Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy

Abstract

Background Long-term transmural double-pigtail stent (DPS) placement is recommended for patients with disconnected pancreatic duct syndrome (DPDS) and peripancreatic fluid collections (peri-PFCs). The long-term safety and efficacy of indwelling DPSs were evaluated.

Methods Medical files of patients treated with DPS for DPDS-associated peri-PFC and with a follow-up ≥ 48 months were reviewed. Early ( < 30 days) and late complications of DPS placement were evaluated and the primary endpoint, i. e., incidence of late complications per 100 patient-years of follow-up, was calculated. Short- and long-term success rates of endoscopic treatment and rate of peri-PFC recurrence were among secondary endpoints.

Results From 2002 to 2014 we identified 116 patients, with mean (SD) follow-up of 80.6 (34.4) months. Among early complications (n = 20), 6 occurred peri-interventionally. Late complications (n = 17) were mainly pain due to DPS-induced ulcer or erosion (n = 10) and 14 of these were treated conservatively or by stent removal; 2 gastro-pancreatico-colo-cutaneous fistulas and 1 persisting bleed required surgical intervention. No DPS-related deaths were recorded. The incidence rate (95 %CI) of late complications was 2.18 (1.27–3.49) per 100 patient-years of follow-up. Short- and long-term success rates (with 95 %CI) of endoscopic treatment were 97.4 % (94.5 %–100 %) and 94 % (89.6 %–98.3 %), respectively. The peri-PFC recurrence rate was 28 % (20.1 %–35.9 %), and 92.3 % of these occurred within the first 2 years. Stent migration, chronic pancreatitis, and length of stent (> 6 cm) were independently associated with higher rates of peri-PFC recurrence.

Conclusions Long-term transmural drainage with DPS is a safe and effective treatment for DPDS-associated peri-PFCs. However, about one quarter of peri-PFCs will recur.

• References

• 1 Deviere J, Antaki F. Disconnected pancreatic tail syndrome: a plea for multidisciplinarity. Gastrointest Endosc 2008; 67: 680-682
• 2 Gupta T, Lemmers A, Tan D. et al. EUS-guided transmural drainage of postoperative collections. Gastrointest Endosc 2012; 76: 1259-1265
• 3 Kozarek RA. Endoscopic therapy of complete and partial pancreatic duct disruptions. Gastrointest Endosc Clin N Am 1998; 8: 39-53
• 4 Tann M, Maglinte D, Howard TJ. et al. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. J Comput Assist Tomogr 2003; 27: 577-582
• 5 Bang JY, Wilcox CM, Navaneethan U. et al. Impact of disconnected pancreatic duct syndrome on the endoscopic management of pancreatic fluid collections. Ann Surg 2018; 267: 561-568
• 6 Lawrence C, Howell DA, Stefan AM. et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008; 67: 673-679
• 7 Neoptolemos JP, London NJ, Carr-Locke DL. Assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis. Br J Surg 1993; 80: 94-99
• 8 Varadarajulu S, Rana SS, Bhasin DK. Endoscopic therapy for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin N Am 2013; 23: 863-892
• 9 Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med 2016; 375: 1972-1981
• 10 Hookey LC, Debroux S, Delhaye M. et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63: 635-643
• 11 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.e581
• 12 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
• 13 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
• 14 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
• 15 Arvanitakis M, Delhaye M, Bali MA. et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65: 609-619
• 16 Bang JY, Holt BA, Hawes RH. et al. Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis. Br J Surg 2014; 101: 1729-1738
• 17 Baron TH, DiMaio CJ, Wang AY. et al. American Gastroenterological Association Clinical Practice Update: Management of pancreatic necrosis. Gastroenterology 2020; 158: 67-75. e61
• 18 Basha J, Lakhtakia S, Nabi Z. et al. Impact of disconnected pancreatic duct on recurrence of fluid collections and new-onset diabetes: do we finally have an answer?. Gut 2020;
• 19 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
• 20 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
• 21 Pelaez-Luna M, Vege SS, Petersen BT. et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 2008; 68: 91-97
• 22 Rana SS, Bhasin DK, Rao C. et al. Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome. Pancreatology 2013; 13: 486-490
• 23 Tellez-Avina FI, Casasola-Sanchez LE, Ramirez-Luna MA. et al. Permanent indwelling transmural stents for endoscopic treatment of patients with disconnected pancreatic duct syndrome: long-term results. J Clin Gastroenterol 2018; 52: 85-90
• 24 Varadarajulu S, Wilcox CM. Endoscopic placement of permanent indwelling transmural stents in disconnected pancreatic duct syndrome: does benefit outweigh the risks?. Gastrointest Endosc 2011; 74: 1408-1412
• 25 Fugazza A, Sethi A, Trindade AJ. et al. International multicenter comprehensive analysis of adverse events associated with lumen-apposing metal stent placement for pancreatic fluid collection drainage. Gastrointest Endosc 2019; 91: 574-583
• 26 Yamauchi H, Iwai T, Kida M. et al. Complications of long-term indwelling transmural double pigtail stent placement for symptomatic peripancreatic fluid collections. Dig Dis Sci 2019; 64: 1976-1984
• 27 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344-349
• 28 Matos C, Metens T, Deviere J. et al. Pancreatic duct: morphologic and functional evaluation with dynamic MR pancreatography after secretin stimulation. Radiology 1997; 203: 435-441
• 29 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
• 30 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
• 31 Spronk I, Korevaar JC, Poos René. et al. Calculating incidence rates and prevalence proportions: not as simple as it seems. BMC Public Health 2019; 6: 512
• 32 Maatman TK, Mahajan S, Roch AM. et al. Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis. Pancreatology 2020; S1424–3903: 30032-30036
• 33 Deviere J, Bueso H, Baize M. et al. Complete disruption of the main pancreatic duct: endoscopic management. Gastrointest Endosc 1995; 42: 445-451
• 34 Nadkarni NA, Kotwal V, Sarr MG. et al. Disconnected pancreatic duct syndrome: endoscopic stent or surgeon's knife?. Pancreas 2015; 44: 16-22
• 35 Seifert H, Biermer M, Schmitt W. et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009; 58: 1260-1266
• 36 Wang L, Elhanafi S, Storm A. et al. Impact of disconnected pancreatic duct syndrome on endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endoscopy 2020;
• 37 Rana SS, Bhasin DK, Sharma R. et al. Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome. Endosc Ultrasound 2015; 4: 208-212