatogenic destruction zones in acute severe pancreatitis can be considered as the only surgical approach in 50% of cases that is comparable with literature data.

Clinical outcome of endoscopic treatment for symptomatic sterile walled-off necrosis.

The majority of patients with symptomatic sterile walled-off necrosis (WON) can be treated conservatively. Although endoscopic transluminal drainage (ETD) is often performed in cases of persistent symptoms, post-procedural iatrogenic infection may occur. This study aimed to evaluate clinical outcomes after ETD of symptomatic sterile WON. This was a retrospective, multicenter, open-label case series of 56 patients with necrotizing pancreatitis who underwent ETD for symptomatic sterile WON between July 2001 and August 2018 at two tertiary referral hospitals. Primary end point was clinically relevant post-procedural iatrogenic infection, defined as need for endoscopic transluminal necrosectomy. Secondary end points included mortality, total number of interventions, hospital stay, and resolution of symptoms at 1-year follow-up. RESULTS : ETD of sterile WON was performed in 56 patients (median age 55 years, 57 % male), who presented with abdominal pain (71 %), gastric outlet obstruction (45 %), jaundice (20 %), and failure to thrive (27 %). A total of 41 patients (73 %) developed clinically relevant post-procedural iatrogenic infection, resulting in a median of 3 (interquartile range [IQR] 2 - 4) endoscopic, radiological, and/or surgical interventions. Mortality rate was 2 %. Median total hospital stay was 12 days (IQR 6 - 17). Resolution of symptoms was reported in 40 of 46 patients (87 %) for whom long-term follow-up data were available (median follow-up 13 months, IQR 6 - 29). ETD of symptomatic sterile WON resulted in high clinical success. Nonetheless, the majority of patients required additional reinterventions for clinically relevant post-procedural iatrogenic infection.

Outcomes of a Structured, Stepwise Approach to Endoscopic Necrosectomy.

Despite the increasing number of procedures being performed, there is no consensus on the optimal approach to performing direct endoscopic necrosectomy (DEN), which is a labor-intensive, nonstandardized intervention. We prospectively validated the usefulness of a predefined, structured, stepwise approach to DEN with the objective of improving procedural efficiency and resource use. A prospective study of patients with necrotizing pancreatitis who after endoscopic transluminal drainage did not have clinical improvement and required DEN. The study was undertaken in 2 phases. Phase I was a retrospective analysis of interventions performed using an unstructured, conventional approach. Median of 3 necrosectomy sessions (range, 2 to 3) were required to achieve 80% treatment success in 20 patients. On the basis of these observations, a structured approach that included 3 steps (debridement, necrosis extraction, and irrigation) was developed and validated prospectively in phase II in 39 patients. The main outcome was to compare procedural efficiency defined as a number of necrosectomy sessions to achieve treatment success. Although there was no significant difference in treatment success (phase I=80.0 vs. phase II=94.9%, P=0.17), the procedure was more efficient in phase II [median session, 2 (interquartile range=1 to 3) vs. 3 (interquartile range=2 to 3); P=0.003]. Multiple logistic regression analysis revealed that a structured, stepwise approach was associated with fewer necrosectomy sessions to achieve treatment success (odds ratio=4.7; 95% confidence interval=1.5-15.0; P=0.008) when adjusted for patient demographics, lab parameters, and disease characteristics. By decreasing the number of necrosectomy sessions, a structured, stepwise approach to endoscopic necrosectomy seems to improve procedural efficiency.