Comparison of early and delayed EUS-guided drainage of pancreatic fluid collection

Abstract

Background and study aims While endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collection (PFC) is recommended to be performed ≥ 4 weeks after onset of acute pancreatitis (AP), early (< 4 weeks) interventions are needed in some symptomatic cases. Despite feasibility of early percutaneous drainage, there have been few studies about early EUS-guided drainage of PFC. Patients and methods Consecutive patients who received EUS-guided drainage (EUS-PCD) of infected or symptomatic PFC at the University of Tokyo were retrospectively studied. Contraindications for EUS-PCD are lack of encapsulation or adhesion to the gastrointestinal tract. Safety and effectiveness of early vs delayed (≥ 4 weeks) EUS-PCD were compared. Results A total of 35 patients underwent EUS-PCD (12 early and 23 delayed) using 19 large-bore fully-covered metallic stent and 16 plastic stents. The median diameter of PFC was 110 mm (40 – 180) and 122 mm (17 – 250) in the early and delayed drainage groups, respectively. Median time from onset of AP to drainage was 23 and 85 days for early and delayed drainage, respectively. The technical success rate of EUS-guided drainage was 100 %. Endoscopic necrosectomy was performed in six early and 16 cases of delayed drainage. The adverse event rate was 25 % (3 bleeding) and 13 % (2 perforations and 1 CO 2 retention) in the early and delayed drainage groups, respectively. Two patients died (1 early and 1 delayed) due to multiorgan failure. Conclusion Endoscopic drainage and subsequent necrosectomy of symptomatic PFC within 4 weeks after onset of acute pancreatitis was feasible, given that the collection was encapsulated and attached to the gastrointestinal tract.

Comparison of endoscopic versus percutaneous drainage of symptomatic pancreatic necrosis in the early (< 4 weeks) phase of illness

“…Few studies have attempted to the role of ETD in managing PNC during early phase of illness and found that it is technically feasible with satisfactory efficacy and acceptable complication rates. [ 19 20 21 22 ] Finally, although studies have demonstrated benefits of ETD over PCD in the form of lower rates of EPF, reintervention rates, rates of surgery, and shorter hospital stay, such a comparison has not been made during early phase of illness. [ 37 38 ]…”

“…(both reported a median time of 23 days). [ 20 21 ] Despite high percentage of solid debris in these collections, nearly two-third of the patients could be managed by multiple double-pigtail transmural plastic stents rather than BFMS. However, merely a single-stage procedure was not sufficient and nearly half of the patients required multiple sessions of DEN prior to improvement.…”

“…Few recently published studies have demonstrated the safety and efficacy of ETD during early phase (<4 weeks) of ANP, thus expanding the indications of endoscopic intervention in ANP. [ 19 20 21 22 ] However, the experience with ETD in early phase is still limited, there are concerns about increased frequency of adverse effects, and its results have not been compared with the conventional step-up PCD approach. In this retrospective study, we report the safety and efficacy of early ETD (<4 week after onset) of ANP with PCD in patients with symptomatic PN.…”

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

“…However, in many cases, the indication for drainage occurs earlier and percutaneous intervention is generally recommended in such situations [ 5 ]. On the other hand, in cases where a lesion is located in the central area of the retroperitoneal region, it is much easier to approach by endoscopy, so endoscopic drainage might be performed after the encapsulation is confirmed [ 25 ].…”

“…The median time for early drainage in these retrospective studies was 19 to 23 days after the onset of acute pancreatitis [ 26 ]. Complications such as perforation or bleeding did not significantly increase in patients who received early drainage [ 25 ].…”