Management Of Walled-off Necrosis Research Articles

Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis

ABSTRACT Background Comparative data on percutaneous catheter drainage (PCD) vs EUS-guided drainage (EUS-D) for management of symptomatic walled-off-necrosis (WON), specially infected WON with/without organ failure(OF) is limited. Methods Patients with symptomatic WON were divided into two groups of PCD and EUS-D, depending on the modality of drainage. Resolution of OF, adverse events, and other outcome measures were recorded. The two modalities were compared among infected WON sub-cohort and also degree of solid component (SC). Results 218 patients (175 males; 80.3%) were included who underwent either PCD (n = 102) or EUS-D (n = 116). Clinical success was significantly higher in the EUS-D group (92.1% vs 64.6%; p < 0.0001) and even for infected WON (n = 128) (p = 0.004), with higher (p = 0.007) and faster (p < 0.0001) OF resolution. Other outcome measures including mortality were significantly higher in the PCD group. Among subgroups, PCD with >40% SC had the worst clinical success/OF resolution rates, while EUS-D with <40% SC had the best outcomes. Conclusion EUS-D should be preferred over PCD in the management of WON, infected or otherwise, for higher clinical success, and higher/faster resolution of OF. PCD should be avoided in WON with>40% SC.

Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial.

Background and study aims Walled-off necrosis (WON) is a known complication of acute necrotizing pancreatitis (ANP). There is no study comparing nasocystic irrigation with hydrogen peroxide (H 2 O 2 ) versus biflanged metal stent (BMS) in the management of WON. The aim of this study was to compare the clinical efficacy of both the treatment strategies. Patients and methods This study was conducted on patients with symptomatic WON who were randomized to nasocystic irrigation with H 2 O 2 (Group A) and BMS placement (Group B). Primary outcomes were clinical and technical success while secondary outcomes were procedure time, adverse events, need for additional procedures, duration of hospitalization, and mortality. Results Fifty patients were randomized into two groups. Group A (n = 25, age 37.8 ± 17.6 years, 16 men) and Group B (n = 25, age 41.8 ± 15.2 years, 17 men). There were no significant differences in baseline characteristics between the two groups. The most common etiology of pancreatitis was alcohol, observed in 27 (54 %) patients. Technical success (100 % vs 96 %, P = 0.98), clinical success (84 % vs 76 %, P = 0.76), requirement of additional procedures (16 % vs 24 %, P = 0.70) and adverse events (4 vs 7, P = 0.06) were comparable in both the groups. The duration to clinical success (34.4 ± 12 vs 14.8 ± 10.8 days, P = 0.001) and procedure time (36 ± 15 vs 18 ± 12 minutes, P = 0.01) were longer in Group A compared to Group B. Conclusions Nasocystic irrigation with H 2 O 2 and BMS are equally effective in the management of WON but time to clinical success and procedure time is longer with nasocystic irrigation.

RWON Study: The Real-World Walled-off Necrosis Study.

Background/AimsThe management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce. MethodsProspectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities. ResultsA total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group. ConclusionsED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.

S1381 Utilizing Fully-Covered Self-Expandable Metallic Stents for Percutaneous Endoscopic Necrosectomy in the Management of Walled-Off Necrosis: A Single Center Experience

S1381 Utilizing Fully-Covered Self-Expandable Metallic Stents for Percutaneous Endoscopic Necrosectomy in the Management of Walled-Off Necrosis: A Single Center Experience

Start of a new TREnD: TransRemnant Endoscopic Drainage for management of walled-off necrosis in a patient with Roux-en-Y gastric bypass.

Start of a new TREnD: TransRemnant Endoscopic Drainage for management of walled-off necrosis in a patient with Roux-en-Y gastric bypass.

Multicenter study of plastic vs. self-expanding metal stents in endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis \u2013 PROMETHEUS: a randomized controlled trial protocol

BackgroundIt seems that lumen-apposing metal stents (LAMS) are displacing plastic stents in the therapy of pancreatic-fluid collection in walled-off necrosis (WON). To date, there is no quality of evidence to recommend LAMS as the standard treatment in the management of WON. The theoretical benefit of LAMS over plastic stents needs to be proven.Methods/designThis is a randomized controlled, multicenter, prospective clinical trial with two parallel groups, without masking. One-hundred and fourteen patients with WON will undergo endoscopic ultrasound (EUS)-guided transmural draining in nine tertiary hospitals in Spain and will be randomized to the LAMS or plastic-stent group. The primary endpoint is the short-term (4 weeks) clinical success determined by the reduction of the collection (to < 50% or < 5 cm in size), along with clinical improvement. Secondary endpoints: long-term (4 months) clinical success (total resolution or 5 cm), procedure duration, level of difficulty, safety, and recurrences.DiscussionThe PROMETHEUS trial has been designed to determine whether LAMS are superior to plastic stents in EUS-guided transmural drainage of WON.Trial registrationClinicalTrials.gov, ID: NCT03100578. Registered on 4 April 2017. https://clinicaltrials.gov/ct2/home

907 Endoscopic Pancreatic Necrosectomy Technique: Know Your "How" to Justify Your "Why"

INTRODUCTION: Walled-off necrosis (WON) is a feared complication of acute pancreatitis that carries significant morbidity. Direct endoscopic necrosectomy (DEN) is preferred over surgical one due to its minimally invasive nature and lower complication rates. However, no endoscopic technique and/or device has been adopted as a gold standard; and endoscopists differ significantly in their DEN preferences. The primary aim of this study was to report our DEN technique and its outcomes. METHODS: Medical records of patients who underwent EN from September 2016 – May 2019 were reviewed. Continuous data was described using mean and standard deviation (SD); categorical data as frequency and proportion (%); and interval data as median and (range). RESULTS: A total of 20 patients underwent DEN after initial drainage with a 10 × 15 mm electrocautery enhanced AXIOS lumen apposing metal stent (LAMS) (Table 1). A total of 23 LAMS were placed (22 trans-gastric and 1 trans-duodenal) Technical success (LAMS correctly deployed between the cavity and the gastric/duodenal lumen) was achieved in 100% of cases. All LAMS were dilated to 15 mm the same day of deployment, and the mean interval from drainage to first DEN was 5.4 days. DEN was repeated until the cavity was empty. A total of 66 DEN were performed. The mean number of DEN/patient was 3.3; each with a mean duration of 50 min. The most commonly used endoscope and device was the single channel gastroscope (83%) and the 27 mm snare (93.9%), respectively. The mean interval between each DEN was 7 days. All LAMS were removed after a mean of 27 days. Three patients were lost to follow up. After a median follow-up time of 14 months (1-28), clinical success (resolution of WON by imaging and patient’s symptoms on follow up visit) was achieved in 94% of cases. Only 1 subject had a major complication (cavity wall rupture with pneumoperitoneum that required surgery). Minor non-life-threatening complications occurred in 9 subjects (Table 2). CONCLUSION: At our center, the most commonly used endoscope and device to perform DEN is the single channel gastroscope and the 27 mm snare, respectively. An average of 3 DEN are required per patient, each one averaging 50 min. Our DEN technique is safe and effective in the management of WON, achieving clinical success in 94% of cases with minimal morbidity and no mortality.

Timing of Endoscopic Necrosectomy Following Transmural Stent Placement for Pancreatic Necrosis.

Pancreatic walled-off necrosis (WON) may require adjunctive direct endoscopic necrosectomy (DEN) following transmural stent placement. DEN is performed immediately or delayed in relation to index endoscopy. There is currently no consensus on the optimal timing of DEN. We review the most recent literature addressing each practice. Some expert opinion prefer delayed DEN; however, recent data reveal immediate DEN may reduce the number of endoscopic sessions required for successful clinical resolution of WON. Future studies are needed to determine the optimal timing for DEN following transmural stent placement for the management of WON.

Endoscopic drainage of pancreatic fluid collections by use ofanovel biflanged stent with electrocautery-enhanced deliverysystem.

Endoscopic drainage of pancreatic fluid collections by use ofanovel biflanged stent with electrocautery-enhanced deliverysystem.

Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis

EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON. A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.$50,000 was established. LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results. LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.

Endoscopic management of walled-off necrosis complicated by colocystic fistula

Endoscopic management of walled-off necrosis complicated by colocystic fistula

Endoscopic Therapy With Lumen-apposing Metal Stents Is Safe and Effective for Patients With Pancreatic Walled-off Necrosis.

Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n= 78), pancreatic duct stent placement for leak (n= 19), hydrogen peroxide-assisted necrosectomy (n= 38), and nasocystic irrigation (n= 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.

Mo1458 Fully Covered Lumen Apposing Metal Stent for the Management of Walled Off Necrosis (Won): a Single Center Experience

Mo1458 Fully Covered Lumen Apposing Metal Stent for the Management of Walled Off Necrosis (Won): a Single Center Experience

集学的治療により救命し得た重症急性膵炎の一例

集学的治療により救命し得た重症急性膵炎の一例

急性膵炎に伴うwalled-off necrosis（WON）の治療——経皮的step-up approach

急性膵炎の合併症の1つであるwalled-off necrosis（WON）は，感染を合併すると治療に難渋する。我々は2009年5月〜2013年5月までに，急性膵炎によるWON 7例（男性6例／女性1例，年齢45〜77歳）に経皮的ドレナージとその後，必要に応じて経皮的内視鏡的necrosectomyを行う治療（step-up approach）（経皮的ドレナージのみ4例，内視鏡的necrosectomy3例）を施行した。Necrosectomyは平均3.6回施行し，重篤な合併症は認めなかった。急性膵炎に伴うWONのstep-up approachは，保存的治療のみでは治療困難な症例に試みるべき治療の1つと考える。なお，経皮的アプローチで危惧される膵液漏については，経乳頭的なルート等で内瘻化することで予防可能である。