Endoscopic ultrasonography-guided drainage combined with trans-duodenoscope cyclic irrigation technique for walled-off pancreatic necrosis

BackgroundEndoscopic ultrasonography-guided drainage has been established as a good treatment modality in the management of walled-off pancreatic necrosis, but the unmanageable infection of postoperation is still a thorny problem due to the poor drainage ability for solid necrotic debris only through transmural stent and nasocystic catheter.AimsIntroduce a novel therapeutic method, namely endoscopic ultrasonography-guided drainage combined with cyclic irrigation technique in managing patients with walled-off pancreatic necrosis.Methods18 patients with severe acute pancreatitis complicated with walled-off pancreatic necrosis received treatment with endoscopic ultrasonography-guided drainage combined with cyclic irrigation were involved in this retrospective study.Results17 of 18 patients with walled-off pancreatic necrosis were treated by this new therapeutic method. Subsequent surgery was performed in 1 case due to uncontrolled infection, complications such as perforation, bleeding or multiple organ failure were not observed. Treatment success rate was high (16 in 17, 94.12%).ConclusionEndoscopic ultrasonography-guided drainage combined with cyclic irrigation is an effective treatment option for symptomatic walled-off pancreatic necrosis to facilitate drainage and obviate the need for subsequent surgery or endoscopic necrosectomy.     

Transgastric pancreatography and EUS-guided drainage of the pancreatic duct

Background/Purpose

Endoscopic transpapillary drainage of the retained pancreatic duct in symptomatic patients with chronic pancreatitis is considered an established treatment option. The aim of this study was to investigate, as an alternative, endoscopic ultrasound (EUS)-guided transgastric pancreatography and drainage of the pancreatic duct, in terms of their feasibility and outcome.

Methods

All consecutive symptomatic patients with failure of the traditional approach to catheterize and drain the pancreatic duct, over a 3-year time period, were enrolled in this prospective, observational single-center study (case series). Feasibility was characterized by success rate, outcome by complication rate (frequency of bleeding or perforation), mortality, and follow-up.

Results

Twelve patients underwent 14 interventions (sex ratio, M/F, 10?:?4; age range, 43–77 years) from November 2002 to October 2005. The main indication was retention of the pancreatic duct associated with pain, in particular: (i) papilla not reachable because of prior gastrointestinal surgery (n = 5); and (ii) not possible to introduce the catheter through the papilla in chronic pancreatitis or “pancreas divisum” (n = 7). Pancreatography was successful in all patients (normal finding with no therapeutic consequence, n = 1 [after pancreaticojejunostomy]), whereas drainage of the pancreatic duct was achieved in 9 patients (69%; attempts, n = 13). The transgastric route was used in 5 patients and the transpapillary route (rendezvous technique with endoscopic retrograde cholangiopancreatography [ERCP]) in 4. There was a complication rate of 42.9%, comprising postinterventional pain (n = 4; 28.6%); bleeding (n = 1); and perforation because of retriever problems (n = 1). The postinterventional pancreatitis rate was 0% and mortality was 0%. The follow-up investigation (range, 4 weeks ? 3 years) revealed that 4 patients (28.6%) subsequently underwent surgical intervention, because of duodenal stenosis (n = 1; 7.1%), suspicious tumor growth (n = 1; 7.1%), and insufficient drainage of the pancreatic duct (n = 2; 14.3%). In 2 subjects (14.3%), endoscopic reinterventions became necessary, which were subsequently successful. There were the following technical problems: 1) Too dense stenosis (n = 3); 2) inadequate equipment (insufficient infeed of the endoscopic tool because of its bending), in each case.

Conclusions

Transgastric pancreatography and EUS-guided drainage of the pancreatic duct are reasonable and feasible alternative options for diagnostic and therapeutic management for selected indications (chronic pancreatitis; anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy), with an acceptable periinterventional risk, which broaden the therapeutic spectrum and may avoid surgery but need further evaluation and follow-up investigation.

     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose

Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated.

Methods

After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct.

Results

ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far.

Conclusions

ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

Early and long-term clinical outcomes of endoscopic interventions for benign pancreatic duct stricture/obstruction-the possibility of additional clinical effects of endoscopic ultrasonography-guided pancreatic drainage-

ObjectivesFor benign pancreatic duct strictures/obstructions (BPDS/O), endoscopic ultrasonography-guided pancreatic drainage (EUS-PD) is performed when endoscopic transpapillary pancreatic drainage (ETPD) fails. We clarified the clinical outcomes for patients with BPDS/O who underwent endoscopic interventions through the era where EUS-PD was available.MethodsForty-five patients with BPDS/O who underwent ETPD/EUS-PD were included. We retrospectively investigated overall technical and clinical success rates for endoscopic interventions, adverse events, and clinical outcomes after successful endoscopic interventions.ResultsThe technical success rates for ETPD and EUS-PD were 77% (35/45) and 80% (8/10), respectively, and the overall technical success rate using two drainage procedures was 91% (41/45). Among the 41 patients who underwent successful endoscopic procedures, the clinical success rates were 97% for the symptomatic patients (35/36). The rates of procedure-related pancreatitis after ETPD and EUS-PD were 13% and 30%, respectively. After successful endoscopic interventions, the cumulative 3-year rate of developing recurrent symptoms/pancreatitis was calculated to be 27%, and only two patients finally needed surgery. Continuous smoking after endoscopic interventions was shown to be a risk factor for developing recurrent symptoms/pancreatitis.ConclusionsBy adding EUS-PD to ETPD, the technical success rate for endoscopic interventions for BPDS/O was more than 90%, and the clinical success rate was nearly 100%. Due to the low rate of surgery after endoscopic interventions, including EUS-PD, for patients with BPDS/O, EUS-PD may contribute to their good clinical courses as a salvage treatment for refractory BPDS/O.     

Prospective randomized pilot trial comparing closed suction drainage and gravity drainage of the pancreatic duct in pancreaticojejunostomy

Background

Pancreaticojejunal anastomotic leakage remains a major complication after pancreatoduodenectomy, and various means of preventing pancreatic leakage have been studied over the past few decades. The purpose of this study was to determine whether closed suction drainage provided a better option than gravity drainage in pancreaticojejunostomy.

Methods

Between 2004 and 2006, a total of 110 patients who underwent pancreaticojejunostomy at our institute were enrolled in this prospective randomized pilot study. Fifty-five patients were allocated to the closed suction drainage (CD) group and 55 to the gravity drainage (GD) group. In each patient a polyethylene pediatric feeding tube was inserted into the remnant pancreatic duct across a duct-to-mucosa type pancreaticojejunostomy and totally externalized. The tube was then connected to the aspiration bag of a Jackson–Pratt drain to generate negative pressure or to a bile bag for natural drainage. Pancreatic fistulas were defined and graded as A, B, or C according to the international study group for pancreatic fistulas (ISGPF) criteria.

Results

No differences were found between the GD and CD groups in age, sex distribution, or diagnosis. A pancreatic fistula occurred in 24 patients (43.6%) in the GD group and in 14 (25.5%) in the CD group (P = 0.045). In the GD group, grade B and C fistula occurred in 6 patients (10.9%), whereas in the CD group, this occurred in 5 patients (9.1%).

Conclusion

In this study, temporary external drainage of the pancreatic duct with closed suction drainage significantly reduced the incidence of grade A pancreatic fistula. A follow-up randomized prospective multicenter study has been initiated.     

Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction

AIM: To determine the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) with a fully covered self-expandable metal stent for managing malignant biliary stricture.METHODS: We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered self-expandable metal stent when endoscopic retrograde cholangiopancreatography (ERCP) fails. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HG) was performed in 9 patients and 4 patients, respectively.RESULTS: The technical and functional success rate was 92.3% (12/13) and 91.7% (11/12), respectively. Using an intrahepatic approach (EUS-HG, n = 4), there was mild peritonitis (n = 1) and migration of the metal stent to the stomach (n = 1). With an extrahepatic approach (EUS-CD, n = 10), there was pneumoperitoneum (n = 2), migration (n = 2), and mild peritonitis (n = 1). All patients were managed conservatively with antibiotics. During follow-up (range, 1-12 mo), there was re-intervention (4/13 cases, 30.7%) necessitated by stent migration (n = 2) and stent occlusion (n = 2).CONCLUSION: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.     

Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography-guided fine-needle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) can now provide a cytopathological diagnosis of underlying pancreatic malignancy with higher success rates than endoscopic retrograde pancreatography (ERP). To determine the significance of EUS-FNA for the diagnosis of pancreatic mass without biliary stricture, the value of cytopathological diagnosis obtained by EUS-FNA was retrospectively compared with that by ERP, and the complications associated with these procedures evaluated. METHODS: Eighty-three patients who were suspected to have a pancreatic mass (excluding a cystic mass), without biliary stricture on conventional ultrasound and/or computed tomography were enrolled. The EUS-FNA biopsy was performed in 53 patients and cytology utilizing ERP was performed in 30 patients. RESULTS: The sampling rate of adequate specimen was 100% in both groups. In the EUS-FNA group, the overall results for the available samples were sensitivity 92.9% and accuracy 94.3%. In contrast, in the ERCP group, the overall results were sensitivity 33.3% and accuracy 46.7%. There was a significant difference between the two groups (P < 0.01). With regard to complications, there was a significant difference (P < 0.01) in the frequency of post-procedure pancreatitis between the EUS-FNA group and ERP group (0%, 0/53 vs 33.3%, 10/30, respectively). CONCLUSION: Endoscopic ultrasonography-guided fine-needle aspiration is safer and more accurate for the cytopathological diagnosis of suspected pancreatic masses without a biliary stricture as compared with cytology during ERP. Endoscopic ultrasonography with FNA should be considered a preferred test (prior to attempting endoscopic retrograde cholangiopancreatography) when a cytological diagnosis of a pancreatic mass is required, especially when there is no biliary obstruction, or when emergent decompression of an obstructed biliary tree is not considered clinically necessary due to lack of signs and symptoms of cholangitis.     

Intraductal papillary mucinous neoplasm of the pancreas with a bifid pancreatic duct

A bifid pancreatic duct presenting a major bifurcation in the main pancreatic duct is one of the anatomical variations of the pancreatic ducts. We encountered a 71-year-old female with a 5-cm-diameter branch duct intraductal papillary mucinous neoplasm of the pancreas in whom preoperative endoscopic retrograde pancreatography demonstrated an anomalous bifurcation of the main pancreatic duct at the body of the pancreas. We performed a distal pancreatectomy, instead of a middle pancreatectomy, with a cutting line at the downstream pancreas to the duct bifurcation point. Intraoperative ultrasonography was useful to confirm the exact location of the pancreatic duct bifurcation as well as the tumor extension. The procedure resulted in a favorable outcome without any postoperative complications. Although a bifid pancreatic duct is an unusual anomalous condition, this case should alert surgeons to be aware of such anatomical variants when performing pancreatic resection, otherwise, incurable pancreatic complications may occur postoperatively.     

Endoscopic ultrasonography‐guided pancreatic duct access: Techniques and literature review of pancreatography,transmural drainage and rendezvous techniques

Endoscopic ultrasonography‐guided (EUS)‐guided pancreatic interventions have gained increasing attention. Here we review EUS‐guided pancreatic duct (PD) access techniques and outcomes. EUS‐guided PD intervention is divided into two types, antegrade and rendezvous techniques, following EUS‐guided pancreatography. In the antegrade technique, pancreaticoenterostomy is carried out by stent placement between the PD and the stomach, duodenum, or jejunum. Transenteric antegrade PD stenting is conducted by stent placement, advancing anteriorly into the PD through the pancreatic tract. The rendezvous technique is carried out by using a guidewire through the papilla or anastomotic site for retrograde stent insertion. In terms of EUS‐guided PD stenting, 11 case reports totaling 75 patients (35 normal anatomy, 40 altered anatomy) have been published. The technical success rate was greater than 70%. Early adverse events, including severe hematoma and severe pancreatitis,occurred in seven (63.6%) of 11 reports. Regarding the rendezvous technique, 12 case reports totaling 52 patients (22 normal anatomy, 30 altered anatomy) have been published. The technical success rate ranged from 25% to 100%. It was 48% in one report that involved more than 20 cases. Once stents were placed, all patients became free of symptoms. Early mild adverse events occurred in four (36.4%) of 11 reports. In conclusion, although it can be risky because of possible serious or even fatal adverse events, including pancreatic juice leakage, perforation and severe acute pancreatitis, EUS‐PD access seems to be promising for treating symptomatic pancreatic diseases caused by PD stricture and pancreaticoenterostomy stricture.     

Endoscopic biliary drainage for patients with unresectable pancreatic cancer with obstructive jaundice who are to undergo gemcitabine chemotherapy

INTRODUCTION Pancreatic cancer is one of the most intractable mali- gnancies of the digestive tract and has a dismal prognosis. Such cancer in most patients is in an advanced stage when they first visit medical facilities, and management of obstructive ja…     

Efficacy of s-type stents for the treatment of the main pancreatic duct stricture in patients with chronic pancreatitis

Objective. Stents have been used to relieve pancreatic duct stricture and upstream dilatation. However, many of these stents are straight-type stents originally manufactured for biliary use. A plastic stent that was developed for use in the pancreatic duct was used in this study and its usefulness investigated.

Material and methods. The stent (s-type stent: 10?Fr in diameter) has two alternate flexions and the shape resembles the tilde mark “～” in appearance. After obtaining informed consent, stents were placed in 20 patients with abdominal pain caused by chronic pancreatitis and stricture of the distal main pancreatic duct. The stents were removed according to the clinical manifestations and replaced with new ones if the stricture persisted.

Results. In total, 33 stents were placed in 20 patients. Pain relief was attained in 19 patients (95%). The stricture improved after one stenting in 8 patients (40%). Owing to persistent stricture, the stenting was repeated in 11 patients. The 50% stent indwelling period was 369.0 days. No proximal or distal migration of the stent occurred and there were no serious complications.

Conclusions. In view of its long durability as a stent and no migration, the s-stent is safe and useful for the management of pancreatic ductal strictures in patients with chronic pancreatitis.     

Biliary drainage of the common bile duct with an enteral metal stent

In this case report we present an elderly patient who was referred to our hospital with recurrent episodes of cholangitis that persisted after placement of five metal stents for a distal common bile duct （CBD） stenosis.All metal stents were endoscopically removed from the CBD by forceps after balloon dilatation of the papilla. A profoundly dilated CBD with sludge and concrements was seen. To ensure adequate bile drainage an enteral metal stent was inserted in the CBD. This case shows that proximally migrated uncovered metal stents in the CBD can be safely removed endoscopically under certain circumstances. We suggest that in the case of a CBD drainage problem due to an extremely dilated CBD, placement of an enteral metal stent in the CBD could be considered, especially in patients who are unfit for surgery.     

Endoscopic ultrasound‐guided gallbladder drainage for the management of acute cholecystitis (with video)

Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) has been introduced as an alternative to percutaneous transhepatic gallbladder drainage for the treatment of acute cholecystitis in non‐surgical candidates. A systematic review of the English language literature through PubMed search until June 2014 was conducted. One hundred and fifty‐five patients with acute cholecystitis treated with EUS‐GBD in eight studies and 12 case reports, and two patients with EUS‐GBD for other causes were identified. Overall, technical success was obtained in 153 patients (97.45%) and clinical success in 150 (99.34%) patients with acute cholecystitis. Adverse events developed in less than 8% of patients, all of them managed conservatively. EUS‐GBD has been performed with plastic stents, nasobiliary drainage tubes, standard or modified tubular self‐expandable metal stents (SEMS) and lumen‐apposing metal stents (LAMS) by different authors with apparently similar outcomes. No comparison studies between stent types for EUS‐GBD have been reported. EUS‐GBD is a promising novel alternative intervention for the treatment of acute cholecystitis in high surgical risk patients. Feasibility, safety and efficacy in published studies from expert centers are very high compared to currently available alternatives. Further studies are needed to establish the safety and long‐term outcomes of this procedure in other practice settings before EUS‐GBD can be widely disseminated.     

Endoscopic ultrasonography-guided gallbladder drainage: actual technical presentations and review of the literature (with videos)

Background/purpose

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has been developed as an alternative drainage method in patients with acute cholangitis. Here, we describe two successful EUS-GBD cases and review the literature on this topic.

Methods

EUS-GBD was conducted using a curved linear array echoendoscope and a 19-gauge needle.

Results

A 7-Fr double pigtail stent was successfully placed transgastrically in one patient and transduodenally in the other patient, without any serious early adverse events in either patient. No late complications or relapse of acute cholecystitis have been seen during the 3- to 6-month follow-up period.

Conclusions

EUS-GBD holds high potential as an alternative gallbladder decompression procedure. However, because current experience is limited, multicenter trials for the accurate evaluation of this procedure appear to be necessary in the near future.     

Efficacy of endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle aspiration for the diagnosis and grading of pancreatic neuroendocrine tumors

Background and aim: Pancreatic neuroendocrine tumors (pNETs) are histologically categorized according to the WHO 2010 classification by their mitotic index or Ki-67 index as G1, G2, or G3. The present study examined the efficacy of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis and grading of pNET. Methods: We retrospectively reviewed 61 pNETs in 51 patients who underwent EUS between January 2007 and June 2014. All lesions were pathologically diagnosed by surgical resection or EUS-FNA. We evaluated the detection rates of EUS for pNET and sensitivity of EUS-FNA, and compared the Ki-67 index between EUS-FNA samples and surgical specimens. EUS findings were compared between G1 and G2/G3 tumors. Results: EUS showed significantly higher sensitivity (96.7%) for identifying pNET than CT (85.2%), MRI (70.2%), and ultrasonography (75.5%). The sensitivity of EUS-FNA for the diagnosis of pNET was 89.2%. The concordance rate of WHO classification between EUS-FNA and surgical specimens was 69.2% (9/13). The concordance rate was relatively high (87.5%, 5/6) in tumors?<20?mm but lower (57.1%; 4/7) in tumors?≥20?mm. Regarding EUS findings, G2/G3 tumors were more likely to be large (>20?mm), heterogeneous, and have main pancreatic duct (MPD) obstruction than G1 tumors. Multivariate analysis showed large diameter and MPD obstruction were significantly associated with G2/G3 tumors. Conclusions: EUS and EUS-FNA are highly sensitive and accurate diagnostic methods for pNET. Characteristic EUS findings such as large tumor size and MPD obstruction are suggestive of G2/G3 tumors and would be helpful for grading pNETs.     

Endoscopic manometry of the sphincter of Oddi and pancreatic duct in patients with chronic pancreatitis

Summary Conclusion Endoscopic manometry in patients with chronic pancreatitis has demonstrated some manometric abnormalities in the sphincter of Oddi, but these abnormalities have no significant role in the pathogenesis of chronic pancreatitis. Background The study was undertaken to determine whether the sphincter of Oddi dysfunction plays a significant role in the pathogenesis of chronic pancreatitis. Methods Manometric investigation was performed in 32 patients with chronic pancreatitis. Twenty-three of them had alcohol-induced chronic pancreatitis, seven had biliary pancreatitis, and two patients had annular pancreas with chronic pancreatitis. Fifteen of them had dilated main pancreatic duct. Twenty-one cholecystectomized patients with no abnormality of the pancreas and biliary system served as controls. Results This study showed no significant difference in the mean pressures in the pancreatic duct, sphincter of Oddi (basal and phasic), and frequency of the sphincter of Oddi phasic contractions when comparing patients and controls. Sphincter of Oddi basal pressure (26–44 mmHg) was markedly increased in seven patients, whereas three patients (two of them had increased sphincter of Oddi basal pressure) had increased pancreatic duct pressure (20–24 mmHg). Increased numbers of retrograde contractions were found in seven patients.     

经皮置管负压冲洗联合内镜引流治疗重症急性胰腺炎合并胰腺坏死组织感染

目的 观察经皮置管负压冲洗联合内镜引流(PCD+ NPI+ ED)治疗重症急性胰腺炎(SAP)合并胰腺坏死组织感染(IPN)的临床效果.方法 回顾2011年7月至2012年7月经PCD+ NPI+ED联合技术治疗的17例合并IPN的SAP患者的临床资料,分析临床治疗过程及预后.结果 17例患者IPN确诊距发病时间为(26.9 ±7.9)d.13例革兰阴性菌感染,3例革兰阳性菌感染,1例侵袭性真菌感染.首次PCD+ NPI治疗距发病时间为(34.8±11.6)d.B超引导下置管1例,CT引导下置管8例,B超和CT联合引导下置管8例,每例患者平均所置负压冲洗引流管为(3.5±1.2)根.首次ED治疗距首次PCD+ NPI时间为(26.7 ±9.6)d,每例患者平均ED治疗(2.1 ±0.9)次.2例中转剖腹手术引流,距确诊IPN时间分别为24d和56 d.17例患者均无PCD+ NPI置管相关并发症发生,第1例患者在ED治疗过程中发生出血,ED治疗后2例并发十二指肠瘘,1例并发高位空肠瘘,1例并发降结肠瘘,2例腹腔出血.无新发脏器功能障碍和脓毒血症.1例在PCD+ NPI+ ED联合治疗前即并发多器官功能不全和脓毒血症,虽中转剖腹手术引流仍无法有效控制脓毒血症而病死.结论 PCD+ NPI+ ED联合技术可使IPN患者避免剖腹手术引流,减少并发症发生,改善患者预后.     

内镜胆道内支架引流治疗伴肝脏转移的胰头癌16例

目的:评价伴肝脏转移的胰头癌患者内镜胆道内支架引流治疗的临床意义.方法:门诊就诊和转院的胰头癌伴有肝脏转移患者,如具有严重的梗阻性黄疸则符合内镜逆行胆胰管造影救治指征,然后按照知情同意的原则进入治疗研究计划.均应用内镜胆道内支架引流技术,包括金属内支架和塑料支架.治疗出院后随访观察至患者死亡.结果:16例患者进入治疗研究,其中伴有腹膜后淋巴结转移5例.均采用内镜胆道支架引流术,其中应用胆道金属支架12例,胆道塑料支架4例,胰管内支架6例.治疗后1 wk时梗阻性黄疸缓解率100%,精神状况明显好转75.0%(12/16),食欲改善25.0%(4/16),睡眠改善37.5%(6/16).治疗后的患者最短生存期为9d,最长生存期为134 d,平均81.4 d±50.2 d.随访数据表明治疗有意义的97%,治疗效果满意的11例.结论:对于伴有肝脏转移的胰头癌患者,内镜胆道内支架引流技术不仅能解除梗阻性黄疸,而且可以一定程度的改善生存质量,具有一定的临床应用价值.