Z Gastroenterol 2016; 54(09): 1047-1053
DOI: 10.1055/s-0042-112032
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-guided drainage of abdominal fluid collections after pancreatic surgery: Efficacy and long-term follow-up

EUS gesteuerte Drainage abdomineller Flüssigkeitskollektionen nach Pankreaschirurgie: Effektivität und Langzeitverlauf
U. W. Denzer
1   Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
A. D. Sioulas
1   Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
M. Abdulkarim
2   Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
S. Groth
1   Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
T. Rösch
1   Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
P. Busch
3   Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
J. Izbicki
3   Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
H. Ittrich
4   Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
G. Adam
4   Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
,
G. Schachschal
1   Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
› Author Affiliations
Further Information

Publication History

05 April 2016

04 July 2016

Publication Date:
09 September 2016 (online)

Abstract

Background/Purpose: Endoscopic ultrasound-guided drainage (EUS-GD) of postoperative abdominal fluid collections (POFC) following pancreatic surgery is used as an alternative or complement to percutaneous drainage (PD) procedure. The present single-center retrospective study evaluates its efficacy and safety.

Method: We included consecutive cases with POFC treated by EUS-GD between September 2009 and November 2014 in our department. Technical success, long-term clinical success, recurrence rate and need for surgery were analyzed.

Results: 24 procedures in 20 patients (95 % after pancreatic resection) were assessed. Indications for surgery included tumors/lesions located in the pancreas (15/20), chronic pancreatitis (3/20) and duodenal adenoma not completely resectable endoscopically (2/20). EUS-GD was performed within a median of 30 days (IQR: 8.25) for a median fluid collection size of 72.5 mm (IQR: 46.25), requiring a mean of 1.2 sessions with placement of a mean of 2.1 plastic stents (7 Fr/10 Fr) per patient for a mean of 89 days (IQR: 127). Microbiology of aspirated fluid revealed positive cultures in 13 patients, mostly polymicrobial, isolated positive for fungal and 3 multidrug-resistant gram negative (MRGN) in 4 cases. An additional transpapillary drainage was inserted in 1/20 patients. 4/20 patients received PD, mostly before EUS-GD. Technical and clinical success was achieved in 20/20 (100 %) and 18/20 (90 %) patients, respectively, while 2 patients required re-operation. During follow-up (median 630 days after stent removal, range: 45 – 2160), recurrence occurred in 1/18 (5.5 %) patient that was referred for surgery. No death or severe adverse events were noted.

Conclusion: EUS-GD is an effective, minimally invasive and safe method for therapy of POFC after pancreatic surgery offering long-term remission in about 95 % of cases.

Zusammenfassung

Einleitung: Die endosonografisch gesteuerte transmurale Drainage (EUS-GD) von postoperativen Flüssigkeitskollektionen (POFC) wird vermehrt alternativ oder ergänzend zu perkutanen Drainageverfahren durchgeführt. Diese retrospektive Single Center Studie analysiert Effektivität und Sicherheit der Methode nach Pankreaschirurgie.

Methode: Alle konsekutiven postoperativen Verhalte mit klinischer Indikation zur EUS-GD zwischen 09/2009 und 11/2014 wurden eingeschlossen. Analysiert wurden die technische und klinische Erfolgsrate im Langzeitverlauf sowie die Rezidivrate und Re-Operationen.

Ergebnisse: 24 Prozeduren wurden bei 20 Patienten überwiegend nach Pankreasresektionen (95 %) durchgeführt. Zugrundeliegende Operationsindikationen waren Pankreastumore (15/20), chronische Pankreatitis (3/20) und Duodenaladenome (2/20). Die EUD-GD erfolgte im Median 30 Tage postoperativ (IQR 8,25) bei einer medianen POFC Größe von 72,5 mm (IQR 46,25). Pro Patient wurden im Mittel 1,2 Sitzungen mit 2,1 Plastikendoprothesen (7 Fr/10 Fr) durchgeführt, die mittlere Stentliegedauer lag bei 89 Tagen (IQR 127). Die mikrobiologische Untersuchung der Aspirate ergab positive Kulturen bei 13 Patienten meist polymikrobiell, isoliert positiv für Candida oder 3- MRGN in 4/13. Eine zusätzliche nasozystische Spülsonde wurde bei 1/20 Patienten eingelegt, perkutane Drainagen bei 4/20 meist vor der EUS-GD. Der technische und klinische Erfolg lag bei 100 % (20/20) bzw. 90 % (18/20), wobei eine Re-Operation bei 2 Patienten erforderlich war. Im Follow-up (median 630 Tage nach Stententfernung, range: 45 – 2160) trat ein Operationspflichtiges Rezidiv auf (5,5 %, 1/18) auf, keine schweren unerwünschten Ereignisse.

Schlussfolgerung: EUS-GD ist eine effektive, minimal invasive und sichere Methode zur Drainage von POFC. Nach Pankreaschirurgie kommt es in etwa 95 % der Fälle zu Langzeitremission der Verhalte.

 
  • References

  • 1 Men S, Akhan O, Koroglu M. Percutaneous drainage of abdominal abscess. Eur J Radiol 2002; 43: 204-218
  • 2 Adams DB, Anderson MC. Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst. Ann Surg 1992; 215: 571-576 ; discussion 576–578
  • 3 Giovannini M, Pesenti C, Rolland AL et al. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope. Endoscopy 2001; 33: 473-477
  • 4 Shami VM, Talreja JP, Mahajan A et al. EUS-guided drainage of bilomas: A new alternative?. Gastrointest Endosc 2008; 67: 136-140
  • 5 Wehrmann T, Stergiou N, Vogel B et al. Endoscopic debridement of paraesophageal, mediastinal abscesses: A prospective case series. Gastrointest Endosc 2005; 62: 344-349
  • 6 Consiglieri CF, Escobar I, Gornals JB. EUS-guided transesophageal drainage of a mediastinal abscess using a diabolo-shaped lumen-apposing metal stent. Gastrointest Endosc 2015; 81: 221-222
  • 7 Saxena P, Kumbhari V, Khashab MA. EUS-guided drainage of a mediastinal abscess. Gastrointest Endosc 2014; 79: 998-999
  • 8 Noh SH, Park DH, Kim YR et al. EUS-guided drainage of hepatic abscesses not accessible to percutaneous drainage (with videos). Gastrointest Endosc 2010; 71: 1314-1319
  • 9 Seewald S, Imazu H, Omar S et al. EUS-guided drainage of hepatic abscess. Gastrointest Endosc 2005; 61: 495-498
  • 10 Alcaide N, Vargas-Garcia AL, de la Serna-Higuera C et al. EUS-guided drainage of liver abscess by using a lumen-apposing metal stent (with video). Gastrointest Endosc 2013; 78: 941-942 ; discussion 942
  • 11 Itoi T, Ang TL, Seewald S et al. Endoscopic ultrasonography-guided drainage for tuberculous liver abscess drainage. Dig Endosc 2011; 23 (Suppl. 01) 158-161
  • 12 Ang TL, Seewald S, Teo EK et al. EUS-guided drainage of ruptured liver abscess. Endoscopy 2009; 41 (Suppl. 02) E21-E22
  • 13 Lee DH, Cash BD, Womeldorph CM et al. Endoscopic therapy of a splenic abscess: Definitive treatment via EUS-guided transgastric drainage. Gastrointest Endosc 2006; 64: 631-634
  • 14 Giovannini M, Bories E, Moutardier V et al. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 2003; 35: 511-514
  • 15 Piraka C, Shah RJ, Fukami N et al. EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid collections and abscesses. Gastrointest Endosc 2009; 70: 786-792
  • 16 Ulla-Rocha JL, Vilar-Cao Z, Sardina-Ferreiro R. EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery. Ther Adv Gastroenterol 2012; 5: 95-102
  • 17 Decker C, Varadarajulu S. EUS-guided drainage of an intra-abdominal abscess after liver transplantation. Gastrointest Endosc 2011; 73: 1056-1058
  • 18 Hadithi M, Bruno MJ. Endoscopic ultrasound-guided drainage of pelvic abscess: A case series of 8 patients. World J Gastrointest Endosc 2014; 6: 373-378
  • 19 Puri R, Choudhary NS, Kotecha H et al. Endoscopic ultrasound-guided pelvic and prostatic abscess drainage: Experience in 30 patients. Indian J Gastroenterol 2014; 33: 410-413
  • 20 Puri R, Eloubeidi MA, Sud R et al. Endoscopic ultrasound-guided drainage of pelvic abscess without fluoroscopy guidance. J Gastroenterol Hepatol 2010; 25: 1416-1419
  • 21 Seewald S, Brand B, Omar S et al. EUS-guided drainage of subphrenic abscess. Gastrointest Endosc 2004; 59: 578-580
  • 22 Fernandez-Urien I, Vila JJ, Jimenez FJ. Endoscopic ultrasound-guided drainage of pelvic collections and abscesses. World J Gastrointest Endosc 2010; 2: 223-227
  • 23 Varadarajulu S, Drelichman ER. Effectiveness of EUS in drainage of pelvic abscesses in 25 consecutive patients (with video). Gastrointest Endosc 2009; 70: 1121-1127
  • 24 Varadarajulu S, Drelichman ER. EUS-guided drainage of pelvic abscess (with video). Gastrointest Endosc 2007; 66: 372-376
  • 25 Ramesh J, Bang JY, Trevino J et al. Comparison of outcomes between endoscopic ultrasound-guided transcolonic and transrectal drainage of abdominopelvic abscesses. J Gastroenterol Hepatol 2013; 28: 620-625
  • 26 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
  • 27 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
  • 28 Varadarajulu S, Wilcox CM, Christein JD. EUS-guided therapy for management of peripancreatic fluid collections after distal pancreatectomy in 20 consecutive patients. Gastrointest Endosc 2011; 74: 418-423
  • 29 Gupta T, Lemmers A, Tan D et al. EUS-guided transmural drainage of postoperative collections. Gastrointest Endosc 2012; 76: 1259-1265
  • 30 Tilara A, Gerdes H, Allen P et al. Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections. J Am Coll Surg 2014; 218: 33-40
  • 31 Azeem N, Baron TH, Topazian MD et al. Outcomes of endoscopic and percutaneous drainage of pancreatic fluid collections arising after pancreatic tail resection. J Am Coll Surg 2012; 215: 177-185
  • 32 Kwon YM, Gerdes H, Schattner MA et al. Management of peripancreatic fluid collections following partial pancreatectomy: A comparison of percutaneous versus EUS-guided drainage. Surg Endosc 2013; 27: 2422-2427
  • 33 Téllez-Ávila F, Carmona-Aguilera GJ, Valdovinos-Andraca F et al. Postoperative abdominal collections drainage: Percutaneous versus guided by endoscopic ultrasound. Dig Endosc 2015; 27: 762-766
  • 34 Behrman SW, Zarzaur BL. Intra-abdominal sepsis following pancreatic resection: Incidence, risk factors, diagnosis, microbiology, management, and outcome. Am Surg 2008; 74: 572-578 ; discussion 578–579
  • 35 Shah RJ, Shah JN, Waxman I 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
  • 36 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; . pii: S1542-3565(16)30196-3. [Epub ahead of print.]