Safety and Efficacy of Long-Term Transmural Plastic Stent Placement After Removal of Lumen Apposing Metal Stent in Resolved Pancreatic Fluid Collections with Duct Disconnection at Head/Neck of Pancreas.

BACKGROUND AND AIMS: Replacing lumen apposing metal stents (LAMS) with permanent indwelling plastic stents after the resolution of pancreatic fluid collections (PFC) in patients with disconnected pancreatic duct (DPD) is a debatable issue. We retrospectively evaluated the safety and efficacy of replacing LAMS with long-term indwelling transmural plastic stents in patients with DPD at head/neck of pancreas. METHODS: The database of patients with PFC who underwent endoscopic transmural drainage with LAMS over the last three years was retrospectively analyzed to identify patients with DPD at the level of the head/neck of the pancreas. The patients were divided into two groups: Group A where LAMS could be replaced with plastic stents and Group B, where LAMS could not be replaced with plastic stents. The two groups were compared for recurrence of symptoms/PFC and complications. RESULTS: Out of 53 patients studied, 39 patients (34 males; mean age: 35.7 ± 6.6 years) were included in Group A and 14 patients in Group B (11 males; mean age: 33.4 ± 5.9 years). The demographic profile as well as indwelling time of LAMS was comparable between two groups. PFC recurrence was observed in 2/39 (5.1%) patients in group A and 6/14 (42.8%) patients in group B (p = 0.0001) with one patient in group A and 5 patients in group B requiring repeat intervention for recurrent PFC. CONCLUSIONS: Long-term transmural plastic stent placement after removal of LAMS in pancreatic duct disconnection at head/neck of the pancreas is safe and effective strategy to prevent the recurrence of PFC.

Endoscopic step up: When and how.

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a "step-up approach" of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

A New Entity of Walled off Extra Pancreatic Necrosis is Associated with Better Outcomes Following Endoscopic Transmural Drainage.

BACKGROUND AND AIMS: Previous studies have shown that patients with extra-pancreatic necrosis (EPN) alone are associated with better outcomes than patients with pancreatic necrosis (PN) in acute pancreatitis (AP). The natural history and drainage outcome of pancreatic collections resulting from PN vs. EPN has not been studied. METHODS: Clinical records of a prospectively maintained cohort of AP patients who underwent endoscopic drainage of walled of necrosis (WON) were reviewed. Computed tomography (CT) done on day 4 to 7 of illness was reviewed to identify EPN alone (Group 1) or PN with or without EPN (Group 2). Group 1 and 2 were compared for WON characteristics, as well as outcome and adverse effects of endoscopic drainage. RESULTS: Seventy-one patients in Group 2 (57 males; mean age 38.6±11.5 years) were compared with sixteen patients in Group 1 (12 males; mean age 34.5±10.8 years). WON developing in Group 2 were significantly larger (11.7±2.8 cm vs. 9.5±2.03 cm) with higher solid necrotic debris (30.4±9.8% vs. 13.7±7.2%). Endoscopic transmural drainage of WON associated with PN required a greater number of direct endoscopic necrosectomy (DEN) sessions along with a longer time for resolution. The time taken for resolution correlated with size (r=0.629, p <0.01) and solid debris content (r=0.647, p<0.01), which were significantly higher in the PN group. CONCLUSIONS: This new entity of walled of extra pancreatic necrosis alone has lesser solid necrotic debris and its endoscopic drainage is associated with better outcomes as compared to patients with walled off pancreatic necrosis.

Portal Cavernoma Cholangiopathy in Children: An Evaluation Using Magnetic Resonance Cholangiography and Endoscopic Ultrasound.

BACKGROUND: Portal cavernoma cholangiopathy (PCC) refers to abnormalities of the extra- and intrahepatic bile ducts in patients with portal cavernoma. The literature on PCC in children is very scarce. This study aimed at characterizing PCC in children with extrahepatic portal venous obstruction (EHPVO) using endoscopic ultrasound (EUS) and magnetic resonance cholangiography/portovenography (MRC/MRPV). METHODS: A total of 53 consecutive children diagnosed with EHPVO were prospectively evaluated for PCC using MRC/MRPV and EUS. Chandra classification was used for type of involvement and Llop classification for grading of severity. RESULTS: All 53 children (100%) had PCC changes on MRC/EUS, but none were symptomatic. Extrahepatic ducts (EHDs) and intrahepatic ducts were involved in majority (85%), and 58.5% had severe changes. Periductal thickening/irregularity (71%) was the commonest change in intrahepatic ducts, whereas irregular contour of the duct with scalloping (68%); common bile duct (CBD) angulation (62.3%) were the frequent changes in the EHDs. Increased CBD angulation predisposed to CBD strictures (P = 0.004). Both left and right branches of portal vein were replaced by collaterals in all children. Among the EUS biliary changes, para-pericholedochal, intrapancreatic, and intramural gall bladder collaterals had significant association with severity, with higher frequency of occurrence in children with the most severe Llop Grade. CONCLUSIONS: PCC develops early in the disease course of EHPVO, in children, but is asymptomatic despite severe changes. EUS biliary changes are more likely to be observed with increasing severity of PCC.

Contrast-enhanced endoscopic ultrasound features of tubercular lymphadenopathy.

There is lack of data on the contrast-enhanced endoscopic ultrasound features of tubercular lymph node; our retrospective analysis of 37 patients with enlarged mediastinal and abdominal lymph nodes showed heterogeneous enhancement in the great majority (70%).