Endoscopic pancreatic necrosectomy: why scuff when you can flush the muck – make it an easy row to hoe

Abstract

Background and aims Endoscopic ultrasound (EUS) guided drainage of symptomatic pancreatic walled-off necrosis (WON) followed by fully covered self-expanding metal stent (FCSEMS) placement offers several advantages such as higher technical success rate and the option of necrosectomy. The aim of this study was to evaluate the safety and efficacy of EUS guided drainage of patients with WON by using FCSEMS and intracavitary lavage with a solution containing hydrogen peroxide and adopting a step-up approach.

Methods A prospective open label study was carried out at a single tertiary care center between January 2014 and January 2016. Patients with symptomatic WON who underwent EUS guided drainage followed by FCSEMS placement were included. Primary end points were complete drainage with improvement in symptoms or major adverse events. Secondary end points were minor adverse events related to the procedures.

Results A total of 64 patients (mean age 36 years; 52 males) were included. Technical success was achieved in 100 % of patients and clinical success was achieved in 90.6 %. Complete drainage was achieved with FCSEMS alone in 18 (28.1 %), FCSEMS with necrosectomy using lavage in 40 (62.5 %), FCSEMS with percutaneous drainage (PCD) in 5 (7.8 %), and 1 (1.6 %) patient required salvage surgery. The major adverse event was life threatening bleeding in 3 (4.7 %) patients. Minor adverse events were non-life threatening bleeding in 2 (3.1 %) patients and stent migration in 3 (4.7 %) patients.

Conclusion EUS guided WON drainage with FCSEMS followed by necrosectomy with lavage using a solution containing hydrogen peroxide as a step-up approach is a minimally invasive and effective method with a high technical and clinical success rate. Patients with solid debris > 40 % need aggressive management.

• References

• 1 Banks PA, Bollen TL, Dervenis C. et al. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
• 2 Smith IB, Gutierrez JP, Ramesh J. et al. Endoscopic extra-cavitary drainage of pancreatic necrosis with fully covered self-expanding metal stents (fcSEMS) and staged lavage with a high-flow water jet system. Endosc Int Open 2015; 03: E154-E160
• 3 Johnson MD, Walsh RM, Henderson JM. et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol 2009; 43: 586-590
• 4 Varadarajulu S, Bang JY, Sutton BS. et al. Equal efficacy of endoscopic and surgical cysto-gastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145: 583-590
• 5 Park DH, Lee SS, Moon SH. et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009; 41: 842-848
• 6 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
• 7 Gornals JB, Consiglieri CF, Busquets J. et al. Endoscopic necrosectomy of walled-off pancreatic necrosis using a lumen-apposing metal stent and irrigation technique. Surg Endosc 2016; 30: 2592-2602
• 8 Sharaiha RZ, Tyberg A, Khashab MA. et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016; 14: 1797-1803
• 9 Shah RJ, Shah JN, Waxman L. et al. Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents. Clin Gastroenterol Hepatol 2015; 13: 747-752
• 10 Chandran S, Efthymiou M, Kaffes A. et al. Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos). Gastrointest Endosc 2015; 81: 127-135
• 11 Walter D, Will U, Sanchez-Yague A. et al. A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy 2015; 47: 63-67
• 12 Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 2012; 262: 751-764
• 13 Gutierrez JP, Wilcox CM, Mönkemüller K. New technique to carry out endoscopic necrosectomy lavage using a pump. Dig Endosc 2014; 26: 117-118
• 14 Baron TH, Kozarek RA. Endotherapy for organized pancreatic necrosis: perspectives after 20 years. Clin Gastroenterol Hepatol 2012; 10: 1202-1207
• 15 Bapaye A, Itoi T, Kongkam P. et al. New fully covered large-bore wide-flare removable metal stent for drainage of pancreatic fluid collections: results of a multicenter study. Dig Endosc 2015; 27: 499-504
• 16 Rinninella E, Kunda R, Dollhopf M. et al. EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video). Gastrointest Endosc 2015; 82: 1039-1046
• 17 Siddiqui AA, Adler DG, Nieto J. et al. EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen apposing stent: a large retrospective, multicenter U.S. experience. Gastrointest Endosc 2016; 83: 699-707
• 18 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
• 19 Gardner TB, Coelho-Prabhu N, Gordon SR. et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73: 718-726
• 20 Dhir V, Teoh AY, Bapat M. et al. EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self-expandable metal stents with pancreatic ductal stenting in selected patients. Gastrointest Endosc 2015; 82: 650-657