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Abstract
Introduction. According to the literature, approximately 10–15% of patients with acute necrotizing pancreatitis experience disease progression complicated by the formation of walled-off pancreatic necrosis (WOPN). This condition usually requires interventional treatment. In recent years, the management of infected pancreatic necrosis has evolved. Alongside the widespread use of standard minimally invasive ultrasound-guided percutaneous interventions, endoscopic treatment methods involving stents have also been employed.
Purpose. To improve treatment outcomes in patients with WOPN through the broad application of endoscopic techniques (endosonography, endoscopy).
Materials and methods. An analysis of endoscopic treatment in 26 patients with WOPN was conducted at the National Scientific Center of surgery and transplantology named after O. O. Shalimov of Ukraine over the period 2018–2023. The majority of patients were male — 19 (73.1%), while 7 (26.9%) were female. The mean age of the patients was 43±2.6 years. Endoscopic ultrasound (EUS) was performed using a convex echovideoendoscope Olympus GF-UCT 180 and the ultrasound center Olympus EU-ME2. The primary causes of acute pancreatitis were gallstone disease (56.5%), dietary errors (35.5%), and unknown causes (8%). Based on the integrity of the gastric wall adjacent to the WOPN, patients were divided into groups: group 1 — without gastric wall defect (n=14); group 2 — with partial gastric wall defect (the endoscope cannot pass through the gastric wall into the WOPN cavity; necrotic material is not visualized from the gastric lumen) (n=8); group 3 — with complete gastric wall defect (the endoscope can pass, and necrotic material is visualized from the gastric lumen) (n=4).
Results. In group 1, under echoendoscopic guidance, a cystogastrostomy was created, and a fully covered nitinol stent was placed, followed by removal of necrotic material using endoscopic tools. In group 2, under endoscopic control at the site of the developing gastric wall defect, balloon hydrodilation was performed to allow placement of a metal stent, followed by removal of necrotic debris. In group 3, under endoscopic control, necrotic material from the WOPN was removed via the gastric lumen. The number of endoscopic procedures per patient ranged from 2 to 8, with an average of 4 interventions per patient. In the postoperative period, complications were observed in 5 (19.2%) patients: bleeding in 2 (7.6%), stent obstruction in 2 (7.6%), and stent migration in 1 (3.8%). These complications were managed conservatively. The effectiveness of treatment was assessed based on clinical parameters, laboratory markers (white blood cells, procalcitonin, C-reactive protein), and instrumental studies (ultrasound, CT scan of the abdominal cavity).
No mortality was recorded. All patients fully recovered.
Conclusions. Minimally invasive treatment of complicated WOPN under endosonographic guidance allows for stabilization of the patient's condition, reduction of postoperative complications and mortality, shortening of hospitalization time, improvement of the quality of life after surgery, and acceleration of rehabilitation.
References
Anderloni A., Fabbri C., Nieto J. et al. The safety and efficacy of a new 20-mm lumen apposing metal stent (lams) for the endoscopic treatment of pancreatic and peripancreatic fluid collections: a large international, multicenter study. Surg Endosc. 2021; 35: 1741–1748. https://doi.org/10.1007/s00464-020-07567-8.
Bang J. Y., Holt B. A., Hawes R. H. et al. Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis. Br J Surg. 2014; 101: 1729–38. https://doi.org/10.1002/bjs.9664.
Bang J. Y., Wilcox C. M., Hawes R. et al. Outcomes of a Structured, Stepwise Approach to Endoscopic Necrosectomy. J Clin Gastroenterol. 2021; 55(7): 631–637. https://doi.org/10.1097/MCG.0000000000001392.
Baron T. H., DiMaio C. J., Wang A. Y. et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2022; 10(4): E420–E428. https://doi.org/10.1055/a-1783-9229.
Binda C., Dabizzi E., Anderloni A. et al. Single-step endoscopic ultrasound-guided multiple gateway drainage of complex walled off necrosis with lumen apposing metal stents. Eur J Gastroenterol Hepatol. 2020; 32: 1401–1404. https://doi.org/10.1097/MEG.0000000000001793.
Boxhoorn L., Verdonk R. C., Besselink M. G. et al. Comparison of lumen-apposing metal stents versus double-pigtail plastic stents for infected necrotising pancreatitis. Gut. 2023; 72: 66–72. https://doi.org/10.1136/gutjnl-2021-325632.
Fabbri C., Luigiano C., Lisotti et al. Endoscopic ultrasound-guided treatments: Are we getting evidence based — a systematic review. World J Gastroenterol. 2014; 20: 8424–48. https://doi.org/10.3748/wjg.v20.i26.8424.
Feng L., Guo J., Wang S. et al. Endoscopic transmural drainage and necrosectomy in acute necrotizing pancreatitis: a review. J Transl Intern Med. 2021; 9: 168–176. https://doi.org/10.2478/jtim-2021-0031.
Gupta P., Gupta J., Kumar C. et al. Aggressive percutaneous catheter drainage protocol for necrotic pancreatic collections. Dig Dis Sci. 2020; 65: 3696–3701. https://doi.org/10.1007/s10620-020-06116-6.
Haney C. M., Kowalewski K. F., Schmidt M. W. et al. Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc. 2020; 34(6): 2429–2444. https://doi.org/10.1007/s00464-020-07469-9.
Kahaleh M., Shami V. M., Conaway M. R. et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: A prospective comparison with conventional endoscopic drainage. Endoscopy. 2006; 38: 355–9. https://doi.org/10.1055/s-2006-925249.
Keshavarz P., Azrumelashvili T., Yazdanpanah F. et al. Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis. Eur J Radiol. 2021; 144: 109978. https://doi.org/10.1016/j.ejrad.2021.109978.
Khan S., Chandran S., Chin J. et al. Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. J Gastroenterol Hepatol. 2021; 36: 3395–3401. https://doi.org/10.1111/jgh.15658.
Mukai S., Itoi T., Baron T. H. et al. Endoscopic ultrasound-guided placement of plastic vs. bifl anged metal stents for therapy of walled-off necrosis: A retrospective single-center series. Endoscopy. 2015; 47: 47–55. https://doi.org/10.1055/s-0034-1377966.
Mukai S., Itoi T., Sofuni A. et al. Expanding endoscopic interventions for pancreatic pseudocyst and walled-off necrosis. J Gastroenterol. 2015; 50: 211–20. https://doi.org/10.1007/s00535-014-0957-8.
Ng P. Y., Rasmussen D. N., Vilmann P. et al. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts: Medium-term assessment of outcomes and complications. Endosc Ultrasound. 2013; 2: 199–203. https://doi.org/10.4103/2303-9027.121245.
Panamonta N., Ngamruengphong S., Kijsirichareanchai K. et al. Endoscopic ultrasound-guided versus conventional transmural techniques have comparable treatment outcomes in draining pancreatic pseudocysts. Eur J Gastroenterol Hepatol. 2012; 24: 1355–62. https://doi.org/10.1097/MEG.0b013e32835871eb.
Puli S. R., Graumlich J. F., Pamulaparthy S. R. et al. Endoscopic transmural necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis. Can J Gastroenterol Hepatol. 2014; 28: 50–3. https://doi.org/10.1155/2014/539783.
Rische S., Riecken B., Degenkolb J. et al. Transmural endoscopic necrosectomy of infected pancreatic necroses and drainage of infected pseudocysts: A tailored approach. Scand J Gastroenterol. 2013; 48: 231–40. https://doi.org/10.3109/00365521.2012.752029.
Săftoiu A., Ciobanu L., Seicean A. et al. Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent. BMC Gastroenterol. 2013; 13: 93. https://doi.org/10.1186/1471-230X-13-93.
Saluja S., Srivastava S., Govind S. et al. Endoscopic cystogastrostomy versus surgical cystogastrostomy in the management of acute pancreatic pseudocysts. J Minim Access Surg. 2019; 16: 126–131. https://doi.org/10.4103/jmas.JMAS_109_18.
Varadarajulu S., Bang J. Y., Sutton B. S. et al. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013; 145: 583–90. https://doi.org/10.1053/j.gastro.2013.05.046.
Varadarajulu S., Christein J. D., Tamhane A. et al. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc. 2008; 68: 1102–11. https://doi.org/10.1016/j.gie.2009.05.026.
Varadarajulu S., Lopes T. L., Wilcox C. M. et al. EUS versus surgical cystogastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc. 2008; 68: 649–55.
Yasuda I., Takahashi K. Endoscopic management of walled-off pancreatic necrosis. Dig Endosc. 2021; 33: 335–341.