Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience.

Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of "step-up" endoscopic transmural approach for treatment of WON. Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided "step up" transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN. Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1). "Step up" endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.

Rana SS ，Sharma V ，Sharma R ，Gupta R ，Bhasin DK ... -  《-》

Endoscopic ultrasonography-guided transmural drainage of walled-off pancreatic necrosis: Comparison between a specially designed fully covered bi-flanged metal stent and multiple plastic stents.

Endoscopic ultrasonography (EUS)-guided drainage of walled-off necrosis (WON) may be carried out by placement of multiple plastic stents (MPS) or specially designed fully covered bi-flanged metal stents (BFMS). Comparative data on efficacy of these two stent types for WON drainage are limited. This retrospective study compares outcomes of WON drainage using BFMS and MPS. During a 10-year period, 133 patients underwent EUS-guided WON drainage. MPS or BFMS were placed in a WON cavity through a single puncture, and direct endoscopic necrosectomy (DEN) was carried out whenever clinically necessary. Data in the two cohorts were retrospectively compared for primary outcomes - clinical success, adverse events and mortality; and secondary outcomes - DEN requirement, mean DEN sessions, need for salvage surgery and hospital stay. MPS were placed in 61 and BFMS in 72 patients. Patients undergoing BFMS drainage required fewer DEN sessions (mean 1.46 vs 2.74, P < 0.05), had fewer adverse events (5.6% vs 36.1%, P < 0.05), needed salvage surgery less often (2.7% vs 26.2%, P < 0.05), and had significantly shorter hospital stay (4.1 vs 8 days, P < 0.05) compared to those undergoing MPS drainage. There was no difference in DEN requirement (P = 0.217) and mortality (P = 0.5) in both groups. Overall clinical success with BFMS was superior to MPS (94% vs 73.7%, P < 0.05). BFMS appear to be superior to MPS for EUS-guided WON drainage in terms of clinical success, number of DEN sessions, adverse events, need for salvage surgery and hospital stay.

Bapaye A ，Dubale NA ，Sheth KA ，Bapaye J ，Ramesh J ，Gadhikar H ，Mahajani S ，Date S ，Pujari R ，Gaadhe R ... -  《-》

Endoscopic ultrasonography-guided drainage of pancreatic fluid collections.

Endoscopic ultrasound (EUS)-guided drainage is now firmly established as the best option for drainage of walled-off pancreatic fluid collections (PFC). It has high clinical efficacy, similar to surgical and percutaneous approaches, but with lower morbidity and costs. It is superior to non-EUS-guided approaches because even collections without endoluminal bulging can be successfully drained. Transmural drainage alone is sufficient for pseudocysts, but in the context of walled-off pancreatic necrosis (WON), adjunctive direct endoscopic necrosectomy (DEN) may be required. Traditionally, double pigtail plastic stents (PS) were used for transmural drainage, but, recently, fully covered self-expandable metallic stents (FCSEMS) customized for PFC drainage have become available and are increasingly used, especially in the management of WON, because the larger-diameter stent facilitates drainage and insertion of an endoscope into the WON cavity for DEN. The present review will discuss the evidence for EUS-guided drainage and DEN, the technical problems involved, and the roles of PS and FCSEMS in PFC drainage.

Ang TL ，Teoh AYB 《-》

American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis.

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.

Baron TH ，DiMaio CJ ，Wang AY ，Morgan KA ... -  《-》

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals.

Rana SS ，Sharma R ，Ahmed SU ，Gupta R ... -  《-》