Introduction

In general, it is recognized that there is a considerable risk of complications following early endotherapy in the development of pancreatic fluid collections. However, there is still limited information regarding the optimal timing for endosonography (EUS)-guided drainage once a well-defined wall has formed and the relative risk of complications in subsequent interventions.

Aims & Methods

Our study aims to examine the risk of the first EUS-guided drainage compared to the following interventions in pancreatic fluid collections and necrosis. Data on EUS-guided drainage of pancreatic fluid collections performed between 2018 and 2022 at three endoscopy units of Charité- Berlin, regardless of the etiology, were reviewed and analyzed. Adverse events were defined and graded according to the recommendations of the American Society of Gastrointestinal Endoscopy¹. A severe event following an endoscopic procedure is defined as one that necessitates unplanned admission, prolongs hospital stay by > 10 nights, requires ICU admission for > 1 night, or results in surgery or permanent disability. The Cox proportional hazards regression model was used to examine the relationship between the timing of EUS-guided therapy and the occurrence of complications, adjusting for patient- and procedure-related (age, gender, body-mass index, comorbidities, etiology, size) covariates.

Results

In a cohort of 102 patients (72.5% male, mean age 57.0 ± 14.1 years), 202 procedures were performed, of which 71 (35.1%) were necrosectomies. The predominant etiology was fluid collection complicating pancreatic resection (31.4%), followed by alcohol-induced (22.5%) and biliary (18.6%) pancreatitis. Nearly half of the cases presented with necrotic particles on pre-interventional imaging and 85.3% had a fully definable wall. Adverse events were observed in 24 of the 202 (11.9%) procedures. Six were classified as severe and predominantly occurred during the initial session. The most frequently reported adverse event was bleeding (4.5%), followed by abdominal pain (1.9%), infection (1.9%), and perforation (0.9%). Three patients died within 30 days after the intervention and were indirectly associated with iatrogenic-induced infection of previously sterile collection. In the Cox proportional hazards regression analysis, which was adjusted for confounding variables, the first intervention emerged as a significant predictor of complications, with a hazard ratio (HR) of 3.5 (95% CI 1.2-10.7). This finding suggests an increased risk of complications during the initial endotherapy session for pancreatic fluid collections. Conversely, there was an association between the post-pancreatitis fluid collections and complications with an HR of 3.1 (95% CI 0.7- 14.0) compared to post-surgery collections but it did not reach statistical significance. The procedure's duration and the collection size were not associated with the risk of complications.

Conclusion

In the EUS-guided therapy of pancreatic fluid collections, the initial intervention emerged as a significant predictor of complications. While post-pancreatitis collections tend toward a higher complication rate compared to post-surgical collections, early intervention strategies require careful consideration to reduce risks.

References

1. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010 Mar;71(3):446-54.

Introduction

The etiology and natural history of fluid collections complicate pancreatic resection differ from those associated with pancreatitis. Understanding whether one group benefits more from EUS-guided drainage could facilitate the development of condition-specific treatment protocols.

Aims & Methods

We aimed to compare the efficacy and safety of EUS-guided drainage of fluid collections following pancreatic resection and post-pancreatitis pseudocysts. This study evaluates the outcomes of patients who underwent EUS-guided drainage for pancreatic fluid collection without necrosis complicating pancreatic resection (PR) at a high-volume tertiary university center from 2018 to 2022. These patients were compared to a matched cohort with post-pancreatitis (PP) fluid collections without solid components, using a 1:1 ratio for confounding factors. In both conditions, treatment was standardized to involve the implantation of 10 French double-pigtail stents as the therapeutic modality. Primary outcomes included the duration of hospital stay and the total number of interventions required for treatment success. This encompassed the initial intervention, stent removals and replacements, and any additional procedures, such as managing complications during a 12-month follow-up. Early clinical success of EUS-guided drainage was defined as (1) a reduction of the collection to <50% within 3 months, as confirmed by follow-up imaging, and (2) clinical improvement. Late clinical success was determined by the complete resolution of the lesion within 12 months. Secondary endpoints were the duration of ICU stay, mortality, and adverse events, defined according to the lexicon of the American Society of Gastrointestinal Endoscopy¹.

Results

In the final analysis, 54 patients (70.4% male, mean age 57.7 ± 13.9) were included, 27 in each group. The most common cause within the PP group was alcohol-induced pancreatitis (40.7%), followed by biliary (18.5%) and idiopathic (14.8%) etiology. In the PR- group most patients have had a pancreatic tail resection (55.6%), followed by pylorus-preserving pancreaticoduodenectomy (22.2%) and total or subtotal pancreatic resection (22.2%). No significant differences were observed between the cohorts in relation to potential confounding variables, including age, gender, comorbidities, presence of fluid infection, number and type of stents utilized, time interval to initial intervention, and pre-drainage size of fluid collections. The number of reinterventions and clinical success after EUS-guided drainage were similar in both groups. While the overall hospital stay was not significantly different between the groups, the PP patients showed a significantly longer need for ICU services compared to the post-surgery group (11.9 vs. 1.7 days, p=0.03). The complications rate tends to be higher in the post-pancreatitis group but did not reach significance due to the low number of events that occurred (29.6 vs. 7.4%, p=0.08).

Conclusion

Despite comparable clinical outcomes after EUS-guided drainage in both groups, patients with post-pancreatitis fluid collection were associated with greater ICU utilization and tended to experience higher complication rates at initial intervention.

References

1. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010 Mar;71(3):446-54.

Introduction

There has been a shift from percutaneous drainage towards endoscopic ultrasound (EUS)-guided drainage for management of post-operative pancreatic fluid collections (POPFC). However, available series have been limited by sample size and little is known about the factors that may influence clinical success.

Aims & Methods

Our aim was to evaluate the outcomes of EUS-guided drainage of POPFC following pancreatic surgery and identify predictors of clinical success.
We performed a retrospective review of patients who underwent EUS-guided drainage of POPFC between 2014 and August 2024 at three academic centers. Primary outcome was clinical success, defined as the complete radiological regression of the collection and resolution of symptoms without the need for additional drainage procedures.

Results

In total, 265 cases were included (mean age 64 [SD±13.9] years, 37% pylorus-resecting pancreatoduodenectomy). Early drainage (≤14 days) was performed in 52% of cases (n=138) and DPPS were used in 209 cases (79%).
Clinical success with a single EUS drainage procedure was achieved in 160 cases (60.4%). Step-up interventions were required in 67 patients (25.3%), 37 of which required endoscopic revision only. Technical success was achieved in 90% (n=238) and adverse events occurred in 43 cases (16%).
Stent type, drainage timing, splenectomy and drainage route did not seem to significantly influence clinical success. Multivariate analysis including stent type and surgical history, showed that distal pancreatectomy was an independent risk factor for clinical failure.

Conclusion

EUS-guided drainage of POPFC was effective in the majority of cases with a single procedure, although distal pancreatectomy was suggested as an independent risk factor for clinical failure. These results further support the use of EUS-guided drainage for the management of postoperative collections.

Disclosure

HH declares no competing interests. MB received trial support from Boston Scientific and holds consultancy agreements with Dekra, Ovesco and Prion Medical. GV received lecture fees from Boston Scientific and travel grants from Pentax Medical and Euromedical. RVW holds a consultancy agreement with Boston Scientific. Schalk van der Merwe holds the Cook chair in Interventional endoscopy, has consultancy agreements with Cook, Pentax and Olympus and co-chairs the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy.

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

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

Peri-pancreatic fluid collections (PFCs) are frequent complications of acute pancreatitis and their management, especially in the presence of necrosis, is often challenging. Invasive interventions are indicated in case of PFC infection or symptoms related to organ compression. Endoscopic ultrasound (EUS)-guided transluminal drainage rapidly developed over time and the introduction of new dedicated stents represented a game changer of PFC treatment. In particular Bi-Flanged Metal Stent (BFMS) and Lumen Apposing Metal Stent (LAMS), with their technical characteristics, facilitate to create a stable connection between the gastrointestinal wall and the target cavity, allowing the introduction of the endoscope through the stent for direct therapeutic intervention, reporting high rates of technical and clinical success. To date, only one retrospective study have compared Nagi and Hot-Axios for EUS-guided drainage of PFCs.

Aims & Methods

The present study aimed to retrospectively evaluate the safety, technical and clinical success of the two different dedicated metal stents for EUS-guided drainage of PFC. Data from a large multicenter series of patients with PFCs treated with Hot-Axios and Nagi stents were retrieved among 30 italian centers during a 5-year period (January 2016–July 2020). Technical and clinical success, rate of adverse events were taken into account as outcome measures. To overcome biases owing to the different distribution of covariates among patients who were treated with the two kinds of stent, a 1-to-1 match was created using propensity score analysis.

Results

Out of 476 patients underwent EUS-guided drainage of PFC, 386 were treated with Hot-Axios and 90 with Nagi stent, with a median follow-up of 290 days (95% CI 244 to 361). After 1:1 propensity score matching two groups were compared, 84 subjects who experienced Hot-Axios and 84 Nagi stent, resulting well comparable in terms of several variables. Median age was 62 (49.5-73) years in the Hot-Axios group and 63 (50-74) years in the Nagi group (p=0.40), male patients were 70% and 61% in the two groups, respectively (p=0.59). WON represented 39% of cases in the Hot-Axios and 32% in the Nagi group (p=0.70); 52% and 61% of PFCs were located in the body of pancreas in the two groups respectively (p=0.62) with a median width of 92 mm (61-120) in the Hot-Axios and 88 mm (56-110) in the Nagi group (p=0.25).
The two stents did not differ in terms of adverse events (AE) rate (13% versus 15%, p=0.29).
Overall, 11 AEs were observed in the Hot-Axios group, of which 3 (3.5%) mild, 4 (4.7%) moderate, 3 (3.5%) severe and 1 (1.1%) fatal, whereas 13 AEs were registered in the Nagi group, of which 3 (3.5%), 5 (5.9%), 3 (3.5%), and 2 (2.3%) mild, moderate, severe and fatal, respectively (p=0.63). Most common AE was bleeding (5.9% in both groups). Collection recurrence was observed in 4 cases after Hot-Axios (4.7%) and 3 cases (3.5%) after Nagi stent (p=1.0).
Technical and clinical success in the two groups were respectively 92% versus 95% (p=0.36) and 91% versus 94% (p=0.64).

Conclusion

Although literature is not univocal on which type of stent offers the best outcome for EUS-guided PFC drainage, our study demonstrates that, among dedicated metal stents, Hot-Axios and Nagi stent have similar technical and clinical success rate with comparable safety profile, suggesting that the choice of one stent over another should be multifactorial, based on clinical and technical aspects and/or personal expertise, rather than just efficacy rate.

Disclosure

Chiara Coluccio is lecturer for Steris.
Andrea Anderloni is consultant for Boston Scientific, Olympus and Medtronic.
Carlo Fabbri is consultant for Boston Scientific and lecturer for Steris and Q3 Medical.
All the other authors have no conflict of interest to declare