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

It is unknown how stent types relate to clinical outcomes of endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts. This multicenter retrospective study aimed to compare the clinical outcomes between a lumen-apposing metal stent (LAMS) and a plastic stent.

Aims & Methods

Among 357 patients with pancreatic fluid collections in a large multi-institutional WONDERFUL consortium, we included 123 patients who received EUS-guided drainage of a pancreatic pseudocyst (16 and 107 cases with LAMS and plastic stent(s), respectively). We examined clinical treatment success, procedure-related adverse events, and pseudocyst recurrence.

Results

There were no differences between the groups regarding demographics (e.g., age and sex) and disease characteristics (e.g., size, encapsulation status, and the timing of drainage in relation to the onset of acute pancreatitis). The clinical success rates were comparable between the LAMS and plastic stent groups (94% vs. 87%, respectively; P = 0.40). The stent types were not associated with the time to clinical success (median, 25 days vs. 22 days for the LAMS and plastic stent groups, respectively; P = 0.56), the overall rate of procedure-related adverse events (0% vs. 5.6%, P = 0.33), or the rate of recurrence following clinical success (6.7% vs. 17%, P = 0.19).

Conclusion

In patients receiving EUS-guided drainage of pancreatic pseudocysts, clinical outcomes appeared to be comparable between the LAMS and plastic stent groups. If validated, our findings would support the feasibility of plastic stents in this patient population, which is a more cost-effective treatment modality than LAMSs. We, the WONDERFUL study group, have launched a randomized non-inferiority trial of plastic stents compared to a LAMS in this setting (NCT#06133023).

Disclosure

H.I. declares research funding from Boston Scientific Japan, Fujifilm, and Piolax Medical Devices; and honoraria from Boston Scientific Japan, Century Medical, Create Medic, Fujifilm, Gadelius Medical, Hitachi Medical, Japan Lifeline, Kaneka, Kawasumi Laboratories, Olympus Medical, Piolax Medical Devices, Sumitomo Bakelite, UMIDAS, and Zeon Medical; and contributions from Boston Scientific Japan, Gadelius Medical, Japan Lifeline, and Zeon Medical. Y.N. is an editorial board member of Digestive Endoscopy and declares research funding from Boston Scientific Japan, Century Medical, Fujifilm, Gadelius Medical, HOYA Pentax Medical, Hitachi Medical, Kaneka, and Medico’s Hirata; and honoraria from Boston Scientific Japan, Fujifilm, Gadelius Medical, Hitachi Medical, J-MIT, Medico’s Hirata, and Olympus Medical. This work was not supported by any of those companies. The other authors declare no conflicts of interest related to this article.

Introduction

Pancreatic fluid collection (PFC) often necessitates drainage or necrosectomy. Recently, minimally invasive endoscopic treatments have emerged as the first-line approach. However, limited data are available on the outcomes of such treatments in elderly patients.

Aims & Methods

This study aimed to evaluate the clinical outcomes of endoscopic treatment for PFC in elderly patients using a large-scale, multicenter cohort from Japan. This retrospective analysis included 349 patients who underwent endoscopic ultrasound-guided pancreatic fluid drainage (EUS-PFD) for PFC. The study cohort, derived from 11 institutions within the WONDERFUL study group between 2010 and 2021, was stratified into an elderly group (n = 54, aged ≥75 years) and a non-elderly group (n = 295). Treatment outcomes were compared between the two groups.

Results

The Charlson Comorbidity Index (CCI) of ≥2 was significantly more prevalent in the elderly group (28.4% vs. 10.1%, p < 0.001). No significant differences were observed between the groups in terms of gender, BMI, etiology of pancreatitis, or indications for treatment. PFC characteristics, including lesion proportion, size, morphology, and the prevalence of walled-off necrosis (WON), were comparable between the groups. However, pre-treatment white blood cell counts were significantly higher in the elderly group (10,250/μL vs. 8,060/μL, p= 0.003), and pre-treatment albumin levels were significantly lower (2.35 g/dL vs. 2.85 g/dL, p < 0.001). Clinical success rates of endoscopic treatment were similar between the elderly and non-elderly groups (82% vs. 87%, p = 0.29), as were rates of endoscopic necrosectomy (24.1% vs. 31.9%, p = 0.54), adverse events (16.7% vs. 17.6%, p = 0.99), surgical conversion (1.9% vs. 7.1%, p = 0.22), PFC recurrence (1.9% vs. 9.4%, p = 0.10), time to clinical success (41 days vs. 46 days, p = 0.49), number of endoscopic treatments (2 vs. 3, p = 0.19), and total treatment duration (86 minutes vs. 114 minutes, p = 0.54). However, the mortality rate was significantly higher in the elderly group (16.7% vs. 5.1%, p = 0.005). Multivariate analysis identified a statistically significant association between CCI ≥2 and mortality (odds ratio [OR]: 5.37, 95% confidence interval [CI]: 1.59–11.4, p = 0.007), while the elderly group showed a trend toward significance (OR: 3.31, 95% CI: 0.93–11.7, p = 0.06).

Conclusion

Elderly patients undergoing endoscopic treatment for PFC exhibited higher comorbidity burdens compared to their younger counterparts, as reflected by higher CCI scores. Despite comparable safety and clinical efficacy outcomes, mortality was significantly higher in the elderly cohort. These findings underscore the importance of comprehensive risk assessment, particularly considering systemic comorbidities, prior to initiating endoscopic treatment for PFC in elderly patients.

Introduction

The appropriate whole-body management is mandatory for successful endoscopic ultrasound (EUS)-guided interventions for symptomatic pancreatic fluid collections (PFCs). However, comorbidity status has not been fully examined in relation to clinical outcomes of patients with endoscopically managed PFCs.
Methods: Using a multi-institutional cohort of 413 patients receiving EUS-guided

Aims & Methods

Using a multi-institutional cohort of 413 patients receiving EUS-guided treatment of PFCs in 2010-2019, we examined the associations of Charlson Comorbidity Index (CCI) with in-hospital mortality and other outcomes. Multivariable logistic regression analysis was conducted with adjustment for potential confounders. The findings were validated using a sample of 4,053 patients treated at 486 hospitals in 2010-2020 within a Japanese nationwide inpatient database.

Results

In the clinical cohort, CCI was positively associated with the risk of in-hospital mortality (P_trend < 0.001). Compared to patients with CCI = 0, patients with CCI of 1-2, 3-5, and ≥ 6 had adjusted odds ratios (95% confidence intervals) of 1.36 (0.41-4.47), 7.89 (2.59-24.0), and 9.68 (2.68-34.2), respectively. In the validation cohort, a similar positive association was observed; the corresponding odds ratios were 1.75 (95% confidence interval, 1.28-2.39), 1.80 (1.07-3.06), and 5.26 (2.99-9.27), respectively (P_trend < 0.001). The associations of higher CCI with higher bleeding risk and longer length of stay were observed in the nationwide cohort (P_trend < 0.001), but not in the clinical cohort (P_trend> 0.22).

Conclusion

Higher levels of CCI were associated with higher risk of in-hospital mortality among patients receiving EUS-guided treatment of PFCs, suggesting the potential of CCI in stratifying the periprocedural mortality risk in this population.

References

1) Charlson ME, Pompei P, Ales KL et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases 1987; 40: 373-383
2) Hamada T, Yasunaga H, Nakai Y et al. No weekend effect on outcomes of severe acute pancreatitis in Japan: data from the diagnosis procedure combination database. J Gastroenterol 2016; 51: 1063-1072
3) Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
4) Baron TH, DiMaio CJ, Wang AY et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158: 67-75.e61
5) Trikudanathan G, Wolbrink DRJ, van Santvoort HC et al. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156: 1994-2007.e1993

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

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.