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Ang TL, Kwek AB, Tan SS, Ibrahim S, Fock KM, Teo EK
Correspondence: Adj A/Prof Ang Tiing Leong, tiing_leong_ang@cgh.com.sg
ABSTRACT
Introduction Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris.
Methods This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates.
Results Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8–17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered.
Conclusion DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.
Keywords: debridement, endoscopic drainage, infected pseudocyst, pancreatic necrosis
Singapore Med J 2013; 54: 206-211; http://dx.doi.org/10.11622/smedj.2013074
REFERENCES
| 1. Seewald S, Ang TL, Teng KC, Soehendra N. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc 2009; 21(1 suppl):S61-5. http://dx.doi.org/10.1111/j.1443-1661.2009.00860. | ||||
| 2. Seewald S, Ang TL, Kida M, Teng KY, Soehendra N. EUS 2008 Working Group document: evaluation of EUS-guided drainage of pancreatic-fluid collections (with video). Gastrointest Endosc 2009; 69(2 suppl):S13-21. http://dx.doi.org/10.1016/j.gie.2008.10.061 | ||||
| 3. Varadarajulu S, Lopes TL, Wilcox CM, et al. EUS versus surgical cystgastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc 2008; 68:649-55. http://dx.doi.org/10.1016/j.gie.2008.02.057 | ||||
| 4. Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63:635-43. http://dx.doi.org/10.1016/j.gie.2005.06.028 | ||||
| 5. Gardner TB, Chahal P, Papachristou GI, et al. A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Gastrointest Endosc 2009; 69:1085-94. http://dx.doi.org/10.1016/j.gie.2008.06.061 | ||||
| 6. Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000; 356:653-5. http://dx.doi.org/10.1016/S0140-6736(00)02611-8 | ||||
| 7. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm. Gastrointest Endosc 2005; 62:92-100. http://dx.doi.org/10.1016/S0016-5107(05)00541-9 | ||||
| 8. Bollen TL, Besselink MG, van Santvoort HC, Gooszen HG, van Leeuwen MS. Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms. Pancreas 2007; 35:107-13. http://dx.doi.org/10.1097/mpa.0b013e31804fa189 | ||||
| 9. Ang TL, Teo EK, Fock KM. EUS-guided drainage of infected pancreatic pseudocyst: use of a 10F Soehendra dilator to facilitate a double-wire technique for initial transgastric access (with videos). Gastrointest Endosc 2008; 68:192-4. http://dx.doi.org/10.1016/j.gie.2007.11.018 | ||||
| 10. Rodriguez JR, Razo AO, Targarona J, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008; 247:294-9. http://dx.doi.org/10.1097/SLA.0b013e31815b6976 | ||||
| 11. Besselink MG, Verwer TJ, Schoenmaeckers EJ, et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007; 142:1194-1201. http://dx.doi.org/10.1001/archsurg.142.12.1194 | ||||
| 12. Vege SS, Baron TH. Management of pancreatic necrosis in severe acute pancreatitis. Clin Gastroenterol Hepatol 2005; 3:192-6. http://dx.doi.org/10.1016/S1542-3565(04)00668-8 | ||||
| 13. Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology 2002; 2:565-73. http://dx.doi.org/10.1159/000071269 | ||||
| 14. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491-502. http://dx.doi.org/10.1056/NEJMoa0908821 | ||||
| 15. Babu BI, Siriwardena AK. Current status of minimally invasive necrosectomy for post-inflammatory pancreatic necrosis. HPB (Oxford) 2009; 11:96-102. http://dx.doi.org/10.1111/j.1477-2574.2009.00041.x | ||||
| 16. Parikh PY, Pitt HA, Kilbane M, et al. Pancreatic necrosectomy: North American mortality is much lower than expected. J Am Coll Surg 2009; 209:712-9. http://dx.doi.org/10.1016/j.jamcollsurg.2009.08.009 | ||||
| 17. Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007; 245:943-51. http://dx.doi.org/10.1097/01.sla.0000254366.19366.69 | ||||
| 18. Charnley RM, Lochan R, Gray H, et al. Endoscopic necrosectomy as primary therapy in the management of infected pancreatic necrosis. Endoscopy 2006; 38:925-8. http://dx.doi.org/10.1055/s-2006-944731 | ||||
| 19. Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009; 58:1260-6. http://dx.doi.org/10.1136/gut.2008.163733 | ||||
| 20. Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73:718-26. http://dx.doi.org/10.1016/j.gie.2010.10.053 | ||||
| 21. Seewald S, Ang TL, Richter H, et al. Long-term results after endoscopic drainage and necrosectomy of symptomatic pancreatic fluid collections. Dig Endosc 2012; 24:36-41. http://dx.doi.org/10.1111/j.1443-1661.2011.01162.x | ||||
| 22. Bakker OJ, Van Sanvoort HC, van Brunschot S, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307:1053-61. http://dx.doi.org/10.1001/jama.2012.276 | ||||
| 23. Fink D, Soares R, Matthews JB, Alverdy JC. History, goals, and technique of laparoscopic pancreatic necrosectomy. J Gastrointest Surg 2011; 15:1092-7. http://dx.doi.org/10.1007/s11605-011-1506-x | ||||
| 24. Gluck M, Ross A, Irani S, et al. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol 2010; 8:1083-8. http://dx.doi.org/10.1016/j.cgh.2010.09.010 | ||||
| 25. Nealon WH, Bhutani M, Riall TS, et al. A unifying concept: pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis. J Am Coll Surg 2009; 208:790-9. http://dx.doi.org/10.1016/j.jamcollsurg.2008.12.027 | ||||
| 26. Telford JJ, Farrell JJ, Saltzman JR, et al. Pancreatic stent placement for duct disruption. Gastrointest Endosc 2002; 56:18-24. http://dx.doi.org/10.1067/mge.2002.125107 | ||||
| 27. Seewald S, Brand B, Groth S, et al. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc 2004; 59:463-70. http://dx.doi.org/10.1016/S0016-5107(03)02708-1 | ||||
| 28. Ang TL, Teo EK, Fock KM. Endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic collections. J Dig Dis 2009; 10:213-24. http://dx.doi.org/10.1111/j.1751-2980.2009.00388.x | ||||
| 29. Arvanitakis M, Delhaye M, Bali MA, et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65:609-19. http://dx.doi.org/10.1016/j.gie.2006.06.083 | ||||