A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy

Abstract

There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.

Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study

“…As such, CT or MRI could be reserved for those patients in which complications are suspected, whereas transabdominal ultrasound, a more cost-effective approach, may be used to triage timing of repeat endoscopic interventions (DEN, stent removal, etc). Given the current wide variation in practice, particularly in treatment of WON, randomized studies are urgently needed to help establish best practice consensus 24 .…”

Endoscopic ultrasound-guided transmural drainage by cauterytipped lumen-apposing metal stent: exploring the possible indications

“…This issue is still under debate. Guo et al [ 21 ], in a multi-institutional consensus on how to perform EUS-guided peri-PFC drainage and endoscopic necrosectomy, suggested that LAMS should be the standard of care for the creation of an endoscopic cystenterostomy in WON. On the other hand, in a recent randomized trial [ 22 ] that compared LAMS with a plastic stent for WON treatment, serious adverse events were observed in the LAMS group; the authors concluded that LAMS removal should be performed at 3 weeks, if the WON has resolved, to decrease complications.…”

Lumen-apposing metal stents (LAMS) versus plastic stents for EUS-guided drainage of walled-off necrosis (WON) (LVPWON): study protocol for a multicenter randomized controlled trial

“…Recently, a novel lumen-apposing metal stent (LAMS) with a larger luminal diameter (≥ 10 mm) has been successfully used for EUS-guided drainage of PFC [ 8 ]. A multi-institutional consensus made by 22 expert endosonographers recommended that LAMS should be the standard of care for WON drainage [ 9 ].…”