Efficacy of Early Endoscopic Ultrasound-Guided Transluminal Drainage for Postoperative Pancreatic Fistula

Abstract

Background. Endoscopic ultrasound-guided transluminal drainage (EUS-TD) is generally performed 4 weeks after disease onset for evacuating pancreatic fluid collections. However, the optimal timing for conducting the procedure in those diagnosed with postoperative pancreatic fistula (POPF) has not been established. We aimed to elucidate the efficacy and safety of early EUS-TD procedures for treating POPF. Methods. We retrospectively reviewed patients diagnosed with POPF who underwent EUS-TD in the Kyushu University Hospital between 2008 and 2019. Clinical features were comparatively analyzed between the two patient groups who underwent either early (≤15 days postoperatively) or late (>15 days postoperatively) EUS-TD. Factors prolonging hospital stay were also analyzed using Cox proportional hazard models. Results. Thirty patients (median age, 64.5 years) were enrolled. The most common initial operation was distal pancreatectomy with splenectomy (60.0%). Median size of POPF was 69.5 (range, 38–145) mm, and median time interval between surgery and EUS-TD was 17.5 (range, 3–232) days. Totally, 47% patients underwent early EUS-TD. Rates of technical success, clinical success, and complications were 100%, 97%, and 6.9%, respectively. No recurrence of POPF occurred during a median follow-up period of 14 months. Clinical characteristics and outcomes were comparable between the early and late drainage patient groups, except for the rates of infection and nonencapsulation of POPF, which were significantly higher in the early drainage group. Performing simultaneous internal and external drainage (hazard ratio (HR): 0.31; 95% confidence interval (CI): 0.11–0.93, p = 0.04 ) and conducting ≥2 treatment sessions (HR: 0.26; 95% CI: 0.08–0.84, p = 0.02 ) were significantly associated with prolonged hospitalization after EUS-TD. Conclusions. EUS-TD is a safe and effective method for managing POPF, regardless of when it is performed in the postoperative period. Once infected POPF occurs, clinicians should not hesitate to perform EUS-TD even within 15 days of the initial operation.

The Role of EUS-Guided Drainage in the Management of Postoperative Fluid Collections after Pancreatobiliary Surgery

“…A number of studies have demonstrated the safety and efficacy of early EUS-guided drainage for POFC. EUS-guided drainage in some of these studies was performed within two weeks of surgery and sometimes even as early as three days after surgery [19]. These studies are limited by their retrospective nature, small sample sizes, and potential for selection bias [7,[16][17][18][19]23,24].…”

“…Subgroup analysis in one of these studies even demonstrated no significant difference in terms of clinical outcomes or complications for patients undergoing acute drainage within 14 days of surgery [17]. These results were then replicated in dedicated studies comparing acute EUSguided drainage within two weeks of surgery to those performed after two weeks [18,19]. These studies are summarised in Table 2 below.…”

“…The most common type of stent inserted for POFC drainage is a double-pigtail plastic stent (DPPS). Out of 19 studies reviewed (see Table 4), 15 studies had between one and three 7-10-French DPPSs inserted as the initial form of drainage for some or all of their patients [2][3][4]6,7,9,10,[14][15][16][17][18][19]25,26]. Most authors follow a standard protocol for EUS-guided drainage.…”

“…There are only three studies (see Table 5) examining the use of LAMSs in patients with POFC that had more than 30 patients [5,17,32]. Two other studies only utilised LAMSs in fewer than five patients, and therefore, no meaningful conclusions can be drawn [16,19]. The technical and clinical success rates of the larger studies range from 93.6% to 96.8% and from 89.3% to 91.9%, respectively [5,32].…”

“…The authors then internalise the drain about one week after the initial procedure. The second method is the selective use of nasocystic drains only if there was necrotic debris or purulent fluid with poor drainage [10,15,18,19,26]. The routine use of nasocystic drains runs counter to the original intention of EUS-guided drainage to reduce external drains and their associated problems.…”