The Role of EUS-Guided Drainage in the Management of Postoperative Fluid Collections after Pancreatobiliary Surgery

Postoperative fluid collection (POFC) is a challenging complication following pancreatobiliary surgery. Traditional treatment with surgical drainage is associated with significant morbidity, while percutaneous drainage is associated with a higher rate of recurrence and the need for repeated interventions. Studies have shown that endoscopic ultrasound (EUS)-guided drainage may offer a promising solution to this problem. There are limited data on the ideal therapeutic protocol for EUS-guided drainage of POFC including the timing for drainage; type, size, and number of stents to use; and the need for endoscopic debridement and irrigation. Current practices extrapolated from the treatment of pancreatic pseudocysts and walled-off necrosis may not be applicable to POFC. There are increasing data to suggest that drainage procedures may be performed within two weeks after surgery. While most authors advocate the use of double pigtail plastic stents (DPPSs), there have been a number of reports on the use of novel lumen-apposing metal stents (LAMSs), although no direct comparisons have been made between the two.

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628 Lumen Apposing Metal Stents Compared With Double Pigtail Plastic Stents in the Management of Pancreatic Pseudocysts and Walled-Off Necrosis: A 5 Year Single Center Study

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2017.03.129 ◽

2017 ◽

Vol 85 (5) ◽

pp. AB90 ◽

Cited By ~ 1

Author(s):

Bryan B. Brimhall ◽

Samuel Han ◽

Philip D. Tatman ◽

Brian C. Brauer ◽

Sachin B. Wani ◽

...

Keyword(s):

Plastic Stents ◽

Pancreatic Pseudocysts ◽

Metal Stents ◽

Single Center ◽

Single Center Study ◽

Walled Off Necrosis ◽

Center Study

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Endoscopic ultrasound-guided placement of plastic pigtail stents for the drainage of refractory malignant ascites

Endoscopy International Open ◽

10.1055/s-0043-118746 ◽

2017 ◽

Vol 05 (11) ◽

pp. E1096-E1099 ◽

Cited By ~ 1

Author(s):

Rafael Romero-Castro ◽

Victoria Jimenez-Garcia ◽

Jaime Boceta-Osuna ◽

Luis Castilla-Guerra ◽

Francisco Pellicer-Bautista ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Poor Prognosis ◽

Malignant Ascites ◽

Refractory Ascites ◽

Plastic Stents ◽

Pancreatic Pseudocysts ◽

Metal Stents ◽

Ultrasound Guided ◽

Walled Off Necrosis

AbstractEndoscopic ultrasound (EUS)-guided drainage is now the treatment of choice in cases of pancreatic pseudocysts and walled-off necrosis, especially in the absence of luminal bulging and in patients with portal hypertension. Malignant refractory ascites usually heralds a poor prognosis and substantially impairs the quality of life of patients because of the symptoms experienced and the need for repeated paracentesis. EUS-guided placement of lumen-apposing, fully covered, self-expandable metal stents (FCSEMS) has been reported for the drainage of malignant ascites. Herein, we present the results of EUS-guided placement of plastic pigtails stents for the drainage of refractory malignant ascites in three patients. The aim was to improve symptoms and minimize the possible drawbacks of large-caliber FCSEMS. In this preliminary experience, EUS-guided placement of plastic stents was feasible and avoided further paracentesis.

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Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections

Endoscopic Ultrasound ◽

10.4103/eus.eus_7_19 ◽

2019 ◽

Vol 8 (2) ◽

pp. 82 ◽

Cited By ~ 9

Author(s):

DouglasG Adler ◽

BabuP Mohan ◽

Mahendran Jayaraj ◽

Ravishankar Asokkumar ◽

Mohammed Shakhatreh ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Plastic Stents ◽

Metal Stents ◽

Pancreatic Fluid Collections ◽

Pancreatic Fluid ◽

Fluid Collections ◽

Walled Off Necrosis ◽

Better Than

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Comparative Randomized Multicenter Study Of Plastic Vs. Self-expanding Metal Stents In The Endoscopic Ultrasound-guided Drainage Of Walled-off Pancreatic Necrosis

10.21203/rs.2.16362/v1 ◽

2019 ◽

Author(s):

joan b gornals ◽

Manuel Perez-Miranda ◽

Enrique Vazquez-Sequeiros ◽

Juan Vila ◽

Jose M Esteban ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Clinical Success ◽

Fluid Collection ◽

Plastic Stents ◽

Metal Stents ◽

Controlled Clinical Trial ◽

Pancreatic Fluid Collection ◽

Pancreatic Fluid ◽

Tertiary Hospitals ◽

Walled Off Necrosis

Abstract Background: It seems that the appearance of lumen-apposing metal stents (LAMS), are displacing the role of plastic stents in the therapy of pancreatic fluid collection as walled-off necrosis (WON). To date there is no quality of evidence to recommend LAMS as the standard treatment in management of WON. The theoretical benefit of LAMS over PLASTIC stents, need to be proved.Methods/design: This is a multicenter prospective study, superiority, randomized controlled clinical trial by parallel groups, without masking. One hundred fourteen patients with WON will be Endoscopic ultrasound (EUS)-guided transmural drained in 9 tertiary hospitals in Spain and will be randomized to the LAMS or PLASTIC stent group. The primary endpoint is to assess the short-term (4 weeks) clinical success determined by the reduction of the collection (to <50% or < 5cm in size), along with clinical improvement. Secondary endpoints: the long-term (4 months) clinical success (total resolution or 5cm); the procedure’s duration, the level of difficulty, safety and recurrences.Discussion: The PROMETHEUS trial has been designed to response if LAMS are superior over PLASTIC stents in the EUS-guided transmural drainage of WON. Trial registration: ClinicalTrials.gov, NCT03100578. Registered on April 4, 2017. https://clinicaltrials.gov/ct2/home

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Multicenter study of plastic vs. self-expanding metal stents in endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis – PROMETHEUS: a randomized controlled trial protocol

Trials ◽

10.1186/s13063-019-3988-x ◽

2019 ◽

Vol 20 (1) ◽

Author(s):

Joan B. Gornals ◽

◽

Manuel Perez-Miranda ◽

Enrique Vazquez-Sequeiros ◽

Juan Vila ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Clinical Success ◽

Controlled Trial ◽

Fluid Collection ◽

Plastic Stents ◽

Metal Stents ◽

Pancreatic Fluid Collection ◽

Randomized Controlled ◽

Link Type ◽

Walled Off Necrosis

Abstract Background It seems that lumen-apposing metal stents (LAMS) are displacing plastic stents in the therapy of pancreatic-fluid collection in walled-off necrosis (WON). To date, there is no quality of evidence to recommend LAMS as the standard treatment in the management of WON. The theoretical benefit of LAMS over plastic stents needs to be proven. Methods/design This is a randomized controlled, multicenter, prospective clinical trial with two parallel groups, without masking. One-hundred and fourteen patients with WON will undergo endoscopic ultrasound (EUS)-guided transmural draining in nine tertiary hospitals in Spain and will be randomized to the LAMS or plastic-stent group. The primary endpoint is the short-term (4 weeks) clinical success determined by the reduction of the collection (to < 50% or < 5 cm in size), along with clinical improvement. Secondary endpoints: long-term (4 months) clinical success (total resolution or 5 cm), procedure duration, level of difficulty, safety, and recurrences. Discussion The PROMETHEUS trial has been designed to determine whether LAMS are superior to plastic stents in EUS-guided transmural drainage of WON. Trial registration ClinicalTrials.gov, ID: NCT03100578. Registered on 4 April 2017. https://clinicaltrials.gov/ct2/home

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Plastic stents are more cost-effective than lumen-apposing metal stents in management of pancreatic pseudocysts

Endoscopy International Open ◽

10.1055/a-0611-5082 ◽

2018 ◽

Vol 06 (07) ◽

pp. E780-E788 ◽

Cited By ~ 8

Author(s):

Yen-I Chen ◽

Mouen Khashab ◽

Viviane Adam ◽

Ge Bai ◽

Vikesh Singh ◽

...

Keyword(s):

Cost Effective ◽

Sensitivity Analyses ◽

Plastic Stents ◽

Pancreatic Pseudocysts ◽

Metal Stents ◽

Endoscopic Drainage ◽

Success Rates ◽

Initial Management ◽

Pancreatic Fluid ◽

Fluid Collections

Abstract Background and study aims Endoscopic ultrasound-guided drainage is an effective and accepted primary modality for management of pancreatic pseudocyst (PP). A lumen-apposing metal stent (LAMS) has recently been developed specifically for drainage of pancreatic fluid collections which may be superior to using traditional plastic stents (PS) but is more expensive. Because use of a stent involves a risk of unplanned endoscopy, percutaneous drainage (PCD) and surgery, their costs should also be included in the comparison and a cost-effectiveness analysis of LAMS and PS should therefore be performed Patients and methods A decision tree was developed assessing both endoscopic drainage strategies for patients with PP: LAMS and PS over a 6-month time horizon. For each strategy, inpatients received a stent and were followed for subsequent need for direct further interventions or adverse events leading to unplanned endoscopy, PCD, surgery, or successful endoscopic drainage using probabilities obtained from the literature. The unit of effectiveness was successful endoscopic drainage without need for PCD or surgery. Sensitivity analyses were performed. Results Success rates were 93.9 % for LAMS and 96.96 % for PS. Respective costs per successful drainage were US $ 18,129 (LAMS) and US $ 10,403 (PS). The LAMS strategy was thus characterized as dominated by the PS approach because it was costlier and less effective than PS. Both deterministic and probabilistic sensitivity analyses confirmed the robustness of these findings. Conclusion Use of LAMS is not less effective and more costly than PS in management of patients with PP. As such, PS should be preferred over LAMS as initial management of these patients.

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Comparative outcomes of endoscopic ultrasound–guided cystogastrostomy for peripancreatic fluid collections: a systematic review and meta-analysis

Therapeutic Advances in Gastrointestinal Endoscopy ◽

10.1177/2631774519843400 ◽

2019 ◽

Vol 12 ◽

pp. 263177451984340 ◽

Cited By ~ 1

Author(s):

Benjamin D. Renelus ◽

Daniel S. Jamorabo ◽

Hashroop K. Gurm ◽

Niel Dave ◽

William M. Briggs ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Pancreatic Necrosis ◽

Meta Analysis ◽

Fluid Collection ◽

Plastic Stents ◽

Pancreatic Pseudocysts ◽

Technical Success ◽

Ultrasound Guided ◽

Technical Success Rate ◽

Fluid Collections

Background: Endoscopic ultrasound–guided cystogastrostomy has become the first-line treatment for symptomatic peripancreatic fluid collections. The aim of this study is to analyze the efficacy and safety of cystogastrostomy via a meta-analysis of the literature. Methods: We performed a systematic search of PubMed and Medline databases for studies published from January 2005 to May 2018. We included randomized controlled trials along with retrospective and prospective observational studies reporting endoscopic ultrasound–guided cystogastrostomy stent placement for peripancreatic fluid collections. The primary outcome for our meta-analysis was complete peripancreatic fluid collection resolution on imaging. Our secondary outcomes included comparative efficacy and safety of the procedure for pseudocysts and walled-off pancreatic necrosis using metal and plastic stents. Results: Seventeen articles involving 1708 patients met our inclusion criteria for meta-analysis. Based upon the random effects model, the pooled technical success rate of cystogastrostomy was 88% (95% confidence interval = 83–92 with I2 = 85%). There was no difference in the technical success rate between pancreatic pseudocysts and walled-off pancreatic necrosis (91% and 86%, respectively p = nonsignificant). The adverse event rates for metal and plastic stents were equivalent (14% and 18%, respectively, p = nonsignificant). Conclusion: Endoscopic ultrasound–guided cystogastrostomy stents are effective in the treatment of pancreatic pseudocysts and walled-off pancreatic necrosis. We found no difference in technical success or adverse event rates of drainage based on peripancreatic fluid collection type or stent used.

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Multicenter Study Of Plastic Vs. Self-expanding Metal Stents In Endoscopic Ultrasound-drainage Of Walled-off Pancreatic Necrosis – Prometheus: A Randomised Controlled Trial Protocol

10.21203/rs.2.16362/v2 ◽

2019 ◽

Author(s):

joan b gornals ◽

Manuel Perez-Miranda ◽

Enrique Vazquez-Sequeiros ◽

Juan Vila ◽

Jose M Esteban ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Clinical Success ◽

Controlled Trial ◽

Fluid Collection ◽

Plastic Stents ◽

Metal Stents ◽

Controlled Clinical Trial ◽

Pancreatic Fluid Collection ◽

Randomised Controlled ◽

Walled Off Necrosis

Abstract Background: It seems that the appearance of lumen-apposing metal stents (LAMS), are displacing the role of plastic stents in the therapy of pancreatic fluid collection as walled-off necrosis (WON). To date there is no quality of evidence to recommend LAMS as the standard treatment in management of WON. The theoretical benefit of LAMS over PLASTIC stents, need to be proved. Methods/design: This is a multicenter prospective study, superiority, randomized controlled clinical trial by parallel groups, without masking. One hundred fourteen patients with WON will be Endoscopic ultrasound (EUS)-guided transmural drained in 9 tertiary hospitals in Spain and will be randomized to the LAMS or PLASTIC stent group. The primary endpoint is to assess the short-term (4 weeks) clinical success determined by the reduction of the collection (to <50% or < 5cm in size), along with clinical improvement. Secondary endpoints: the long-term (4 months) clinical success (total resolution or 5cm); the procedure’s duration, the level of difficulty, safety and recurrences. Discussion: The PROMETHEUS trial has been designed to response if LAMS are superior over PLASTIC stents in the EUS-guided transmural drainage of WON. Trial registration: ClinicalTrials.gov, NCT03100578. Registered on April 4, 2017. https://clinicaltrials.gov/ct2/home

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Use of Lumen-Apposing Stents for the Treatment of Postsurgical Fluid Collections: A Case Series and a Review of Literature

Case Reports in Gastrointestinal Medicine ◽

10.1155/2019/7656950 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

Priyanka Priyanka ◽

William Hsueh ◽

John Nasr

Keyword(s):

Motor Vehicle ◽

Motor Vehicle Accident ◽

Fluid Collection ◽

Case Series ◽

Plastic Stents ◽

Metal Stents ◽

Pancreatic Fluid Collection ◽

Pancreatic Fluid ◽

Whipple’S Procedure ◽

Fluid Collections

Lumen-apposing metal stents (LAMS) use in gastrointestinal endoscopy has been on the rise for various indications for the last few years. Currently, LAMS is a well-established treatment for post-pancreatitis peri-pancreatic fluid collections and walled-off necrosis (WON), but it is still not a standard of care in the treatment of post-surgical fluid collections (PSFC). Most of the earlier studies for treatment of PSFC utilized double pigtail plastic stents (DPS). We present a series of 3 cases where LAMS was successfully used for PSFC drainage. The cases include a patient with perigastric abscess after Whipple’s procedure, a case of peri-pancreatic collection after distal pancreatectomy, and a patient with peri-pancreatic fluid collection after right partial hepatectomy and splenectomy due to lacerations from a motor vehicle accident.

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