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BACKGROUND: Closure of gastrointestinal defects can reduce postprocedural adverse events. Over-the-scope clips and an over-the-scope suturing system are widely available, yet their use may be limited by defect size, location, operator skill level, and need to reinsert the endoscope with the device attached. The introduction of a through-the-scope helix tack suture system (TTSS) allows for closure of large irregular defects using a gastroscope or colonoscope, without the need for endoscope withdrawal. Since its approval 3 years ago, only a handful of studies have explored outcomes using this novel device. METHODS: Multiple databases were searched for studies looking at TTSS closure from inception until August 2023. The primary outcomes were the success of TTSS alone and TTSS with clips for complete defect closure. Secondary outcomes included complete closure based on procedure type (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) and adverse events. RESULTS: Eight studies met the inclusion criteria (449 patients, mean defect size 34.3 mm). Complete defect closure rates for TTSS alone and TTSS with adjunctive clips were 77.2% (95%CI 66.4-85.3; I2=79%) and 95.2% (95%CI 90.3-97.7; I2=42.5%), respectively. Complete defect closure rates for EMR and ESD were 99.2% (95%CI 94.3-99.9; I2 = 0%) and 92.1% (95%CI 85-96; I2=0%), respectively. The adverse event rate was 5.4% (95%CI 2.7-10.3; I2=55%). CONCLUSION: TTSS is a novel device for closure of postprocedural defects, with relatively high technical and clinical success rates. Comparative studies of closure devices are needed.
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Técnicas de Sutura , Humanos , Técnicas de Sutura/instrumentação , Técnicas de Sutura/efeitos adversos , Ressecção Endoscópica de Mucosa/instrumentação , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Suturas/efeitos adversos , Endoscopia Gastrointestinal/instrumentação , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/métodos , Resultado do TratamentoRESUMO
Video 1Demonstration of the management of a recurrent symptomatic hepatic cyst that was complicated by a buried lumen-apposing metal stent in the gastric antrum and a liver abscess.
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Video 1Suturing pexy to seal a leak around an esophageal stent in the setting of a malignant esophago-pleural fistula.
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BACKGROUND AND AIMS: Palliation of malignant gastric outlet obstruction (mGOO) allows resumption of peroral intake. Although surgical gastrojejunostomy (SGJ) provides durable relief, it may be associated with a higher morbidity, interfere with chemotherapy, and require an optimum nutritional status. EUS-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative. We aimed to conduct the largest comparative series to date between EUS-GE and SGJ for mGOO. METHODS: This multicenter retrospective study included consecutive patients undergoing SGJ or EUS-GE at 6 centers. Primary outcomes included time to resumption of oral intake, length of stay (LOS), and mortality. Secondary outcomes included technical and clinical success, reintervention rates, adverse events (AEs), and resumption of chemotherapy. RESULTS: A total of 310 patients were included (EUS-GE, n = 187; SGJ, n = 123). EUS-GE exhibited significantly lower time to resumption of oral intake (1.40 vs 4.06 days, P < .001), at lower albumin levels (2.95 vs 3.33 g/dL, P < .001), and a shorter LOS (5.31 vs 8.54 days, P < .001) compared with SGJ; there was no difference in mortality (48.1% vs 50.4%, P = .78). Technical (97.9% and 100%) and clinical (94.1% vs 94.3%) success was similar in the EUS-GE and SGJ groups, respectively. EUS-GE had lower rates of AEs (13.4% vs 33.3%, P < .001) but higher reintervention rates (15.5% vs 1.63%, P < .001). EUS-GE patients exhibited significantly lower interval time to resumption of chemotherapy (16.6 vs 37.8 days, P < .001). Outcomes between the EUS-GE and laparoscopic (n = 46) surgical approach showed that EUS-GE had shorter interval time to initiation/resumption of oral intake (3.49 vs 1.46 days, P < .001), decreased LOS (9 vs 5.31 days, P < .001), and a lower rate of AEs (11.9% vs 17.9%, P = .003). CONCLUSIONS: This is the largest study to date showing that EUS-GE can be performed among nutritionally deficient patients without affecting the technical and clinical success compared with SGJ. EUS-GE is associated with fewer AEs while allowing earlier resumption of diet and chemotherapy.
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Derivação Gástrica , Obstrução da Saída Gástrica , Humanos , Estudos Retrospectivos , Endossonografia , Stents , Gastroenterostomia , Obstrução da Saída Gástrica/etiologia , Obstrução da Saída Gástrica/cirurgiaRESUMO
Video 1Management of disconnected segments 5 and 6 bile leaks.
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DESCRIPTION: Endoscopic gallbladder drainage is a feasible and efficacious alternative to percutaneous drainage in the management of acute cholecystitis for high-risk surgical candidates. Endoscopic ultrasound-guided gallbladder drainage and per-oral cholecystoscopy is facilitated by the use of lumen-apposing metal stents. Endoscopic ultrasound-guided gallbladder drainage should be performed by those expert in advanced therapeutic endoscopic ultrasound. Multidisciplinary collaboration between interventional radiology and surgery is paramount in the care of these patients. Choosing the optimal drainage method is dependent on individual patient characteristics. METHODS: This commentary was drawn from a review of the literature to provide practical advice. Because this was not a systematic review, we did not perform any formal rating of the quality of evidence or strength of the presented considerations. This expert commentary was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer-review by the Clinical Practice Updates Committee and external peer-review through standard procedures of Clinical Gastroenterology and Hepatology.
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Colecistite Aguda , Vesícula Biliar , Humanos , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/cirurgia , Colecistite Aguda/diagnóstico por imagem , Colecistite Aguda/cirurgia , Endossonografia/métodos , Drenagem/métodos , Endoscopia/métodos , Stents , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Interventions for malignant small-bowel obstruction (SBO) may be limited by extent of peritoneal disease, rendering surgical or traditional endoscopic methods (ie, luminal stenting or decompressive gastrostomy) unfeasible. We demonstrated the novel use of EUS-guided lumen-apposing metal stent placement for enterocolonic bypass in patients with malignant SBO who were deemed high risk for surgery. METHODS: Across 3 tertiary U.S. centers, a retrospective series of consecutive patients underwent attempted EUS-guided enterocolostomy (EUS-EC) for palliation of acute SBO because of malignant causes. Technique and devices used were described, and patient demographics and outcome data were collected. RESULTS: Ten patients were included, of whom 9 (90.0%) were men, with a mean age of 64.5 ± 14.0 years and who were 1.5 ± 2.1 years postdiagnosis. Technical success was achieved in 8 of 10 patients (80.0%) and clinical success in 7 of 10 (70.0%), with a single major adverse event (10.0%) of aspiration. Median time until resumption of oral intake was 1.0 day (range, 0-8) after the procedure, with an interval to discharge home of 6.5 days and survival of 57.0 days. CONCLUSIONS: EUS-EC is a new alternative for palliation of acute SBO because of advanced malignant disease when conservative measures fail and other surgical or endoscopic options are not possible. Additional larger studies with longer duration of follow-up are needed to further define efficacy and safety of this approach.
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Endossonografia , Neoplasias , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Endossonografia/métodos , Estudos Retrospectivos , Stents/efeitos adversos , Drenagem/métodos , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND AND AIMS: EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS: This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS: Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS: Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.
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Colangiopancreatografia Retrógrada Endoscópica , Derivação Gástrica , Humanos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Estudos de Casos e Controles , Estudos Retrospectivos , Derivação Gástrica/métodos , Endoscopia Gastrointestinal/efeitos adversos , Stents/efeitos adversosRESUMO
OBJECTIVE: To evaluate the safety and efficacy of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS). BACKGROUND: For patients with acute cholecystitis who are poor surgical candidates, EUS-GBD using a LAMS is an important treatment alternative to percutaneous gallbladder drainage. METHODS: We conducted a regulatory-compliant, prospective multicenter trial at 7 tertiary referral centers in the United States of America and Belgium. Thirty consecutive patients with mild or moderate acute cholecystitis who were not candidates for cholecystectomy were enrolled between September 2019 and August 2021. Eligible patients had a LAMS placed transmurally with 30 to 60-day indwell if removal was clinically indicated, and 30-day follow-up post-LAMS removal. Endpoints included days until acute cholecystitis resolution, reintervention rate, acute cholecystitis recurrence rate, and procedure-related adverse events (AEs). RESULTS: Technical success was 93.3% (28/30) for LAMS placement and 100% for LAMS removal in 19 patients for whom removal was attempted. Five (16.7%) patients required reintervention. Mean time to acute cholecystitis resolution was 1.6±1.5 days. Acute cholecystitis symptoms recurred in 10.0% (3/30) after LAMS removal. Five (16.7%) patients died from unrelated causes. Procedure-related AEs were reported to the FDA in 30.0% (9/30) of patients, including one fatal event 21 days after LAMS removal; however, no AEs were causally related to the LAMS. CONCLUSIONS: For selected patients with acute cholecystitis who are at elevated surgical risk, EUS-GBD with LAMS is an alternative to percutaneous gallbladder drainage. It has high technical and clinical success, with low recurrence and an acceptable AE rate. Clinicaltrials.gov, Number: NCT03767881.
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Colecistite Aguda , Vesícula Biliar , Humanos , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/cirurgia , Estudos Prospectivos , Resultado do Tratamento , Colecistite Aguda/diagnóstico por imagem , Colecistite Aguda/cirurgia , Endossonografia , Drenagem/efeitos adversos , Stents , Ultrassonografia de IntervençãoRESUMO
Background and study aims Malignant disease accounts for up to 80â% of gastric outlet obstruction (GOO) cases, which may be treated with duodenal self-expanding metal stents (SEMS), surgical gastrojejunostomy (GJ), and more recently endoscopic-ultrasound-guided gastroenterostomy (EUS-GE). These three treatments have not been compared head-to-head in a randomized trial. Methods We searched the Embase and MEDLINE databases for studies published January 2015-February 2021 assessing treatment of malignant GOO using duodenal SEMS, endoscopic (EUS-GE) or surgical (laparoscopic or open) GJ. Efficacy outcomes assessed included technical and clinical success rates, GOO recurrence and reintervention. Safety outcomes included procedure-related bleeding or perforation, and stent-related events for the duodenal SEMS and EUS-GE arms. Results EUS-GE had a lower rate of technical success (95.3%) than duodenal SEMS (99.4â%) or surgical GJ (99.9%) ( P â=â0.0048). For duodenal SEMS vs. EUS-GE vs. surgical GJ, rates of clinical success (88.9â% vs. 89.0â% vs. 92.3â% respectively, P â=â0.49) were similar. EUS-GE had a lower rate of GOO recurrence based on limited data ( P â=â0.0036), while duodenal SEMS had a higher rate of reintervention ( P â=â0.041). Overall procedural complications were similar (duodenal SEMS 18.7â% vs. EUS-GE 21.9â% vs. surgical GJ 23.8â%, P â=â0.32), but estimated bleeding rate was lowest ( P â=â0.0048) and stent occlusion rate was highest ( P â=â0.0002) for duodenal SEMS. Conclusions Duodenal SEMS, EUS-GE, and surgical GJ showed similar clinical efficacy for the treatment of malignant GOO. Duodenal SEMS had a lower procedure-related bleeding rate but higher rate of reintervention.
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BACKGROUND AND AIMS: Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS: This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS: Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS: EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.
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Derivação Gástrica , Pancreatopatias , Colangiopancreatografia Retrógrada Endoscópica/métodos , Endossonografia/métodos , Feminino , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatopatias/cirurgia , Estudos Retrospectivos , StentsRESUMO
BACKGROUND: Concomitant malignant biliary and gastric outlet obstruction can be difficult to manage endoscopically with traditional endoscopic retrograde cholangiopancreatography (ERCP) and luminal stenting. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HG) and gastrojejunostomy (GJ) are novel techniques that can relieve both obstructions in a single session. This study aims to describe the outcomes of combined, single session EUS-HG and EUS-GJ. METHODS: This is a two-center retrospective study of consecutive patients who underwent same session EUS-HG and EUS-GJ. The primary outcome was technical success. Secondary outcomes included adverse events (AE), reduction in total serum bilirubin, length of hospital stay (LOS), and re-intervention rates. RESULTS: A total of 23 patients underwent EUS-HG and EUS-GJ (12 males, mean age 66.4 years). Twenty-one were performed for malignant obstruction. Technical success was 100% and 95.6% for HG and GJ, respectively. All patients subsequently tolerated a soft diet and 72.7% (16/22) of patients had a 50% reduction in bilirubin post-procedure. The median LOS for the 17 patients who were not discharged home immediately following the procedure was 2 (range 1-20) days. There were five AEs (2 mild, 3 moderate). Only three patients required reintervention (interventional radiology-guided biliary drainage, stent exchange for a benign biliary stricture, and placement of a second stent through an occluded distal common bile duct stent) over a median follow-up of 78 days. One patient with pancreatic cancer underwent successful tumor resection. CONCLUSION: Single session EUS-guided double bypass (HG and GJ) is technically feasible and safe when conducted by experienced endosonographers. Larger, comparative studies are needed.
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Neoplasias dos Ductos Biliares , Colestase , Derivação Gástrica , Idoso , Bilirrubina , Colangiopancreatografia Retrógrada Endoscópica , Drenagem , Endossonografia , Humanos , Masculino , Estudos Retrospectivos , Stents , Ultrassonografia de IntervençãoRESUMO
Background and study aims Indications for accessing the duodenum, and/or excluded stomach in Roux-en-Y gastric bypass (RYGB) patients extend beyond diagnosis and treatment of pancreaticobiliary maladies. Given the high technical and clinical success of EUS-directed transgastric ERCP (EDGE) in RYGB anatomy, we adopted this transgastric (anterograde) approach to evaluate and treat luminal and extraluminal pathology in and around the excluded gut in RYGB patients. EUS-directed transgastric intervention ("EDGI"), other than ERCP, is the terminology we have chosen to describe this heterogenous group of transgastric diagnostic and/or interventional endoscopic procedures (transgastric interventions) performed via a lumen-apposing mental stent (LAMS) in select patients with RYGB. Patients and methods A multicenter (nâ=â4), retrospective study of RYGB patients with suspected luminal or extraluminal pathology, in or around the duodenum and/or excluded stomach, underwent EDGI using LAMS between December 2015 and January 2019. Results A total of 14 patients (78.6â% women; mean age, 55.7â+â12.4 years) underwent EDGI via LAMS. Technical and clinical success rates of EDGI were 100â%. The most common transgastric interventions were diagnostic EUS of extraluminal pathology (nâ=â6, 42.7â%) and endoscopic biopsy of gastroduodenal luminal abnormalities (nâ=â5, 35.7â%). Two moderate-severity adverse events due to LAMS maldeployment occurred during EUS-JG creation (14.3â%), and each instance was successfully rescued with a bridging stent. Conclusions A variety of gastroduodenal luminal and extraluminal disorders in RYGB patients can be effectively diagnosed and managed using EDGI via LAMS.
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PURPOSE OF REVIEW: Acute cholecystitis is conventionally managed with cholecystectomy; however, when this occurs in the non-operative patient, it requires consideration for alternative means of gallbladder drainage (GBD). RECENT FINDINGS: Suitable endoscopic methods for GBD include transpapillary cystic duct stent or endoscopic ultrasound (EUS)-guided transmural stent placement. Importantly, patients who undergo endoscopic GBD have comparable outcomes to those who undergo placement of percutaneous transhepatic catheters by interventional radiology (IR). There is evolving evidence to support endoscopic gallbladder drainage by EUS or ERCP with transpapillary stenting for patients who are non-operative candidates. There appear to be advantages over percutaneous drainage in terms of lower rates of recurrent cholecystitis, faster clinical resolution of symptoms, and omission of external drain-related complications. However, careful consideration of individual characteristics is warranted in the care of these complicated patients. The technical and clinical considerations for endoscopic methods of GB drainage are discussed in this review article.
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BACKGROUND AND AIMS: There is an evolving role for EUS-guided transmural gallbladder (GB) drainage. Endoscopic transpapillary GB drainage is a well-established, nonoperative treatment for acute cholecystitis. We compared the outcomes of 78 cases of EUS-guided versus transpapillary GB drainage at a single, U.S.-based, high-volume endoscopy center. METHODS: This was a retrospective analysis performed from May 2013 to January 2018, identified from a database of nonoperative patients with acute cholecystitis. Both electrocautery-enhanced and nonelectrocautery-enhanced lumen-apposing metal stents were used. For transpapillary drainage, guidewire access was obtained and then a transpapillary 7F × 15-cm double-pigtail plastic stent was placed. RESULTS: In patients who had successful transpapillary or transmural drainage, demographics data were similar. Technical success was observed in 39 of 40 patients (97.5%) who underwent first attempt at EUS-guided drainage versus 32 of 38 patients (84.2%) for first-attempt transpapillary drainage (adjusted odds ratio, 9.83; 95% confidence interval, .93-103.86). Clinical success was significantly higher with EUS drainage in 38 of 40 patients (95.0%) versus transpapillary drainage in 29 of 38 patients (76.3%) (adjusted odds ratio, 7.14; 95% confidence interval, 1.32-38.52). Recurrent cholecystitis was lower in the EUS-guided drainage group (2.6% vs 18.8%, respectively; P = .023) on univariate analysis but only trended to significance in a multiple regression model. Duration of follow-up, reintervention rates, hospital length of stay, and overall adverse event rates were similar between groups. CONCLUSIONS: EUS-guided GB drainage results in a higher clinical success rate compared with transpapillary drainage and may be associated with a lower recurrence rate of cholecystitis. However, transpapillary drainage should be considered as the first-line treatment for patients who are surgical candidates but require temporizing measures or require an ERCP for alternative reasons.
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Ampola Hepatopancreática , Colecistite Aguda/cirurgia , Colestase Extra-Hepática/cirurgia , Drenagem/métodos , Endoscopia do Sistema Digestório/métodos , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Colestase Extra-Hepática/etiologia , Endossonografia , Feminino , Cálculos Biliares/complicações , Humanos , Masculino , Metais , Pessoa de Meia-Idade , Neoplasias/complicações , Estudos Retrospectivos , Cirurgia Assistida por ComputadorRESUMO
Background/Aims: Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. Methods: We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. Results: Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). Conclusions: This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.
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Infecções Bacterianas/mortalidade , Drenagem/mortalidade , Pancreatopatias/mortalidade , Pancreatite Necrosante Aguda/mortalidade , Stents/efeitos adversos , Adulto , Idoso , Infecções Bacterianas/complicações , Infecções Bacterianas/cirurgia , Bases de Dados Factuais , Drenagem/instrumentação , Drenagem/métodos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Pâncreas/patologia , Pâncreas/cirurgia , Pancreatopatias/complicações , Pancreatopatias/cirurgia , Fístula Pancreática/etiologia , Fístula Pancreática/mortalidade , Pancreatite Necrosante Aguda/microbiologia , Pancreatite Necrosante Aguda/cirurgia , Admissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE. METHODS: This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected. RESULTS: 18 patients (mean age 64.2 years, 72â% post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8â%) and jaundice (33.3â%). Clinical success included resolution of symptoms in 88.9â% and improvement to allow hospital discharge in 11.1â%. Technical success was achieved in 100â% of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2â%). Three adverse events (16.7â%) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6â% vs. 76.5â%; Pâ<â0.001). CONCLUSION: EUS-EE seems to be safe and effective in the treatment of ALS.âIndirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.