Endoscopic ultrasonography–guided transmural drainage of pseudocysts

Endoscopic ultrasonography (EUS) has emerged as an important diagnostic and therapeutic tool in management of gastrointestinal diseases. One of the most common uses of EUS is in the diagnosis, management, and treatment of pancreatic cysts and pseudocysts. EUS allows characterization of pancreatic cysts and safe drainage of pancreatic pseudocysts. This chapter will focus on indications, techniques, and outcomes of EUS-guided pseudocyst drainage.     

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.     

Endoscopic ultrasound in pancreatic diseases

There are many indications for the use of endoscopic ultrasound (EUS) in the management of patients with pancreatic diseases. High-resolution imaging of the pancreas is achievable due to the close proximity between luminal structures and the pancreas. Since its introduction, EUS has had a significant impact on the diagnosis of pancreatic diseases. The detection of small lesions and neuroendocrine pancreatic tumors as well as the preoperative staging of pancreatic adenocarcinoma have been improved employing EUS. For the detection of small pancreatic tumors <2 cm in diameter, EUS appears to be the most sensitive method. EUS adds significant information to the differential diagnosis between pancreatic cancer and chronic pancreatitis, and it may be further enhanced by EUS-guided fine-needle aspiration. While the role of EUS in distinguishing between benign and malignant cystic pancreatic tumors is under discussion, EUS-guided drainage of pancreatic pseudocysts is an accepted treatment option for symptomatic individuals. One of the most important advantages of EUS apart from tumor staging is the early detection of chronic pancreatitis. EUS is as good as endoscopic retrograde cholangiopancreatography in diagnosing chronic pancreatitis in advanced stages. In early stages of the disease, when the ductal system remains normal, EUS appears to be a superior diagnostic modality because it can detect features of chronic pancreatitis in the parenchyma not visible by other techniques.     

ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED SIMULTANEOUS INTERNAL AND EXTERNAL DRAINAGE OF INFECTED PANCREATIC PSEUDOCYSTS

The procedure for endoscopic ultrasonography (EUS)‐guided cystodrainage of pancreatic pseudocysts has been established but, at times, we encounter difficult cases because of infected pseudocysts. We report successful simultaneous internal and external drainage performed in three patients with severely infectious pancreatic pseudocysts.     

An endoscopic perspective on pancreatic pseudocysts

Significant advances in endoscopic, radiologic, and surgical techniques have transformed the management of pancreatic pseudocysts. The present review focuses upon advances in the endoscopic management of pseudocysts and incorporation of these techniques into an overall management approach. Findings with endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography often guide the choice of drainage method. Endoscopic drainage can be achieved through the transpapillary or transmural routes. EUS has increasingly become an integral part of transmural pseudocyst drainage.     

Pancreatic Pseudocysts

Opinion statement Pseudocysts complicate acute pancreatitis in less than 5% of cases and chronic pancreatitis in 20% to 40% of cases. A pseudocyst is a localized collection of pancreatic fluid surrounded by a wall of granulation tissue and collagen. It takes 4 to 6 weeks for a fluid collection to mature and become a true pseudocyst. Unlike other cystic lesions of the pancreas from which they should be differentiated, pseudocysts lack an epithelial layer. Patients with pseudocysts present with a range of symptoms and signs. Pseudocysts are imaged using transabdominal ultrasound, CT, endoscopic ultrasound (EUS), and MRI. EUS confers an advantage over other imaging modalities in that certain EUS features are suggestive of pseudocysts over other cystic lesions. The diagnostic accuracy of EUS has improved further with the use of EUS-guided fine-needle aspiration. Therapeutic options include watchful observation or intervention. In our opinion, if acute pseudocysts are uncomplicated, asymptomatic, and do not appear to be enlarging on serial imaging, it is preferable to withhold intervention because many of these cysts resolve spontaneously. However, one needs to beware of the possibility of complications such as infection in unresolved pseudocysts. Pseudocysts associated with chronic pancreatitis are less likely to resolve spontaneously and are drained by intervention more frequently. Of the three interventional options, namely endoscopic, percutaneous, and surgical drainage, endoscopic drainage should be the treatment of choice if certain criteria are met. Preinterventional endoscopic retrograde cholangiopancreatography is mandatory to define ductal anatomy. If there is communication between the pseudocyst and the pancreatic duct, a transpapillary approach is preferred. Use of EUS should increase the number of cases in which pseudocysts can be drained endoscopically. Surgery should be reserved for cases in which there is a concern about malignancy or when there is glandular disruption.     

Endoscopic approach to pancreatic pseudocysts: An American perspective

Pancreatic pseudocysts, abscesses, and walled-off pancreatic necrosis are types of pancreatic fluid collections that arise as a consequence of pancreatic injury. Pain, early satiety, biliary obstruction, and infection are all indications for drainage. Percutaneous-radiologic drainage, surgical drainage, and endoscopic drainage are the three traditional approaches to the drainage of pancreatic pseudocysts. The endoscopic approach to pancreatic pseudocysts has evolved over the past thirty years and endoscopists are often capable of draining these collections. In experienced centers endoscopic ultrasound-guided endoscopic drainage avoids complications related to percutaneous drainage and is less invasive than surgery.     

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.     

EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses

AIM: To compare the results for endoscopic ultrasound (EUS)-guided drainage of clear fluid pancreatic pseudocysts with the results for abscess drainage. METHODS: All patients referred for endoscopic drainage of a fluid collection were prospectively included. The outcome was recorded. RESULTS: Altogether 26 pseudocysts or abscesses were treated in 25 (6 female) patients. One endoscopist performed the procedures. Non-infected pseudocysts were present in 15 patients and 10 patients had infected fluid collectio...     

Endoscopic ultrasound in clinical practice

Endoscopic ultrasonography (EUS) is an accurate technique for the diagnosis and staging of benign and malignant lesions in the gastrointestinal tract and the mediastinum. EUS overcomes the limitations of other imaging diagnostic methods and gives the possibility to obtain tissue for histologic diagnosis (EUS guided FNA). The most useful indications of EUS are differentiation of submucosal tumors, staging for neoplasia, examination of the pancreato-biliary system and therapeutics. EUS can distinguish extrinsic compressions from intramural lesions and defines their nature (solid, cystic or vascular) and origin. EUS is useful for local staging of esophageal, gastric, duodenal, and rectal cancer using the TNM (tumor, node, metastases) system, as well as for diagnosing and staging of pancreatic lesions. The addition of EUS-guided FNA has improved the ability to detect malignant lymph node invasion. EUS is also highly sensitive for the diagnosis of choledocholithiasis, avoiding unnecessary danger of diagnostic ERCP. New therapeutic indications of EUS include drainage of pancreatic pseudocysts and abscesses and celiac plexus block and neurolysis. EUS has become an indispensable diagnostic method in gastroenterological everyday practice and should be part of most endoscopy units.     

Initial evaluation of a novel prototype forward-viewing US endoscope in transmural drainage of pancreatic pseudocysts (with videos)

BACKGROUND: Transmural endoscopic drainage has become the treatment of first choice for uncomplicated pseudocysts. Drainage is mostly performed with presently available therapeutic oblique-viewing (45 degrees ) US endoscopes. Puncturing at an angle sometimes hampers successful completion of the procedure, because the force that is applied while introducing instruments through the working channel is not fully exerted at the tip of the accessory but instead drives the endoscope away from the gut wall. A prototype forward-viewing US endoscope was developed to overcome this difficulty. OBJECTIVE: Evaluation of an initial experience with a novel prototype forward-viewing US endoscope in endoscopic drainage of pancreatic pseudocysts. DESIGN: Retrospective, observational study. SETTING: Two tertiary-referral centers. PATIENTS: Seven patients were treated. INTERVENTIONS: Endoscopic drainage of pancreatic pseudocyst with a novel forward-viewing US endoscope. MAIN OUTCOME MEASUREMENTS: Successful endoscopic drainage. OBSERVATIONS: In all cases drainage was successfully performed without complications. In 2 cases, the procedure was initially started with a conventional side-viewing EUS scope, but it proved impossible to puncture the pseudocyst. However, with the use of the forward-viewing EUS scope, both pseudocysts were successfully punctured. LIMITATIONS: Small sample size. CONCLUSIONS: Initial clinical experience with this novel prototype forward-view US endoscope for transmural drainage of pancreatic pseudocyst is favorable. It provides better control during puncturing of the cyst wall and creates a possibility to drain collections that are inaccessible with a conventional therapeutic side-viewing US endoscope.     

Endoscopic ultrasound‐guided pancreatic duct drainage

Endoscopic ultrasound (EUS) has evolved from a purely diagnostic procedure to one with therapeutic capabilities. One of the most challenging therapeutic intervention for endosonographers is EUS‐guided pancreatic drainage. The development of this technique has allowed access and drainage of the main pancreatic duct after failed endoscopic retrograde pancreatography and can avoid invasive procedures such as surgical and percutaneous interventions. This review discusses the indications, technique, challenges, and an algorithmic approach to EUS‐guided pancreatic drainage.     

Endoscopic management of pancreatic pseudocysts

Techniques of endoscopic pseudocyst management continue to evolve, but the principles of proper patient selection and careful consideration of the available therapeutic options remain unchanged. Endoscopic management is considered first-line therapy in the treatment of symptomatic pseudocysts. Clinicians should be vigilant in the evaluation of all peripancreatic fluid collections to exclude the presence of a pancreatic cystic neoplasm and avoid draining an immature collection. Expectant management with periodic observation should be considered for the minimally symptomatic patients, even after the traditional 6 weeks of maturation. Further, symptoms, complications, and expansion on serial imaging should prompt intervention by endoscopic, surgical, or percutaneous methods. Pseudocysts should only be punctured when the wall has had sufficient time to mature and after pseudoaneurysm has been ruled out by careful imaging. Small to moderately sized pseudocysts (< 4–6 cm) that communicate with the pancreatic duct are good candidates for endoscopic transpapillary stenting. For larger lesions requiring transmural drainage, EUS guidance is preferable, but good results can be achieved with ENL. EUS may be particularly useful in permitting drainage in patients with suspected perigastric varices or if an endoscopically visible bulge is not apparent. Necrosis is a significant factor for a worse outcome; aggressive debridement with nasocystic or percutaneous endoscopic gastrostomy-cystic catheter lavage plus manual endoscopic techniques for clearing debris should be used. Endoscopic failure, especially in cases with significant necrosis, should be managed operatively. Percutaneous drainage is a good option for immature infected pseudocysts or in patients who are not optimal candidates for other procedures. Close cooperation between endoscopists, surgeons, interventional radiologists, and other healthcare providers is paramount in successfully managing these patients.     

中国胰腺假性囊肿内镜诊治专家共识意见(2022年)

胰腺假性囊肿是急慢性胰腺炎常见并发症,其治疗常需要多学科参与。目前国内存在胰腺假性囊肿治疗理念不统一、干预时机不明确、并发症处理不完善等问题,本共识结合国内外最新循证医学证据,形成包括胰腺假性囊肿定义和分类、影像及内镜诊断、治疗指征等10大类,共30项推荐意见规范胰腺假性囊肿临床诊疗流程,推广以内镜介入治疗为主的综合治疗新技术。     

Endoscopic management of pancreatic pseudocysts and necrosis

Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.     

The role of therapeutic endoscopic ultrasound now and for the future

Therapeutic endoscopic ultrasound (EUS) became possible after the advent of the linear echoendoscope and the EUS guided fine needle aspiration. Over the past two decades, the indications for therapeutic EUS have expanded and evidence regarding its utility has been steadily accumulating. Randomized studies have shown EUS to be effective for cancer pain relief (celiac plexus neurolysis), pancreatic fluid collection drainage, and biliary drainage. Prospective studies have shown EUS-guided biliary drainage to be safe and effective in patients with failed ERCP. There is evidence to suggest that EUS is effective for pancreatic duct drainage, gallbladder drainage, and drainage of pelvic collections. EUS may also be useful for targeted cancer treatment via brachytherapy, radiofrequency ablation, or injection therapy. Therapeutic EUS is likely to play an increasingly important role in endoscopic therapy of gastrointestinal diseases in the near future.     

Endoscopic ultrasound in the evaluation and treatment of chronic pancreatitis.

Endoscopic ultrasound (EUS) was developed in the 1970s specifically for the purpose of improved imaging of the pancreas. The close proximity of the pancreas to the gastric and duodenal lumen allows EUS to obtain high-resolution images, unobstructed by overlying bowel gas. EUS has fewer complications than endoscopic retrograde cholangiopancreatography (ERCP) and can detect features of chronic pancreatitis (CP) in the pancreatic parenchyma and duct that are not visible to any other imaging modality. Because of this high sensitivity, questions have arisen whether EUS is oversensitive, especially to 'early" CP. Without a definitive gold standard against which to measure EUS (or ERCP and function testing), it is currently not possible to know the true accuracy of these modalities for early CP. There is now an extensive body of literature suggesting that these early changes detected by EUS correlate with histologic changes of CP, and may predict response to pancreatic therapy. EUS is uniquely suited to performing endoscopic cyst drainage for pancreatic pseudocysts and for controlling the pain of CP by EUS-directed celiac plexus block. For endoscopic cystenterostomy, EUS allows the endoscopist to localize the cyst, determine if the cyst is drainable, and guide a needle and stent into the cyst in a single step. Several major questions remain. Can EUS features of CP guide other forms of therapy for CP such as enzyme replacement, sphincter of Oddi therapy, and stent therapy? Can the detection of early CP by EUS, and subsequent therapy, delay or prevent the onset of more severe CP? Can EUS detect early forms for dysplasia and malignancy in patients who are at high risk for pancreatic carcinoma? Do changes of "early" CP detected by EUS progress to more classic changes (calicification) over time?     

Interventional endoscopic ultrasonography: current status and future direction

Although first performed more than 20 years ago, endoscopic ultrasonography (EUS) has only recently been used for interventional/therapeutic purposes. The recognition and application of this versatile procedure by gastroenterologists who perform endoscopy has reached an all-time high, and the demand for symposia and tutorials devoted to EUS rivals that of endoscopic retrograde cholangiopancreatography 20 to 25 years ago. EUS has become an established part of the endoscopic armamentarium for many gastroenterologists. Despite its proved clinical utility for staging gastrointestinal (and lung) cancers, and its use in delineating the nature of "submucosal" tumors of the gastrointestinal tract, EUS has continued to evolve. Within the past 10 years, the safety and efficacy of EUS as a means of guiding tissue acquisition via fine-needle aspiration has been demonstrated, increasing its utility in gastrointestinal oncology. Newer indications currently under clinical investigation include the use of EUS as a delivery mechanism for novel immune-based and viral-based "chemo" therapeutic agents for patients with pancreatic cancer. Finally, the role of EUS as a reliable method to guide therapy to control the often refractory abdominal pain in patients with pancreatic cancer and/or chronic pancreatitis is being verified in clinical trials. The following is a brief overview of the current state-of-the-art in interventional EUS.     

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB): past, present, and future

Endoscopic ultrasound (EUS) is a combination of endoscopy and intraluminal ultrasonography. EUS also enables ultrasonographic images of high resolution to be obtained. However, whether a lesion is malignant or benign cannot be diagnosed solely from the findings of EUS. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was developed to enhance the diagnostic capabilities of EUS by providing additional pathological findings. Though more than 10 years have passed since EUS-FNAB was first used for pancreatic disease, EUS FNAB has not been widely accepted in Japan. This may be due to the technical difficulties, relatively low sensitivity for the detection of malignancies, and Japanese gastroenterologists' and surgeons' inherent conservative way of thinking. We describe here a short history of EUS-FNAB, with details of technical tips, current indications and contraindications, diagnostic accuracy, and complications. The clinical utility of EUS-FNAB has been gradually understood and EUS-FNAB procedures have been increasing in number in Japan. So in the near future, EUS followed by EUS-FNAB will be routinely performed in the same manner as gastrointestinal endoscopy, followed by biopsy under direct vision. Also, therapeutic EUS procedures, such as EUS-guided celiac plexus neurolysis, pancreatic tumor ablation, drainage of pancreatic pseudocysts, and the development of an anastomosis may become feasible as less invasive and safer techniques than those used at present.     

Long term outcome of endoscopic drainage of pancreatic pseudocysts

Objective: Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures. Methods: All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates. Results: Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (>1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%. Conclusion: Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of <1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.