Introduction

Pancreatic fluid collections (PFC) are debris or fluid of the pancreas that need to be drained out. This may result from surgery or necrotizing pancreatitis. This meta-analysis compared the outcomes of PFC through endoscopic and percutaneous interventions.

Aims & Methods

A medical database was searched up to June 2022, comparing the outcomes of endoscopic drainage (ED) and percutaneous drainage (PD) for the PFC. Eligible studies reporting clinical and technical success and adverse events were selected.

Results

Seventeen studies with 1170 patients were included for meta-analysis, of which 543 patients underwent ED and 627 underwent PD. Odd ratio (OR) of technical success was 0.81 (95% confidence interval (CI) 0.31, 2.1) and clinical success was in the favor of ED group at OR 2.23 (95% CI 1.45, 3.41). Adverse events OR 0.62 (95% CI 0.27, 1.39) and stent migration OR 0.61 (95% CI 0.10, 3.88) were the same in both groups, but hospital stay pooled mean difference of 15.02 days (95% CI 9.86, 20.18), mortality OR 0.24 (95% CI 0.09, 0.67), and re-interventions OR 0.25 (95% CI 0.16, 0.40) favored ED.

Conclusion

ED is safe and efficient for PFC with higher clinical success, lower mortality rate, hospital stay, and re-interventions compared with PD.

Introduction

Pancreatic fluid collections (PFCs) are significant local complications that can arise from acute pancreatitis, and its management often involves drainage, although the benefits of metal stents over plastic stents remain uncertain. This meta-analysis compared the efficacy and safety of metal stents versus plastic stents for endoscopic ultrasound (EUS)-guided drainage of PFCs.

Aims & Methods

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing metal with plastic stents for drainage of PFCs. The odds ratio (OR) was used for binary outcomes and the mean difference (MD) for continuous outcomes with their respective 95% confidence interval (CI).

Results

This study included eight RCTs and over 500 patients. Procedure duration was shorter in the metal stent arm compared with the plastic stent arm (MD -10.63; 95%CI -16.12 to -5.15, p<0.001). However, there was no statistically significant difference between metal and plastic stents in clinical success (p=0.78), technical success (p=0.65), overall mortality (p=0.48), recurrence (p=0.23), number of interventions (p=0.85), need of necrosectomy (p=0.35), need of surgery (p=0.35), length of hospitalization (p=0.86), exocrine insufficiency (p=0.54), endocrine insufficiency (p=0.77), and AEs (p=0.36).

Conclusion

Metal stents for EUS-guided drainage of PFCs are associated with a shorter procedure duration. Besides that, it did not improve other clinically relevant outcomes in comparison with plastic stents.

Introduction

Post-operative pancreatic fluid collections (POPFCs) are common adverse events after pancreatic surgery and may need interventions. Endoscopic ultrasound (EUS)-guided drainage for POPFCs is increasingly reported, but its appropriate timing has not been fully elucidated.

Aims & Methods

The aim of this meta-analysis was to evaluate treatment outcomes of POPFCs according to the timing of EUS-guided drainage. Using PubMed, Embase, Web of Science, and the Cochrane database, we identified clinical studies published until December 2022 with data comparing outcomes of early and delayed EUS-guided drainage for POPFCs. We pooled data on adverse events (AEs), mortality, and technical and clinical success rates, using the random-effects model.

Results

From 1,415 papers identified in the initial literature search, we identified 6 retrospective studies, including 128 and 107 patients undergoing early and delayed EUS-guided drainage for POPFCs. The threshold of early and delayed drainage ranged from 14 to 30 days. Distal pancreatectomy was the major cause of POPFCs, ranging from 44 to 100%. Reported AE rates of EUS-guided drainage of POPFCs ranged from 4% to 46%, and the pooled odds ratio (OR) for adverse events was 0.81 (95% confidence interval [CI], 0.40-1.64, P = 0.55) comparing early to delayed drainage. There was no evidence on heterogeneity between the studies (P_{heterogeneity} = 0.93 and I² = 0%). There was no procedure-related mortality, and technical success was achieved in all cases. Clinical success rates were reported as 90 to 97% and were comparable between early and delayed drainage groups with a pooled OR of 0.60 (95% CI, 0.20-1.83, P = 0.37).

Conclusion

POPFCs can be managed by early EUS-guided drainage without an increase in AEs.

References

1. Varadarajulu S, Trevino JM, Christein JD. EUS for the management of peripancreatic fluid collections after distal pancreatectomy. Gastrointest Endosc 2009;70:1260-5.
2. 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.
3. Caillol F, Godat S, Turrini O, et al. Fluid collection after partial pancreatectomy: EUS drainage and long-term follow-up. Endoscopic Ultrasound 2019;8:91-8.
4. Storm AC, Levy MJ, Kaura K, et al. Acute and early EUS-guided transmural drainage of symptomatic postoperative fluid collections. Gastrointest Endosc 2020;91:1085-91.e1.
5. Fujimori N, Osoegawa T, Aso A, et al. Efficacy of Early Endoscopic Ultrasound-Guided Transluminal Drainage for Postoperative Pancreatic Fistula. Canadian Journal of Gastroenterology and Hepatology 2021;2021.
6. Oh D, Lee H, Song TJ, et al. Effectiveness of early endoscopic ultrasound-guided drainage for postoperative fluid collection. Surg Endosc 2022;36:135-42.

Disclosure

Y.N. received research grants from Boston Scientific Japan, HOYA Corporation, and honoraria from Boston Scientific Japan, Fujifilm Corporation, Olympus Corporation. H.I. received research grants from Boston Scientific Japan, Fujifilm Corporation, Fujifilm Health Care Corporation, Gadelius Medical KK, Zeon Medical Inc., and honoraria from Boston Scientific Japan, Fujifilm Corporation, Taewoong Medical Devices, Olympus Corporation, Century Medical,Inc. and Cook Medical Japan G.K. Y.I. received honoraria from Gadelius Medical KK and Medicos Hirata.

Introduction

Management of pancreatic fluid collection (PFC), a serious late complication of acute pancreatitis, is critical to the improvement of its prognosis. Technical innovations such as endoscopic ultrasound (EUS)-guided drainage, lumen-apposing metal stents (LAMSs), and endoscopic necrosectomy (EN) have facilitated the minimally invasive approach to symptomatic PFCs that previously required surgical interventions. Although there has been extensive research, there remains a lack of consensus on important aspects such as the optimal timing of interventions, stent selection, and indications for necrosectomy. A better understanding of the variations in the treatment strategies would help us to identify unmet needs in this setting and design clinical studies for the standardized treatment algorithm.

Aims & Methods

To clarify the current status of PFC management in Japan and address unresolved issues. A comprehensive questionnaire survey was e-mailed to 80 centers with pancreatobiliary interventional endoscopists in Japan. The questionnaire consisted of 40 questions about the criteria for treatment indications, stent selection, and direct endoscopic necrosectomy as well as 6 case vignettes.

Results

A total of 73 centers responded to the questionnaire (response rate, 91.3%). Regarding the timing of EUS-guided drainage, 48 centers (65.8%) initiated treatment when the encapsulation of a PFC was confirmed within 4 weeks of the onset of pancreatitis, while 18 centers (24.7%) did at the same timing even if the encapsulation was considered incomplete. It should be noted that despite the revision of the Atlanta Classification and the proposal to define encapsulation as pancreatic necrosis after 4 weeks, a significant number of centers chose to perform intervention before that time. For symptomatic walled-off necrosis (WON) with low-level liquification, 45 centers (61.6%) chose a LAMS, and 16 centers (21.9%) injected saline to facilitate the expansion of the proximal flange of LAMS. The criteria for LAMS placement varied, with 8 centers (11.0%) using a liquid component of 50% or more as a criterion. On the other hand, 6 centers (8.2%) tended to perform EN and place a LAMS despite the prominent presence of necrotic material. Regarding the indications for necrosectomy, 44 centers (60.3%) chose it when there was no improvement after drainage, while 22 centers (30.1%) performed it during or immediately after the initial drainage session when necrotic material was prominent Forty-nine centers (67.1%) performed necrosectomy between 2 and 7 days after endoscopic drainage. All centers confirmed the absence of pseudoaneurysms before drainage, with prophylactic transcatheter arterial embolization performed in 64 centers (87.7%).

Conclusion

This Japanese multicenter survey revealed considerable variations in treatment strategies for PFC in terms of the timing and indications of interventions and stent selection. The findings of this study emphasized the need for continuous data collection and analysis to fill current gaps in treatment approaches. Future research should aim to develop evidence-based guidelines that can clarify the optimal timing of treatment and intervention criteria.

Introduction

Recent advancement in endoscopic ultrasonography (EUS)-guided treatment has improved clinical outcomes of patients with pancreatic fluid collections (PFCs). However, there is still a debate on preventive effect of long-term placement of a transmural plastic stent (PS) on recurrence after successful resolution of PFC. We conducted a systematic review and meta-analysis evaluating PFC recurrence rates with and without a transmural PS after EUS-guided treatment.

Aims & Methods

We conducted a systematic literature search using PubMed, Web of Science, Embase, and the Cochrane database to identify clinical studies comparing outcomes with and without transmural PS published until September 2022. We pooled data on PFC recurrence and adverse events using the random-effects model.

Results

Seven studies (randomized controlled trial, 2; prospective study, 1; retrospective study, 4), including 333 patients with long-term transmural PS and 289 patients without PS, were identified. The rate of PFC recurrence was significantly lower in patients with transmural PS (pooled odds ratio [OR] 0.24, 95% confidence interval [CI] 0.06-0.95; P = 0.042). A similar trend was observed when analyzing three prospective studies (OR 0.14, 95% CI 0.02-0.85; P = 0.033). In a subgroup analysis limited to studies focusing on patients with disconnected pancreatic duct syndrome that has been reported to be a risk factor for PFC recurrence, the odds ratio was numerically lower than that for the entire cohort (OR 0.14, 95% CI 0.04-0.46). Adverse events associated with long-term transmural PS placement were reported in four studies. The rate of adverse events was 4.1%, whereas asymptomatic stent migration was observed in 22.3%. We conducted a meta-regression analysis, which suggested that the types of stents utilized for the initial EUS-guided drainage (lumen-apposing metal stent vs. PS) had no significant influence on the association between long-term transmural PS and PFC recurrence.

Conclusion

In this meta-analysis, long-term PS placement could reduce the risk of PFC recurrence. Given the potential adverse events of indwelling PS, such as stent obstruction or bleeding, our results should be confirmed in prospective comparative studies.

Disclosure

Y.N. received research grants from Boston Scientific Japan, HOYA Corporation, and honoraria from Boston Scientific Japan, Fujifilm Corporation, Olympus Corporation. H.I. received research grants from Boston Scientific Japan, Fujifilm Corporation, Fujifilm Health Care Corporation, Gadelius Medical KK, Zeon Medical Inc., and honoraria from Boston Scientific Japan, Fujifilm Corporation, Taewoong Medical Devices, Olympus Corporation, Century Medical,Inc. and Cook Medical Japan G.K. Y.I. received honoraria from Gadelius Medical KK and Medicos Hirata.

Introduction

Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients’ lives and medical resources. Endoscopic ultrasound (EUS)-ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS-ablation on PCL in terms of complete or partial response and safety.

Aims & Methods

A systematic search in Medline, Cochrane and Scopus databases was performed until April 2023 for studies assessing the performance of the various EUS-ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% Confidence Intervals (95%CI).

Results

Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS-ablation was achieved in 44% (95%CI: 31-57; 352/767; I2=93.7%), and the respective partial response rate was 30% (95%CI:20-39; 206/767; I2=86.1%). Adverse events were recorded in 14% (95%CI: 8-20; 164/840; I2=87.2%) of cases, rated as mild in 10% [(95%CI: 5-15); 128/840; I2=86.7%]; and severe in 4% (95%CI: 3-5; 36/840; I2=0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64-76; I2=42.3%) for ethanol/paclitaxel, 44% (95%CI: 33-54; I2= 0%) for lauromacrogol, 32% (95%CI: 27-36; I2=88.4%) for ethanol and 13% (95%CI: 4-22; I2=95.8%) for RFA. Considering adverse events, the ethanol-based sub-group rated the highest percentage [16% (95%CI: 13-20; I2:91.0%)].

Conclusion

EUS-ablation of pancreatic cysts provides acceptable rates of complete resolution and low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.

Disclosure

Nothing to declare

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. However, how to best achieve safe and effective bile duct cannulation is still debated. Endoscopists doing ERCP routinely recognize the differences in the macroscopic appearance of the major papilla. This has led to a conception that certain appearances of the papilla are more difficult to cannulate and, therefore, more prone to adverse events.

Aims & Methods

We aimed to quantify the influence of papilla morphology on ERCP outcomes.
PROSPERO registration number: CRD42022360894. We systematically searched three medical databases from inception in September 2022. Studies detailing the cannulation or the rate of adverse events in the context of papilla morphology were included. For the primary classification of the major papilla, the Haraldsson system was used, differentiating four morphological types. Data on studies using other classification systems were also collected. A pooled event rate with a 95% confidence interval (CI) was used for the effect size measure. For the test of subgroup differences, a "Cochrane Q" test was used. The risk of bias assessment was performed using the Joanna Briggs Institute Critical Appraisal tool for studies reporting prevalence.

Results

A total of 17 studies were eligible, and 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I („regular”) papilla (26%; CI: 18–37), followed by type III („protruding or bulging”) (35%; CI: 25–48) and type II („small”) papilla (39%; CI: 28–52). The highest rate was observed in the case of type IV („creased or ridged”) papilla (41%; CI: 28–55). For post-ERCP pancreatitis, the event rate was the highest in type II („small”) papilla (11%; CI: 8–15) and the lowest in type I („regular”) (6%; CI: 5–8) and III („protruding or bulging”) papilla (6%; CI: 4–8). There was no statistically significant difference in the cannulation failure and post-ERCP bleeding event rates between the different papilla types. Similar trends were observed in the analyses including other classification systems comparable to the Haraldsson's. Most studies carried a low risk of bias.

Conclusion

In conclusion, other types are associated with a higher rate of difficult cannulation compared to the regular papilla type. The small papilla is associated with a higher rate of post-ERCP pancreatitis.